Does the effect of adolescent health behaviours on adult cardiometabolic health differ by socioeconomic background? Protocol for a population-based cohort study

INTRODUCTION

Adolescence is a sensitive period for cardiometabolic health. Yet, it remains unknown if adolescent health behaviours, such as alcohol use, smoking, diet and physical activity, have differential effects across socioeconomic strata. Adopting a life-course perspective and a causal inference framework, we aim to assess whether the effects of adolescent health behaviours on adult cardiometabolic health differ by levels of neighbourhood deprivation, parental education and occupational class. Gaining a better understanding of these social disparities in susceptibility to health behaviours can inform policy initiatives that aim to improve population health and reduce socioeconomic inequalities in cardiometabolic health.

METHODS AND ANALYSIS

We will conduct a secondary analysis of the Young Finns Study, which is a longitudinal population-based cohort study. We will use measures of health behaviours-smoking, alcohol use, fruit and vegetable consumption, and physical activity-as exposure and parental education, occupational class and neighbourhood deprivation as effect modifiers during adolescence (ages 12-18 years). Eight biomarkers of cardiometabolic health (outcomes)-waist circumference, body mass index, blood pressure, low-density lipoprotein cholesterol, apolipoprotein B, plasma glucose and insulin resistance-will be measured when participants were aged 33-40. A descriptive analysis will investigate the clustering of health behaviours. Informed by this, we will conduct a causal analysis to estimate effects of single or clustered adolescent health behaviours on cardiometabolic health conditional on socioeconomic background. This analysis will be based on a causal model implemented via a directed acyclic graph and inverse probability-weighted marginal structural models to estimate effect modification.

ETHICS AND DISSEMINATION

The Young Finns study was conducted according to the guidelines of the Declaration of Helsinki, and the protocol was approved by ethics committees of University of Helsinki, Kuopio, Oulu, Tampere and Turku. We will disseminate findings at international conferences and a manuscript in an open-access peer-reviewed journal.

Connecting cohorts of Finnish biobanks creates a research resource for the study of healthy ageing

AIMS

Connecting cohorts with biobanks is a Finnish biobank collaboration, creating an infrastructure for the study of healthy ageing. We aimed to develop a model for data integration and harmonisation between different biobanks with procedures for joint access.

METHODS

The heart of the collaboration is the integrated datasets formed by using data from three biobanks: (a) Arctic Biobank, hosting regional birth cohorts and cohorts of elderly; (b) hospital-affiliated Borealis Biobank of Northern Finland; and (c) THL Biobank, hosting population-based cohorts. The datasets were created by developing a data dictionary, harmonising cohort data and with a joint pseudonymisation process.

RESULTS

The connecting cohorts with biobanks resource at its widest consists altogether of almost 1.4 million individuals from collaborating biobanks. Utilising data from 107,000 cohort participants, we created harmonised datasets that contain attributes describing metabolic risk and frailty for studies of healthy ageing. These data can be complemented with medical data available from Biobank Borealis and with samples taken at hospital settings for approximately 38,000 cohort participants. In addition, the harmonised connecting cohorts with biobanks datasets can be expanded with supplementary data and samples from the collaborating biobanks.

CONCLUSIONS

The connecting cohorts with biobanks datasets provide a unique resource for research on ageing-related personalised healthcare and for real-world evidence studies. Following the FAIR principles on findability, accessibility, interoperability, and reusability, the reused and harmonised datasets are findable and made accessible for researchers. The same approach can be further utilised to develop additional datasets for other research topics.

Trajectories of cardiovascular risk predict pregnancy outcomes: The Bogalusa Heart Study and the Cardiovascular Risk in Young Finns Study

BACKGROUND

Life course patterns of change in risk-trajectories-affect health.

OBJECTIVES

To examine how trajectories of cardiovascular risk factors are associated with pregnancy and birth outcomes.

METHODS

Data from two cohort studies participating in the International Childhood Cardiovascular Consortium-The Bogalusa Heart Study (BHS; started in 1973, N = 903 for this analysis) and the Cardiovascular Risk in Young Finns Study (YFS; started in 1980, N = 499) were used. Both followed children into adulthood and measured cardiovascular risk factors, including body mass index (BMI), systolic and diastolic blood pressure (SBP/DBP), total, lipoprotein (LDL)- and high density lipoprotein (HDL)-cholesterol and serum triglycerides. Discrete mixture modelling was used to divide each cohort into distinct trajectories according to these risk factors from childhood to early adulthood, and these groups were then used to predict pregnancy outcomes including small for gestational age (SGA; <10th study-specific percentile of gestational age by sex), preterm birth (PTB; <37 weeks' gestation), hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM), with control for age at baseline and at first birth, parity, socioeconomic status, BMI and smoking.

RESULTS

The models created more trajectories for BMI, SBP and HDL-cholesterol in the YFS than in BHS, for which three classes generally seemed to be sufficient to represent the groups in the population across risk factors. In BHS, the association between the higher and flatter DBP trajectory and PTB was aRR 1.77, 95% confidence interval [CI] 1.06, 2.96. In BHS the association between consistent total cholesterol and PTB was aRR 2.16, 95% CI 1.22, 3.85 and in YFS the association between elevated high trajectory and PTB was aRR 3.35, 95% CI 1.28, 8.79. Elevated-increasing SBP was associated with a higher risk of GH in BHS and increasing or persistent-obese BMI trajectories were associated with GDM in both cohorts (BHS: aRR 3.51, 95% CI 1.95, 6.30; YFS: aRR 2.61, 95% CI 0.96, 7.08).

CONCLUSIONS

Trajectories of cardiovascular risk, particularly those that represent a consistent or more rapid worsening of cardiovascular health, are associated with a higher risk of pregnancy complications.

The Novel Ceramide- and Phosphatidylcholine-Based Risk Score for the Prediction of New-Onset of Hypertension

Ceramides and other sphingolipids are implicated in vascular dysfunction and inflammation. They have been suggested as potential biomarkers for hypertension. However, their specific association with hypertension prevalence and onset requires further investigation. This study aimed to identify specific ceramide and phosphatidylcholine species associated with hypertension prevalence and onset. The 2002 FINRISK (Finnish non-communicable risk factor survey) study investigated the association between coronary event risk scores (CERT1 and CERT2) and hypertension using prevalent and new-onset hypertension groups, both consisting of 7722 participants, over a span of 10 years. Ceramide and phosphatidylcholine levels were measured using tandem liquid chromatography-mass spectrometry. Ceramide and phosphatidylcholine ratios, including ceramide (d18:1/18:0), ceramide (d18:1/24:1), phosphatidylcholine (16:0/16:0), and the ratio of ceramide (d18:1/18:0)/(d18:1/16:0), are consistently associated with both prevalence and new-onset hypertension. Ceramide (d18:1/24:0) was also linked to both hypertension measures. Adjusting for covariates, CERT1 and CERT2 showed no-longer-significant associations with hypertension prevalence, but only CERT2 predicted new-onset hypertension. Plasma ceramides and phosphatidylcholines are crucial biomarkers for hypertension, with imbalances potentially contributing to its development. Further research is needed to understand the underlying mechanisms by which ceramides will contribute to the development of hypertension.

Development of non-communicable disease risk factors in Finland: projections up to 2040

BACKGROUND

Non-communicable diseases are a major cause of mortality and morbidity worldwide. They share the same behavioural risk factors (smoking, sedentary behaviour, alcohol consumption and an unhealthy diet), all of which are modifiable risk factors, and biological consequences (hypertension, elevated total cholesterol, obesity and diabetes).

METHODS

Using data from a series of cross-sectional health examination surveys conducted among the adult population in Finland from 1997 to 2017, a projection of risk factor development (smoking, leisure time sedentary behaviour, hypertension, elevated total cholesterol, overweight and obesity, and diabetes) up to the year 2040 was made. The projections were estimated using a multiple imputation method.

RESULTS

Smoking prevalence is estimated to continue to decline up to 2040, similar to hypertension and elevated total cholesterol. By contrast, obesity and diabetes will develop unfavourably, with an increase in prevalence. The increase in obesity is mainly due to polarisation - that is, normal-weight people remain of a normal weight, but overweight people tend to gain more weight and become obese. The observed and estimated changes for leisure time sedentary lifestyle were not statistically significant.

CONCLUSIONS

Projections of risk factors for non-communicable diseases are needed to guide public health policies and programmes, decision-making and the allocation of health care resources for prevention and care. In Finland, favourable developments have been seen in many of the risk factors, but obesity and diabetes show unfavourable development. There is a need to continue regular, systematic monitoring of the development of risk factors through health examination surveys and to set national goals and programmes to tackle the existing problems.

Identification of complement factor H variants that predispose to pre-eclampsia: A genetic and functional study

OBJECTIVE

The objective of the study was to investigate the role of genetic variants in complement proteins in pre-eclampsia.

DESIGN

In a case-control study involving 609 cases and 2092 controls, five rare variants in complement factor H (CFH) were identified in women with severe and complicated pre-eclampsia. No variants were identified in controls.

SETTING

Pre-eclampsia is a leading cause of maternal and fetal morbidity and mortality. Immune maladaptation, in particular, complement activation that disrupts maternal-fetal tolerance leading to placental dysfunction and endothelial injury, has been proposed as a pathogenetic mechanism, but this remains unproven.

