Improving cardiovascular control in a hypertensive population in primary care. Results from a staff training intervention

OBJECTIVE

A pilot study to evaluate a staff training intervention implementing a nurse-led hypertension care model.

DESIGN AND SETTING

Clinical and laboratory data from all primary care centres (PCCs) in the Swedish region Västra Götaland (VGR), retrieved from regional registers. Intervention started 2018 in 11 PCCs. A total of 190 PCCs served as controls. Change from baseline was assessed 2 years after start of intervention.

INTERVENTION

Training of selected personnel, primarily in drug choice, team-based care, measurement techniques, and use of standardized medical treatment protocols.

PATIENTS

Hypertensive patients without diabetes or ischemic heart disease were included. The intervention and control groups contained approximately 10,000 and 145,000 individuals, respectively.

MAIN OUTCOME MEASURES

Blood pressure (BP) <140/90 mmHg, LDL-cholesterol (LDL-C) <3.0 mmol/L, BP ending on -0 mmHg (digit preference, an indirect sign of manual measuring technique), choice of antihypertensive drugs, cholesterol lowering therapy and attendance patterns were measured.

RESULTS

In the intervention group, the percentage of patients reaching the BP target did not change significantly, 56%-61% (control 50%-52%), non-significant. However, the percentage of patients with LDL-C < 3.0 mmol/L increased from 34%-40% (control 36%-36%), p = .043, and digit preference decreased, 39%-27% (control 41%-35%), p = 0.000. The number of antihypertensive drugs was constant, 1.63 - 1.64 (control 1.62 - 1.62), non-significant, but drug choice changed in line with recommendations.

CONCLUSION

Although this primary care intervention based on staff training failed to improve BP control, it resulted in improved cardiovascular control by improved cholesterol lowering treatment.

Long-term secondary prevention and outcome following acute coronary syndrome: real-world results from the Swedish Primary Care Cardiovascular Database

AIMS

Most studies of treatment adherence after acute coronary syndrome (ACS) are based on prescribed drugs and lack long-term follow-up or consecutive data on risk factor control. We studied the long-term treatment adherence, risk factor control, and its association to recurrent ACS and death.

METHODS AND RESULTS

We retrospectively included 3765 patients (mean age 75 years, 40% women) with incident ACS from 1 January 2006 until 31 December 2010 from the Swedish Primary Care Cardiovascular Database of Skaraborg. All patients were followed until 31 December 2014 or death. We recorded blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), recurrent ACS, and death. We used data on dispensed drugs to calculate the proportion of days covered for secondary prevention medications. Cox regressions were used to analyse the association of achieved BP and LDL-C to recurrent ACS and death. The median follow-up time was 4.8 years. The proportion of patients that reached BP of <140/90 mm Hg was 58% at Year 1 and 66% at Year 8. 65% of the patients reached LDL-C of <2.5 mmol/L at Year 1 and 56% at Year 8; however, adherence to statins varied from 43% to 60%. Only 62% of the patients had yearly measured BP, and only 28% yearly measured LDL-C. Systolic BP was not associated with a higher risk of recurrent ACS or death. Low-density lipoprotein cholesterol of 3.0 mmol/L was associated with a higher risk of recurrent ACS {hazard ratio [HR] 1.19 [95% confidence interval (CI) 1.00-1.40]} and death HR [1.26 (95% CI 1.08-1.47)] compared with an LDL-C of 1.8 mmol/L.

CONCLUSION

This observational long-term real-world study demonstrates low drug adherence and potential for improvement of risk factors after ACS. Furthermore, the study confirms that uncontrolled LDL-C is associated with adverse outcome even in this older population.

Hypertension: sex-related differences in drug treatment, prevalence and blood pressure control in primary care

Antihypertensive treatment is equally beneficial for reducing cardiovascular risk in both men and women. Despite this, the drug treatment, prevalence and control of hypertension differ between men and women. Men and women respond differently, particularly with respect to the risk of adverse events, to many antihypertensive drugs. Certain antihypertensive drugs may also be especially beneficial in the setting of certain comorbidities - of both cardiovascular and extracardiac nature - which also differ between men and women. Furthermore, hypertension in pregnancy can pose a considerable therapeutic challenge for women and their physicians in primary care. In addition, data from population-based studies and from real-world data are inconsistent regarding whether men or women attain hypertension-related goals to a higher degree. In population-based studies, women with hypertension have higher rates of treatment and controlled blood pressure than men, whereas real-world, primary-care data instead show better blood pressure control in men. Men and women are also treated with different antihypertensive drugs: women use more thiazide diuretics and men use more angiotensin-enzyme inhibitors and calcium-channel blockers. This narrative review explores these sex-related differences with guidance from current literature. It also features original data from a large, Swedish primary-care register, which showed that blood pressure control was better in women than men until they reached their late sixties, after which the situation was reversed. This age-related decrease in blood pressure control in women was not, however, accompanied by a proportional increase in use of antihypertensive drugs and female sex was a significant predictor of less intensive antihypertensive treatment.

The association between peripheral arterial disease and risk for hip fractures in elderly men is not explained by low hip bone mineral density. Results from the MrOS Sweden study

In this prospective study in Swedish elderly men, PAD based on an ABI < 0.9 was associated with an increased risk of hip fracture, independent of age and hip BMD. However, after further adjustments for comorbidity, medications, physical function, and socioeconomic factors, the association diminished and was no longer statistically significant.

INTRODUCTION

To examine if peripheral arterial disease (PAD) is associated with an increased risk for hip fracture in men independent of hip BMD.

METHODS

Ankle-brachial index (ABI) was assessed in the Swedish MrOS (Osteoporotic Fractures in Men) study, a prospective observational study including 3014 men aged 69-81 years at baseline. PAD was defined as ABI < 0.90. Incident fractures were assessed in computerized X-ray archives. The risk for hip fractures was calculated using Cox proportional hazard models. At baseline, BMD was assessed using DXA (Lunar Prodigy and Hologic QDR 4500) and functional measurements and blood samples were collected. Standardized questionnaires were used to collect information about medical history, falls, and medication.

RESULTS

During 10 years of follow-up, 186 men had an incident hip fracture. The hazard ratio (HR) for hip fracture in men with PAD was 1.70 (95% CI 1.14-2.54), adjusted for age and study site. Additional adjustment for total hip BMD marginally affected this association (HR 1.64; 95% CI 1.10-2.45). In a final multivariate model, the HR attenuated to a non-significant HR 1.38 (95% CI 0.91-2.11) adjusted for age, site, hip BMD, BMI, falls, smoking, eGFR, handgrip strength, walking speed, former hip fracture, antihypertensive treatment, diabetes, education, and history of cardiovascular disease.

