Large improvements in major cardiovascular risk factors in the population of northern Sweden: the MONICA study 1986-2009

Difference in risk factor profile for abdominal aortic aneurysm and thoracic aortic aneurysm

OBJECTIVE

Previous studies suggest partly different risk factor profiles of thoracic aortic aneurysms (TAAs) and abdominal aortic aneurysms (AAAs), but prospective data are scarce. The purpose of this prospective population-based case-control study was to investigate differences in risk factor profile between TAAs and AAAs.

METHODS

Participants in two prospective population-based studies, the Västerbotten Intervention Project (VIP) and the Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study, between 1986 and 2010, underwent cardiovascular risk assessments, including blood samples, oral glucose tolerance test, blood pressure readings, and a self-reported health questionnaire. All individuals who were later diagnosed with TAAs or AAAs were identified. Age, sex, and time-matched controls were selected from the same cohorts, aiming at four controls/case. Adjusted odds ratios (aORs) for potential risk factors for later diagnosis of TAAs and AAAs, respectively, were estimated by multivariate conditional logistic regression analyses.

RESULTS

From a total of 96,196 individuals with prospectively collected data in the VIP/MONICA cohort, a total of 236 individuals with AAAs (181 men and 55 women) and 935 matched controls, and 168 individuals with TAAs (115 men and 53 women) and 662 controls were included. The average age at baseline examination was 57.0 ± 5.7 years for AAA cases and controls, and 52.1 ± 8.8 years for TAA cases and controls. Mean time between baseline examination and diagnosis of AAAs/TAAs was 12.1 and 11.7 years, respectively. There was a clear difference in risk factor profile between AAAs and TAAs. Smoking, hypertension, and coronary artery disease were significantly associated with later diagnosis of AAAs, with highest aORs for a history of smoking (aOR, 10.3; 95% confidence interval [CI], 6.3-16.8). For TAAs, hypertension was the only positive risk factor (aOR, 1.7; 95% CI, 1.1-2.7), whereas smoking was not associated. Diabetes was not associated with either AAAs or TAAs; neither was self-reported physical activity.

CONCLUSIONS

In this prospective, population-based, case-control study, risk factor profile differed between AAAs and TAAs. This suggests a partially different etiology for TAAs and AAAs.

Cardiometabolic risk factors in the Swedish Werlabs cohort based on self-initiated health screening: cohort profile

PURPOSE

There is limited research on individuals undergoing self-initiated health examinations, and the Werlabs cohort will be a base for such research.

PARTICIPANTS

All individuals aged 18 or older who had undertaken a self-initiated health examination at Werlabs AB with at least one recorded value of creatinine or cholesterol in Sweden (from 1 January 2015 through 31 December 2023) was included. Medical history and anthropometric measurements were self-reported through an online questionnaire. We describe cohort baseline characteristics, demographic variables and cardiometabolic risk factors.

FINDINGS TO DATE

The study population includes 149 556 individuals who provided at least one health screening. The median (IQR) age was 43 (33-54) years and 54% were women. The most common self-reported chronic disease was hypertension (4.5%), followed by cardiovascular disease (0.9%) and 12.6% reported values of obesity. The prevalence was 2.1% for diabetes, 1.2% for kidney disease (including an estimated glomerular filtration rate of <60 mL/min/1.73 m2), 57.8% for a low-density lipoprotein cholesterol level of >3.0 mmol/L and 4.1% for anaemia (haemoglobin <120 g/L and <130 g/L for women and men, respectively). Interestingly, 1.5% of the individuals had a glucose measurement of >7.0 mmol/L, without reporting a previous diagnosis of diabetes. In an analysis restricted to 621 individuals with recorded blood pressure data between the age of 40 and 70 years and without existing cardiovascular disease, diabetes or kidney disease, 35,4% were classified as high or very high cardiovascular risk according to the 2021 ESC guidelines on cardiovascular disease prevention and with lipid levels that made them eligible for lipid-lowering therapy.

FUTURE PLANS

The Werlabs cohort comprises a rather healthy and young population that can provide opportunities for future studies on individuals undergoing self-initiated health examinations and has the potential to impact treatment of cardiometabolic risk factors.

Thirty-six-year trends (1986-2022) in cigarette smoking and snus use in northern Sweden: a cross-sectional study

OBJECTIVES

To examine the 36-year trends in tobacco use in northern Sweden.

DESIGN AND OUTCOME MEASURE

Cross-sectional analysis of the eight population-based surveys that constitute the northern Sweden MONICA study (1986, 1990, 1994, 1999, 2004, 2009, 2014 and 2022). Cigarette smoking and snus use were self-reported via questionnaires, and age-adjusted percentages of cigarette smoking (including occasional use) and snus use were calculated via logit models.

SETTING

General population of Norrbotten and Västerbotten (the two northernmost counties of Sweden).

PARTICIPANTS

6678 women and 6320 men, aged 25 to 74 years, were included for analysis. A total of 191 participants were excluded due to missing data on either cigarette smoking or snus use.

RESULTS

Cigarette smoking decreased on a survey-to-survey basis, reaching a minimum in 2022 of 4.9% among men and 9.7% among women, corresponding to a percentage point change of 26.3 and 20.8, respectively, compared with 1986 (pwithin-group<0.01). With respect to snus, the use increased steeply up until 1999 among men, after which it persisted around 25% to 30% (26.2% in 2022), with percentage point changes between 6.6 and 13.4 compared with 1986 (pwithin-group<0.01). The percentage of female snus users was extremely low in the first surveys but increased continuously over time, reaching a maximum of 13.0% in 2022 and a percentage point change of 12.5 since 1986 (pwithin-group<0.01). Cigarette smoking-but not snus use-was more common in Norrbotten than in Västerbotten in 2022 (pbetween-group<0.01).

CONCLUSIONS

A substantial decline in cigarette smoking has occurred over time in northern Sweden, particularly among men and more notably in Västerbotten. In contrast, snus use has become increasingly common in both sexes and in both counties.

Sauna bathing in northern Sweden: results from the MONICA study 2022

Frequent sauna bathing has been associated with a reduced risk of cardiovascular disease and proposed as a mediator for improved health. Therefore, the aim was to describe and compare sauna bathers with non-sauna bathers in northern Sweden based on their demographics, health and life attitudes, and to describe sauna bathers' sauna habits. Questions on sauna bathing habits were included in the questionnaire for the participants in the Northern Sweden MONICA (multinational monitoring of trends and determinants in cardiovascular disease) study, conducted during spring of 2022, inviting adults 25-74 years living in the two northernmost counties of Sweden (Norr- and Västerbotten), randomly selected from the population register. Of the 1180 participants in MONICA 2022, 971 (82%) answered the question about sauna bathing. Of these, 641 (66%) were defined as sauna bathers. Sauna bathers reported less hypertension diagnosis and self-reported pain. They also reported higher levels of happiness and energy, more satisfying sleep patterns, as well as better general and mental health. Sauna bathers were younger, more often men and found to have a healthier life-profile compared to non-sauna bathers. Additionally, the results suggest that the positive effects associated with sauna bathing plateaued from 1-4 times per month.

Cohort profile: The Obesity and Disease Development Sweden (ODDS) study, a pooled cohort

PURPOSE

The Obesity and Disease Development Sweden (ODDS) study was designed to create a large cohort to study body mass index (BMI), waist circumference (WC) and changes in weight and WC, in relation to morbidity and mortality.

PARTICIPANTS

ODDS includes 4 295 859 individuals, 2 165 048 men and 2 130 811 women, in Swedish cohorts and national registers with information on weight assessed once (2 555 098 individuals) or more (1 740 761 individuals), in total constituting 7 733 901 weight assessments at the age of 17-103 years in 1963-2020 (recalled weight as of 1911). Information on WC is available in 152 089 men and 212 658 women, out of whom 108 795 have repeated information on WC (in total 512 273 assessments). Information on morbidity and mortality was retrieved from national registers, with follow-up until the end of 2019-2021, varying between the registers.

FINDINGS TO DATE

Among all weight assessments (of which 85% are objectively measured), the median year, age and BMI (IQR) is 1985 (1977-1994) in men and 2001 (1991-2010) in women, age 19 (18-40) years in men and 30 (26-36) years in women and BMI 22.9 (20.9-25.4) kg/m2 in men and 23.2 (21.2-26.1) kg/m2 in women. Normal weight (BMI 18.5-24.9 kg/m2) is present in 67% of assessments in men and 64% in women and obesity (BMI≥30 kg/m2) in 5% of assessments in men and 10% in women. The median (IQR) follow-up time from the first objectively measured or self-reported current weight assessment until emigration, death or end of follow-up is 31.4 (21.8-40.8) years in men and 19.6 (9.3-29.0) years in women. During follow-up, 283 244 men and 123 457 women died.

