Lifelong cumulative incidence of acquired aortic stenosis and its predictors in a large middle-aged men population followed up to 42 years

Background

Acquired aortic stenosis (AS) is the most common valvular disorder that rises exponentially with age; it has high mortality after symptoms appear. Factors that predict the development of AS are still unknown. Some studies imply that the atherosclerotic factors are involved in the development of AS, but the findings have been heterogeneous.

Purpose

To estimate lifelong cumulative incidence of AS and analyse its predictors.

Methods

We included a random sample of men, born 1915–1925 in Gothenburg, Sweden, and examined them in 1970–1973 (participation rate 75%). They were between 47 and 55 years in the beginning and 57–65 years when the examination-period ended. Out of 7493 men 57 were excluded due to myocardial infarction prior to baseline; 7436 were thus followed from the inclusion date until a discharge diagnosis of AS or death, with a maximum follow up time of 42 years and mean follow-up time 26.8 years. Men with AS were identified from the Swedish National Patient Register and those who died from the Swedish Cause of Death Register. We used machine learning to identify the most important factors that predict AS. For these factors, we then estimated hazard ratios for the risk to acquire AS through Cox proportional hazards model.

Results

The lifelong cumulative incidence to acquire AS was 2.66% (198 out of 7436 individuals). For men with measurements approximately at the quartiles of the pulse pressure distribution, more specifically 44, 52, 62 mm Hg, the estimated cumulative risk were 1.97%, 2.74% and 3.07% respectively. For the body mass index (BMI) we had accordingly for measurements around 23, 25 and 27 kg/m2 estimated cumulative risk 2.52%, 2.80%, 2.79% respectively. For cholesterol values of 5, 6 and 7 mmol/l (approximately at quartile divisions) the estimated cumulative risk was 1.77%, 1.79% and 3.20% respectively. The estimated cumulative risks for the younger, with age around 47 and the older participants, with age around 55 were 1.76% and 2.68 respectively. Men with family history of infarction in a sibling had an estimated cumulative risk at 4.66% level whereas those with not at 2.51%.

The factors that were significantly associated with the development of AS in the Cox proportional model are: cholesterol level (HR=1.24, CI 95% 1.11–1.39, p=0.0001), pulse pressure (HR=1.01, CI 95% 1.01–1.02, p=0.0037), BMI (HR=1.06, CI 95% 1.02–1.11, p=0.0089), age (HR=1.11, CI 95% 1.04–1.19, p=0.0010) and family history of myocardial infarction in a sibling (HR=2.38, CI 95% 1.50–3.79, p=0.0002).

Conclusion

Lifelong cumulative incidence of acquired AS is approximately 2.7%. Multiple factors known also to be associated with arteriosclerosis were identified to increase the life-long risk of developing AS.

Funding Acknowledgement

Type of funding source: None

Social Support and Subclinical Coronary Artery Disease in Middle-Aged Men and Women: Findings from the Pilot of Swedish CArdioPulmonary bioImage Study

Social support has been associated with coronary artery disease (CAD), particularly in individuals who have sustained a cardiovascular event. This study investigated the relationship between social support and subclinical CAD among 1067 healthy middle-aged men and women. Social support was assessed with validated social integration and emotional attachment measures. Subclinical CAD was assessed as a coronary artery calcium score (CACS) using computed tomography. There was no association between social support and CACS in men. In women, low social support was strongly linked to cardiovascular risk factors, high levels of inflammatory markers, and CACS > 0. In a logistic regression model, after adjustment for 12 cardiovascular risk factors, the odds ratio (95% confidence intervals) for CACS > 0 in women with the lowest social integration, emotional attachment, and social support groups (reference: highest corresponding group) were 2.47 (1.23-5.12), 1.87 (0.93-3.59), and 4.28 (1.52-12.28), respectively. Using a machine learning approach (random forest), social integration was the fourth (out of 12) most important risk factor for CACS > 0 in women. Women with lower compared to higher or moderate social integration levels were about 14 years older in "vascular age". This study showed an association between lack of social support and subclinical CAD in middle-aged women, but not in men. Lack of social support may affect the atherosclerotic process and identify individuals vulnerable to CAD events.

Trends in mortality after first hospitalization with atrial fibrillation diagnosis in Sweden 1987 to 2006

BACKGROUND

To examine trends in 3-year mortality after a first hospitalization with diagnosed atrial fibrillation in a large cohort with and without important comorbidities.

METHODS

The Swedish Hospital Discharge and Cause of Death Registries were linked to investigate trends in mortality for all patients 35 to 84 years hospitalized for the first time with a discharge diagnosis (principal or contributory) of atrial fibrillation in Sweden during 1987 to 2006.We performed an analysis of temporal trends in mortality stratified for presence or absence of co-morbidities affecting survival.

RESULTS

Exactly 376,000 patients (56% male, mean age 72 years) with a first diagnosis of atrial fibrillation during 1987–2006 were identified and followed for 3 years. Patients with one or more of the prespecified comorbidities had the highest mortality and the largest absolute decline in mortality, but patients without these comorbidities had a slightly larger relative decline (absolute risk reduction in 3-year mortality (AAR) from 42.5 to 34.7%, Hazard Ratio (HR) 0.76; 95% confidence interval (95% CI) 0.74 to 0.77 versus ARR 16.2% to 11.7%, HR 0.71; 0.68 to 0.74. In patients aged below 65 years,with no comorbidities, there was minimal change inmortality, and they still had a 2 times increased mortality compared to the general population (SMR 1.95; 1.84-2.06).

