Neighbourhood deprivation and hospitalization for atrial fibrillation in Sweden

Increased risk of venous thromboembolism in young and middle-aged individuals with hereditary angioedema: a family study

ABSTRACT

Hereditary angioedema (HAE), caused by C1 inhibitor protein deficiency, was recently shown to be associated with an increased risk for venous thromboembolism (VTE). To our knowledge, this is the first national family study of HAE, which aimed to determine the familial risk of VTE. The Swedish Multi-Generation Register was linked to the Swedish National Patient Register for the period of 1964 to 2018. Only patients with HAE with a validated diagnosis were included in the study and were linked to their family members. Hazard ratios (HRs) and 95% confidence intervals (CIs) for VTE were calculated for patients with HAE in comparison with relatives without HAE. Among 2006 individuals (from 276 pedigrees of 365 patients with HAE), 103 individuals were affected by VTE. In total, 35 (9.6%) patients with HAE were affected by VTE, whereas 68 (4.1%) non-HAE relatives were affected (P < .001). The adjusted HR for VTE among patients with HAE was 2.51 (95% CI, 1.67-3.77). Patients with HAE were younger at the first VTE than their non-HAE relatives (mean age, 51 years vs 63 years; P < .001). Before the age of 70 years, the HR for VTE among patients with HAE was 3.62 (95% CI, 2.26-5.80). The HR for VTE for patients with HAE born after 1964 was 8.29 (95% CI, 2.90-23.71). The HR for VTE for patients with HAE who were born in 1964 or earlier was 1.82 (95% CI, 1.14-2.91). HAE is associated with VTE among young and middle-aged individuals in Swedish families with HAE. The effect size of the association is in the order of other thrombophilias. We suggest that HAE may be considered a new rare thrombophilia.

Heart failure in first- and second-generation immigrants aged 18-54 years in Sweden: A national study

PURPOSE

We aimed at analysing the risk of congestive heart failure (CHF) among first- and second-generation immigrants in younger age groups.

METHODS

All individuals aged 18-54 years, n = 3 973 454 in the first-generation study and n = 3 817 560 in the second-generation study, were included. CHF was defined as at least one registered diagnosis in the National Patient Register between 1 January 1998 and 31 December 2018. Cox regression analysis was used to estimate the relative risk [hazard ratios (HRs) with 99% confidence intervals (CIs)] of incident CHF with adjustments for age, co-morbidities and socio-demographics.

RESULTS

In the first-generation study, a total of 85 719 cases of CHF were registered, 54 369 men and 31 350 women, where fully adjusted models showed HRs for all foreign-born men of 1.12 (99% CI 1.06-1.17) and for women of 0.99 (0.92-1.05). Groups with higher risk included men from Eastern Europe, Central Europe, Africa and Asia and women from Africa and Asia, and a lower risk was found among Latin American women. In the second-generation study, a total of 88 999 cases of CHF were registered, 58 403 men and 30 596 women, where fully adjusted models showed HRs for second-generation men of 1.04 (0.99-1.09) and women of 0.97 (0.90-1.04).

CONCLUSIONS

The higher risk in some foreign-born groups needs to be paid attention to in clinical practice. The fact that almost all increased risks were attenuated and absent in second-generation immigrants suggests that lifestyle and environmental factors are more important than genetic differences in the risk of CHF.

Social drivers in atrial fibrillation occurrence, screening, treatment, and outcomes: systematic-narrative hybrid review

The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

Environmental Exposome and Atrial Fibrillation: Emerging Evidence and Future Directions

There has been increased awareness of the linkage between environmental exposures and cardiovascular health and disease. Atrial fibrillation is the most common sustained cardiac arrhythmia, affecting millions of people worldwide and contributing to substantial morbidity and mortality. Although numerous studies have explored the role of genetic and lifestyle factors in the development and progression of atrial fibrillation, the potential impact of environmental determinants on this prevalent condition has received comparatively less attention. This review aims to provide a comprehensive overview of the current evidence on environmental determinants of atrial fibrillation, encompassing factors such as air pollution, temperature, humidity, and other meteorologic conditions, noise pollution, greenspace, and the social environment. We discuss the existing evidence from epidemiological and mechanistic studies, critically evaluating the strengths and limitations of these investigations and the potential underlying biological mechanisms through which environmental exposures may affect atrial fibrillation risk. Furthermore, we address the potential implications of these findings for public health and clinical practice and identify knowledge gaps and future research directions in this emerging field.

Sarcoidosis in first- and second-generation immigrants: a cohort study of all adults 18 years of age and older in Sweden

BACKGROUND

There is a lack of studies on sarcoidosis among immigrants, which is of interest as there may be genetic and environmental characteristics affecting immigrants from certain countries. We aimed to study hazard ratios (HRs) of sarcoidosis in first- and second-generation immigrants, comparing them with native Swedes in the total adult Swedish population.

METHODS

We conducted a nationwide study of individuals ≥18 y of age. Sarcoidosis was defined as at least two registered diagnoses in the National Patient Register between 1 January 1998 and 31 December 2018. Cox regression analysis was used to estimate HRs with 99% confidence intervals (CIs) of first registration of sarcoidosis in first- and second-generation immigrants compared with native Swedes. The Cox regression models were stratified by sex and adjusted for age, comorbidities and sociodemographic characteristics.

RESULTS

In total, 6 175 251 were included in the first-generation study, with 12 617 cases of sarcoidosis, and 4 585 529 in the second-generation study, with 12 126 cases. The overall sarcoidosis risk was lower in foreign-born men (fully adjusted HR 0.63 [99% CI 0.57 to 0.69]) but not in foreign-born women (fully adjusted HR 0.98 [99% CI 0.90 to 1.06]). The overall risk was slightly lower in second-generation immigrants (HR 0.82 [99% CI 0.78 to 0.88]). Women from Asia exhibited a higher risk (HR 1.25 [99% CI 1.02 to 1.53)], while a potential trend was observed among women from Africa (HR 1.47 [99% CI 0.99 to 2.19]).

CONCLUSIONS

Sarcoidosis risk was lower in foreign-born men but not in women and also lower in second-generation immigrants.

Hypertension in Pregnancy Among Immigrant and Swedish Women: A Cohort Study of All Pregnant Women in Sweden

BACKGROUND

Little is known about risks of hypertensive disorders of pregnancy in both first- and second-generation immigrant women in Europe and other Western countries; such knowledge may help elucidate the influence of genetic versus social factors on such risks. We aimed to study both first- and second-generation immigrant women for the presence of all types of hypertension (preexisting hypertension, gestational hypertension, preeclampsia, and eclampsia) during pregnancy.

METHODS AND RESULTS

A cohort study was conducted using data derived from the Swedish National Birth Register, the National Patient Register, and the Total Population Register. We used Cox regression analysis to compute hazard ratios (HRs) and 99% CIs while adjusting for sociodemographic factors and comorbidities. The first-generation study included a total of 1 084 212 deliveries and 68 311 hypertension cases, and the second-generation study included 989 986 deliveries and 67 505 hypertension cases. The fully adjusted HR (with 99% CI) for hypertension in pregnancy among first-generation immigrant women was 0.69 (0.66-0.72), and among second-generation immigrant women, it was 0.88 (0.86-0.91), compared with Swedish-born women with 2 Swedish-born parents. Women born in Finland or with parent(s) from Finland had higher risks, with fully adjusted HRs (99% CIs) of 1.30 (1.18-1.43) and 1.12 (1.07-1.17), respectively.

CONCLUSIONS

Both first- and second-generation immigrant women had overall lower risks of hypertension in pregnancy compared with other Swedish women. However, the risk reduction was less pronounced in second-generation compared with first-generation immigrant women, suggesting that environmental factors in Sweden may have an important influence on risk of hypertension during pregnancy.

Diabetes risk during pregnancy among second-generation immigrants: A national cohort study in Sweden

BACKGROUND AND AIMS

Gestational diabetes is more common in many first-generation immigrant women in Europe and other Western countries. Less is known about second-generation immigrant women; such knowledge is needed to understand generational influences on diabetes risk. We aimed to study second-generation immigrant women regarding the presence of all types of diabetes during pregnancy.