CONCLUSION

This study suggests that PAD is associated with an increased risk for hip fracture independently of hip BMD in elderly Swedish men. However, the high frequency of comorbidity and lower physical performance among men with PAD might partly explain this association.

Long-term risk factor control after acute coronary syndrome; results from the Swedish primary care cardiovascular database

Background

Most secondary prevention studies after acute coronary syndrome (ACS) have relatively short follow-up time, and less is known about long-term risk factor control in patients after ACS.

Purpose

We aimed to study and describe the long-term risk factor control, treatment adherence and outcome after ACS.

Methods

We identified 3765 patients (mean age 75 years, 40% women) with an incident ACS between 2006 and 2010 in the Swedish Primary Care Cardiovascular Database. All participants were followed from index ACS until 31 December 2014 or death. We annually recorded blood pressure, low density lipoprotein cholesterol (LDL-C), dispensed prescription of drugs, recurrent ACS, and death. Data were collected from electronic medical records at the primary care centres, the Swedish Prescribed Drug Register, the Swedish Patient Register, and the Cause of Death Register. We calculated annually proportion of days covered (PDC) for secondary prevention medication. PDC value of ≥80% was considered cut off for medication adherence.

Results

The median follow-up time was 4.8 years (min 1.8 and max 8.0). 1890 new ACS-events were recorded during the follow up; the annual incidence of recurrent ACS was 17.3%, 12.9%, 8.9%, 8.0%, 7.6%, 6.5%, 5.2%, and 5.0% (for year 1 to year 8 respectively). 1859 (49.4%) patients died during the follow up. The annual incidence of death was 19.9%, 7.9%, 7.1%, 8.3%, 7.9%, 8.2%, 6.7%, and 6.4% (for year 1 to year 8 respectively). The annual proportion of patients that achieved the blood pressure target &lt;140/90 mm Hg was 57.8%, 60.9%, 62.7%, 63.3%, 64.9%, 63.1%, 62.4%, and 66.1% (for year 1 to year 8 respectively). The annual mean number of antihypertensive medications for each patient was 1.5, 1.3, 1.3, 1.3, 1.4, 1.4, 1.4, and 1.5 (for year 1 to year 8 respectively). The annual proportion of patients that achieved LDL-C &lt;1.8 mmol/L was 23.1%, 21.7%, 19.8%, 18.2%, 15.7%, 19.6%, 18.3%, and 16.7% (for year 1 to year 8 respectively). The annual proportion of patients in treatment with statins was 55.3%, 57.5%, 58.7%, 59.2%, 63.0%, 63.7%, 64.1%, and 67.7% (for year 1 to year 8 respectively). The annual proportion of patients in treatment with acetylsalicylic acid was 79.6%, 76.4%, 76.2%, 78.9%, 78.3%, 79.2%, and 80.8% % (for year 1 to year 8 respectively). The annual proportion of patients in treatment with P2Y12-inhibitors was 24.3%, 7.2%, 5.4%, 6.0%, 7.2%, 8.1%, 7.9% and 8.2% (for year 1 to year 8 respectively).

Conclusion

This retrospective long-term real-world study from primary care demonstrates a large potential for improvement of risk factor control in patients after ACS. More specific, this study demonstrates underutilized treatment with antihypertensive medication and statins, while adherence to antiplatelet therapy was found to be high.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Astra Zeneca

Socioeconomic status affects achievement of blood pressure target in hypertension: contemporary results from the Swedish primary care cardiovascular database

OBJECTIVE

To assess the relation between socioeconomic status and achievement of target blood pressure in hypertension.

DESIGN

Retrospective longitudinal cohort study between 2001 and 2014.

SETTING

Primary health care in Skaraborg, Sweden.

SUBJECTS

48,254 patients all older than 30 years, and 53.3% women, with diagnosed hypertension.

MAIN OUTCOME MEASURES

Proportion of patients who achieved a blood pressure target <140/90 mmHg in relation to the country of birth, personal disposable income, and educational level.

RESULTS

Patients had a lower likelihood of achieving the blood pressure target if they were born in a Nordic country outside Sweden [risk ratio 0.92; 95% confidence interval (CI) 0.88-0.97], or born in Europe outside the Nordic countries (risk ratio 0.87; 95% CI 0.82-0.92), compared to those born in Sweden. Patients in the lowest income quantile had a lower likelihood to achieve blood pressure target, as compared to the highest quantile (risk ratio 0.93; 95% CI 0.90-0.96). Educational level was not associated with outcome. Women but not men in the lowest income quantile were less likely to achieve the blood pressure target. There was no sex difference in achieved blood pressure target with respect to the country of birth or educational level.

CONCLUSION

In this real-world population of primary care patients with hypertension in Sweden, being born in a foreign European country and having a lower income were factors associated with poorer blood pressure control.KEY POINTSThe association between socioeconomic status and achieving blood pressure targets in hypertension has been ambiguous.•In this study of 48,254 patients with hypertension, lower income was associated with a reduced likelihood to achieve blood pressure control.•Being born in a foreign European country is associated with a lower likelihood to achieve blood pressure control.•We found no association between educational level and achieved blood pressure control.

Trends in blood pressure, blood lipids, and smoking from 259 753 patients with hypertension in a Swedish primary care register: results from QregPV

AIMS

To describe 8-year trends in blood pressure (BP) control, blood lipid control, and smoking habits in patients with hypertension from QregPV, a primary care register in the Region of Västra Götaland, Sweden.

METHODS AND RESULTS

QregPV features clinical data on BP, low-density lipoprotein cholesterol (LDL-C), and smoking habits in 392 277 patients with hypertension or coronary heart disease or diabetes mellitus or any combination of the three diagnoses. Data from routine clinical practice have been automatically reported on a monthly basis to QregPV from all primary care centres in Västra Götaland (population 1.67 million) since 2010. Additional data on diagnoses, dispensed drugs and socioeconomic factors were acquired through linkage to regional and national registers. We identified 259 753 patients with hypertension, but without coronary heart disease and diabetes mellitus, in QregPV. From 2010 to 2017, the proportion of patients with BP <140/90 mmHg increased from 38.9% to 49.1%, while the proportion of patients with LDL-C <2.6 mmol/L increased from 19.7% to 21.1% and smoking decreased from 15.7% to 12.3%. However, in 2017, only 10.0% of all patients with hypertension had attained target levels of BP <140/90 mmHg, LDL-C < 2.6 mmol/L while being also non-smokers. The remaining 90.0% were still exposed to at least one uncontrolled, modifiable risk factor for cardiovascular disease.

CONCLUSIONS

These regionwide data from eight consecutive years in 259 753 patients with hypertension demonstrate a large potential for risk factor improvement. An increased use of statins and antihypertensive drugs should, in addition to lifestyle modifications, decrease the risk of cardiovascular disease in these patients.