FUTURE PLANS

The large sample size and long follow-up of the ODDS Study will provide robust results on anthropometric measures in relation to risk of common diseases and causes of deaths, and novel findings in subgroups and rarer outcomes.

Association between the COVID-19 pandemic and mental health in very old people in Sweden

BACKGROUND

During the COVID-19 pandemic, Sweden implemented social distancing measures to reduce infection rates. However, the recommendation meant to protect individuals particularly at risk may have had negative consequences. The aim of this study was to investigate the impact of the COVID-19 pandemic on very old Swedish peoples' mental health and factors associated with a decline in mental health.

METHODS

We conducted a cross-sectional study among previous participants of the SilverMONICA (MONItoring of Trends and Determinants of CArdiovascular disease) study. Of 394 eligible participants, 257 (65.2%) agreed to participate. Of these, 250 individuals reported mental health impact from COVID-19. Structured telephone interviews were carried out during the spring of 2021. Data were analysed using the χ2 test, t-test, and binary logistic regression.

RESULTS

Of 250 individuals (mean age: 85.5 ± 3.3 years, 54.0% women), 75 (30.0%) reported a negative impact on mental health, while 175 (70.0%) reported either a positive impact (n = 4) or no impact at all (n = 171). In the binary logistic regression model, factors associated with a decline in mental health included loneliness (odds ratio [95% confidence interval]) (3.87 [1.83-8.17]) and difficulty adhering to social distancing recommendations (5.10 [1.92-13.53]). High morale was associated with positive or no impact on mental health (0.37 [0.17-0.82]).

CONCLUSIONS

A high percentage of very old people reported a negative impact on mental health from the COVID-19 pandemic, primarily from loneliness and difficulty adhering to social distancing measures, while high morale seemed to be a protective factor.

Incidence and percentage of survival after cardiac arrest outside and inside hospital: A comparison between two regions in Sweden

Aim

To compare the incidence and percentage of survival after cardiac arrest outside and inside hospital where cardiopulmonary resuscitation (CPR) had been started between two regions in Sweden in a 10-year perspective.

Methods

A retrospective observational study including CPR treated patients both after out-of-hospital and in-hospital cardiac arrest (OHCA and IHCA) in Sweden, 2013-2022. Data was retrieved from the Swedish Registry of Cardiopulmonary Resuscitation (SRCR).

Results

The overall incidence of OHCA and IHCA events were 2,940 in Dalarna (having a lower population and population density) and 16,187 in Västra Götaland (having a higher population and population density). The overall incidence of survival when OHCA and IHCA were combined was 20 per 100,000 person years in Dalarna and 19 per 100,000 person years in Västra Götaland. The corresponding result for OHCA was 9 versus 7 and for IHCA 11 versus 12. The overall percentage of survival was 20% in Dalarna and 19% in Västra Götaland. The corresponding result for OHCA was 13% versus 10% and for IHCA 37% versus 36%.

Conclusion

Overall, there was no marked difference neither in incidence nor in percentage of survival after cardiac arrest between the two regions. However, regarding cardiac arrest that took place outside hospital both incidence and percentage of survival was higher in Dalarna than in Västra Götaland despite the fact that the former had lower population density.

Adipokines are possible risk markers for aortic stenosis requiring surgery

OBJECTIVES

Aortic stenosis (AS) is the most prevalent valvular heart disease among adults. The adipocyte-derived hormones, leptin and adiponectin, have profound metabolic actions. We examined whether these adipokines are independently associated with future aortic valve replacement (AVR).

DESIGN

In this longitudinal case-control study, we identified 336 cases who had undergone AVR due to AS, and who had previously participated in population-based health surveys. Two referents were matched to each case and leptin and adiponectin concentrations were analysed from stored baseline survey samples. Uni- and multivariable logistic regression analyses were used to estimate the risk of future AVR. An additional cohort was identified for validation including 106 cases with AVR and 212 matched referents.

RESULTS

Median age (interquartile range (IQR)) in years at survey was 59.9 (10.4) and at surgery 68.3 (12.7), and 48% were women. An elevated concentration of leptin was not associated with future AVR (odds ratio [95% confidence interval]) (1.10 [0.92-1.32]), although leptin was associated with a higher risk in patients with coronary artery disease (CAD) having more than 5 years between survey and AVR (1.41 [1.08-1.84]). Adiponectin was not associated with higher risk for future AVR (0.95 [0.82-1.11]), although after stratification for age, higher levels were associated with reduced risk for AVR in persons aged ≥60 years at surgery (0.79 [0.64-0.98]). In the validation study, leptin was associated with future AVR whereas adiponectin was not. None of the associations remained significant after adjustment for body mass index (BMI).

CONCLUSIONS

The adipokine leptin may promote the development of AS.

Occupational physical activity and resting blood pressure in male construction workers

OBJECTIVE

This study investigated the association between occupational physical activity (OPA) and resting blood pressure in a cohort of Swedish construction workers.

METHODS

The final sample included 241,176 male construction workers. Occupations with low OPA were foremen and white-collar workers. The most frequent occupations in the medium OPA group were electricians, pipe workers, and machine operators, and in the high OPA group woodworkers, concrete workers, and painters.

RESULTS

Mixed effects models showed higher systolic and lower diastolic blood pressure with higher OPA, but the associations varied depending on the year of participation and participant age as shown by significant interaction terms (OPA*age, OPA*calendar year, age*calendar year). Age-stratified linear regression analyses showed a pattern of slightly higher systolic (1.49, 95% confidence interval: 1.08-1.90 mmHg) and lower diastolic (0.89, 95% confidence interval: 0.65-1.13 mmHg) blood pressure when comparing low with high OPA, but not among the oldest age groups.

CONCLUSION

Despite a rather large contrast in OPA, the differences in systolic and diastolic blood pressure according to OPA were small.

Untargeted plasma metabolomics and risk of colorectal cancer-an analysis nested within a large-scale prospective cohort

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer-related death worldwide, but if discovered at an early stage, the survival rate is high. The aim of this study was to identify novel markers predictive of future CRC risk using untargeted metabolomics.

METHODS

This study included prospectively collected plasma samples from 902 CRC cases and 902 matched cancer-free control participants from the population-based Northern Sweden Health and Disease Study (NSHDS), which were obtained up to 26 years prior to CRC diagnosis. Using reverse-phase liquid chromatography-mass spectrometry (LC-MS), data comprising 5015 metabolic features were obtained. Conditional logistic regression was applied to identify potentially important metabolic features associated with CRC risk. In addition, we investigated if previously reported metabolite biomarkers of CRC risk could be validated in this study population.

RESULTS

In the univariable analysis, seven metabolic features were associated with CRC risk (using a false discovery rate cutoff of 0.25). Two of these could be annotated, one as pyroglutamic acid (odds ratio per one standard deviation increase = 0.79, 95% confidence interval, 0.70-0.89) and another as hydroxytigecycline (odds ratio per one standard deviation increase = 0.77, 95% confidence interval, 0.67-0.89). Associations with CRC risk were also found for six previously reported metabolic biomarkers of prevalent and/or incident CRC: sebacic acid (inverse association) and L-tryptophan, 3-hydroxybutyric acid, 9,12,13-TriHOME, valine, and 13-OxoODE (positive associations).

CONCLUSIONS

These findings suggest that although the circulating metabolome may provide new etiological insights into the underlying causes of CRC development, its potential application for the identification of individuals at higher risk of developing CRC is limited.

Prevalence of angina pectoris and association with coronary atherosclerosis in a general population

OBJECTIVE

To assess the contemporary prevalence of, and factors associated with angina pectoris symptoms, and to examine the relationship to coronary atherosclerosis in a middle-aged, general population.

METHODS

Data were based on the Swedish CArdioPulmonary bioImage Study (SCAPIS), in which 30 154 individuals were randomly recruited from the general population between 2013 and 2018. Participants that completed the Rose Angina Questionnaire were included and categorised as angina or no angina. Subjects with a valid coronary CT angiography (CCTA) were categorised by degree of coronary atherosclerosis; ≥50% obstruction (obstructive coronary atherosclerosis), <50% obstruction or any atheromatosis (non-obstructive coronary atherosclerosis) or none (no coronary atherosclerosis).

