The impact of changes in leisure time physical activity on changes in cardiovascular risk factors: results from The Finnmark 3 Study and SAMINOR 1, 1987-2003.

OBJECTIVE: The aim of this study was to examine the associations between changes in leisure time physical activity and changes in cardiovascular risk factors over 16 years and whether they differ between two ethnic groups in Norway. METHODS: Data were extracted from two population-based studies. Altogether, 3671 men and women participated in both surveys, and 30% reported being of Sami ethnicity. Leisure time physical activity was self-reported, and cardiovascular risk factors were measured. ANCOVA analysis was used to examine associations between changes in physical activity and changes in cardiovascular risk factors. RESULTS: After adjustment for age, sex, smoking, ethnicity and respective baseline values, favourable changes in body mass index (BMI) and levels of triglycerides were most pronounced in those who were active in both surveys (p < 0.05) whereas the opposite was the situation for cholesterol levels (p = 0.003). Changes in systolic blood pressure, diastolic blood pressure and resting heart rate were not significantly associated with change in physical activity. Ethnicity did not influence the associations between physical activity and cardiovascular risk factors. CONCLUSION: Traditional cardiovascular risk factors were to a small extent associated with change in leisure time physical activity. Persistent physical activity was associated with beneficial changes in BMI and triglycerides.

Trends in rates, patient selection and prognosis of coronary revascularisations in Finland between 1994 and 2013: the CVDR.

AIMS: The aim of the study was to investigate the 20-year trends in rates, patient selection and prognosis of coronary revascularisations in Finland. METHODS AND RESULTS: We identified patients from nationwide registers who had undergone first-ever percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) between 1994 and 2013. We examined changes in procedure rates, patient characteristics and estimated hazard ratios (HR) and 95% confidence intervals for cardiovascular events during this period. Between 1994 and 2013, 85,482 PCIs and 74,338 CABGs were performed. During this period, PCI rates more than quadrupled while CABG rates declined by two thirds. Between 1994-1998 and 2009-2013, the proportion of urgent procedures and mean patient age increased while the proportion of women remained stable. Although unadjusted mortality rose, the multivariable-adjusted HRs for 28-day mortality (PCI: 0.62 [0.49-0.79]; CABG: 0.62 [0.54-0.72]) and five-year incidence of cardiovascular death (PCI: 0.72 [0.66-0.80]; CABG: 0.77 [0.72-0.83]), myocardial infarction (PCI: 0.47 [0.44-0.50]; CABG: 0.31 [0.29-0.32]) and stroke (PCI: 0.37 [0.34-0.40]; CABG: 0.36 [0.33-0.38]) were lower in the last five-year period than in the period 1994-1998. CONCLUSIONS: Although revascularisation patients are older than before, post-procedural prognosis has improved drastically in recent years. Understanding the changing characteristics and prognosis of these patients is important for the interpretation of previous and future studies.

Healthy lifestyle status, antihypertensive treatment and the risk of heart failure among Finnish men and women.

OBJECTIVE: To compare the association between antihypertensive drug treatment and heart failure (HF) risk with the association between engaging in a healthy lifestyle and HF risk. METHODS: We prospectively investigated the single and joint associations of lifestyle factors and awareness, treatment, blood pressure control status with HF risk among 38 075 Finns, who were 25-74 years old and free of HF at baseline. RESULTS: During a median follow-up of 14.1 years, 638 men and 445 women developed HF. Engaging in a healthy lifestyle was associated with an decreased risk of HF. Compared with normotensive people, hypertensive patients with and without antihypertensive treatment had a higher risk of HF. Hypertensive patients who used antihypertensive drugs but did not engage in a healthy lifestyle had a significantly higher risk of HF [HR 1.75; 95% confidence interval (CI) 1.39-2.21] than hypertensive patients who did not use antihypertensive drugs but engaged in a healthy lifestyle. In addition, compared with hypertensive patients who used antihypertensive drugs and engaged in a healthy lifestyle, hypertensive patients who did not use antihypertensive drug or engage in a healthy lifestyle had a significantly higher risk of HF (HR 1.55; 95% CI 1.24-1.95). CONCLUSION: The present study demonstrates that HF risk was lower in hypertensive patients who engaged in a healthy lifestyle but higher in hypertensive people using antihypertensive drug treatment.

