Lifetime and 10-year risks of cardiovascular mortality in relation to risk factors in middle and old age: 50-year follow-up of the Whitehall study of London Civil Servants

BACKGROUND

Cardiovascular disease (CVD)-related mortality has declined substantially in the United Kingdom (UK) in recent decades, but the continued relevance of conventional risk factors for prediction of CVD mortality throughout the life-course is uncertain. We compared the 10-year risks and lifetime risks of CVD mortality associated with conventional risk factors recorded in middle and old age.

METHODS

The Whitehall study was a prospective study of 19,019 male London civil servants (mean age 52 years) when enrolled in 1967-1970 and followed-up for 50 years for cause-specific mortality. In 1997, 7044 (83%) survivors (mean age 77 years) were re-surveyed. The 10-year and lifetime risks of CVD mortality were estimated by levels of CVD risk factors recorded in middle-age and old-age, respectively.

RESULTS

By July 2020, 97% had died (22%, 51% and 80% before age 70, 80 and 90 years, respectively) and 7944 of 17,673 deaths (45%) were from CVD. The 10-year and lifetime risks of CVD death increased linearly with higher levels of CVD risk factors recorded in middle-age and in old-age. Individuals in the top versus bottom 5% of CVD risk scores in middle age had a 10.3% (95% CI:7.2-13.4) vs 0.6% (0.1-1.2) 10-year risk of CVD mortality, a 61.4% (59.4-65.3) vs 31.3% (24.1-34.5) lifetime risk of CVD mortality and a 12-year difference in life expectancy from age 50 years. The corresponding differences using a CVD risk score in old-age were 11.0% (4.4-17.5) vs 0.8% (0.0-2.2) for 10-year risk and 42.1% (28.2-50.0) vs 30.3% (6.0-38.0) for lifetime risk of CVD mortality and a 6-year difference in life expectancy from age 70 years.

CONCLUSIONS

Conventional risk factors remained highly predictive of CVD mortality and life expectancy through the life-course. The findings highlight the relevance of estimation of both lifetime risks of CVD and 10-year risks of CVD for primary prevention of CVD.

Reconsidering the developmental origins of adult disease paradigm: The 'metabolic coordination of childbirth' hypothesis

In uncomplicated pregnancies, birthweight is inversely associated with adult non-communicable disease (NCD) risk. One proposed mechanism is maternal malnutrition during pregnancy. Another explanation is that shared genes link birthweight with NCDs. Both hypotheses are supported, but evolutionary perspectives address only the environmental pathway. We propose that genetic and environmental associations of birthweight with NCD risk reflect coordinated regulatory systems between mother and foetus, that evolved to reduce risks of obstructed labour. First, the foetus must tailor its growth to maternal metabolic signals, as it cannot predict the size of the birth canal from its own genome. Second, we predict that maternal alleles that promote placental nutrient supply have been selected to constrain foetal growth and gestation length when fetally expressed. Conversely, maternal alleles that increase birth canal size have been selected to promote foetal growth and gestation when fetally expressed. Evidence supports these hypotheses. These regulatory mechanisms may have undergone powerful selection as hominin neonates evolved larger size and encephalisation, since every mother is at risk of gestating a baby excessively for her pelvis. Our perspective can explain the inverse association of birthweight with NCD risk across most of the birthweight range: any constraint of birthweight, through plastic or genetic mechanisms, may reduce the capacity for homeostasis and increase NCD susceptibility. However, maternal obesity and diabetes can overwhelm this coordination system, challenging vaginal delivery while increasing offspring NCD risk. We argue that selection on viable vaginal delivery played an over-arching role in shaping the association of birthweight with NCD risk.

Machine-learning-derived heart and brain age are independently associated with cognition

BACKGROUND AND PURPOSE

A heart age biomarker has been developed using deep neural networks applied to electrocardiograms. Whether this biomarker is associated with cognitive function was investigated.

METHODS

Using 12-lead electrocardiograms, heart age was estimated for a population-based sample (N = 7779, age 40-85 years, 45.3% men). Associations between heart delta age (HDA) and cognitive test scores were studied adjusted for cardiovascular risk factors. In addition, the relationship between HDA, brain delta age (BDA) and cognitive test scores was investigated in mediation analysis.

RESULTS

Significant associations between HDA and the Word test, Digit Symbol Coding Test and tapping test scores were found. HDA was correlated with BDA (Pearson's r = 0.12, p = 0.0001). Moreover, 13% (95% confidence interval 3-36) of the HDA effect on the tapping test score was mediated through BDA.

DISCUSSION

Heart delta age, representing the cumulative effects of life-long exposures, was associated with brain age. HDA was associated with cognitive function that was minimally explained through BDA.

Associations between serum high-density lipoprotein cholesterol levels and cause-specific mortality in a general population of 345 000 men and women aged 20-79 years

BACKGROUND

Benefits of elevated high-density lipoprotein cholesterol (HDL-C) levels are challenged by reports demonstrating U-shaped relations between HDL-C levels and all-cause mortality; the association with cause-specific mortality is less studied.

METHODS

A total of 344 556 individuals (20-79 years, 52 % women) recruited from population-based health screening during 1985-2003 were followed until the end of 2018 for all-cause and cause-specific mortality by serum HDL-C level at inclusion of <30, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89, 90-99 and >99 mg/dl (< 0.78, 0.78-1.01, 1.04-1.27, 1.30-1.53, 1.55-1.79, 1.81-2.04, 2.07-2.31, 2.33-2.56, >2.56 mmol/L). Hazard ratios (HRs) were adjusted for sex, age, calendar period, smoking, total cholesterol, triglycerides, systolic blood pressure, physical activity, educational length, body mass index and ill health.

RESULTS

During a mean follow-up of 22 years, 69 505 individuals died. There were U-shaped associations between HDL-C levels and all-cause, cancer and non-cardiovascular disease/non-cancer mortality (non-CVD/non-cancer), whereas for CVD there was increased risk of death only at lower levels. With HDL-C stratum 50-59 mg/dl (1.30-1.53 mmol/L) as reference, HRs [95% confidence intervals (CIs)] for levels >99 mg/dl (>2.56 mmol/L) were 1.32 (1.21-1.43), 1.05 (0.89-1.24), 1.26 (1.09-1.46) and 1.68 (1.48-1.90) for all-cause, CVD, cancer and non-CVD/non-cancer mortality, respectively. For HDL-C levels <30 mg/dl (0.78 mmol/L), the corresponding HRs (95% CIs) were 1.30 (1.24-1.36), 1.55 (1.44-1.67), 1.14 (1.05-1.23) and 1.19 (1.10-1.29). The mortality from alcoholic liver disease, cancers of mouth-oesophagus-liver, chronic liver diseases, chronic obstructive pulmonary disease, accidents and diabetes increased distinctly with increasing HDL-C above the reference level. HDL-C levels lower than the reference level were mainly associated with increased mortality of ischaemic heart disease (IHD), other CVDs, stomach cancer and diabetes.

CONCLUSIONS

Higher HDL-C levels were associated with increased mortality risk of several diseases which also have been associated with heavy drinking, and lower HDL-C levels were associated with increased mortality from IHD, other CVDs, gastric cancer and diabetes.

Deep learning-derived cardiovascular age shares a genetic basis with other cardiac phenotypes

Artificial intelligence (AI)-based approaches can now use electrocardiograms (ECGs) to provide expert-level performance in detecting heart abnormalities and diagnosing disease. Additionally, patient age predicted from ECGs by AI models has shown great potential as a biomarker for cardiovascular age, where recent work has found its deviation from chronological age ("delta age") to be associated with mortality and co-morbidities. However, despite being crucial for understanding underlying individual risk, the genetic underpinning of delta age is unknown. In this work we performed a genome-wide association study using UK Biobank data (n=34,432) and identified eight loci associated with delta age ([Formula: see text]), including genes linked to cardiovascular disease (CVD) (e.g. SCN5A) and (heart) muscle development (e.g. TTN). Our results indicate that the genetic basis of cardiovascular ageing is predominantly determined by genes directly involved with the cardiovascular system rather than those connected to more general mechanisms of ageing. Our insights inform the epidemiology of CVD, with implications for preventative and precision medicine.

Life history trade-offs associated with exposure to low maternal capital are different in sons compared to daughters: Evidence from a prospective Brazilian birth cohort

Background

Environmental exposures in early life explain variability in many physiological and behavioural traits in adulthood. Recently, we showed that exposure to a composite marker of low maternal capital explained the clustering of adverse behavioural and physical traits in adult daughters in a Brazilian birth cohort. These associations were strongly mediated by whether or not the daughter had reproduced by the age of 18 years. Using evolutionary life history theory, we attributed these associations to trade-offs between competing outcomes, whereby daughters exposed to low maternal capital prioritised investment in reproduction and defence over maintenance and growth. However, little is known about such trade-offs in sons.

Methods

We investigated 2,024 mother-son dyads from the same birth cohort. We combined data on maternal height, body mass index, income, and education into a composite "maternal capital" index. Son outcomes included reproductive status at the age of 18 years, growth trajectory, adult anthropometry, body composition, cardio-metabolic risk, educational attainment, work status, and risky behaviour (smoking, violent crime). We tested whether sons' early reproduction and exposure to low maternal capital were associated with adverse outcomes and whether this accounted for the clustering of adverse outcomes within individuals.

