Somogyi JC, Bir Biro Gy, Gy, Hotzel Hotzel D D (eds): (eds): Nutrition Nutrition and and Cardiovascular Cardiovascular Risks. Risks. Somogyi Bibl Nutr Nutr Dieta. Dieta. Basel, Basel, Karger, 1992, 1992, No 49, pp 36-46 Bibi
of Coronary Risk and Prevention of Disease in Childhood Heart Disease Maria Ι ria Barna
and progression progression of of atherosclerosis atherosclerosis is is aa slow slow process, process, The development and [5]. Prevention can only only be be successful successful at that stage stage beginning in childhood [5]. is therefore primarily the task of the pediatrician. and is Cardiovascular diseases joint effect effect of of different different Cardiovascular diseasesdevelop developdue due to to the joint factors, í.e. i.e. genetic susceptibility susceptibility and environmental factors. factors. According According to factors, present knowledge, knowledge, about 250 risk factors our present factors should be be taken into account. into 44 large large groups groups [9]: [9]: These are divided into (l) Initiators: Initiators: breakdown breakdown of of vessel vessel wall wall integrity; integrity; hypertension hypertension [ [18]; 18]; (1) smoking [[16]; 16];high-lipid high-lipiddiets; diets; homocystinuria; homocystinuria; psychosocial psychosocial factors, factors, etc. (2) Promoters: enhance cholesterol and cholesterol ester infiltration into (2) atheromatous lesion; lesion; increase increase LDL-cholesterol; LDL-cholesterol; increase increase VLDL-cholesVLDL-cholesthe atheromatous HDL-cholesterol; lipid-rich smoking; proterol; decrease HDL-cholesterol; lipid-rich diet; diet; diabetes [7]; smoking; 13] and and vitamin CC [[17] 17] deficiency; deficiency; psychosocial psychosocial factors, longed vitamin B6 [[13] [4] etc. (3) Potentiators: by enhancing the activity ofthrombocytes of thrombocytes and throm(3) bogenesis, may effects of i.e. bogenesis, may potentiate potentiate the the effects of both both initiators initiators and promoters, i.e. contraceptives [1 [11], smoking, oral contraceptives 1 ],diabetes diabetes [3], [3], reduced reduced fibrinolytic fibrinolytic activity TXA2 concentration concentration [[10], 10], lipid-rich lipid-rich diet, psychosocial factors, factors, etc. [[12], 12], high ΤΧΑ2 (4) Precipitators — - not notonly onlyatherogenic atherogenic factors: factors: may may cause cause heart heart attack (4) by inducing ischemic events; events; physical physical exertion; exertion; cold cold water; water; all all potentiators; potentiators; smoking; changes weather; hypertension hypertension [20]; [20]; prolonged prolonged nitrate nitrate smoking; changes in in the weather; psychosocial factors, exposure; psychosocial factors, etc. Prevention childhood when when vessel vessel alterations are Prevention should should be started in childhood early stage. stage. In the initial stage, stage, the main task is to decrease decrease the only at an early initiators and promoters to the minimum. At that time, the most important problem is keeping serum serum lipids and blood pressure at normal levels and not
Downloaded by: Université de Paris 193.51.85.197 - 2/7/2020 4:37:32 AM
Department, St. St. Lászl Laszlo Hospital, Hospital, Budapest, Budapest, Hungary Hungary Pediatrics Department,
37 37
Risk and Prevention of CHD in Childhood
°% % 60 60-
50 5040 40-
00"cr σ .;::' 009 σ4
30 3020 20 10 10::::
10 10-
lili
:;:: :.;.
30 30
~~~~
> 1.4 >5.0 > 5.0 < 1.1 < LDLC/HDLC
nη == 116 < 2.7 (normal) n=25>2.7 n= 25> 2.7
Analyses of suggest that over 40% of the energy energy intake is Analyses of children's children's diet suggest is very high. from fat (first of all all saturated fat) and dietary cholesterol intake is of 141 141 children are presented in table 2. Lipid parameters of Eighty children triglyceride, cholesterol Eighty children showed showed normal triglyceride, cholesterol and HDL-cholesterol levels. levels. An triglyceride increase increase was 11 cases, cases, lesterol An isolated triglyceride was observed observed in 11 increase in total cholesterol cholesterol in 24 24 and and decrease decrease in in HDL-cholesterol HDL-cholesterol in 17 17 increase children. In 55 cases cases aa simultaneous simultaneous increase increase was found in in triglyceride triglyceride and children. cholesterol levels. levels. In one case, case, besides besides the the triglyceride triglyceride increase, increase, a total cholesterol In one was observed. decrease in HDL-cholesterol was observed. In 2 children an increase in total level was cholesterol level was accompanied accompanied by by a decrease decrease in HDL-cholesterol. HDL-cholesterol. In one case, also triglyceride, triglyceride, total cholesterol and HDL-cholesterol HDL-cholesterol levels levels were in case, the pathological pathological range. 2. 7(LDLatherogen index was also calculated. calculated. We We considered considered under 2.7(LDLThe etherogen ClHDL-C) value as appropriate. This This index index value value was was found to to be be definitely definitely C/HDL-C) high in 25 children.