The validity of heart failure diagnoses obtained from administrative registers.

BACKGROUND: Population-based administrative registers could be used for identifying heart failure (HF) cases. However, the validity of the classification obtained from administrative registers is not known. DESIGN: The validity of HF diagnoses obtained by record linkage of administrative databases in Finland was assessed against classification by three independent physicians. METHODS: Data from the nationwide registers in Finland - the Hospital Discharge Register, Causes of Death Register, Drug Reimbursement Register, and pharmacy prescription data - were linked with the FINRISK 1997 survey data. Cases with hospitalizations before the survey date with HF as one of the discharge diagnoses, cases with special reimbursement for HF drugs before the survey date and cases with the use of furosemide before the survey date were classified as HF in the registers. All these cases, cases with baseline brain natriuretic peptide > 100 pg/ml, and cases with use of digoxin were independently assessed by two physicians as HF/no HF. Discrepant cases were solved by a third physician. This classification was considered as the gold standard, against which the registers were assessed. RESULTS: The specificity of the registers was 99.7% (95% CI 99.5-99.8%), positive predictive value 85.9% (95% CI 79.7-90.5%), negative predictive value 97.9% (95% CI 97.6-98.2%), and sensitivity 48.5% (95% CI 42.9-54.2%). CONCLUSIONS: Classification obtained from administrative registers has high specificity and can be used in follow-up studies with HF as an end point. Sensitivity is modest and administrative data should be used with caution for surveillance.

Serum γ-glutamyltransferase and the risk of heart failure in men and women in Finland.

OBJECTIVES: To evaluate the association of serum γ-glutamyltransferase (GGT) levels with heart failure (HF) risk in the Finnish population. DESIGN: Prospective population-based cohort study. SETTING: The present study, which is a part of FINRISK study, was carried out in Finland. Subject study cohorts included 18 353 Finnish men and 19 726 women who were 25-74 years of age and free of HF at baseline. Main outcome measures HF (636 men and 445 women) during a mean follow-up of 14.5 years. RESULTS: Baseline measurement of different levels of serum GGT was used to predict incident HF. The multivariable-adjusted (age, sex, study area, study year, smoking, education, alcohol consumption, physical activity, valvular heart disease, body mass index (BMI), systolic blood pressure, total cholesterol at baseline, myocardial infarction and diabetes at baseline and during follow-up) HRs of HF at five GGT groups (using the 25th, 50th, 75th and 90th percentiles) were 1.00, 1.16 (95% CI: 0.97 to 1.38), 1.20 (1.00 to 1.45), 1.29 (1.04 to 1.60) and 1.82 (1.45 to 2.29) (P(trend)<0.001). Stratification by smoking status, alcohol consumption and BMI gave similar results, while stronger association was observed among subjects aged <60 years (P(trend)=0.001) compared with subjects 60+ years of age (P(trend)=0.173). CONCLUSIONS: Moderate to high levels of serum GGT (from the 50th to the 90th percentiles) were significantly associated with incident HF in men and women in Finland, and the predictive power was stronger in subjects aged <60 years.

Lifestyle factors in relation to heart failure among Finnish men and women.

BACKGROUND: The role of lifestyle factors in explaining the risk of heart failure (HF) is not properly established. METHODS AND RESULTS: The national population-based study included 18 346 Finnish men and 19 729 women who were 25 to 74 years of age and free of HF at baseline. Multivariable Cox proportional hazards regression models was used to examine the association between lifestyle factors (smoking, body mass index [BMI], physical activity, vegetable consumption, fruit consumption, and alcohol consumption) and HF risk. During a median follow-up of 14.1 years (interquartile range, 5.9 to 20.9 years), 638 men and 445 women developed HF. Fruit consumption and alcohol consumption were dropped out of the analyses because no significant associations with the risk of HF were found. When 4 modifiable lifestyle factors (smoking, BMI, physical activity, and vegetable intake) were included in the analysis, the multivariable-adjusted (age, education, systolic blood pressure, total cholesterol, and histories of myocardial infarction, valvular heart disease, diabetes and using antihypertensive drugs) hazard ratios (HRs) of HF associated with engaging in 0, 1, 2, 3, and 4 healthy lifestyle factors were 1.00, 0.69 (95% confidence interval [CI], 0.54 to 0.87), 0.45 (95% CI, 0.35 to 0.58), 0.34 (95% CI, 0.25 to 0.46), and 0.31 (95% CI, 0.17 to 0.56) (P<0.001 for trend) for men, and 1.00, 0.53 (95% CI, 0.33 to 0.85), 0.42 (95% CI, 0.26 to 0.67), 0.24 (95% CI, 0.14 to 0.39), and 0.19 (95% CI, 0.09 to 0.40) (P<0.001 for trend) for women, respectively. CONCLUSIONS: The present study demonstrates an inverse association between healthy lifestyle patterns and the risk of HF in Finnish men and women.