METHODS AND RESULTS

A cohort study was conducted using the Swedish National Birth Register, the National Patient Register, and the Total Population Register. We used Cox regression analysis to compute hazard ratios (HRs) and 99% confidence intervals (99% CI) for any diabetes during pregnancy and specific subtypes (gestational diabetes, pre-existing diabetes type 1, pre-existing diabetes type 2) in second-generation immigrant women compared with Swedish-born women with two Swedish-born parents while adjusting for sociodemographic factors, family history of diabetes, body mass index, smoking habits, and comorbidities. The study population included a total of 989,986 deliveries and 17,938 diabetes cases. The fully adjusted HR (with 99% CI) for any type of diabetes during pregnancy among second-generation immigrant women was 1.11 (1.05-1.18). Higher risks were found in women with parents from Africa, Asia, or Eastern Europe, as well as Denmark. A lower risk for pre-existing type 1 diabetes was found overall and for women with parents from most geographic regions.

CONCLUSION

In this national cohort study, the risk of all types of diabetes during pregnancy was increased in second-generation immigrant women. Diabetes prevention and treatment is especially important in these women both before and during pregnancy.

Association of Neighborhood Disadvantage and Anticoagulation for Patients with Atrial Fibrillation in the Veterans Health Administration: the REACH-AF Study

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia, the management of which includes anticoagulation for stroke prevention. Although disparities in anticoagulant prescribing have been well documented for individual socioeconomic factors, less is known about the association of neighborhood-level disadvantage and anticoagulation for AF.

OBJECTIVE

To assess the association between neighborhood disadvantage and anticoagulant initiation for patients with incident AF.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A cohort of patients enrolled in the Veterans Health Administration (VA) with incident AF from January 2014 through December 2020 from the Race, Ethnicity, and Anticoagulant CHoice in Atrial Fibrillation (REACH-AF) Study.

MAIN MEASURES

The primary exposure was neighborhood disadvantage quantified using area deprivation index (ADI), classified by quintiles (Q). The outcomes were initiation of any anticoagulant therapy (warfarin or direct oral anticoagulant, DOAC) within 90 days of AF diagnosis and DOAC use among initiators. We used mixed effects logistic regression to assess the association between ADI and anticoagulant therapy, incorporating a fixed effect for treatment site and baseline patient, provider, and facility covariates.

KEY RESULTS

Among 161,089 patients, 105,489 (65.5%) initiated any anticoagulant therapy, and 78,903 (74.8%) used DOACs. Any anticoagulant therapy increased 3.2 percentage points (63.0% to 66.2%; p<.001) from Q1 to Q5, whereas DOAC use decreased 8.2 percentage points (79.4% to 71.2%; p<.0001) across quintiles. The adjusted odd ratios of any anticoagulant therapy were non-significantly different for Q2-Q5 than Q1. The adjusted odds of DOAC use decreased progressively from 0.89 (95% CI, 0.84-0.94) in Q2 to 0.77 (95% CI, 0.73-0.83) in Q5 compared to Q1 (p<.0001).

CONCLUSIONS

Among Veterans with incident AF, we observed similar initiation of any anticoagulant, though neighborhood deprivation was associated with decreased DOAC use among anticoagulant initiators. Future interventions to improve pharmacoequity in anticoagulant prescribing for AF should consider the role of neighborhood-level determinants of health inequities.

Blood pressure, hypertension and the risk of atrial fibrillation: a systematic review and meta-analysis of cohort studies

Elevated blood pressure and hypertension have been associated with increased risk of atrial fibrillation in a number of epidemiological studies, however, the strength of the association has differed between studies. We conducted a systematic review and meta-analysis of the association between blood pressure and hypertension and atrial fibrillation. PubMed and Embase databases were searched for studies of hypertension and blood pressure and atrial fibrillation up to June 6th 2022. Cohort studies reporting adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) of atrial fibrillation associated with hypertension or blood pressure were included. A random effects model was used to estimate summary RRs. Sixty eight cohort studies were included in the meta-analysis. The summary RR was 1.50 (95% CI: 1.42-1.58, I2 = 98.1%, n = 56 studies) for people with hypertension compared to those without hypertension (1,080,611 cases, 30,539,230 participants), 1.18 (95% CI: 1.16-1.21, I2 = 65.9%, n = 37 studies) per 20 mmHg increase in systolic blood pressure (346,471 cases, 14,569,396 participants), and 1.07 (95% CI: 1.03-1.11, I2 = 91.5%, n = 22 studies) per 10 mmHg increase in diastolic blood pressure (332,867 cases, 14,354,980 participants). There was evidence of a nonlinear association between diastolic blood pressure and atrial fibrillation with a steeper increase in risk at lower levels of diastolic blood pressure, but for systolic blood pressure the association appeared to be linear. For both systolic and diastolic blood pressure, the risk increased even within the normal range of blood pressure and persons at the high end of systolic and diastolic blood pressure around 180/110 mmHg had a 1.8-2.3 fold higher risk of atrial fibrillation compared to those with a blood pressure of 90/60 mmHg. These results suggest that elevated blood pressure and hypertension increases the risk of atrial fibrillation and there is some increase in risk even within the normal range of systolic and diastolic blood pressure.

Transforming Atrial Fibrillation Research to Integrate Social Determinants of Health: A National Heart, Lung, and Blood Institute Workshop Report

Importance

Only modest attention has been paid to the contributions of social determinants of health to atrial fibrillation (AF) risk factors, diagnosis, symptoms, management, and outcomes. The diagnosis of AF provides unique challenges exacerbated by the arrhythmia's often paroxysmal nature and individuals' disparate access to health care and technologies that facilitate detection. Social determinants of health affect access to care and management decisions for AF, increasing the likelihood of adverse outcomes among individuals who experience systemic disadvantages. Developing effective approaches to address modifiable social determinants of health requires research to eliminate the substantive inequities in health care delivery and outcomes in AF.

Observations

The National Heart, Lung, and Blood Institute convened an expert panel to identify major knowledge gaps and research opportunities in the field of social determinants of AF. The workshop addressed the following social determinants: (1) socioeconomic status and access to care; (2) health literacy; (3) race, ethnicity, and racism; (4) sex and gender; (5) shared decision-making in systemically disadvantaged populations; and (6) place, including rurality, neighborhood, and community. Many individuals with AF have multiple adverse social determinants, which may cluster in the individual and in systemically disadvantaged places (eg, rural locations, urban neighborhoods). Cumulative disadvantages may accumulate over the life course and contribute to inequities in the diagnosis, management, and outcomes in AF.

Conclusions and Relevance

Workshop participants identified multiple critical research questions and approaches to catalyze social determinants of health research that address the distinctive aspects of AF. The long-term aspiration of this work is to eradicate the substantive inequities in AF diagnosis, management, and outcomes across populations.

Cardiomyopathy among first- and second-generation immigrants in Sweden: a nationwide total population study

PURPOSE

We aimed to analyze the risk of cardiomyopathies (CMPs) among first-generation and second-generation immigrants.

METHODS

All individuals aged 18 years of age and older, n = 6,123,661 in the first-generation study, and n = 4,587,764 in the second-generation study were analyzed. CMP was defined as at least one registered diagnosis in the National Patient Register between January 1, 1998 and December 31, 2018. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 99% confidence intervals (CI)) of incident CMP with adjustments made for age, cancer, other comorbidities, and sociodemographic factors.

RESULTS

In the first-generation study, a total of 33,321 CMP cases were registered, 20,780 men and 12,541 women, where the fully adjusted models showed HRs (99% CI) for all foreign-born men of 0.92 (0.86-0.98) and for women of 0.90 (0.83-0.98). For dilated CMP, the risk was higher for men from Nordic countries, more specifically men from Finland, and lower for men and women from Asia. For hypertrophic CMP, the risk was higher for men from Africa and Asia. For other types of CMPs, the risk was lower in men and women from Asia. In the second-generation study, a total of 26,559 cases were registered (17,620 men and 8939 women), with no significant differences overall or among specific groups, when Swedish-born with foreign-born parents were compared to Swedish-born with Swedish-born parents.