Downloaded by: Université de Paris 193.51.85.197 - 2/7/2020 4:37:32 AM
n=24 η=24
TG+T-C TG+ HDLC
Risk and Prevention of of CHD in Childhood Risk
45
3. Serum lipid parameters of of offspring offspring of parents who had suffered suffered infarcts on the Table 3. first and second examinations first
T-C Τ-C
HDL-C
Ι
II
I
II
I
II
10/41
5/41
20/41 20/41
15/41
14/41
9/41 9/41
In the course of caring, caring, all all children children were wereattended attended both both individually and groups. For the sake sake of improving their educational educational standard, the same same in groups. was done as as in the other form of our model examination. was: Our primary aim was: (a) Increasing students' knowledge knowledge of CHD risk factors concepts. (a) (b) Decreasing CHD risk behaviors, such cigarette smoking smoking and Decreasing CHD risk behaviors, such as cigarette (b) of foods high in saturated fat, cholesterol and salt. consumption of (c) Increasing Increasing levels consumption of levels of of aerobic aerobic physical physical activity activity and and consumption (c) complex carbohydrates. (d) Lowering Lowering heart (d) heart rate, blood pressure, body mass index, and skin fold thickness. connections between between diet, diet, life-style life-style and and chronic chronic diseases diseases were shown The connections lectures, in in practice practice (sampling, (sampling, snacks snacks recipes) recipes) and informal discusdiscusin lectures, and in informal sions. At regular regular club meetings meetings we sions. we teach teach them those alterations which are and in in life-style life-style in order to avoid developing atherosclerosis required in diet and of children at risk risk are supervised. as adults. Lipid parameters of life-style, the Possibly because because of the the effect effect of of altered altered dietary dietary habits and life-style, showed considsame values of children presented on repeated examinations showed erable improvement. Table 3 shows aa favorable favorable trend trend of change change in in lipid lipid parameters parameters of children examined for the second time. Out of of 41 41 children at the first examination, we examined increased triglyceride triglyceride levels in only 5 cases found increased cases at at the the second second examination. examination. total cholesterol cholesterol level second The total level was was increased increased in in 20 20 children children and and at the second 15 cases. cases. At the first first examination, the HDL-cholesterol examination only only in in 15 examination 14 children cases. level was was decreased decreased in in 14 children and at the second one in 99 cases. suggest that The results of the model examinations suggest that by by optimalization optimalization of and change change of of life-style, life-style, the risk for CHD may be decreased. diet and Atherosclerosis in Atherosclerosis in adult adult age age has has to to be be prevented in childhood.