Blood pressure levels and risk of haemorrhagic stroke in patients with atrial fibrillation and anticoagulants: results from a primary care cohort with hypertension

Background

Haemorrhagic stroke (HS) is a serious condition that kills and debilitates many of those afflicted by it. Hypertension and oral anticoagulation (OAC) are independent risk factors for HS. Many patients with atrial fibrillation (AF) have hypertension and OAC. The concomitance of hypertension and OAC confers an even higher risk of haemorrhagic stroke, but less is known about the association between specific blood pressure levels and the risk of HS in patients with AF and OAC.

Purpose

To assess the risk of haemorrhagic stroke at different systolic blood pressure (SBP) levels in a primary care population with hypertension, AF and OAC.

Methods

We identified 3972 patients with hypertension, AF and OAC in a primary care database in southern Sweden. We followed patients from Jan 1, 2006 until a first event of HS, death, cessation of OAC or Dec 31, 2016. HS was defined as ICD-10 diagnosis codes: I60, I61, and I62. We analysed the association between SBP levels and HS by dividing SBP into five categories: &lt;130, 130–139, 140–159, 160–179 and ≥180 mmHg. We also fitted a spline curve to visualise the relationship between SBP and HS. Hazard ratios (HR) were calculated for the SBP categories with a Cox proportional hazards model. The 130–139 group was used as a reference in the model. We identified age, sex, previous stroke, platelet inhibitor treatment, alcohol abuse and smoking as possible confounders with a directed acyclic graph and included them as co-variates in the model.

Results

We identified 51 cases of HS during follow-up. In the categorical analysis of SBP, point estimates of HRs for HS increased gradually from the lowest SBP category to the 160–179 category. Only the 160–179 category had a significantly different HR (3.76, CI 1.56–9.04) than the reference 130–139 category, however. See Table 1. No other co-variates were significantly associated with HS. The spline curve, Figure 1, illustrates a significantly increased HR for HS in the 140–175 SBP range.

Conclusions

In this real-world primary care cohort with hypertension, AF and OAC, we found that SBP in the 160–179 mmHg range was significantly associated with an increased risk of haemorrhagic stroke. Our findings emphasise the importance of blood pressure control in this patient category.

Figure 1. Continuous and categorical SBP & HS risk

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The study was financed by grants from the Swedish state under the agreement between the Swedish government and the country councils, the ALF-agreement.

Adherence to lipid-lowering guidelines for secondary prevention and potential reduction in CVD events in Swedish primary care: a cross-sectional study

OBJECTIVES

The protective effect of lipid-lowering treatment for secondary prevention after coronary heart disease (CHD) has been well documented. Current guidelines recommend a target level for low-density lipoprotein cholesterol (LDL-C) of ≤1.8 mmol/L. The aim was to describe lipid-lowering treatment patterns and to provide an estimate of the potential reductions in cardiovascular disease (CVD) events with improved adherence to guidelines.

DESIGN

Cross-sectional.

SETTING

Primary care in a large Swedish region.

PARTICIPANTS

37 120 patients with CHD in a Swedish regional primary care quality register (QregPV), by 31 December 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of patients on statin treatment and proportion of patients achieving LDL-C ≤1.8 mmol/L. Estimated number of CVD events calculated for (1) current treatment, (2) improved treatment and (3) lowered LDL-C, based on applying rate reductions from meta-analyses of randomised trials to the potentially undertreated population. Risk estimation modelling was based on 52 042 patients in the same register on January 2011 followed for 5 years.

RESULTS

Of 37 120 patients, 18% reached LDL-C ≤1.8 mmol/L and 32% were not on statin treatment. Based on individual risks, the estimated number of CVD events in the study group over 5 years was 9209/37 120. If all patients without a statin or with less potent statin treatment were given atorvastatin 80 mg, an estimated reduction of CVD events by 14% (7901 vs 9209) was seen. If all patients achieved LDL-C ≤1.8 mmol/L, the number of events was estimated to be reduced by 18% (7577 vs 9209).

CONCLUSION

One-third of patients with CHD in primary care were not on lipid-lowering treatment. Based on the assumption that included patients would react to statin therapy the same way as the patients in randomised trials, improved adherence to treatment guidelines could lead to a substantial reduction in new CVD events.

The impact of diabetes, education and income on mortality and cardiovascular events in hypertensive patients: A cohort study from the Swedish Primary Care Cardiovascular Database (SPCCD)

Objective

In this study we aimed to estimate the effect of diabetes, educational level and income on the risk of mortality and cardiovascular events in primary care patients with hypertension.

Methods

We followed 62,557 individuals with hypertension diagnosed 2001–2008, in the Swedish Primary Care Cardiovascular Database. Study outcomes were death, myocardial infarction, and ischemic stroke, assessed using national registers until 2012. Cox regression models were used to estimate adjusted hazard ratios of outcomes according to diabetes status, educational level, and income.

Results

During follow-up, 13,231 individuals died, 9981 were diagnosed with diabetes, 4431 with myocardial infarction, and 4433 with ischemic stroke. Hazard ratios (95% confidence intervals) for diabetes versus no diabetes: mortality 1.57 (1.50–1.65), myocardial infarction 1.24 (1.14–1.34), and ischemic stroke 1.17 (1.07–1.27). Hazard ratios for diabetes and ≤9 years of school versus no diabetes and >12 years of school: mortality 1.56 (1.41–1.73), myocardial infarction 1.36 (1.17–1.59), and ischemic stroke 1.27 (1.08–1.50). Hazard ratios for diabetes and income in the lowest fifth group versus no diabetes and income in the highest fifth group: mortality 3.82 (3.36–4.34), myocardial infarction 2.00 (1.66–2.42), and ischemic stroke 1.91 (1.58–2.31).

Conclusions

Diabetes combined with low income was associated with substantial excess risk of mortality, myocardial infarction and ischemic stroke among primary care patients with hypertension.

Obesity, overweight and risk for cardiovascular disease and mortality in young women

AIMS

The aim of this study was to investigate the relation between body mass index (BMI) in young women, using weight early in pregnancy as a proxy for pre-pregnancy weight, and risk for early cardiovascular disease (CVD) and mortality.

