Thyroid-stimulating hormone and risk of sudden cardiac death, total mortality and cardiovascular morbidity.

BACKGROUND: Previous data on the association of thyroid function with total mortality, cardiovascular disease (CVD) outcomes and sudden cardiac death (SCD) are conflicting or limited. We investigated associations of thyroid-stimulating hormone (TSH) with these outcomes in a nationwide population-based prospective cohort study. METHODS: We examined 5211 participants representative of the Finnish population aged ≥30 years in 2000-2001 and followed them for a median of 13.2 years. Using Cox proportional hazards regression models adjusted for baseline age, gender, smoking, diabetes, systolic blood pressure and total and high-density lipoprotein cholesterol, we assessed the associations of continuous baseline TSH and TSH categories (low [<0.4 mU/L], reference range [0.4-3.4 mU/L] and high [>3.4 mU/L]) with incident total mortality, SCD, coronary heart disease events, stroke, CVD, major adverse cardiac events and atrial fibrillation. RESULTS: High TSH at baseline was related to a greater risk of total mortality (HR 1.34, 95% CI 1.02-1.76) and SCD (HR 2.28, 95% CI 1.13-4.60) compared with TSH within the reference range. High TSH was not associated with the other outcomes (P ≥ .51), whereas low TSH was not associated with any of the outcomes (P ≥ .09). TSH at baseline over the full range did not have a linear relation with any of the outcomes (P ≥ .17). TSH showed a U-shaped association with total mortality after a restricted cubic spline transformation (P = .01). CONCLUSIONS: Thyroid function abnormalities could be linked with higher risks of total mortality and SCD. Large-scale randomized studies are needed for evidence-based recommendations regarding treatment of mild thyroid failure.

Association of thyroid-stimulating hormone with lipid concentrations: an 11-year longitudinal study.

BACKGROUND: Scant data exist on the longitudinal association between thyroid function and lipid concentrations. We investigated associations of TSH and lipid concentrations cross-sectionally and longitudinally in a nationwide population sample. METHODS: A total of 5205 randomly sampled participants representative of Finns aged ≥30 years were examined in 2000-2001 and included in cross-sectional analyses. A total of 2486 were re-examined 11 years later and included in longitudinal analyses. With linear regression models adjusted for age, gender, smoking and body mass index, we assessed the associations of baseline TSH and TSH categories (low, reference range and high) with total, high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol; apolipoprotein A1 and B; and triglycerides at baseline and follow-up. RESULTS: At baseline, higher TSH associated with higher total cholesterol (ß = 0·025, standard error [SE] = 0·007, P < 0·001), LDL cholesterol (ß = 0·020, SE = 0·007, P = 0·002), apolipoprotein B (ß = 0·006, SE = 0·002, P < 0·001) and log triglycerides (ß = 0·008, SE = 0·003, P = 0·004), but not with other lipid outcomes. Higher baseline TSH associated with higher total cholesterol (ß = 0·056, SE = 0·026, P = 0·033), LDL cholesterol (ß = 0·057, SE = 0·023, P = 0·015) and apolipoprotein B (ß = 0·012, SE = 0·006, P = 0·028) at follow-up in women, but not with any lipid outcomes in men. Participants with high TSH at baseline had a 0·22 mmol/l (95% confidence interval 0·02-0·41 mmol/l) higher LDL cholesterol at follow-up (P = 0·028) than participants with TSH in the reference range (0·4-3·4 mU/l). However, exclusion of participants with high-risk baseline lipid values rendered these positive longitudinal associations nonsignificant (P ≥ 0·098). CONCLUSIONS: We could confirm a modest association between higher TSH and an adverse lipid profile cross-sectionally but not indisputably longitudinally.

Incidence rates, correlates, and prognosis of electrocardiographic P-wave abnormalities - a nationwide population-based study.

