Elsevier

The Lancet

Volume 346, Issues 8991–8992, 30 December 1995, Pages 1647-1653
The Lancet

COMMENTARY
Cholesterol, diastolic blood pressure, and stroke: 13 000 strokes in 450 000 people in 45 prospective cohorts

https://doi.org/10.1016/S0140-6736(95)92836-7Get rights and content

Abstract

Individual studies of stroke have not clearly answered two questions: on the relation, if any, between total blood cholesterol and stroke; and on how the strength of the relation between diastolic blood pressure and stroke varies with age. The associations of blood cholesterol and diastolic blood pressure with subsequent stroke rates were investigated by review of 45 prospective observational cohorts involving 450 000 individuals with 5-30 years of follow-up (mean 16 years, total 7·3 million person-years of observation), during which 13 397 participants were recorded as having had a stroke. Most of these were fatal strokes in studies that recorded only mortality and not incidence, but about one-quarter were from studies that recorded both fatal and non-fatal strokes. After standardisation for age, there was no association between blood cholesterol and stroke except, perhaps, in those under 45 years of age when screened. This lack of association was not influenced by adjustment for sex, diastolic blood pressure, history of coronary heart disease, or ethnicity (Asian or non-Asian). However, because the types of the strokes were not centrally available, the lack of any overall relation might conceal a positive association with ischaemic stroke together with a negative association with haemorrhagic stroke. When the highest and the lowest of the six blood pressure categories were compared, the difference in usual diastolic blood pressure was 27 mm Hg (102 vs 75 mm Hg), and there was a fivefold difference in stroke risk. This fivefold difference was seen both in those with a pre-existing history of coronary heart disease and in those without it. The proportional difference in stroke risk, however, was more extreme in middle than in old age. Among those aged <45, 45-64, and 65+ when screened, the differences in the relative risks of stroke (between the highest diastolic blood pressure category and a combination of the lowest two categories) were tenfold, fivefold, and twofold, respectively. However, because the absolute stroke risks are greater in old age, the absolute differences in the annual stroke rates showed an opposite pattern, being 2, 5, and 8 per thousand, respectively. This suggests that the effects of therapeutic blood pressure reductions should be assessed separately in middle age and in old age.

References (54)

  • Sa Tornberg et al.

    Cancer incidence and cancer mortality in relation to serum cholesterol

    J Natl Cancer Inst

    (1989)
  • P. Knekt et al.

    Risk factors for subarachnoid hemorrhage in a longitudinal population study

    J Clin Epidemiol

    (1991)
  • Cs Cox et al.

    Plan and operation of the NHANES(I) Epidemiologic Follow-up Study, 1987. National Center for Health Statistics

    Vital Health Stat

    (1992)
  • A. Menotti et al.

    Twenty-year stroke mortality and prediction in twelve cohorts of the Seven Countries Study

    Int J Epidemiol

    (1990)
  • Ch Lin et al.

    Cerebrovascular diseases in a fixed population of Hiroshima and Nagasaki, with special reference to relationship between type and risk factors

    Stroke

    (1984)
  • Tp Szatrowski et al.

    Serum cholesterol, other risk factors, and cardiovascular disease in a Japanese cohort

    J Chron Dis

    (1984)
  • A. Kagan et al.

    Factors related to stroke incidence in Hawaii Japanese men

    Stroke

    (1980)
  • Pa Wolf et al.

    Current status of risk factors for stroke

    Neurol Clin

    (1983)
  • Cg Isles et al.

    Plasma cholesterol, coronary heart disease, and cancer in Renfrew and Paisley survey

    BMJ

    (1989)
  • Y. Goldbourt et al.

    Factors predictive of long-term coronary heart disease mortality among 10,059 male Israeli civil servants and municipal employees. A 23-year mortality follow-up in the Israeli Ischaemic Heart Disease Study

    Cardiology (Basel)

    (1993)
  • P. Puska et al.

    Change in risk factors for coronary heart disease during ten years of a community intervention programme. (North Karelia Project)

    BMJ

    (1983)
  • J. Tuomilehto et al.

    Hypertension, cigarette smoking, and the decline in stroke incidence in Eastern Finland

    Stroke

    (1991)
  • T. Shimamoto et al.

    Trends for coronary heart disease and stroke and their risk factors in Japan

    Circulation

    (1989)
  • Dd Reid et al.

    Cardiorespiratory disease and diabetes among middle-aged male civil servants

    Lancet

    (1974)
  • A. Heyman et al.

    Cerebrovascular disease in the bi-racial population of Evans county, Georgia

    Stroke

    (1971)
  • M. Higgins et al.

    Cholesterol, coronary heart disease, and total mortality in middle-aged and elderly men and women in Tecumseh

    Ann Epidemiol

    (1992)
  • Mw Knuiman et al.

    Mortality trends 1965 to 1989 in Busselton, the site of repeated health surveys and interventions

    Aust J Publ Health

    (1994)
  • Mh Criqui et al.

    Differences between respondents and non-respondents in a population-based cardiovascular disease study

    Am J Epidemiol

    (1978)
  • K. Bjartveit et al.

    The cardiovascular disease study in Norwegian counties: background and organisation

    Acta Med Scand

    (1979)
  • H. Tanaka et al.

    Epidemiologic studies of stroke in Shibata, a Japanese provincial city: preliminary report on risk factors for cerebral infarction

    Stroke

    (1985)
  • Vm Hawthorne et al.

    Smoking and health: the association between smoking behaviour, total mortality, and cardiorespiratory disease in West Central Scotland

    J Epidemiol Comm Health

    (1978)
  • Ag Shaper et al.

    Risk factors for stroke in middle aged British men

    BMJ

    (1991)
  • Ll Haheim et al.

    Risk factors of stroke incidence and mortality. A 12-year follow-up of the Oslo Study

    Stroke

    (1993)
  • Je Keil et al.

    Serum cholesterol— risk factor for coronary disease mortality in younger and older Blacks and Whites. The Charleston Heart Study, 1960-1988

    Ann Epidemiol

    (1992)
  • Pg McGovern et al.

    Trends in mortality, morbidity and risk factor levels for stroke from 1960 through 1990. the Minnesota Heart Survey

    JAMA

    (1991)
  • Z. Chen et al.

    Serum cholesterol concentration and coronary heart disease in a population with low cholesterol concentrations

    BMJ

    (1991)
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    Correspondence to: PSC Secretariat, Department of Clinical Geratology, University of Oxford, Radcliffe Infirmary, Oxford OX2 6HE, UK

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