METHODS AND RESULTS

In this prospective, registry-based study, we used weight data in early pregnancy from women, registered in the Swedish Medical Birth Registry, and who gave birth between 1982 and 2014 (n = 1,495,499; median age 28.3 years). Of the women, 118,212 (7.9%) were obese (BMI ≥ 30 kg/m²) and 29,630 (2.0%) severely obese (BMI ≥ 35 kg/m²). After a follow-up of median 16.3 years, we identified 3295 and 4375 cases of acute myocardial infarction (AMI) and ischemic stroke (IS) corresponding to 13.4 and 17.8 per 100,000 observation years, respectively, occurring at mean ages of 49.8 and 47.3 years. Compared to women with a BMI 20-<22.5 kg/m², the hazard ratio (HR) of AMI increased with higher BMI from 1.40 (95% confidence interval (CI) 1.27-1.54) among women with BMI 22.5-<25.0 kg/m² to 4.71 (95% CI 3.88-5.72) among women with severe obesity, with similar findings for IS and CVD death, after adjustment for age, pregnancy year, parity and comorbidities at baseline. Women with BMI 30-<35.0 and ≥35 kg/m² had increased all-cause mortality with adjusted HR 1.53 (95% CI 1.43-1.63) and 1.83 (95% CI 1.63-2.05), respectively.

CONCLUSION

A significant increase in the risk for early AMI, IS and CVD death was noticeable in overweight young women, with a marked increase in obese women.

P1565Better adherence to lipid lowering guidelines in secondary prevention may result in substantial reduction in cardiovascular events

Introduction

The preventive effect of lipid lowering treatment in secondary prevention after coronary heart disease (CHD) is well documented. In 2015, regional guidelines recommend an LDL cholesterol of ≤1.8 mmol/L for patients with established CHD but the adherence to these guidelines is low.

Purpose

Our aim was to predict potential reductions in cardiovascular disease (CVD) events defined as acute myocardial infarction or stroke if patients: 1) with low-dose/less potent or no statin were treated with Atorvastatin 80 mg, or 2) all reached LDL ≤1.8 mmol/L.

Methods

In total, 37 120 patients with established CHD in a primary care regional register 2015 were studied. Predicted number of CVD events were calculated with actual treatment, with improved treatment and with lowered LDL. For risk estimation we used data from a Cox Proportional Hazards risk estimation model based on patients from 2010 (n=52 042) in combination with data from the literature on effect of statin treatment and LDL reduction. A risk reduction of 22% for CVD events per 1 mmol/L reduction in LDL was used in our model.

The risk prediction model included age, sex, diabetes mellitus, a history of heart failure and/or atrial fibrillations, treatment with acetylic salicylic acid and stroke or AMI past year. Smoking and BMI were excluded due to missing data but sensitivity analysis has shown only small differences in results.

Results

In total, 18% of included patients reached LDL ≤1.8 mmol/L and 32% had no statin treatment. Based on actual LDL levels and treatments, the predicted number of CVD events over 5 years was 9209/37120. If all patients with no statin or less potent statin treatment had been given atorvastatin 80 mg this would lead to a reduction of CVD events by 14% (7901 vs 9209). The largest gain, 33% reduction, occurred when adding statins to patients without previous treatment (1970 vs 2937). Furthermore, if all patients were to reach LDL ≤1.8 mmol/L the predicted number of events would be reduced by 18% (7577 vs 9209).

Conclusion

There is a substantial potential to reduce the number of CVD events in the large population of patients with established CHD in primary care by improved adherence to lipid treatment guidelines.

Acknowledgement/Funding

Närhälsan R&D Health Care, R&D Centre Gothenburg and Södra Bohuslän. the Swedish state under the Agreement concerning research and education of doctor

Visit patterns at primary care centres and individual blood pressure level - a cross-sectional study

OBJECTIVE

Hypertension is a major cause of cardiovascular disease. Nevertheless, blood pressure (BP) is often inadequately treated. We studied visit patterns at primary health care centres (PHCCs) and their relation to individual BP control.

DESIGN AND SETTING

Cross-sectional register-based study on all patients with hypertension who visited 188 PHCCs in a Swedish region.

PATIENTS

A total of 88,945 patients with uncomplicated hypertension age 40-79.

MAIN OUTCOME MEASURES

Odds ratio (OR) for the individual patient to achieve the BP target of ≤140/90 mmHg.

RESULTS

Overall, 63% of patients had BP ≤ 140/90 mmHg (48% BP < 140/90). The PHCC that the patient was enrolled at and, as part of that, more nurse visits at PHCC level was associated with BP control, adjusted OR 1,10 (95% CI 1.01 to 1.21). Patients visiting PHCCs with the highest proportion of visits with nurses had an even higher chance of achieving the BP target, OR 1.19 (95% CI 1.07 to 1.32).

CONCLUSIONS

In a Swedish population of patients with hypertension, about half do not achieve recommended treatment goals. Organisation of PHCC and team care are known as factors influencing BP control. Our results suggests that a larger focus on PHCC organisation including nurse based care could improve hypertension care.

Links between blood pressure and medication intake, well-being, stress, physical activity and symptoms reported via a mobile phone-based self-management support system: a cohort study in primary care

OBJECTIVES

To explore relationships between patients' self-monitoring of blood pressure (BP) and their concurrent self-reports of medication intake, well-being, stress, physical activity and symptoms.

DESIGN

This study is a secondary analysis of a prospective study exploring the 8-week effectiveness of a mobile phone-based self-management support system for patients with hypertension.

SETTING

Four primary healthcare centres situated in urban and suburban communities in Sweden.

PARTICIPANTS

50 patients undergoing treatment for hypertension.

PRIMARY AND SECONDARY OUTCOME MEASURES

Associations between systolic (SBP) and diastolic blood pressure (DBP) and 10 self-report lifestyle-related variables were analysed using linear mixed effects modelling.

RESULTS

Medication intake, better well-being, less stress and greater physical activity were associated variously with lower same-day SBP and DBP. The single strongest association was found between medication intake and SBP, where failure to take medications was associated with an estimated 7.44 mm Hg higher SBP. To a lesser degree, medication intake was also associated with DBP, where DBP was 4.70 mm Hg higher in cases where medications were not taken. Well-being and stress were consistently associated with SBP and DBP, whereas physical activity was associated with only SBP. None of the symptoms-dizziness, headache, restlessness, fatigue or palpitations-were significantly associated with BP.

CONCLUSIONS

Our findings that BP was associated with patients' BP management behaviours and experiences of well-being and stress, but not symptoms suggest that enabling persons with hypertension to monitor and track their BP in relation to medication intake, physical activity, well-being, stress and symptoms may be a fruitful way to help them gain first-hand understanding of the importance of adherence and persistence to treatment recommendations.

TRIAL REGISTRATION NUMBER

NCT01510301; Pre-results.