CONCLUSIONS

We observed a generally lower risk of CMPs among foreign-born individuals, but with a higher risk especially for hypertrophic CMPs for men from Africa and Asia, and a higher risk of dilated CMP for men from Nordic countries.

Valvular heart diseases in immigrants and Swedish-born individuals: a national cohort study

Objectives. The aim of this study was to analyse the risk of valvular heart diseases among foreign-born individuals in Sweden. Design. This was a nationwide study of individuals aged 18 years of age and older (N = 6,118,649; 2,970,055 men and 3,148,594 women). Valvular heart diseases were defined as at least one registered diagnosis in the National Patient Register between 1 January 1998 and 31 December 2012. Cox regression analysis was used to estimate hazard ratios (HR) with 99% confidence intervals (CI) of incident valvular heart diseases in foreign-born individuals compared to Swedish natives. The Cox regression models were adjusted for age, co-morbidities, and sociodemographic factors. Sub-categories were chronic rheumatic valvular heart diseases and non-rheumatic valvular heart diseases. Results. There were 64,979 male cases and 59,075 female cases. Fully adjusted HRs (99% CI) were among immigrant men 0.86 (0.82-0.89) and immigrant women 0.96 (0.92-1.00). For chronic rheumatic valvular disease among immigrant men and women, the HRs were 1.62 (1.37-1.92) and 1.75 (1.52-2.00), respectively, and, for non-rheumatic valvular disease among immigrant men 0.83 (0.80-0.87) and immigrant women 0.92 (0.88-0.96). Increased risks for chronic rheumatic valvular disease were found among men from Southern, Eastern and Central Europe, Africa and Asia and among women from Western, Eastern and Central Europe and Africa, Latin America and Asia. Conclusions. We observed lower risks in general of valvular heart disease, but higher risks of chronic rheumatic valvular heart disease in immigrants, which is important in the clinical situation.

Association of chronic kidney disease with all-cause mortality in patients hospitalized for atrial fibrillation and impact of clinical and socioeconomic factors on this association

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) often co-occur, and many of the same clinical factors and indicators of socioeconomic status (SES) are associated with both diseases. The effect of the estimated glomerular filtration rate (eGFR) on all-cause mortality in AF patients and the impact of SES on this relationship are uncertain.

Materials and methods

This retrospective study examined 968 patients who were admitted for AF. Patients were divided into four groups based on eGFR at admission: eGFR-0 (normal eGFR) to eGFR-3 (severely decreased eGFR). The primary outcome was all-cause mortality. Cox regression analysis was used to identify the effect of eGFR on mortality, and subgroup analyses to determine the impact of confounding factors.

Results

A total of 337/968 patients (34.8%) died during follow-up. The average age was 73.70 ± 10.27 years and there were 522 males (53.9%). More than 39% of these patients had CKD (eGFR < 60 mL/min/1.73 m²), 319 patients with moderately decreased eGFR and 67 with severely decreased eGFR. After multivariate adjustment and relative to the eGFR-0 group, the risk for all-cause death was greater in the eGFR-2 group (HR = 2.416, 95% CI = 1.366-4.272, p = 0.002) and the eGFR-3 group (HR = 4.752, 95% CI = 2.443-9.242, p < 0.00001), but not in the eGFR-1 group (p > 0.05). Subgroup analysis showed that moderately to severely decreased eGFR only had a significant effect on all-cause death in patients with low SES.

Conclusion

Moderately to severely decreased eGFR in AF patients was independently associated with increased risk of all-cause mortality, especially in those with lower SES.

Cardiovascular-related conditions and risk factors in primary care for deprived communities before and during the COVID-19 pandemic: an observational study in Northern England

OBJECTIVES

The North East of England, ranked as having the highest poverty levels and the lowest health outcomes, has the highest cardiovascular disease (CVD) premature mortality. This study aimed to compare CVD-related conditions and risk factors for deprived practice populations with other general practice (GP) populations in Northern England to England overall, before and during COVID-19 to identify changes in recorded CVD-related risk factors and conditions and evidence-based lipid prescribing behaviour.

DESIGN

A population-based observational study of aggregated practice-level data obtained from publicly accessible data sets.

SETTING

34 practices that fall into the 15% most deprived practice populations in England were identified as the most deprived communities in the North East and North Cumbria (Deep End).

PARTICIPANTS

Patients aged ≥16 registered with GP and diagnosed with any form of CVD.

PRIMARY AND SECONDARY OUTCOME MEASURES

CVD-related conditions and risk factors, statin prescribing.

RESULTS

Deep End (n=263 830) had a smaller, younger and more deprived population with lower levels of employment and full-time education and higher smoking prevalence. They had some higher recorded CVD-related conditions than England but lower than the non-Deep End. Atrial fibrillation (-0.9, -0.5), hypertension (-3.7, -1.3) and stroke and transient ischaemic attack rates (-0.5, -0.1) appeared to be lower in the Deep End than in the non-Deep End but the optimal statin prescribing rate was higher (3.1, 8.2) than in England.

CONCLUSION

Recorded CVD-related risk factors and conditions remained comparable before and during COVID-19. These are higher in the Deep End than in England and similar or lower than the non-Deep End, with a higher optimal statin prescribing rate. However, it was not possible to control for age and sex. More work is needed to estimate the consequences of the pandemic on disadvantaged communities and to compare whether the findings are replicated in other areas of deprivation.

The impact of socioeconomic deprivation on the risk of atrial fibrillation in patients with diabetes mellitus: A nationwide population-based study

Objective

To evaluate the relationship between socioeconomic status and the risk of atrial fibrillation (AF) in patients with diabetes mellitus (DM).

Research design and methods

From the National Health Insurance Service (NHIS) database, we identified 2,429,610 diabetic patients who underwent national health check-ups between 2009 and 2012. Tracing back the subjects for 5 years from the date of health check-up, we determined the subjects’ income and whether they received medical aid (MA) during the past 5 years. Subjects were divided into six groups according to the number of years of receiving (MA groups 0 through 5) and into four groups according to socioeconomic status change during the past 5 years. We estimated the risk of AF for each group using the Cox proportional-hazards model.

Results

During a median follow-up of 7.2 ± 1.7 years, 80,257 were newly identified as AF. The MA groups showed a higher risk of AF than the non-MA group with the hazard ratios (HRs) and 95% confidence interval (CI) 1.32 (1.2–1.44), 1.33 (1.22–1.45), 1.23 (1.13–1.34), 1.28 (1.16–1.4), and 1.50 (1.39–1.63) for MA groups 1 through 5, respectively. Dividing subjects according to socioeconomic condition change, those who experienced worsening socioeconomic status (non-MA to MA) showed higher risk compared to the persistent non-MA group (HR 1.54; 95% CI 1.38–1.73).

Conclusion

Low socioeconomic status was associated with the risk of AF in patients with diabetes. More attention should be directed at alleviating health inequalities, targeting individuals with socioeconomic deprivation to provide timely management for AF.

Hearing impairment among adult foreign-born and Swedish-born individuals: A national Swedish study

Objectives

To analyze the risk of hearing impairment in adult first-generation immigrants, i.e., foreign-born individuals as compared to Swedish-born individuals.

Study design

A register-based study follow-up study.

Methods

A nationwide study of individuals 25 years of age and older (N = 5 464 245; 2 627 364 men and 2 836 881 women) in Sweden. Hearing impairment was defined as at least one registered diagnosis in the National Patient Register between January 1^st, 1998 and December 31^st, 2015. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident hearing impairment in foreign-born compared to Swedish-born individuals. Cox regression models were stratified by sex and adjusted for age, comorbidities, and socioeconomic status.

Results

A total of 244 171 cases (124 349 men and 119 822 women) of hearing impairment were registered. Hearing impairment risk expressed as fully adjusted HRs (99% CI) was somewhat lower among immigrant men 0.95 (0.92–97) but not among immigrant women 0.97 (0.95–1.00), with significantly higher fully adjusted HRs among men and women from Asia, and Eastern Europe, and women from Africa.

