The contribution of dietary saturated fatty acids (SFA) to cardiovascular disease (CVD) and mortality remains debated after decades of research. Few previous studies had repeated dietary assessments and power to assess mortality. Evidence for individual SFA is limited. In this large population-based cohort study, we investigated associations between intake of total and individual SFA and risk of total and CVD mortality. Adult residents (mean 41·1 years at baseline) in three Norwegian counties were invited to repeated health screenings between 1974 and 1988 (> 80 % attendance). We calculated cumulative average intakes of macronutrients from semi-quantitative FFQ. Median (interquartile range) intake of SFA was 14·6 % (12·8–16·6 %) of total energy (E%). Hazard ratios (HR) and 95 % CI were estimated using multivariable Cox regression models to assess total, CVD, ischaemic heart disease (IHD) and acute myocardial infarction (AMI) mortality. Among 78 725 participants, 28 555 deaths occurred during a median follow-up of 33·5 years, with 9318 deaths due to CVD. Higher intake of SFA (replacing carbohydrates) was positively associated with all mortality endpoints, including total (HR per 5 E% increment, 1·18; 95 % CI 1·13, 1·23) and CVD mortality (1·16; 95 % CI 1·07, 1·25). Theoretical isoenergetic substitution of SFA with carbohydrates or MUFA was associated with lower risk. Of individual SFA, myristic (14:0) and palmitic acid (16:0) were positively associated with mortality. In summary, dietary SFA intake was strongly associated with higher total and CVD mortality in this long-term cohort study. This supports policies implemented to reduce SFA consumption in favour of carbohydrates and unsaturated fats.

Association of Pulmonary Artery Aneurysm with Ischemic Heart Disease is uncommon, and its surgical management has been rarely described in the literature. Surgical intervention should be individualised according to the coexisting diseases and comorbidities to achieve optimal outcome. We report a case of a 76-year-old man with background history of coronary artery stenting due to ischaemic heart disease. The patient presented with features of coronary compression due to giant pulmonary artery aneurysm. He was operated with replacement of aneurysmal pulmonary trunk with 25 mm Hancock conduit.

The classical deficiency diseases have nearly disappeared from the industrialised world and are thought to be found largely in sub-Saharan Africa and South Asia. More than 80 collected medical articles, mostly from Europe and North America, describe more than 9000 people with low concentrations of copper in organs or tissues or impaired metabolic pathways dependent on copper. More than a dozen articles reveal improved anatomy, chemistry or physiology in more than 1000 patients from supplements containing copper. These criteria are diagnostic of deficiency according to The Oxford Textbook of Medicine. Alzheimer's disease, ischaemic heart disease and osteoporosis receive major emphasis here. However, impaired vision, myelodysplastic syndrome and peripheral neuropathy are mentioned. Copper deficiency probably causes some common, contemporaneous diseases. Advice is provided about opportunities for research. Seemingly authoritative statements concerning the rarity of nutritional deficiency in developed countries are wrong.

We investigated the associations between dietary patterns and chronic disease mortality in Switzerland using an ecological design and explored their spatial dependence, i.e. the tendency of near locations to present more similar and distant locations to present more different values than randomly expected. Data of the National Nutrition Survey menuCH (n 2057) were used to compute hypothesis- (Alternate Healthy Eating Index (AHEI)) and data-driven dietary patterns. District-level standardised mortality ratios (SMR) were calculated using the Swiss Federal Statistical Office mortality data and linked to dietary data geographically. Quasipoisson regression models were fitted to investigate the associations between dietary patterns and chronic disease mortality; Moran’s I statistics were used to explore spatial dependence. Compared with the first, the fifth AHEI quintile (highest diet quality) was associated with district-level SMR of 0·95 (95 % CI 0·93, 0·97) for CVD, 0·91 (95 % CI 0·88, 0·95) for ischaemic heart disease (IHD), 0·97 (95 % CI 0·95, 0·99) for stroke, 0·99 (95 % CI 0·98, 1·00) for all-cancer, 0·98 (95 % CI 0·96, 0·99) for colorectal cancer and 0·93 (95 % CI 0·89, 0·96) for diabetes. The Swiss traditional and Western-like patterns were associated with significantly higher district-level SMR for CVD, IHD, stroke and diabetes (ranging from 1·02 to 1·08) compared with the Prudent pattern. Significant global and local spatial dependence was identified, with similar results across hypothesis- and data-driven dietary patterns. Our study suggests that dietary patterns partly contribute to the explanation of geographic disparities in chronic disease mortality in Switzerland. Further analyses including spatial components in regression models would allow identifying regions where nutritional interventions are particularly needed.