Downloaded by: Université de Paris 193.51.85.197 - 2/7/2020 4:37:32 AM
TG TG
Barna
46
References
Maria Barna, Lászlö Laszl6 Hospital, Prof. Dr. med. Mária Gyali u.5-7 Budapest, Budapest, H-1097 H-I097 (Hungary) (Hungary) Gyáli
Downloaded by: Université de Paris 193.51.85.197 - 2/7/2020 4:37:32 AM
BerensonGS: GS:Cardiovascular CardiovascularRisk RiskFactors Factorsin inChildren. Children. New New York, York, Oxford Univer1 Berenson 1980. sity Press, 1980. Biro Gy:AzAzegészségmegörzési egeszsegmegorzesiprogram program— - kihivas 2 Birö Gy: kihivás aa taplalkozastudomany táplálkozástudomány szamaera. számáera. Magyar Tapalkozastudomanyi 1987. Magyar Tápálkozástudományi Tarsasag Társaság kiadvanya, kiadványa, Hajduszoboszl6 Hajduszoboszlö 11-16, 1987. BrownleeM, M,Cahill CahillGF: GF:Diabetic Diabeticcontrol controland andvascular vascularcomplications. complications. Atheroscler Atheroscler 3 Brownlee 1979;4:29-70. Rev 1979;4:29-70. FrankKA, KA,Heller HellerSS, SS,Kornfeld KornfeldDS: DS: Type Type AAbehavior behavior pattern pattern and and coronary coronary angioangio4 Frank findings. JAMA graphic findings. JAMA 1978;240:761-763. GurrMI: MI:Role RoleofofFats FatsininFood Foodand andNutrition. Nutrition.London, London,Elsevier, Elsevier, 1984. 1984. 5 Gurr GyarfasI:I:Cardiovascular Cardiovasculardiseases diseasesand anddiet: diet: The Thenature natureof ofthe theworldwide worldwide problem problem 6 Gyárfás with emphasis emphasis on Hungary in nutrition health health promotion promotion and and chronic chronic disease disease with on Hungary in nutrition International Perspectives Perspectives Proceedings Proceedings of Joint US: Hungarian Conferprevention. International ence, Guttenberg Kiado, 1989, pp 277-286. ence, Kiadö, 1989, HowardBV, BY,Savage SavagePJ, PJ,Bennion Bennion LJ: LJ: Lipoprotein Lipoprotein composition composition in in diabetes diabetes mellitus. 7 Howard Atherosclerosis 1978;30:153-162. 1978;30: 153-162. Atherosclerosis HoltzmanNA: NA:Hyperlipidemia Hyperlipidemiascreening screening and andSemmelweis Semmelweis re-visited. re-visited. Pediatrics Pediatrics 8 Holtzman 1980;66:838-839. 1980;66:838-839. 246suggested suggested risk risk factors. factors. Atherosclerosis Atherosclerosis HopkinsPN, PN,Williams WilliamsRR: RR:AAsurvey surveyofof246 9 Hopkins 1981;40:1-52. 10 Jacobsen JacobsenDC: DC:Prostaglandins Prostaglandinsand andcardiovascular cardiovasculardisease. disease. Surgery Surgery 1983;93:564-573. 1983;93:564-573. II Jaín JainAK: AK:Cigarette Cigarettesmoking, smoking, use use of oforal oral contraceptives contraceptives and and myocardial myocardial infarction. 11 Gynecol 1976;126:301-307. 1976; 126:30 1-307. Am J Obstet Gynecol 12 Kadish KadishJL: JL:Fibrin Fibrinand and atherogenesis—- aa hypothesis. hypothesis. Atherosclerosis 1979;33:409-413. atherogenesis 13 Levene LeveneCI, CI,Murray MurrayJC: JC:The Theaetiological aetiological role role of of maternal vitamin-B6 vitamin-B 6 deficiency in the 13 of atherosclerosis. Lancet 1977;1:628-629. I 977;i:628-629. development of 14 Mortality MortalityininDeveloped DevelopedCountries. Countries.Wkly WklyEpidemiol Epidemiol Rec Rec 1989;14:103-107. 1989; 14: 103-107. 14 15 Pados Pados Gy:AAhyperlipoproteinaemiák hyperlipoproteinaemiakkorszeril korszerugyögyszeres gy6gyszereskezelése. kezelese. Gyögyszereink Gyogyszereink 15 Gy: 1990;40: 16 1-169. 1990;40:161-169. 16 Schneiderman SchneidermanG, G,Goldstick GoldstickTK: TK:Carbon Carbonmonoxide-induced monoxide-induced arterial arterial wall wall hypoxia hypoxia 16 Atherosclerosis 1978;30:1-15. 1978;30: 1- 15. and atherosclerosis. Atherosclerosis 17 Spittle SpittleCR: CR:Atherosclerosis Atherosclerosis and and vitamin vitamin C. C. Lancet Lancet 1971;íi:1280-1281. 1971 ;ii: 1280- 1281. 17 18 Texon TexonM: M:Atherosclerosis Atherosclerosis— - its hemodynamic hemodynamic basis 18 basis and implication. Med Clins N Am 1974;58:257-268. 19 Uemura UemuraK,K,Pisa PisaZ:Z:Recent Recenttrends trendsinincardiovascular cardiovasculardisease disease mortality mortality in 27 industria19 1985;38: 142-162. lized countries. countries. Wid Wld Hlth Stats Q 1985;38:142-162. Weinreb HL,German GermanE,E,Rosenberg RosenbergBA: BA:AAstudy study of of myocardial infarction in in women. 20 Weinreb HL, 1957;46:285-300. Ann Intern Med 1957;46:285-300.