Hemostatic Responses to Mental Stress during the Menstrual Cycle

To study the effect of sex hormones on the hemostatic responses to stress, blood samples were collected before, during, and after 20 min of mental stress from 9 healthy, non-smoking female volunteers, examined in the follicular and luteal phase. Mental stress caused significant increases in heart rate, blood pressure, and plasma catecholamines. In addition, analysis of variance indicated significant changes of leukocyte count, hematocrit, fibrinogen, von Willebrand factor antigen, t-PA activity and antigen in response to the stress test. However, in contrast to a male group previously investigated, there were no significant changes in factor VII coagulant activity in either menstrual phase. Overall the responses were more pronounced in the luteal as compared to the follicular phase. The findings support the concept that both gender and physiological variations in female sex hormones may modulate hemostatic responses to psychosocial stress.

Relation Between Lipid Profile and New-Onset Atrial Fibrillation in Patients With Systemic Hypertension (From the Swedish Primary Care Cardiovascular Database [SPCCD])

The relation between dyslipidemia and atrial fibrillation (AF) development is still controversial. To assess the impact of lipid profile on new-onset AF, we followed 51,020 primary-care hypertensive patients without AF at baseline. After a mean follow-up time of 3.5 years, AF occurred in 2,389 participants (4.7%). We evaluated the association between total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, and new-onset AF. In a Poisson regression model fully adjusted for common risk factors of AF, we found that 1.0 mmol/l (39 mg/dl) increase in total cholesterol was associated with 19% lower risk of new-onset AF (95% confidence interval [CI] 9% to 28%), and 1.0 mmol/l (39 mg/dl) increase in low-density lipoprotein cholesterol was associated with 16% lower risk of new-onset AF (95% CI 3% to 27%). Gender-specific Poisson regression analyses revealed that increase in total cholesterol by 1.0 mmol/l (39 mg/dl) was found to be associated with lower risk of new-onset AF with 21% in men (95% CI 8% to 32%), and 18% in women (95% CI 1% to 31%). There was no association between high-density lipoprotein cholesterol or triglycerides and new-onset AF, neither in the whole population with respect to separate gender. In conclusion, in a large hypertensive population we found an inverse association between total cholesterol and new-onset AF for both men and women. Our results confirm previous reports of a dyslipidemia paradox, and extend these observations to the hypertensive population.

Acute blood pressure levels and long-term outcome in ischemic stroke

OBJECTIVES

Elevated blood pressure (BP) is common in acute ischemic stroke, but its effect on outcome is not fully understood. We aimed to investigate the association of baseline BP and BP change within the first day after stroke with stroke severity, functional outcome, and mortality.

METHODS

Patients admitted to hospital with acute ischemic stroke (IS) from 15 February 2005 through 31 May 2009 were consecutively included. Acute stroke severity and functional outcome at three and twelve months were investigated using multivariate regression analysis; the association between BP and all-cause mortality at one, three, and twelve was investigated by Cox proportional hazard regression and Kaplan-Meier survival curves.

RESULTS

A total of 799 patients (mean age 78.4 ± 8.0, 48% men) were included. Higher decreases in systolic and mean arterial blood pressure (ΔSBP and ΔMAP) were associated with decreased 1-month mortality (ΔSBP: hazard ratio, HR: 0.981; 95% CI: 0.968 - 0.994; p = .005), 3-month mortality (ΔSBP: HR 0.989; 95% CI 0.981 - 0.998; p-value .014), and twelve-month mortality (ΔSBP: HR 0.989; 95% CI 0.982 - 0.996; p-value .003). Stroke severity was associated with ΔMAP (B coefficient -.46, p-value .011). Higher SBP and MAP on admission were associated with better functional outcome at three (SBP: OR 0.987; 95% CI 0.978 - 0.997; p-value .008 - MAP: OR 0.985; 95% CI 0.971 - 1; p-value .046) and twelve (SBP: OR 0.988; 95% CI 0.979 - 0.998; p-value .015 - MAP: OR 0.983; 95% CI 0.968 - 0.997; p-value .02) months.

CONCLUSION

In this elderly population, higher BP on arrival to the emergency room (ER) and decrease in BP after the patients' arrival to the ward were associated with improved functional outcome and reduced mortality, respectively. These results may reflect a regulatory situation in which elevated initial blood pressure indicates adequate response to cerebral tissue ischemia while subsequent blood pressure decrease instead may be a consequence of partial, successful reperfusion.

Mortality trends and cause of death in patients with new-onset type 2 diabetes and controls: A 24-year follow-up prospective cohort study

AIMS

Our aim was to assess causes of death and temporal changes in excess mortality among patients with new-onset type 2 diabetes in Skaraborg, Sweden.

METHODS

Patients from the Skaraborg Diabetes Register with prospectively registered new-onset type 2 diabetes 1991-2004 were included. Five individual controls matched for sex, age, geographical area and calendar year of study entry were selected using population records. Causes of deaths until 31 December 2014 were retrieved from the Cause of Death Register. Adjusted excess mortality among patients and temporal changes of excess mortality were calculated using Poisson models. Cumulative incidences of cause-specific mortality were calculated by competing risk regression.

RESULTS

During 24 years of follow-up 4364 deaths occurred among 7461 patients in 90,529 person-years (48.2/1000 person-years, 95% CI 46.8-49.7), and 18,541 deaths in 479,428 person-years among 37,271 controls (38.7/1000 person-years, 38.1-39.2). The overall adjusted mortality hazard ratio was 1.47 (p < .0001) among patients diagnosed at study start 1991 and decreased by 2% (p < .0001) per increase in calendar year of diagnosis until 2004. Excess mortality was mainly attributed to endocrine and cardiovascular cause of death with crude subdistributional hazard ratios of 5.06 (p < .001) and 1.22 (p < .001).

CONCLUSIONS

Excess mortality for patients with new-onset type 2 diabetes was mainly attributed to deaths related to diabetes and the cardiovascular system, and decreased with increasing year of diagnosis 1991-2004. Possible explanations could be temporal trends of earlier diagnosis due to lowered diagnostic thresholds and intensified diagnostic activities, as well as improved treatment.

Primary aldosteronism and thyroid disorders in atrial fibrillation: A Swedish nationwide case–control study

Background

Atrial fibrillation is associated with hyperthyroidism. Patients with primary aldosteronism have an increased prevalence of atrial fibrillation. However, the prevalence of primary aldosteronism in the atrial fibrillation population is unknown.

Aim

This nationwide case–control study aimed to compare the prevalence of primary aldosteronism and thyroid disorders in patients with atrial fibrillation with that of age- and sex-matched controls.

Methods

We identified all atrial fibrillation cases in Sweden between 1987 and 2013 ( n = 713,569) by using the Swedish National Patient Register. A control cohort without atrial fibrillation was randomly selected from the Swedish Total Population Register with a case to control ratio of 1:2. This control cohort was matched for age, sex and place of birth ( n = 1,393,953).