Associations between meat consumption and heart disease have been assessed in several studies, but it has been suggested that other dietary factors influence these associations. The aim of the present study was to assess whether meat consumption is associated with ischaemic heart disease (IHD), and if the association is modified by dietary quality. The analyses were based on the cohort of adult participants in the Danish National Survey on Diet and Physical Activity in 2000–2002, 2003–2008 and 2011–2013. From these surveys, information on meat consumption and dietary quality was extracted. The cohort was followed in national registers to identify incident IHD. Associations were estimated using Cox regression analyses adjusting for socio-demographic and lifestyle factors. Analyses of associations between meat consumption and IHD stratified by dietary quality were subsequently evaluated. Among the 8007 participants, the median follow-up was 9·8 years and 439 cases of IHD were recorded. The results suggested a trend between consumption increments of 100 g/d of red meat (hazard ratio (HR) = 1·23; 95 % CI 0·99, 1·53) or of 50 g/d of processed meat (HR = 1·09; 95 % CI 0·93, 1·29) and higher risk of IHD. The trends were, however, not statistically significant. Stratification by dietary quality did not suggest that associations between meat consumption and risk of IHD were modified by dietary quality. This population-based cohort study with detailed dietary information suggested a trend with higher meat consumption being associated with higher risk of IHD, but the association was not statistically significant. Results did not indicate that dietary quality modifies such associations.

Intake of vegetables is recommended for the prevention of myocardial infarction (MI). However, vegetables make up a heterogeneous group, and subgroups of vegetables may be differentially associated with MI. The aim of this study was to examine replacement of potatoes with other vegetables or subgroups of other vegetables and the risk of MI. Substitutions between subgroups of other vegetables and risk of MI were also investigated. We followed 29 142 women and 26 029 men aged 50–64 years in the Danish Diet, Cancer and Health cohort. Diet was assessed at baseline by using a detailed validated FFQ. Hazard ratios (HR) with 95 % CI for the incidence of MI were calculated using Cox proportional hazards regression. During 13·6 years of follow-up, 656 female and 1694 male cases were identified. Among women, the adjusted HR for MI was 1·02 (95 % CI 0·93, 1·13) per 500 g/week replacement of potatoes with other vegetables. For vegetable subgroups, the HR was 0·93 (95 % CI 0·77, 1·13) for replacement of potatoes with fruiting vegetables and 0·91 (95 % CI 0·77, 1·07) for replacement of potatoes with other root vegetables. A higher intake of cabbage replacing other vegetable subgroups was associated with a statistically non-significant higher risk of MI. A similar pattern of associations was found when intake was expressed in kcal/week. Among men, the pattern of associations was overall found to be similar to that for women. This study supports food-based dietary guidelines recommending to consume a variety of vegetables from all subgroups.

Diet is recognised as one modifiable lifestyle factor for ischaemic heart disease (IHD). We aimed at investigating the associations between adherence to the Danish Food-Based Dietary Guidelines (FBDG) indicated by a Dietary Quality Index (DQI) and selected cardiometabolic risk factors in a cross-sectional study with 219 Danish adult participants (59 %women; age 31–65years) with a minimum of one self-rated risk marker of IHD. Information regarding diet was obtained using web-based dietary assessment software and adherence to the Danish FBDG was expressed by a DQI calculated from 5 food and nutrient indicators (whole grain, fish, fruit and vegetables, energy from saturated fat and from added sugar). Background information, blood samples and anthropometrics were collected and blood pressure was measured. Linear regression analyses were used to evaluate the association between DQI and cardiometabolic risk factors. DQI was inversely associated with LDL:HDL ratio and TAG (−0·089 per unit; 95 % CI −0·177, −0·002 and −5 % per unit; 95 % CI −9, 0, respectively) and positively associated with HDL-cholesterol (0·047 mmol/l per unit; 95 % CI 0·007, 0·088). For men, DQI was inversely associated with BMI (−3 %per unit; 95 % CI −5, −1), trunk fat (−1 % per unit; 95 % CI −2, −1), high-sensitivity C-reactive protein (−30 % per unit; 95 % CI −41, −16 %), HbA1c (−0·09 % per unit; 95 % CI −0·14, −0·04), insulin (−13 % per unit; 95 % CI −19, −7) and homoeostatic model assessment-insulin resistance (−14 % per unit; 95 % CI −21, −7). In women, DQI was positively associated with systolic blood pressure (2·6 mmHg per unit; 95 % CI 0·6, 4·6). In conclusion, higher adherence to the current Danish FBDG was associated with a more beneficial cardiometabolic risk profile in a Danish adult population with a minimum of one self-rated risk factor for IHD.