RESULTS

The study population consisted of 28 974 questionnaire responders (median age 57.4 years, female 51.6%, hypertension 19.9%, hyperlipidaemia 7.9%, diabetes mellitus 3.7%), of which 1025 (3.5%) fulfilled the criteria of angina. Coronary atherosclerosis was more common in individuals having angina compared with those with no angina (n=24 602, obstructive coronary atherosclerosis 11.8% vs 5.4%, non-obstructive coronary atherosclerosis 38.9% vs 37.0%, no coronary atherosclerosis 49.4% vs 57.7%, all p<0.001). Factors independently associated with angina were birthplace outside of Sweden (OR 2.58 (95% CI 2.10 to 2.92)), low educational level (OR 1.41 (1.10 to 1.79)), unemployment (OR 1.51 (1.27 to 1.81)), poor economic status (OR 1.85 (1.38 to 2.47)), symptoms of depression (OR 1.63 (1.38 to 1.92)) and high degree of stress (OR 2.92 (1.80 to 4.73)).

CONCLUSION

Angina pectoris symptoms are common (3.5%) among middle-aged individuals of the general population of Sweden, though with low association to obstructive coronary atherosclerosis. Sociodemographic and psychological factors are highly associated with angina symptoms, irrespective of degree of coronary atherosclerosis.

Trends in renal function in Northern Sweden 1986-2014: data from the seven cross-sectional surveys within the Northern Sweden MONICA study

OBJECTIVE

The prevalence of chronic kidney disease (CKD) is increasing globally, and CKD is closely related to cardiovascular disease (CVD). CKD and CVD share several risk factors (RF), such as diabetes, hypertension, obesity and smoking, and the prevalence of these RF has changed during the last decades, and we aimed to study the effect on renal function over time.

DESIGN

Repeated cross-sectional population-based studies.

SETTING

The two Northern counties (Norr- and Västerbotten) in Sweden.

PARTICIPANTS

Within the MONitoring Trends and Determinants of CArdiovascular Disease (MONICA) study, seven surveys were performed between 1986 and 2014, including participants aged 25-64 years (n=10 185).

INTERVENTIONS

None.

MEASURES

Information on anthropometry, blood pressure and cardiovascular risk factors was collected. Creatinine and cystatin C were analysed in stored blood samples and the estimated glomerular filtration rate (eGFR) calculated using the creatinine-based Lund-Malmö revised and Chronic Kidney Disease Epidemiology Collaboration (eGFRcrea) equations as well as the cystatin C-based Caucasian, Asian, Paediatric and Adult cohort (CAPA) equation (eGFRcysC). Renal function over time was analysed using univariable and multivariable linear regression models.

RESULTS

Renal function, both eGFRcrea and eGFRcysC, decreased over time (both p<0.001) and differed between counties and sexes. In a multivariable analysis, study year remained inversely associated with both eGFRcrea and eGFRcysC (both p<0.001) after adjustment for classical cardiovascular RF.

CONCLUSION

Renal function has deteriorated in Northern Sweden between 1986 and 2014.

Dietary habits among snus users: a population-based cross-sectional study

Background

The dietary habits among snus users are largely unknown and have not been accounted for in observational studies on the health effects of snus use.

Aim

To examine whether snus users eat unhealthier than never tobacco users.

Methods

A total of 3,397 male participants, examined between 1994 and 2014 in the Northern Sweden Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study, were included. Snus use and dietary habits were self-reported using questionnaires, from which intakes of different food groups, macronutrients, and a healthy diet score (HDS) were calculated (the latter as a proxy for overall diet quality). The association between snus use and dietary habits was examined by quantile regression models.

Results

In the multivariable-adjusted model, current snus users had a lower HDS (median difference: -0.86 [95% confidence interval: -1.32, -0.40]) than never tobacco users. Snus users also consumed fewer weekly servings of fruits and berries (median difference: -1.03 [-1.65, -0.40]), and their estimated percentage of energy intake consisted of less carbohydrates (median difference: -1.43 [-2.12, -0.74]) and of more total fat (median difference: 0.99 [0.30, 1.67]), saturated fat (median difference: 0.67 [0.29, 1.05]), monounsaturated fat (median difference: 0.44 [0.20, 0.68]), trans fat (median difference: 0.03 [0.01, 0.06]), and alcohol (median difference: 0.21 [0.02, 0.40]).

Conclusion

We observed that snus users had an unhealthier diet than never tobacco users. Future studies on the association between snus use and health outcomes should, therefore, consider diet as a potential confounder.

Association between snus use and lipid status in Swedish men

Snus is a common tobacco product in Sweden, but the cardiovascular risk profile for snus users is less known than for cigarette smokers. We examined the association of snus use with lipid status, particularly in comparison to non-tobacco use and cigarette smoking, using data from 5930 men in the Northern Sweden MONICA study. Tobacco use was self-reported in 1986 to 2014 (24.4% used snus) and blood samples were collected at the same time. Harmonized analyses on non-high-density lipoprotein (non-HDL) cholesterol, HDL cholesterol, and triglycerides were conducted in 2016 to 2018. Three hundred eighty-one snus users had also been examined more than once, allowing us to study the effect of discontinued use (achieved by 21.0%). In multivariable linear regression models, snus use was associated with higher HDL cholesterol and triglyceride concentrations compared to non-tobacco use (p values ≤ 0.04), and it was associated with higher HDL cholesterol concentrations and lower triglyceride concentrations compared to cigarette smoking (p values ≤ 0.02). Snus use was not associated with non-HDL cholesterol concentrations, irrespective of the comparison group (p values ≥ 0.07). There was no indication that higher intensity of snus use led to a worse lipid profile, given that high-consumers had higher HDL cholesterol concentrations than low-consumers (p value = 0.02), or that discontinuation of snus use led to a better lipid profile, given that continued users had lower triglyceride concentrations than discontinued users (p value = 0.03). Further studies are needed to confirm or refute our findings.

Temporal Dementia and Cognitive Impairment Trends in the Very Old in the 21st Century

BACKGROUND

Long-increasing dementia incidence and prevalence trends may be shifting. Whether such shifts have reached the very old is unknown.

OBJECTIVE

To investigate temporal trends in the incidence of dementia and cognitive impairment and prevalence of dementia, cognitive impairment, Alzheimer's disease, vascular dementia, and unclassified dementia among 85-, 90-, and ≥ 95-year-olds in Sweden during 2000-2017.

METHODS

This study was conducted with Umeå 85 + /Gerontological Regional Database data from 2182 85-, 90-, and ≥ 95-year-olds in Sweden collected in 2000-2017. Using logistic regression, trends in the cumulative 5-year incidences of dementia and cognitive impairment; prevalences of dementia, cognitive impairment, Alzheimer's disease, and vascular dementia; and Mini-Mental State Examination thresholds for dementia diagnosis were estimated.

RESULTS

Dementia and cognitive impairment incidences decreased in younger groups, which generally showed more-positive temporal trends. The prevalences of overall dementia, cognitive impairment, and Alzheimer's disease were stable or increasing; longer disease durations and increasing dementia subtype classification success may mask positive changes in incidences. Vascular dementia increased while unclassified dementia generally decreased.

CONCLUSION

The cognitive health of the very old may be changing in the 21st century, possibly indicating a trend break.

Occupational cold exposure in relation to incident airway symptoms in northern Sweden: a prospective population-based study

Objective

To determine if occupational exposure to cold environments is associated with incident airway symptoms in previously healthy workers.

Methods

A prospective, survey-based, closed-cohort study was conducted on a sample of 5017 men and women between 18 and 70 years of age, living in northern Sweden. Data on occupation, occupational and leisure-time cold exposure, airway symptoms, general health, and tobacco habits were collected during the winters of 2015 (baseline) and 2021 (follow-up). Stepwise multiple logistic regression was used to determine associations between baseline variables and incident airway symptoms.

Results

For individuals working at baseline, without physician-diagnosed asthma or chronic obstructive pulmonary disease, reporting any occupational cold exposure was associated with incident wheeze (OR 1.41; 95% CI 1.06–1.87) and incident productive cough (OR 1.37; 95% CI 1.06–1.77), but not incident long-standing cough (OR 0.98; 95% CI 0.74–1.29), after adjusting for age, body mass index, daily smoking, and occupational physical workload. Detailed analysis of the occupational cold exposure rating did not reveal clear exposure–response patterns for any of the outcomes.

Conclusions

Occupational cold exposure was robustly associated with incident wheeze and productive cough in previously healthy workers. This adds further support to the notion that cold air is harmful for the airways, and that a structured risk assessment regarding occupational cold exposure could be considered for inclusion in the Swedish workplace legislation. Further studies are needed to elaborate on exposure–response functions, as well as suggest thresholds for hazardous cold exposure.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-022-01884-2.