World Health Organization definition of myocardial infarction: 2008-09 revision.

BACKGROUND: WHO has played a leading role in the formulation and promulgation of standard criteria for the diagnosis of coronary heart disease and myocardial infarction since early 1970s. METHODS: The revised definition takes into consideration the following: well-resourced settings can use the ESC/ACC/AHA/WHF definition, which has new biomarkers as a compulsory feature; in resource-constrained settings, a typical biomarker pattern cannot be made a compulsory feature as the necessary assays may not be available; the definition must also have provision for diagnosing non-fatal events with incomplete information on cardiac biomarkers and the ECG; to facilitate epidemiologic monitoring definition must recognize fatal events with incomplete or no information on cardiac biomarkers and/or ECG and/or autopsy and/or coronary angiography. RESULTS: Category A definition is the same as ESC/ACC/AHA/WHF definition of MI, and can be applied to settings with no resource constraints. Category B definition of MI is to be applied whenever there is incomplete information on cardiac bio-markers together with symptoms of ischaemia and the development of unequivocal pathological Q waves. Category C definition (probable MI) is to be applied when individuals with MI may not satisfy Category A or B definitions because of delayed access to medical services and/or unavailability of electrocardiography and/or laboratory assay of cardiac biomarkers. In these situations, the term probable MI should be used when there is either ECG changes suggestive of MI or incomplete information on cardiac biomarkers in a person with symptoms of ischaemia with no evidence of a non-coronary reason. CONCLUSIONS: This article presents the 2008-09 revision of the World Health Organization (WHO) definition of myocardial infarction (MI) developed at a WHO expert consultation.

Coffee consumption and the risk of heart failure in Finnish men and women.

OBJECTIVES: To evaluate the association of coffee consumption with the risk of heart failure (HF) in the Finnish population. DESIGN: Prospective population-based cohort study. SETTING: This study, which is a part of FINRISK study, was carried out in Finland. SUBJECTS: Study cohorts included 59,490 Finnish participants aged 25-74 years who were free of HF at baseline. MAIN OUTCOME MEASURES: HF (2020 men and 1807 women) during a mean follow-up of 19.2 years. RESULTS: Multivariable-adjusted (age, study year, body mass index, smoking, education, alcohol consumption, tea consumption, physical activity, systolic blood pressure, history of myocardial infarction, history of valvular heart disease, history of diabetes and total cholesterol) HRs (with 95% CI) of HF associated with the amount of coffee consumption daily (0, 1-2, 3-4, 5-6, 7-9 and ≥10 cups) were 1.00, 0.91 (0.71 to 1.16), 0.88 (0.70 to 1.10), 0.91 (0.73 to 1.13), 0.96 (0.76 to 1.22) and 1.02 (0.80 to 1.30) (p(trend) = 0.485) for men and 1.00, 0.73 (0.56 to 0.97), 0.77 (0.60 to 0.98), 0.68 (0.53 to 0.88), 0.80 (0.61 to 1.04) and 0.88 (0.65 to 1.19) (p(trend) = 0.007) for women, respectively. Stratification by age, smoking status, alcohol consumption, history of type 2 diabetes mellitus and body mass index gave similar results. CONCLUSION: Coffee consumption does not increase the risk of HF in Finnish men and women. In women, an inverse association was observed between low to moderate coffee consumption and the risk of HF.

Occupational, commuting, and leisure-time physical activity in relation to heart failure among finnish men and women.