CONCLUSIONS

Survival after a first hospitalization with a diagnosis of atrial fibrillation improved regardless comorbidities. Patients aged < 65 years old without diagnosed comorbidities still had a poor prognosis compared to the general population.

Incidence of Type 2 diabetes among occupational classes in Sweden: a 35-year follow-up cohort study in middle-aged men

AIMS

To assess if low occupational class was an independent predictor of Type 2 diabetes in men in Sweden over a 35-year follow-up, after adjustment for both conventional risk factors and psychological stress.

METHODS

A random population-based sample of 6874 men aged 47-56 years without a history of diabetes was divided into five occupational classes and the men were followed from 1970 to 2008. Diabetes cases were identified through the Swedish inpatient and death registers. Subdistribution hazard ratios (SHRs) and 95% CIs from competing risk regressions, cumulative incidence and conditional probabilities were calculated, after accounting for the risk of death attributed to other causes.

RESULTS

A total of 907 (13%) men with diabetes were identified over 35 years with a median follow-up of 27.9 years. The cumulative incidence of diabetes, when taking into account death as a competing event, was 11% in high officials, 12% in intermediate non-manual employees, 14% in assistant non-manual employees, 14% in skilled workers, and 16% in unskilled and semi-skilled workers. Men with unskilled and semi-skilled manual occupations had a significantly higher risk of diabetes than high officials (reference) after adjustment for age, BMI, hypertension, smoking and physical activity (SHR 1.39, 95% CI 1.08-1.78). Additional adjustment for self-reported psychological stress did not attenuate the results.

CONCLUSIONS

A low occupational class suggests a greater risk of Type 2 diabetes, independently of conventional risk factors and psychological stress.

Increasing evidence-based treatments to reduce coronary heart disease mortality in Sweden: quantifying the potential gains

OBJECTIVES

Between 1986 and 2002, coronary heart disease (CHD) mortality in Sweden fell by more than 50%. Approximately one-third (4800 fewer deaths) of this decline in age-adjusted CHD mortality could be attributed to treatments in patients with CHD and primary prevention medications. High treatment levels were achieved in some cases, but in others, only 50-80% of eligible patients received appropriate therapy. We therefore examined to what extent increasing the use of specific treatments in eligible patients might have reduced CHD mortality rates in Sweden.

DESIGN AND METHODS

We used the previously validated IMPACT CHD model to combine data on CHD patient numbers, medical and surgical uptake levels and treatment effectiveness. We estimated the number of deaths prevented or postponed for 2002 (baseline scenario) and for an alternative scenario (if at least 60% of eligible patients were treated).

RESULTS

If treatments were increased to consistently cover at least 60% of eligible patients, approximately 8900 deaths could have been postponed or prevented, representing a potential gain of approximately 4100 fewer deaths than actually occurred in 2002. Approximately 45% of the 4100 gain would have come from primary prevention with statins, 23% from acute coronary syndrome treatments, 15% from secondary prevention therapies and 15% from treatments for heart failure.

CONCLUSION

Increasing the proportion of eligible patients with CHD who receive evidence-based treatment could have resulted in approximately 4100 fewer deaths in 2002, almost doubling the actual mortality reduction. These findings further emphasize the importance of aggressively identifying and treating patients with CHD and high-risk individuals.

Twenty-year trends in incidence and 1-year mortality in Swedish patients hospitalised with non-AMI chest pain. Data from 1987-2006 from the Swedish hospital and death registries

OBJECTIVE

To study trends for 20 years in incidence and 1-year mortality in hospitalised patients who received a diagnosis of either angina or unexplained chest pain (UCP) in Sweden.

DESIGN AND SETTING

Register study of all patients aged 25-84 years identified from the Swedish National Hospital Discharge Register who were hospitalised with a first-time diagnosis of UCP or angina pectoris during 1987 to 2006.

PARTICIPANTS

A total of 378 454 patients, 235 855 with UCP and 142 599 with angina.

MAIN OUTCOME MEASURES

1-Year mortality and standardised mortality ratios (SMRs).

RESULTS

From the period 1987-1991 to 2002-2006, the observed 1-year mortality rate in men and women with UCP aged 25-74 years decreased from 2.19% to 1.45% and from 1.85% to 0.91%, respectively. SMRs decreased from 1.67 (95% CI 1.39 to 1.95) and 1.63 (1.27 to 2.00) to 1.09 (0.96 to 1.23) and 0.88 (0.75 to 1.00). Corresponding decreases in 1-year mortality for a discharge diagnosis of angina were from 6.50% to 2.49% in men and from 4.80% to 1.68% in women, with SMRs decreasing from 2.69 (2.33-3.05) and 2.59 (2.06-3.12) to 1.09 (0.93-1.25) and 1.05 (0.81-1.29), respectively. Similar changes occurred in patients aged 75-84 years. Only men with UCP aged 75-84 years still retained a slightly increased mortality (SMR 1.14 (1.01-1.28)).

CONCLUSIONS

The prognosis of patients admitted with chest pain in which acute myocardial infarction has been ruled out has improved for the past 20 years, such that the 1-year mortality of these patients is now similar to that in the general population.

Systematically missing confounders in individual participant data meta-analysis of observational cohort studies

One difficulty in performing meta-analyses of observational cohort studies is that the availability of confounders may vary between cohorts, so that some cohorts provide fully adjusted analyses while others only provide partially adjusted analyses. Commonly, analyses of the association between an exposure and disease either are restricted to cohorts with full confounder information, or use all cohorts but do not fully adjust for confounding. We propose using a bivariate random-effects meta-analysis model to use information from all available cohorts while still adjusting for all the potential confounders. Our method uses both the fully adjusted and the partially adjusted estimated effects in the cohorts with full confounder information, together with an estimate of their within-cohort correlation. The method is applied to estimate the association between fibrinogen level and coronary heart disease incidence using data from 154 012 participants in 31 cohorts.† Copyright © 2009 John Wiley & Sons, Ltd.