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.

Cardiovascular risks before myocardial infarction differences between men and women

Background

Prodromal cardiac symptoms are warning signals preceding cardiac disease. Previous studies have shown some gender differences in prodromal symptoms as well as established risk factors for MI. This study aims to map possible gender differences in social factors and established risk factors preceding myocardial infarction (MI).

Methods

The study includes data of N = 213 middle-aged men and women, all diagnosed with myocardial infarction (ICD-10 I21.9) from the region of south-east Sweden. They answered a questionnaire at discharge from the cardiologic clinic and additional clinical data from medical records were merged from the National Swedeheart Register.

Results

The dominant prodromal symptom for both sexes were experience of chest pain at the onset of MI. The major gender differences were that significantly more females (p = 0.015) had a hyperlipidemia diagnose. Females also reported to have experienced higher stress load the year preceding myocardial infarction with serious life events (p = 0.019), strained economy (p = 0.003), and reports of sadness/depression (p < 0.001). Females reported higher perceived stress load than men (p = 0.006). Men had higher systolic blood pressure than women at hospital admission and a higher systolic- and diastolic blood pressure at discharge.

Conclusions

Influences of the social environment, such as serious life events, strained economy, depression, stress, and sleep deprivation were stronger as potential risk factors for myocardial infarction in women than among men. Of the traditional risk factors only, hyperlipidemia was more frequent among women. These findings could contribute to a deeper understanding of diagnostic differences between gender, as well as a more gender-oriented cardiovascular preventive work.

Smoking tobacco is associated with renal hyperfiltration

Tobacco consumption is a renal risk factor, but the effects on the estimated glomerular filtration rate (eGFR) remain unclear. We aimed to evaluate the possible impact of using tobacco products (smoking and snus) on eGFR based on creatinine or cystatin C. We used a first cohort with 949 participants and a second cohort with 995 participants; none had pre-existing renal disease. All subjects donated a blood sample and completed a questionnaire, including questions about tobacco use. To assess the effect on eGFR, hierarchical multiple linear regression models were used. Active smoking associated independently with a higher eGFRcreatinine in all subjects (p < 0.001; β = 0.11). Further analyses stratified for sex, showed similar findings for men (p < 0.001; β = 0.14) and for women (p = 0.026; β = 0.10). eGFRcystatin C was significantly associated with active smoking in all subjects (p = 0.040; β = -0.05), but no association was seen after stratification for sex. Snus did not associate with eGFR. In conclusion, smoking associated significantly with a higher eGFRcreatinine. The mechanism may be renal hyperfiltration of smaller molecules such as creatinine. This is probably caused by substances from smoked tobacco other than nicotine, as no effect was seen for snus.

Occupational cold exposure is associated with increased reporting of airway symptoms

OBJECTIVE

To determine if exposure to cold environments, during work or leisure time, was associated with increased reporting of airway symptoms in the general population of northern Sweden.

METHODS

Through a population-based postal survey responded to by 12627 subjects, ages 18-70, living in northern Sweden, the occurrence of airway symptoms was investigated. Cold exposure during work or leisure time was self-reported on numerical rating scales. Binary logistic regression was used to determine the statistical association between cold exposure and airway symptoms.

RESULTS

For currently working subjects (N = 8740), reporting any occupational cold exposure was associated to wheeze (OR 1.3; 95% CI 1.1-1.4); chronic cough (OR 1.2; 95% CI 1.1-1.4); and productive cough (OR 1.3; 95% CI 1.1-1.4), after adjusting for gender, age, body mass index, daily smoking, asthma, and chronic obstructive pulmonary disease. Leisure-time cold exposure was not significantly associated to reporting airway symptoms.

CONCLUSIONS

Occupational cold exposure was an independent predictor of airway symptoms in northern Sweden. Therefore, a structured risk assessment regarding cold exposure could be considered for inclusion in the Swedish workplace legislation.

Adverse generational changes in obesity development converge at midlife without increased cardiometabolic risk

OBJECTIVE

Obesity is becoming a global public health problem, but it is unclear how it impacts different generations over the life course. Here, a descriptive analysis of the age-related changes in anthropometric measures and related cardiometabolic risk factors across different generations was performed.

METHODS

The development of anthropometric measures and related cardiometabolic risk factors was studied during 26 years of follow-up in the Doetinchem Cohort Study (N = 6,314 at baseline). All analyses were stratified by sex and generation, i.e., 10-year age groups (20-29, 30-39, 40-49, and 50-59 years) at baseline. Generalized estimating equations were used to test for generational differences.

RESULTS

Weight, BMI, waist circumference, and prevalence of overweight and obesity were higher, in general, in the younger generations during the first 10 to 15 years of follow-up. From age 50 to 59 years onward, these measures converged in all generations of men and women. Among cardiometabolic risk factors, only type 2 diabetes showed an unfavorable shift between the two oldest generations of men.

CONCLUSIONS

It was observed that, compared with the older generations, the younger generations had obesity at an earlier age but did not reach higher levels at midlife and beyond. This increased exposure to obesity was not (yet) associated with increased prevalence of cardiometabolic risk factors.

Decreased plasma lipid levels in a statin-free Danish primary health care cohort between 2001 and 2018

BACKGROUND

Lipid levels in blood have decreased considerably during the past decades in the general population partly due to use of statins. This study aims to investigate the trends in lipid levels between 2001 and 2018 in a statin-free population from primary health care, overall and by sex and age.

METHODS

In a cohort of 634,119 patients from general practice with no diagnoses or medical treatments that affected lipid levels of total cholesterol (TC; n = 1,574,339) between 2001 and 2018 were identified. Similarly, measurements of low-density lipoprotein cholesterol (LDL-C; n = 1,302,440), high-density lipoprotein cholesterol (HDL-C; n = 1,417,857) and triglycerides (TG; n = 1,329,477) were identified.

RESULTS

Mean TC decreased from 5.64 mmol/L (95% CI: 5.63-5.65) in 2001 to 5.17 mmol/L (95% CI: 5.16-5.17) in 2018 while LDL-C decreased from 3.67 mmol/L (95% CI: 3.66-3.68) to 3.04 mmol/L (95% CI: 3.03-3.04). Women aged 70-74 years experienced the largest decreases in TC levels corresponding to a decrease of 0.7 mmol/L. The decrease in LDL-C levels was most pronounced in men ≥85 years with a decrease of 0.9 mmol/L. For both genders, TC and LDL-C levels increased with advancing age until around age 50. After menopause the women had higher TC and LDL-C levels than the men. The median (geometric mean) TG level decreased by 0.4 mmol/L from 2001 to 2008, after which it increased slightly by 0.1 mmol/L until 2018. During life the TG levels of the men were markedly higher than the women's until around age 65-70. HDL-C levels showed no trend during the study period.

CONCLUSIONS

The levels of TC and LDL-C decreased considerably in a statin-free population from primary health care from 2001 to 2018. These decreases were most pronounced in the elderly population and this trend is not decelerating. For TG, levels have started to increase, after an initial decrease.

Dyspnea after pulmonary embolism: a nation-wide population-based case-control study

Dyspnea is common after a pulmonary embolism. Often, but not always, the dyspnea can be explained by pre-existing comorbidities, and only rarely by chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is probably the extreme manifestation of a far more common condition, called the post-pulmonary embolism syndrome. The purpose of this retrospective study was to investigate the prevalence and predictors of dyspnea among Swedish patients that survived a pulmonary embolism, compared to the general population. All Swedish patients diagnosed with an acute pulmonary embolism in 2005 (n = 5793) were identified via the Swedish National Patient Registry. Patients that lived until 2007 (n = 3510) were invited to participate. Of these, 2105 patients responded to a questionnaire about dyspnea and comorbidities. Data from the general population (n = 1905) were acquired from the multinational MONItoring of trends and determinants in CArdiovascular disease health survey, conducted in 2004. Patients with pulmonary embolism had substantially higher prevalences of both exertional dyspnea (53.0% vs. 17.3%, odds ratio (OR): 5.40, 95% confidence intervals (CI): 4.61-6.32) and wake-up dyspnea (12.0% vs. 1.7%, OR: 7.7, 95% CI: 5.28-11.23) compared to control subjects. These differences remained after adjustments and were most pronounced among younger patients. The increased risk for exertional dyspnea and wake-up dyspnea remained after propensity score matching (OR (95% CI): 4.11 (3.14-5.38) and 3.44 (1.95-6.06), respectively). This population-based, nation-wide study demonstrated that self-reported dyspnea was common among patients with previous pulmonary embolism. This finding suggested that a post-pulmonary embolism syndrome might be present, which merits further investigation.