Results

Sons reproducing early were shorter, less educated, and more likely to be earning a salary and showing risky behaviour compared to those not reproducing, but did not differ in foetal growth. Low maternal capital was associated with a greater likelihood of sons' reproducing early, leaving school, and smoking. High maternal capital was positively associated with sons' birth weight, adult size, and staying in school. However, the greater adiposity of high-capital sons was associated with an unhealthier cardio-metabolic profile.

Conclusion

Exposure to low maternal investment is associated with trade-offs between life history functions, helping to explain the clustering of adverse outcomes in sons. The patterns indicated future discounting, with reduced maternal investment associated with early reproduction but less investment in growth, education, or healthy behaviour. However, we also found differences compared to our analyses of daughters, with fewer physical costs associated with early reproduction. Exposure to intergenerational "cycles of disadvantage" has different effects on sons vs. daughters, hence interventions may have sex-specific consequences.

Obesity Prevalence and Associated Socio-Demographic Characteristics and Health Behaviors in Russia and Norway

Associations between obesity and socio-demographic and behavioral characteristics vary between populations. Exploring such differences should throw light on factors related to obesity. We examined associations between general obesity (GO, defined by body mass index) and abdominal obesity (AO, defined by waist-to-hip ratio) and sex, age, socio-economic characteristics (education, financial situation, marital status), smoking and alcohol consumption in women and men aged 40–69 years from the Know Your Heart study (KYH, Russia, N = 4121, 2015–2018) and the seventh Tromsø Study (Tromsø7, Norway, N = 17,646, 2015–2016). Age-standardized prevalence of GO and AO was higher in KYH compared to Tromsø7 women (36.7 vs. 22.0% and 44.2 vs. 18.4%, respectively) and similar among men (26.0 vs. 25.7% and 74.8 vs. 72.2%, respectively). The positive association of age with GO and AO was stronger in KYH vs. Tromsø7 women and for AO it was stronger in men in Tromsø7 vs. KYH. Associations between GO and socio-economic characteristics were similar in KYH and Tromsø7, except for a stronger association with living with spouse/partner in KYH men. Smoking had a positive association with AO in men in Tromsø7 and in women in both studies. Frequent drinking was negatively associated with GO and AO in Tromsø7 participants and positively associated with GO in KYH men. We found similar obesity prevalence in Russian and Norwegian men but higher obesity prevalence in Russian compared to Norwegian women. Other results suggest that the stronger association of obesity with age in Russian women is the major driver of the higher obesity prevalence among them compared to women in Norway.

Nitrate and nitrite contamination in drinking water and cancer risk: A systematic review with meta-analysis

BACKGROUND

Pollution of water sources, largely from wide-scale agricultural fertilizer use has resulted in nitrate and nitrite contamination of drinking water. The effects on human health of raised nitrate and nitrite levels in drinking water are currently unclear.

OBJECTIVES

We conducted a systematic review of peer-reviewed literature on the association of nitrate and nitrite in drinking water with human health with a specific focus on cancer.

METHODS

We searched eight databases from 1 January 1990 until 28 February 2021. Meta-analyses were conducted when studies had the same exposure metric and outcome.

RESULTS

Of 9835 studies identified in the literature search, we found 111 studies reporting health outcomes, 60 of which reported cancer outcomes (38 case-control studies; 12 cohort studies; 10 other study designs). Most studies were set in the USA (24), Europe (20) and Taiwan (14), with only 3 studies from low and middle-income countries. Nitrate exposure in water (59 studies) was more commonly investigated than nitrite exposure (4 studies). Colorectal (15 studies) and gastric (13 studies) cancers were the most reported. In meta-analyses (4 studies) we identified a positive association of nitrate exposure with gastric cancer, OR = 1.91 (95%CI = 1.09-3.33) per 10 mg/L increment in nitrate ion. We found no association of nitrate exposure with colorectal cancer (10 studies; OR = 1.02 [95%CI = 0.96-1.08]) or cancers at any other site.

CONCLUSIONS

We identified an association of nitrate in drinking water with gastric cancer but with no other cancer site. There is currently a paucity of robust studies from settings with high levels nitrate pollution in drinking water. Research into this area will be valuable to ascertain the true health burden of nitrate contamination of water and the need for public policies to protect human health.

What should be the baseline when calculating excess mortality? New approaches suggest that we have underestimated the impact of the COVID-19 pandemic and previous winter peaks

Excess mortality has been used to measure the impact of COVID-19 over time and across countries. But what baseline should be chosen? We propose two novel approaches: an alternative retrospective baseline derived from the lowest weekly death rates achieved in previous years and a within-year baseline based on the average of the 13 lowest weekly death rates within the same year. These baselines express normative levels of the lowest feasible target death rates. The excess death rates calculated from these baselines are not distorted by past mortality peaks and do not treat non-pandemic winter mortality excesses as inevitable.

We obtained weekly series for 35 industrialized countries from the Human Mortality Database for 2000–2020. Observed, baseline and excess mortalities were measured by age-standardized death rates. We assessed weekly and annual excess death rates driven by the COVID-19 pandemic in 2020 and those related to seasonal respiratory infections in earlier years. There was a distinct geographic pattern with high excess death rates in Eastern Europe followed by parts of the UK, and countries of Southern and Western Europe. Some Asia-Pacific and Scandinavian countries experienced lower excess mortality. In 2020 and earlier years, the alternative retrospective and the within-year excess mortality figures were higher than estimates based on conventional metrics. While the latter were typically negative or close to zero in years without extraordinary epidemics, the alternative estimates were substantial. Cumulation of this "usual" excess over 2–3 years results in human losses comparable to those caused by COVID-19.

Challenging the view that non-pandemic seasonal winter mortality is inevitable would focus attention on reducing premature mortality in many countries. As SARS-CoV-2 is unlikely to be the last respiratory pathogen with the potential to cause a pandemic, such measures would also strengthen global resilience in the face of similar threats in the future.

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Conventional estimates of excess mortality underestimate potentially avoidable losses.

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We propose metrics based on best weeks in the same and in earlier years.

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Our alternative metrics estimate higher annual excess mortality in 2020 and 2005-19.

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Mortality peaks in non-pandemic years should be regarded as potentially avoidable.

Socioeconomic inequalities in physiological risk biomarkers and the role of lifestyles among Russians aged 35-69 years

Background

Socioeconomic inequalities in cardiovascular (CVD) health outcomes are well documented. While Russia has one of the highest levels of CVD mortality in the world, the literature on contemporary socio-economic inequalities in biomarker CVD risk factors is sparse. This paper aims to assess the extent and the direction of SEP inequalities in established physiological CVD risk biomarkers, and to explore the role of lifestyle factors in explaining SEP inequalities in physiological CVD risk biomarkers.

Methods

We used cross-sectional data from a general population-based survey of Russians aged 35-69 years living in two cities (n = 4540, Know Your Heart study 2015-18). Logistic models were used to assess the associations between raised physiological risk biomarkers levels (blood pressure levels, cholesterol levels, triglycerides, HbA1C, and C-reactive protein) and socioeconomic position (SEP) (education and household financial constraints) adjusting for age, obesity, smoking, alcohol and health-care seeking behavior.

Results

High education was negatively associated with a raised risk of blood pressure (systolic and diastolic) and C-reactive protein for both men and women. High education was positively associated with total cholesterol, with higher HDL levels among women, and with low triglycerides and HbA1c levels among men. For the remaining risk biomarkers, we found little statistical support for SEP inequalities. Adjustment for lifestyle factors, and particularly BMI and waist-hip ratio, led to a reduction in the observed SEP inequalities in raised biomarkers risk levels, especially among women. High financial constraints were weakly associated with high risk biomarkers levels, except for strong evidence for an association with C-reactive protein (men).

Conclusions

Notable differences in risk biomarkers inequalities were observed according to the SEP measure employed. Clear educational inequalities in raised physiological risk biomarkers levels, particularly in blood pressure and C-reactive protein were seen in Russia and are partly explained by lifestyle factors, particularly obesity among women. These findings provide evidence-based information on the need for tackling health inequalities in the Russian population, which may help to further contribute to CVD mortality decline.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01650-3.

Comparing prevalence of chronic kidney disease and its risk factors between population-based surveys in Russia and Norway

Background

Little data exists on the prevalence of chronic kidney disease (CKD) in the Russian population. We aimed to estimate the prevalence of CKD in a population-based study in Russia, compare with a similar study in Norway, and investigate whether differences in risk factors explained between-study differences in CKD.

Methods

We compared age- and sex-standardised prevalence of reduced eGFR (< 60 ml/min/1.73m² CKD-EPI creatinine equation), albuminuria and or a composite indicator of CKD (one measure of either reduced eGFR or albuminuria) between participants aged 40–69 in the population-based Know Your Heart (KYH) study, Russia (2015–2018 N = 4607) and the seventh Tromsø Study (Tromsø7), Norway (2015–2016 N = 17,646). We assessed the contribution of established CKD risk factors (low education, diabetes, hypertension, antihypertensive use, smoking, obesity) to between-study differences using logistic regression.

