Relative importance of improved hospital treatment and primary prevention. Results from 20 years of the Myocardial Infarction Register, Göteborg, Sweden

Familial effects on survival after myocardial infarction: a registry-based sib-pair study

The chance of surviving an acute myocardial infarction (MI) has increased greatly but many persons still die as a consequence of MI. We assessed the familiality of suffering fatal MI using Swedish registry data. All 4,239 sib-pairs (n = 8,478) where both siblings had suffered an MI and who were born 1932 or later were identified by matching the Swedish National Patient-, Cause of Death and Multi-Generation registries. The Cox proportional hazards model was used to estimate the association between survival times between sibling who had, or not had, a sibling who died within 28 days of their first MI. The risk estimate was adjusted for year of infarction, age at infarction, sex and county for both siblings. The mortality rate was increased the first 28 days after infarction amongst patients who had a sibling who also died within 28 days of infarction (adjusted Hazard ratio (HR) [95 % confidence interval [95 % CI]: 1.44 [1.18-1.75]). These patients also have a worse long-term survival (adjusted HR [95 % CI]: 1.65 [1.24-2.21]). There appears to be familial effects that influence MI survival. This may have important implications for MI prevention strategies but further studies are required to determine if these effects are due to genetic or environmental factors.

Better long-term survival in young and middle-aged women than in men after a first myocardial infarction between 1985 and 2006. An analysis of 8630 patients in the northern Sweden MONICA study

BACKGROUND

There is conflicting and only scant evidence on the effect of gender on long-term survival after a myocardial infarction (MI). Our aim was to analyse sex-specific survival of patients for up to 23 years after a first MI in northern Sweden and to describe time trends.

METHODS

The Northern Sweden MONICA Myocardial Infarction Registry was linked to The Swedish National Cause of Death Registry for a total of 8630 patients, 25 to 64 years of age, 6762 men and 1868 women, with a first MI during 1985-2006. Also deaths before admission to hospital were included. Follow-up ended on August 30, 2008.

RESULTS

Median follow-up was 7.1 years, maximum 23 years and the study included 70 072 patient-years. During the follow-up 45.3% of the men and 43.7% of the women had died. Median survival for men was 187 months (95% confidence interval (CI) 179-194) and for women 200 months (95% CI 186-214). The hazard ratio (HR) for all cause mortality after adjustment for age group was 1.092 (1.010-1.18, P = 0.025) for females compared to males, i.e. 9 percent higher survival in women. After excluding subjects who died before reaching hospital HR declined to 1.017 (95%CI 0.93-1.11, P = 0.7). For any duration of follow-up a higher proportion of women were alive, irrespective of age group. The 5-year survivals were 75.3% and 77.5%, in younger (<57 years) men and women and were 65.5% and 66.3% in older (57-64 years) men and women, respectively. For each of four successive cohorts survival improved. Survival time was longer for women than for men in all age groups.

CONCLUSIONS

Age-adjusted survival was higher among women than men after a first MI and has improved markedly and equally in both men and women over a 23-year period. This difference was due to lower risk for women to die before reaching hospital.

Long-term prognosis after hospital admission for acute myocardial infarction from 1987 to 2006

BACKGROUND

Recent population-based estimates for long-term cardiovascular disease (CVD) mortality after hospitalization for a first acute myocardial infarction (AMI) are not well established.

METHODS

Data from the Swedish hospital discharge and death registries were used to record all first-ever hospital admissions in patients (n=348,772) 35-84 years with AMI from 1987 to 2006 and subsequent all-cause and CVD case fatality during up to 5 years.

RESULTS

During the 20-year period, 28-day case fatality was reduced by almost two thirds in patients aged <75 years. For cases with a first AMI 1999-2002 long-term case fatality for men surviving the first 28 days and <55 years was 10.3/1000 person years, with rates of 23.6, 58.0 and 137.0 for men aged 55-64, 65-74 and 75-84 years. Corresponding figures for women were 10.5, 24.3, 51.8, 124.1 deaths/1000 years. In 1999-2002 estimated long-term risk of fatal CVD (based on survival until 2007) for men below 55 years was 6.1/1000 years, and 13.8, 34.6, 92.9 for men aged 55-64, 65-74, and 75-84 years, respectively. Corresponding figures for women were 4.8, 11.9, 30.1, 86.2/1000 years. The total reduction in CVD case fatality was two thirds among patients aged <55 and approximately one third among those aged 75-84.