Defining abnormal cold sensitivity using the Cold Intolerance Symptom Severity questionnaire: a population study

Cold sensitivity, a common and disabling sequela of hand injury, can be assessed using the Cold Intolerance Symptom Severity (CISS) questionnaire, rating symptoms on a scale from 4 to 100. The primary objective of this study was to define a clinical cut-off for abnormal cold sensitivity based on the CISS score in a healthy working-age population. The secondary objective was to investigate how age, gender and previous injuries and diseases influence CISS scoring. In this study, 1239 out of 1582 selected healthy subjects of working age living in northern Sweden completed the questionnaire, yielding a response rate of 78%. The 95th percentile for the CISS score was 49.5 for men and 53.0 for women. The effects of age, gender and previous injuries and diseases were minor and not considered clinically relevant. The results support that a CISS score above 50 should be considered as abnormal cold sensitivity.Level of evidence: III.

Health-related quality of life in hypothyroidism-A population-based study, the WHO MONICA Project

OBJECTIVE

To explore health-related quality of life (HRQoL) among subjects with hypothyroidism compared to subjects without hypothyroidism in the general population. HRQoL is important in clinical practice. Hypothyroidism is prevalent, mainly found in women, and increasing with age.

DESIGN

Cohort study of random population sample.

PATIENTS

Women and men, n = 414 (39-78 years) from the WHO MONICA project, Gothenburg, Sweden, participated. Hypothyroidism was defined as subjects having levothyroxine supplementation or serum thyroid-stimulating hormone (S-TSH) >4.2 mU/L.

MEASUREMENTS

Health-related quality of life was measured with Psychological General Well-Being Index (PGWB), Nottingham Health Profile (NHP), Short Form 36 Health Survey (SF-36) and a single item self-rated health scale (0-100), and stress was rated 1-6. The results were adjusted for age, sex and comorbidity using analysis of covariance (ANCOVA).

RESULTS

Hypothyroidism was found in 70 subjects (17%). They scored worse HRQoL than controls regarding Sleep (p < .001), Social isolation (p = .01) and Total NHP (p < .05), and had more medication in general 2.7 ± 2.5 vs. 1.8 ± 2.1, p < .05. Subjects with levothyroxine (n = 40) showed similar results as the total hypothyroid group. Subjects unaware of their newly detected elevated STSH (n = 30) showed lower HRQoL in Sleep (p < .01) and Pain (p < .05) in NHP. HRQoL was similar in subjects with and without positive thyroperoxidase antibodies (TPO-Ab) either in those with hypothyroidism (44% TPO-Ab) or controls (9% TPO-Ab).

CONCLUSION

Men and women with hypothyroidism in the general population reported having more issues with Sleep and Social isolation than those without hypothyroidism irrespective of TPO-Ab. Scores were similar in all of the other HRQoL domains measuredAQ5.

Swedish snus use is associated with mortality: a pooled analysis of eight prospective studies

BACKGROUND

The health consequences of the use of Swedish snus, including its relationship with mortality, have not been fully established. We investigated the relationship between snus use and all-cause and cause-specific mortality (death due to cardiovascular diseases, cancer diseases and all other reasons, respectively) in a nationwide collaborative pooling project.

METHODS

We followed 169 103 never-smoking men from eight Swedish cohort studies, recruited in 1978-2010. Shared frailty models with random effects at the study level were used in order to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of mortality associated with snus use.

RESULTS

Exclusive current snus users had an increased risk of all-cause mortality (aHR 1.28, 95% CI 1.20-1.35), cardiovascular mortality (aHR 1.27, 95% CI 1.15-1.41) and other cause mortality (aHR 1.37, 95% CI 1.24-1.52) compared with never-users of tobacco. The risk of cancer mortality was also increased (aHR 1.12, 95% CI 1.00-1.26). These mortality risks increased with duration of snus use, but not with weekly amount.

CONCLUSIONS

Snus use among men is associated with increased all-cause mortality, cardiovascular mortality, with death from other causes and possibly with increased cancer mortality.

Contribution of cystatin C- and creatinine-based definitions of chronic kidney disease to cardiovascular risk assessment in 20 population-based and 3 disease cohorts: the BiomarCaRE project

BACKGROUND

Chronic kidney disease has emerged as a strong cardiovascular risk factor, and in many current guidelines, it is already considered as a coronary heart disease (CHD) equivalent. Routinely, creatinine has been used as the main marker of renal function, but recently, cystatin C emerged as a more promising marker. The aim of this study was to assess the comparative cardiovascular and mortality risk of chronic kidney disease (CKD) using cystatin C-based and creatinine-based equations of the estimated glomerular filtration rate (eGFR) in participants of population-based and disease cohorts.

METHODS

The present study has been conducted within the BiomarCaRE project, with harmonized data from 20 population-based cohorts (n = 76,954) from 6 European countries and 3 cardiovascular disease (CVD) cohorts (n = 4982) from Germany. Cox proportional hazards models were used to assess hazard ratios (HRs) for the various CKD definitions with adverse outcomes and mortality after adjustment for the Systematic COronary Risk Evaluation (SCORE) variables and study center. Main outcome measures were cardiovascular diseases, cardiovascular death, and all-cause mortality.

RESULTS

The overall prevalence of CKD stage 3-5 by creatinine- and cystatin C-based eGFR, respectively, was 3.3% and 7.4% in the population-based cohorts and 13.9% and 14.4% in the disease cohorts. CKD was an important independent risk factor for subsequent CVD events and mortality. For example, in the population-based cohorts, the HR for CVD mortality was 1.72 (95% CI 1.53 to 1.92) with creatinine-based CKD and it was 2.14 (95% CI 1.90 to 2.40) based on cystatin-based CKD compared to participants without CKD. In general, the HRs were higher for cystatin C-based CKD compared to creatinine-based CKD, for all three outcomes and risk increased clearly below the conventional threshold for CKD, also in older adults. Net reclassification indices were larger for a cystatin-C based CKD definition. Differences in HRs (between the two CKD measures) in the disease cohorts were less pronounced than in the population-based cohorts.

CONCLUSION

CKD is an important risk factor for subsequent CVD events and total mortality. However, point estimates of creatinine- and cystatin C-based CKD differed considerably between low- and high-risk populations. Especially in low-risk settings, the use of cystatin C-based CKD may result in more accurate risk estimates and have better prognostic value.

Troponin T but not C reactive protein is associated with future surgery for aortic stenosis: a population-based nested case-referent study

AIMS

High-sensitivity troponin T (hs-TnT) and high-sensitivity C reactive protein (hs-CRP) may convey prognostic information in patients with aortic stenosis (AS). This study evaluated if hs-TnT and hs-CRP associate with myocardial mass, and risk of future surgery for AS.

METHODS

In total, 336 patients (48% women) with surgery for AS with previous participation in large population surveys were identified. Preoperatively, myocardial mass and the presence of coronary artery disease (CAD) were assessed. Two matched referents were allocated for each case, and hs-TnT and hs-CRP were determined in stored plasma from the baseline survey. Conditional logistic regression analysis was used to estimate the risk (OR (95% CI)) related to one (natural logarithm) SD increase in hs-TnT and hs-CRP. Kaplan-Mayer and Cox regression analyses were used to evaluate time to surgery.

RESULTS

Median age (IQR) was 59.8 (10.3) years at survey, and median time between survey and surgery was 10.9 (9.3) years. Hs-TnT was independently associated with surgery for AS (1.24 (1.06-1.44)) irrespective of CAD, whereas Hs-CRP was not (1.05 (0.90-1.22)). Elevated hs-TnT levels at survey associated with shorter time to surgery (p<0.001), and with increased myocardial mass (p=0.002). Hs-CRP did not associate with time to surgery or with myocardial mass.

CONCLUSIONS

Hs-TnT-but not hs-CRP-was associated with increased risk of-and shorter time to-future surgery for AS. Hs-TnT associated with myocardial mass at surgery which indicates that hs-TnT could be a potential biomarker for determining intervention.

Time trends and socioeconomic differences in blood pressure levels: The Northern Sweden MONICA study 1994–2014

Background

People with low socioeconomic status have higher blood pressure (BP), increasing their risk of myocardial infarction and stroke. We hypothesized that the gap in systolic (SBP) and diastolic (DBP) BP, according to educational level, has decreased over time but, that economical vulnerability would confer higher BP.

Methods

A total of 4564 women and 4363 men aged 25–74 years participated in five population-based surveys in the Northern Sweden MONICA study between 1994 and 2014 (participation rate 76.8–62.5%).