Results

Prevalence of reduced eGFR or albuminuria was 6.5% (95% Confidence Interval (CI) 5.4, 7.7) in KYH and 4.6% (95% CI 4.0, 5.2) in Tromsø7 standardised for sex and age. Odds of both clinical outcomes were higher in KYH than Tromsø7 (reduced eGFR OR 2.06 95% CI 1.67, 2.54; albuminuria OR 1.54 95% CI 1.16, 2.03) adjusted for sex and age. Risk factor adjustment explained the observed between-study difference in albuminuria (OR 0.92 95% CI 0.68, 1.25) but only partially reduced eGFR (OR 1.42 95% CI 1.11, 1.82). The strongest explanatory factors for the between-study difference was higher use of antihypertensives (Russian sample) for reduced eGFR and mean diastolic blood pressure for albuminuria.

Conclusions

We found evidence of a higher burden of CKD within the sample from the population in Arkhangelsk and Novosibirsk compared to Tromsø, partly explained by between-study population differences in established risk factors. In particular hypertension defined by medication use was an important factor associated with the higher CKD prevalence in the Russian sample.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02738-2.

Seroprevalence of antibodies against SARS-CoV-2 in the adult population during the pre-vaccination period, Norway, winter 2020/21

BackgroundSince March 2020, 440 million people worldwide have been diagnosed with COVID-19, but the true number of infections with SARS-CoV-2 is higher. SARS-CoV-2 antibody seroprevalence can add crucial epidemiological information about population infection dynamics.AimTo provide a large population-based SARS-CoV-2 seroprevalence survey from Norway; we estimated SARS-CoV-2 seroprevalence before introduction of vaccines and described its distribution across demographic groups.MethodsIn this population-based cross-sectional study, a total of 110,000 people aged 16 years or older were randomly selected during November-December 2020 and invited to complete a questionnaire and provide a dried blood spot (DBS) sample.ResultsThe response rate was 30% (31,458/104,637); compliance rate for return of DBS samples was 88% (27,700/31,458). National weighted and adjusted seroprevalence was 0.9% (95% CI (confidence interval): 0.7-1.0). Seroprevalence was highest among those aged 16-19 years (1.9%; 95% CI: 0.9-2.9), those born outside the Nordic countries 1.4% (95% CI: 1.0-1.9), and in the counties of Oslo 1.7% (95% CI: 1.2-2.2) and Vestland 1.4% (95% CI: 0.9-1.8). The ratio of SARS-CoV-2 seroprevalence (0.9%) to cumulative incidence of virologically detected cases by mid-December 2020 (0.8%) was slightly above one. SARS-CoV-2 seroprevalence was low before introduction of vaccines in Norway and was comparable to virologically detected cases, indicating that most cases in the first 10 months of the pandemic were detected.ConclusionFindings suggest that preventive measures including contact tracing have been effective, people complied with physical distancing recommendations, and local efforts to contain outbreaks have been essential.

Deep neural networks reveal novel sex-specific electrocardiographic features relevant for mortality risk

Aims

Incorporation of sex in study design can lead to discoveries in medical research. Deep neural networks (DNNs) accurately predict sex based on the electrocardiogram (ECG) and we hypothesized that misclassification of sex is an important predictor for mortality. Therefore, we first developed and validated a DNN that classified sex based on the ECG and investigated the outcome. Second, we studied ECG drivers of DNN-classified sex and mortality.

Methods and results

A DNN was trained to classify sex based on 131 673 normal ECGs. The algorithm was validated on internal (68 500 ECGs) and external data sets (3303 and 4457 ECGs). The survival of sex (mis)classified groups was investigated using time-to-event analysis and sex-stratified mediation analysis of ECG features. The DNN successfully distinguished female from male ECGs {internal validation: area under the curve (AUC) 0.96 [95% confidence interval (CI): 0.96, 0.97]; external validations: AUC 0.89 (95% CI: 0.88, 0.90), 0.94 (95% CI: 0.93, 0.94)}. Sex-misclassified individuals (11%) had a 1.4 times higher mortality risk compared with correctly classified peers. The ventricular rate was the strongest mediating ECG variable (41%, 95% CI: 31%, 56%) in males, while the maximum amplitude of the ST segment was strongest in females (18%, 95% CI: 11%, 39%). Short QRS duration was associated with higher mortality risk.

Conclusion

Deep neural networks accurately classify sex based on ECGs. While the proportion of ECG-based sex misclassifications is low, it is an interesting biomarker. Investigation of the causal pathway between misclassification and mortality uncovered new ECG features that might be associated with mortality. Increased emphasis on sex as a biological variable in artificial intelligence is warranted.

Mortality among Care Home Residents in England during the first and second waves of the COVID-19 pandemic: an observational study of 4.3 million adults over the age of 65

BACKGROUND

Residents in care homes have been severely impacted by COVID-19. We describe trends in the mortality risk among residents of care homes compared to private homes.

METHODS

On behalf of NHS England we used OpenSAFELY-TPP to calculate monthly age-standardised risks of death due to all causes and COVID-19 among adults aged >=65 years between 1/2/2019 and 31/03/2021. Care home residents were identified using linkage to Care and Quality Commission data.

FINDINGS

We included 4,340,648 people aged 65 years or older on the 1st of February 2019, 2.2% of whom were classified as residing in a care or nursing home. Age-standardised mortality risks were approximately 10 times higher among care home residents compared to those in private housing in February 2019: comparative mortality figure (CMF) = 10.59 (95%CI = 9.51, 11.81) among women, and 10.87 (9.93, 11.90) among men. By April 2020 these relative differences had increased to more than 17 times with CMFs of 17.57 (16.43, 18.79) among women and 18.17 (17.22, 19.17) among men. CMFs did not increase during the second wave, despite a rise in the absolute age-standardised COVID-19 mortality risks.

INTERPRETATION

COVID-19 has had a disproportionate impact on the mortality of care home residents in England compared to older residents of private homes, but only in the first wave. This may be explained by a degree of acquired immunity, improved protective measures or changes in the underlying frailty of the populations. The care home population should be prioritised for measures aimed at controlling COVID-19.

FUNDING

Medical Research Council MR/V015737/1.

Comparison of methods for predicting COVID-19-related death in the general population using the OpenSAFELY platform

BACKGROUND

Obtaining accurate estimates of the risk of COVID-19-related death in the general population is challenging in the context of changing levels of circulating infection.

METHODS

We propose a modelling approach to predict 28-day COVID-19-related death which explicitly accounts for COVID-19 infection prevalence using a series of sub-studies from new landmark times incorporating time-updating proxy measures of COVID-19 infection prevalence. This was compared with an approach ignoring infection prevalence. The target population was adults registered at a general practice in England in March 2020. The outcome was 28-day COVID-19-related death. Predictors included demographic characteristics and comorbidities. Three proxies of local infection prevalence were used: model-based estimates, rate of COVID-19-related attendances in emergency care, and rate of suspected COVID-19 cases in primary care. We used data within the TPP SystmOne electronic health record system linked to Office for National Statistics mortality data, using the OpenSAFELY platform, working on behalf of NHS England. Prediction models were developed in case-cohort samples with a 100-day follow-up. Validation was undertaken in 28-day cohorts from the target population. We considered predictive performance (discrimination and calibration) in geographical and temporal subsets of data not used in developing the risk prediction models. Simple models were contrasted to models including a full range of predictors.

RESULTS

Prediction models were developed on 11,972,947 individuals, of whom 7999 experienced COVID-19-related death. All models discriminated well between individuals who did and did not experience the outcome, including simple models adjusting only for basic demographics and number of comorbidities: C-statistics 0.92-0.94. However, absolute risk estimates were substantially miscalibrated when infection prevalence was not explicitly modelled.

CONCLUSIONS

Our proposed models allow absolute risk estimation in the context of changing infection prevalence but predictive performance is sensitive to the proxy for infection prevalence. Simple models can provide excellent discrimination and may simplify implementation of risk prediction tools.

Seroprevalence of SARS-Cov-2 Antibodies in Adults, Arkhangelsk, Russia

Population-based data on coronavirus disease in Russia and on the immunogenicity of the Sputnik V vaccine are sparse. In a survey of 1,080 residents of Arkhangelsk 40–75 years of age, 65% were seropositive for IgG. Fifteen percent of participants had been vaccinated; of those, 97% were seropositive.

Excess mortality in Russia and its regions compared to high income countries: An analysis of monthly series of 2020

Background

Russia has been portrayed in media as having one of the highest death tolls due to the COVID-19 pandemic in the world. However, the precise scale of excess mortality is still unclear. We provide the first estimates of excess mortality in Russia as a whole and its regions in 2020, placing this in an international context.

Methods

We used monthly death rates for Russia and 83 regions plus the equivalent for 36 comparator countries. Expected mortality was derived in two ways using averages in the same months in preceding years and the same averages adjusted for secular trends. Excess death rates were estimated for the whole year and the last 3 quarters. We also estimated the relationships between excess mortality and reported COVID-19 cases and deaths across countries and Russian regions.

Results

Estimating excess deaths rates based on the trend-adjusted average, Russia had the highest excess mortality of any of the 37 countries considered. Using the simple average, Russia had the third highest. Most of the excess deaths were recorded in the 4th quarter of 2020 and the level and trajectory of excess mortality in Russia and most of Eastern European countries differed from that in Western countries. While both the cumulative number of COVID-19 cases and deaths showed positive correlations with excess mortality across countries (r=0.65 and r=0.75, p<0.001), the association across the Russian regions was, surprisingly, negative for cases (r=-0.34, p<0.01) and deaths (r=-0.09, p=0.42). When we replaced reported deaths with final data from death certificates the correlation was positive (r=0.38, p<0.001).