of Coronary Risk and Prevention of Disease in Childhood Heart Disease Maria Ι ria Barna
and progression progression of of atherosclerosis atherosclerosis is is aa slow slow process, process, The development and [5]. Prevention can only only be be successful successful at that stage stage beginning in childhood [5]. is therefore primarily the task of the pediatrician. and is Cardiovascular diseases joint effect effect of of different different Cardiovascular diseasesdevelop developdue due to to the joint factors, í.e. i.e. genetic susceptibility susceptibility and environmental factors. factors. According According to factors, present knowledge, knowledge, about 250 risk factors our present factors should be be taken into account. into 44 large large groups groups [9]: [9]: These are divided into (l) Initiators: Initiators: breakdown breakdown of of vessel vessel wall wall integrity; integrity; hypertension hypertension [ [18]; 18]; (1) smoking [[16]; 16];high-lipid high-lipiddiets; diets; homocystinuria; homocystinuria; psychosocial psychosocial factors, factors, etc. (2) Promoters: enhance cholesterol and cholesterol ester infiltration into (2) atheromatous lesion; lesion; increase increase LDL-cholesterol; LDL-cholesterol; increase increase VLDL-cholesVLDL-cholesthe atheromatous HDL-cholesterol; lipid-rich smoking; proterol; decrease HDL-cholesterol; lipid-rich diet; diet; diabetes [7]; smoking; 13] and and vitamin CC [[17] 17] deficiency; deficiency; psychosocial psychosocial factors, longed vitamin B6 [[13] [4] etc. (3) Potentiators: by enhancing the activity ofthrombocytes of thrombocytes and throm(3) bogenesis, may effects of i.e. bogenesis, may potentiate potentiate the the effects of both both initiators initiators and promoters, i.e. contraceptives [1 [11], smoking, oral contraceptives 1 ],diabetes diabetes [3], [3], reduced reduced fibrinolytic fibrinolytic activity TXA2 concentration concentration [[10], 10], lipid-rich lipid-rich diet, psychosocial factors, factors, etc. [[12], 12], high ΤΧΑ2 (4) Precipitators — - not notonly onlyatherogenic atherogenic factors: factors: may may cause cause heart heart attack (4) by inducing ischemic events; events; physical physical exertion; exertion; cold cold water; water; all all potentiators; potentiators; smoking; changes weather; hypertension hypertension [20]; [20]; prolonged prolonged nitrate nitrate smoking; changes in in the weather; psychosocial factors, exposure; psychosocial factors, etc. Prevention childhood when when vessel vessel alterations are Prevention should should be started in childhood early stage. stage. In the initial stage, stage, the main task is to decrease decrease the only at an early initiators and promoters to the minimum. At that time, the most important problem is keeping serum serum lipids and blood pressure at normal levels and not
Downloaded by: Université de Paris 193.51.85.197 - 2/7/2020 4:37:32 AM
Department, St. St. Lászl Laszlo Hospital, Hospital, Budapest, Budapest, Hungary Hungary Pediatrics Department,
37 37
Risk and Prevention of CHD in Childhood
°% % 60 60-
50 5040 40-
00"cr σ .;::' 009 σ4
30 3020 20 10 10::::
10 10-
lili
:;:: :.;.
30 30
~~~~
> 1.4 >5.0 > 5.0 < 1.1 < LDLC/HDLC
nη == 116 < 2.7 (normal) n=25>2.7 n= 25> 2.7
Analyses of suggest that over 40% of the energy energy intake is Analyses of children's children's diet suggest is very high. from fat (first of all all saturated fat) and dietary cholesterol intake is of 141 141 children are presented in table 2. Lipid parameters of Eighty children triglyceride, cholesterol Eighty children showed showed normal triglyceride, cholesterol and HDL-cholesterol levels. levels. An triglyceride increase increase was 11 cases, cases, lesterol An isolated triglyceride was observed observed in 11 increase in total cholesterol cholesterol in 24 24 and and decrease decrease in in HDL-cholesterol HDL-cholesterol in 17 17 increase children. In 55 cases cases aa simultaneous simultaneous increase increase was found in in triglyceride triglyceride and children. cholesterol levels. levels. In one case, case, besides besides the the triglyceride triglyceride increase, increase, a total cholesterol In one was observed. decrease in HDL-cholesterol was observed. In 2 children an increase in total level was cholesterol level was accompanied accompanied by by a decrease decrease in HDL-cholesterol. HDL-cholesterol. In one case, also triglyceride, triglyceride, total cholesterol and HDL-cholesterol HDL-cholesterol levels levels were in case, the pathological pathological range. 2. 7(LDLatherogen index was also calculated. calculated. We We considered considered under 2.7(LDLThe etherogen ClHDL-C) value as appropriate. This This index index value value was was found to to be be definitely definitely C/HDL-C) high in 25 children.