Conclusions

We observed a somewhat lower risk of hearing impairment among foreign-born men, but there was a higher risk among men and women from some regions.

Association Between Neighborhood-Level Poverty and Incident Atrial Fibrillation: a Retrospective Cohort Study

BACKGROUND

Atrial fibrillation (AF) is a leading cause of cardiovascular morbidity and mortality. While neighborhood-level factors, such as poverty, have been related to prevalence of AF risk factors, the association between neighborhood poverty and incident AF has been limited.

OBJECTIVE

Using a large cohort from a health system serving the greater Chicago area, we sought to determine the association between neighborhood-level poverty and incident AF.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Adults, aged 30 to 80 years, without baseline cardiovascular disease from January 1, 2005, to December 31, 2018.

MAIN MEASURES

We geocoded and matched residential addresses of all eligible patients to census-level poverty estimates from the American Community Survey. Neighborhood-level poverty (low, intermediate, and high) was defined as the proportion of residents in the census tract living below the federal poverty threshold. We used generalized linear mixed effects models with a logit link function to examine the association between neighborhood poverty and incident AF, adjusting for patient demographic and clinical AF risk factors.

KEY RESULTS

Among 28,858 in the cohort, patients in the high poverty group were more often non-Hispanic Black or Hispanic and had higher rates of AF risk factors. Over 5 years of follow-up, 971 (3.4%) patients developed incident AF. Of these, 502 (51.7%) were in the low poverty, 327 (33.7%) in the intermediate poverty, and 142 (14.6%) in the high poverty group. The adjusted odds ratio (aOR) of AF was higher for the intermediate poverty compared with that for the low poverty group (aOR 1.23 [95% CI 1.01-1.48]). The point estimate for the aOR of AF incidence was similar, but not statistically significant, for the high poverty compared with the low poverty group (aOR 1.25 [95% CI 0.98-1.59]).

CONCLUSION

In adults without baseline cardiovascular disease managed in a large, integrated health system, intermediate neighborhood poverty was significantly associated with incident AF. Understanding neighborhood-level drivers of AF disparities will help achieve equitable care.

Incident cases of vision impairment and blindness among adult foreign-born and Swedish-born individuals: A national Swedish study

PURPOSE

To analyse risk of vision impairment (VI) and blindness in adult foreign-born individuals and Swedish-born individuals.

METHODS

A nationwide study of individuals 18 years of age and older (N = 6,042,891; 2,902,918 men and 3,139,973 women) in Sweden. VI (in general) and blindness was defined as at least one registered diagnosis in the National Patient Register between January 1, 1998 and December 31, 2015. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident VI in foreign-born compared to Swedish-born individuals. The Cox regression models were stratified by sex and adjusted for age, co-morbidities, and for sociodemographic status.

RESULTS

A total of 14,597 cases (6433 men and 8164 women) of VI were registered, with an age-standardized incidence per 100,000 person-years of 10.37 in men and 11.03 in women. VI (in general) was more common in immigrants, fully adjusted HRs (95% CI) were for immigrant men 1.38 (95% CI, 1.29-1.48) and women 1.24 (95% CI, 1.16-1.32), with significantly higher HRs among men and women from Eastern Europe, Africa, Latin America and Asia. Higher risks of blindness were also seen for immigrant men, HR 1.75 (95% CI 1.36-2.25), as well as for the other degrees of VI among immigrant men, HR 1.36 (95% CI 1.26-1.47), and immigrant women, HR 1.26 (95% CI 1.18-1.35).

CONCLUSIONS

We observed a generally higher risk of VI among foreign-born men and women, especially from some regions.

Association between magnesium in drinking water and atrial fibrillation incidence: a nationwide population-based cohort study, 2002-2015

BACKGROUND

Atrial fibrillation (AF) is a common heart rhythm disorder and a risk factor of adverse cardiovascular diseases. Established causes do not fully explain the risk of AF and unexplained risk factors might be related to the environment, e.g. magnesium in drinking water. Low magnesium levels in drinking water might be associated with higher risk of cardiovascular diseases including AF. With detailed individual data from nationwide registries and long-term magnesium exposure time series, we had a unique opportunity to investigate the association between magnesium in drinking water and AF.

OBJECTIVE

We evaluated the association between magnesium concentration in drinking water and AF risk.

METHODS

A nationwide register-based cohort study (2002-2015) was used including individuals aged ≥30 years. Addresses were linked with water supply areas (n = 2418) to obtain time-varying drinking water magnesium exposure at each address. Five exposure groups were defined based on a 5-year rolling time-weighted average magnesium concentration. AF incidence rate ratios (IRRs) between exposure groups were calculated using a Poisson regression of incidence rates, adjusted for sex, age, and socioeconomic position. Robustness of results was investigated with different exposure definitions.

RESULTS

The study included 4,264,809 individuals (44,731,694 person-years) whereof 222,998 experienced an incident AF. Magnesium exposure ranged from 0.5 to 62.0 mg/L (mean = 13.9 mg/L). Estimated IRR (95% CI) compared to the referent exposure group (< 5 mg/L) was 0.98 (0.97-1.00) for the second lowest exposure group (5-10 mg/L), and 1.07 (1.05-1.08) for the two highest exposure groups (15-62 mg/L). Strongest positive associations were observed among those aged ≥80 years and with lowest education group. An inverse association was found among individuals with highest education group.

CONCLUSION

There might be a small beneficial effect on AF of an increase in magnesium level in drinking water up to 10 mg/L, though an overall positive association was observed. The unexpected positive association and different associations observed for subgroups suggest a potential influence of unaccounted factors, particularly in vulnerable populations. Future research on magnesium in drinking water and cardiovascular diseases needs to focus on contextual risk factors, especially those potentially correlating with magnesium in drinking water.

Social determinants of atrial fibrillation

Atrial fibrillation affects almost 60 million adults worldwide. Atrial fibrillation is associated with a high risk of cardiovascular morbidity and death as well as with social, psychological and economic burdens on patients and their families. Social determinants - such as race and ethnicity, financial resources, social support, access to health care, rurality and residential environment, local language proficiency and health literacy - have prominent roles in the evaluation, treatment and management of atrial fibrillation. Addressing the social determinants of health provides a crucial opportunity to reduce the substantial clinical and non-clinical complications associated with atrial fibrillation. In this Review, we summarize the contributions of social determinants to the patient experience and outcomes associated with this common condition. We emphasize the relevance of social determinants and their important intersection with atrial fibrillation treatment and outcomes. In closing, we identify gaps in the literature and propose future directions for the investigation of social determinants and atrial fibrillation.

Geographical variation and clustering are found in atrial fibrillation beyond socioeconomic differences: a Danish cohort study, 1987-2015

BACKGROUND

The prevalence and incidence rate of atrial fibrillation (AF) increase worldwide and AF is a risk factor for more adverse cardiovascular diseases including stroke. Approximately 44% of AF cases cannot be explained by common individual risk factors and risk might therefore also be related to the environment. By studying geographical variation and clustering in risk of incident AF adjusted for socioeconomic position at an individual level, potential neighbourhood risk factors could be revealed.

METHODS

Initially, yearly AF incidence rates 1987-2015 were estimated overall and stratified by income in a register-based cohort study. To examine geographical variation and clustering in AF, we used both spatial scan statistics and a hierarchical Bayesian Poisson regression analysis of AF incidence rates with random effect of municipalities (n = 98) in Denmark in 2011-2015.

RESULTS

The 1987-2015 cohort included 5,453,639 individuals whereof 369,800 were diagnosed with an incident AF. AF incidence rate increased from 174 to 576 per 100,000 person-years from 1987 to 2015. Inequality in AF incidence rate ratio between highest and lowest income groups increased from 23% in 1987 to 38% in 2015. We found clustering and geographical variation in AF incidence rates, with incidence rates at municipality level being up to 34% higher than the country mean after adjusting for socioeconomic position.