"Nonspecific" chest pain associated with high long-term mortality: results from the primary prevention study in Göteborg, Sweden

BACKGROUND

The syndrome angina pectoris with effort-related chest pain or discomfort is usually easy to recognize. However, vague and nonspecific symptoms may cause little reason for extensive evaluation. The prognosis of such patients in the general population has so far not been well described.

HYPOTHESIS

The study was undertaken to investigate long-term prognosis in men with chest pain considered to be nonspecific in comparison with men with typical angina pectoris (AP) or prior myocardial infarction (MI), and men without chest pain.

METHODS

At the second screening of the Göteborg Primary Prevention Study in 1974-1977, 6,488 men aged 51 to 59 years at baseline were available for the present analysis. Men who had responded positively to a postal questionnaire about chest pain during exercise or at rest were interviewed by a physician according to a Rose questionnaire at the screening examination. Those with typical or probable AP were further examined by single experienced physician. The following four groups were formed: Group 1: men who did not complain of chest pain (n = 5,545). Group 2: men who had not consulted any doctor because of chest pain, but who had chest pain according to a questionnaire (n = 441); these men were not considered to have AP according to a three-step examination by experienced physicians. Group 3: typical AP (n = 232). Group 4: men who had suffered an MI (n = 134).

RESULTS

During 16 years of follow-up, coronary heart disease (CHD) mortality for Groups 1-4 was 8.0, 19.5, 24.8, and 48.5%, respectively. Mortality from all cardiovascular diseases was 11.5, 24.5, 31.2, and 59.0%, respectively. Noncardiovascular disease mortality was 14.1, 17.7, 14.3, and 8.7%, respectively. Thus, the relative risk (RR) for CHD mortality among men with nonspecific chest pain (Group 2) was 2.77 [95% confidence interval (CI) 2.20, 3.50], for all cardiovascular disease mortality 2.46 (95% CI 2.00, 3.02), and for noncardiovascular disease mortality 1.60 (95% CI 1.28, 2.00). Total mortality in this group was as high (44%) as among those with typical AP (45%), but the highest mortality was found among men with a previous MI (68%). In men without chest pain it was 26%. Patients of Groups 2-4 had higher levels of cardiovascular risk factors than those in Group 1. Neither any specific questions in the Rose questionnaire, nor electrocardiographic changes at rest (uncommon) were of prognostic significance. Serum cholesterol, systolic blood pressure, diabetes, and smoking were significant predictors of outcome, both with respect to fatal CHD and to total mortality during the 16-year follow-up.

CONCLUSION

We found a high cardiovascular as well as noncardiovascular mortality among patients with chest pain who had not been considered to have AP at a three-step examination procedure. It is important to be suspicious of early CHD symptoms in men (and women?) with "nonspecific" chest symptoms and to analyze their cardiovascular risk factor pattern further because they are at considerably higher risk for future events than those in whom CHD is not suspected.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Information to the relatives of people with ostomies: is it satisfactory and adequate?

PURPOSE

The aim of this study was to evaluate how relatives of patients with an ostomy rated the various aspects of care, how they perceived the quality of the care provided, and how they ranked their involvement in the care. Patients' satisfaction was also sought, particularly their perception of relatives' involvement.

DESIGN

Descriptive cross-sectional.

SETTINGS AND SUBJECTS

The study comprised a colostomy group (32 pairs) and an ileostomy group (28 pairs). All patients attended a stoma outpatient clinic.

METHODS

Quality of care was assessed using the identity-oriented dimension of the validated questionnaire Qualityof Care from the Patient's Perspective. Questionnaires were mailed to patients and their relatives.

RESULTS

Relatives and patients in both study groups considered most topics covered by the questionnaire to be important. Half of the patients with an ileostomy and their relatives and approximately 30% of those in the colostomy group were dissatisfied with the information they received, however. Moreover, a greater proportion (41-89%) of the patients were unhappy with the opportunities they were offered to participate in the decision-making process. Patients with an ileostomy and their relatives tended to be more dissatisfied with the quality of care than the colostomy group, but the difference was not statistically significant.

CONCLUSION

The topics covered by the questionnaire were considered important to both patients and their relatives. Information and counseling offered by the ET nurses and the colorectal surgeons were judged to be unsatisfactory, indicating the need for frequently assessing and improving general standards of quality of care.

Trends in overweight and obesity from 1985 to 2002 in Göteborg, West Sweden

OBJECTIVE

To study secular trends in overweight and selected correlates in men and women in Göteborg, Sweden.

DESIGN

Cross-sequential population-based surveys.

SUBJECTS

A total of 2931 female and 2691 male subjects aged 25-64 y participated in WHO MONICA surveys (1985, 1990, 1995) and the INTERGENE study (2002).

MEASUREMENTS

Body mass index (BMI), waist-to-hip ratio (WHR), prevalence of overweight (BMI> or =25 kg/m(2)), and obesity (BMI> or =30 kg/m(2)).

RESULTS

Mean body weight increased by 3.3 kg for women and 5 kg for men, with a significant upward trend for BMI in men but not women over the 17-y observation period. The prevalence of overweight and obesity increased significantly in both sexes over the period. The largest increase was observed in men, and in women aged 25-34 y. In 2002, the prevalence of overweight was 38% in women and 58% in men, and the prevalence of obesity was 11% in women and 15% in men. No significant secular trends were observed for WHR, but there was an upward trend in prevalence of WHR>0.85 in women. A decreased prevalence of smoking in both sexes was observed together with an increase in reported leisure time physical activity. No significant secular trends were observed in rates of self-reported diabetes, although the risk of diabetes attributable to obesity was 24%.