POPULATION

We genotyped 609 pre-eclampsia cases and 2092 controls from FINNPEC and the national FINRISK cohorts.

METHODS

Complement-based functional and structural assays were conducted in vitro to define the significance of these five missense variants and each compared with wild type.

MAIN OUTCOME MEASURES

Secretion, expression and ability to regulate complement activation were assessed for factor H proteins harbouring the mutations.

RESULTS

We identified five heterozygous rare variants in complement factor H (L3V, R127H, R166Q, C1077S and N1176K) in seven women with severe pre-eclampsia. These variants were not identified in controls. Variants C1077S and N1176K were novel. Antigenic, functional and structural analyses established that four (R127H, R166Q, C1077S and N1176K) were deleterious. Variants R127H and C1077S were synthesised, but not secreted. Variants R166Q and N1176K were secreted normally but showed reduced binding to C3b and consequently defective complement regulatory activity. No defect was identified for L3V.

CONCLUSIONS

These results suggest that complement dysregulation due to mutations in complement factor H is among the pathophysiological mechanisms underlying severe pre-eclampsia.

The interactions between host genome and gut microbiome increase the risk of psychiatric disorders: Mendelian randomization and biological annotation

BACKGROUND

The correlation between human gut microbiota and psychiatric diseases has long been recognized. Based on the heritability of the microbiome, genome-wide association studies on human genome and gut microbiome (mbGWAS) have revealed important host-microbiome interactions. However, establishing causal relationships between specific gut microbiome features and psychological conditions remains challenging due to insufficient sample sizes of previous studies of mbGWAS.

METHODS

Cross-cohort meta-analysis (via METAL) and multi-trait analysis (via MTAG) were used to enhance the statistical power of mbGWAS for identifying genetic variants and genes. Using two large mbGWAS studies (7,738 and 5,959 participants respectively) and12 disease-specific studies from the Psychiatric Genomics Consortium (PGC), we performed bidirectional two-sample mendelian randomization (MR) analyses between microbial features and psychiatric diseases (up to 500,199 individuals). Additionally, we conducted downstream gene- and gene-set-based analyses to investigate the shared biology linking gut microbiota and psychiatric diseases.

RESULTS

METAL and MTAG conducted in mbGWAS could boost power for gene prioritization and MR analysis. Increases in the number of lead SNPs and mapped genes were witnessed in 13/15 species and 5/10 genera after using METAL, and MTAG analysis gained an increase in sample size equivalent to expanding the original samples from 7% to 63%. Following METAL use, we identified a positive association between Bacteroides faecis and ADHD (OR, 1.09; 95 %CI, 1.02-1.16; P = 0.008). Bacteroides eggerthii and Bacteroides thetaiotaomicron were observed to be positively associated with PTSD (OR, 1.11; 95 %CI, 1.03-1.20; P = 0.007; OR, 1.11; 95 %CI, 1.01-1.23; P = 0.03). These findings remained stable across statistical models and sensitivity analyses. No genetic liabilities to psychiatric diseases may alter the abundance of gut microorganisms.Using biological annotation, we identified that those genes contributing to microbiomes (e.g., GRIN2A and RBFOX1) are expressed and enriched in human brain tissues.

CONCLUSIONS

Our statistical genetics strategy helps to enhance the power of mbGWAS, and our genetic findings offer new insights into biological pleiotropy and causal relationship between microbiota and psychiatric diseases.

Cumulative incidence and risk factors of myocardial infarction during 20 years of follow-up: comparing two cohorts of middle-aged men born 30 years apart

OBJECTIVE

To study cumulative incidence and predictors of myocardial infarction (MI) in two random general population samples consisting of middle-aged Swedish men born 30 years apart.

METHOD

Results from the "Study of Men Born In 1913" and the "Study of Men Born In 1943", two longitudinal cohort studies performed in the same geographic area and using the same methodology were compared. Both cohorts were followed prospectively from 50 to 70 years of age. MI was defined as first myocardial infarction, fatal or non-fatal.

RESULTS

Men born in 1943 had a 34% lower cumulative risk of first MI [HR 0.66 (0.50-0.88), p = 0.0051] during follow-up as compared to men born in 1913. Interaction analysis showed that hypertension had a significantly higher impact on risk of MI in cohort 1943 than in cohort 1913 [HR 2.33 (95% CI 1.41-3.83)] and [HR 1.10 (0.74-1.62)], p = 0.0009 respectively. The population attributable risk for hypertension was 2.5-fold higher in the cohort of men born in 1943 as compared to men born in 1913, and diabetes mellitus and sedentary lifestyle attributed more to MI risk in cohort 1943 than in cohort 1913. On the contrary, smoking and total cholesterol have less attributable risk to MI in cohort 1943 than in cohort 1913.

CONCLUSION

Despite declining incident MI and improved cardiovascular prevention in general, hypertension remains an increasingly important attributable risk factor to MI together with diabetes mellitus and sedentary lifestyle over time.

Public health impact of antihypertensive medication use on arterial blood pressure: A pooled cross-sectional analysis of population health surveys

The early initiation of antihypertensive drug therapy is conceived as one of the most important public health interventions addressing cardiovascular risk in the population. However, the actual contribution of this public health intervention to reduce blood pressure (BP) at the population level is largely unknown. Hence, the aim of the present investigation is to estimate the potential public health effects of the use of antihypertensive medication on BP in the population aged 16 and older. Data from three population health surveys periodically conducted in the United States, England, and Scotland are analysed (N = 362,275). The secular trends of BP measurements and the potential public health impact of the use of antihypertensive medications on BP over time are analysed in a series of linear mixed models. Between 1992 and 2019, a secular trend of decreasing systolic and diastolic BP occurred (-16.24 99% CI [-16.80; -15.68] and -3.08 99% CI [-3.36; -2.80] mmHg, respectively). The potential public health impact of the use of antihypertensive medications in the period 1992-2019 on systolic BP was estimated to lie between -8.56 99% CI [-8.34; -8.77] and -8.68 99% CI [-8.33; -9.03] mmHg. Average reduction of diastolic BP was in the range of -5.56 99% CI [-5.71; -5.42] and -6.55 99% CI [-6.78; -6.32] mmHg. The observed changes in the distribution of BP measurements over time were found to be more strongly related to secular trends affecting the whole populations, rather than to increases in the proportion of individuals taking antihypertensive medications.

Gut microbiome and atrial fibrillation-results from a large population-based study

BACKGROUND

Atrial fibrillation (AF) is an important heart rhythm disorder in aging populations. The gut microbiome composition has been previously related to cardiovascular disease risk factors. Whether the gut microbial profile is also associated with the risk of AF remains unknown.

METHODS

We examined the associations of prevalent and incident AF with gut microbiota in the FINRISK 2002 study, a random population sample of 6763 individuals. We replicated our findings in an independent case-control cohort of 138 individuals in Hamburg, Germany.

FINDINGS

Multivariable-adjusted regression models revealed that prevalent AF (N = 116) was associated with nine microbial genera. Incident AF (N = 539) over a median follow-up of 15 years was associated with eight microbial genera with false discovery rate (FDR)-corrected P < 0.05. Both prevalent and incident AF were associated with the genera Enorma and Bifidobacterium (FDR-corrected P < 0.001). AF was not significantly associated with bacterial diversity measures. Seventy-five percent of top genera (Enorma, Paraprevotella, Odoribacter, Collinsella, Barnesiella, Alistipes) in Cox regression analyses showed a consistent direction of shifted abundance in an independent AF case-control cohort that was used for replication.

INTERPRETATION

Our findings establish the basis for the use of microbiome profiles in AF risk prediction. However, extensive research is still warranted before microbiome sequencing can be used for prevention and targeted treatment of AF.

FUNDING

This study was funded by European Research Council, German Ministry of Research and Education, Academy of Finland, Finnish Medical Foundation, and the Finnish Foundation for Cardiovascular Research, the Emil Aaltonen Foundation, and the Paavo Nurmi Foundation.

Case Fatality in Patients With Aneurysmal Subarachnoid Hemorrhage in Finland: A Nationwide Register-Based Study

BACKGROUND AND OBJECTIVES

Although single-center studies have reported declining case fatality rates (CFRs) of aneurysmal subarachnoid hemorrhage (SAH), nationwide reports that also include sudden-death SAHs with long uninterrupted study periods have remained limited. Moreover, little is known about whether the time-dependent trends of SAH CFR differ by age and/or sex. Thus, we aimed to characterize the nationwide changes of SAH CFRs in Finland between 1998 and 2017.

METHODS

We used 2 externally validated nationwide registers to identify all hospitalized and nonhospitalized (sudden-death) aneurysmal SAH events in Finland during 1998-2017. In addition to overall 30-day CFRs, we determined annual proportions of sudden-death and 30-day CFRs among hospitalized patients with SAH. To estimate time-dependent trends, we calculated annual age-adjusted and sex-adjusted CFR changes (percent with 95% CIs).