Results

SBP decreased by 10 mmHg in women and 4 mmHg in men, while DBP was unchanged. Treatment with antihypertensives increased in all but the youngest men. The prevalence of BP control in the population (&lt;140/90 mmHg) increased and in 2014 reached 75% among women and 70% among men. The decrease in SBP was more pronounced in people without university education than in people with university education and DBP showed the same pattern, regardless of education.

After adjustment for confounding factors, age, male sex, higher body mass index, and being born in a Nordic country were related to higher SBP and DBP. University education was related to lower SBP, while variables mirroring economic vulnerability were not associated with BP levels.

Conclusions

BP levels as well as the socioeconomic gap in BP has decreased in Sweden but people with a lower level of education still have higher SBP. Lacking economic resources is not associated with high BP.

Secular trends in cardiovascular risk factors among women aged 45-54 years in Gothenburg, Sweden, from 1980 to 2014

Background

A declining trend in mean cholesterol levels and smoking has been observed in high-income western countries during the last few decades, whereas obesity rates have increased. Simultaneously, mortality from coronary heart disease has decreased. The aim of the present study was to determine whether the trends in cardiovascular risk factors have continued in successive cohorts of middle-aged women over a period of 34 years.

Methods

Six population-based, cross-sectional samples of women (n = 2294) mean age: 49.8 years (range: 45–54), living in Gothenburg, Sweden, were investigated between 1980 and 2014.

Results

Body mass index (BMI) increased over time, with a mean BMI of 24.7 kg/m² in 1980 to 25.7 kg/m² in 2013–2014, corresponding to a weight gain of 4.5 kg, together with an increase in the proportion of obese individuals (BMI ≥ 30 kg/m²) from 10.4 to 16.6% (p = 0.0012). The proportion of smokers and women with hypertension decreased from 34.5 to 12.8% (p = 0.0006) and from 37.7 to 24.5% (p < 0.0001) respectively. Mean total serum cholesterol levels decreased from 6.23 (SD 1.09) mmol/L in 1980 to 5.43 (SD 0.98) mmol/L in 2013–2014 (p < 0.0001). Self-reported leisure time regular exercise increased from 7.8% in 1980 to 35.6% in 2013–2014 (p < 0.0001). For women born in 1963, the prevalence ratio of not having any of five major cardiovascular risk factors was 1.82 (95% confidence interval (CI) 1.38–2.41), compared with women born in 1925–1934.

Conclusion

The trend towards increasing obesity, more leisure-time physical activity and less smoking remains, while the decrease in serum cholesterol appears to have abated.

Phosphatidylethanol Levels, As a Marker of Alcohol Consumption, Are Associated With Risk of Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Previous observational studies have shown a moderately increased risk of intracerebral hemorrhage (ICH) with high self-reported alcohol consumption. However, self-reported data tend to underestimate alcohol consumption. Phosphatidylethanol is a specific biomarker reflecting alcohol intake during the last month and correlates with the amount of alcohol consumed. The present study aimed to investigate the association between phosphatidylethanol levels and the risk of future ICH.

METHODS

This population-based nested case-referent study was conducted within the Northern Sweden Health and Disease Cohort. At baseline, all participants underwent a health examination, including a questionnaire with questions about alcohol consumption. A blood sample was collected and stored at -80°C, and phosphatidylethanol 16:0/18:1 levels were measured in packed erythrocytes. Cases (n=97) were diagnosed with a first-ever ICH between 1985 and 2007. Two referents (n=180) were matched to each case.

RESULTS

The mean age at baseline was 55 years, 39% of participants were women, and the mean time from blood sampling to ICH was 7.3 years. Only phosphatidylethanol and hypertension remained independently associated with ICH in a multivariable model. Participants with phosphatidylethanol >0.30 μmol/L had an increased risk of ICH compared with those with phosphatidylethanol <0.01 μmol/L (odds ratio, 4.64 [95% CI, 1.49-14.40]).

CONCLUSIONS

High blood concentrations of phosphatidylethanol were associated with an increased risk of future ICH. This association was independent of hypertension and other risk factors for ICH. Our findings suggest that phosphatidylethanol, as a marker of alcohol consumption, may be used as a risk marker of future ICH.

High frequency of intermediary alleles in the HTT gene in Northern Sweden - The Swedish Huntingtin Alleles and Phenotype (SHAPE) study

Trinucleotide (CAG) repeat expansions longer than 39 in the huntingtin (HTT) gene cause Huntington's disease (HD). The frequency of intermediate alleles (IA) with a length of 27-35 in the general population is not fully known, but studied in specific materials connected to the incidence of HD. The Swedish Huntingtin Alleles and Phenotype (SHAPE) study aims to assess the frequency of trinucleotide repeat expansions in the HTT gene in north Sweden. 8260 individuals unselected for HD from the counties of Norr- and Västerbotten in the north of Sweden were included. DNA samples were obtained and analysis of the HTT gene was performed, yielding data on HTT gene expansion length in 7379 individuals. A high frequency of intermediate alleles, 6.8%, was seen. Also, individuals with repeat numbers lower than ever previously reported (<5) were found. These results suggest a high frequency of HD in the norther parts of Sweden. Subsequent analyses may elucidate the influence of IA:s on traits other than HD.

No association between moist oral snuff (snus) use and oral cancer: pooled analysis of nine prospective observational studies

Aims: Worldwide, smokeless-tobacco use is a major risk factor for oral cancer. Evidence regarding the particular association between Swedish snus use and oral cancer is, however, less clear. We used pooled individual data from the Swedish Collaboration on Health Effects of Snus Use to assess the association between snus use and oral cancer. Methods: A total of 418,369 male participants from nine cohort studies were followed up for oral cancer incidence through linkage to health registers. We used shared frailty models with random effects at the study level, to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for confounding factors. Results: During 9,201,647 person-years of observation, 628 men developed oral cancer. Compared to never-snus use, ever-snus use was not associated with oral cancer (adjusted HR 0.90, 95% CI: 0.74, 1.09). There were no clear trends in risk with duration or intensity of snus use, although lower intensity use (⩽ 4 cans/week) was associated with a reduced risk (HR 0.65, 95% CI: 0.45, 0.94). Snus use was not associated with oral cancer among never smokers (HR 0.87, 95% CI: 0.57, 1.32). Conclusions: Swedish snus use does not appear to be implicated in the development of oral cancer in men.

Comparison of incidence rates and risk factors of heart failure between two male cohorts born 30 years apart

OBJECTIVE

To compare two cohorts of middle-aged men from the general population born 30 years apart for incidence and predictors of heart failure (HF).

METHODS

Two population samples of men, born in 1913 (n=855) and in 1943 (n=797), were examined at 50 years of age and followed up for 21 years (1963-1994 and 1993-2014). Cox regression analysis was used to examine the impact of different factors on the risk of developing HF.

RESULTS

Eighty men born in 1913 (9.4%) and 42 men born in 1943 (5.3%) developed HF during follow-up; adjusted HRs comparing the two cohorts (born 1943 vs 1913) were: 0.46 (95% CI 0.28 to 0.74, p=0.002). In both cohorts, higher body mass index, higher diastolic blood pressure, treatment for hypertension, onset of either atrial fibrillation (AF), ischaemic heart disease and diabetes mellitus were associated with higher risk of HF. Higher heart rate was associated with an increased risk only in men born in 1913, whereas higher systolic blood pressure (SBP), smoking, higher glucose, higher cholesterol and physical inactivity were associated with an increased risk in men born in 1943. AF contributed higher risk of incident HF, whereas SBP and physical inactivity contributed lower risk in men born in 1943 compared with men born in 1913.

CONCLUSIONS

Men born in 1943 had half the risk of HF after their 50s than those born 30 years earlier. AF, obesity, ischaemic heart disease, diabetes and hypertension remain important precursors of HF.

The role of Apolipoprotein E epsilon4 in the association between psychosocial working conditions and dementia

In this population-based prospective study, we examined the association of job demand-control combinations with dementia, and explored the roles of Apolipoprotein E epsilon4 (APOE ɛ4) and work duration in this association. A total of 2,579 dementia-free individuals aged 60+ years from Sweden were followed over 12 years. Dementia diagnosis was made by physicians. Lifelong occupational experience was collected, and job demands and control were assessed using a psychosocial job-exposure matrix. Data were analyzed using multivariate Cox proportional hazard models. During the follow-up, 282 people developed dementia. Passive jobs (low control/low demands) were related to a higher risk of dementia compared with active jobs (high control/high demands) among the younger-old (aged ≤72 years), but not among the older-old (aged ≥78 years). Among the younger-old, compared to those with no passive job experience, those with 11+ years in passive jobs had a higher dementia risk. The joint-effect analyses showed that APOE ɛ4 carriers with passive jobs had an even higher risk of dementia compared to APOE ɛ4 non-carriers with active jobs. These findings suggest that passive jobs are related to a higher dementia risk among the younger-old. APOE ɛ4 and long work duration may amplify the impact of passive jobs on dementia.