OBJECTIVES: The purpose of this study was to examine the association of different levels of occupational, commuting, and leisure-time physical activity and heart failure (HF) risk. BACKGROUND: The role of different types of physical activity in explaining the risk of HF is not properly established. METHODS: Study cohorts included 28,334 Finnish men and 29,874 women who were 25 to 74 years of age and free of HF at baseline. Baseline measurement of different types of physical activity was used to predict incident HF. RESULTS: During a mean follow-up of 18.4 years, HF developed in 1,868 men and 1,640 women. The multivariate adjusted (age; smoking; education; alcohol consumption; body mass index; systolic blood pressure; total cholesterol; history of myocardial infarction, valvular heart disease, diabetes, lung disease, and use of antihypertensive drugs; and other types of physical activity) hazard ratios of HF associated with light, moderate, and active occupational activity were 1.00, 0.90, and 0.83 (p = 0.005, for trend) for men and 1.00, 0.80, and 0.92 (p = 0.007, for trend) for women, respectively. The multivariate adjusted hazard ratios of HF associated with low, moderate, and high leisure-time physical activity were 1.00, 0.83, and 0.65 (p < 0.001, for trend) for men and 1.00, 0.84, and 0.75 (p < 0.001, for trend) for women, respectively. Active commuting had a significant inverse association with HF risk in women, but not in men, before adjustment for occupational and leisure-time physical activity. The joint effects of any 2 types of physical activity on HF risk were even greater. CONCLUSIONS: Moderate and high levels of occupational or leisure-time physical activity are associated with a reduced risk of HF.

Hyperglycemia and incidence of ischemic and hemorrhagic stroke-comparison between fasting and 2-hour glucose criteria.

BACKGROUND AND PURPOSE: We examined the impact of hyperglycemia on ischemic and hemorrhagic stroke incidence comparing criteria based on fasting plasma glucose (FPG) and 2-hour plasma glucose (2-hour PG). METHODS: Data from 9 European cohorts comprising 18 360 individuals between 25 to 90 years of age were collaboratively analyzed. The maximum length of follow-up varied between 4.9 to 36.8 years. Hazards ratios (95% confidence intervals) for stroke incidence were estimated using Cox-proportional hazards model adjusting for known risk factors. RESULTS: In individuals without a prior history of diabetes, the multivariate-adjusted hazards ratio for ischemic stroke corresponding to 1 SD increase in FPG was 1.12 (1.02 to 1.22) and in 2-hour PG 1.14 (1.05 to 1.24). Adding 2-hour PG to the model with FPG significantly improved the prediction of the model for the incidence of ischemic stroke (chi(2)=4.72, P=0.03), whereas FPG did not improve the 2-hour PG model prediction (chi(2)=0.25, P=0.62). A significantly increased hazard ratio was also observed for previously diagnosed diabetes (2.26 [1.51 to 3.38]) and for screen-detected diabetes defined by FPG (1.48 [1.08 to 2.02]) and 2-hour PG (1.60 [1.18 to 2.16]). None of the criteria predicted hemorrhagic stroke. CONCLUSIONS: Diabetes defined by either of the criteria predicted the future risk of ischemic stroke but not the hemorrhagic stroke. The prediction is stronger for elevated 2-hour PG than for FPG levels.

Prevalence estimation and follow-up of aortic regurgitation subjects in a Norwegian Sami population.

OBJECTIVES: To estimate the prevalence of aortic regurgitation (AR) in the Sami population and its association with ankylosing spondylitis and HLA-B27. DESIGN: A random sample from two Norwegian Sami communities was invited to participate in a health survey. Echocardiography was carried out for 84% of the 416 invited. Logistic regression analysis was used to estimate the odds ratios (OR). The AR persons entered a clinical follow-up programme. RESULTS: Altogether 28 subjects had AR. Weighted overall prevalence of AI was 8.8%. OR of AR for ankylosing spondylitis, age and HLA-B27 were 7.4 (95% CI: 1, 1-49, 0), 1.08 (95% CI, 1, 03-2, 14) and 1.8 (95% CI: 0, 6-5, 4), respectively. CONCLUSIONS: The prevalence of AR was 8.8% in the Sami populations in Northern Norway, which is comparable to that reported in other populations; however, data from other populations are sparse. AR was strongly associated with ankylosing spondylitis, but not with HLA-B27 antigen. The progress rate of AR seems to be low; no clinically significant hemodynamic changes were noted during the 14-to-17-year follow-up programme.