RESULTS

Between 1998 and 2017, we identified 9,443 cases with SAH (57.6% women), of which 2,245 (23.8%) died before hospitalization and 3,715 (39.3%) died within 30 days after SAH. Among the 7,198 hospitalized patients with SAH, the 30-day CFR was 20.4%. During the study period, the overall age-adjusted and sex-adjusted CFR declined by an average of 1.8% (1.1%-2.6%) per year. The decreases were especially notable in the proportion of sudden deaths among middle-aged (aged 40-64 years) and older (aged 65 years or older) women (2.9% [1.1%-4.7%] and 2.3% [0.7%-4.0%] per year, respectively) and in the CFRs of hospitalized young (younger than 40 years) and middle-aged women (9.1% [2.3%-15.7%] and 4.3% [2.3%-6.5%] per year, respectively). On the contrary, the 30-day CFR of older (aged 65 years or older) hospitalized men increased by 3.5% (0.7%-6.3%) per year, while the proportions of older men who died before hospitalization remained unchanged.

DISCUSSION

The overall CFR of SAH seems to be decreasing, at least among women. The continued high CFR of hospitalized older men requires attention from clinicians and epidemiologists, especially if this trend is also common in other countries.

Initial statin dose after myocardial infarction and long-term cardiovascular outcomes

AIMS

Effective statin therapy is a cornerstone of secondary prevention after myocardial infarction (MI). Real-life statin dosing is nevertheless suboptimal and largely determined early after MI. We studied long-term outcome impact of initial statin dose after MI.

METHODS AND RESULTS

Consecutive MI patients treated in Finland who used statins early after index event were retrospectively studied (N = 72 401; 67% men; mean age 68 years) using national registries. High-dose statin therapy was used by 26.3%, moderate dose by 69.2%, and low dose by 4.5%. Differences in baseline features, comorbidities, revascularisation, and usage of other evidence-based medications were adjusted for with multivariable regression. The primary outcome was major adverse cardiovascular or cerebrovascular event (MACCE) within 10 years. Median follow-up was 4.9 years. MACCE was less frequent in high-dose group compared with moderate dose [adjusted hazard ratio (HR) 0.92; P < 0.0001; number needed to treat (NNT) 34.1] and to low dose [adj.HR 0.81; P < 0.001; NNT 13.4] as well as in moderate-dose group compared with low dose (adj.HR 0.88; P < 0.0001; NNT 23.4). Death (adj.HR 0.87; P < 0.0001; NNT 23.6), recurrent MI (adj.sHR 0.91; P = 0.0001), and stroke (adj.sHR 0.86; P < 0.0001) were less frequent with a high- vs. moderate-dose statin. Higher initial statin dose after MI was associated with better long-term outcomes in subgroups by age, sex, atrial fibrillation, dementia, diabetes, heart failure, revascularisation, prior statin usage, or usage of other evidence-based medications.

CONCLUSION

Higher initial statin dose after MI is dose-dependently associated with better long-term cardiovascular outcomes. These results underline the importance of using a high statin dose early after MI.

Comprehensive nationwide incidence and prevalence trends of atrial fibrillation in Finland

Objective

Atrial fibrillation (AF) is a worldwide healthcare challenge owing to population ageing. In this study, we assessed the current trends in the incidence and prevalence of AF for the first time in an unselected, nationwide population.

Methods

In the Finnish Anticoagulation in Atrial Fibrillation study, we gathered comprehensive data including all primary, secondary and tertiary healthcare visits and drug reimbursement from national healthcare registers to identify all patients with incident AF between 2004 and 2018 in Finland. Incident AF was defined as new-onset AF occurring after 2007. Time trends for the incidence and prevalence of AF were calculated and stratified by sex and age.

Results

A total of 411 387 patients with AF diagnosis were documented in Finland during 2004–2018. In 2018, the incidence and prevalence of AF in the total Finnish population were 469/100 000 and 4.1%, respectively. The incidence of new-onset AF in the adult population (≥20 years) increased from 471/100 000 in 2007 to 604/100 000 in 2018, but the age-adjusted incidence remained stable. The prevalence of AF increased in the adult population from 2.5% to 5.2%, and was higher in men than in women (5.9% vs 4.6%, p<0.001). The incidence and prevalence of AF increased with age and were 3194/100 000 and 23.4% in patients older than 75 years.

Conclusions

Based on comprehensive nationwide data including primary care, we observed an increasing incidence and prevalence of AF over time. This increase was strongly age-dependent with the age-standardised incidence remaining stable during 2007–2018.

Trial registration number

NCT04645537.

Incidence of first-ever transient ischemic attack in Eastern Finland

OBJECTIVES

The incidence of stroke has been declining in Finland, as well as in Europe. However, it is unclear whether the incidence of transient ischemic attack (TIA) is also decreasing. In fact, the TIA incidence in the Finnish population has never been reported. Therefore, here we investigated the incidence of TIA in the Eastern Finnish population in 2017.

MATERIALS AND METHODS

All patients with suspected TIA, from a defined catchment area, were referred to a neurological emergency unit at Kuopio University Hospital (KUH) in the Northern Savonia region of Eastern Finland, which had a population of 246,653 in 2017. The original study population comprised TIA patients diagnosed based on the WHO TIA criteria in 2017. Incidence rates were calculated by dividing the number of TIA cases by the number of people in different age groups.

RESULTS

Among 432 patients with a suspected TIA referred to the neurological emergency unit at Kuopio University Hospital in 2017, 293 were living in Northern Savonia and were ultimately diagnosed with TIA after neurological examinations. The number of first-ever TIAs was 211. The crude incidence of all TIA was 122/100,000 inhabitants, and of first-ever TIA was 86/100,000. The age-standardized incidence (European population 2010) of the first-ever TIA was calculated to be 64/100,000. The mean age of first-ever TIA patients was 70 years: 72 years for women versus 68 years for men.

CONCLUSIONS

We found a high incidence of TIA in Eastern Finland.

Lipidome- and Genome-Wide Study to Understand Sex Differences in Circulatory Lipids

Background Despite well-recognized differences in the atherosclerotic cardiovascular disease risk between men and women, sex differences in risk factors and sex-specific mechanisms in the pathophysiology of atherosclerotic cardiovascular disease remain poorly understood. Lipid metabolism plays a central role in the development of atherosclerotic cardiovascular disease. Understanding sex differences in lipids and their genetic determinants could provide mechanistic insights into sex differences in atherosclerotic cardiovascular disease and aid in precise risk assessment. Herein, we examined sex differences in plasma lipidome and heterogeneity in genetic influences on lipidome in men and women through sex-stratified genome-wide association analyses. Methods and Results We used data consisting of 179 lipid species measured by shotgun lipidomics in 7266 individuals from the Finnish GeneRISK cohort and sought for replication using independent data from 2045 participants. Significant sex differences in the levels of 141 lipid species were observed (P<7.0×10-4). Interestingly, 121 lipid species showed significant age-sex interactions, with opposite age-related changes in 39 lipid species. In general, most of the cholesteryl esters, ceramides, lysophospholipids, and glycerides were higher in 45- to 50-year-old men compared with women of same age, but the sex differences narrowed down or reversed with age. We did not observe any major differences in genetic effect in the sex-stratified genome-wide association analyses, which suggests that common genetic variants do not have a major role in sex differences in lipidome. Conclusions Our study provides a comprehensive view of sex differences in circulatory lipids pointing to potential sex differences in lipid metabolism and highlights the need for sex- and age-specific prevention strategies.

Inframe insertion and splice site variants in MFGE8 associate with protection against coronary atherosclerosis

Cardiovascular diseases are the leading cause of premature death and disability worldwide, with both genetic and environmental determinants. While genome-wide association studies have identified multiple genetic loci associated with cardiovascular diseases, exact genes driving these associations remain mostly uncovered. Due to Finland's population history, many deleterious and high-impact variants are enriched in the Finnish population giving a possibility to find genetic associations for protein-truncating variants that likely tie the association to a gene and that would not be detected elsewhere. In a large Finnish biobank study FinnGen, we identified an association between an inframe insertion rs534125149 in MFGE8 (encoding lactadherin) and protection against coronary atherosclerosis. This variant is highly enriched in Finland, and the protective association was replicated in meta-analysis of BioBank Japan and Estonian biobank. Additionally, we identified a protective association between splice acceptor variant rs201988637 in MFGE8 and coronary atherosclerosis, independent of the rs534125149, with no significant risk-increasing associations. This variant was also associated with lower pulse pressure, pointing towards a function of MFGE8 in arterial aging also in humans in addition to previous evidence in mice. In conclusion, our results suggest that inhibiting the production of lactadherin could lower the risk for coronary heart disease substantially.

Risk of Dementia After Hospitalization Due to Traumatic Brain Injury: A Longitudinal Population-Based Study

BACKGROUND AND OBJECTIVES

Traumatic brain injury (TBI) is considered a potential modifiable dementia risk factor. We aimed to determine whether TBI actually increases the risk of dementia when adjusting for other relevant dementia risk factors.

METHODS

This was a national prospective longitudinal cohort study that included random and representative population samples from different parts of Finland of patients 25 through 64 years of age from 1992 to 2012. Major TBI was defined as a diagnosis of traumatic intracranial hemorrhage and hospital length of stay (LOS) ≥3 days and minor TBI was defined as a diagnosis of concussion and hospital LOS ≤1 day. Dementia was defined as any first hospital contact with a diagnosis of dementia, first use of an antidementia drug, or dementia as an underlying or contributing cause of death. Follow-up was until death or end of 2017.