Conclusion

Russia has one of the largest absolute burden of excess mortality in 2020 but there is a counter-intuitive negative association between excess mortality and cumulative incidence at the regional level. Under-recording of COVID-19 cases seems to be a problem in some regions.

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Russia has experienced one of the highest excess mortality in 2020, particularly in the 4th quarter of the year.

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The patterns of excess mortality in Russia are most similar to those observed in most other CEE countries.

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Started in late spring in the two largest cities (Moscow and Saint Petersburg), Russian excess mortality spread to all regions of Russia by the end of 2020.

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The negative association between excess mortality and reported cases among Russian regions can be explained by under-recording of the latter.

Evidence of large systematic differences between countries in assigning ischaemic heart disease deaths to myocardial infarction: the contrasting examples of Russia and Norway

BACKGROUND

There is considerable variation in mortality rates from myocardial infarction (MI) across high-income countries, some of which may be artefactual.

METHODS

Time trends in mortality rates from ischaemic heart disease (IHD) and MI were analysed for a set of high-income countries from the end of the 1970s. Using individual-level mortality data from Russia (2005-2017) and Norway (2005-2016), we investigated factors associated with the proportion of total IHD deaths certified as due to MI.

RESULTS

In most countries, MI mortality rates have dramatically declined from the 1970s. However, the share of MI in total IHD deaths varies substantially across countries. In Russia, only 12% of IHD deaths had MI assigned as the underlying cause vs 63% in Norway. IHD deaths occurring outside of hospital without autopsy were far less likely to be assigned as MI in Russia (2%) than in Norway (59%).

CONCLUSIONS

Although established international criteria for MI require specific clinical or post-mortem evidence, it appears that certifying specialists in different countries may interpret these criteria differently. At one extreme, Russian doctors may only assign MI as a cause of death when there is specific pathophysiological evidence. At the other extreme, their counterparts in Norway may be willing to specify MI as the cause even when this evidence is not available. Internationally established criteria for MI diagnosis are challenging to apply for out-of-hospital deaths. Differences between countries in how certifiers interpret these criteria may account for at least some of the international variation in MI mortality rates.

Factors associated with excess all-cause mortality in the first wave of the COVID-19 pandemic in the UK: A time series analysis using the Clinical Practice Research Datalink

BACKGROUND

Excess mortality captures the total effect of the Coronavirus Disease 2019 (COVID-19) pandemic on mortality and is not affected by misspecification of cause of death. We aimed to describe how health and demographic factors were associated with excess mortality during, compared to before, the pandemic.

METHODS AND FINDINGS

We analysed a time series dataset including 9,635,613 adults (≥40 years old) registered at United Kingdom general practices contributing to the Clinical Practice Research Datalink. We extracted weekly numbers of deaths and numbers at risk between March 2015 and July 2020, stratified by individual-level factors. Excess mortality during Wave 1 of the UK pandemic (5 March to 27 May 2020) compared to the prepandemic period was estimated using seasonally adjusted negative binomial regression models. Relative rates (RRs) of death for a range of factors were estimated before and during Wave 1 by including interaction terms. We found that all-cause mortality increased by 43% (95% CI 40% to 47%) during Wave 1 compared with prepandemic. Changes to the RR of death associated with most sociodemographic and clinical characteristics were small during Wave 1 compared with prepandemic. However, the mortality RR associated with dementia markedly increased (RR for dementia versus no dementia prepandemic: 3.5, 95% CI 3.4 to 3.5; RR during Wave 1: 5.1, 4.9 to 5.3); a similar pattern was seen for learning disabilities (RR prepandemic: 3.6, 3.4 to 3.5; during Wave 1: 4.8, 4.4 to 5.3), for black or South Asian ethnicity compared to white, and for London compared to other regions. Relative risks for morbidities were stable in multiple sensitivity analyses. However, a limitation of the study is that we cannot assume that the risks observed during Wave 1 would apply to other waves due to changes in population behaviour, virus transmission, and risk perception.

CONCLUSIONS

The first wave of the UK COVID-19 pandemic appeared to amplify baseline mortality risk to approximately the same relative degree for most population subgroups. However, disproportionate increases in mortality were seen for those with dementia, learning disabilities, non-white ethnicity, or living in London.

Long-term trends in blood pressure and hypertension in Russia: an analysis of data from 14 health surveys conducted in 1975-2017

Background

Hypertension is recognized as an important contributor to high cardiovascular mortality in Russia. A comprehensive analysis of data from Russian studies that measured blood pressure in population-based samples has not been previously undertaken. This study aims to identify trends and patterns in mean blood pressure and the prevalence of hypertension in Russia over the most recent 40 years.

Methods

We obtained anonymized individual records of blood pressure measurements from 14 surveys conducted in Russia in 1975–2017 relating to a total of 137,687 individuals. For comparative purposes we obtained equivalent data from 4 surveys in the USA and England for 23,864 individuals. A meta-regression on aggregated data adjusted for education was undertaken to estimate time trends in mean systolic and diastolic blood pressure, the prevalence of elevated blood pressure (> 140/90 mmHg), and hypertension (defined as elevated blood pressure and/or the use of blood pressure-lowering) medication. A meta-analysis of pooled individual-level data was used to assess male-female differences in blood pressure and hypertension.

Results

During the period 1975–2017 mean blood pressure, the prevalence of elevated blood pressure and hypertension remained stable among Russian men. Among Russian women, mean systolic blood pressure decreased at an annual rate of 0.25 mmHg (p < 0.1) at age 35–54 years and by 0.8 mmHg (p < 0.01) at ages 55 and over. The prevalence of elevated blood pressure also decreased by 0.8% per year (p < 0.01), but the prevalence of hypertension remained stable. Mean blood pressure and prevalence of hypertension were higher in Russia compared to the USA and England at all ages and for both sexes.

Conclusions

In contrast to the generally observed downward trend in elevated blood pressure in many other countries, levels in Russia have changed little over the past 40 years, although there are some positive trends among women. Improved strategies to bring down the high levels of mean blood pressure and hypertension in Russia compared to countries such as England and the USA are important to further reduce the high burden of CVD in Russia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12320-4.

Between-study differences in grip strength: a comparison of Norwegian and Russian adults aged 40-69 years

BACKGROUND

Identifying individuals with low grip strength is an initial step in many operational definitions of sarcopenia. As evidence indicates that contemporaneous Russian populations may have lower mean levels of grip strength than other populations in northern Europe, we aimed to: compare grip strength in Russian and Norwegian populations by age and sex; investigate whether height, body mass index, education, smoking status, alcohol use and health status explain observed differences and; examine implications for case-finding low muscle strength.

METHODS

We used harmonized cross-sectional data on grip strength and covariates for participants aged 40-69 years from the Russian Know Your Heart study (KYH) (n = 3833) and the seventh survey of the Norwegian Tromsø Study (n = 5598). Maximum grip strength (kg) was assessed using the same protocol and device in both studies. Grip strength by age, sex and study was modelled using linear regression and between-study differences were predicted from these models. Sex-specific age-standardized differences in grip strength and in prevalence of low muscle strength were estimated using the European population standard of 2013.

RESULTS

Normal ranges of maximum grip strength in both studies combined were 33.8 to 67.0 kg in men and 18.7 to 40.1 kg in women. Mean grip strength was higher among Tromsø than KYH study participants and this difference did not vary markedly by age or sex. Adjustment for covariates, most notably height, attenuated between-study differences but these differences were still evident at younger ages. For example, estimated between-study differences in mean grip strength in fully adjusted models were 2.2 kg [95% confidence interval (CI) 1.4, 3.1] at 40 years and 1.0 kg (95% CI 0.5, 1.5) at 65 years in men (age × study interaction P = 0.09) and 1.1 kg (95% CI 0.4, 1.9) at age 40 years and -0.2 kg (95% CI -0.7, 0.3) at 65 years in women (age × study interaction P < 0.01).

CONCLUSIONS

We found between-study differences in mean grip strength that are likely to translate into greater future risk of sarcopenia and poorer prospects of healthy ageing for Russian than Norwegian study participants. For example, the average Russian participant had a similar level of grip strength to a Norwegian participant 7 years older. Our findings suggest these differences may have their origins in childhood highlighting the need to consider interventions in early life to prevent sarcopenia.

Obesity prevalence and associations with socio-economic and behavioral factors in population-based studies in Russia and Norway, 2015–2017

Background

Obesity is an epidemic of XXI century, as its prevalence doubled during the last forty years. As Russia and Norway are countries with different life expectancy there could be differences in obesity and its correlates.

Purpose

To investigate and compare prevalence and socio-economic and behavioral factors associated with obesity in Russia and Norway with data from population-based studies.

Methods

We used multivariable logistic regression to examine associations of obesity (body mass index&gt;30 kg/m2) with socio-economic factors (age, education, marital status, and poor financial situation defined as difficulty to afford clothes) and behavioral characteristics (smoking, alcohol use) in participants aged 40–69 years from the Know Your Heart study (Russia, 2015–2017, N=4 106) and the seventh Study (Norway, 2015–16, N=17 604). All results for covariates are mutually adjusted. Between-study comparisons of the associations of obesity with the same covariates were performed through investigation of their interactions with the “study” variable.

