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Better long-term survival in young and middle-aged women than in men after a first myocardial infarction between 1985 and 2006. an analysis of 8630 patients in the Northern Sweden MONICA Study
Rose-Marie Isaksson, Jan-H?kan Jansson, Dan Lundblad, Ulf N?slund, Karin Zingmark, Mats Eliasson
BMC Cardiovascular Disorders , 2011, DOI: 10.1186/1471-2261-11-1
Abstract: The Northern Sweden MONICA Myocardial Infarction Registry was linked to The Swedish National Cause of Death Registry for a total of 8630 patients, 25 to 64 years of age, 6762 men and 1868 women, with a first MI during 1985-2006. Also deaths before admission to hospital were included. Follow-up ended on August 30, 2008.Median follow-up was 7.1 years, maximum 23 years and the study included 70 072 patient-years. During the follow-up 45.3% of the men and 43.7% of the women had died. Median survival for men was 187 months (95% confidence interval (CI) 179-194) and for women 200 months (95% CI 186-214). The hazard ratio (HR) for all cause mortality after adjustment for age group was 1.092 (1.010-1.18, P = 0.025) males compared to females, i.e. 9 percent higher survival in women. After excluding subjects who died before reaching hospital HR declined to 1.017 (95%CI 0.93-1.11, P = 0.7). For any duration of follow-up a higher proportion of women were alive, irrespective of age group. The 5-year survivals were 75.3% and 77.5%, in younger (<57 years) men and women and were 65.5% and 66.3% in older (57-64 years) men and women, respectively. For each of four successive cohorts survival improved. Survival time was longer for women than for men in all age groups.Age-adjusted survival was higher among women than men after a first MI and has improved markedly and equally in both men and women over a 23-year period. This difference was due to lower risk for women to die before reaching hospital.Mortality from myocardial infarction (MI) in Sweden, as in most other developed countries, has decreased markedly during recent decades[1]. The international MONICA collaboration hypothesizes that the decline is mainly due to a decrease in the classical risk factors -- smoking, cholesterol and blood pressure [2], although recent modelling strongly emphasizes the pivotal role of lower cholesterol [3]. However, MI still remains the most common cause of death in Sweden and other western regions
Silent myocardial infarction in women with impaired glucose tolerance: The Northern Sweden MONICA study
Dan Lundblad, Mats Eliasson
Cardiovascular Diabetology , 2003, DOI: 10.1186/1475-2840-2-9
Abstract: Within the Northern Sweden MONICA project a population survey was performed in 1986. Electrocardiograms (ECG's) were recorded for half of the survey (n = 790) and oral glucose test was carried out in 78 % of those. The association between subjects with ECG's indicating previously unknown myocardial infarction (ukMI), IGT and conventional risk factors were analyzed by logistic regression for men and women separately, adjusting for age, smoking, hypercholesterolemia and hypertension.Impaired glucose tolerance was significantly more common among women with ukMI, but not in men, compared to the group with normal ECG. In men, no variable was significantly associated with ukMI although the odds ratio (OR) for hypercholesterolemia was of borderline significance, 3.2 (95% confidence interval (CI) 0.9 to 11). The OR of having ukMI was 4.1 (CI 1.1 to 15) in women with IGT compared to women with normal glucose tolerance after multiple adjustment. The OR for hypertension was of borderline significance; 3.3 (CI 0.97 to 11).We found that IGT was associated with ECG findings indicating silent myocardial infarction in women in a middle-aged general population in northern Sweden. The results persisted even after adjusting for known risk factors.Diabetes contributes strongly to the risk of CVD with a risk that is increased four to six times, both for stroke and myocardial infarction [1]. The increase in risk for myocardial infarction seem to be more pronounced in women than in men [2].The prevalence of IGT in the general population is 2–3 times higher than that of previously unknown diabetes, which, in turn, is as common as known diabetes [3]. Patients with impaired glucose tolerance have an increased risk of CVD that is independent of traditional risk factors such as hypertension, smoking and hypercholesterolemia [4] and it has been suggested that slightly elevated glucose levels, even in the non-diabetic range, might be associated with increased macrovascular disease. Thus, the ris
Longer pre-hospital delay in first myocardial infarction among patients with diabetes: an analysis of 4266 patients in the Northern Sweden MONICA Study  [cached]
?ngerud Karin Hellstr?m,Brulin Christine,N?slund Ulf,Eliasson Mats
BMC Cardiovascular Disorders , 2013, DOI: 10.1186/1471-2261-13-6
Abstract: Background Reperfusion therapy reduces both morbidity and mortality in myocardial infarction, but the effectiveness depends on how fast the patient receives treatment. Despite the time-dependent effectiveness of reperfusion therapy, many patients with myocardial infarction have delays in seeking medical care. The aim of this study was to describe pre-hospital delay in a first myocardial infarction among men and women with and without diabetes and to describe the association between pre-hospital delay time and diabetes, sex, age, symptoms and size of residential area as a proxy for distance to hospital. Methods This population based study was based on data from 4266 people aged 25–74 years, with a first myocardial infarction registered in the Northern Sweden MONICA myocardial infarction registry between 2000 and 2008. Results The proportion of patients with delay times ≥ 2 h was 64% for patients with diabetes and 58% for patients without diabetes. There was no difference in delay time ≥ 2 h between men and women with diabetes. Diabetes, older age and living in a town or rural areas were factors associated with pre-hospital delay times ≥ 2 h. Atypical symptoms were not a predictor for pre-hospital delay times ≥ 2 h, OR 0.59 (0.47; 0.75). Conclusions A higher proportion of patients with diabetes have longer pre-hospital delay in myocardial infarction than patients without diabetes. There are no differences in pre-hospital delay between men and women with diabetes. The largest risk difference for pre-hospital delay ≥ 2 h is between women with and without diabetes. Diabetes, older age and living in a town or rural area are predictors for pre-hospital delay ≥ 2 h.