BACKGROUND: Scant data exist on incidence rates, correlates, and prognosis of electrocardiographic P-wave abnormalities in the general population. METHODS: We recorded ECG and measured conventional cardiovascular risk factors in 5667 Finns who were followed up for incident atrial fibrillation (AF). We obtained repeat ECGs from 3089 individuals 11years later. RESULTS: The incidence rates of prolonged P-wave duration, abnormal P terminal force (PTF), left P-wave axis deviation, and right P-wave axis deviation were 16.0%, 7.4%, 3.4%, and 2.2%, respectively. Older age and higher BMI were associated with incident prolonged P-wave duration and abnormal PTF (P≤0.01). Higher blood pressure was associated with incident prolonged P-wave duration and right P-wave axis deviation (P≤0.01). During follow-up, only prolonged P-wave duration predicted AF (multivariable-adjusted hazard ratio, 1.38; P=0.001). CONCLUSIONS: Modifiable risk factors associate with P-wave abnormalities that are common and may represent intermediate steps of atrial cardiomyopathy on a pathway leading to AF.

Association between thyroid-stimulating hormone and blood pressure in adults: an 11-year longitudinal study.

BACKGROUND: The results of longitudinal studies on the association between thyroid function and blood pressure (BP) are divided. This study aimed to investigate this association in cross-sectional and longitudinal settings in a nationwide, random sample representative of the Finnish adult population aged 30 and over. METHODS: The study sample was randomly drawn from the population register. A total of 5655 participants were included in the baseline analyses and 3453 in the 11-year prospective analyses. The associations between baseline TSH and (i) BP and BP change over time; and (ii) prevalent and incident hypertension were assessed using linear and logistic models, adjusted for age, gender, smoking and body mass index. RESULTS: A positive association (ß ± standard error) was observed between TSH and diastolic (0·36 ± 0·12, P = 0·003) but not systolic BP (0·16 ± 0·21, P = 0·45) at baseline. TSH was negatively associated with 11-year BP change in men (systolic: -0·92 ± 0·41, P = 0·03; diastolic: -0·66 ± 0·26, P = 0·01) but not in women (P ≥ 0·09 for systolic and diastolic BP change). Participants in the highest TSH tertile within the TSH reference interval (0·4-3·4 mU/L), as compared with the lowest, had increased odds of prevalent (odds ratio 1·22, 95% confidence interval 1·05-1·43, P = 0·01) but not incident hypertension (odds ratio 0·93, 95% confidence interval 0·73-1·19, P = 0·58). CONCLUSIONS: A modest association was found between increasing TSH and prevalent but not incident hypertension. TSH was inversely associated with BP change in men in our study. These findings contest an independent role of thyroid function at normal to near-normal levels in the pathogenesis of hypertension.

Self-reported obstructive sleep apnea, simple snoring, and various markers of sleep-disordered breathing as predictors of cardiovascular risk.

PURPOSE: Our objective was to investigate whether self-reported obstructive sleep apnea (OSA), simple snoring, and various markers of sleep-disordered breathing (SDB) are associated with cardiovascular risk. METHODS: We examined a representative nationwide cohort of 5177 Finnish adults aged ≥30 years. The participants underwent measurement of traditional cardiovascular risk factors and answered SDB-related questions derived from the Basic Nordic Sleep Questionnaire, which were used to operationalize self-reported OSA. The primary end point was incidence of a cardiovascular event (cardiovascular mortality, non-fatal myocardial infarction, non-fatal stroke, hospitalization for heart failure, or coronary interventions). RESULTS: During a median follow-up of 11.2 years and 52,910 person-years of follow-up, 634 participants suffered a cardiovascular event. In multivariable-adjusted Cox models, self-reported OSA (hazard ratio [HR] 1.34; 95 % confidence interval [CI] 1.04-1.73; p = 0.03) was an independent predictor of cardiovascular events. Self-reported simple snoring by itself was not associated with future cardiovascular events (HR 0.88 versus non-snorers, 95 % CI 0.75-1.04, p = 0.15). However, among snorers (n = 3152), frequent breathing cessations (HR 2.19, 95 % CI 1.26-3.81, p = 0.006) and very loud and irregular snoring (HR 1.82, 95 % CI 1.31-2.54, p < 0.001) were associated with cardiovascular risk. CONCLUSIONS: Self-reported OSA and SDB-related snoring variables are associated with cardiovascular risk, whereas simple snoring is not. In clinical practice and in surveys, questions concerning only habitual snoring should be amended with questions focusing on respiratory pauses and snoring stertorousness, which can be used to estimate the risk of OSA and cardiovascular events.