Results

The age-standardized prevalence of obesity was higher in Russia among women (36.8 vs 22.0%, p&lt;0.001) and did not differ among men (26.7 vs 25.7%, p=0.224). In Russian women, obesity was positively associated with age of 50–69 years relative to 40–49 years (OR=2.5, 95% CI 2.0–3.1), no university education (OR=1.5, 95% CI 1.2–1.8), and poor financial situation (OR=1.5, 95% CI 1.2–1.9). In Norwegian women, obesity was negatively associated with the age of 50–69 years (OR=0.8, 95% CI 0.8–1.0), current smoking (OR=0.8, 95% CI 0.7–1.0) and drinking alcohol ≥2 times per week (OR=0.6, 95% CI 0.5–0.6), and positively associated with no university education (OR=1.5, 95% CI 1.3–1.7), previous smoking (OR=1.3, 95% CI 1.1–1.4), and drinking ≥5 alcohol drinks per occasion (OR=1.7, 95% CI 1.3–2.2). In Russian men, obesity was positively associated with living with spouse/partner (OR=1.5, 95% CI 1.1–2.2), drinking alcohol ≥2 times per week (OR=1.4, 95% CI 1.1–1.8), and negatively associated with current smoking (OR=0.6, 95% CI 0.4–0.8). In Norwegian men, obesity was positively associated with no university education (OR=1.4, 95% CI 1.2–1.6), previous smoking (OR=1.3, 95% CI 1.2–1.5), and drinking ≥5 alcohol drinks per occasion (OR=1.7, 95% CI 1.5–1.9), and negatively associated with current smoking (OR=0.8, 95% CI 0.7–1.0) and drinking alcohol ≥2 times per week (OR=0.7, 95% CI 0.6–0.7). Interactions with the “study” variable in women were significant for age, financial situation, frequency of alcohol use; in men - for living with spouse/partner, frequency of alcohol use, number of alcohol drinks taken per occasion.

Conclusion

The prevalence of obesity was higher in Russian compared to Norwegian women, but there was no difference between Russian and Norwegian men. There were different between-country patterns of the associations of obesity with the socio-economic and behavioral characteristics.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The Know Your Heart study was a component of International Project on Cardiovascular Disease in Russia and funded by Wellcome Trust Strategic Award [100217], UiT The Arctic University of Norway, Norwegian Institute of Public Health, and Norwegian Ministry of Health and Care Services. The Tromsø Study was funded by UiT The Arctic University of Norway, Northern Norway Regional Health Authority, Norwegian Ministry of Health and Care Services, Norwegian Research Council, and various public and charity research funds in Norway. PhD scholarship and operational funds of the first author were provided by Northern State Medical University, Arkhangelsk, Russia and by UiT The Arctic University of Norway

The short-term mortality fluctuation data series, monitoring mortality shocks across time and space

The COVID-19 pandemic has revealed substantial coverage and quality gaps in existing international and national statistical monitoring systems. It is striking that obtaining timely, accurate, and comparable across countries data in order to adequately respond to unexpected epidemiological threats is very challenging. The most robust and reliable approach to quantify the mortality burden due to short-term risk factors is based on estimating weekly excess deaths. This approach is more reliable than monitoring deaths with COVID-19 diagnosis or calculating incidence or fatality rates affected by numerous problems such as testing coverage and comparability of diagnostic approaches. In response to the emerging data challenges, a new data resource on weekly mortality has been established. The Short-term Mortality Fluctuations (STMF, available at www.mortality.org ) data series is the first international database providing open-access harmonized, uniform, and fully documented data on weekly all-cause mortality. The STMF online vizualisation tool provides an opportunity to perform a quick assessment of the excess weekly mortality in one or several countries by means of an interactive graphical interface.

What on-line searches tell us about public interest and potential impact on behaviour in response to minimum unit pricing of alcohol in Scotland

AIMS

To investigate whether the introduction of minimum unit pricing (MUP) in Scotland on 1 May 2018 was reflected in changes in the likelihood of alcohol-related queries submitted to an internet search engine, and in particular whether there was any evidence of increased interest in purchasing of alcohol from outside Scotland.

DESIGN

Observational study in which individual queries to the internet Bing search engine for 2018 in Scotland and England were captured and analysed. Fluctuations over time in the likelihood of specific topic searches were examined. The patterns seen in Scotland were contrasted with those in England.

SETTING

Scotland and England.

PARTICIPANTS

People who used the Bing search engine during 2018.

MEASUREMENTS

Numbers of daily queries submitted to Bing in 2018 on eight alcohol-related topics expressed as a proportion of queries on that day on any topic. These daily likelihoods were smoothed using a 14-day moving average for Scotland and England separately.

FINDINGS

There were substantial peaks in queries about MUP itself, cheap sources of alcohol and online alcohol outlets at the time of introduction of MUP in May 2018 in Scotland, but not England. These were relatively short-lived. Queries related to intoxication and alcohol problems did not show a MUP peak, but were appreciably higher in Scotland than in England throughout 2018.

CONCLUSIONS

Analysis of internet search engine queries appears to show that a fraction of people in Scotland may have considered circumventing minimum unit pricing in 2018 by looking for on-line alcohol retailers. The overall higher levels of queries related to alcohol problems in Scotland compared with England mirrors the corresponding differences in alcohol consumption and harms between the countries.

What factors explain the much higher diabetes prevalence in Russia compared with Norway? Major sex differences in the contribution of adiposity

INTRODUCTION

Compared with many other countries Russia has a high prevalence of diabetes in men and women. However, contrary to what is found in most other populations, the risk is greater among women than men. The reasons for this are unclear.

RESEARCH DESIGN AND METHODS

Prevalence and risk factors for diabetes at ages 40-69 years were compared in two population-based studies: Know Your Heart (KYH) (Russia, 2015-2018, n=4121) and the seventh wave of the Tromsø Study (Tromsø 7) (Norway, 2015-2016, n=17 649). Diabetes was defined by the level of glycated hemoglobin and/or self-reported diabetes and/or diabetes medication use. Marginal structural models were used to estimate the role of key risk factors for diabetes in differences between the studies.

RESULTS

Age-standardized prevalence of diabetes was higher in KYH compared with Tromsø 7 in men (11.6% vs 6.2%) and in women (13.2% vs 4.3%). Age-adjusted ORs for diabetes in KYH compared with Tromsø 7 were 2.01 (95% CI 1.68 to 2.40) for men and 3.66 (95% CI 3.13 to 4.26) for women. Adiposity (body mass index and waist circumference) explained none of this effect for men but explained 46.0% (39.6, 53.8) for women. Addition of smoking and C reactive protein, as further mediators, slightly increased the percentage explained of the difference between studies to 55.5% (46.5, 66.0) for women but only to 9.9% (-0.6, 20.8) for men.

CONCLUSIONS

Adiposity is a key modifiable risk factor that appears to explain half of the almost threefold higher female prevalence of diabetes in Russia compared with Norway, but none of the twofold male difference.

Studying accelerated cardiovascular ageing in Russian adults through a novel deep-learning ECG biomarker

Background: A non-invasive, easy-to-access marker of accelerated cardiac ageing would provide novel insights into the mechanisms and aetiology of cardiovascular disease (CVD) as well as contribute to risk stratification of those who have not had a heart or circulatory event. Our hypothesis is that differences between an ECG-predicted and chronologic age of participants (δage) would reflect accelerated or decelerated cardiovascular ageing Methods: A convolutional neural network model trained on over 700,000 ECGs from the Mayo Clinic in the U.S.A was used to predict the age of 4,542 participants in the Know Your Heart study conducted in two cities in Russia (2015-2018). Thereafter, δage was used in linear regression models to assess associations with known CVD risk factors and markers of cardiac abnormalities. Results: The biomarker δage (mean: +5.32 years) was strongly and positively associated with established risk factors for CVD: blood pressure, body mass index (BMI), total cholesterol and smoking. Additionally, δage had strong independent positive associations with markers of structural cardiac abnormalities: N-terminal pro b-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin T (hs-cTnT) and pulse wave velocity, a valid marker of vascular ageing. Conclusion: The difference between the ECG-age obtained from a convolutional neural network and chronologic age (δage) contains information about the level of exposure of an individual to established CVD risk factors and to markers of cardiac damage in a way that is consistent with it being a biomarker of accelerated cardiovascular (vascular) ageing. Further research is needed to explore whether these associations are seen in populations with different risks of CVD events, and to better understand the underlying mechanisms involved.

External validation of a deep learning electrocardiogram algorithm to detect ventricular dysfunction

OBJECTIVE

To validate a novel artificial-intelligence electrocardiogram algorithm (AI-ECG) to detect left ventricular systolic dysfunction (LVSD) in an external population.

BACKGROUND

LVSD, even when asymptomatic, confers increased morbidity and mortality. We recently derived AI-ECG to detect LVSD using ECGs based on a large sample of patients treated at the Mayo Clinic.

METHODS

We performed an external validation study with subjects from the Know Your Heart Study, a cross-sectional study of adults aged 35-69 years residing in two cities in Russia, who had undergone both ECG and transthoracic echocardiography. LVSD was defined as left ventricular ejection fraction ≤ 35%. We assessed the performance of the AI-ECG to identify LVSD in this distinct patient population.