Association between Ambient Temperature and Acute Myocardial Infarction Hospitalisations in Gothenburg, Sweden: 1985–2010  [PDF]
Janine Wichmann, Annika Rosengren, Karin Sj?berg, Lars Barregard, Gerd Sallsten
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0062059
Abstract: Cardiovascular disease (CVD) is the number one cause of death globally and evidence is steadily increasing on the role of non-traditional risk factors such as meteorology and air pollution. Nevertheless, many research gaps remain, such as the association between these non-traditional risk factors and subtypes of CVD, such as acute myocardial infarction (AMI). The objective of this study was to investigate the association between daily ambient temperature and AMI hospitalisations using a case-crossover design in Gothenburg, Sweden (1985–2010). A secondary analysis was also performed for out-of-hospital ischemic heart disease (IHD) deaths. Susceptible groups by age and sex were explored. The entire year as well as the warm (April?September) and cold periods (October–March) were considered. In total 28 215 AMI hospitalisations (of 22 475 people) and 21 082 out-of-hospital IHD deaths occurred during the 26-year study period. A linear exposure-response corresponding to a 3% and 7% decrease in AMI hospitalisations was observed for an inter-quartile range (IQR) increase in the 2-day cumulative average of temperature during the entire year (11°C) and the warm period (6°C), respectively, with and without adjustment for PM10, NO2, NOx or O3. No heat waves occurred during the warm period. No evidence of an association in the cold period nor any association between temperature and IHD deaths in the entire year, warm or cold periods - with and without adjusting for PM10, NO2, NOx or O3 was found. No susceptible groups, based on age or sex, were identified either. The inverse association between temperature and AMI hospitalisations (entire year and warm period) in Gothenburg is in accordance with the majority of the few other studies that investigated this subtype of CVD.
Changes in Clinical Profile, Treatment, and Mortality in Patients Hospitalised for Acute Myocardial Infarction between 1985 and 2008  [PDF]
Sjoerd T. Nauta, Jaap W. Deckers, Martijn Akkerhuis, Mattie Lenzen, Maarten L. Simoons, Ron T. van Domburg
PLOS ONE , 2011, DOI: 10.1371/journal.pone.0026917
Abstract: Objectives To quantify the impact of the implementation of treatment modalities into clinical practice since 1985, on outcome of patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI). Methods All consecutive patients admitted for STEMI or NSTEMI at the Thoraxcenter between 1985 and 2008 were included. Baseline characteristics, pharmacological and invasive treatment modalities, and survival status were collected. The study population was categorised in three groups of patients: those hospitalised between 1985–1990, 1990–2000, and 2000–2008. Results We identified 14,434 patients hospitalised for myocardial infarction (MI). Both STEMI and NSTEMI patients were increasingly treated with the current guideline based therapy. In STEMI, at 30 days following admission, cumulative mortality rate decreased from 17% in 1985–1990 to 13% in 1990–2000, and to 6% in 2000–2008. Adjusted 30-day and three-year mortality in the last period was 80% and 68% lower than in 1985, respectively. In NSTEMI, at 30 days following admission, cumulative mortality rate decreased from 6% in 1985–1990 to 4% in 1990–2000, and to 2% in 2000–2008. Adjusted 30-day and three-year mortality in the last period was 78% and 49% lower than in 1985, respectively. For patients admitted between 2000 and 2008, 3 year survival of STEMI and NSTEMI patients was 87% and 88%, respectively. Conclusions Our results indicate substantial improvements in acute- and long-term survival in patients hospitalised for MI, related to improved acute- as well as long-term treatment. Early medical evaluation in suspected MI and intensive early hospital treatment both remain warranted in the future.
