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10 Blood analytes Emanuela Falaschetti and Paola Primatesta
This chapter presents findings on blood analytes including total cholesterol, high-density lipoprotein cholesterol (HDL-cholesterol), C-reactive protein, fibrinogen, haemoglobin, ferritin and glycated haemoglobin from a non-fasting blood sample, and low-density lipoprotein cholesterol (LDL-cholesterol), triglycerides and glucose from a fasting blood sample. Most of these analytes are independently associated with cardiovascular disease (CVD). Given the low prevalence of CVD among young people, the fasting blood sample was collected only from informants aged 35 and over. In 1999 the general population sample did not have a nurse visit and no blood was taken, except from a small sub-sample. For analytes included in the 1998 survey, 1998 has been used as the comparison group. The three fasting blood analytes, and glycated haemoglobin, were not covered in 1998, and the small 1999 general population sub-sample is used as the comparison group (see 'The nurse visit' in Chapter 1 Introduction, Section 1.5.6). Among men, a non-fasting blood sample was obtained from about 80% or more of those who had a nurse visit in every group except Bangladeshi men (75%), and a fasting blood sample from more than 60% in every group except Bangladeshi (50%) and Pakistani men (56%). Among women the percentage was generally lower than among men, ranging from 60% in Bangladeshi women to 83% in Irish women for the non-fasting blood sample and from 38% in Bangladeshi women to 71% in Irish women for the fasting blood sample. The remainder of informants either refused to give a blood sample or the nurse was unable to obtain a sample from them. Not all blood samples taken yielded valid analytes. The proportion of men providing valid analytes from non-fasting blood samples was greater than 70% in all cases except for fibrinogen in Black Caribbean (69%), Bangladeshi (65%) and Chinese men (67%). Among women, Bangladeshi women showed the lowest percentages, ranging from 50% for ferritin to 58% for glycated haemoglobin. Valid sample percentages were lower from the fasting blood sample. The lowest for men were found among Bangladeshi men, with valid sample percentages ranging from 36% for LDL-cholesterol to 48% for glucose, and Bangladeshi women, from 26% for LDL-cholesterol to 36% for glucose. Pakistani women also had low rates (from 40% for LDL-cholesterol to 44% for glucose). The other minority ethnic groups showed percentages around 50% and 60%. The small numbers of available cases in some groups, especially for
fasting blood, result in large confidence intervals. In some groups
the samples have been judged too small for data to be shown in the tables.
Where the response rate is low, there is also a possibility that those
who do not provide blood have different characteristics from those who
do. Some caution is therefore necessary when interpreting the results. 10.2 Total cholesterol and HDL-cholesterol 10.2.1 Introduction Cholesterol is a substance used to help digest fats, strengthen cell membranes and make hormones. When blood cholesterol reaches high levels, it can build up on artery walls, increasing the risk of blood clots, heart attack and stroke. There is strong evidence that lowering cholesterol concentrations reduces mortality from coronary heart disease (CHD).1,2 The West of Scotland Coronary Prevention Study (WOSCOPS) found that cholesterol-lowering drug therapy significantly reduced the incidence of myocardial infarction and death from cardiovascular causes without adversely affecting the risk of death from non-cardiovascular causes in men with moderate hypercholesterolaemia and no history of myocardial infarction.3,4 Several guidelines have been drawn up giving different