RESULTS

Among 4277 subjects in this external population-based validation study, 0.6% had LVSD (compared to 7.8% of the original clinical derivation study). The overall performance of the AI-ECG to detect LVSD was robust with an area under the receiver operating curve of 0.82. When using the LVSD probability cut-off of 0.256 from the original derivation study, the sensitivity, specificity, and accuracy in this population were 26.9%, 97.4%, 97.0%, respectively. Other probability cut-offs were analysed for different sensitivity values.

CONCLUSIONS

The AI-ECG detected LVSD with robust test performance in a population that was very different from that used to develop the algorithm. Population-specific cut-offs may be necessary for clinical implementation. Differences in population characteristics, ECG and echocardiographic data quality may affect test performance.

Quantifying the contribution of established risk factors to cardiovascular mortality differences between Russia and Norway

Surprisingly few attempts have been made to quantify the simultaneous contribution of well-established risk factors to CVD mortality differences between countries. We aimed to develop and critically appraise an approach to doing so, applying it to the substantial CVD mortality gap between Russia and Norway using survey data in three cities and mortality risks from the Emerging Risk Factor Collaboration. We estimated the absolute and relative differences in CVD mortality at ages 40-69 years between countries attributable to the risk factors, under the counterfactual that the age- and sex-specific risk factor profile in Russia was as in Norway, and vice-versa. Under the counterfactual that Russia had the Norwegian risk factor profile, the absolute age-standardized CVD mortality gap would decline by 33.3% (95% CI 25.1-40.1) among men and 22.1% (10.4-31.3) among women. In relative terms, the mortality rate ratio (Russia/Norway) would decline from 9-10 to 7-8. Under the counterfactual that Norway had the Russian risk factor profile, the mortality gap reduced less. Well-established CVD risk factors account for a third of the male and around a quarter of the female CVD mortality gap between Russia and Norway. However, these estimates are based on widely held epidemiological assumptions that deserve further scrutiny.

Impact of alcohol on mortality in Eastern Europe: Trends and policy responses

Within the global context, Eastern Europe has been repeatedly identified as the area with the highest levels of alcohol-related health harms. Although the Berlin Wall fell in 1989, and the Soviet Union collapsed soon afterwards, alcohol-related mortality in Eastern Europe remains far higher than in Western Europe. However, despite the high burden of alcohol harm and mortality in Eastern Europe, with the partial exception of Russia, relatively little is known about the country-specific impact of alcohol on health and mortality and the various policy responses to it. In response to this, an international symposium was held in Vilnius, Lithuania in June 2017 entitled Persisting burden of alcohol in Central and Eastern Europe: recent evidence and measurement issues. This special section of Drug and Alcohol Review is based on a selection of the papers presented at this symposium, providing for the first time a broad overview of the problem of alcohol-related mortality in a diverse range of Eastern European countries linked to a description and analysis of alcohol control initiatives that have been developed. While there is strong evidence of the influence of history, culture and education across European countries having a profound and persistent effect on differences in drinking patterns and preferences, there is, nevertheless, evidence that effective policy responses have been mounted in a range of countries.

Prevalence of symptoms, ever having received a diagnosis and treatment of depression and anxiety, and associations with health service use amongst the general population in two Russian cities

BACKGROUND

Little is known about the burden of common mental disorders in Russia despite high levels of suicide and alcohol-related mortality. Here we investigated levels of symptoms, self-reports of ever having received a diagnosis and treatment of anxiety and depression in two Russian cities.

METHODS

The study population was men and women aged 35-69 years old participating in cross-sectional population-based studies in the cities of Arkhangelsk and Novosibirsk (2015-18). Participants completed an interview which included the PHQ-9 and GAD-7 scales, questions on whether participants had ever received a diagnosis of depression or anxiety, and health service use in the past year. Participants also reported current medication use and medications were coded in line with the WHO anatomical therapeutic classification (ATC). Depression was defined as PHQ-9 ≥ 10 and Anxiety as GAD-7 ≥ 10.

RESULTS

Age-standardised prevalence of PHQ-9 ≥ 10 was 10.7% in women and 5.4% in men (GAD-7 ≥ 10 6.2% in women; 3.0% in men). Among those with PHQ-9 ≥ 10 17% reported ever having been diagnosed with depression (equivalent finding for anxiety 29%). Only 1.5% of those with PHQ-9 ≥ 10 reported using anti-depressants and 0.6% of those with GAD-7 ≥ 10 reported using anxiolytics. No men with PHQ-9 ≥ 10 and/or GAD-7 ≥ 10 reported use of anti-depressants or anxiolytics. Use of health services increased with increasing severity of both depression and anxiety.

CONCLUSION

There was a large gap between symptoms and reporting of past diagnosis and treatment of common mental disorders in two Russian cities. Interventions aimed at improving mental health literacy and reducing stigma could be of benefit in closing this substantial treatment gap.

Trends in life expectancy and age-specific mortality in England and Wales, 1970-2016, in comparison with a set of 22 high-income countries: an analysis of vital statistics data

BACKGROUND

Since 2010, the rate of improvement in life expectancy in the UK has slowed. We aimed to put this trend in the context of changes over the long term and in relation to a group of other high-income countries.

METHODS

We compared sex-specific trends in life expectancy since 1970 and age-specific mortality in England and Wales with median values for 22 high-income countries (in western Europe, Australia, Canada, New Zealand, Japan, and the USA). We used annual mortality data (1970-2016) from the Human Mortality Database.

FINDINGS

Until 2011-16, male life expectancy in England and Wales followed the median life expectancy of the comparator group. By contrast, female life expectancy was below the median and is among the lowest of the countries considered. In 2011-16, the rate of improvement in life expectancy slowed sharply for both sexes in England and Wales, and slowed more moderately in the comparator group because of negative trends in all adult age groups. This deceleration resulted in a widening gap between England and Wales and the comparators from 2011 onwards. Since the mid-2000s, for the first time, mortality rates in England and Wales among people aged 25-50 years were appreciably higher than in the comparator group.

INTERPRETATION

Although many countries have seen slower increases in life expectancy since 2011, trends in England and Wales are among the worst. The poor performance of female life expectancy over the long-term is in part driven by the relative timing of the smoking epidemic across countries. The previously overlooked higher mortality among young working-age adults in England and Wales relative to other countries deserves urgent attention.

FUNDING

None.

Untreated hypertension in Russian 35-69 year olds - a cross-sectional study

BACKGROUND

The Russian Federation has among the highest rates of cardiovascular disease (CVD) in the world and a high rate of untreated hypertension remains an important risk factor. Understanding who is at greatest risk is important to inform approaches to primary prevention.

METHODS

2,353 hypertensive 35-69 year olds were selected from a population-based study, Know Your Heart, conducted in Arkhangelsk and Novosibirsk, Russian Federation, 2015-2018. The associations between untreated hypertension and a range of co-variates related to socio-demographics, health, and health behaviours were examined.

RESULTS

The age-standardised prevalence of untreated hypertension was 51.1% (95% CI 47.8-54.5) in males, 28.8% (25.4-32.5) in females, and 40.0% (37.5-42.5) overall. The factors associated with untreated hypertension relative to treated hypertension were younger ages, self-rated general health as very good-excellent, not being obese, no history of CVD events, no evidence of diabetes or chronic kidney disease, and not seeing a primary care doctor in the past year as well as problem drinking for women and working full time, lower education, and smoking for men.

CONCLUSION

The study found relatively high prevalence of untreated hypertension, especially, in men. Recent initiatives to strengthen primary care provision and implementation of a general health check programme (dispansarisation) are promising, although further studies should evaluate other, potentially more effective strategies tailored to the particular circumstances of this population.

Pharmacological management of modifiable cardiovascular risk factors (blood pressure and lipids) following diagnosis of myocardial infarction, stroke and diabetes: comparison between population-based studies in Russia and Norway

BACKGROUND

Cardiovascular disease (CVD) mortality is substantially higher in Russia than in neighbouring Norway. We aimed to compare blood pressure- and lipid-lowering medication use and proportion meeting treatment targets between general population samples in the two countries in those with CVD and diabetes.

METHODS

The study population was adults aged 40-69 years reporting a diagnosis of myocardial infarction (MI), stroke and/or diabetes participating in cross-sectional population-based studies in Russia (Know Your Heart (KYH) 2015-18 N = 626) and Norway (The Tromsø Study 2015-16 (Tromsø 7) N = 1353). Reported medications were coded according to the 2016 WHO Anatomical Therapeutic Chemical Classification system. Treatment targets were defined using the Joint European Societies guidelines for CVD prevention in clinical practice (2016).

RESULTS

Age- and sex-standardized prevalence of use of lipid-lowering medications was higher in Tromsø 7 for all three conditions with a disproportionately large difference in those reporting MI (+ 48% (95% CI 39, 57%)). Proportion meeting treatment targets for LDL cholesterol was poor in both studies (age- and sex-standardized prevalence of control KYH vs Tromsø 7: MI 5.1% vs 10.1%; stroke 11.6% vs 5.8%; diabetes 24.9% vs 23.3%). Use of antihypertensive medication was higher in KYH for stroke (+ 40% (95% CI 30, 50%)) and diabetes (+ 27% (95% CI 19, 34%)) groups but approximately equal for the MI group (- 1% (95% CI -1, 1%)). Proportion meeting blood pressure targets was lower in KYH vs Tromsø 7 (MI 51.8% vs 76.3%; stroke 49.5% vs 69.6%; diabetes 51.9% vs 63.9%).