Arterial wall thickening, stimulated by low-grade systemic inflammation, underlies many cardiovascular events. As diet is a significant moderator of systemic inflammation, the dietary inflammatory index (DIITM) has recently been devised to assess the overall inflammatory potential of an individual’s diet. The primary objective of this study was to assess the association of the DII with common carotid artery–intima-media thickness (CCA–IMT) and carotid plaques. To substantiate the clinical importance of these findings we assessed the relationship of DII score with atherosclerotic vascular disease (ASVD)-related mortality, ischaemic cerebrovascular disease (CVA)-related mortality and ischaemic heart disease (IHD)-related mortality more. The study was conducted in Western Australian women aged over 70 years (n 1304). Dietary data derived from a validated FFQ (completed at baseline) were used to calculate a DII score for each individual. In multivariable-adjusted models, DII scores were associated with sub-clinical atherosclerosis: a 1 sd (2·13 units) higher DII score was associated with a 0·013-mm higher mean CCA–IMT (P=0·016) and a 0·016-mm higher maximum CCA–IMT (P=0·008), measured at 36 months. No relationship was seen between DII score and carotid plaque severity. There were 269 deaths during follow-up. High DII scores were positively associated with ASVD-related death (per sd, hazard ratio (HR): 1·36; 95 % CI 1·15, 1·60), CVA-related death (per sd, HR: 1·30; 95 % CI 1·00, 1·69) and IHD-related death (per sd, HR: 1·40; 95 % CI 1·13, 1·75). These results support the hypothesis that a pro-inflammatory diet increases systemic inflammation leading to development and progression of atherosclerosis and eventual ASVD-related death.

The theory, in brief outline here, implicating deficiency of Cu in the aetiology and pathophysiology of IHD explains more attributes of the disease than any other theory. This theory satisfies several of Hill’s criteria of a half-century ago for deducing association between an environmental feature and presence of an illness. Most important is the temporal association between the rise of IHD and the decrease in dietary Cu since the 1930s along with a parallel increase in the supplementation of pregnant women with Fe, a Cu antagonist. There are more than eighty anatomical, chemical and physiological similarities between animals deficient in Cu and individuals with IHD. Few of these similarities have been produced by other dietary manipulations because feeding cholesterol induces Cu deficiency in animals. The most recent of these to be identified is decreased serum dehydroepiandrosterone. Some concomitant aspects of Cu metabolism and utilisation have been identified in other theories about heart disease: fetal programming, homocysteine, and Fe overload.

Studies on placental size and cardiovascular disease have shown inconsistent results. We followed 10,503 men and women born in Uppsala, Sweden, 1915–1929 from 1964 to 2008 to assess whether birth characteristics, including placental weight and placenta/birth weight ratio, were predictive of future ischaemic heart disease (IHD). Adjustments were made for birth cohort, age, sex, mother’s parity, birth weight, gestational age and social class at birth. Placental weight and birth weight were negatively associated with IHD. The effect of placental weight on IHD was stronger in individuals from medium social class at birth and in those with low education. Men and women from non-manual social class at birth had the lowest risk for IHD as adults. We conclude that low foetal growth rate rather than placental weight was more predictive of IHD in the Swedish cohort. However, the strong effect of social class at birth on risk for IHD did not appear to be mediated by foetal growth rate.

This is the third in a series of three papers. In the first paper we describe a comprehensive stochastic model of an individual's lifetime that includes diagnosis with ischaemic heart disease and stroke and also the development of the major risk factors for these conditions. The second paper discusses in some detail models for changes in body mass index (BMI) and also the effects of these changes, in particular the current trend towards increasing prevalence of obesity, on diabetes, cardiovascular diseases and expected future lifetime. This paper is devoted to the following applications of the model described in the first paper:

(a) quantifying the effects of smoking and of changes in smoking habits, and,

(b) quantifying the effects of treatment with statins (drugs designed to lower cholesterol).