advice for managing hyperlipidaemia. The recent National Service Framework's guidelines on prevention of coronary heart disease in clinical practice suggest a cholesterol target of less than 5.0 mmol/l for both primary and secondary prevention.5 HDL-cholesterol is the fraction of cholesterol that removes cholesterol from the blood by carrying it to the liver where it is metabolised. HDL-cholesterol is inversely and independently associated with the risk of developing CHD,6,7 and low levels of HDL-cholesterol are also associated with a worse prognosis after myocardial infarction.8 A recent prospective study on middle-aged British men showed that higher levels of HDL-cholesterol were associated with a significant decrease in risk of nonfatal stroke.9 Modifiable risk factors such as smoking, alcohol consumption, raised body mass index and blood pressure are known to lower the concentrations of HDL-cholesterol. Attention is generally recommended for HDL-cholesterol concentrations below 1 mmol/l. LDL-cholesterol is described with the fasting blood sample in Section 10.8. For consistency with 1998, people on lipid lowering drugs were excluded from the analysis. 10.2.2 Total cholesterol and HDL-cholesterol, by minority ethnic group Mean observed total cholesterol was generally lower in minority ethnic groups than in the general population, for both men and women. Among Black Caribbean, Pakistani and Bangladeshi men mean total cholesterol was 5.0 mmol/l compared to 5.5 mmol/l in the general population. Among women, it was lower in Black Caribbean (4.9 mmol/l) Pakistani (4.8 mmol/l) and Bangladeshi (4.7 mmol/l) women than in the general population (5.6 mmol/l). The standardised ratio of means was significantly lower than 1 in all minority ethnic groups with the exception of Indian and Irish men (varying from 0.94 in Black Caribbean men to 0.96 in Bangladeshi men and from 0.93 in Black Caribbean women to 0.98 in Irish women). Mean HDL-cholesterol was lower than in the general population (1.3 mmol/l for men and 1.6 mmol/l for women) in Pakistanis (1.1 mmol/l for men and 1.4 mmol/l for women; ratio of means 0.87 for men and 0.88 for women), in Bangladeshis (1.1 mmol/l for men and 1.3 mmol/l for women; ratio of means 0.83 for men and 0.80 for women) and in Indian women (1.4 mmol/l; ratio of means 0.92). On the other hand Black Caribbean men had mean HDL-cholesterol higher than the general population (1.5 mmol/l vs 1.3 mmol/l) and a standardised ratio of means significantly higher than 1 (1.14). Among men, the observed prevalence of high total cholesterol (5.0 mmol/l or more) ranged from 47.8% for Bangladeshi men to 67.5% for Irish men, compared to 66.3% for men in the general population. Even though Bangladeshis had the lowest observed prevalence of high total cholesterol, their standardised risk ratio was not significantly lower than 1, but the ratio was significantly lower than 1 for Black Caribbean, Pakistani and Chinese men. Among women, prevalence of high total cholesterol in all the minority ethnic groups (varying from 35.7% for Bangladeshi to 63.4% for Irish) was lower than in the general population (67.1%), the standardised risk ratios being all significantly less than 1 except for the Irish. Figure 10A The observed prevalence of low HDL-cholesterol (less than 1.0 mmol/l)
varied considerably between minority ethnic groups, Pakistanis and Bangladeshis
reporting the highest rates for both sexes, and was much higher among
men than among women in every group. Indian women, and Pakistani and
Bangladeshi men and women, had relatively high age-standardised prevalence
of low HDL-cholesterol. The risk ratio for Bangladeshis was 2.68 for
men and 3.67 for women. Black Caribbeans had relatively low prevalence
of low HDL-cholesterol (risk ratio 0.61 for men and 0.57 for women).