CONCLUSIONS

We identified different patterns of medication use in people with CVD and diabetes. However despite higher use of lipid-lowering medication in the Norwegian study treatment to target for total cholesterol was poor in both Russian and Norwegian studies. In contrast we found higher levels of use of antihypertensive medications in the Russian study but also that less participants met treatment targets for blood pressure. Further work should investigate what factors are responsible for this seeming paradox and how management of modifiable risk factors for secondary prevention could be improved.

Why does Russia have such high cardiovascular mortality rates? Comparisons of blood-based biomarkers with Norway implicate non-ischaemic cardiac damage

Background

Russia has one of the highest rates of mortality from cardiovascular disease (CVD). At age 35–69 years, they are eight times higher than in neighbouring Norway. Comparing profiles of blood-based CVD biomarkers between these two populations can help identify reasons for this substantial difference in risk.

Methods

We compared age-standardised mean levels of CVD biomarkers for men and women aged 40–69 years measured in two cross-sectional population-based studies: Know Your Heart (KYH) (Russia, 2015–2018; n=4046) and the seventh wave of the Tromsø Study (Tromsø 7) (Norway, 2015–2018; n=17 646). A laboratory calibration study was performed to account for inter-laboratory differences.

Results

Levels of total, low-density lipoprotein-, high-density lipoprotein-cholesterol and triglycerides were comparable in KYH and Tromsø 7 studies. N-terminal pro-b-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT) and high-sensitivity C-reactive protein (hsCRP) were higher in KYH compared with Tromsø 7 (NT-proBNP was higher by 54.1% (95% CI 41.5% to 67.8%) in men and by 30.8% (95% CI 22.9% to 39.2%) in women; hs-cTnT—by 42.4% (95% CI 36.1% to 49.0%) in men and by 68.1% (95% CI 62.4% to 73.9%) in women; hsCRP—by 33.3% (95% CI 26.1% to 40.8%) in men and by 35.6% (95% CI 29.0% to 42.6%) in women). Exclusion of participants with pre-existing coronary heart disease (279 men and 282 women) had no substantive effect.

Conclusions

Differences in cholesterol fractions cannot explain the difference in CVD mortality rate between Russia and Norway. A non-ischemic pathway to the cardiac damage reflected by raised NT-proBNP and hs-cTnT is likely to contribute to high CVD mortality in Russia.

Effect of adiposity on differences in carotid plaque burden in studies conducted in Norway and Russia: a cross-sectional analysis of two populations at very different risk of cardiovascular mortality

OBJECTIVES

Large differences exist in the burden of cardiovascular disease (CVD) between Russia and Western European countries including Norway. Obesity prevalence may contribute to the differences. We investigated whether difference in the level of adiposity, assessed using body mass index and waist-to-hip ratio(WHR), could explain intercountry differences in the burden of carotid plaque, a measure of atherosclerosis, in the populations.

DESIGN

Cross-sectional analysis. Logistic and linear regression models were used.

SETTING

We used population-based cross-sectional Know Your Heart (KYH) study in Russia and the Tromsø 7 study (Tromsø 7) in Norway.

PARTICIPANTS

3262 and 1800 men and women aged 40-69 years in KYH and Tromsø 7, respectively.

PRIMARY AND SECONDARY OUTCOME

The presence of carotid plaques and plaque score assessed using ultrasound.

RESULTS

The presence of carotid plaques and plaque score were higher in KYH than Tromsø 7 regardless of age group and sex. A positive association between carotid plaque burden and adiposity was found (OR of having at least one plaque per SD in WHR 1.18 (95% CI 1.06 to 1.31) for men; 1.15 (1.06 to 1.25) for women)) adjusted for age, smoking and education in a pooled analysis of the two studies. There was little evidence of the interaction between study and adiposity. These effects did not differ between the two studies. However, neither adiposity nor CVD risk factors (smoking, systolic blood pressure, cholesterol, glycosylated haemoglobin) explained the higher carotid plaque burden in KYH compared with Tromsø 7.

CONCLUSION

Adiposity, especially abdominal adiposity, is a risk factor for carotid plaque in Russia and Norway, although neither adiposity nor established CVD risk factors explained the higher plaque burden in Russia. To reduce the CVD burden in Russia, beyond prevention and treatment of adiposity, further research is required to understand why Russia has a high burden of atherosclerosis.

Primary care use and cardiovascular disease risk in Russian 40-69 year olds: a cross-sectional study

BACKGROUND

The Russian Federation has very high cardiovascular disease (CVD) mortality rates compared with countries of similar economic development. This cross-sectional study compares the characteristics of CVD-free participants with and without recent primary care contact to ascertain their CVD risk and health status.

METHODS

A total of 2774 participants aged 40-69 years with no self-reported CVD history were selected from a population-based study conducted in Arkhangelsk and Novosibirsk, Russian Federation, 2015-2018. A range of co-variates related to socio-demographics, health and health behaviours were included. Recent primary care contact was defined as seeing primary care doctor in the past year or having attended a general health check under the 2013 Dispansarisation programme.

RESULTS

The proportion with no recent primary care contact was 32.3% (95% CI 29.7% to 35.0%) in males, 16.3% (95% CI 14.6% to 18.2%) in females, and 23.1% (95% CI 21.6% to 24.7%) overall. In gender-specific age-adjusted analyses, no recent contact was also associated with low education, smoking, very good to excellent self-rated health, no chest pain, CVD 10-year SCORE risk 5+%, absence of hypertension control, absence of hypertension awareness and absence of care-intensive conditions. Among those with no contact: 37% current smokers, 34% with 5+% 10-year CVD risk, 32% untreated hypertension, 20% non-anginal chest pain, 18% problem drinkers, 14% uncontrolled hypertension and 9% Grade 1-2 angina. The proportion without general health check attendance was 54.6%.

CONCLUSION

Primary care and community interventions would be required to proactively reach sections of 40-69 year olds currently not in contact with primary care services to reduce their CVD risk through diagnosis, treatment, lifestyle recommendations and active follow-up.

Time trends in smoking in Russia in the light of recent tobacco control measures: synthesis of evidence from multiple sources

BACKGROUND

The study aims at identifying long-term trends and patterns of current smoking by age, gender, and education in Russia, including the most recent period from 2008 during which tobacco control policies were implemented, and to estimate the impact on mortality of any reductions in prevalence. We present an in-depth analysis based on an unprecedentedly large array of survey data.

METHODS

We examined pooled micro-data on smoking from 17 rounds of the Russian Longitudinal Monitoring Study of 1996-2016, 11 other surveys conducted in Russia in 1975-2017, and two comparator surveys from England and the USA. Standardization by age and education, regression and meta-analysis were used to estimate trends in the prevalence of current smoking by gender, age, and educational patterns.

RESULTS

From the mid-1970s to the mid-2000s smoking prevalence among men was relatively stable at around 60%, after which time prevalence declined in every age and educational group. Among women, trends in smoking were more heterogeneous. Prevalence more than doubled above the age of 55 years from very low levels (< 5%). At younger ages, there were steep increases until the mid-2000s after which prevalence has declined. Trends differed by educational level, with women in the lowest educational category accounting for most of the long-term increase. We estimate that the decline in male smoking may have contributed 6.2% of the observed reduction in cardiovascular deaths among men in the period 2008-16.

CONCLUSIONS

The implementation of an effective tobacco control strategy in Russia starting in 2008 coincided with a decline in smoking prevalence among men from what had been stable, high levels over many decades regardless of age and education. Among women, the declines have been more uneven, with young women showing recent downturns, while the smoking prevalence in middle age has increased, particularly among those with minimal education. Among men, these positive changes will have made a small contribution to the reduction in mortality seen in Russia since 2005.

Self-reported health as a predictor of mortality: A cohort study of its relation to other health measurements and observation time

Self-reported health (SRH) is widely used as an epidemiological instrument given the changes in public health since its introduction in the 1980s. We examined the association between SRH and mortality and how this is affected by time and health measurements in a prospective cohort study using repeated measurements and physical examinations of 11652 men and 12684 women in Tromsø, Norway. We used Cox proportional hazard regression to estimate hazard ratios (HRs) of death for SRH, controlling for pathology, biometrics, smoking, sex and age. SRH predicted mortality independently of other, more objective health measures. Higher SRH was strongly associated with lower mortality risk. Poor SRH had HR 2.51 (CI: 2.19, 2.88). SRH is affected by disease, mental health and other risk factors, but these factors had little impact on HRs (Poor SRH: HR 1.99; CI: 1.72, 2.31). SRH predicted mortality, but with a time-dependent effect. Time strongly affected the hazard ratio for mortality, especially after ten-year follow-up (Poor SRH HR 3.63 at 0-5 years decreased to HR 1.58 at 15-21 years). SRH has both methodological and clinical value. It should not be uncritically utilised as a replacement instrument when measures of physical illness and other objective health measures are lacking.

The association between anthropometric measures of adiposity and the progression of carotid atherosclerosis

Background

Few reports are available on the contribution of general and abdominal obesity to the progression of carotid atherosclerosis in late adulthood. This study investigated the impact of four simple anthropometric measures of general and abdominal obesity on the progression of carotid atherosclerosis and the extent to which the association between adiposity and the progression of plaque burden is mediated by cardiometabolic markers.