Results

The prevalence of primary aldosteronism in December 2013 was 0.056% in the atrial fibrillation cohort and 0.024% in controls. At the same time, the prevalence of hypothyroidism was 5.9% in the atrial fibrillation cohort and 3.7% in controls. The prevalence of hyperthyroidism was 2.3% in the atrial fibrillation cohort and 0.8% in controls.

Conclusion

This study shows, for the first time, a doubled prevalence of primary aldosteronism in a large cohort of patients with atrial fibrillation compared with the general population. There is also an increased prevalence of hypo- and hyper-thyroidism in patients with atrial fibrillation compared with the general population.

Aldosterone to Renin Ratio as a Screening Instrument for Primary Aldosteronism in a Middle-Aged Population with Atrial Fibrillation

Atrial fibrillation seems to be overrepresented among patients with primary aldosteronism. The aim of this study was to determine the usefulness of aldosterone to renin ratio as a screening instrument for primary aldosteronism in an atrial fibrillation population with relatively low cardiovascular risk profile. A total of 149 patients <65 years and with history of AF were screened for primary aldosteronism using aldosterone to renin ratio. Pathologically increased aldosterone to renin ratio (>65 pmol/mIU) was found in 15 participants (10.1%). Further investigation of the positive screened participants and confirmatory saline infusion test resulted in a diagnosis of primary aldosteronism in four individuals out of 149 (2.6%). Three out of the four individuals with primary aldosteronism had previously been diagnosed with hypertension, but only one out of the four had uncontrolled blood pressure, that is, >140/90 mmHg. All participants had normal potassium levels. Individuals with increased aldosterone to renin ratio had significantly higher mean systolic and diastolic blood pressure in comparison to participants with normal aldosterone to renin ratio (136 vs. 126 mmHg, p=0.02 and 84 vs. 78 mmHg, p=0.02). These findings suggest that assessment of aldosterone to renin ratio can be useful for identification of underlying primary aldosteronism in patients with diagnosed atrial fibrillation and hypertension in spite of well controlled blood pressure and normokalemia.

Non-steroidal anti-inflammatory drugs and blood pressure control in patients treated for hypertension: results from the Swedish primary care cardiovascular database

PURPOSE

The aim of this observational cohort study was to investigate blood pressure level and the possibility to reach target blood pressure during concomitant use of NSAID in hypertensive patients.

MATERIALS AND METHODS

From the Swedish primary care cardiovascular database (SPCCD) a cohort of 5463 patients (2007 to 2008) with at least one prescription of NSAID dispensed 6 months prior to the last blood pressure measurement were included. Clinical data were extracted from computerized medical records and linked to the Prescribed Drug Register. Multivariable logistic regression models were used for analysis.

RESULTS

Patients with NSAID usage were younger, more often female, with lower creatinine concentrations, more musculoskeletal diagnosis and less cardiovascular comorbidity compared to patients without dispensed NSAID (p < .0001 for all). Regular dose of NSAID was not associated with a decreased possibility to reach target blood pressure. A correlation between the dose of naproxen and an increase in SBP of 7 mm Hg was found. Impairment in renal function did not influence the association between blood pressure control and NSAID (p = .27).

CONCLUSION

In hypertensive patients with concomitant use of NSAID the chance to reach target blood pressure was not impaired. In intermediate and frequent users of NSAID there was a dose response relation with naproxen and SBP which was not found in diclofenac and ibuprofen.

Persistence to antihypertensive drug classes: A cohort study using the Swedish Primary Care Cardiovascular Database (SPCCD)

The aim was to study persistence to, and switching between, antihypertensive drug classes and to determine factors associated with poor persistence.This was an observational cohort study. The Swedish Primary Care Cardiovascular Database includes data from medical records, socioeconomic data, filled prescriptions, and hospitalizations from national registries for 75,000 patients with hypertension. Patients included in the study were initiated on antihypertensive drug treatment in primary healthcare in 2006 to 2007. We defined class persistence as the proportion remaining on the initial drug class, including 30 days of gap. Patients with a filled prescription of another antihypertensive drug class after discontinuation of the initial drug, including 30 days of gap, were classified as switchers. Persistence to the various drug classes were compared with that for diuretics.We identified 4997 patients (mean age 60 ± 12 years in men and 63 ± 13 years in women). Out of these, 95 (2%) filled their first prescription for fixed combination therapy and 4902 (98%) for monotherapy, including angiotensin converting enzyme inhibitors (37%), angiotensin receptor blockers (4%), beta blockers (21%), calcium channel blockers (8%), and diuretics (28%). Persistence to the initial drug class was 57% after 1 year and 43% after 2 years. There were no differences in persistence between diuretics and any of the other antihypertensive drug classes, after adjustment for confounders. Discontinuation (all adjusted) was more common in men (P = 0.004), younger patients (P < 0.001), those with mild systolic blood pressure elevation (P < 0.001), and patients born outside the Nordic countries (P < 0.001). Among 1295 patients who switched drug class after their first prescription, only 21% had a blood pressure recorded before the switch occurred; and out them 69% still had high blood pressures.In conclusion, there appears to be no difference in drug class persistence between diuretics and other major antihypertensive drug classes, when factors known to be associated with poor persistence are taken into account.

Blood pressure and complications in individuals with type 2 diabetes and no previous cardiovascular disease: national population based cohort study

OBJECTIVES

 To compare the risk associated with systolic blood pressure that meets current recommendations (that is, below 140 mm Hg) with the risk associated with lower levels in patients who have type 2 diabetes and no previous cardiovascular disease.

DESIGN

 Population based cohort study with nationwide clinical registries, 2006-12. The mean follow-up was 5.0 years.

SETTING

 861 Swedish primary care units and hospital outpatient clinics.

PARTICIPANTS

 187 106 patients registered in the Swedish national diabetes register who had had type 2 diabetes for at least a year, age 75 or younger, and with no previous cardiovascular or other major disease.

MAIN OUTCOME MEASURES

 Clinical events were obtained from the hospital discharge and death registers with respect to acute myocardial infarction, stroke, a composite of acute myocardial infarction and stroke (cardiovascular disease), coronary heart disease, heart failure, and total mortality. Hazard ratios were estimated for different levels of baseline systolic blood pressure with clinical characteristics and drug prescription data as covariates.

RESULTS

 The group with the lowest systolic blood pressure (110-119 mm Hg) had a significantly lower risk of non-fatal acute myocardial infarction (adjusted hazard ratio 0.76, 95% confidence interval 0.64 to 0.91; P=0.003), total acute myocardial infarction (0.85, 0.72 to 0.99; P=0.04), non-fatal cardiovascular disease (0.82, 0.72 to 0.93; P=0.002), total cardiovascular disease (0.88, 0.79 to 0.99; P=0.04), and non-fatal coronary heart disease (0.88, 0.78 to 0.99; P=0.03) compared with the reference group (130-139 mm Hg). There was no indication of a J shaped relation between systolic blood pressure and the endpoints, with the exception of heart failure and total mortality.