CONCLUSIONS

Geographical variations and clustering in AF incidence rates exist. Compared to previous studies from Alberta, Canada and the United States, we show that geographical variations exist in a country with free access to healthcare and even when accounting for socioeconomic differences at an individual level. An increasing social inequality in AF was seen from 1987 to 2015. Therefore, when planning prevention strategies, attention to individuals with low income should be given. Further studies focusing on identification of neighbourhood risk factors for AF are needed.

Osteoporotic fractures among foreign-born individuals: a national Swedish study

In this national study of osteoporotic fractures in foreign-born individuals, we found a lower risk of osteoporotic fractures in general among foreign-born individuals compared with Swedish-born, especially in immigrants from southern Europe. A higher risk was found among some groups, i.e. men and women from Bosnia and Iraq and men from Lebanon.

INTRODUCTION

The aim of this study was to analyse risk of osteoporotic fractures in foreign-born individuals compared with Swedish-born individuals.

METHODS

This was a nationwide study of individuals 50 years of age and older (N = 2,775,736). Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm or vertebrae, in the National Patient Register between January 1, 1998, and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 99% confidence intervals (CI)) of incident osteoporotic fractures in foreign-born compared with Swedish-born individuals. The Cox regression models were stratified by sex and adjusted for age, comorbidities and sociodemographic status.

RESULTS

A total of 362,899 osteoporotic fractures were registered (96,847 among men and 266,052 among women), with hip fractures dominating (54.0% among men, 42.6% among women). Fully adjusted HRs (99% CI) were for all immigrant men 0.75 (99% CI, 0.73-0.78) and women 0.83 (99% CI, 0.81-0.84), with significantly lower HRs among most groups but with higher HRs in certain countries. For the specific fractures, higher HRs were found for lower forearm fractures for men from Asia and for vertebral fractures among women from Asia.

CONCLUSIONS

We observed a generally lower risk of osteoporotic fractures among first-generation immigrants, with few exceptions.

The association between sociodemographic characteristics and dementia in patients with atrial fibrillation

Objectives

Association between socio-demographic factors and dementia risk is studied in general but not for atrial fibrillation (AF) patients.

Methods

We studied AF patients ≥ 45 years in Sweden 1998–2012 (n = 537,513) using the Total Population Register for socio-demographic factors, the Swedish Cause of Death Register, and the National Patient Register (NPR) for incident dementia. Cox regression with hazard ratios (HR) and 95% confidence intervals (CI) was used for the association between exposure and outcome, adjusting for age and comorbidities.

Results

Totally 30,332 patients (5.6%) were diagnosed with dementia during the follow-up (mean 5.4 years). Of these, 14,097 were men (4.9%) and 16,235 were women (6.5%). Lower educational levels (reference: highest level) were associated with increased dementia, HRs (95% CI) for basic school for men 1.23 (1.18–1.29) and women 1.36 (1.30–1.42), and middle-level school for men 1.17 (1.11–1.22) and women 1.28 (1.22–1.34). Divorced men and women (reference: married) showed increased risk of dementia, HR 1.07 (1.01–1.13) and 1.12 (1.06–1.18), respectively, while widowed men showed lower risk, HR 0.84 (0.80–0.88). High deprivation neighborhood socio-economic status (NSES; reference: medium level) was associated with increased dementia in men, HR 1.11 (1.05–1.17), and low deprivation neighborhood socio-economic status (NSES) with increased dementia in men and women, HR 1.12 (1.06–1.18) and 1.18 (1.12–1.24), respectively.

Conclusions

Some results were expected, i.e. association between lower educational level and dementia. The higher risk of dementia in low deprivation NSES-areas could be due to a higher awareness about dementia, and subsequent earlier diagnosis and treatment of dementia.

Electronic supplementary material

The online version of this article (10.1007/s40520-019-01449-3) contains supplementary material, which is available to authorized users.

Levothyroxine treatment is associated with an increased relative risk of overall and organ specific incident cancers - a cohort study of the Swedish population

High thyroid hormone values have been associated with an increased risk of incident cancers, especially breast cancer but also lung cancer and any solid cancers. We explored whether there is an increased risk of overall and cause-specific cancers in those receiving levothyroxine treatment. We included all individuals ≥ 18 years in Sweden (N = 8,573,313) on January 1 2009, and identified patients with two or more dispensed prescriptions of levothyroxine 2005-2006 (n = 253,193, 3.0 %). A cancer diagnosis in the Swedish Cancer Register 2009-2015 was used as outcome. We excluded patients with a cancer diagnosis before 2005. Cox regression was used (hazard ratios, HRs, and 95 % confidence intervals, CI) with adjustments for age, socioeconomic/neighborhood factors and co-morbidities. Totally 399,751 cases of incident cancer were identified, with a slight increased overall risk associated with levothyroxine treatment for both men, adjusted HR 1.06 (95 % CI 1.03-1.10), and women, adjusted HR 1.08 (95 % CI 1.07-1.10). For men, increased risks were found for cancers of the thyroid gland and other endocrine glands. For women, increased risks were found for cancers of the breast, endometrium, other female genitals (ovaries not included), stomach, colon, liver, pancreas, urinary bladder, skin, leukemia, and unspecified primary tumor. Unlike men, for women, no increased risk was found for cancer of the thyroid gland. In conclusions, levothyroxine treatment was associated with an excess cancer risk, including many different types of cancer, especially among women. Our results need confirmation by other studies, but levothyroxine is recommended to be prescribed only on approved indications.

Annual rate of newly treated atrial fibrillation by age and gender in France, 2010-2016

Few studies are available on atrial fibrillation (AF) burden at a whole country scale. The objective was to estimate the rate of AF patients newly treated with oral anticoagulants (OAC) in France each year between 2010 and 2016 and to describe age and gender differences. We used the French national health data system. For each year between 2010 and 2016, we identified patients aged over 20 initiating OAC. OAC indicated for the treatment of AF was determined by hospitalization diagnoses, specific procedures and registered long-term disease status, or a multiple imputation process for patients with no recorded information as to why they initiated OAC. Among the 421,453 individuals initiating OAC treatment in 2016, the estimated number of newly treated AF patients was 210,131, women accounting for 46%, patients under 65 years old 17%, and 21.4% of patients living in most deprived area. Age-standardized rates reached 400/100,000 inhabitants. Approximately 19% of patients were recently hospitalized for heart failure and 7% for stroke. Age-standardized rates increased by 35% over the study period in both genders, with a marked increase in patients under 55 (+ 41%) and those over 85 years old (+ 60%). Annual rates of AF patients newly treated with OAC increased by 35% between 2010 and 2016. Important differences in rates were observed according to age, gender and the deprivation level of the living area.

Socioeconomic position and risk of atrial fibrillation: a nationwide Danish cohort study

AIM

To examine the association between socioeconomic position and the risk of atrial fibrillation (AF) in different stages of life in a population of Danish citizens.

METHODS

Register-based study. We followed all individuals turning 35, 50, 65 or 80 years from 1 January 1996 to 31 December 2005 until AF, death, emigration or the end of study period (31 December 2015). Exposure was education and income. We used Cox regression for the HRs (95% CI) and the pseudo-observation method for the adjusted risk difference (RD) (%).

RESULTS

A total of 2 173 857 participants were enrolled and 151 340 incident cases of AF occurred over a median of 13.6 years of follow-up. Adjusted HR (95% CI) of incident AF for the youngest age group with the highest education (ref lowest) was 0.62 (0.50 to 0.77) (women) and 0.85 (0.76 to 0.96) (men). The associations attenuated with increasing age, that is, HRs for the oldest age group were 1.04 (0.97 to 1.10) and 0.98 (0.96 to 1.04), respectively. The corresponding adjusted RDs (%) were: -0.28 (-0.43 to -0.14), -0.18 (-0.36 to -0.01), 3.04 (-0.55 to 6.64) and -0.74 (-3.38 to 2.49), respectively. Similar but weaker associations were found for income.