Methods

Four thousand three hundred forty-five adults (median age 60) from the population-based Tromsø Study were followed over 7 years from the first carotid ultrasound screening to the next. The progression of carotid atherosclerosis was measured in three ways: incidence of plaques in previously plaque-free participants; change in the number of plaques; and total plaque area (TPA). We used generalised linear models to investigate the association between each adiposity measure – body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) – and each outcome. Models were adjusted for potential confounders (age, sex, smoking, education, physical activity). The pathways through which any associations observed might operate were investigated by further adjusting for cardiometabolic mediators (systolic blood pressure, cholesterol, and HbA1c).

Results

There was little evidence that adiposity was related to the formation of new plaques during follow-up. However, abdominal adiposity was associated with TPA progression. WHtR showed the largest effect size (mean change in TPA per one standard deviation (SD) increase in WHtR of 0.665 mm², 95% confidence interval 0.198, 1.133) while BMI showed the smallest. Effect sizes were substantially reduced after the adjustment for potential mediators.

Conclusions

Abdominal obesity indirectly measured with WC seems more strongly associated with the progression of TPA than general obesity. These associations appear to be largely mediated by known cardiometabolic markers.

Uncontrolled and apparent treatment resistant hypertension: a cross-sectional study of Russian and Norwegian 40-69 year olds

BACKGROUND

Uncontrolled hypertension is a major cardiovascular risk factor. We examined uncontrolled hypertension and differences in treatment regimens between a high-risk country, Russia, and low-risk Norway to gain better understanding of the underlying factors.

METHODS

Population-based survey data on 40-69 year olds with hypertension defined as taking antihypertensives and/or having high blood pressure (140+/90+ mmHg) were obtained from Know Your Heart Study (KYH, N = 2284), Russian Federation (2015-2018) and seventh wave of The Tromsø Study (Tromsø 7, N = 5939), Norway (2015-2016). Uncontrolled hypertension was studied in the subset taking antihypertensives (KYH: N = 1584; Tromsø 7: 2792)and defined as having high blood pressure (140+/90+ mmHg). Apparent treatment resistant hypertension (aTRH) was defined as individuals with uncontrolled hypertension on 3+ OR controlled on 4+ antihypertensive classes in the same subset.

RESULTS

Among all those with hypertension regardless of treatment status, control of blood pressure was achieved in 22% of men (KYH and Tromsø 7), while among women it was 33% in Tromsø 7 and 43% in KYH. When the analysis was limited to those on treatment for hypertension, the percentage uncontrolled was higher in KYH (47.8%, CI 95 44.6-50.9%) than Tromsø 7 (38.2, 36.1-40.5%). The corresponding figures for aTRH were 9.8% (8.2-11.7%) and 5.7% (4.8-6.8%). Antihypertensive monotherapies were more common than combinations and used by 58% in Tromsø 7 and 44% in KYH. In both KYH and Tromsø 7, untreated hypertension was higher in men, those with no GP visit in the past year and problem drinkers. In both studies, aTRH was associated with older age, CVD history, obesity, and diabetes. In Tromsø 7, also male gender and any drinking. In KYH, also chronic kidney disease.

CONCLUSION

There is considerable scope for promoting combination therapies in line with European treatment guidelines in both study populations. The factors associated with untreated hypertension overlap with known correlates of treatment non-adherence and health check non-attendance. In contrast, aTRH was characterised by obesity and underlying comorbidities potentially complicating treatment.

Hospital admissions and mortality in the 15 years after a first-time hospital contact with an alcohol problem: a prospective cohort study using the entire Danish population

BACKGROUND

Potential benefits of preventing continued alcohol intake in individuals presenting at the hospital with an alcohol problem can be highlighted by studying their excess risk of subsequent morbidity and mortality.

METHODS

All Danish residents with a first-time hospital contact with alcohol problems (intoxication, harmful use or dependence) in 1998-2002 were followed through 2012 using healthcare registries. We compared their cause-specific rates of hospital admission and mortality to the expected rates derived from the general population by calculating standardized incidence rate ratios.

RESULTS

The 26 716 men and 12 169 women who were hospitalized with alcohol problems (median age 44 years) had more than 10 times the rate of subsequent admission to psychiatric departments and three times the rate of subsequent admission to somatic departments compared with the general population. In particular, the hospital admission rates for gastroenterological disease and injuries were high. The cumulative all-cause 10-year mortality risk was 29% [95% confidence interval (CI), 28-30] in men and 26% (95% CI, 24-27) in women with alcohol problems. The ratios of observed to expected death rate for all-cause mortality were 4.0 (95% CI, 3.8-4.1) in men and 4.3 (95% CI, 4.0-4.7) in women and, for causes of death fully attributable to alcohol, 16 (95% CI, 15-17) in men and 33 (95% CI, 29-38) in women.

CONCLUSIONS

Individuals hospitalized with alcohol problems have much higher rates of subsequent alcohol-related hospital admission and mortality than the general population. Increased focus on preventing continued alcohol consumption in these individuals may reduce their subsequent morbidity and mortality.

The changing relation between alcohol and life expectancy in Russia in 1965–2017

Introduction and Aims

Design and Methods

Results

Discussion and Conclusions

Evidence for a Direct Harmful Effect of Alcohol on Myocardial Health: A Large Cross-Sectional Study of Consumption Patterns and Cardiovascular Disease Risk Biomarkers From Northwest Russia, 2015 to 2017

Background Alcohol drinking is an increasingly recognized risk factor for cardiovascular disease. However, there are few studies of the impact of harmful and hazardous drinking on biomarkers of myocardial health. We conducted a study in Russia to investigate the impact of heavy drinking on biomarkers of cardiac damage and inflammation. Methods and Results The Know Your Heart study recruited a random sample of 2479 participants from the population of northwest Russia (general population) plus 278 patients (narcology clinic subsample) with alcohol problems. The general population sample was categorized into harmful drinkers, hazardous drinkers, nonproblem drinkers, and nondrinkers, according to self-reported level of alcohol consumption, whereas the narcology clinic sample was treated as the separate group in the analysis. Measurements were made of the following: (1) high-sensitivity cardiac troponin T, (2) NT-proBNP (N-terminal pro-B-type natriuretic peptide), and (3) hsCRP (high-sensitivity C-reactive protein). The narcology clinic subsample had the most extreme drinking pattern and the highest levels of all 3 biomarkers relative to nonproblem drinkers in the general population: high-sensitivity cardiac troponin T was elevated by 10.3% (95% CI, 3.7%-17.4%), NT-proBNP by 46.7% (95% CI, 26.8%-69.8%), and hsCRP by 69.2% (95% CI, 43%-100%). In the general population sample, NT-proBNP was 31.5% (95% CI, 3.4%-67.2%) higher among harmful drinkers compared with nonproblem drinkers. Overall, NT-proBNP and hsCRP increased with increasing intensity of alcohol exposure (test of trend P<0.001). Conclusions These results support the hypothesis that heavy alcohol drinking has an adverse effect on cardiac structure and function that may not be driven by atherosclerosis.

Global myocardial longitudinal strain in a general population-associations with blood pressure and subclinical heart failure: The Tromsø Study

The early detection of subclinical myocardial dysfunction can contribute to the treatment and prevention of heart failure (HF). The aim of the study was to (i) describe myocardial global longitudinal strain (GLS) patterns in a large general population sample from Norway and their relation to established cardiovascular disease (CVD) risk factors; (ii) to determine its normal thresholds in healthy individuals and (iii) ascertain the relation of myocardial GLS to stage A subclinical heart failure (SAHF). Participants (n = 1855) of the 7th survey of the population-based Tromsø Study of Norway (2015-2016) with GLS measurements were studied. Linear and logistic regression models were used for assessment of the associations between CVD risk factors and GLS. Mean GLS (SD) in healthy participants was - 15.9 (2.7) % in men and - 17.8 (3.1) % in women. Among healthy subjects, defined as those without known cardiovascular diseases and comorbidities, GLS declined with age. An increase of systolic blood pressure (SBP) of 10 mm Hg was associated with a 0.2% GLS reduction. Myocardial GLS in individuals with SAHF was 1.2% lower than in participants without SAHF (p < 0.001). Mean myocardial GLS declines with age in both sexes, both in a general population and in the healthy subsample. SBP increase associated with GLS decline in women. Our findings indicate high sensitivity of GLS for early subclinical stages of HF.

Reflection on modern methods: calculating a sample size for a repeatability sub-study to correct for measurement error in a single continuous exposure

Using a continuous exposure variable that is measured with random error in a univariable linear regression model leads to regression dilution bias: the observed association between the exposure and outcome is smaller than it would be if the true value of the exposure could be used. A repeatability sub-study, where a sample of study participants have their data measured again, can be used to correct for this bias. It is important to perform a sample size calculation for such a sub-study, to ensure that correction factors can be estimated with sufficient precision. We describe how a previously published method can be used to calculate the sample size from the anticipated size of the correction factor and its desired precision, and demonstrate this approach using the example of the cross-sectional studies conducted as part of the International Project on Cardiovascular Disease in Russia study. We also provide correction factors calculated from repeat data from the UK Biobank study, which can be used to help plan future repeatability studies.