Studies of autopsies indicate that atherosclerosis begins in childhood and is related to risk factors for coronary heart disease in the same way as for adult atherosclerosis.1 In Spain, despite risk factors for coronary heart disease being common, incidence of myocardial infarction and related mortality rates are among the lowest in the world.2 3 This paradox may be explained in two ways. One theory proposes that there is a time lag between increased consumption of animal fat and raised serum cholesterol concentrations, which have occurred more recently in Mediterranean populations than in other Western countries, and the expected increase in rates of coronary heart disease. 4 An alternative explanation is that Mediterranean countries share behavioural and socioeconomic factors that prevent or delay atherogenesis.5 If this is true, the arteries of young Spaniards should be free from atheroma. We studied autopsies to evaluate the prevalence and severity of atherosclerosis in several arterial beds of young trauma victims from Barcelona. We report the results of left coronary artery evaluation.
Participants, methods, and resultsAt four forensic laboratories in Barcelona we consecutively collected specimens from 65 young and healthy people (50 men and 15 women) aged 12-35 years who died of external causes. We measured thiocyanate in postmortem serum by spectrophotometry (an objective measure of smoking), and we determined lipoprotein cholesterol with an enzymatic method. We measured the circumference of the waist and hips, and we analysed subcutaneous abdominal adipose tissue by gas chromatography for fatty acids.After weighing the heart, we dissected the left coronary artery and stained 3 m transverse sections embedded in paraffin with haematoxylin eosin. We graded the severity of atherosclerotic lesions microscopically using the criteria of the American Heart Association. 1 We used 2 tests, Fisher's exact test, or unpaired t tests with a 5% alpha risk to examine whether atherosclerosis was related to age and if severity of lesions was associated to risk factors.Mean age was 24 years, and 33 (51%) were smokers. Mean waist to hip ratio, heart weight, and cholesterol concentration (0.84, 327 g, and 4.42 mmol/l) were within 95% confidence intervals of reference values. Fibrous plaques were present in 17 (34%; 95% confidence interval 21% to 49%) men but were absent (0; 0% to 22%) in women. Compared with the 33 men without plaques, the 17 men with plaques were on average 6 years older (P < 0.001) and had significantly higher serum total cholesterol (by 0.76 mmol/l) and very low density lipoprotein cholesterol (by 0.27 mmol/l) (P < 0.05 for both) (figure). Measures of adiposity, smoking behaviour, and the fatty acids in adipose tissue were similar in men with and without plaques.
CommentWe found unexpectedly high numbers of plaques in young Spanish men, similar to the prevalence in populations with much higher rates of coronary heart disease, 1 for Barcelona, a geographical location with low incidence of myocardial i...
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