Diabetes worsens the outcome of acute ischemic stroke.

OBJECTIVE: To characterize acute stroke events in diabetic patients in a population-based stroke register and to determine the influence of diabetes on the outcome of acute stroke. METHODS: Four thousand three hundred and ninety patients were recorded in the FINMONICA and FINSTROKE registers after their first ischemic stroke from 1990 to 1998. We followed mortality and stroke outcome for up to 4 weeks after the onset of acute stroke. RESULTS: Of the 4390 patients who had had an ischemic stroke, 43.6% were male and 25.1% (1103) had diabetes. Their mean age was 72.4 (S.D. 12.0) years and this was similar in patients with and without diabetes (72.9 years versus 72.3 years, p=0.18). Subjects with diabetes were more likely to be hypertensive (55% versus 38%, p<0.001) and have a history of myocardial infarction (20% versus 16%, p<0.001) than the non-diabetic stroke patients. Mortality at 4 weeks from the onset was higher in diabetic than in non-diabetic patients (20.0% versus 16.9% p=0.020). At day 28 after the stroke attack, diabetic patients were more likely to be disabled when compared with non-diabetic subjects (43.3% versus 33.5%, p<0.001). Using logistic regression analysis, adjusted for age-group, sex, previous medical history (MI, AF or TIA), diabetes was found to be a significant predictor of disability after stroke (OR=1.51, 95% CI 1.27-1.81). CONCLUSIONS: Diabetes, which affected one-fourth of the ischemic stroke patients on our register, was associated with a higher risk of death and disability after the onset of stroke. Preventing diabetes in the elderly population improves the short-term prognosis of acute ischemic stroke.

The validity of the Finnish Hospital Discharge Register and Causes of Death Register data on coronary heart disease.

BACKGROUND AND DESIGN: The recent introduction of sensitive markers of myocardial injury is likely to affect the epidemiology of coronary heart disease (CHD). The American Heart Association together with other societies and research agencies have recently published a new definition on acute CHD to improve consistency in epidemiological and clinical studies (referred here as the '2003 definition'). METHODS: In this study we compare the data on CHD events in the Finnish National Hospital Discharge Register (HDR) and the Causes of Death Register (CDR) with the population-based myocardial infarction (MI) register, FINMONICA/FINAMI. The FINMONICA/FINAMI events were classified according to the 2003 definition. The relevant International Classification of Diseases (ICD) codes from the HDR and CDR were used. RESULTS: Using the 2003 definition as the reference, the overall sensitivity of the ICD codes for MI in the combined HDR and CDR was 83% and the positive predictive value (PPV) was 90%. When the ICD codes for unstable angina were added to the analyses, the sensitivity improved to 85% and the PPV declined to 83%. In the age group 35-74 the sensitivity of the MI codes improved over time, in men from 64% in 1988-1992 to 81% in 1998-2002, and in women from 61 to 78%, respectively. The oldest age group, 75 years or older, had sensitivity and PPV values comparable to those of the younger. CONCLUSION: Diagnoses of fatal and non-fatal CHD events in the Finnish HDR and Causes of Death register were reasonably valid indicators for hard CHD events when compared with the FINMONICA/FINAMI register data.

Declining incidence and mortality of stroke in persons aged > or = 75 years in Finland; the FINSTROKE study.

BACKGROUND: The average life expectancy of a person aged 75 in Finland is approximately 10 years. A substantial threat to the quality of life during these years is stroke, which is common among the elderly, may hamper independent living and places a substantial burden on health care resources. The aim of the present study was to analyse the trends in incidence, mortality and prognosis of acute stroke events in persons aged > or = 75 years in Finland. DESIGN: A population-based stroke register study. METHODS: The FINSTROKE register recorded all stroke events in persons aged > or = 75 years (n=5493) among inhabitants of the town of Turku from 1982 to 1992 and again from 1996 to 1998, and in the Kuopio area from 1990 to 1997. RESULTS: At the end of the study period, the age group > or = 75 years constituted 3.8% of the population of study areas among men and 8.7% among women. This population segment contributed 35% of strokes among men and 66% among women. Of all strokes in this age group, 73% occurred among women. Data suggested that the mortality and incidence of acute stroke events were declining, but the 28-day case fatality did not change. At day 28 after the onset of stroke, only 26% of men and 19% of women had recovered well enough to be capable of independent living. CONCLUSIONS: Stroke mortality among the elderly is declining in Finland, which is mainly due to the decline in the incidence of stroke events.

