Similarities and differences between coronary heart disease and stroke in the associations with cardiovascular risk factors: The Japan Collaborative Cohort Study


      • Some risk factors are shared by coronary heart disease (CHD) and stroke, while others are not.
      • Hypertension was comparably associated with mortality by CHD and that by stroke.
      • Smoking and diabetes associated more strongly with mortality by CHD than by stroke.


      Background and aims

      Coronary heart disease (CHD) and stroke have common risk factors, but some of these differ in the magnitude or direction of associations between CHD and stroke. We assessed whether the impact of each risk factor differed between CHD and stroke mortality in Asians.


      In total, 104 910 subjects aged 40–79 years without histories of cancer, CHD and stroke at baseline were followed between 1988 and 2009. Competing-risks analysis was used to test for differences in the associations of each risk factor with two endpoints (CHD and stroke). Population attributable fractions (PAFs) were also calculated for these endpoints to estimate the population impact of each risk factor.


      During a median 19.1-year follow-up, 1554 died from CHD and 3163 from stroke. The association of hypertension with CHD was similar to that with stroke in terms of the magnitude and direction (multivariable-adjusted hazard ratio for CHD: 1.63 vs. stroke: 1.73 in men and 1.70 vs. 1.66 in women). Conversely, the magnitude of these associations differed for smoking (CHD: 1.95 vs. stroke: 1.23 in men and 2.45 vs. 1.35 in women) and diabetes (1.49 vs. 1.09 in men and 2.08 vs. 1.39 in women). The highest PAF for CHD was caused by smoking in men and by hypertension in women; that for stroke was caused by hypertension in both sexes.


      Hypertension associations and PAFs were consistent between CHD and stroke, but not for other risk factors. These findings may be useful to optimize public health intervention strategies.