CONCLUSIONS

Long-term case fatality after hospitalization for AMI decreased markedly from 1987 to 2006, particularly with respect to CVD mortality and in younger patients. However, because of a steep increase in case fatality with age and a large proportion of older patients, long-term prognosis overall still remains poor.

Effects of a global health and risk assessment tool for prevention of ischemic heart disease in an individual health dialogue compared with a community health strategy only results from the Live for Life health promotion programme

OBJECTIVE

To evaluate the effect of an individual health dialogue on health and risk factors for ischemic heart disease in addition to that of a community based strategy.

METHOD

Inhabitants in four communities in the area of Skaraborg, Sweden were invited to a health examination including a health dialogue both at the age of 30 and 35 (target communities). In another four communities inhabitants were invited only at the age of 35 (reference communities). Health and risk factors in 35-year old inhabitants in the target communities who participated in the health dialogue in 1989-1991 and 1994-1996 were analysed and compared with 35-year olds in the reference communities participating during the same periods of time.

RESULTS

Inhabitants in communities where there had been a previous individualised health intervention programme had, on the community level, a more favourable development concerning dietary habits, mental stress, body mass index, waist circumference, cholesterol, blood pressure and metabolic risk profile compared to inhabitants in communities with only a community based health intervention programme.

CONCLUSIONS

An individual lifestyle oriented health dialogue supported by a global health and risk assessment pedagogic tool seems to be more effective than a community health strategy only.

Time trends in incidence of myocardial infarction in male and female dominated occupations in Stockholm, Sweden

Aims: To investigate time trends in first acute myocardial infarction (MI) incidence in male and female dominated occupations in Stockholm during 1977—1996. Methods: Population-based case-control study, where all first events of acute MI among participants aged 40—69 in Stockholm 1977—1996 were identified, using registers of hospital discharges and deaths. Controls were selected randomly using national population registers. There were 16,531 male and 4382 female cases and 117,015 male and 102,083 female controls. In all, 222 female cases worked in male dominated occupations and 844 male cases worked in female dominated occupations. Results: Both women and men in male dominated occupations showed an elevated relative risk of first MI compared to other employees during the study period. Between 1985—1996, when there was a general decline in MI incidence in Sweden, women in male dominated occupations tended to show an increasing trend. Women in female dominated high and intermediate occupations had a lower relative risk of MI compared to other women in the same socioeconomic group. In male dominated and non-manual female dominated occupations a decline in the incidence of MI was seen during 1985—1996 in men but not in women. Conclusions: Work in male dominated occupations appears to be associated with an increased risk of MI in both genders. There is a need to investigate possible work related or other factors that may be driving this elevated risk.

Social capital, institutional (vertical) trust and smoking: a study of daily smoking and smoking cessation among ever smokers

OBJECTIVES

The associations between vertical (institutional) trust in the healthcare system and the mass media (newspapers and television), and daily smoking and smoking cessation were investigated.

METHODS

The 2004 public-health survey in Scania is a cross-sectional study. A total of 27,757 persons aged 18-80 years answered a postal questionnaire, which represents 59% of the random sample. A logistic regression model was used to investigate the associations between institutional trust in the healthcare system and the mass media, and daily smoking and smoking cessation. A multivariate analysis was performed to investigate the importance of possible confounders (age, country of origin, education, economic stress, generalized trust in other people) on the differences in daily smoking and smoking cessation according to trust in the healthcare system and the mass media.

RESULTS

14.9% of the men and 18.1% of the women were daily smokers. Middle-aged respondents were daily smokers to a significantly higher extent than the young. Respondents with low trust in the healthcare system had significantly higher odds ratios of daily smoking, 1.88 (95% CI 1.38-2.57) among men and 2.05 (95% CI 1.51-2.78) among women, while respondents with low trust in the mass media had no significant odds ratios of daily smoking, 1.01 (0.67-1.52) among men and 1.55 (0.97-2.47) among women, after multiple adjustments.