RESULTS

Of 31,909 participants, 288 were hospitalized due to a major TBI and 406 were hospitalized due to a minor TBI. There was a total of 976 incident dementia cases during a median follow-up of 15.8 years. After adjusting for age and sex, hospitalization due to major TBI (hazard ratio [HR] 1.51, 95% CI 1.03-2.22), but not minor TBI, increased the risk of dementia. After additional adjustment for educational status, smoking status, alcohol consumption, physical activity, and hypertension, the association between major TBI and dementia weakened (HR 1.30, 95% CI 0.86-1.97). The risk factors most strongly attenuating the association between major TBI and dementia were alcohol consumption and physical activity.

DISCUSSION

There was an association between hospitalized major TBI and incident dementia. The association was diluted after adjusting for confounders, especially alcohol consumption and physical activity. Hospitalization due to minor TBI was not associated with an increased risk of dementia.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that major TBI is associated with incident dementia.

40-65 Yaş Erkeklerin Gerçek ve Algıladıkları Kardiyovasküler Hastalık Risklerinin Karşılaştırılması: Bir Kesitsel Çalışma

Objective: To determine the actual cardiovascular diseases risk and to compare it with the perceived risk in 40-65 years old men. Methods: We conducted a cross-sectional study in a population determined to be 21.039 men and sample consisted of 400 men. The actual cardiovascular diseases risks of these respondents were calculated using HeartScore, classified as low, moderate, high, or very high. The respondents’ perception of their cardiovascular disease’s risks was categorized as wrong optimists/pessimists and realists. We used multivariate logistic regression models to determine the relationships between perceived cardiovascular diseases risk and independent variables (age, diabetes, hypertension, etc.). Required ethics committee and institutional permissions were obtained for the duly conduct of the study. Results: It was determined in our study that while 8.3% (n=33) of the men had a high-risk level for cardiovascular disease, 52.5% (n=210) had a very high level. Forty-eight percent of the participants perceive their CVD risks to be lower than they are and 23.8% to perceive it higher than they are. Correct estimation rate of CVD risk was 28.2%. The variables affecting the actual cardiovascular diseases risk were diastolic blood pressure, body mass index, and level of physical activity. 13.3% (n=53) of respondents perceived their cardiovascular diseases risks as high and 8% (n=32) as very high. The variables affecting an incorrect perceived cardiovascular diseases risk are being 61-65 years of age (odds ratio=0.34, 95% confidence interval: 0.16-0.73) and a diagnosis of diabetes mellitus (odds ratio=0.45, 95% confidence interval: 0.20-0.99). Conclusion: We observed that more than half of the residents were at a very high level of risk for cardiovascular disease, and approximately one out of every two respondents perceived their risk of cardiovascular disease to be lower than the actual risk. It is recommended risk reducing behaviors be developed and awareness of risk be raised.

Level and trend of total plasma cholesterol in national and subnational of Iran: a systematic review and age-spatio-temporal analysis from 1990 to 2016

Purpose

We aimed to estimate the level and trend of plasma cholesterol and raised total cholesterol (TC > 200 mg/dl) prevalence at national and subnational level of Iran.

Methods

Nine national surveys and 27 studies, encompassing 3,505 unique points on over 500,000 adults, aged > 25 years with a report of laboratory measurement of TC were found. Age-spatio-temporal model and Gaussian Process Regression were used to estimate mean TC for each sex, 5-year age groups, and 31 provinces from 1990 to 2016.

Results

At national level, age-standardized prevalence of TC > 200 mg/dL has decreased from 57·2%(53·3-61·1) to 22·4%(20·5-24·3) in women and 53·2%(49·1-57·3) to 18·0%(16·4-19·6) in men. TC distribution presented a condensation between 170-200 mg/dL. At subnational level, decreasing and converging patterns of raised TC prevalence were detected.

Conclusion

The decrease in raised TC is likely the result of statin widespread use, food industry improvements, and the expanded primary health care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-022-01052-w.

Early prediction of incident liver disease using conventional risk factors and gut-microbiome-augmented gradient boosting

The gut microbiome has shown promise as a predictive biomarker for various diseases. However, the potential of gut microbiota for prospective risk prediction of liver disease has not been assessed. Here, we utilized shallow shotgun metagenomic sequencing of a large population-based cohort (N > 7,000) with ∼15 years of follow-up in combination with machine learning to investigate the predictive capacity of gut microbial predictors individually and in conjunction with conventional risk factors for incident liver disease. Separately, conventional and microbial factors showed comparable predictive capacity. However, microbiome augmentation of conventional risk factors using machine learning significantly improved the performance. Similarly, disease-free survival analysis showed significantly improved stratification using microbiome-augmented models. Investigation of predictive microbial signatures revealed previously unknown taxa for liver disease, as well as those previously associated with hepatic function and disease. This study supports the potential clinical validity of gut metagenomic sequencing to complement conventional risk factors for prediction of liver diseases.

How Communicating Polygenic and Clinical Risk for Atherosclerotic Cardiovascular Disease Impacts Health Behavior: an Observational Follow-up Study

BACKGROUND

Prediction tools that combine polygenic risk scores with clinical factors provide a new opportunity for improved prediction and prevention of atherosclerotic cardiovascular disease, but the clinical utility of polygenic risk score has remained unclear.

METHODS

We collected a prospective cohort of 7342 individuals (64% women, mean age 56 years) and estimated their 10-year risk for atherosclerotic cardiovascular disease both by a traditional risk score and a composite score combining the effect of a polygenic risk score and clinical risk factors. We then tested how returning the personal risk information with an interactive web-tool impacted on the participants' health behavior.

RESULTS

When reassessed after 1.5 years by a clinical visit and questionnaires, 20.8% of individuals at high (>10%) 10-year atherosclerotic cardiovascular disease risk had seen a doctor, 12.4% reported weight loss, 14.2% of smokers had quit smoking, and 15.4% had signed up for health coaching online. Altogether, 42.6% of persons at high risk had made one or more health behavioral changes versus 33.5% of persons at low/average risk such that higher baseline risk predicted a favorable change (OR [CI], 1.53 [1.37-1.72] for persons at high risk versus the rest, P<0.001), with both high clinical (P<0.001) and genomic risk (OR [CI], 1.10 [1.03-1.17], P=0.003) contributing independently.

CONCLUSIONS

Web-based communication of personal atherosclerotic cardiovascular disease risk-data including polygenic risk to middle-aged persons motivates positive changes in health behavior and the propensity to seek care. It supports integration of genomic information into clinical risk calculators as a feasible approach to enhance disease prevention.

Secular trends in serum lipid profiles in young adults in Norway, 2001-19

Background

Lower prevalence of major cardiovascular disease (CVD) risk factors, such as dyslipidemia, hypertension and smoking, can explain a substantial part of the decline in CVD mortality and incidence for the past decades in Western countries. However, some studies have indicated less favorable trends in risk factors in recent years. We have assessed time trends in lipid profiles among young adults in Norway measured between 2001 and 2019.

Methods

Samples of serum lipids analyzed at one large medical laboratory in Oslo, Norway, mainly requisitioned by primary care physicians, were analyzed cross-sectionally to estimate year-to-year trends among men and women aged 18-49 years. We also assessed the lipid distributions and proportions with adverse lipid levels.

Results

In total, more than 2,6 million blood samples, comprising more than 1 million individuals (mean age 37.7 years) from all regions of Norway were included. All measures improved among all age groups in both women and men, especially in total and non-HDL cholesterol (-0.22 and -0.25 mmol/l per decade, respectively). There were downward shifts in the population distribution of total, non-HDL-C and LDL-C. The overall prevalences of total cholesterol ≥5.0 mmol/l and non-HDL-C ≥3.9 mmol/l similarly decreased, from ∼63 to 46% and from ∼52 to 34%, respectively. More than 1/3 had elevated levels of total and/or non-HDL-C in 2019.

Conclusion

In a large proportion of the Norwegian population aged 18-49 years old, the lipid profiles improved during the last two decades. As the use of lipid-lowering medications is low in this age group, this likely reflects favorable secular trends.

Health-related quality of life in patients with chronic orofacial pain compared with other chronic pain patients

Background

Health‐related quality of life (HRQoL) of orofacial pain patients is lower than that of the general population and impaired in multiple dimensions. The aim of the present study was to investigate HRQoL of orofacial pain patients in comparison with patients suffering from other chronic pain disorders.

Materials and Methods

One hundred and fifty‐one tertiary care facial pain patients (mean age, 50 years; standard deviation [SD], 15; 119 females), were compared with 312 other non‐cancer chronic pain patients (mean age, 46 years; SD, 13; 204 women), recruited from three multidisciplinary pain clinics in Finland. The groups were compared using the 15D, and pain‐related measures such as pain interference, pain acceptance, anxiety, depression, and sleep. Statistical comparisons between groups were done using t test, χ² test, or analysis of covariance. Multivariate linear regression analysis was used to study whether pain‐related aspects influencing HRQoL are similar between the patient groups.

Results

The 15D score was significantly higher in facial pain patients (0.823; SD, 0.114) indicating better HRQoL in comparison with other chronic pain patients (0.732; SD, 0.107) (p < .001). The 15D profiles of studied populations resembled each other but orofacial pain patients showed significantly higher scores for most individual 15D dimensions. Dimensions regarding discomfort and symptoms and sleep were most affected in both groups. Orofacial pain patients showed less psychosocial disability and better acceptance of their pain. Pain acceptance was a weaker explanatory factor of HRQoL in orofacial pain patients.