CONCLUSION

The results indicate that 25-64-y-olds in the recent survey were more overweight and obese than earlier studied MONICA participants. The increase in BMI was more pronounced in men while abdominal obesity increased principally in women. Although obesity and overweight are clearly important risk factors for type 2 diabetes, the number of diabetics remains low and any secular increase is not yet apparent.

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis

CONTEXT

Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke.

OBJECTIVE

To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data.

DATA SOURCES

Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators.

STUDY SELECTION

All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded.

DATA EXTRACTION

Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias.

DATA SYNTHESIS

Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design.

CONCLUSIONS

In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

Risk of coronary events by baseline factors during 28 years follow-up and three periods in a random population sample of men

AIMS

To investigate the predictive value of risk factors for coronary events measured in midlife during three separate periods over a follow-up period extending through 28 years.

METHODS

A total of 7437 men aged 47-55 years and free of myocardial infarction at baseline were examined. Risk of coronary events (nonfatal myocardial infarction and coronary deaths) was analysed for the entire period and for 0-15, 16-21 and 22-28 years' follow-up, using age-adjusted and multiple Cox regression analyses.

RESULTS

Age, diabetes, elevated blood pressure and serum cholesterol were all independently associated with increased risk of coronary events for the entire 28 years as well as for each of the periods. A family history of coronary events amongst fathers, mothers and siblings was independently significant for the entire follow-up period, and the risk did not decline with extended follow-up. Effort-related chest pain was a strong and independent risk factor for the first 21 years but not thereafter. The importance of smoking decreased over time and was not significantly associated with outcome during the last period. Stress was also significant for the entire 28 years, but in selected periods only up to 21 years. Body mass index, low physical activity and low social class were inconsistently or not at all related to outcome in multiple analyses.

Hospitalizations for atrial fibrillation in the general male population: morbidity and risk factors

OBJECTIVES

To analyse the incidence, prevalence, aetiology, risk factors and prognosis of hospitalizations for atrial fibrillation.

SUBJECTS

A random population sample of 7495 men aged 47-55 years was first examined in 1970-73. During follow-up until 1996 (mean 25.2 years) 754 men were hospitalized with a diagnosis of atrial fibrillation.

RESULTS

In the age groups of 55-64, 65-74 and 75-79 years, the incidence rate was 2.0, 5.8 and 17.3 per 1000 person years, and the prevalence 1.2, 4.2 and 8.0%, respectively. Definite or possible coronary heart disease was diagnosed in 46.0%, heart failure in further 20.2% and valvular heart disease or cardiomyopathy in 4.5%. In bivariate analysis adjusted for age, the following factors were significantly associated with future hospitalization for fibrillation: a family history of myocardial infarction, stroke in mother, dyspnoea at entry, alcohol abuse, high body stature and body weight, high blood pressure but not diabetes, high serum cholesterol, high heart rate, smoking, coffee consumption or psychological stress. Significant risk factors in multivariate analysis were age, odds ratio (OR) [95% confidence interval (CI)] -1.11 (1.07, 1.16) per year, hospitalization for coronary heart disease or heart failure -6.77 (5.17, 8.87), stroke in mother - 1.49 (1.15, 1.93), high body stature -1.04 (1.03, 1.06) per cm, high body mass index (BMI) -1.07 (1.04, 1.10) per kg m(-2), as well as hypertension -1.33 (1.07, 1.65). After a diagnosis of atrial fibrillation, mortality was increased by 3.3 times.

CONCLUSION

In spite of a clinical association with coronary heart disease, risk factors for atrial fibrillation were only partly the same. Prevention includes avoidance of weight gain and control of blood pressure as well as prevention of myocardial infarction and heart failure.

Heart failure in the general population of men--morbidity, risk factors and prognosis

AIMS

To analyse the prevalence, aetiology and prognosis of heart failure.

METHODS AND RESULTS

A random population sample of men (n=7495) was examined at baseline in 1970-73 and followed until 1996. During up to 27 years, 937 men were hospitalized for heart failure. For the statistical analysis, odds ratios and 95% confidence intervals, multivariate logistic regression and time-dependent Cox analysis were used. The incidence rate was 2.1, 9.1 and 11.5 per 1000 person-years in the age groups 55-64, 65-74 and 75-79, and the prevalences were 0.6, 2.8 and 6.2%, respectively. Valvular heart disease was the aetiology in 5.8%, coronary heart disease only or in combination with hypertension in 58.8%, and hypertension only in 20.3%, and various combinations with diabetes in 4.5%. Of the remaining 12.1%, 96% were smokers and 64% were registered for alcohol abuse. Risk factors were increasing age, myocardial infarction in the family, diabetes mellitus, chest pain, tobacco smoking, high coffee consumption, alcohol abuse, high body mass index, high blood pressure as well as treatment for hypertension, but not high total cholesterol or psychological stress. Mortality after the diagnosis was increased eight times.

CONCLUSIONS

Coronary heart disease and hypertension were the most common concomitant diseases. Risk factors were similar to those in coronary heart disease, and also alcohol abuse, but not high total cholesterol, low physical activity or psychological stress. Mortality was high.

Risk factors for myocardial infarction among Swedish railway engine drivers during 10 years follow-up

BACKGROUND

Railway engine drivers have had an increased risk of myocardial infarction which could be due to reported low decision latitude and low social support but not to elevated somatic risk factors.