Insulin resistance is associated with poorer verbal fluency performance in women.

AIMS/HYPOTHESIS: Type 2 diabetes is an independent risk factor for cognitive decline. Insulin resistance occurring during midlife may increase the risk of cognitive decline later in life. We hypothesised that insulin resistance is associated with poorer cognitive performance and that sex and APOE*E4 might modulate this association. METHODS: The association of insulin resistance and APOE*E4 genotype on cognitive function was evaluated in a nationwide Finnish population-based study (n = 5,935, mean age 52.5 years, range 30-97 years). HOMA-IR was used to measure insulin resistance. Cognitive function was tested by word-list learning, word-list delayed-recall, categorical verbal fluency and simple and visual-choice reaction-time tests. Linear regression analysis was used to determine the association between HOMA-IR and the results of the cognitive tests. RESULTS: Higher HOMA-IR was associated with poorer verbal fluency in women (p < 0.0001) but not in men (p = 0.56). Higher HOMA-IR was also associated with poorer verbal fluency in APOE*E4 -negative individuals (p = 0.0003), but not in APOE*E4 carriers (p = 0.28). Furthermore, higher HOMA-IR was associated with a slower simple reaction time in the whole study group (p = 0.02). CONCLUSIONS/INTERPRETATION: To our knowledge, this is the first comprehensive, population-based study, including both young and middle-aged adults, to report that female sex impacts the association of HOMA-IR with verbal fluency. Our study was cross-sectional, so causal effects of HOMA-IR on cognition could not be evaluated. However, our results suggest that HOMA-IR could be an early marker for an increased risk of cognitive decline in women.

Social, lifestyle and demographic inequalities in hypertension care.

AIMS: Recent nationwide in-depth analyses on inequalities in hypertension prevalence and care are scarce. This study assessed sociodemographic and lifestyle factors associated with the prevalence, awareness, treatment and control of hypertension in Finland. METHODS: A representative nationwide sample (participation rate 58%) of the Finnish adult population underwent a health examination and interview in 2011. After excluding participants with missing data, 4230 people were included in the analyses. Weighted regression modelling was used to explore the associations of sociodemographic and lifestyle factors with the prevalence, awareness, treatment and control of hypertension. RESULTS: The prevalence, awareness, treatment and control rates of hypertension (blood pressure ⩾140/90 mmHg or antihypertensive medication) in Finland were 47%, 57%, 51% and 48%, respectively. Older age, male sex, lower education, retirement, higher BMI, never-smoking and heavy alcohol use were associated with a higher prevalence of hypertension (p<0.05). In contrast, younger age, non-retirement, lower BMI, smoking and high physical activity were associated with lower awareness and treatment rates (p<0.05). In addition, male sex was associated with lower awareness rates (p<0.01). Hypertension control was better in younger participants (p<0.05). CONCLUSIONS: In addition to high prevalence and moderate treatment rates of hypertension, serious sociodemographic and lifestyle inequities in hypertension care exist in Finland. Hypertension is more prevalent in older people of lower socio-economic status with adverse lifestyles. However, hypertension is more often unrecognised and untreated among people with low risk of hypertension.

Risk stratification by self-measured home blood pressure across categories of conventional blood pressure: a participant-level meta-analysis.