Return to work after first myocardial infarction in 1991-1996 in Finland.

BACKGROUND: A substantial number of myocardial infarctions (MI) occur at working age. It is, however, insufficiently well known how many of these patients return to work after their MI. METHODS: Sources of information were the Hospital Discharge Register, the Causes of Death Register and the registers for social security benefits. Availability for the labour market was used as the return to work criterion. Altogether 10,244 persons (8,733 men, 1,511 women) aged 35-59 years had their first MI or coronary death during 1991-1994 in Finland. Persons who survived for 28 days and were not on pension at the time of MI were included in a two-year follow-up. RESULTS: Twenty-nine per cent of patients were already pensioned at the time of their first MI. Of the patients not pensioned at the time of their MI, 4,929 were alive two years after the event. Of them, 38% of men and 40% of women received disability pension, 3% of both genders were on sick leave and 1% of both genders were on unemployment pension. The remainder, 58% of men and 56% of women, did not receive any of these benefits, thus, being available to the labour force. CONCLUSIONS: Nearly one-third of persons having their first MI at working age were already out of the labour force at the time of their MI. Of those who were not pensioned and who survived the event, slightly more than half were available to the labour market two years later.

Socioeconomic inequities in invasive cardiac procedures after first myocardial infarction in Finland in 1995.

OBJECTIVE: We examined socioeconomic disparities in coronary procedure rates after first events among hospitalized myocardial infarction (MI) patients. STUDY DESIGN AND SETTING: Information on MI patients in 1995 in Finland was obtained from the Finnish Cardiovascular Disease Register Project. Data on comorbidity, invasive treatments, hospitalizations, mortality, and socioeconomic status were obtained by linking data from the Finnish Hospital Discharge Register, cause of death register, population census, and the health insurance register using personal identity numbers. RESULTS: In 1995, 5172 patients aged 40 to 74 years were hospitalized for first MI. This corresponds to age-standardized event rates of 354/100,000 for men and 152/100,000 for women. Within 2 years, 33% of men and 21% of women underwent an invasive coronary procedure. Men in the lowest income third underwent 25% (95% confidence interval [CI] 12-36) fewer procedures than men in the highest third. Among women, the corresponding difference was 43% (95% CI 24-57). These disparities persisted throughout the 2-year follow-up, and they were not reduced by adjustment for comorbidity or hospital district. CONCLUSION: Socioeconomic disparities were observed in receipt of invasive cardiac procedures. More attention should be paid to equitable distribution of scarce health care resources.

Continuous 15-year decrease in incidence and mortality of stroke in Finland: the FINSTROKE study.

BACKGROUND AND PURPOSE: The purpose of this study was to analyze the incidence and mortality trends in stroke events among persons 25 to 74 years of age in Finland during 1983 to 1997. METHODS: The population-based FINSTROKE register recorded 5650 new strokes among persons 25 to 74 years of age in 2 geographical areas of Finland: 2770 in the Kuopio area (east central Finland) and 2880 in Turku (southwestern Finland). Of these, 3065 were men and 2585 were women. RESULTS: The rates of acute stroke events fell during the whole study period in both men and women. In both FINSTROKE areas combined, the average annual decline in the age-standardized incidence of first stroke events was 2.0% (95% confidence interval [CI], -2.8 to -1.2; P<0.001) among men and 1.7% (95% CI, -2.6 to -0.8; P<0.001) among women. The decline in the incidence of ischemic stroke was even steeper, 2.9%/y (95% CI, -4.9 to -1.1; P<0.001) among men and 3.1%/y (95% CI, -5.0 to -1.1; P<0.001) among women, whereas the incidence of intracerebral hemorrhage and subarachnoid hemorrhage did not change. Mortality from all stroke events declined in the FINSTROKE areas by 3.7%/y (95% CI, -5.3 to -2.0; P<0.001) among men and by 4.1%/y (95% CI, -5.9 to -2.4; P<0.001) among women. The 28-day case fatality of all stroke events also tended to decline, but the decline was of borderline statistical significance only (P=0.07 among men, P=0.05 among women). CONCLUSIONS: Incidence and mortality of stroke events declined significantly in these 2 register areas in Finland during the 15-year period of 1983 to 1997.