For both sexes, mean total cholesterol generally increased with age
in minority ethnic groups, as in the general population (though men
had similar values in the age groups 35-54 and 55 and over). Mean HDL-cholesterol
did not vary much between the three age categories while the prevalence
of low HDL-cholesterol showed an increase between age 16-34 and 35-54
in most minority ethnic groups. 10.2.3 Total cholesterol and HDL-cholesterol, by socio-economic variables Mean total cholesterol did not show significant differences between manual and non-manual social classes in the general population or in any other minority ethnic group with the exception of Chinese and Black Caribbean women. Chinese women had higher mean total cholesterol in non-manual (5.3 mmol/l) than in manual social classes (4.8 mmol/l), the latter being significantly lower than in the general population (ratio of means 0.88), while the opposite was true for Black Caribbean women (4.8 mmol/l in non-manual and 5.1 mmol/l in manual). The prevalence of high total cholesterol presented a pattern consistent with that shown by the means, being higher in non-manual than manual social classes for Chinese women (53.9% vs 39.8%) and lower in non-manual than manual social classes for Black Caribbean women (36.6% vs 51.6%). Chinese women also showed a social class difference in HDL-cholesterol,
the observed mean in non-manual social classes (1.7 mmol/l) being greater
than in manual (1.4 mmol/l). The same pattern was found among Irish
women (1.7 mmol/l in non-manual and 1.5 mmol/l in manual). 10.3.1 Introduction The body releases C-reactive protein (CRP) into the bloodstream when blood vessels leading to the heart are damaged (a common result of atherosclerosis). The protein's level indicates the degree of inflammation occurring in the lining of the arteries. Baseline levels of CRP in apparently healthy persons or patients with stable angina pectoris constitute an independent risk factor for cardiovascular events,10,11,12,13 whereas the rise in CRP after acute myocardial infarction (AMI)14,15,16,17 or during unstable angina pectoris 18,19,20 correlates with these events. In the literature there is no recommendation for a C-reactive protein threshold, either among whites or among minority ethnic groups. The distribution of C-reactive protein was not normal, being very skewed to the left, and both the arithmetic mean and the median are presented in the tables. Those with a C-reactive protein level in the range defined by the top quintile of the general population (>3.7 mg/l for men, >4.9 mg/l for women) are referred to below as having 'high' C-reactive protein. It has been demonstrated, in people of European origin, that CRP levels within the upper quartile/quintile of the normal range constitute an increased risk for cardiovascular events, both in apparently healthy persons and in persons with pre-existing angina pectoris.21 10.3.2 C-reactive protein, by minority ethnic group C-reactive protein levels in the general population were higher among women (median 1.7 mg/l) than men (median 1.4 mg/l). A similar difference was found within each minority ethnic group. Within sex, levels were high for Pakistani women (risk ratio for high
C-reactive protein 2.02) and low for Chinese men (0.60) and women (0.55)
and for Black Caribbean men (0.74).
a C-reactive protein levels were measured in mg/l to one
decimal place, yielding a distribution of discrete values rather
than a continuous distribution. As a result of this, the top quintile
value (4.9 mg/l) was the value exceeded Median C-reactive protein increased with age in both sexes in the
six minority ethnic groups, as in the general population, being much
higher in the oldest (aged 55 and over) than in the younger age groups. 10.3.3 C-reactive protein, by socio-economic variables Men's C-reactive protein levels were generally similar between non-manual and manual social classes. Levels were lower in non-manual than manual social classes in Irish women (medians 1.4 mg/l and 2.4 mg/l). The proportion of people with high C-reactive protein was higher in
non-manual than manual social classes in Chinese men (9.2% vs 4.6%;
risk ratios 0.68 vs 0.31) 10.4.1 Introduction Plasma fibrinogen is a major determinant of platelet aggregation and blood viscosity. It is a major independent risk factor for cardiovascular disease (CVD) and may interact with lipids to promote CVD risk. Different studies have consistently shown that hyperfibrinogenemia is positively related to coronary and cerebrovascular diseases.22,23,24 10.4.2 Fibrinogen, by minority ethnic group Fibrinogen did not show differences between minority ethnic groups. Observed median fibrinogen in each group was around 2.4 g/l or 2.5 g/l for men and 2.6 g/l or 2.7 g/l for women. Fibrinogen increased with age in every minority ethnic group for both
men and women and was higher among women than among men. 10.4.3 Fibrinogen, by socio-economic variables Fibrinogen did not show significant differences between manual and
non-manual social classes, except for Irish men and women, among whom
both mean and median fibrinogen were higher in manual than in non-manual