Conclusion

Compared to other non‐cancer chronic pain, chronic pain in the orofacial area causes less impairment in HRQoL. Orofacial pain patients showed less psychosocial disability and better pain acceptance.

Risk Factors, Subsequent Disease Onset, and Prognostic Impact of Myocardial Infarction and Atrial Fibrillation

Background Although myocardial infarction (MI) and atrial fibrillation (AF) are frequent comorbidities and share common cardiovascular risk factors, the direction and strength of the association of the risk factors with disease onset, subsequent disease incidence, and mortality are not completely understood. Methods and Results In pooled multivariable Cox regression analyses, we examined temporal relations of disease onset and identified predictors of MI, AF, and all-cause mortality in 108 363 individuals (median age, 46.0 years; 48.2% men) free of MI and AF at baseline from 6 European population-based cohorts. During a maximum follow-up of 10.0 years, 3558 (3.3%) individuals were diagnosed exclusively with MI, 1922 (1.8%) with AF but no MI, and 491 (0.5%) individuals developed both MI and AF. Association of sex, systolic blood pressure, antihypertensive treatment, and diabetes appeared to be stronger with incident MI than with AF, whereas increasing age and body mass index showed a higher risk for incident AF. Total cholesterol and daily smoking were significantly related to incident MI but not AF. Combined population attributable fraction of cardiovascular risk factors was >70% for incident MI, whereas it was only 27% for AF. Subsequent MI after AF (hazard ratio [HR], 1.68; 95% CI, 1.03-2.74) and subsequent AF after MI (HR, 1.75; 95% CI, 1.31-2.34) both significantly increased overall mortality risk. Conclusions We observed different associations of cardiovascular risk factors with both diseases indicating distinct pathophysiological pathways. Subsequent diagnoses of MI and AF significantly increased mortality risk.

Combined effects of host genetics and diet on human gut microbiota and incident disease in a single population cohort

Human genetic variation affects the gut microbiota through a complex combination of environmental and host factors. Here we characterize genetic variations associated with microbial abundances in a single large-scale population-based cohort of 5,959 genotyped individuals with matched gut microbial metagenomes, and dietary and health records (prevalent and follow-up). We identified 567 independent SNP-taxon associations. Variants at the LCT locus associated with Bifidobacterium and other taxa, but they differed according to dairy intake. Furthermore, levels of Faecalicatena lactaris associated with ABO, and suggested preferential utilization of secreted blood antigens as energy source in the gut. Enterococcus faecalis levels associated with variants in the MED13L locus, which has been linked to colorectal cancer. Mendelian randomization analysis indicated a potential causal effect of Morganella on major depressive disorder, consistent with observational incident disease analysis. Overall, we identify and characterize the intricate nature of host-microbiota interactions and their association with disease.

The genetic background of the associations between sense of coherence and mental health, self-esteem and personality

PURPOSE

Sense of coherence (SOC) represents coping and can be considered an essential component of mental health. SOC correlates with mental health and personality, but the background of these associations is poorly understood. We analyzed the role of genetic factors behind the associations of SOC with mental health, self-esteem and personality using genetic twin modeling and polygenic scores (PGS).

METHODS

Information on SOC (13-item Orientation of Life Questionnaire), four mental health indicators, self-esteem and personality (NEO Five Factor Inventory Questionnaire) was collected from 1295 Finnish twins at 20-27 years of age.

RESULTS

In men and women, SOC correlated negatively with depression, alexithymia, schizotypal personality and overall mental health problems and positively with self-esteem. For personality factors, neuroticism was associated with weaker SOC and extraversion, agreeableness and conscientiousness with stronger SOC. All these psychological traits were influenced by genetic factors with heritability estimates ranging from 19 to 66%. Genetic and environmental factors explained these associations, but the genetic correlations were generally stronger. The PGS of major depressive disorder was associated with weaker, and the PGS of general risk tolerance with stronger SOC in men, whereas in women the PGS of subjective well-being was associated with stronger SOC and the PGSs of depression and neuroticism with weaker SOC.

CONCLUSION

Our results indicate that a substantial proportion of genetic variation in SOC is shared with mental health, self-esteem and personality indicators. This suggests that the correlations between these traits reflect a common neurobiological background rather than merely the influence of external stressors.

Absolute and relative risk prediction in cardiovascular primary prevention with a modified SCORE chart incorporating ceramide-phospholipid risk score and diabetes mellitus

Aims

A risk score, CERT2, based on distinct ceramide and phosphatidylcholine lipid species, has shown robust performance in predicting cardiovascular risk in secondary prevention. Here, our aim was to investigate the predictive value of CERT2 in primary prevention compared to classical lipid biomarkers and its compatibility with clinical characteristics used in the SCORE risk chart.

Methods and results

Four ceramides [Cer(d18:1/16:0), Cer(d18:1/18:0), Cer(d18:1/24:0), Cer(d18:1/24:1)] and three phosphatidylcholines [PC(14:0/22:6), PC(16:0/22:5), PC(16:0/16:0)] were analysed by targeted tandem liquid chromatography–mass spectrometry method in FINRISK 2002, which is a population-based risk factor survey investigating men and women aged 25–74 years. Primary prevention subjects (N = 7324) were followed up for 10 years for the following outcomes: incident coronary heart disease (CHD), cardiovascular disease (CVD), major adverse cardiovascular event (MACE), stroke, and heart failure. Hazard ratios per standard deviation obtained from adjusted Cox proportional hazard models were significant for all these endpoints, and the highest for fatal ones, i.e. fatal CHD [1.45 (95% confidence interval 1.07–1.97)], CVD [1.39 (1.06–1.83)], and MACE [1.39 (1.07–1.80)]. The categorical net reclassification improvement was 0.051 for the 10-year risk of incident CVD. Incidence of fatal events was over 10-fold more frequent in the highest CERT2 category compared to the lowest risk category and modified SCORE risk charts, utilizing CERT2 and diabetes mellitus, increased granularity of risk assessment compared to a chart utilizing total cholesterol.

Conclusion

CERT2 is a significant predictor of incident cardiovascular outcomes and risk charts utilizing this score provide an easy tool to estimate relative and absolute risk for incident CVD.

Efficient computation of Faith's phylogenetic diversity with applications in characterizing microbiomes

The number of publicly available microbiome samples is continually growing. As data set size increases, bottlenecks arise in standard analytical pipelines. Faith's phylogenetic diversity (Faith's PD) is a highly utilized phylogenetic alpha diversity metric that has thus far failed to effectively scale to trees with millions of vertices. Stacked Faith's phylogenetic diversity (SFPhD) enables calculation of this widely adopted diversity metric at a much larger scale by implementing a computationally efficient algorithm. The algorithm reduces the amount of computational resources required, resulting in more accessible software with a reduced carbon footprint, as compared to previous approaches. The new algorithm produces identical results to the previous method. We further demonstrate that the phylogenetic aspect of Faith's PD provides increased power in detecting diversity differences between younger and older populations in the FINRISK study's metagenomic data.

Early middle age cholesterol levels and the association with age-related macular degeneration

PURPOSE

To examine whether serum cholesterol in early middle age is associated with age-related macular degeneration (AMD) later in life.

METHODS

A group of Helsinki Businessmen Study (HBS) participants (n = 209) were recruited for the study. Total cholesterol (TC), triglyceride and body mass index (BMI) were measured at the HBS baseline visit in 1964-1973. Lipid subfractions, BMI, smoking status and statin use were recorded in 2011 and fundus photographs graded for AMD in 2005-2012. The subjects were genotyped for the main AMD risk single nucleotide polymorphisms (SNPs).

RESULTS

TC measured at baseline 1964-1973 was significantly higher in subjects later developing intermediate or late AMD (6.67 mmol/l versus 6.20 mmol/l, p = 0.024) or with drusen size of ≥125 µm (6.68 mmol/l versus 6.21 mmol/l, p = 0.030) compared with the rest of the study population. TC, LDL and TG values at follow-up 2011 were lower in subjects with AMD compared to those without, whereas HDL levels showed no difference. In multivariate analysis, baseline TC associated with intermediate or late AMD (OR 1.59, p = 0.004) and drusen size ≥ 125 µm (OR 1.57, p = 0.006) when corrected for age, BMI, AMD risk SNPs and smoking. Lipid values measured 2011 had no associations after correction.

CONCLUSIONS

High systemic total cholesterol in early middle age may have a role in the initial development of AMD, especially in patients later developing large drusen.

Experiences from the harmonization of Finnish national population-based health survey data

Aims: There are several advantages to pooling survey data from individual studies over time or across different countries. Our aim is to share our experiences on harmonizing data from 13 Finnish health examination surveys covering the years 1972–2017 and to describe the challenges related to harmonizing different variable types using two questionnaire variables – blood pressure measurement and total cholesterol assessment – as examples. Methods: Data from Finnish national population-based health surveys were harmonized as part of the research project ‘Projections of the Burden of Disease and Disability in Finland – Health Policy Prospects’, including variables from questionnaires, objective health measurements and results from the laboratory analysis of biological samples. The process presented in the Maelstrom Research guidelines for data harmonization was followed with minor adjustments. Results: The harmonization of data from objective measurements and biomarkers was reasonably straightforward, but questionnaire items proved more challenging. Some questions and response options had changed during the covered time period. This concerned, for example, questionnaire items on the availability and use of medication and diet. Conclusions: The long time period – 45 years – made harmonization more complicated. The survey questions or response options had changed for some topics due to changes in society. However, common core variables for topics that were especially relevant for the project, such as lifestyle factors and certain diseases or conditions, could be harmonized with sufficient comparability. For future surveys, the use of standardized survey methods and the proper documentation of data collection are recommended to facilitate harmonization.