Are changes in mortality from stroke caused by changes in stroke event rates or case fatality? Results from the WHO MONICA Project.

BACKGROUND AND PURPOSE: Mortality from stroke has been declining over recent decades in most countries, except in Eastern Europe. In this analysis, based on the World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease (WHO MONICA) Project, we explored to what extent these trends are due to changes in stroke event rate and to changes in case fatality. METHODS: The WHO MONICA Project collected standardized data from 14 populations in 9 countries. All acute strokes occurring in men and women 35 to 64 years of age were included. Registration was carried out between 1982 and 1995, resulting in time spans from 7 to 13 years. Trends in event rates and case fatality were calculated as average annual percentage change. RESULTS: Up to 6-fold differences were observed in stroke mortality. Mortality declined in 8 of 14 populations in men and in 10 of 14 populations in women. An increase in mortality was observed in Eastern Europe. In the populations with a declining trend, about two thirds of the change could be attributed to a decline in case fatality. In populations with increasing mortality, the rise was explained by an increase in case fatality. CONCLUSIONS: In most populations, changes in stroke mortality, whether declining or increasing, were principally attributable to changes in case fatality rather than changes in event rates. Whether this was due to changes in the management of stroke or changes in disease severity cannot be established on the basis of these results.

Trends in stroke and coronary heart disease in the WHO MONICA Project.

BACKGROUND AND PURPOSE: Coronary heart disease (CHD) and stroke are leading causes of death and disability. Because they share major common risk factors, it would be expected that trends in mortality and incidence of these 2 major cardiovascular diseases would be similar. METHODS: Data from the World Health Organization (WHO) Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Project were used to compare 10-year trends in mortality, event rates, and case fatality from both CHD and stroke. Fifteen populations in the WHO MONICA Project provided data on both CHD (60 763 events) and stroke (10 442 events) in men and women aged 35 to 64 years (23.4 million person-years of observation in total). RESULTS: Trends for the 2 cardiovascular diseases varied within and between populations, and when data from all populations were combined, trends in CHD and stroke mortality differed in men (P=0.001) but not in women, whereas trends in event rates differed significantly in both men and women (P<0.001 and P=0.011, respectively). The differences in trends for CHD and stroke case fatality were not statistically significant in either men or women. In sensitivity analyses, differences in trends in event rates remained statistically significant in men (P<0.001) but not in women. CONCLUSIONS: Trends for CHD and stroke mortality rates, event rates, and case fatality differ substantially between and within the study populations.

Do trends in population levels of blood pressure and other cardiovascular risk factors explain trends in stroke event rates? Comparisons of 15 populations in 9 countries within the WHO MONICA Stroke Project. World Health Organization Monitoring of Trends and Determinants in Cardiovascular Disease.

BACKGROUND AND PURPOSE: Previous studies have indicated a reasonably strong relationship between secular trends in classic cardiovascular risk factors and stroke incidence within single populations. To what extent variations in stroke trends between populations can be attributed to differences in classic cardiovascular risk factor trends is unknown. METHODS: In the World Health Organization Monitoring of Trends and Determinants in Cardiovascular Disease (WHO MONICA) Project, repeated population surveys of cardiovascular risk factors and continuous monitoring of stroke events have been conducted in 35- to 64-year-old people over a 7- to 13-year period in 15 populations in 9 countries. Stroke trends were compared with trends in individual risk factors and their combinations. A 3- to 4-year time lag between changes in risk factors and change in stroke rates was considered. RESULTS: Population-level trends in systolic blood pressure showed a strong association with stroke event trends in women, but there was no association in men. In women, 38% of the variation in stroke event trends was explained by changes in systolic blood pressure when the 3- to 4-year time lag was taken into account. Combining trends in systolic blood pressure, daily cigarette smoking, serum cholesterol, and body mass index into a risk score explained only a small fraction of the variation in stroke event trends. CONCLUSIONS: In this study, it appears that variations in stroke trends between populations can be explained only in part by changes in classic cardiovascular risk factors. The associations between risk factor trends and stroke trends are stronger for women than for men.