OBJECTIVE

To study somatic and psychosocial risk factors for myocardial infarction among railway engine drivers prospectively.

DESIGN

A prospective study of 2318 drivers followed for 10 years.

METHODS

Risk factors were surveyed in conjunction with periodic health checks at 15 different centres but with common methodology and commonly used questionnaires. Questionnaire and register information on myocardial infarction during follow-up was recorded.

RESULTS

Within this group of engine drivers, age, family history of myocardial infarction, systolic blood pressure and low body height were independent predictors of myocardial infarction, but diabetes, elevated serum cholesterol and smoking were not. Neither were a longer time in the occupation or work-related psychosocial factors. The drivers were all at the lower end of the decision authority and latitude scale and had low social support. With this limited span, it may be difficult to detect these variables as risk factors within this group.

CONCLUSIONS

Several well-known, somatic risk factors for myocardial infarction were documented in this study, whereas psychosocial working conditions, which were common to all the drivers, were not significantly related to outcome.

Psychosocial risk factors for myocardial infarction among Swedish railway engine drivers [corrected]

BACKGROUND

Several earlier investigations have found an increased incidence of myocardial infarction among male drivers and, not least, among railway engine drivers. In a previous study we found that increased serum cholesterol, blood pressure or tobacco smoking did not explain this increased risk.

OBJECTIVE

To investigate psychosocial factors and primarily work-related factors among male engine drivers.

DESIGN

Engine drivers were compared with random population samples in a cross-sectional study.

METHOD

Two thousand three hundred and eighteen engine drivers aged 25-59 years were compared with 331 randomly selected men who were mainly from the Göteborg MONICA population study. Job demands and job decision latitude as well as social support were the main factors compared.

RESULTS

Job demands were reported as being significantly lower by both younger and older engine drivers compared to their referents (P = 0.002 and P = 0.0001, respectively). Decision latitude was reported as being lower by both younger and older engine drivers than among controls (P = 0.0001 for both groups). Engine drivers experienced deficient support from their superiors compared to the referents (P = 0.0001 for younger as well as older engine drivers). Low decision latitude was associated with significantly higher diastolic blood pressure (r = -0.11 and P = 0.0001), but otherwise there were no significant relationships between psychosocial work characteristics and somatic risk factors.

CONCLUSIONS

The combination of low decision latitude and low social support seems to be a key factor in the increased risk of myocardial infarction among railway engine drivers. They generally undertake shift work which may be an additional risk factor for myocardial infarction.

Somatic risk factors for myocardial infarction among Swedish railway engine drivers

BACKGROUND

Previous studies have indicated an increased incidence of myocardial infarction among railway engine drivers.

OBJECTIVE

To analyse whether somatic risk factors for myocardial infarction among male drivers in different geographical areas in Sweden differed from that in general population samples drawn from the same geographical areas.

DESIGN

A cross-sectional study comparing drivers and men from the general population.

METHODS

Engine railway drivers aged 25-59 years (n = 2318) were compared with randomly selected men (n = 3016) with respect to their serum cholesterol, systolic and diastolic blood pressures and smoking habits.

RESULTS

The levels of the risk factors did not differ between engine drivers and the reference groups except for the Stockholm area which showed a higher percentage of tobacco smokers as well as higher means for systolic and diastolic blood pressures. The risk ratio compared with the reference samples was significantly elevated in Stockholm but not in any of the other areas.

CONCLUSIONS

These somatic risk factors for myocardial infarction do not explain the approximately 40% reported increase in myocardial infarction incidence among railway engine drivers. In the following study, psychosocial factors will also be examined.

Independent importance of psychosocial factors for prognosis after myocardial infarction

AIMS

As a primary aim it was tested whether the 10-year prognosis after a myocardial infarction is related to psychological stress, lack of social support, anxiety, and/or depressive tendency. A secondary aim was to analyse the prognostic importance of a series of other psychosocial factors as well as interactions.

METHODS

Non-selected patients aged below 65 years with a first infarction (230 men and 45 women) were followed for 10 years with 100% assessment of morbidity and cause-specific mortality. Baseline somatic and psychosocial variables were collected with the aid of standard, validated questionnaires.

RESULTS

In multivariate analysis, factors increasing risk for coronary mortality included female sex (hazard ratio, +/- 95% confidence interval) 2.47 (1.06, 5.71), signs of left ventricular failure 3.93 (1.87, 8.26), ventricular dysrhythmia 3 months after the infarction 5.45 (2.21, 13. 42), high depression scores 3.16 (1.38, 7.25) and lack of social support 2.75 (1.29, 5.89). All-cause mortality was significantly related to left ventricular failure, ventricular dysrhythmias, and high depression scores with borderline significance for female sex and social support. Prognosis was affected during the entire follow-up period. It was not significantly associated with age, marital status, education, extra work, mental strain at work or in the marriage, anxiety, dissatisfaction with family life, problems with children, dissatisfaction with the financial situation, life events, anger-in, irritability, type A behaviour, or health locus of control. Incidence of nonfatal infarction was not associated with any of the baseline variables.

CONCLUSION

In addition to known somatic predictors of prognosis after a myocardial infarction, prognosis is strongly influenced by depression and lack of social support, but not to a series of other psychosocial factors. It is recommended to use self-reporting scales to detect prognostically important psychosocial problems.

Does immigration contribute to decreasing CHD incidence? Coronary risk factors among immigrants in Göteborg, Sweden

OBJECTIVES

To investigate if an increasing proportion of immigrants may have contributed to the decreasing trend in coronary heart disease (CHD) in Sweden during the last few decades and to analyse the cardiovascular risk factor pattern in immigrants compared to Swedish-born subjects.