Long-term population-based trends in the incidence of cardiovascular disease in individuals with type 1 diabetes from Finland: a retrospective, nationwide, cohort study

BACKGROUND

Cardiovascular disease is the main determinant of premature mortality in patients with type 1 diabetes. However, time trends regarding different types of cardiovascular disease in childhood-onset type 1 diabetes with a long timespan from the diagnosis of diabetes are not well established. This study aimed to investigate the cumulative incidence of cardiovascular disease in individuals with type 1 diabetes in a population-based cohort in Finland, the country with the world's highest incidence of type 1 diabetes.

METHODS

In this retrospective, nationwide registry-based, cohort study, all patients who were diagnosed between Jan 1, 1965, and Dec 31, 1999 with type 1 diabetes when they were younger than 15 years old in Finland were followed up and monitored for the occurrence of cardiovascular disease (including coronary artery disease, stroke, peripheral artery disease, and heart failure) until the end of 2016 and for cardiovascular disease mortality until 2017. Cumulative incidences of cardiovascular disease were calculated by the Fine and Gray method according to the year of diabetes diagnosis using six diagnosis cohorts: 1965-69, 1970-74, 1975-1979, 1980-84, 1985-89, 1990-94, and 1990-95. Trends in cardiovascular disease event rates were analysed by Fine and Gray competing risks regression models using year of diabetes diagnosis as continuous variable. In addition, non-linearity in trends was assessed with restricted cubic splines. The excess risk of coronary artery disease and stroke was estimated by comparison with the risk in the Finnish general population by calculating standardised incidence ratios (SIRs) and their time trends. The data for Finnish general population were drawn from the Cardiovascular Disease Register of the National Institute of Health and Welfare. The SIRs were calculated as ratios of observed and expected number of events in individuals with type 1 diabetes during 1991-2014.

FINDINGS

11 766 individuals were included in this study. During 361 033 person-years of follow-up and a median of 29·6 years (IQR 22·3-37·9) follow-up, a total of 1761 individuals had single or multiple types of cardiovascular disease events. 2686 events (864 [32·2%] coronary artery disease events, of which 663 were acute myocardial infarctions; 497 [18·5%] strokes; 854 [31·8%] peripheral artery diseases, of which 498 were lower extremity amputations; and 471 [17·5%] heart failure events) were reported until Dec 31, 2016, and 1467 deaths until Dec 31, 2017. Cardiovascular disease risk decreased linearly by 3·8% (hazard ratio [HR] 0·96 [95% CI 0·96-0·97]; p<0·0001) by later calendar year of diabetes diagnosis (p<0·0001). There was a decrease in the SIRs for both coronary artery disease and stroke within all 10-year age groups under 65 years, except for stroke in the oldest age group. However, the SIR was still 8·9 (95% CI 3·9-17·5) for coronary artery disease and 2·9 (1·3-5·7) for stroke in those diagnosed with type 1 diabetes in the 1990s. Finally, the cardiovascular disease death rate decreased constantly by diagnosis year.

INTERPRETATION

The risk of cardiovascular disease has decreased over time in Finland in individuals with childhood-onset type 1 diabetes. However, there is still considerable excess cardiovascular disease risk in individuals with type 1 diabetes compared with the general population. These results highlight the need for studies on the mechanisms of atherosclerosis from the time of diagnosis of type 1 diabetes to facilitate early and effective prevention of cardiovascular disease in these individuals.

FUNDING

Folkhälsan Research Foundation, Academy of Finland, Wilhelm and Else Stockmann Foundation, Liv och Hälsa Society, Novo Nordisk Foundation, Finnish Foundation for Cardiovascular Research, Finnish Diabetes Research Foundation, Diabetes Research Foundation, Medical Society of Finland, Sigrid Jusélius Foundation, and Helsinki University Hospital Research Funds.

Discrepancies in Observed and Predicted Longitudinal Change in Central Hemodynamic Measures: The Framingham Heart Study

[Figure: see text].

Changes in Cardiovascular Risk Factors in Residents of the Siberian Region (According to Epidemiological Studies)

Aim. To analyze prevalence of cardiovascular risk factors in the Kemerovo region based on the results of epidemiological studies (2013 and 2016).

Material and methods. The study was based on two large epidemiological studies of the Kemerovo region: on 2013, «The epidemiology of cardiovascular diseases and their risk factors in the Russian Federation» and on 2016, «The prospective study of urban and rural epidemiology: study of the influence of social factors on chronic non-infectious diseases in low, middle and high income countries». In the study we analyzed cardiovascular risk factors using identical questionnaires, functional, anthropometric, biochemical means and measured on identical scales. As a result, we analyzed the prevalence of smoking, diabetes mellitus, overweight and obesity, abdominal obesity, hypercholesterolemia and hypertriglyceridemia, high levels of low-density lipoprotein (LDL).

Results. Univariate analysis indicates that in the sample of 2016, compared to the sample of 2013, the prevalence of smoking is statistically significantly lower, as well as the proportion of participants with high cholesterol levels, but not taking lipid-lowering drugs. In contrast, the prevalence of diabetes, hypercholesterolemia and hypertriglyceridemia is higher. In women, the frequency of abdominal obesity on 2016 is lower than on 2013: at 35-44 age group odds ratio (OR) =0.67 with 95% confidence interval (CI) 0.44-1.03, at 45-54 age group OR =0.47 with 95% CI 0.31-0.72, 55-65 age group OR =0.49 with 95% CI 0.30-0.79. A high incidence of diabetes, hypercholesterolemia and hypertriglyceridemia is characteristic mainly of older women (55-65 age group): accordingly, OR =1.96 with 95% CI 1.19-3.22, OR =1.42 with 95% CI 1,02-1.97, OR =1.51 at 95% CI 1.08-2.12. In the 45-54 age group of men, they smoked statistically significantly less often on 2016 compared to 2013, OR =0.59 with 95% CI 0.36-0.96. The prevalence of overweight and obesity in both samples is the same: for women, the OR for overweight in different age groups is within 0.74-0.87, for men - within 0.95-1.78; for obesity OR in women is from 0.70 to 0.79, in men - from 1.03 to 1.34.

Conclusion. A significant advantage of the study is the analysis of changes in prevalence in age and gender groups, which showed significant differences in the dynamics of men and women in different age categories for a number of risk factors. Analysis of the dynamics of the prevalence of cardiovascular risk factors makes it possible to assess the effectiveness of state and regional policies in the field of health protection and, first of all, "risk groups” that require closer attention, development and implementation of targeted health-saving technologies.

Pharmacogenetics of Bleeding and Thromboembolic Events in Direct Oral Anticoagulant Users

This study aimed to analyze associations between genetic variants and the occurrence of clinical outcomes in dabigatran, apixaban, and rivaroxaban users. This was a retrospective real-world study linking genotype data of three Finnish biobanks with national register data on drug dispensations and healthcare encounters. We investigated several single-nucleotide variants (SNVs) in the ABCG2, ABCB1, CES1, and CYP3A5 genes potentially associated with bleeding or thromboembolic events in direct oral anticoagulant (DOAC) users based on earlier research. We used Cox regression models to compare the incidence of clinical outcomes between carriers and noncarriers of the SNVs or haplotypes. In total, 1,806 patients on apixaban, dabigatran, or rivaroxaban were studied. The ABCB1 c.3435C>T (p.Ile1145=, rs1045642) SNV (hazard ratio (HR) 0.42, 95% confidence interval (CI), 0.18-0.98, P = 0.044) and 1236T-2677T-3435T (rs1128503-rs2032582-rs1045642) haplotype (HR 0.44, 95% CI, 0.20-0.95, P = 0.036) were associated with a reduced risk for thromboembolic outcomes, and the 1236C-2677G-3435C (HR 2.55, 95% CI, 1.03-6.36, P = 0.044) and 1236T-2677G-3435C (HR 5.88, 95% CI, 2.35-14.72, P < 0.001) haplotypes with an increased risk for thromboembolic outcomes in rivaroxaban users. The ABCB1 c.2482-2236G>A (rs4148738) SNV associated with a lower risk for bleeding events (HR 0.37, 95% CI, 0.16-0.89, P = 0.025) in apixaban users. ABCB1 variants are potential factors affecting thromboembolic events in rivaroxaban users and bleeding events in apixaban users. Studies with larger numbers of patients are warranted for comprehensive assessment of the pharmacogenetic associations of DOACs and their relevance for clinical practice.

Primary cardiovascular risk prediction by LDL-cholesterol in Caucasian middle-aged and older adults: a joint analysis of three cohorts

AIMS

Low-density lipoprotein cholesterol (LDL-C) is an established causal driver of atherosclerotic cardiovascular disease (ASCVD), but its performance and age-dependency as a biomarker for incident events and mortality arising from ASCVD is less clear. The aim was to determine the value of LDL-C as a susceptibility/risk biomarker for incident coronary heart disease (CHD), ASCVD, and stroke events and deaths, for the age groups <50 and ≥50 years.