CONCLUSION

Higher level of education and income was associated with a lower risk of being diagnosed with AF in young individuals but the association decreased with increasing age and was almost absent for the oldest age cohort. However, since AF is relatively rare in the youngest the RDs were low.

Association Between Relevant Co-Morbidities and Dementia With Atrial Fibrillation-A National Study

BACKGROUND

The risk of dementia is increased in patients with atrial fibrillation (AF).

OBJECTIVE

To study relevant co-morbidities and incident dementia (vascular dementia, Alzheimers disease, other dementia and all dementia) in AF patients.

METHODS

All adults (n = 537,513) ≥45 years diagnosed with AF in hospitals in Sweden 1998-2012 were included. Cox regression was used to estimate hazard ratios (HR) with 95% CIs for association between co-morbidities, and incident dementia, after adjustment for age, residence place in Sweden, and socio-economic factors.

RESULTS

Totally 30,332 patients (5.6%) were diagnosed with dementia during the follow-up, with 14,097 men (4.9%) and 16,235 women (6.5%). After adjustments (HRs; 95% CI), hypertension was associated with lower risk of incident dementia (all types) in men (0.79; 0.76-0.82) and women (0.77; 0.74-0.79). Higher risk of dementia was seen in patients with stroke, diabetes, depression and anxiety. Lower risks of dementia were also seen in AF patients with concomitant coronary heart disease and congestive heart failure.

CONCLUSIONS

The findings regarding incident dementia need to be interpreted with great caution, owing to possible "survival bias" or reversed causation. However, the lower associated risks of dementia associated with hypertension could possibly be explained by protective effects of certain antihypertensive drugs.

Socioeconomic factors and mortality in patients with atrial fibrillation-a cohort study in Swedish primary care

Background

Preventing ischaemic stroke attracts significant focus in atrial fibrillation (AF) cases. Less is known on the association between socioeconomic factors and mortality and cardiovascular outcomes in patients with AF.

Methods

Our study population included adults (n=12 283) ≥45 years diagnosed with AF at 75 primary care centres in Sweden 2001-07. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for the association between the exposures educational level, marital status, neighbourhood socioeconomic status and the outcomes all-cause mortality, after adjustment for age, and comorbid cardiovascular conditions.

Results

During a mean of 5.8 years (SD 2.4) of follow-up, 3954 (32.3%) patients had died; 1971 were women (35.0%) and 1983 were men (29.8%). Higher educational level was associated with a reduced mortality in fully adjusted models: HR 0.85 (95% CI 0.77-0.96) for secondary school in men, HR 0.73 (95% CI 0.60-0.88) for college/university in women, and HR 0.82 (95% CI 0.71-0.94) for college/university in men, compared to primary school. Unmarried men and divorced men had an increased risk of death, compared with married men: HR 1.25 (95% CI 1.05-1.50), and HR 1.23 (95% CI 1.07-1.42), respectively. College/university education level was also associated with lower risk of myocardial infarction in men and women, and lower risk of congestive heart failure in women.

Conclusion

More attention could be paid to individuals of lower levels of formal education, and unmarried men, in order to provide timely management for AF and prevent its debilitating complications.

Atrial fibrillation in immigrants under the age of 45 y in Sweden

AIM

To study association between country of birth and risk of first-onset atrial fibrillation (AF) in first- and second-generation immigrants to Sweden under 45 y of age.

METHODS

The study population included all individuals (n = 3 248 457) under the age of 45 y in Sweden, including immigrants (n = 722 249). AF was defined as first registered diagnosis in the National Patient Register. Association between country of birth and risk of AF was assessed by Cox regression, calculating HRs and 95% CIs, using Swedish-born individuals as referents. All models were stratified by sex, and in different models were adjusted for age, area of residence in Sweden, educational level, marital status, neighbourhood socioeconomic status and co-morbidity(ies).

RESULTS

A higher fully adjusted HR of incident AF was found in the total sample of first-generation immigrants, 1.44 (95% CI 1.35 to 1.54), in males born in Denmark, Lebanon and Iraq, and in females born in Turkey and Iraq. Lower HRs were found in male and female immigrants from Latin America and Iran, and female immigrants from Finland. Among second-generation immigrants, the fully adjusted HR was significantly lower, 0.70 (95% CI 0.58 to 0.83).

CONCLUSIONS

Clinicians may show a greater awareness of AF in some groups of younger immigrants to enable early diagnosis.

End-Stage Kidney Diseases in Immigrant Groups: A Nationwide Cohort Study in Sweden

BACKGROUND

Our aim was to study the association between the country of birth and incident end-stage kidney disease (ESKD) in several immigrant groups in Sweden, using individuals born in Sweden or with Swedish-born parents as referents.

METHODS

A cohort study of first- and second-generation immigrants residing in Sweden between January 1, 1998 and December 31, 2012 was performed. Outcomes were defined as having at least one registered diagnosis of ESKD in the National Patient Register. The incidence of ESKD in different immigrant groups was used in the Cox regression models to estimate hazard ratios (HRs) and 95% CIs. All models were stratified by sex and adjusted for age, geographical residence, educational level, marital status, and neighbourhood socioeconomic status.

RESULTS

Compared to their referents, higher incidence rates and HRs of ESKD (HR; 95% CI) were observed in general among foreign-born men (1.10; 1.04-1.16) and women (1.12; 1.04-1.21) but not among second-generation immigrants (persons born in Sweden with foreign-born parents). A particularly high -incidence was noted among men and women from -East-European countries, as well as from non-European regions. A lower incidence of ESKD was noted among men from Finland.

CONCLUSIONS

We observed substantial differences in incidence of ESKD between immigrant groups and the Swedish-born population, which may be clinically relevant when monitoring preventive measures in patient subgroups with a higher risk of deteriorating kidney disease, and suggest higher attention to hypertension and diabetes control in immigrants. Mechanisms attributable to the migration process or ethnic differences may lead to an increased risk of ESKD.

Heart failure in immigrant groups: a cohort study of adults aged 45 years and over in Sweden

OBJECTIVE

An increased risk of being diagnosed with coronary heart disease or atrial fibrillation has been shown among different immigrant groups. However, less is known on the risk of being diagnosed with congestive heart failure (CHF).

DESIGN

We studied CHF in immigrants including all adults ≥45 years in Sweden (n = 3,274,119) from 1998 to 2012. CHF was defined as at the first event registered in the National Patient Register. Risk of incident CHF in immigrant groups compared to the Swedish-born population was assessed by Cox regression, stratified by sex, adjusting for age, socio-demographic status, and co-morbidities.

RESULTS

During a mean follow-up of 14 years in total, a total of 302,340 (9.2%) events of CHF were registered. We found the following: higher incidence in men from Bosnia, Iraq, Lebanon, Russia and Africa; among women from Bosnia, Iraq, Lebanon, Turkey, Central Europe and Finland; lower incidence in men from Iceland, Latin America, Southern Europe, Norway and Western Europe; and among women from Iceland, Southern Europe, Norway, Denmark and Western Europe.

CONCLUSION

It is important to be aware of the increased incidence of CHF in some immigrant groups, especially from countries and areas where the immigrants have been refugees, in order to enable for a timely diagnosis, treatment of and prevention of CHF and its debilitating complications.

Associations between socioeconomic status, atrial fibrillation, and outcomes: a systematic review

BACKGROUND

Atrial fibrillation (AF) is a growing epidemic and evidence of a relationship to socioeconomic status (SES) is inconsistent. We aimed to summarize the literature about SES and AF and defined two objectives: (1) To examine the association between SES and the risk of AF; (2) To examine the association between SES and AF-related outcomes in an AF-population.

METHODS

We performed a separate search for each objective in Ovid-MEDLINE and Ovid-Embase. For objective 1, the population included was healthy participants and outcome of interest was AF. For objective 2, the population included were patients with AF and outcome of interest was mortality, treatment, ablation for AF, knowledge about AF, and morbidity.

RESULTS

For objective 1, 12 studies were included. No consistent pattern for an association between SES and the risk of AF was discovered. For objective 2, 39 studies comprising 42 outcomes were included. The majority of studies showed an association between low SES and increased mortality and morbidity.