POPULATION AND METHODS

CVD risk factors were investigated within the framework of the WHO MONICA project. A random sample of 1618 men and women aged 25-64 years responded to the invitation to a screening procedure including questionnaires and physical and laboratory examination. Data on myocardial infarctions (MI) were collected from the Göteborg Myocardial Infarction Register. Data from the City Council secretariat were used to estimate the number of immigrants in the total population.

RESULTS

In 1995, immigrants constituted 22.4% of the population between 25 and 64 years of age in Göteborg. The incidence of MI in immigrants, 21.7%, was similar to that in Swedish-born subjects. Non-Finnish immigrants reported more unemployment, low physical activity during leisure time and psychological stress than Swedish subjects. Immigrant men also smoked more. BMI and WHR were significantly higher in immigrant women and Finnish immigrants had higher blood pressure than Swedes. Total- and LDL-cholesterol were higher in Finnish men. HDL-cholesterol was significantly lower and s-triglycerides significantly higher in non-Finnish immigrants of both genders.

CONCLUSION

The decreasing trend in CHD in Sweden during the last few decades is not due to an increasing number of immigrants from 'low-risk countries'. On the contrary, the immigrants in the present study seem to have a worse CVD risk factor profile than Swedes.

[Prognosis is often poor in chest pain not interpreted as angina pectoris. Simultaneous occurrence of cardiovascular risk factors increases the risk of premature death]

BACKGROUND

Typical angina pectoris is easy to recognize, but coronary insufficiency may present with nonspecific chest discomfort.

AIMS OF STUDY

We wanted to investigate long-term prognosis in men with different types of chest pain.

METHODS

A random population sample comprising 5,773 men aged 51-57 years at baseline were followed for 16 years.

RESULTS

Mortality due to coronary heart disease was 8.0% among men without chest pain, 19.5% (total mortality 44%) among those with non-specific chest pain, 24.8% (total mortality 45%) among those with typical angina and 48.5% among those with a history of myocardial infarction at baseline.

CONCLUSION

Non-specific chest pain is associated with poor prognosis, and coronary risk factors have strong predictive value.

Calcaneal ultrasound measurements are determined by age and physical activity. Studies in two Swedish random population samples

AIM

To present reference values and correlations with body composition, blood variables and lifestyle factors.

SUBJECTS

Two random population samples from Göteborg, Sweden, one comprising 184 men and 455 women aged 25-64 years (MONICA) and the other 860 women aged 55-82 years (BEDA) were studied.

METHODS

Calcaneal ultrasound measurement (LUNAR Achilles) and bioimpedance were measured. Smoking habits, coffee consumption, physical activity, psychological stress, education and marital status, as well as blood lipids, blood pressure, and fractures were studied.

RESULTS

Broadband ultrasound attenuation and stiffness were higher in men than in women (P < 0. 001), but speed of sound did not differ between sexes. Speed of sound, broadband ultrasound attenuation and stiffness decreased with age (P < 0.001). In both sexes speed of sound, broadband ultrasound attenuation and stiffness correlated positively to body size variables, and negatively with smoking in women after adjustment for age. Speed of sound, broadband ultrasound attenuation and stiffness were positively related to physical activity in both sexes, and these relationships were the only ones that remained in multivariate analyses in addition to age (negative). Osteoporotic fractures increased with age. Speed of sound, broadband ultrasound attenuation and stiffness were lower amongst women with osteoporotic fractures.

CONCLUSION

Speed of sound, broadband ultrasound attenuation and stiffness decreased with age and increased with physical activity, but body weight and height were not correlated in multivariate analyses. Osteoporotic fractures increased with age and were associated with lower calcaneal ultrasound values.

Job control, job demands and social support at work in relation to cardiovascular risk factors in MONICA 1995, Göteborg

BACKGROUND

Job control and work environment are related to risk of coronary heart disease (CHD), but there is limited understanding of the independent risks associated with these factors.

OBJECTIVE

To investigate the association between psychosocial work characteristics and biological risk factors for both sexes for a random population sample in Göteborg, Sweden.

DESIGN

A cross-sectional study.

METHODS

We used an age-stratified random sample of men and women aged 25-64 years comprising 1200 men and 1412 women, from which 746 men and 872 women responded to the invitation for screening, which included questionnaires and physical/laboratory investigations in 1995.

RESULTS

Women had lower job control than did men (P=0.00001); job demands were equal and social support at work slightly higher among women (P=0.04). Job control was positively related to education and social group. Smoking women had low job control and high job demands. Women with high grades of psychological stress had low job control and low social support at work (P=0.001 and P=0.01). For both sexes job demands were high (P=0.0001) among those who reported high psychological stress. Men with high job control and high social support at work were more physically active during leisure time. Subjects with job strain had low social support (P=0.01). Job-stress factors were not related to biological coronary risk factors.

CONCLUSIONS

Women had lower job control than did men. Job control was positively related to education, social class and physical activity. Psychosocial factors were not related to biological coronary risk factors.

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

OBJECTIVE

To analyse to what extent declines in incidence and mortality of coronary artery disease can be attributed to improved hospital and post-hospital treatment in contrast to how much is due to primary prevention.

DESIGN

A register for non-fatal and fatal myocardial infarction and sudden coronary death registered in in-hospital as well as out-of-hospital events between 1975 and 1994.

SETTING

City of Göteborg, Sweden, with 450,000 inhabitants.