CONCLUSIONS

 Lower systolic blood pressure than currently recommended is associated with significantly lower risk of cardiovascular events in patients with type 2 diabetes. The association between low blood pressure and increased mortality could be due to concomitant disease rather than antihypertensive treatment.

Blood Pressure Response to Losartan and Continuous Positive Airway Pressure in Hypertension and Obstructive Sleep Apnea

RATIONALE

Obstructive sleep apnea (OSA) is common in people with hypertension, particularly resistant hypertension. Treatment with an antihypertensive agent alone is often insufficient to control hypertension in patients with OSA.

OBJECTIVES

To determine whether continuous positive airway pressure (CPAP) added to treatment with an antihypertensive agent has an impact on blood pressure (BP) levels.

METHODS

During the initial 6-week, two-center, open, prospective, case-control, parallel-design study (2:1; OSA/no-OSA), all patients began treatment with an angiotensin II receptor antagonist, losartan, 50 mg daily. In the second 6-week, sex-stratified, open, randomized, parallel-design study of the OSA group, all subjects continued to receive losartan and were randomly assigned to either nightly CPAP as add-on therapy or no CPAP.

MEASUREMENTS AND MAIN RESULTS

Twenty-four-hour BP monitoring included assessment every 15 minutes during daytime hours and every 20 minutes during the night. Ninety-one patients with untreated hypertension underwent a home sleep study (55 were found to have OSA; 36 were not). Losartan significantly reduced systolic, diastolic, and mean arterial BP in both groups (without OSA: 12.6, 7.2, and 9.0 mm Hg; with OSA: 9.8, 5.7, and 6.1 mm Hg). Add-on CPAP treatment had no significant changes in 24-hour BP values but did reduce nighttime systolic BP by 4.7 mm Hg. All 24-hour BP values were reduced significantly in the 13 patients with OSA who used CPAP at least 4 hours per night.

CONCLUSIONS

Losartan reduced BP in OSA, but the reductions were less than in no-OSA. Add-on CPAP therapy resulted in no significant changes in 24-hour BP measures except in patients using CPAP efficiently. Clinical trial registered with www.clinicaltrials.gov (NCT00701428).​

Cardiovascular response to stress and perceived stress is not altered 40 years after hypertensive pregnancies

OBJECTIVE

Women experiencing hypertensive pregnancies have an increased risk for cardiovascular disease. Whether stress increase the risk is unknown. The objective was to test if cardiovascular response to stress and/or perceived stress differed in relation to blood pressure status during pregnancy 40 years earlier.

METHODS

Cardiovascular response was examined with mental stress test, and perceived stress was evaluated with a questionnaire in 105 women.

RESULTS

Resting heart rate was higher, and pulse reactivity was lower in women with previous hypertensive pregnancies. Neither blood pressure nor perceived stress differed.

CONCLUSION

Response to physical or psychological stress is not affected many years after pregnancy.

Effect of catheter-based renal sympathetic denervation on 24-h ambulatory blood pressure in patients with resistant hypertension

We investigated the effect of renal denervation on office blood pressure (OBP) and 24-h ambulatory blood pressure (BP) measurement (ABPM) at baseline and 6 months after intervention in 25 consecutive patients with resistant hypertension. Mean baseline 24-h ABPM and OBP were 158/88 mmHg and 169/96 mmHg, respectively. Patients were treated with an average of 4 ± 1 antihypertensive drugs. Among the 22 patients included in data analysis, mean ambulatory systolic and diastolic BP were reduced by 6 mmHg from 158 ± 17 to 152 ± 20 mmHg (p < 0.05) and by 3 mmHg from 88 ± 12 to 85 ± 14 mmHg (p = ns) after 6 months follow-up, respectively. Blood pressure reduction was most pronounced during daytime with a decrease of 9 mmHg from 164 ± 17 to 155 ± 19 (p < 0.05) in systolic (SBP) and 6 mmHg from 94 ± 14 to 88 ± 14 mmHg in diastolic BP (DBP) (p < 0.05). Night-time SBP mmHg and DBP were similar at baseline compared with follow-up. Systolic and diastolic OBP during follow-up were significantly reduced by 17 mmHg from 169 ± 20 to 152 ± 21 (p < 0.05) and by 9 mmHg from 96 ± 16 to 87 ± 13 mmHg (p < 0.05), respectively. These results provide new insight into the effect of renal denervation on ABPM day- and night-time blood pressure profile in comparison with OBP. The decrease in ABPM was identified during daytime registration and was less pronounced compared with reduction of OBP.

Electrocardiographic abnormalities and elevated cTNT at admission for intracerebral hemorrhage: predictors for survival?

BACKGROUND

Cerebrovascular lesions are often associated with electrocardiographic (ECG) abnormalities. The main purpose of this work was to investigate the prognostic value of ECG abnormalities and/or elevated cardiac troponin (cTNT) on admission in patients with nontraumatic intracerebral hemorrhage (ICH).

METHODS

Ninety-seven consecutive patients with ICH were included. The predictive value of ECG abnormalities and increased TNT on survival were evaluated using Cox proportional hazard model.

RESULTS

The most frequently observed ECG abnormalities were the presence of a Q wave (39.6%), followed by prolonged QTc (>0.44 s; 35.4%), which was an independent predictor for long-term mortality (P = 0.019). No difference in QTc was observed between patients with right versus left ICH. Increased cTNT levels at admission had no prognostic value.

CONCLUSION

Various ECG changes were common in patients presenting with an ICH, but only prolonged QTc was found to be an independent predictor of poor survival during follow-up after ICH.

PP107. Cardiovascular parameters 40 years after hypertensive pregnancies

INTRODUCTION

Epidemiological data indicate an increased cardiovascular risk in women with previous hypertensive pregnancies. There are few clinical investigations regarding the mechanisms that could mediate this increased risk.

OBJECTIVES

The aim of the present study was to clarify if any deterioration in the cardiovascular, metabolic or neuroendocrine status is present in women 40 years after pregnancies complicated by hypertension.

METHODS

Three hundred and nineteen women were invited to take part in a follow up investigation regarding cardiovascular regulation. One hundred and five women accepted to participate - 50 with previously hypertensive pregnancies (HTP) and 55 with normotensive pregnancies (NTP). Office and ambulatory blood pressure levels, central blood pressure and pulse wave velocity, echocardiographic measurements (RWT, LVMI, LA, LA-RA, diastolic function, strain) and P-glucose, HbA1c, S-leptin, S-hsCRP, P-renin, P-Noradrenaline and NT-proBNP were examined. Women who choose not to participate (n=214) were followed up with a questionnaire regarding their previous pregnancies and present cardiovascular health.