BACKGROUND: The Global Burden of Diseases Study 2010 reported that hypertension is worldwide the leading risk factor for cardiovascular disease, causing 9.4 million deaths annually. We examined to what extent self-measurement of home blood pressure (HBP) refines risk stratification across increasing categories of conventional blood pressure (CBP). METHODS AND FINDINGS: This meta-analysis included 5,008 individuals randomly recruited from five populations (56.6% women; mean age, 57.1 y). All were not treated with antihypertensive drugs. In multivariable analyses, hazard ratios (HRs) associated with 10-mm Hg increases in systolic HBP were computed across CBP categories, using the following systolic/diastolic CBP thresholds (in mm Hg): optimal, <120/<80; normal, 120-129/80-84; high-normal, 130-139/85-89; mild hypertension, 140-159/90-99; and severe hypertension, ≥160/≥100. Over 8.3 y, 522 participants died, and 414, 225, and 194 had cardiovascular, cardiac, and cerebrovascular events, respectively. In participants with optimal or normal CBP, HRs for a composite cardiovascular end point associated with a 10-mm Hg higher systolic HBP were 1.28 (1.01-1.62) and 1.22 (1.00-1.49), respectively. At high-normal CBP and in mild hypertension, the HRs were 1.24 (1.03-1.49) and 1.20 (1.06-1.37), respectively, for all cardiovascular events and 1.33 (1.07-1.65) and 1.30 (1.09-1.56), respectively, for stroke. In severe hypertension, the HRs were not significant (p≥0.20). Among people with optimal, normal, and high-normal CBP, 67 (5.0%), 187 (18.4%), and 315 (30.3%), respectively, had masked hypertension (HBP≥130 mm Hg systolic or ≥85 mm Hg diastolic). Compared to true optimal CBP, masked hypertension was associated with a 2.3-fold (1.5-3.5) higher cardiovascular risk. A limitation was few data from low- and middle-income countries. CONCLUSIONS: HBP substantially refines risk stratification at CBP levels assumed to carry no or only mildly increased risk, in particular in the presence of masked hypertension. Randomized trials could help determine the best use of CBP vs. HBP in guiding BP management. Our study identified a novel indication for HBP, which, in view of its low cost and the increased availability of electronic communication, might be globally applicable, even in remote areas or in low-resource settings.

Thyroid-stimulating hormone reference range and factors affecting it in a nationwide random sample.

BACKGROUND: Previous studies with mainly selected populations have proposed contradicting reference ranges for thyroid-stimulating hormone (TSH) and have disagreed on how screening, age and gender affect them. This study aimed to determine a TSH reference range on the Abbott Architect ci8200 integrated system in a large, nationwide, stratified random sample. To our knowledge this is the only study apart from the NHANES III that has addressed this issue in a similar nationwide setting. The effects of age, gender, thyroid peroxidase antibody (TPOAb)-positivity and medications on TSH reference range were also assessed. METHODS: TSH was measured from 6247 participants randomly drawn from the population register to represent the Finnish adult population. TSH reference ranges were established of a thyroid-healthy population and its subpopulations with increasing and cumulative rigour of screening: screening for overt thyroid disease (thyroid-healthy population, n=5709); screening for TPOAb-positivity (risk factor-free subpopulation, n=4586); and screening for use of any medications (reference subpopulation, n=1849). RESULTS: The TSH reference ranges of the thyroid-healthy population, and the risk factor-free and reference subpopulations were 0.4-4.4, 0.4-3.7 and 0.4-3.4 mU/L (2.5th-97.5th percentiles), respectively. Although the differences in TSH between subgroups for age (p=0.002) and gender (p=0.005) reached statistical significance, the TSH distribution curves of the subgroups were practically superimposed. CONCLUSIONS: We propose 0.4-3.4 mU/L as a TSH reference range for adults for this platform, which is lower than those presently used in most laboratories. Our findings suggest that intensive screening for thyroid risk factors, especially for TPOAb-positivity, decreases the TSH upper reference limit.

Risk assessment of echocardiographic left ventricular hypertrophy with electrocardiography, body mass index and blood pressure.