CONCLUSION

Low SES was associated with poorer outcomes when AF was present. These findings may imply that health-care professionals and policy interventions should focus on the promotion of AF-education and management among patients with AF and low SES.

Mortality in patients with atrial fibrillation and common co-morbidities - a cohort study in primary care

OBJECTIVE

To study the association between cardiovascular co-morbidities and mortality risk in primary care patients with atrial fibrillation.

METHODS

The study population included all adults (n = 12,283) ≥ 45 years diagnosed with AF at 75 primary care centres in Sweden between 2001 and 2007. The outcome was mortality (until 2010) and data were explored for co-morbidities using Cox regression with hazard ratios (HRs). Analyses were performed stratified by sex and by age-group (45-64, 65-74 and ≥75 years of age) with adjustment for age, socio-economic factors and relevant co-morbidities.

RESULTS

During a mean of 5.8 years (standard deviation 2.4) of follow-up, 3954 (32%) patients died (1971 (35%) women, and 1983 (30%) men). High HRs were found for congestive heart disease (CHF) and cerebrovascular diseases for all age-groups among men and women (except for the 45-64 year old women); for coronary heart disease among the oldest men; for diabetes among the 65-74 year old men and the 45-64 year old women. Low HRs were found for hypertension among women ≥75 years of age.

CONCLUSIONS

In this clinical setting, CHF and cerebrovascular diseases were consistently associated with mortality in all age-groups. The possible protective effect by hypertension among elderly women should be interpreted with caution. KEY MESSAGES We found congestive heart failure and cerebrovascular diseases to be consistently associated with mortality in both women and men. We found hypertension to be associated with lower mortality risk among women ≥75 years of age, although this finding must be interpreted with caution. Depression was found to be associated with increased mortality risk among men and women aged 65-74 years of age.

Atrial fibrillation in immigrant groups: a cohort study of all adults 45 years of age and older in Sweden

To study the association between country of birth and incident atrial fibrillation (AF) in several immigrant groups in Sweden. The study population included all adults (n = 3,226,752) aged 45 years and older in Sweden. AF was defined as having at least one registered diagnosis of AF in the National Patient Register. The incidence of AF in different immigrant groups, using Swedish-born as referents, was assessed by Cox regression, expressed in hazard ratios (HRs) and 95% confidence intervals (CI). All models were stratified by sex and adjusted for age, geographical residence in Sweden, educational level, marital status, and neighbourhood socioeconomic status. Compared to their Swedish-born counterparts, higher incidence of AF [HR (95% CI)] was observed among men from Bosnia 1.74 (1.56–1.94) and Latvia 1.29 (1.09–1.54), and among women from Iraq 1.96 (1.67–2.31), Bosnia 1.88 (1.61–1.94), Finland 1.14 (1.11–1.17), Estonia 1.14 (1.05–1.24) and Germany 1.08 (1.03–1.14). Lower incidence of AF was noted among men (HRs ≤ 0.60) from Iceland, Southern Europe (especially Greece, Italy and Spain), Latin America (especially Chile), Africa, Asia (including Iraq, Turkey, Lebanon and Iran), and among women from Nordic countries (except Finland), Southern Europe, Western Europe (except Germany), Africa, North America, Latin America, Iran, Lebanon and other Asian countries (except Turkey and Iraq). In conclusion, we observed substantial differences in incidence of AF between immigrant groups and the Swedish-born population. A greater awareness of the increased risk of AF development in some immigrant groups may enable for a timely diagnosis, treatment and prevention of its debilitating complications, such as stroke.

Socioeconomic Status as a Predictor of Mortality in Patients Admitted With Atrial Fibrillation

Lower socioeconomic status (SES) is associated with a higher risk of cardiovascular disease. However, the association between SES and mortality in patients with atrial fibrillation (AF) is not clear. We examined whether SES predicts all-cause mortality in patients hospitalized with AF. This is a retrospective study of patients aged >18 years, admitted with a primary diagnosis of AF to Montefiore Medical Center between 2000 and 2010. Multivariable logistic regression models were used to determine predictors of survival adjusted for age, gender, heart failure, diabetes mellitus, chronic kidney disease, previous myocardial infraction, chronic obstructive pulmonary disease, hypertension, peripheral vascular disease, and SES. SES was determined using the New York City Department of Health Standardized Score (a log composite score of household income, value of housing units, net rental income, household occupations, and educational level). The cohort was divided into quartiles based on SES score, with Q4 the highest and Q1 the lowest SES score. There were 4,503 patients identified with a mean follow up of 4.5 years in the following SES quartiles: Q1 (n = 1,132), Q2 (n = 1,119), Q3 (n = 1,126), and Q4 (n = 1,126). The unadjusted mortality varied across quartiles (Q1 to Q4), 54%, 58%, 56%, and 59%, respectively (p = 0.004). After controlling for other variables in the multivariable analysis, patients with the lowest SES (Q1) had a significantly higher mortality than patients in the quartile with the highest (Q4) SES (odds ratio 1.3, CI 1.1 to 1.5). In conclusion, patients admitted to the hospital with AF have varying mortality based on their SES. After controlling for co-morbidities, patients with AF and lower SES scores had higher mortality. Further research studies are warranted to study this risk of increased mortality in AF population.

Gout in immigrant groups: a cohort study in Sweden

Our aim was to study the association between country of birth and incidence of gout in different immigrant groups in Sweden. The study population included the whole population of Sweden. Gout was defined as having at least one registered diagnosis in the National Patient Register. The association between incidence of gout and country of birth was assessed by Cox regression, with hazard ratios (HRs) and 95% confidence intervals (95% CI), using Swedish-born individuals as referents. All models were conducted in both men and women, and the full model was adjusted for age, place of residence in Sweden, educational level, marital status, neighbourhood socio-economic status and co-morbidities. The risk of gout varied by country of origin, with highest estimates, compared to Swedish born, in fully adjusted models among men from Iraq (HR 1.82, 95% CI 1.54-2.16), and Russia (HR 1.69, 95% CI 1.26-2.27), and also high among men from Austria, Poland, Africa and Asian countries outside the Middle East; and among women from Africa (HR 2.23, 95% CI 1.50-3.31), Hungary (HR 1.98, 95% CI 1.45-2.71), Iraq (HR 1.76, 95% CI 1.13-2.74) and Austria (HR 1.70, 95% CI 1.07-2.70), and also high among women from Poland. The risk of gout was lower among men from Greece, Spain, Nordic countries (except Finland) and Latin America and among women from Southern Europe, compared to their Swedish counterparts. The increased risk of gout among several immigrant groups is likely explained by a high cardio-metabolic risk factor pattern needing attention.

Neighborhood socioeconomic characteristics and statin medication in patients with myocardial infarction: a Swedish nationwide follow-up study

Background

Coronary heart disease (CHD) and myocardial infarction (MI) are associated with neighborhood-level socioeconomic status (SES). Statins are important drugs for secondary prevention of MI. However, no study has determined whether neighborhood-level SES is associated with statin medication in MI patients. We aimed to determine whether there is a difference in statin medication rate in MI patients across different levels of neighborhood SES.

Methods

All patients in Sweden, diagnosed with incident MI from January 1st, 2000 until December 31^st 2010, were followed (n = 116,840). Of these, 89.7 % received statin medication. Data were analyzed by multilevel logistic regression, with individual-level characteristics (age, marital status, family income, educational attainment, country of origin, urban/rural status and comorbidities/chronic conditions related to MI) as covariates.

Results

Low neighborhood-level SES was significantly associated with low statin medication rate (Odds Ratio 0.80). In the full model, which took into account individual-level socioeconomic characteristics and MI comorbidities, the odds no longer remained significant.

Conclusions

Individual-level approaches may be most important in health care policies regarding statin medication in MI patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0319-y) contains supplementary material, which is available to authorized users.

Neighborhood Deprivation and Risk of Age-Related Eye Diseases: A Follow-up Study in Sweden

PURPOSE

To examine whether there is an association between neighborhood deprivation and age-related eye diseases, particularly macular degeneration, cataract, diabetes-related eye complications, and glaucoma.