Arterial hypertension and diastolic blood pressure associate with aortic stenosis

OBJECTIVES

Due to age-related differences in aortic valve structure, it is likely that the pathophysiology of aortic stenosis (AS) and associated risk factors differ between age groups. Here we prospectively studied the influence of traditional cardiovascular risk factors on AS development requiring surgery among patients without concomitant coronary artery disease (CAD) and stratified for age.

DESIGN

This study included 322 patients, who had prior to surgery for AS participated in population-based surveys, and 131 of them had no visible CAD upon preoperative coronary angiogram. For each case, we selected four referents matched for age, gender, and geographic area. To identify predictors for surgery, we used multivariable conditional logistic regression with a model including arterial hypertension (or measured blood pressure and antihypertensive medication), cholesterol levels, diabetes, body mass index (BMI), and smoking.

RESULTS

In patients without CAD, future surgery for AS was associated with arterial hypertension and elevated levels of diastolic blood pressure in patients younger than 60 years at surgery (odds ratio [95% confidence interval]), (3.40 [1.45-7.93] and 1.60 [1.09-2.37], respectively), and with only impaired fasting glucose tolerance in patients 60 years or older at surgery (3.22 [1.19-8.76]).

CONCLUSION

Arterial hypertension and elevated diastolic blood pressure are associated with a risk for AS requiring surgery in subjects below 60 years of age. Strict blood pressure control in this group is strongly advocated to avoid other cardiovascular diseases correlated to hypertension. If hypertension and elevated diastolic blood pressure are risk factors for developing AS requiring surgery need further investigations. Notably, elevated fasting glucose levels were related to AS requiring surgery in older adults without concomitant CAD.

Time trends of vitamin D concentrations in northern Sweden between 1986 and 2014: a population-based cross-sectional study

Purpose

Vitamin D, produced through cutaneous photosynthesis or ingested via foods or supplements, has generated considerable research interest due to its potential health effects. However, epidemiological data on the time trends of vitamin D status are sparse, especially from northern Europe. We examined the time trend of vitamin D concentrations in northern Sweden between 1986 and 2014.

Methods

We used data on 11,129 men and women (aged 25–74 years) from seven population-based surveys (the Northern Sweden MONICA study), recruited between 1986 and 2014. Serum vitamin D (25-hydroxyvitamin D) status was measured using a one-step immunoassay (Abbott Architect). Multivariable linear regression models, adjusted for age, sex, and a number of other variables, were used to estimate the time trend of vitamin D concentrations.

Results

The mean value of vitamin D in the entire study population was 19.9 ng/mL [standard deviation (SD) 7.9], with lower values in men (19.4 ng/mL; SD 7.5) than in women (20.5 ng/mL; SD 8.2). Using the survey in 1986 as reference category, the multivariable-adjusted mean difference [95% confidence interval (CI)] in ng/mL was 2.7 (2.2, 3.3) in 1990, 3.2 (2.7, 3.7) in 1994, 1.6 (1.0, 2.1) in 1999, − 2.0 (− 2.5, − 1.4) in 2004, 1.0 (0.4, 1.5) in 2009, and 3.1 (2.5, 3.6) in 2014.

Conclusion

In this large cross-sectional study, we observed no clear upward or downward trend of vitamin D concentrations in northern Sweden between 1986 and 2014.

Electronic supplementary material

The online version of this article (10.1007/s00394-019-02142-x) contains supplementary material, which is available to authorized users.

D-Dimer Is Associated With First-Ever Intracerebral Hemorrhage

Background and Purpose- Hypertension is the most important risk factor for intracerebral hemorrhage (ICH), but further characterization is needed for groups at high risk of ICH. One way to predict the risk of developing a disease is with plasma biomarkers. This study aimed to investigate the association between the biomarker, D-dimer, and ICH risk. Methods- This population-based, nested case-control study was conducted using data from 2 population-based surveys; the Västerbotten Intervention Programme and MONICA Northern Sweden (Monitoring Trends and Determinants in Cardiovascular Disease). All participants underwent a health examination and blood sampling at baseline before the event. Cases (n=141) were diagnosed with a first-ever ICH between 1985 and March 2007. One or 2 controls (n=255) were matched to each case. Results- The median age was 60 years; 39% of participants were women; and the median time from blood sampling to ICH was 5.2 years. When D-dimer was evaluated as a continuous variable, it was significantly associated with ICH. After multivariable adjustment (for hypertension, body mass index, cholesterol levels, diabetes mellitus, and smoking), the odds ratio was 1.36 per SD of D-dimer (95% CI, 1.05-1.77). When participants were stratified in 3 groups according to time from blood sampling at health examination to ICH, we found that the association between D-dimer levels and ICH was most pronounced in individuals with the shortest time from blood sampling to ICH event (<3.5 years; odds ratio, 1.78; 95% CI, 1.05-3.05). Conclusions- High plasma concentrations of D-dimer were associated with increased risk of a future ICH, after adjusting for cardiovascular risk factors. This association was predominantly driven by the cases with the shortest time from blood sampling to ICH event.

Community pharmacies offer a potential high-yield and convenient arena for total cholesterol and CVD risk screening

Background

Moderately elevated blood total cholesterol (TC), blood glucose (BG) and blood pressure (BP) are rarely symptomatic and as such many individuals remain untreated. We studied the yield of an in-pharmacy screening for identifying undetected high TC and strategies to reach those with absence of prior measurement of TC, BG and BP.

Methods

A cross-sectional TC screening study with complementary TC measurements and self-administered questionnaire was conducted for 1 week in each of 2012 and 2014 in 148 and 149 BootsTM Norge AS community pharmacies nationwide in Norway.

Results

Non-medicated adults (n = 21 090) with mean age 54.5 ± 16.0 were included. The study population resembled the Norwegian population in regards to body mass index, educational level, smokers and physical inactivity level, but with an overrepresentation of middle-aged women. Of 20 743 with available data, 11% (n = 2337) were unaware of their high TC ≥7.0 mmol/L, and an additional 8% were unaware of TC ≥6.2 mmol/L. More than 40% of the study sample had not measured TC or BG before. In order for future screenings to reach those who are less likely to have previously measured TC and BG, our results suggest that young, low-educated, overweight men and women should be targeted for TC measurement, whereas normal weigh men in all ages should be targeted for BG measurement.

Conclusions

In total 19% in an in-pharmacy screening were unaware of their elevated TC of ≥6.2 mmol/L. We also identified characteristics that could be used reach those who are less likely to have measured TC and BG.

Long-term survival after stroke in Lithuania: Data from Kaunas population-based stroke registry

BACKGROUND

There is a lack of reliable epidemiological data on long-term survival trends of first-ever stroke patients in Lithuanian population.

AIMS

To evaluate trends in long-term survival after stroke and to determine the influence of some sociodemographic and lifestyle factors, time and subtype of stroke, and stroke care on survival.

METHODS

All stroke events included in Kaunas stroke register database were ascertained and validated according to the standardized criteria outlined by the WHO MONICA Project. The study included all patients in Kaunas (Lithuania) city aged 25 to 64 years who experienced a stroke between 1986 and 2011. Death time was confirmed by the Office for National Death Statistics. Estimates of stroke long-term survival data and factors influencing survival changes were made by applying the Kaplan-Meier and Cox regression analysis.

RESULTS

During the study period, 4,129 persons aged 25-64 years suffered from a first-ever stroke: 2,215 (53.6%) of them were men and 1,914 (46.4%)-women. Ischemic stroke was significantly more frequent in males than in females (80.6% and 78.6%, respectively, p<0.05) and subarachnoid hemorrhage was more common in women than in men (9.0% and 7.0% respectively, p <0.05). Of all first-ever stroke patients, 3,272 (79.2%) survived 1 year and 2,905 (70.4%) survived 5 years after stroke onset. The 1- and 5-years survival rate after a first-ever stroke in women was significantly higher as compared with that in men (Log-rank test p = 0.0001). The older (55-64 year) persons had poorer 1-year and 5-years survival rate as compared with persons in the younger (25-54 years) age group (Log-rank test p = 0.0001). Among persons with a first-ever stroke who had their stroke in 2007-2011, 1- and 5-year survival rate was higher compared with that in persons who had had a stroke in 1986-1990 and in 1997-2001 (Log-rank test p = 0.0001). The persons with a first-ever ischemic stroke had a better chance to survive first 1- and 5-years after stroke compared with persons who had intracerebral or subarachnoid haemorrhage. Only female gender was associated with higher 1- and 5-year survival rate after first-ever stroke. The older age, previous myocardial infarction and diabetes mellitus were associated with lower 1- and 5-year survival rate after first-ever stroke.