METHODS AND RESULTS

The performance of LDL-C was evaluated in three cohorts, FINRISK 2002 (n = 7709), HUSK (n = 5431), and ESTHER (n = 4559), by Cox proportional hazards models, C-statistics, and net reclassification index calculations. Additionally, the hazard ratios (HRs) for the three cohorts were pooled by meta-analysis. The most consistent association was observed for CHD [95% confidence interval (CI) for HRs per standard deviation ranging from 0.99 to 1.37], whereas the results were more modest for ASCVD (0.96-1.18) due to lack of association with stroke (0.77-1.24). The association and discriminatory value of LDL-C with all endpoints in FINRISK 2002 and HUSK were attenuated in subjects 50 years and older [HRs (95% CI) obtained from meta-analysis 1.11 (1.04-1.18) for CHD, 1.15 (1.02-1.29) for CHD death, 1.02 (0.98-1.06) for ASCVD, 1.12 (1.02-1.23) for ASCVD death, and 0.97 (0.89-1.05) for stroke].

CONCLUSION

In middle-aged and older adults, associations between LDL-C and all the studied cardiovascular endpoints were relatively weak, while LDL-C showed stronger association with rare events of pre-mature CHD or ASCVD death among middle-aged adults. The predictive performance of LDL-C also depends on the studied cardiovascular endpoint.

Taxonomic signatures of cause-specific mortality risk in human gut microbiome

The collection of fecal material and developments in sequencing technologies have enabled standardised and non-invasive gut microbiome profiling. Microbiome composition from several large cohorts have been cross-sectionally linked to various lifestyle factors and diseases. In spite of these advances, prospective associations between microbiome composition and health have remained uncharacterised due to the lack of sufficiently large and representative population cohorts with comprehensive follow-up data. Here, we analyse the long-term association between gut microbiome variation and mortality in a well-phenotyped and representative population cohort from Finland (n = 7211). We report robust taxonomic and functional microbiome signatures related to the Enterobacteriaceae family that are associated with mortality risk during a 15-year follow-up. Our results extend previous cross-sectional studies, and help to establish the basis for examining long-term associations between human gut microbiome composition, incident outcomes, and general health status.

Substantial Within-Country Variation in the Incidence of Subarachnoid Hemorrhage: A Nationwide Finnish Study

OBJECTIVE

To study whether the incidence of subarachnoid hemorrhage (SAH) varies between geographic regions of Finland.

METHODS

By utilizing the nationwide Causes of Death and Hospital Discharge Registers, we identified all first-ever, hospitalized, and sudden-death (dying before hospitalization) SAH events in Finland between 1998 and 2017. Based on the patients' home residence, we divided SAHs into 5 geographic regions: southern, central, western, eastern, and northern Finland. We calculated crude and European age-standardized (European Standard Population [ESP] 2013) SAH incidence rates for each region and used a Poisson regression model to calculate age-, sex-, and calendar year-adjusted incidence rate ratios (IRRs) and 95% confidence intervals for regional and time-dependent differences.

RESULTS

During the total 106,510,337 cumulative person-years, we identified 9,443 first-ever SAH cases, of which 24% resulted in death before hospitalization. As compared to western Finland, where the SAH incidence was the lowest (7.4 per 100,000 persons), the ESP-standardized SAH incidence was 1.4 times higher in eastern (10.2 per 100,000 persons; adjusted IRR, 1.37 [1.27-1.47]) and northern Finland (10.4 per 100,000 persons; adjusted IRR, 1.40 [1.30-1.51]). These differences were similar when men and women were analyzed independently. Although SAH incidence rates decreased in all 5 regions over 2 decades, the rate of decrease varied significantly by region.

CONCLUSION

SAH incidence appears to vary substantially by region in Finland. Our results suggest that regional SAH studies can identify high-risk subpopulations, but can also considerably over- or underestimate incidence on a nationwide level.

Causal Effect of MMP-1 (Matrix Metalloproteinase-1), MMP-8, and MMP-12 Levels on Ischemic Stroke: A Mendelian Randomization Study

[Figure: see text].

Case fatality of hospital-treated intracerebral hemorrhage in Finland - A nationwide population-based registry study

BACKGROUND

Case-fatality of Intracerebral hemorrhage (ICH) has been reported to have improved in some areas recently. Previous reports have shown that in Finland ICH survival has improved already from the 1980s. We aimed to investigate if this trend has continued and to assess possible predictors for death.

METHODS

All patients hospitalized for ICH in Finland in 2004-2018 over 16 years of age were identified from a national registry. Survival was analyzed using the national causes of death registry with median follow-up of 5.1 years (max 15.0 years).

RESULTS

20,391 persons with ICH (53.5% men) were identified. Patient age increased during the study period with men being younger than women. One-month case-fatality was 28.4% and decreased during the study period. One-month and long-term case-fatality increased with patient age. Five-year survival was over 64% in patients <65 years of age and < 33% in those >75 years of age. In a multivariate analysis patient age, sex, comorbidity burden and diagnoses of atrial fibrillation, hypertension and coagulopathy were all independently associated with both 30-day and long-term survival. Survival was better in men than women at all time points but in the multivariate analysis male sex was associated with a slightly higher risk (hazard ratio 1.10, 95% CI 1.06-1.14) of death in the long-term follow-up. Compared to general population, excess case-fatality was high and highly age-dependent in both sexes.

CONCLUSIONS

Case-fatality of hospital-treated ICH has continued to decrease in Finland. Prognosis is strongly associated with patient age and more modestly with patient sex and comorbidities.

Integrating data from multiple Finnish biobanks and national health-care registers for retrospective studies: Practical experiences

Aim: This case study aimed to investigate the process of integrating resources of multiple biobanks and health-care registers, especially addressing data permit application, time schedules, co-operation of stakeholders, data exchange and data quality. Methods: We investigated the process in the context of a retrospective study: Pharmacogenomics of antithrombotic drugs (PreMed study). The study involved linking the genotype data of three Finnish biobanks (Auria Biobank, Helsinki Biobank and THL Biobank) with register data on medicine dispensations, health-care encounters and laboratory results. Results: We managed to collect a cohort of 7005 genotyped individuals, thereby achieving the statistical power requirements of the study. The data collection process took 16 months, exceeding our original estimate by seven months. The main delays were caused by the congested data permit approval service to access national register data on health-care encounters. Comparison of hospital data lakes and national registers revealed differences, especially concerning medication data. Genetic variant frequencies were in line with earlier data reported for the European population. The yearly number of international normalised ratio (INR) tests showed stable behaviour over time. Conclusions: A large cohort, consisting of versatile individual-level phenotype and genotype data, can be constructed by integrating data from several biobanks and health data registers in Finland. Co-operation with biobanks is straightforward. However, long time periods need to be reserved when biobank resources are linked with national register data. There is a need for efforts to define general, harmonised co-operation practices and data exchange methods for enabling efficient collection of data from multiple sources.

Secular trends of population attributable risk of overweight and obesity for hypertension among Chinese adults from 1991 to 2011

We determined if the increasing trend in hypertension can be partly attributed to increasing prevalence of overweight/obesity in China over the past two decades. Data were collected from 1991 to 2011 and the population attributable risk (PAR), which is used to estimate the intervention effect on hypertension if overweight/obese, were eliminated. Linear regression was used to evaluate the secular trends. The age-standardized prevalence of overweight and obesity increased by 26.32% with an overall slope of 1.27% (95% CI: 1.12–1.43%) per year. Hypertension also increased by 12.37% with an overall slope of 0.65% (95% CI: 0.51–0.79%) per year. The adjusted ORs of overweight/obesity for hypertension across the survey years remained unchanged; however, the trend in PAR increased steadily from 27.1 to 44.6% with an overall slope of 0.81% (95% CI: 0.34–1.28%) per year (P = 0.006). There was no significant gender difference in the slopes of increasing PAR, as measured by regression coefficients (β = 0.95% vs. β = 0.63% per year, P = 0.36). Over the past two decades, the increase in the prevalence of hypertension in China was partly attributed to the overweight/obesity epidemic, which highlights the importance of controlling weight and further reducing the burden of hypertension.

Pharmacogenetics of Anticoagulation and Clinical Events in Warfarin-Treated Patients: A Register-Based Cohort Study with Biobank Data and National Health Registries in Finland

PURPOSE

To assess the association between VKORC1 and CYP2C9 variants and the incidence of adverse drug reactions in warfarin-treated patients in a real-world setting.

MATERIALS AND METHODS

This was a register-based cohort study (PreMed) linking data from Finnish biobanks, national health registries and patient records between January 1st 2007 and June 30th 2018. The inclusion criteria were: 1) ≥18 years of age, 2) CYP2C9 and VKORC1 genotype information available, 3) a diagnosis of a cardiovascular disease, 4) at least one warfarin purchase, 5) regular INR tests. Eligible individuals were divided into two warfarin sensitivity groups; normal responders, and sensitive and highly sensitive responders based on their VKORC1 and CYP2C9 genotypes. The incidences of clinical events were compared between the groups using Cox regression models.