RESULTS

Seventy-one per cent of the decline in attacks could be attributed to a decline in first infarctions. Of the decrease in coronary deaths, 63% was due to a decline in out-of-hospital mortality. Previous registrations for myocardial infarction were considerably more common amongst people who died in hospital (29%) than amongst those who died out-of-hospital (11-16%) or who survived an infarction (11-13%). Out-of-hospital resuscitation contributed to about half of the reduction in out-of-hospital mortality. Thus, most of the decline in incidence and about half of the decline in sudden coronary deaths was due to primary preventive measures. Population data on risk factors indicate a decline of 37% between 1963 and 1995 in coronary risk amongst consecutive cohorts of 50-year-old men in the community.

CONCLUSION

Out-of-hospital resuscitation, treatment in coronary care units and post-infarct treatment improved considerably, but changes in primary risk factors were also of major importance for the decline in incidence and mortality.

Increased fracture frequency in adult patients with hypopituitarism and GH deficiency

Fracture frequency was studied in 107 hypopituitary patients with GH deficiency (GHD) (69 men, mean age 53 years, range 18-74 and 38 women, mean age 54 years, range 31-73). Routine hormonal replacement therapy was given, except GH. Five male patients and 15 female patients with untreated hypogonadism were allocated to a separate group. The mean duration of hypopituitarism was 13.4 years. The prevalence of a history of fractures was assessed using questionnaires. A subsample of the Göteborg WHO MONICA Project was used as a reference population (n = 323). The total fracture frequency was threefold higher (P < 0.001) in patients (24.1%) compared with controls (8.7%) (odds ratio 3.49) (1.85-6.56; 95% confidence intervals). In men (n = 64) the fracture frequency was 25.0%, compared with 7.8% among the controls (P < 0.001). In women (n = 23) the fracture frequency was 21.7%, compared with 9.5% among the controls (P = 0.08). The odds ratios for fracture frequency were 3.97 (1.81-8.40; 95% confidence intervals) and 2.64 (0.89-7.81; 95% confidence intervals) in men and women respectively. In conclusion, adult hypopituitary patients with GHD had a threefold increased fracture frequency compared with controls. Further studies are needed to ascertain whether long-term recombinant human GH treatment can reduce the fracture rate in hypopituitary patients with GHD.

Risk factors for cardiovascular disease during the period 1985-1995 in Göteborg, Sweden. The GOT-MONICA Project

AIMS

To report levels of cardiovascular risk factors in 1985, 1990 and 1995 in three population samples in Göteborg, Sweden, and to compare with previous population risk factor levels.

POPULATION

The study was performed within the framework of the WHO MONICA Project which compares risk factor levels as well as the incidence of coronary heart disease and stroke in 38 populations.

METHODS

Three random samples of men and women aged 25-34, 35-44, 45-54 and 55-64 comprising 152-218 subjects in each age group who responded to the invitation for screening procedures which included questionnaires, physical and laboratory investigations in 1985, 1990 and 1995.

RESULTS

More men than women had smoked, except for those aged 35-44 where there was no difference between men and women. The proportion of men who had smoked decreased strongly between the first and third investigations (P < 0.0001), particularly amongst the younger age-groups, with a similar tendency amongst women. In the 25-44-years age group there was a tendency towards more women than men to be smokers in 1995. Snuff was used by 27% and 19% of men aged 25-34 and 35-44 years, respectively, in 1995. Up to 5% of women used snuff; higher in the younger age groups. More young men than women reported regular physical activity during leisure time with a tendency towards an increase from 1985 to 1995. The proportion of men reporting psychological stress varied little over the study period, but women aged 25-34 reported increased stress from 1985 to 1995. Body weight increased whereas height remained stable and consequently body mass index increased in men and women (P = 0.0001). Similarly, waist:hip ratio (measured in 1990 and 1995 only) also increased (P = 0.0001). Mean systolic and diastolic blood pressure increased with age and there was also a small increase between 1985 and 1995. Systolic blood pressure increased by a mean of 1.24 mmHg per 5-year period independent of sex and age (P = 0.0001). Antihypertensive treatment increased with age, but was stable between 1985 and 1995. Serum total and LDL cholesterol concentrations increased with age, and there was a nonsignificant tendency also to higher HDL cholesterol concentrations at older ages. Serum total cholesterol concentration declined between 1985 and 1995, and HDL cholesterol declined significantly between 1985 and 1995 in all age groups for men and women only when all age groups were analysed together. Similar to total cholesterol, levels of LDL cholesterol declined between 1985 and 1995 for all ages. Serum triglyceride levels increased for men and women between 1985 and 1995.

Coronary heart disease attack rate, incidence and mortality 1975-1994 in Göteborg, Sweden

MATERIAL AND METHODS

Data from the Göteborg myocardial infarction register were used to investigate trends in attack rate, incidence of non-fatal myocardial infarction and mortality from coronary heart disease in persons aged 64 and below during the period 1975-1994.

RESULTS

Myocardial infarction was defined according to strict criteria which remained the same throughout the study period. Attack rate and incidence were 3-5 times higher among men than women. The ratio of recurrent infarcts out of all attacks increased with increasing age and was 14%, 20% and 24% for men aged 35-44, 45-54, and 55-64, respectively. Corresponding rates for women were 8%, 14%, and 22%, respectively. Both attack rate and incidence decreased significantly by 2.1-3.9% per year during the study period for most age groups. The 28-day fatality rate (hospitalized as well as non-hospitalized cases) tended to decline, but significantly so only in the oldest men. The same was true for 28-day fatality among hospitalized patients. The majority of all coronary heart disease deaths occurred outside hospital in people unaware they had coronary heart disease. Mortality from coronary heart disease decreased by 2.0-6.8% per year during the study period. In-hospital treatment of myocardial infarction with intravenous beta-blockers followed by oral treatment, nitroglycerin and thrombolytics increased during the study period. Coronary surgery and angioplasty were used in less than 5% of patients during the study period, but increased substantially in 1994.