social classes (ratio of means 1.00 in non-manual and 1.08 in manual
for men and 0.98 in non-manual and 1.05 in manual for women). 10.5.1 Introduction Haemoglobin is the protein, in the red blood cells, that transports molecular oxygen from the lungs throughout the body. In disease, as well as in certain situations in which physiological adjustments take place, the quantity of haemoglobin may be reduced below normal levels, a condition known as anaemia (haemoglobin <12.0 g/dl), or may be increased above normal, leading to erythrocytosis (also called polycythemia). In anaemia the blood is capable of carrying only a reduced amount of oxygen to tissues, a condition that stimulates the lungs to increase the respiratory rate in order to pick up more oxygen and the heart to increase its rate (pulse) in order to increase the volume of blood delivered to the tissues. 10.5.2 Haemoglobin, by minority ethnic group Among men, observed mean haemoglobin was slightly higher in minority ethnic groups (ranging from 14.8 g/dl in Indian to 15.1 g/dl in Chinese) than in the general population (14.7 g/dl), with the exception of Black Caribbean (14.4 g/dl). The opposite was true among women, observed mean haemoglobin in the minority ethnic groups (except Irish who had the same mean value) being lower than in the general population (13.2 g/dl) and varying from 12.4 g/dl for Pakistani to 13.1 g/dl for Chinese. Among men, only Chinese men had age-adjusted mean haemoglobin significantly higher (though only by a small amount) than the general population (age-standardised ratio of means 1.02). Black Caribbean men had significantly lower age-standardised mean haemoglobin than the general population (ratio of means 0.97). Among women, Black Caribbean and South Asian women had significantly lower age-standardised mean haemoglobin than the general population (ratio of means 0.95). Age-standardised mean haemoglobin was about the same for Chinese and Irish women as in the general population. The prevalence of anaemia was generally low among men, being highest among Pakistani men (2.9% compared with 1.6% in the general population) and lowest among Irish and Bangladeshi men (0.3%). Among women, in contrast, prevalence was higher, especially for minority ethnic groups. Except for Chinese women (13.5%) and Irish women (9.4%), who had a prevalence broadly similar to women in the general population (10.1%), the prevalence of anaemia ranged from 25.5% in Black Caribbean to 30.7% in Indian women. Those observed results were consistent with age-standardised risk
ratios, which were significantly lower than 1 among Irish men and significantly
higher than 1 among Pakistani men and all women except Chinese and Irish.
The age-adjusted prevalence of anaemia in Black Caribbean, Indian, Pakistani
and Bangladeshi women was about three times higher than the general
population. The risk ratios for women are shown in the inset table and
in Figure 10C.
Age patterns within minority ethnic groups were similar to those of the general population. Tables 10.12, 10.13, Figure 10C 10.5.3 Haemoglobin, by socio-economic variables Haemoglobin did not show significant differences between manual and
non-manual social classes in any minority ethnic group. 10.6.1 Introduction Ferritin is the major iron storage protein. The serum ferritin level is directly proportional to the amount of iron stored in the body. As low haemoglobin can have causes other than low iron, ferritin provides a more specific indicator of low iron status. However, plasma ferritin concentrations are increased in iron overload, liver diseases, infections, inflammatory conditions, and malignancy. A case-control study showed that, in the presence of other risk factors, serum ferritin might adversely affect ischaemic heart disease risk in the elderly.25 Nevertheless, studies investigating whether iron status can be considered a cardiovascular risk factor presented conflicting results. A Finnish study found that a high stored iron level, as assessed by elevated serum ferritin concentration, is a risk factor for coronary heart disease26 but subsequent studies have not provided consistent results. For the purpose of this section attention is given to low levels of ferritin, defined as below the lowest quintile value of the general population. 10.6.2 Ferritin, by minority ethnic group A very high level of ferritin was present in Chinese men and women, with an observed median of 157.8 ng/ml among men (compared with 89.0 ng/ml in the general population) and 52.0 ng/ml among women (compared with 39.0 ng/ml in the general population). Median ferritin was lower than in the general population among Indian and Pakistani men 65.5 ng/ml and 69.8 ng/ml respectively) and women (23.0 ng/ml and 22.0 ng/ml respectively), and also among Bangladeshi women (23.0 ng/ml). Compared with the general population, the proportion of people with
low ferritin (with levels in the bottom quintile of the general population)
was significantly higher among Indian and Pakistani men and among Indian,
Pakistani and Bangladeshi women. In these three groups the proportion
with low ferritin was higher than 40%, and their age-standardised risk
ratios were significantly higher than 1.