RESULTS

The cohort consisted of 2508 participants (45% women, mean age of 69 years), of whom 65% were categorized as normal responders and 35% sensitive or highly sensitive responders. Compared to normal responders, sensitive and highly sensitive responders had fewer INR tests below 2 (median: 33.3% vs 43.8%, 95% CI: -13.3%, -10.0%) and more above 3 (median: 18.2% vs 6.7%, 95% Cl: 8.3%, 10.8%). The incidence (per 100 patient-years) of bleeding outcomes was 5.4 for normal responders and 5.6 for the sensitive and highly sensitive responder group (HR=1.03, 95% CI: 0.74, 1.44). The incidence of thromboembolic outcomes was 4.9 and 7.8, respectively (HR=1.48, 95% CI: 1.08, 2.03).

CONCLUSION

In a real-world setting, genetically sensitive and highly sensitive responders to warfarin had more high INR tests and required a lower daily dose of warfarin than normal responders. However, the risk for bleeding events was not increased in sensitive and highly sensitive responders. Interestingly, the risk of thromboembolic outcomes was lower in normal responders compared to the sensitive and highly sensitive responders.

TRIAL REGISTRATION

NCT04001166.

Association between social jet lag, quality of diet and obesity by diurnal preference in Finnish adult population

The evening type has been associated with unhealthy behaviors and adverse health outcomes, such as unhealthy dietary habits and obesity. Misalignment between biological and social rhythms, referred to as social jet lag (SJL), has been considered to explain these outcomes, because evening types are more prone to SJL. However, the existing evidence has been inconsistent and SJL by diurnal preference has hardly been examined. We examined the associations between SJL, the quality of the diet, and the prevalence of obesity by diurnal preference. This dataset included 6779 Finns (55% women, aged 25-74 years) from the National FINRISK 2012 and DILGOM 2014 studies. Diurnal preference was assessed with a shortened version of the Morningness-Eveningness Questionnaire (MEQ). SJL was calculated with the sleep-corrected formula (SJL_sc). SJL was divided into three groups by the degree of SJL (<1h, ≥1h but <2h and ≥2h). The dietary intake was assessed with a validated food frequency questionnaire (FFQ) and the quality of the diet with the Baltic Sea Diet Score. Body weight, height, and waist circumference (WC) were measured, and the body mass index (BMI) was calculated (kg/m²). Analysis of covariance (ANCOVA) followed by Bonferroni multiple comparison post-hoc tests and logistic regression models were used to analyze the differences between the lowest and the highest SJL groups by diurnal preference. In the highest SJL group (≥2h), there were more evening types than morning types (7%-points, p < .001). Overall, those in the highest SJL_sc group were on average younger than those in the lowest SJL_sc group (p< .001). Also, those in the highest SJL_sc group tended to have lower adherence to the Baltic Sea Diet compared to the participants in the lowest SJL_sc group, but this difference reached significance only in morning types (p = .006). Furthermore, morning types in the highest SJL_sc group had higher BMI and WC compared to the morning types in the lowest SJL_sc group (BMI, p = .016; WC, p = .012). In conclusion, evening types had on average more SJL than morning types, but the degree of SJL was associated with the quality of the diet and obesity only in the morning types.

An expanded analysis framework for multivariate GWAS connects inflammatory biomarkers to functional variants and disease

Multivariate methods are known to increase the statistical power to detect associations in the case of shared genetic basis between phenotypes. They have, however, lacked essential analytic tools to follow-up and understand the biology underlying these associations. We developed a novel computational workflow for multivariate GWAS follow-up analyses, including fine-mapping and identification of the subset of traits driving associations (driver traits). Many follow-up tools require univariate regression coefficients which are lacking from multivariate results. Our method overcomes this problem by using Canonical Correlation Analysis to turn each multivariate association into its optimal univariate Linear Combination Phenotype (LCP). This enables an LCP-GWAS, which in turn generates the statistics required for follow-up analyses. We implemented our method on 12 highly correlated inflammatory biomarkers in a Finnish population-based study. Altogether, we identified 11 associations, four of which (F5, ABO, C1orf140 and PDGFRB) were not detected by biomarker-specific analyses. Fine-mapping identified 19 signals within the 11 loci and driver trait analysis determined the traits contributing to the associations. A phenome-wide association study on the 19 representative variants from the signals in 176,899 individuals from the FinnGen study revealed 53 disease associations (p < 1 × 10-4). Several reported pQTLs in the 11 loci provided orthogonal evidence for the biologically relevant functions of the representative variants. Our novel multivariate analysis workflow provides a powerful addition to standard univariate GWAS analyses by enabling multivariate GWAS follow-up and thus promoting the advancement of powerful multivariate methods in genomics.

Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension

High blood pressure is one of the most important risk factors for ischaemic heart disease, stroke, other cardiovascular diseases, chronic kidney disease and dementia. Mean blood pressure and the prevalence of raised blood pressure have declined substantially in high-income regions since at least the 1970s. By contrast, blood pressure has risen in East, South and Southeast Asia, Oceania and sub-Saharan Africa. Given these trends, the prevalence of hypertension is now higher in low-income and middle-income countries than in high-income countries. In 2015, an estimated 8.5 million deaths were attributable to systolic blood pressure >115 mmHg, 88% of which were in low-income and middle-income countries. Measures such as increasing the availability and affordability of fresh fruits and vegetables, lowering the sodium content of packaged and prepared food and staples such as bread, and improving the availability of dietary salt substitutes can help lower blood pressure in the entire population. The use and effectiveness of hypertension treatment vary substantially across countries. Factors influencing this variation include a country's financial resources, the extent of health insurance and health facilities, how frequently people interact with physicians and non-physician health personnel, whether a clear and widely adopted clinical guideline exists and the availability of medicines. Scaling up treatment coverage and improving its community effectiveness can substantially reduce the health burden of hypertension.

Links between gut microbiome composition and fatty liver disease in a large population sample

Fatty liver disease is the most common liver disease in the world. Its connection with the gut microbiome has been known for at least 80 y, but this association remains mostly unstudied in the general population because of underdiagnosis and small sample sizes. To address this knowledge gap, we studied the link between the Fatty Liver Index (FLI), a well-established proxy for fatty liver disease, and gut microbiome composition in a representative, ethnically homogeneous population sample of 6,269 Finnish participants. We based our models on biometric covariates and gut microbiome compositions from shallow metagenome sequencing. Our classification models could discriminate between individuals with a high FLI (≥60, indicates likely liver steatosis) and low FLI (<60) in internal cross-region validation, consisting of 30% of the data not used in model training, with an average AUC of 0.75 and AUPRC of 0.56 (baseline at 0.30). In addition to age and sex, our models included differences in 11 microbial groups from class Clostridia, mostly belonging to orders Lachnospirales and Oscillospirales. Our models were also predictive of the high FLI group in a different Finnish cohort, consisting of 258 participants, with an average AUC of 0.77 and AUPRC of 0.51 (baseline at 0.21). Pathway analysis of representative genomes of the positively FLI-associated taxa in (NCBI) Clostridium subclusters IV and XIVa indicated the presence of, e.g., ethanol fermentation pathways. These results support several findings from smaller case-control studies, such as the role of endogenous ethanol producers in the development of the fatty liver.

Polygenic burden has broader impact on health, cognition, and socioeconomic outcomes than most rare and high-risk copy number variants

Copy number variants (CNVs) are associated with syndromic and severe neurological and psychiatric disorders (SNPDs), such as intellectual disability, epilepsy, schizophrenia, and bipolar disorder. Although considered high-impact, CNVs are also observed in the general population. This presents a diagnostic challenge in evaluating their clinical significance. To estimate the phenotypic differences between CNV carriers and non-carriers regarding general health and well-being, we compared the impact of SNPD-associated CNVs on health, cognition, and socioeconomic phenotypes to the impact of three genome-wide polygenic risk score (PRS) in two Finnish cohorts (FINRISK, n = 23,053 and NFBC1966, n = 4895). The focus was on CNV carriers and PRS extremes who do not have an SNPD diagnosis. We identified high-risk CNVs (DECIPHER CNVs, risk gene deletions, or large [>1 Mb] CNVs) in 744 study participants (2.66%), 36 (4.8%) of whom had a diagnosed SNPD. In the remaining 708 unaffected carriers, we observed lower educational attainment (EA; OR = 0.77 [95% CI 0.66-0.89]) and lower household income (OR = 0.77 [0.66-0.89]). Income-associated CNVs also lowered household income (OR = 0.50 [0.38-0.66]), and CNVs with medical consequences lowered subjective health (OR = 0.48 [0.32-0.72]). The impact of PRSs was broader. At the lowest extreme of PRS for EA, we observed lower EA (OR = 0.31 [0.26-0.37]), lower-income (OR = 0.66 [0.57-0.77]), lower subjective health (OR = 0.72 [0.61-0.83]), and increased mortality (Cox's HR = 1.55 [1.21-1.98]). PRS for intelligence had a similar impact, whereas PRS for schizophrenia did not affect these traits. We conclude that the majority of working-age individuals carrying high-risk CNVs without SNPD diagnosis have a modest impact on morbidity and mortality, as well as the limited impact on income and educational attainment, compared to individuals at the extreme end of common genetic variation. Our findings highlight that the contribution of traditional high-risk variants such as CNVs should be analyzed in a broader genetic context, rather than evaluated in isolation.