CONCLUSION

Coronary heart disease and mortality in ages below 65 years are now decreasing in Sweden. Decreasing short-term mortality is almost certainly due to more efficient treatment in hospital, but as the majority of coronary heart disease deaths occur outside hospital and in people unaware they have coronary heart disease, primary prevention is still very important.

Sunlight increases serum 25(OH) vitamin D concentration whereas 1,25(OH)2D3 is unaffected. Results from a general population study in Göteborg, Sweden (The WHO MONICA Project)

OBJECTIVE

To determine serum 25-hydroxyvitamin D3 [25(OH)D3] and its 1-hydroxylated metabolite [1,25(OH)2D3] and relate them to anthropometric data, life-style habits, blood pressure and selected biochemical analytes.

DESIGN

Random population samples of men and women.

SETTING

Göteborg, Sweden, population size 450,000 inhabitants. The study was performed within the framework of the WHO MONICA Project.

SUBJECTS

2000 randomly selected subjects were invited to the main MONICA screening. Out of those 1421 (71%) participated. Fifty individuals in each of four age-groups, 25-64 years, were selected at random for the present analyses (184 men and 198 women).

RESULTS

The concentration of 25(OH)D3 was similar in both sexes whereas 1,25(OH)2D3 concentration was higher in women than in men (P = 0.01). 25(OH)D3 correlated positively to sun exposure, physical activity and negatively to intact parathyroid hormone (PTH) in both sexes, and also negatively to blood pressure in men. The remaining significant relationship for 25(OH)D3, when age and sun exposure were taken into account in multivariate analyses, was a negative correlation to intact PTH in both sexes. 1,25(OH)2D3 correlated positively to intact PTH in both men and women, negatively to height in men, positively to fibrinogen in men and positively to psychological stress and osteocalcin in women. When all variables were included in multivariate analyses 1,25(OH)2D3 concentration correlated negatively to age and positively to intact PTH and osteocalcin in both sexes together.

CONCLUSIONS

Sunlight was the only external factor that influenced 25(OH)D3 concentration whereas 1,25(OH)2D3 was unaffected by sun exposure. 1,25(OH)2D3 was not related to environmental or life style factors but declined by age and correlated positively to intact PTH and osteocalcin.

SPONSORSHIP

Grants from the Swedish Medical Research Council and the Swedish Heart and Lung Foundation.

Serum intact parathyroid hormone in a random population sample of men and women: relationship to anthropometry, life-style factors, blood pressure, and vitamin D

Intact parathyroid hormone (PTH) in serum was determined in a random population sample and was related to age, sex, body composition, life-style factors, blood pressure, blood lipids, plasma fibrinogen, and serum IGF-1, osteocalcin, and vitamin D. Within the framework of the WHO MONICA Project in the city of Göteborg, Sweden, 181 men and 166 women aged 25-64 years were studied. Intact PTH concentrations varied with age but were similar in both sexes (range 4-82 ng/liter) [mean (+/- SD) 23.8 +/- 10.4 ng/liter in men and 25.1 +/- 10.6 ng/liter in women]. Intact PTH concentrations increased with increasing age, body mass index, systolic blood pressure, and 1,25(OH)2D3 and decreased with increasing 25(OH)D3 in all subjects. Additionally, in men, intact PTH correlated positively to diastolic blood pressure and negatively to coffee consumption. In women, PTH also correlated negatively to smoking and IGF-1. In a multivariate analysis including all variables, age lost its significance. In both sexes there were independent positive relations between intact PTH and body mass index and 1,25(OH)2D3, and negative relations between PTH and smoking habits as well as 25(OH)D3; among men there was also negative relations between PTH and coffee consumption. The results indicate that life-style factors such as smoking and coffee consumption decrease the serum concentration of intact PTH, and the same effect is seen in individuals with low body mass index. Coffee intake, smoking, and low body mass index are also known to adversely affect bone mineral content, highlighting the relationship between PTH and bone metabolism.

Serum insulin-like growth factor I in a random population sample of men and women: relation to age, sex, smoking habits, coffee consumption and physical activity, blood pressure and concentrations of plasma lipids, fibrinogen, parathyroid hormone and osteocalcin

OBJECTIVE

There is a clinical need for population based reference values for serum insulin-like growth factor I (IGF-I). We have therefore determined serum IGF-I concentrations in a random population sample from Sweden and have related the levels to age, sex, life style factors, blood pressure, body composition, blood lipids, plasma fibrinogen, parathyroid hormone (PTH) and osteocalcin.

PATIENTS

Within the framework of the WHO MONICA Project in the city of Göteborg, Sweden, 197 men and 195 women aged 25-64 years were studied.

RESULTS

Women aged 25-34 years had higher IGF-I concentration than men (mean 278 vs 227 micrograms/l) but in the interval 55-64 years values were lower in women than in men (158 vs 171 micrograms/l). IGF-I correlated positively with height and inversely with age, body mass index, systolic blood pressure and total cholesterol in both sexes. Negative relations between IGF-I and high density lipoprotein-cholesterol, as well as with amount of tobacco smoked, were found in men, and between IGF-I and diastolic blood pressure, triglycerides and PTH in women. When age was allowed for in multivariate analyses, most of these relations disappeared. However, among men IGF-I was positively associated with fibrinogen and negatively with age and smoking. IGF-I was negatively associated with age and coffee consumption in women.

CONCLUSION

The present data can be used as reference values for IGF-I (at least in Caucasians) for the diagnosis of growth hormone disturbances and as guidelines for growth hormone substitution.