Among Black Caribbean men median ferritin increased with age, being
highest at age 55 and over, while in the general population and the
other minority ethnic groups median ferritin among men was highest in
those aged 35-54. Among women, median ferritin increased with age in
most minority ethnic groups. 10.6.3 Ferritin, by socio-economic variables Among men, Chinese men, like those in the general population, had
median ferritin higher in non-manual than manual social classes. The
opposite was true for Black Caribbean men. Women did not show significant
differences between manual and non-manual social classes. 10.7.1 Introduction The percentage of glycated haemoglobin is the percentage of haemoglobin in the circulation to which glucose is bound. It reflects the prevailing level of blood glucose during approximately three months preceding the measurement. Elevated glycated haemoglobin in diabetic patients is associated with increased mortality following acute myocardial infarction and is a marker for short-term mortality following acute myocardial infarction in non-diabetic subjects also.27 Glycated haemoglobin was investigated from age 16 for minority ethnic groups and from age 35 for the general population (in the latter case, from a small sub-sample only: see 'The nurse visit' in Chapter 1: Introduction, Section 1.5.6). For the purpose of comparing minority ethnic groups with the general population, Table 10.22 shows mean glycated haemoglobin in informants aged 35 and over. In section 10.7.2, the abbreviation GHB denotes the glycated haemoglobin percentage, that is, the percentage glycated haemoglobin forms of total haemoglobin. 10.7.2 Glycated haemoglobin, by minority ethnic group Observed mean GHB was slightly higher in minority ethnic groups than in the general population (5.6% for both men and women), except in the case of Irish women (5.3%). The highest level was registered in Bangladeshi men (6.9%) and Pakistani women (6.4%). Among all minority ethnic groups except Pakistanis, observed mean GHB was slightly higher in men than in women, while in the general population there was no gender difference. On an age-standardised basis, mean GHB was slightly higher among minority
ethnic groups, the standardised ratios of means being significantly
higher than 1 for both men and women in all groups except Irish women
(ratio of means 0.97, significantly lower than 1).
All groups showed mean GHB increasing by age in both men and women. 10.8.1 Introduction Low-density lipoprotein (LDL) is the form in which cholesterol is carried into the blood and is the main cause of harmful fatty build-up in arteries. The higher the LDL-cholesterol level in the blood, the greater the heart disease risk. Major clinical trials conducted over the past decade have consistently demonstrated that lowering LDL-cholesterol resulted in a prompt and significant decrease in major coronary events and total mortality. A LDL-cholesterol level of 3.0 mmol/l or above is referred to in what follows as 'high' LDL-cholesterol.5 Triglycerides, or simple fats, are molecules composed only of fatty acids and glycerol. There is increasing evidence that serum triglycerides are a significant and independent risk factor for CVD. In a few studies, triglyceride levels did remain predictive of subsequent development of CHD after adjustment for HDL-cholesterol, which suggests a possible role for triglycerides in the development of CHD.28,29 Moreover in a recent prospective study baseline triglyceride level predicted subsequent CVD mortality among relatives in familial hypertriglyceridemia (FHTG) families, adding to the growing evidence for the importance of hypertriglyceridemia (triglycerides >=1.6 mmol/l) as a risk factor for CVD.30 Some plasma constituents occur in plasma in low concentration but have a high turnover rate and great physiological importance. Among these is glucose, the blood sugar. Glucose is absorbed from the gastrointestinal tract or may be released into the circulation from the liver. It provides a source of energy for tissue cells and is the only source for some, including the red cells. If blood sugars run high for long periods of time, this can pose significant problems in the long-term such as eye disease, kidney disease, heart attacks and strokes. High blood sugars can pose health problems in the short-term as well. So it is important to keep blood sugars under control, and treat high blood sugars when they occur. New WHO guidelines for diagnosing diabetes adopted in the UK include a fasting plasma glucose threshold of 7.0 mmol/l.31 It is known that high fasting plasma glucose (FPG) levels and diabetes are associated with a high incidence of cardiovascular disease (CVD) and all-cause mortality.32,33,34 On the other hand, low plasma glucose levels may cause brain and heart problems.35 10.8.2 LDL-cholesterol Among men Black Caribbean, Pakistani and Bangladeshi