Downloaded by: Université de Paris 193.51.85.197 - 2/7/2020 4:37:32 AM
n=24 η=24
TG+T-C TG+ HDLC
Risk and Prevention of of CHD in Childhood Risk
45
3. Serum lipid parameters of of offspring offspring of parents who had suffered suffered infarcts on the Table 3. first and second examinations first
T-C Τ-C
HDL-C
Ι
II
I
II
I
II
10/41
5/41
20/41 20/41
15/41
14/41
9/41 9/41
In the course of caring, caring, all all children children were wereattended attended both both individually and groups. For the sake sake of improving their educational educational standard, the same same in groups. was done as as in the other form of our model examination. was: Our primary aim was: (a) Increasing students' knowledge knowledge of CHD risk factors concepts. (a) (b) Decreasing CHD risk behaviors, such cigarette smoking smoking and Decreasing CHD risk behaviors, such as cigarette (b) of foods high in saturated fat, cholesterol and salt. consumption of (c) Increasing Increasing levels consumption of levels of of aerobic aerobic physical physical activity activity and and consumption (c) complex carbohydrates. (d) Lowering Lowering heart (d) heart rate, blood pressure, body mass index, and skin fold thickness. connections between between diet, diet, life-style life-style and and chronic chronic diseases diseases were shown The connections lectures, in in practice practice (sampling, (sampling, snacks snacks recipes) recipes) and informal discusdiscusin lectures, and in informal sions. At regular regular club meetings meetings we sions. we teach teach them those alterations which are and in in life-style life-style in order to avoid developing atherosclerosis required in diet and of children at risk risk are supervised. as adults. Lipid parameters of life-style, the Possibly because because of the the effect effect of of altered altered dietary dietary habits and life-style, showed considsame values of children presented on repeated examinations showed erable improvement. Table 3 shows aa favorable favorable trend trend of change change in in lipid lipid parameters parameters of children examined for the second time. Out of of 41 41 children at the first examination, we examined increased triglyceride triglyceride levels in only 5 cases found increased cases at at the the second second examination. examination. total cholesterol cholesterol level second The total level was was increased increased in in 20 20 children children and and at the second 15 cases. cases. At the first first examination, the HDL-cholesterol examination only only in in 15 examination 14 children cases. level was was decreased decreased in in 14 children and at the second one in 99 cases. suggest that The results of the model examinations suggest that by by optimalization optimalization of and change change of of life-style, life-style, the risk for CHD may be decreased. diet and Atherosclerosis in Atherosclerosis in adult adult age age has has to to be be prevented in childhood.