RESULTS

The investigations did not reveal differences in any examined variables regarding blood pressure, echocardiographic parameters or blood analysis for metabolic and neurohumoral balance. Twenty-five individuals were diagnosed with hypertension in the HTP group (mean BP 145/86mmHg) and 17 subjects in the NTP group (mean BP 145/87mmHg). The questionnaire was answered by 79% of the participants and revealed that these women had an impaired cardiovascular health compared to the group investigated.

CONCLUSION

Blood pressure, metabolic and neuroendocrine parameters are not permanently worsened in all women with previous hypertensive pregnancies. There exist disparities within the group of women with previous hypertensive pregnancies and there are women without obvious cardiovascular or metabolic dysfunction 40 years after the hypertensive manifestation during pregnancy.

Antihypertensive effect of low-frequency transcutaneous electrical nerve stimulation (TENS) in comparison with drug treatment

Hypertension is a major risk factor for vascular disease, yet blood pressure (BP) control is unsatisfactory low, partly due to side-effects. Transcutaneous electrical nerve stimulation (TENS) is well tolerated and studies have demonstrated BP reduction. In this study, we compared the BP lowering effect of 2.5 mg felodipin once daily with 30 min of bidaily low-frequency TENS in 32 adult hypertensive subjects (mean office BP 152.7/90.0 mmHg) in a randomized, crossover design. Office BP and 24-h ambulatory BP monitoring (ABPM) were performed at baseline and at the end of each 4-week treatment and washout period. Felodipin reduced office BP by 10/6 mmHg (p <0.001 respectively) and after washout BP rose to a level still significantly lower than at baseline. TENS reduced office BP by 5/1.5 mmHg (p <0.01, ns). After TENS washout, BP was further reduced and significantly lower than at baseline, but at levels similar to BP after felodipin washout and therefore reasonably caused by factors other than the treatment per se. ABPM revealed a significant systolic reduction of 3 mmHg by felodipin, but no significant changes were noted after TENS. We conclude that our study does not present any solid evidence of BP reduction of TENS.

Effects of estrogen plus progesterone on hemodynamic and vascular reactivity in hypertensive postmenopausal women

AIMS

To investigate the medium-term effects of estrogen plus progesterone therapy (EPT) on vascular reactivity, endothelial function and hemodynamic responses in 20 hypertensive postmenopausal women.

METHODS

This randomized, double-blind, cross-over, placebo-controlled study investigates the effect of 6 months of EPT (conjugated equine estrogen plus medroxyprogesterone). Blood pressure (office and ambulatory), heart rate and heart rate variability (HRV) were measured at baseline and following EPT/placebo treatment. In eight women, we used a wire-myograph to assess endothelial function and contractile response of subcutaneous arteries to transmural nerve stimulation (TNS) and exogenous noradrenaline.

RESULTS

EPT decreased vascular reactivity to cumulative TNS compared with baseline (p<0.01) and placebo (p<0.05). Moreover, EPT diminished sensitivity to exogenous noradrenaline (p<0.05). Although EPT reinforced response to acetylcholine, we observed no difference in maximal relaxation induced by substance P or acetylcholine. EPT did not affect ambulatory blood pressure, heart rate or HRV.

CONCLUSIONS

Oral combined medium-term EPT reduces adrenergic reactivity in subcutaneous arteries from treated hypertensive postmenopausal women. EPT might act postjunctionally at the adrenergic vascular receptor level. In the present study, EPT neither reduces sympathetic activity nor increases vagal tone, and thus does not support an effect on the central hemodynamic system.

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.

Psychosocial profile in men and women with unexplained chest pain

OBJECTIVE

The aim of this study was to compare men and women with unexplained chest pain (UCP) to a randomly selected population sample free of clinical heart disease with regard to sleep problems, mental strain at work, stress at home, negative life events and health-related quality of life (HRQOL).

DESIGN AND SUBJECTS

The study was conducted at a university hospital in Sweden including 231 patients aged 25-69 without any organic cause for chest pain. As a reference group, 1069 participants, were recruited from the INTERGENE population-based study.

RESULTS

Patients with UCP had more sleep problems (OR = 1.8, P < 0.0001), were almost three times more worried about stress at work (OR = 2.9, P < 0.0001), or had more stress at home (OR = 2.8, P < 0.0001), and were twice as likely to have negative life events (OR = 2.1, P < 0.0001). Women, but not men, with UCP, had a higher prevalence of cardiovascular risk factors (obesity, smoking, diabetes and hypertension) compared with references. With regard to HRQOL, UCP patients scored significantly lower than references in all dimensions of the SF-36.

CONCLUSIONS

In comparison with a healthy reference group, patients with UCP reported more sleep problems, mental strain at work, stress at home and negative life events and had lower health-related quality of life. Aside from immigration the strongest independent psychosocial factors were mental strain at work and negative life events last year in men and stress at home in women.

Depression, anxiety, stress, social interaction and health-related quality of life in men and women with unexplained chest pain

Background

Unexplained chest pain (UCP) is a common reason for emergency hospital admission and generates considerable health-care costs for society. Even though prior research indicates that psychological problems and impaired quality of life are common among UCP patients, there is lack of knowledge comparing UCP patients with a reference group from the general population. The aim of this study was to analyse differences between men and women with UCP and a reference group in terms of psychosocial factors as depression, anxiety, stress, social interaction and health-related quality of life (HRQOL).

Methods

A self-administered questionnaire about psychosocial factors was completed by 127 men and 104 women with acute UCP admitted consecutively to the Emergency Department (ED) or as in-patients on a medical ward. A reference group from the general population, 490 men and 579 women, participants in the INTERGENE study and free of clinical heart disease, were selected.

Results

The UCP patients were more likely to be immigrants, have a sedentary lifestyle, report stress at work and have symptoms of depression and trait-anxiety compared with the reference group. After adjustment for differences in age, smoking, hypertension and diabetes, these factors were still significantly more common among patients with UCP. In a stepwise multivariate model with mutual adjustment for psychosocial factors, being an immigrant was associated with a more than twofold risk in both sexes. Stress at work was associated with an almost fourfold increase in risk among men, whereas there was no independent impact for women. In contrast, depression only emerged as an independent risk factor in women. Trait-anxiety and a low level of social interaction were not independently associated with risk in either men or women. Patients with UCP were two to five times more likely to have low scores for HRQOL.

Conclusion

Both men and women with UCP had higher depression scores than referents, but an independent association was only found in women. Among men, perceived stress at work emerged as the only psychosocial variable significantly associated with UCP.