This is the second in a series of three papers. In the first paper we describe a comprehensive stochastic model of an individual's lifetime that includes diagnosis with ischaemic heart disease and stroke and also the development of the major risk factors for these conditions. The third paper is devoted to some applications of this model.

In this paper we discuss the effect of BMI on diabetes, heart disease and mortality and we use data from the Framingham Heart Study and the Health Survey for England to develop stochastic models for changes in an individual's BMI. Some of these models incorporate time trends leading to increasing prevalence of obesity. We then use these models to investigate how future expected lifetime and future expected healthy lifetime depend on BMI.

Our conclusions are that if the prevalence of obesity increases, even to an extreme degree, then the prevalence of diabetes and hypertension in the population will increase, possibly to a significant extent, but the prevalence of heart disease and stroke will increase by a much smaller amount and the effect on expected future lifetime will be small.

We construct a stochastic model of an individual's lifetime that includes diagnosis with ischaemic heart disease and stroke and also the development of the major risk factors for these conditions: hypercholesterolaemia, hypertension, diabetes and obesity. Smoking, another major risk factor, is treated deterministically. Mathematically, the model is a continuous time, finite state space Markov process, with the individual's age playing the rôle of time. The model is parameterised using data from the Framingham Heart Study, with parameter values adjusted so that the model is appropriate for UK conditions in the early 21st century. The model has been designed so that it can be used to quantify the effects of:

(i) trends, in particular increasing prevalence of obesity.

(ii) changes in behaviour, in particular smoking patterns, and

(iii) treatments, in particular statins for hypercholesterolaemia.

These applications are covered in two accompanying papers.

Chronic mild dehydration has been associated with several diseases, including fatal IHD and stroke. It has been suggested that hydration through total fluid intake (or water) is inversely associated with IHD or stroke mortality. The objective of the present study was to evaluate the relationship between total fluid (and specific beverage) intake and IHD or stroke mortality in the Netherlands Cohort Study (NLCS). In 1986, 120 852 participants aged 55–69 years were enrolled into the NLCS. Mortality data were collected over a 10-year follow-up period. Analysis was done through a case–cohort approach, and it was based on the subjects without a history of heart disease, stroke or diabetes at baseline. A total of 1789 IHD mortality cases and 708 stroke mortality cases occurred during the follow-up. Higher total fluid consumption was not associated with either IHD mortality or stroke mortality in men or women. When analysing specific beverages, a positive association between coffee consumption (increment 270 ml/d) and IHD mortality was observed in men (hazard ratio (HR) 1·09, 95 % CI 1·00, 1·18), while an inverse relationship was observed in women (HR: 0·88, 95 % CI 0·78, 1·00). For tea consumption (increment of 253 ml/d), an inverse relationship with IHD mortality was observed in men (HR: 0·91, 95 % CI 0·83, 1·00). No association with water intake was observed. In the study population, fresh water consumption was very low. In conclusion, total fluid intake was not associated with IHD or stroke mortality in either men or women. Coffee consumption was inversely associated with IHD mortality in women only, while a higher tea intake was associated with lower IHD mortality in men only.

A 24-year-old female without previous symptoms or known heart disease consulted a general practitioner with dyspnoea which had slowly worsened over a period of two years. She was treated for asthma, without investigations, until she presented with rapid atrial fibrillation, chest pain and pulmonary oedema necessitating admission to hospital, where she was found to have “mitral” regur-gitation (of the left-sided atrioventricular valve) and congenitally corrected transposition. At operation the grossly regurgitant left-sided morphologically tricuspid valve was replaced by a “top-hat” inverted aortic valve homograft. The procedure resulted in intermittent heart block, needing a pacemaker, and continued myocardial failure which progressed with new right-sided valvar regurgitation. She died a few months later. Post mortem examination confirmed the double discordance, and showed a fistula around the tricuspid valvar prosthesis, left atrial thrombus and changes in the mitral valve. There was also an unsuspected area of old myocardial ischaemia, associated with severe hypoplasia of the circumflex branch of the right-sided coronary artery. This was considered probably to have been of embolic origin.

Common arterial trunk is frequently associated with anomalies of coronary arterial origin and distribution. We describe two infants in whom coronary intervention was performed during the repair of common arterial trunk, with reversal of ischaemic left ventricular dysfunction. We discuss the surgical implications of recognition of the coronary arterial anomalies during the repair of common arterial trunk.