men had a slightly lower observed mean LDL-cholesterol (3.3 mmol/l, 3.2 mmol/l and 3.3 mmol/l respectively) than the general population (3.5 mmol/l) but only Pakistani and Bangladeshi men also had a standardised ratio of means significantly lower than 1 (0.91 and 0.94 respectively). Among women mean LDL-cholesterol was significantly lower than in the general population (3.5 mmol/l) for Black Caribbean (3.1 mmol/l), Pakistani (3.0 mmol/l) and Chinese women (2.9 mmol/l), with age-standardised ratios of means significantly lower than 1 (0.95, 0.89 and 0.94 respectively). Chinese men had the highest prevalence of high LDL-cholesterol (3 mmol/l and over) together with high total cholesterol among men (68.1% compared to 62.4% in the general population) and the lowest among women (39.4% compared to 59.0% in the general population) although the standardised risk ratio was significantly different from 1 only among men (1.73). On the other hand the standardised risk ratios were significantly higher than 1 also among the other minority ethnic groups for men (with the exception of Bangladeshi men) and among Indian and Irish women even though most of their observed proportion were not higher than that of the general population. The tables also show the prevalence of high LDL-cholesterol alone.
In all groups about 90% of people who had high LDL-cholesterol also
had high total cholesterol.
[ ] warns of small sample bases (less than 50 cases). For most minority ethnic groups the numbers were too small to look
at the differences between the age groups. In the general population
and Irish group the pattern in the two age groups considered (35-54
and 55 and over) was similar, mean LDL-cholesterol being about the same
in both age groups in men and generally lower in women aged 35-54 than
in those aged 55 and over.
10.8.3 Triglycerides Bangladeshi men and women had the highest mean triglycerides (observed men 2.5 mmol/l, women 2.0 mmol/l; standardised ratio of means 1.43 for men and 1.48 for women). Relatively high values were also present in Indian, Pakistani and Irish men with mean triglycerides greater than 2.0 mmol/l compared with 1.7 mmol/l in the general population. Age standardisation confirmed that among men Indian, Pakistani, Bangladeshi and Irish had significantly higher triglycerides than the general population while it was significantly lower in the other groups. Among women, every group except Black Caribbean women had significantly higher triglycerides than the general population. Pakistani and Bangladeshi men and women had the highest prevalence of high triglycerides (1.6 mmol/l or above), with more than 60% in Bangladeshis (men 64.3%, women 64.0%) and Pakistani men (men 60.5%, women 45.1%). Prevalence was lowest among Black Caribbeans (men 28.3%, women 17.9%). In the general population it was 35.2% for men and 31.2% for women. The age-standardised prevalence of high triglycerides tended to be higher in minority ethnic groups than in the general population (age-standardised risk ratios were above 1.0), with the exception of Black Caribbean men and women, Chinese men and Bangladeshi women, for whom there was no significant difference from the general population. The level of triglycerides was generally higher among men aged 35-54 than those aged 55 and over, but the opposite was true among women, with no significant differences in this respect between minority ethnic groups. In summary, the lipid profile of the minority ethnic groups showed some important differences. South Asian men seemed to have a less favourable lipid profile than other groups; with a lower concentration of HDL-cholesterol and higher concentration of triglycerides than men in the general population. Black Caribbean men had lower levels of triglycerides and higher levels of HDL-cholesterol. These findings are consistent with previously reported results. A
recent cross sectional study showed that South Asians had higher glucose
than Europeans and that Bangladeshis had the highest triglycerides concentrations;
among South Asians, Indians had the highest total cholesterol and high
density lipoprotein cholesterol concentrations and Bangladeshis the
lowest.36 A comparison between
South Asians and Europeans showed that South Asians had higher fasting,
plasma triglycerides and lower HDL-cholesterol concentrations.37
Further studies found that Black Caribbean men had higher HDL-cholesterol
and lower triglycerides than whites; this could partly explain their
low rates of coronary heart disease.38,
39 10.8.4 Glucose Every minority ethnic group except Irish had higher mean glucose than
the general population in both men and women, being highest in Bangladeshi
men (6.9 mmol/l, compared with 5.8 mmol/l among men in the general population)
and in Pakistani women (6.2 mmol/l, compared with 5.3 mmol/l among women
in the general population). It was generally higher in men than in women.