Downloaded by: Université de Paris 193.51.85.197 - 2/7/2020 4:37:32 AM
TG TG
Barna
46
References
Maria Barna, Lászlö Laszl6 Hospital, Prof. Dr. med. Mária Gyali u.5-7 Budapest, Budapest, H-1097 H-I097 (Hungary) (Hungary) Gyáli
Downloaded by: Université de Paris 193.51.85.197 - 2/7/2020 4:37:32 AM
BerensonGS: GS:Cardiovascular CardiovascularRisk RiskFactors Factorsin inChildren. Children. New New York, York, Oxford Univer1 Berenson 1980. sity Press, 1980. Biro Gy:AzAzegészségmegörzési egeszsegmegorzesiprogram program— - kihivas 2 Birö Gy: kihivás aa taplalkozastudomany táplálkozástudomány szamaera. számáera. Magyar Tapalkozastudomanyi 1987. Magyar Tápálkozástudományi Tarsasag Társaság kiadvanya, kiadványa, Hajduszoboszl6 Hajduszoboszlö 11-16, 1987. BrownleeM, M,Cahill CahillGF: GF:Diabetic Diabeticcontrol controland andvascular vascularcomplications. complications. Atheroscler Atheroscler 3 Brownlee 1979;4:29-70. Rev 1979;4:29-70. FrankKA, KA,Heller HellerSS, SS,Kornfeld KornfeldDS: DS: Type Type AAbehavior behavior pattern pattern and and coronary coronary angioangio4 Frank findings. JAMA graphic findings. JAMA 1978;240:761-763. GurrMI: MI:Role RoleofofFats FatsininFood Foodand andNutrition. Nutrition.London, London,Elsevier, Elsevier, 1984. 1984. 5 Gurr GyarfasI:I:Cardiovascular Cardiovasculardiseases diseasesand anddiet: diet: The Thenature natureof ofthe theworldwide worldwide problem problem 6 Gyárfás with emphasis emphasis on Hungary in nutrition health health promotion promotion and and chronic chronic disease disease with on Hungary in nutrition International Perspectives Perspectives Proceedings Proceedings of Joint US: Hungarian Conferprevention. International ence, Guttenberg Kiado, 1989, pp 277-286. ence, Kiadö, 1989, HowardBV, BY,Savage SavagePJ, PJ,Bennion Bennion LJ: LJ: Lipoprotein Lipoprotein composition composition in in diabetes diabetes mellitus. 7 Howard Atherosclerosis 1978;30:153-162. 1978;30: 153-162. Atherosclerosis HoltzmanNA: NA:Hyperlipidemia Hyperlipidemiascreening screening and andSemmelweis Semmelweis re-visited. re-visited. Pediatrics Pediatrics 8 Holtzman 1980;66:838-839. 1980;66:838-839. 246suggested suggested risk risk factors. factors. Atherosclerosis Atherosclerosis HopkinsPN, PN,Williams WilliamsRR: RR:AAsurvey surveyofof246 9 Hopkins 1981;40:1-52. 10 Jacobsen JacobsenDC: DC:Prostaglandins Prostaglandinsand andcardiovascular cardiovasculardisease. disease. Surgery Surgery 1983;93:564-573. 1983;93:564-573. II Jaín JainAK: AK:Cigarette Cigarettesmoking, smoking, use use of oforal oral contraceptives contraceptives and and myocardial myocardial infarction. 11 Gynecol 1976;126:301-307. 1976; 126:30 1-307. Am J Obstet Gynecol 12 Kadish KadishJL: JL:Fibrin Fibrinand and atherogenesis—- aa hypothesis. hypothesis. Atherosclerosis 1979;33:409-413. atherogenesis 13 Levene LeveneCI, CI,Murray MurrayJC: JC:The Theaetiological aetiological role role of of maternal vitamin-B6 vitamin-B 6 deficiency in the 13 of atherosclerosis. Lancet 1977;1:628-629. I 977;i:628-629. development of 14 Mortality MortalityininDeveloped DevelopedCountries. Countries.Wkly WklyEpidemiol Epidemiol Rec Rec 1989;14:103-107. 1989; 14: 103-107. 14 15 Pados Pados Gy:AAhyperlipoproteinaemiák hyperlipoproteinaemiakkorszeril korszerugyögyszeres gy6gyszereskezelése. kezelese. Gyögyszereink Gyogyszereink 15 Gy: 1990;40: 16 1-169. 1990;40:161-169. 16 Schneiderman SchneidermanG, G,Goldstick GoldstickTK: TK:Carbon Carbonmonoxide-induced monoxide-induced arterial arterial wall wall hypoxia hypoxia 16 Atherosclerosis 1978;30:1-15. 1978;30: 1- 15. and atherosclerosis. Atherosclerosis 17 Spittle SpittleCR: CR:Atherosclerosis Atherosclerosis and and vitamin vitamin C. C. Lancet Lancet 1971;íi:1280-1281. 1971 ;ii: 1280- 1281. 17 18 Texon TexonM: M:Atherosclerosis Atherosclerosis— - its hemodynamic hemodynamic basis 18 basis and implication. Med Clins N Am 1974;58:257-268. 19 Uemura UemuraK,K,Pisa PisaZ:Z:Recent Recenttrends trendsinincardiovascular cardiovasculardisease disease mortality mortality in 27 industria19 1985;38: 142-162. lized countries. countries. Wid Wld Hlth Stats Q 1985;38:142-162. Weinreb HL,German GermanE,E,Rosenberg RosenbergBA: BA:AAstudy study of of myocardial infarction in in women. 20 Weinreb HL, 1957;46:285-300. Ann Intern Med 1957;46:285-300.