Association of daily tar and nicotine intake with incident myocardial infarction: Results from the population-based MONICA/KORA Augsburg Cohort Study 1984 - 2002
Qiu-Li Zhang, Jens Baumert, Karl-Heinz Ladwig, H-Erich Wichmann, Christa Meisinger, Angela D?ring
BMC Public Health , 2011, DOI: 10.1186/1471-2458-11-273
Abstract: The study was based on 4,099 men and 4,197 women participating in two population-based MONICA Augsburg surveys between 1984 and 1990 and followed up within the KORA framework until 2002. During a mean follow-up of 13.3 years, a number of 307 men and 80 women developed an incident MI event. Relative risks were calculated as hazard ratios (HRs) estimated by Cox proportional hazards models adjusted for cardiovascular risk factors.In the present study, male regular smokers consumed on average more cigarettes per day than female regular smokers (20 versus 15) and had a higher tar and nicotine intake per day. In men, the MI risk compared to never-smokers increased with higher tar intake: HRs were 2.24 (95% CI 1.40-3.56) for 1-129 mg/day, 2.12 (95% CI 1.37-3.29) for 130-259 mg/day and 3.01 (95% CI 2.08-4.36) for ≥ 260 mg/day. In women, the corresponding associations were comparable but more pronounced for high tar intake (HR 4.67, 95% CI 1.76-12.40). Similar associations were observed for nicotine intake.The present study based on a large population-based sample adds important evidence of cumulative effects of tar and nicotine intake on the risk of incident MI. Even low or medium tar and nicotine intake revealed substantial risk increases as compared to never-smokers. Therefore, reduction of tar and nicotine contents in cigarettes cannot be seen as a suitable public health policy in preventing myocardial infarction.Cigarette smoking is a central issue in public health policy as it has been shown to be associated with an elevated risk of various cardiovascular diseases and types of cancer [1,2]. Smoking has been determined as one of the most important risk factors for myocardial infarction (MI) [3-5], but it was shown that smoking cessation can reduce this risk [6]. Many countries and international agencies have made great efforts to change smoking behaviour and to encourage smokers to quit smoking, e.g. by preventing initiation of tobacco use, promoting cessation among ado
Likelihood of Treatment in a Coronary Care Unit for a First-Time Myocardial Infarction in Relation to Sex, Country of Birth and Socioeconomic Position in Sweden  [PDF]
Dong Yang, Stefan James, Ulf de Faire, Lars Alfredsson, Tomas Jernberg, Tahereh Moradi
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0062316
Abstract: Objective To examine the relationship between sex, country of birth, level of education as an indicator of socioeconomic position, and the likelihood of treatment in a coronary care unit (CCU) for a first-time myocardial infarction. Design Nationwide register based study. Setting Sweden. Patients 199 906 patients (114 387 men and 85,519 women) of all ages who were admitted to hospital for first-time myocardial infarction between 2001 and 2009. Main outcome measures Admission to a coronary care unit due to myocardial infarction. Results Despite the observed increasing access to coronary care units over time, the proportion of women treated in a coronary care unit was 13% less than for men. As compared with men, the multivariable adjusted odds ratio among women was 0.80 (95% confidence interval 0.77 to 0.82). This lower proportion of women treated in a CCU varied by age and year of diagnosis and country of birth. Overall, there was no evidence of a difference in likelihood of treatment in a coronary care unit between Sweden-born and foreign-born patients. As compared with patients with high education, the adjusted odds ratio among patients with a low level of education was 0.93 (95% confidence interval 0.89 to 0.96). Conclusions Foreign-born and Sweden-born first-time myocardial infarction patients had equal opportunity of being treated in a coronary care unit in Sweden; this is in contrast to the situation in many other countries with large immigrant populations. However, the apparent lower rate of coronary care unit admission after first-time myocardial infarction among women and patients with low socioeconomic position warrants further investigation.