CONCLUSIONS

This population-based study of patients with first-ever stroke demonstrated that the long-term survival was better in women than men, and improved significantly in both men and women during the past decade. Long-term survival was better of those with first-ever ischemic stroke and of younger age- 25 to 54 years.

Modelling the health co-benefits of sustainable diets in the UK, France, Finland, Italy and Sweden

BACKGROUND/OBJECTIVES

It is not known if diets lower in greenhouse gas (GHG) emissions are also healthier. We evaluated the population health implications of changing to more sustainable diets in the UK, France, Finland, Italy and Sweden.

SUBJECTS/METHODS

We developed a life table model to simulate mortality and morbidity from diet-related diseases over the lifetime of the current population. Populating the model with locally available data for each country, we simulated the impact of country-specific dietary scenarios that had been optimised to meet dietary recommendations and reduce GHG emissions. Outcome measures included a change in disease-specific deaths, life expectancy and disability-adjusted life years (DALYs).

RESULTS

Diets that meet nutritional recommendations lead to substantial improvements in population health, ranging from 0.19 (95% uncertainty interval: 0.18-0.21) DALYs per person in Italy up to 0.89 (0.80-0.98) DALYs per person in Finland. Simultaneously reducing GHG emissions does not reduce the size of this impact, and in some cases produces additional health benefits. If sustainable diets can be maintained throughout adulthood, life expectancy would increase by between 2.3 (1.6-3.2) and 6.8 (5.5-8.5) months by country. However, results are sensitive to assumptions about how quickly changes in diet can influence disease, and future trends in disease.

CONCLUSIONS

Modelling the health impact of diets that are both nutritional and low in GHG emissions shows the potential for significant co-benefits in health and sustainability from dietary changes. Future work is needed to find effective interventions to deliver healthy sustainable diets.

The association between circulating endostatin levels and incident myocardial infarction

OBJECTIVE

Increased levels of circulating endostatin have been observed in patients with prevalent ischemic heart disease. However, the association between circulating endostatin, and incident myocardial infarction (MI) is less studied. Our main aim was to study the association between circulating endostatin and incident MI in the community adjusted for established cardiovascular risk factors in men and women.

DESIGN

Circulating endostatin was measured in a nested case control study based on three large community-based Swedish cohorts, including 533 MI cases, and 1003 age-, sex- and cohort-matched controls. Odds ratios (OR) with 95% confidence intervals (CI) were calculated with adjustments for established cardiovascular risk factors.

RESULTS

Higher endostatin was associated with a higher incidence of MI independently of established cardiovascular risk factors (OR 1.19, 95% CI 1.03-1.37, p = .02), but this association was abolished after additional adjustment for C-reactive protein. Sex-stratified analyses suggest that the association was substantially stronger in women as compared to men.

CONCLUSIONS

In our community based sample, higher endostatin predicted incident myocardial infarction predominantly in women but not independently of CRP. Thus, our findings do not support a broad utility of endostatin measurements for the prediction of incident myocardial infarction in clinical practice.

Proteomic Biomarkers for Incident Aortic Stenosis Requiring Valvular Replacement

Background:

Aortic valve stenosis (AS) is the most common indication for cardiac valve surgery; untreated AS is linked to high mortality. The etiological background of AS is unknown. Previous human studies were typically based on case-control studies. Biomarkers identified in prospective studies could lead to novel mechanistic insights.

Methods:

Within a large population survey with blood samples obtained at baseline, 334 patients were identified who later underwent surgery for AS (median age [interquartile range], 59.9 [10.4] years at survey and 68.3 [12.7] at surgery; 48% female). For each case, 2 matched referents were allocated. Plasma was analyzed with the multiplex proximity extension assay for screening of 92 cardiovascular candidate proteins. Conditional logistic regression models were used to assess associations between each protein and AS, with correction for multiple testing. A separate set of 106 additional cases with 212 matched referents was used in a validation study.

Results:

Six proteins (growth differentiation factor 15, galectin-4, von Willebrand factor, interleukin 17 receptor A, transferrin receptor protein 1, and proprotein convertase subtilisin/kexin type 9) were associated with case status in the discovery cohort; odds ratios ranged from 1.25 to 1.37 per SD increase in the protein signal. Adjusting the multivariable models for classical cardiovascular risk factors at baseline yielded similar results. Subanalyses of case-referent triplets (n=133) who showed no visible coronary artery disease at the time of surgery in the index person supported associations between AS and growth differentiation factor 15 (odds ratio, 1.40; 95% confidence interval, 1.10-1.78) and galectin-4 (odds ratio, 1.27; 95% confidence interval, 1.02-1.59), but these associations were attenuated after excluding individuals who donated blood samples within 5 years before surgery. In triplets (n=201), which included index individuals with concurrent coronary artery disease at the time of surgery, all 6 proteins were robustly associated with case status in all sensitivity analyses. In the validation study, the association of all but 1 (interleukin 17 receptor A) of these proteins were replicated in patients with AS with concurrent coronary artery disease but not in patients with AS without coronary artery disease.

Conclusions:

We provide evidence that 5 proteins were altered years before AS surgery and that the associations seem to be driven by concurrent atherosclerotic disease.

Comparison of trends in cardiovascular risk factors between two regions with and without a community and primary care prevention programme

Background The effect of primary prevention of cardiovascular disease is debated. The Västerbotten Intervention Programme (VIP) is an individual and community-based public health programme that comprises the whole county of Västerbotten (VB). In the neighbouring county of Norrbotten (NB), no programmes have been implemented. Method Between 1994 and 2014, five surveys were performed in the two counties on persons aged 40 to 75 years within the Northern Sweden MONICA Study. The number of subjects participating was 6600 (75.4%). We compared time trends in risk factors between the two counties using regression models including age, county and year of survey. To test whether time trends differed between counties, the interaction between county and year was included in the models. Results Systolic blood pressure declined in both counties, and the decline was faster in Västerbotten than in Norrbotten ( p = 0.043 for interaction county*year). Diastolic blood pressure declined in VB but increased in NB ( p < 0.001). Cholesterol levels declined at a similar rate in both counties whereas body mass index increased in both counties. Fasting glucose decreased in VB ( p = 0.003) and increased in NB. The prevalence of regular smokers decreased faster in VB than in NB ( p = 0.01). Trend in waist and hip circumference, known diabetes, having an academic degree, being physically inactive or 10 year cardiovascular mortality according to SCORE did not differ. Conclusion Blood pressure, glucose and smoking improved at a faster rate in the county with a community and primary care-based intervention than in the county without such an intervention.

Cold sensitivity and associated factors: a nested case-control study performed in Northern Sweden

Purpose

To identify factors associated with the reporting of cold sensitivity, by comparing cases to controls with regard to anthropometry, previous illnesses and injuries, as well as external exposures such as hand–arm vibration (HAV) and ambient cold.

Methods

Through a questionnaire responded to by the general population, ages 18–70, living in Northern Sweden (N = 12,627), cold sensitivity cases (N = 502) and matched controls (N = 1004) were identified, and asked to respond to a second questionnaire focusing on different aspects of cold sensitivity as well as individual and external exposure factors suggested to be related to the condition. Conditional logistic regression analyses were performed to determine statistical significance.

Results

In total, 997 out of 1506 study subjects answered the second questionnaire, yielding a response rate of 81.7%. In the multiple conditional logistic regression model, identified associated factors among cold sensitive cases were: frostbite affecting the hands (OR 10.3, 95% CI 5.5–19.3); rheumatic disease (OR 3.1, 95% CI 1.7–5.7); upper extremity nerve injury (OR 2.0, 95% CI 1.3–3.0); migraines (OR 2.4, 95% CI 1.3–4.3); and vascular disease (OR 1.9, 95% CI 1.2–2.9). A body mass index ≥ 25 was inversely related to reporting of cold sensitivity (0.4, 95% CI 0.3–0.6).

Conclusions

Cold sensitivity was associated with both individual and external exposure factors. Being overweight was associated with a lower occurrence of cold sensitivity; and among the acquired conditions, both cold injuries, rheumatic diseases, nerve injuries, migraines and vascular diseases were associated with the reporting of cold sensitivity.