METHODS

The study population comprised a nationwide sample of 2,060,887 men and 2,250,851 women aged 40 years or older living in Sweden who were followed from 1 January 2000 until the first hospitalization/outpatient registration for age-related eye disease during the study period, death, emigration, or the end of the study period on 31 December 2010. Multilevel logistic regression was used to estimate the association between neighborhood deprivation and age-related eye diseases.

RESULTS

In men, the odds ratio (OR) for age-related eye diseases for those living in high-deprivation neighborhoods compared to those living in low-deprivation neighborhoods remained significant after adjustment for potential confounding factors (macular degeneration, OR 1.08, 95% confidence interval [CI] 1.03-1.12; cataract, OR 1.31, 95% CI 1.26-1.35; diabetes-related eye complications, OR 1.36, 95% CI 1.30-1.43; glaucoma, OR 1.11, 95% CI 1.06-1.15). In women, similar patterns were observed (macular degeneration, OR 1.11, 95% CI 1.07-1.15; cataract, OR 1.36, 95% CI 1.31-1.40; diabetes-related eye complications, OR 1.50, 95% CI 1.42-1.59; glaucoma, OR 1.12, 95% CI 1.08-1.17).

CONCLUSION

Our results suggest that neighborhood deprivation is associated with age-related eye diseases in both men and women. These results implicate that individual- as well as neighborhood-level factors are important for preventing age-related eye diseases.

Neighbourhood socio-economic status and all-cause mortality in adults with atrial fibrillation: A cohort study of patients treated in primary care in Sweden

OBJECTIVE

Our aim was to study the potential impact of neighbourhood socio-economic status (SES) on all-cause mortality in patients with atrial fibrillation (AF) treated in primary care.

METHODS

Study population included adults (n=12,283) of 45 years and older diagnosed with AF in 75 primary care centres in Sweden. Association between neighbourhood SES and all-cause mortality was explored using Cox regression analysis, with hazard ratios (HRs) and 95% confidence intervals (95% CIs), and by Laplace regression where years to death (95% CI) of the first 10% of the participants were used as an outcome. All models were conducted in both men and women and adjusted for age, educational level, marital status, change of neighbourhood status, cardiovascular co-morbidities, anticoagulant treatment and statin treatment. High- and low-neighbourhood SES were compared with middle SES as reference group.

RESULTS

After adjustments for potential confounders, higher relative risk of all-cause mortality (HR 1.49, 95% CI 1.13-1.96) was observed in men living in low SES neighbourhoods compared to those from middle SES neighbourhoods. The results were confirmed using Laplace regression; the time until the first 10% of the men in low SES neighbourhoods died was 1.45 (95% CI 0.48-2.42) years shorter than for the men in middle SES neighbourhoods.

CONCLUSIONS

Increased rates of heart disease and subsequent mortality among adults in deprived neighbourhoods raise important clinical and public health concerns. These findings could serve as an aid to policy-makers when allocating resources in primary health care settings as well as to clinicians who encounter patients in deprived neighbourhoods.

Neighborhood deprivation and warfarin, aspirin and statin prescription - A cohort study of men and women treated for atrial fibrillation in Swedish primary care

BACKGROUND

We aimed to study differences in the prescribing of warfarin, aspirin and statins to patients with atrial fibrillation (AF) in socio-economically diverse neighborhoods. We also aimed to explore the effects of neighborhood deprivation on the relationship between CHADS2 risk score and warfarin prescription.

METHODS

Data were obtained from primary health care records that contained individual clinical data that were linked to national data on neighborhood of residence and a deprivation index for different neighborhoods. Logistic regression was used to estimate the potential neighborhood differences in prescribed warfarin, aspirin and statins, and the association between the CHADS2 score and prescribed warfarin treatment, in neighborhoods with high, middle (referent) and low socio-economic (SES).

RESULTS

After adjustment for age, socio-economic factors, co-morbidities and moves to neighborhoods with different SES during follow-up, adults with AF living in high SES neighborhoods were more often prescribed warfarin (men odds ratio (OR) (95% confidence interval (CI): 1.44 (1.27-1.62); and women OR (95% CI): 1.19 (1.05-1.36)) and statins (men OR (95% CI): 1.23 (1.07-1.41); women OR (95% CI): 1.23 (1.05-1.44)) compared to their counterparts residing in middle SES. Prescription of aspirin was lower in men from high SES neighborhoods (OR (95% CI): 0.75 (0.65-0.86)) than in those from middle SES neighborhoods. Higher CHADS2 risk scores were associated with higher warfarin prescription which remained after adjustment for neighborhood SES.

CONCLUSIONS

The apparent inequalities in pharmacotherapy seen in the present study call for resource allocation to primary care in neighborhoods with low and middle socio-economic status.

End stage renal disease risk and neighbourhood deprivation: a nationwide cohort study in Sweden

BACKGROUND

Chronic kidney disease has been associated with socioeconomic disparities and neighbourhood deprivation. We aimed to determine whether there is an association between neighbourhood deprivation and end stage renal disease (ESRD), and whether this association is independent of individual-level sociodemographic factors and comorbidities.

METHODS

National Swedish data registers were used. The entire Swedish population aged 20-69 years was followed from January 1, 2001 until December 31, 2010. Data were analysed by multilevel logistic regression, with individual-level sociodemographic factors (age, marital status, family income, education level, country of birth, urban/rural status, and mobility) and comorbidities at the first level and neighbourhood deprivation at the second level.

RESULTS

Neighbourhood deprivation was significantly associated with ESRD (age-adjusted odds ratio [OR] 1.45, 95% confidence interval [CI] 1.34-1.56 in men and OR 1.59, 95% CI 1.44-1.75 in women). The ORs for ESRD in men and women living in the most deprived neighbourhoods remained significantly increased when adjusted for age and individual-level sociodemographic factors (OR 1.25, 95% CI 1.15-1.35 in men and OR 1.30, 95% CI 1.17-1.44 in women). In the full model, which took account of sociodemographic factors and comorbidities, the ORs for ESRD remained significantly increased (OR 1.17, 95% CI 1.07-1.27 in men and OR 1.18, 95% CI 1.06-1.31 in women).

CONCLUSION

Neighbourhood deprivation is independently associated with ESRD in both men and women irrespective of individual-level sociodemographic factors and comorbidities.

Socioeconomic status and the incidence of atrial fibrillation in whites and blacks: the Atherosclerosis Risk in Communities (ARIC) study

BACKGROUND

No previous studies have examined the interplay among socioeconomic status, sex, and race with the risk of atrial fibrillation (AF).

METHODS AND RESULTS

We prospectively followed 14 352 persons (25% black, 75% white, 55% women, mean age 54 years) who were free of AF and participating in the Atherosclerosis Risk in Communities (ARIC) study. Socioeconomic status was assessed at baseline (1987-1989) through educational level and total family income. Incident AF through 2009 was ascertained from electrocardiograms, hospitalizations, and death certificates. Cox regression was used to estimate hazard ratios and 95% CIs of AF for education and family income. Interactions were tested between socioeconomic status and age, race, or sex. Over a median follow-up of 20.6 years, 1794 AF cases occurred. Lower family income was associated with higher AF risk (hazard ratio 1.45, 95% CI 1.27 to 1.67 in those with income less than $25 000 per year compared with those with $50 000 or more per year). The association between education and AF risk varied by sex (P=0.01), with the lowest education group associated with higher AF risk in women (hazard ratio 1.88, 95% CI 1.55 to 2.28) but not in men (hazard ratio 1.15, 95% CI 0.97 to 1.36) compared with the highest education group. Adjustment for cardiovascular risk factors attenuated the associations. There were no interactions with race or age. Blacks had lower AF risk than whites in all income and education groups.

CONCLUSIONS

Lower family income was associated with a higher AF risk overall, whereas the impact of education on AF risk was present only in women. Differences in socioeconomic status do not explain the lower risk of AF in blacks compared with whites.