Elsevier

The Lancet

Volume 348, Issue 9027, 31 August 1996, Pages 567-572
The Lancet

Articles
Symptoms of chronic bronchitis and the risk of coronary disease

https://doi.org/10.1016/S0140-6736(96)02374-4Get rights and content

Summary

Background

Experimental and epidemiological studies show a positive association between coronary disease and various infections in different organs, both viral and bacterial and both acute and chronic. Most attention has been paid to dental infections and infections in the respiratory tract. We have studied how chronic respiratory infection predicts coronary disease.

Methods

We defined chronic respiratory infection by the occurrence of symptoms of chronic bronchitis. We also analysed whether any association with coronary disease incidence and mortality is independent of the known major cardiovascular risk factors and whether it is similar among persons in different occupations. Our cohort study was a 13-year follow-up of 19 444 randomly selected eastern Finnish men and women born between 1913 and 1947 and examined in either 1972 or 1977.

Findings

During follow-up, there were 1419 first coronary events, either fatal or non-fatal, and 614 coronary deaths. Among men, the age-adjusted and study-year-adjusted risk ratio of long lasting-symptoms of chronic bronchitis (during as much as 3 months in a year) was 1·52 (95% CI 1·33-1·75) for coronary disease and 1·74 (CI 1·43-2·11) for coronary death. Among women the risk ratios were 1·38 (1·07-1·78) and 1·49 (0·98-2·27), respectively. Inclusion of smoking, serum cholesterol, and systolic blood pressure into the models decreased risk ratios to 1·36 (1·17-1·56) and 1·55 (1·26-1·90) in men and to 1·34 (1·04-1·74) and 1·41 (0·92-2·16) in women, respectively. The risk of coronary disease associated with the symptoms of chronic bronchitis was similar among blue-collar and white-collar workers but the association was not found among farmers.

Interpretation

Symptoms of chronic bronchitis predicted the risk of coronary disease independently from the known major cardiovascular risk factors. If the observed association is causal, prevention and improved management of chronic infections may have played a role in the decrease in coronary disease mortality observed in eastern Finland in the past two decades.

Introduction

High serum total-cholesterol, high blood pressure, and smoking are the major risk factors for coronary disease. Obesity, physical inactivity, diabetes, and low high-density-lipoprotein cholesterol also contribute to the risk. Although these factors explain most coronary disease, other factors are also involved. There are various putative risk factors, such as high levels of plasma fibrinogen and other disturbances in blood coagulation, low intake of antioxidants, and psychosocial stress.1

Since early this century case reports and uncontrolled studies have associated infections with the development of coronary disease. More recently, experimental and epidemiological studies have shown a positive association between infections and coronary disease.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 These include infections in different organs, both viral and bacterial and acute and chronic. Most attention has been paid to dental infections and infections in the respiratory tract.7

An influenza-like syndrome resembling acute respiratory infection often precedes myocardial infarction.5, 6 Another respiratory infection often associated with coronary disease is due to Chlamydia pneumoniae.8, 9, 10, 11, 12, 13 C pneumoniae is a common cause of both acute and chronic lung infections.10, 11 In several studies, chronic chlamydia pneumonia was more frequent in patients with myocardial infarction than in controls.7, 8, 11, 13

We have analysed how chronic respiratory infection, defined by the occurrence of symptoms of chronic bronchitis, predicts coronary disease and coronary mortality during a 13-year follow-up among middle-aged men and women. We also analysed potential confounders and whether the risk is similar among different occupations.

Section snippets

Participants and surveys

Risk-factors were surveyed in 1972 and 1977 in the eastern Finnish provinces of North Karelia and Kuopio. A random sample of 6-6% of the population born between 1913 and 1947 was drawn in both areas. In the present analyses the two cohorts were pooled. The total sample was 23 801. Participation rate was 87% among men and 91% among women. Those who participated on both surveys were included only in the first cohort. Of 21 251 responders, 484 were excluded because of a reported history of

Results

Symptoms of chronic bronchitis were more common among smokers than non-smokers (table 1). Among men, only 51% of smokers were free of symptoms, compared with 74% of ex-smokers and 79% of never-smokers. Respective proportions of symptom-free women were 67, 85, and 80%. Among smoking men, the average number of cigarettes smoked daily was 14·7 in subjects without symptoms of chronic bronchitis, 17·4 among those with grade-one symptoms, and 18·6 among those with grade-two symptoms. Among smoking

Discussion

Symptoms of chronic bronchitis predicted the risk of coronary disease independent from the known major cardiovascular risk factors. About one-third in men and one-fifth in women of the excess risk of coronary disease, which associated with the symptoms of chronic bronchitis, was mediated through smoking. Adjustment for the other risk factors, serum cholesterol and blood pressure, had only a minor effect on this association. In our cohorts, the population attributable fraction of coronary

References (30)

  • P Saikku et al.