The standardised ratio of means was significantly higher than 1 in all
minority ethnic groups except Black Caribbean men and Irish men and
women.
The observed prevalence of high glucose (>=7 mmol/l or above) was generally higher in men in minority ethnic groups (except Irish men) than in the general population and the differences were even more marked for women. Among men, the observed prevalence ranged from 16.6% in Black Caribbean to 41.7% in Bangladeshi men (excluding Irish men with 10.9%) compared to 11.3% in the general population. Among women it ranged from 6.0% in Irish women to 17.3% in Pakistani women, compared with only 3.0% in the general population. After adjustment by age, all groups of men, including Irish men, had a prevalence of high glucose significantly higher than the general population. The standardised risk ratios were all very high, reaching 5.71 in Bangladeshi among men and 12.44 in Pakistani among women but it should be noted that the standard errors were large (1.35 and 4.74 respectively). The pattern by age was the same in every minority ethnic group, increasing
from age 35-54 to age 55 and over for both men and women.
References and notes 1 Law MR, Wald NJ, Thompson SG. By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ 1994; 308:367-73. 2 Gould AL, Rossouw JE, Santanello NC, et al. Cholesterol reduction yields clinical benefit. A new look at old data. Circulation 1995; 91:2274-82. 3 Shepherd J, Cobbe SM, Ford I, Isles CG, Lorimer AR, MacFarlane PW, McKillop JH, Packard CJ. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. New England Journal of Medicine. 1995; 333:1301-7. 4 No authors listed. The effects of pravastatin on hospital admission in hypercholesterolemic middle-aged men: West of Scotland Coronary Prevention Study. J Am Coll Cardiol. 1999; 33:909-15. 5 National Service Framework for Coronary Hearth Disease. Modern Standards and Service Models. 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Diabetologia 1994; 37:765-772. 10.1 Response to blood sample, by minority ethnic group 10.2 Percentages providing valid samples for each analyte, by minority ethnic group 10.3 Total cholesterol and HDL-cholesterol, by minority ethnic group 10.4 Total cholesterol and HDL-cholesterol, by age within minority ethnic group 10.5 Total cholesterol and HDL-cholesterol, by social class of head of household 10.6 C-reactive protein, by minority ethnic group 10.7 C-reactive protein, by age within minority ethnic group 10.8 C-reactive protein, by social class of head of household 10.9 Fibrinogen, by minority ethnic group 10.10 Fibrinogen, by age within minority ethnic group 10.11 Fibrinogen, by social class of head of household 10.12 Haemoglobin, by minority ethnic group 10.13 Haemoglobin, by age within minority ethnic group 10.14 Haemoglobin, by social class of head of household 10.15 Ferritin, by minority ethnic group 10.16 Ferritin, by age within minority ethnic group 10.17 Ferritin, by social class of head of household 10.18 Glycated haemoglobin, by minority ethnic group 10.19 Glycated haemoglobin, by age within minority ethnic group 10.20 LDL-cholesterol, by minority ethnic group 10.21 LDL-cholesterol, by age within minority ethnic group 10.22 Triglycerides, by minority ethnic group 10.23 Triglycerides, by age within minority ethnic group 10.24 Glucose, by minority ethnic group 10.25 Glucose, by age within minority ethnic group
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