Socio-economic differences in life expectancy among persons with diabetes mellitus or myocardial infarction: results from the German MONICA/KORA study
Laura Perna, Uta Thien-Seitz, Karl-Heinz Ladwig, Christa Meisinger, Andreas Mielck
BMC Public Health , 2010, DOI: 10.1186/1471-2458-10-135
Abstract: The dataset consists of 13,427 participants (6,725 men, 6,702 women) aged 25-74 years, recruited in the region of Augsburg in Germany through three independent cross-sectional representative surveys conducted in 1984/85, 1989/90, 1994/95, with a mortality follow up in 1998 and 2002. We use a parametric model for the survival function based on the Weibull distribution, in which the hazard function is described in terms of two parameters. We estimate these parameters with a maximum likelihood method that takes into account censoring and data truncation.The difference in LE between the lowest and the highest socio-economic group is estimated to be 3.79 years for men and 4.10 years for women. Diabetes mellitus reduces LE of men from the upper three income quartiles by 4.88 years, and LE of men belonging to the lowest income quartile by 7.97 years. For women, the corresponding figures are 5.79 and 5.72 years. Myocardial infarction reduces LE of men and women from the upper three income quartiles by 3.65 and 3.75 years, respectively, and LE of men and women belonging to the lowest income quartile by 5.11 and 10.95 years, respectively.This study shows that in Germany the differences in LE by socio-economic status are comparable to those found in other European countries, and that these differences seem to increase when diabetes mellitus or myocardial infarction is present. The statistical method used allows estimates of LE with relatively small datasets.Life expectancy (LE) is an estimate of the average number of years that a person can expect to live. It can be defined both at birth and at any later age. It reflects the mortality rates of a population as a function of age for the year for which it is calculated. As such, it is only dependent on the observed average age-specific death rates and it should not be viewed as a reflection of future mortality rates [1].From a public health perspective, LE at birth represents a fundamental measure of a population's state of gener
No connection between the level of exposition to statins in the population and the incidence/mortality of acute myocardial infarction: An ecological study based on Sweden's municipalities
Staffan Nilsson, Sigvard M?lstad, Catarina Karlberg, Jan-Erik Karlsson, Lars-G?ran Persson
Journal of Negative Results in BioMedicine , 2011, DOI: 10.1186/1477-5751-10-6
Abstract: The utilisation rate of statins increased almost three times for both men and women between 1998 and 2002. During 1998-2000 the incidence of AMI decreased clearly for men but only slightly for women. Mortality decreased from 1998 to 2002. The change in statin utilisation from 1998 to 2000 showed no correlation to the change in AMI mortality from 2000 to 2002. Statin utilisation and AMI- incidence or mortality showed no correlations when adjusting for socio-economic deprivation, antidiabetic drugs and geographic coordinates.Despite a widespread and increasing utilisation of statins, no correlation to the incidence or mortality of AMI could be detected. Other factors than increased statin treatment should be analysed especially when discussing the allocation of public resources.The premature mortality of cardiovascular disease has been declining the last decades in Sweden as well as in many other countries. This is true regarding acute myocardial infarction (AMI) as well, according to nation wide Swedish statistics of AMI covering the period from 1987 to present [1]. On a population basis, a previous study reported a possible negative correlation between the utilisation of lipid lowering drugs and death in ischemic heart disease 1989 - 1993 in Swedish municipalities [2].During recent years, the statin utilisation has continued to increase and reliable AMI incidence data on a municipality level has become available [3]. Randomised controlled trials have shown unequivocal benefits of statin treatment [4-6]. A detectable relation between statin utilisation and AMI incidence/mortality on a population basis should be of great interest for decisions about allocation of preventive resources.The aim of this study was to evaluate if there exists an ecological correlation between AMI mortality/incidence and statin utilisation for men and women in different age groups in Sweden's municipalities.The study included 289 of 290 Swedish municipalities. One municipality was excluded d
The Professional Medical Journal , 2011,
Abstract: Thrombolytic therapy for Acute Myocardial Infarction has been one of the most potent treatment ever developed for conditionthat kill more patients worldwide than any other. Objective: To evaluate the benefit and efficacy or observational studies of streptokinase therapy on ST-segment elevation resolution in different types of myocardial infarction that focus especially on the younger age group less than forty years. Study design: To observe the streptokinase therapy, in ST-segment elevation resolution, in age less than 40 years and in different types of myocardial infarction. Place & duration of study: The study was conducted at national institute of cardiovascular diseases (NICVD) of Pakistan, Karachi. Subject and Methods: All patients fulfilling the inclusion criteria for thrombolytic therapy were included. Baseline ECG recorded before streptokinase infusion and repeated at completion of infusion i.e. 90 minutes, day 1 and day 2. Results: Streptokinase therapy on blood pressure, CKMB, and ST-segment resolution at 90 minutes, day 1, and Day2 in less than 40-year of age patient. The mean systolicblood pressure was 124+ 3.32 and 112+3.00 pre and post SK therapy reflecting a percentage decrease of 6.67 and highly significant(P<0.001). The Diastolic blood pressure was decrease to 6.25% with a mean value of 76.80+ 2.70 and 72+1.91 before and after theStreptokinase therapy’s, segment resolution at 90 minutes was decreased to 52.01 percent from the baseline and continued to decrease at Day-1 and Day-2 with a percentage reduction of 70.65 and 83.69 % respectively. The P values were highly significant (P<0.001). Conclusions: Thrombolysis improves survival when given within 12 hours of the onset of symptoms. The magnitude of benefit is greatest when reperfusion is established early. Age itself should not be considered a contraindication for fibronolysis
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