CONCLUSIONS

Institutional (vertical) trust in the healthcare system but not the mass media was significantly associated with lower odds of daily smoking and higher odds of having quit smoking if ever smoker. The healthcare system seems to be a potent arena for tobacco prevention.

Time trends in the incidence of myocardial infarction among professional drivers in Stockholm 1977-96

AIMS

To investigate time trends in the incidence of first myocardial infarction (MI) among bus, taxi, and lorry drivers in Stockholm.

METHODS

In this population based case-control study, all first events of acute MI among men aged 40-69 in Stockholm County 1977-96 were identified using registers of hospital discharges and deaths. Controls were selected randomly from the general population. National censuses were used for information on occupational titles. A total of 20,364 cases and 136,342 controls were included in the study. Among these, 1183 cases and 6072 controls had worked as drivers.

RESULTS

During 1977-84 the MI incidence was higher in all three driver groups than among other manual workers. There was a decline in MI incidence among drivers as well as in the general population during the study period. The decline was greater among drivers than among other manual workers. During 1985-96 the relative risk remained increased compared to other manual workers among taxi and lorry drivers, but not among bus drivers.

CONCLUSIONS

Despite a reduced MI incidence for professional drivers in recent years, preventive measures to reduce the risk of MI in these occupational groups, and in particular among taxi and lorry drivers, continue to be of importance.

Primary prevention of cardiovascular disease by an occupational health service

BACKGROUND

Worksites are considered to be a key channel for the delivery of interventions to prevent cardiovascular disease. The aim of this study was to evaluate the effect on the blood cholesterol levels of an intervention program offered by an occupational health service.

METHODS

The intervention group consisted of 95 employees and the reference group consisted of 74 employees, in all, 169 subjects, with a serum cholesterol > or = 5.2 mmol/l. Both groups completed a standardized questionnaire. Occupational health nurses carried out the blood sampling before and after the program. The intervention group was then offered counseling on physical activity and a dietician offered individual counseling on healthy food habits. The reference group was not the subject of the intervention program.

RESULTS

The mean cholesterol level decreased by 0.3 mmol/l (5%) in the intervention group and for the men the decrease was 0.5 mmol/l, while the mean level of the reference group was unchanged. Furthermore, there was a nonsignificant decrease of the mean triglyceride level in the intervention group.

CONCLUSION

The results of this controlled trial indicates that risk factors for cardiovascular disease can be reduced by interventions at the worksite. Even modest reductions of cholesterol levels may reduce the risk to a tangible degree.

Attack rate, mortality and case fatality for acute myocardial infarction in Sweden during 1987-95. Results from the national AMI register in Sweden

OBJECTIVE

To assess trends in attack rate, mortality and case-fatality of acute myocardial infarction (AMI) in Sweden.

SETTING

All 303 324 Swedes discharged from hospitals, or deceased, with a diagnosis of AMI between 1987 and 1995.

DESIGN

Analysis based on the National AMI Register in Sweden. The National AMI Register was assembled by linking the records of the National Hospital Discharge Register and the National Cause of Death Register in Sweden.

MAIN OUTCOME MEASURES

Age-standardized attack rate, mortality and case fatality rates for AMI.

RESULTS

Between 1987 and 1995, the age-standardized attack rate of AMI declined by 11% for men and 10% for women, whilst mortality from AMI decreased by 14% for both sexes. The decrease was most pronounced for men below the age of 64, with a reduction of 22% in attack rate and nearly 30% in mortality. There was no change over time in the case fatality rates on the date of attack, including also deaths outside hospital, whilst case fatality within 28 days decreased from 49 to 45% amongst men, and 45 to 42% amongst women. This reduction persisted over 1 year of follow-up.

CONCLUSIONS

The decrease in attack rate of AMI in Sweden may be attributed both to changes in risk factors amongst the population and to improved medical intervention. The decline in case fatality rates indicates that improved treatment of patients with AMI has contributed to the reduction in mortality. However, the high, and essentially unchanged, proportion of deaths outside hospital stresses the importance of disease prevention.