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        • Takashima N.
        • Ohkubo T.
        • Miura K.
        • Okamura T.
        • Murakami Y.
        • et al.
        Long-term risk of BP values above normal for cardiovascular mortality.
        J. Hypertens. 2012; 30: 2299-2306
        • Mons U.
        • Müezzinler A.
        • Gellert C.
        • Schöttker Ben
        • Abnet C.C.
        • et al.
        Impact of smoking and smoking cessation on cardiovascular events and mortality among older adults: meta-analysis of individual participant data from prospective cohort studies of the CHANCES consortium.
        BMJ. 2015; 350 (h1551–0)
        • Preis S.R.
        • Hwang S.-J.
        • Coady S.
        • Pencina M.J.
        • D'Agostino R.B.
        • et al.
        Trends in all-cause and cardiovascular disease mortality among women and men with and without diabetes mellitus in the Framingham Heart Study, 1950 to 2005.
        Circulation. 2009; 119: 1728-1735
        • Ronksley P.E.
        • Brien S.E.
        • Turner B.J.
        • Mukamal K.J.
        • Ghali W.A.
        Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis.
        BMJ. 2011; 342: d671
        • Ni Mhurchu C.
        • Rodgers A.
        • Pan W.H.
        • Gu D.F.
        • Woodward M.
        Asia Pacific Cohort Studies Collaboration, Body mass index and cardiovascular disease in the Asia-Pacific Region: an overview of 33 cohorts involving 310 000 participants.
        Int. J. Epidemiol. 2004; 33: 751-758
        • Nocon M.
        • Hiemann T.
        • Müller-Riemenschneider F.
        • Thalau F.
        • Roll S.
        • et al.
        Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis.
        Eur. J. Cardiovasc Prev. Rehabil. 2008; 15: 239-246
        • Ueshima H.
        Explanation for the Japanese paradox: prevention of increase in coronary heart disease and reduction in stroke.
        JAT. 2007; 14: 278-286
        • Hasuo Y.
        • Ueda K.
        • Kiyohara Y.
        • Wada J.
        • Kawano H.
        • et al.
        Accuracy of diagnosis on death certificates for underlying causes of death in a long-term autopsy-based population study in Hisayama, Japan; with special reference to cardiovascular diseases.
        J. Clin. Epidemiol. 1989; 42: 577-584
        • Rubin D.B.
        Multiple Imputation for Nonresponse in Surveys.
        John Wiley & Sons, Hoboken, NJ, USA2009
        • Noordzij M.
        • Leffondré K.
        • van Stralen K.J.
        • Zoccali C.
        • Dekker F.W.
        • et al.
        When do we need competing risks methods for survival analysis in nephrology?.
        Nephrol. Dial. Transpl. 2013; 28: 2670-2677
        • Okamura T.
        Dyslipidemia and cardiovascular disease: a series of epidemiologic studies in Japanese populations.
        J. Epidemiol. 2010; 20: 259-265
        • Reiner Z.
        Managing the residual cardiovascular disease risk associated with HDL-cholesterol and triglycerides in statin-treated patients: a clinical update.
        Nutr. Metab. Cardiovasc Dis. 2013; 23: 799-807
        • Townsend N.
        • Nichols M.
        • Scarborough P.
        • Rayner M.
        Cardiovascular disease in Europe — epidemiological update 2015.
        Eur. Heart J. 2015; 36 (ehv428–2705)
        • Yusuf S.
        • Hawken S.
        • Ounpuu S.
        • Dans T.
        • Avezum Á.
        • et al.
        Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.
        Lancet. 2004; 364: 937-952
        • O'Donnell M.J.
        • Xavier D.
        • Liu L.
        • Zhang H.
        • Chin S.L.
        • et al.
        Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study.
        Lancet. 2010; 376: 112-123
        • Saito I.
        • Yamagishi K.
        • Kokubo Y.
        • Yatsuya H.
        • Iso H.
        • et al.
        Association between mortality and incidence rates of coronary heart disease and stroke: the Japan Public Health Center-based prospective (JPHC) study.
        Int. J. Cardiol. 2016; 222: 281-286
        • Katanoda K.
        • Marugame T.
        • Saika K.
        • Satoh H.
        • Tajima K.
        • et al.
        Population attributable fraction of mortality associated with tobacco smoking in Japan: a pooled analysis of three large-scale cohort studies.
        J. Epidemiol. 2008; 18: 251-264
        • Haapanen-Niemi N.
        • Vuori I.
        • Pasanen M.
        Public health burden of coronary heart disease risk factors among middle-aged and elderly men.
        Prev. Med. 1999; 28: 343-348
        • National Health and Nutrition Survey in Japan
        The Ministry of Health, Labour and Welfare.
        (in Japanese)2014 (20 February 2017)
        • Patient Survey in Japan
        The Ministry of Health, Labour and Welfare.
        (in Japanese)2014 (20 February 2017)
        • Cui R.
        • Iso H.
        • Toyoshima H.
        • Date C.
        • Yamamoto A.
        • et al.
        Serum total cholesterol levels and risk of mortality from stroke and coronary heart disease in Japanese: the JACC study.
        Atherosclerosis. 2007; 194: 415-420
        • Brien S.E.
        • Ronksley P.E.
        • Turner B.J.
        • Mukamal K.J.
        • Ghali W.A.
        Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies.
        BMJ. 2011; 342: d636
        • Heuschmann P.U.
        • Kircher J.
        • Nowe T.
        • Dittrich R.
        • Reiner Z.
        • et al.
        Control of main risk factors after ischaemic stroke across Europe: data from the stroke-specific module of the EUROASPIRE III survey.
        Eur. J. Prev. Cardiol. 2015; 22: 1354-1362
        • Zhao M.
        • Cooney M.T.
        • Klipstein-Grobusch K.
        • Vaartjes I.
        • De Bacquer D.
        • et al.
        Simplifying the audit of risk factor recording and control: a report from an international study in 11 countries.
        Eur. J. Prev. Cardiol. 2016; 23: 1202-1210
        • Kotseva K.
        • Wood D.
        • De Bacquer D.
        • De Backer G.
        • Rydén L.
        • et al.
        EUROASPIRE IV: a European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries.
        Eur. J. Prev. Cardiol. 2016; 23: 636-648