    Chronic Chlamydia pneumoniae infection as a risk factor for coronary artery disease in the Helsinki Heart study

    Ann Intern Med

    (1992)
  • DH Thom et al.

    Chlamydia pneumoniae strain TWAR antibody and angiographically demonstrated coronary artery disease

    Arterioscler Thromb

    (1991)
  • M Odeh et al.

    Chlamydial infections and the heart: a review

    Eur J Clin Microbiol Inf Dis

    (1992)
  • JT Grayston et al.

    A new respiratory tract pathogen: Chlamydia pneumoniae strain TWAR

    J Infect Dis

    (1990)
  • KL Godzik et al.

    In vitro susceptibility of human vascular wall cells to infection with Chlamydia pneumoniae

    J Clin Microbiol

    (1995)
  • Cited by (225)

    • Systemic vascular health is compromised in both confirmed and unconfirmed asthma

      2022, Respiratory Medicine
      Citation Excerpt :

      However, participants with confirmed asthma reported greater asthma symptoms, had lower baseline FEV1 and greater post-bronchodilator reversibility compared to unconfirmed asthma participants. Previous studies have indicated there may be a direct link between respiratory morbidity and cardiovascular risk [12,13], and reduced endothelial function, elevated arterial stiffness, and systemic inflammation has been associated with worse asthma disease severity and declining control [31,32,33]. Conversely, the lack of differences between unconfirmed and confirmed asthma in our study would indicate that the impaired endothelial function is unlikely due to common causes of respiratory symptoms, reduced lung function, or airway reversibility alone, but rather suggests that other important contributing factors may be present.

    • The Wide-Ranging Spectrum of Cough-Induced Complications and Patient Harm

      2020, American Journal of Medicine
      Citation Excerpt :

      Chronic cough whether productive or dry, was found to be an independent predictor of MI with significant odds ratio of 1.6 or 1.8, respectively.36 Although not followed by other studies, these data strongly confirm a previous study from Finland37 and moreover, risk correlated with increased plasma fibrinogen level, an acute-phase reactant, and could well be explained by chronic cough-associated chronic pulmonary inflammation, an established novel risk factor of atherosclerosis. Another intriguing type of myocardial injury is stress cardiomyopathy (Takotsubo) that was reported after particularly bad bouts of coughing in 2 women.

    • Bronchiectasis and Chronic Suppurative Lung Disease

      2019, Kendig's Disorders of the Respiratory Tract in Children
    • Blue-collar work and women's health: A systematic review of the evidence from 1990 to 2015

      2018, SSM - Population Health
      Citation Excerpt :

      Several studies identified chemical exposures a risk factor not only for cancers among blue-collar women (Betenia, Costello, & Eisen, 2012; Oddone et al., 2014; Richiardi et al., 2004; Thompson, Kriebel, Quinn, Wegman, & Eisen, 2005), but also for psychiatric distress and depression (Bromet, Dew, Parkinson, Cohen, & Schwartz, 1992; Parkinson et al., 1990). Increased job demand, job conflict, subjective monotony, skill underutilization and sexual harassment were all identified as risk factors for psychiatric distress (Goldenhar, Swanson, Hurrell, Ruder, & Deddens, 1998; Kivimäki et al., 2007; Melamed, Ben-Avi, Luz, & Green, 1995), although reduced psychological distress was observed among blue-collar women with adequate social support (Bromet et al., 1992; Brunette, Smith, & Punnett, 2011). Factors such as work control, job strain, and occupational stress do not appear to be associated with cardiovascular disease among blue-collar women (Hall, Johnson, & Tsou, 1993; Tsutsumi, Kayaba, & Ishikawa, 2011; Tsutsumi, Kayaba, Tsutsumi, & Igarashi, 2001).

    View all citing articles on Scopus
    View full text