AIMS: Electrocardiography (ECG) has a high specificity but unfortunately low sensitivity to detect anatomic left ventricular hypertrophy (LVH). In this study, ECG amplitude and products were examined as continuous variables together with blood pressure (BP) and body mass index (BMI) to find out a simple method to predict echocardiographic (ECHO)-LVH. An age- and gender-stratified population-based sample of men (n = 121) and women (n = 135) aged 35-64 years enriched with newly diagnosed untreated hypertensive men (n = 138) and women (n = 97) in the Turku area in south-western Finland was studied. MAJOR FINDINGS: Cornell voltage (or Cornell product), systolic BP (SBP) and BMI were all independent determinants of ECHO-LVH and left ventricular mass (LVM) indexed by height (LVMI). According to multivariate regression analyses with Cornell voltage (Cornell product), BMI and BP as explanatory variables, the three determinants explained 46-48% (47-49%) of the variation in LVMI among men and 50-54% (52-57%) among women. Score tables were constructed to estimate the probability of LVH. The estimated probability of ECHO-LVH increased in men gradually from 0% to 81% (79%) along with increased Cornell voltage (Cornell product) tertiles and in women respectively from 0% to 95% (97%). CONCLUSION: The sensitivity of ECG to detect ECHO-LVH can be markedly enhanced by using ECG amplitudes and products as continuous variables. The risk tables using Cornell voltages or products, BMI and SBP enable an easy and effective way to estimate the probability of ECHO-LVH.

Mortality and Cardiovascular End Points In Relation to the Aortic Pulse Wave Components: An Individual-Participant Meta-Analysis.

BACKGROUND: Wave separation analysis enables individualized evaluation of the aortic pulse wave components. Previous studies focused on the pressure height with overall positive but differing results. In the present analysis, we assessed the associations of the pressure of forward and backward (Pfor and Pref) pulse waves with prospective cardiovascular end points, with extended analysis for time to pressure peak (Tfor and Tref). METHODS: Participants in 3 IDCARS (International Database of Central Arterial Properties for Risk Stratification) cohorts (Argentina, Belgium, and Finland) aged ≥20 years with valid pulse wave analysis and follow-up data were included. Pulse wave analysis was done using the SphygmoCor device, and pulse wave separation was done using the triangular method. The primary end points consisted of cardiovascular mortality and nonfatal cardiovascular and cerebrovascular events. Multivariable-adjusted Cox regression was used to calculate hazard ratios. RESULTS: A total of 2206 participants (mean age, 57.0 years; 55.0% women) were analyzed. Mean±SDs for Pfor, Pref, Tfor, and Tfor/Tref were 31.0±9.1 mm Hg, 20.8±8.4 mm Hg, 130.8±35.5, and 0.51±0.11, respectively. Over a median follow-up of 4.4 years, 146 (6.6%) participants experienced a primary end point. Every 1 SD increment in Pfor, Tfor, and Tfor/Tref was associated with 27% (95% CI, 1.07-1.49), 25% (95% CI, 1.07-1.45), and 32% (95% CI, 1.12-1.56) higher risk, respectively. Adding Tfor and Tfor/Tref to existing risk models improved model prediction (∆Uno's C, 0.020; P<0.01). CONCLUSIONS: Pulse wave components were predictive of composite cardiovascular end points, with Tfor/Tref showing significant improvement in risk prediction. Pending further confirmation, the ratio of time to forward and backward pressure peak may be useful to evaluate increased afterload and signify increased cardiovascular risk.

Derivation of an Outcome-Driven Threshold for Aortic Pulse Wave Velocity: An Individual-Participant Meta-Analysis.

BACKGROUND: Aortic pulse wave velocity (PWV) predicts cardiovascular events (CVEs) and total mortality (TM), but previous studies proposing actionable PWV thresholds have limited generalizability. This individual-participant meta-analysis is aimed at defining, testing calibration, and validating an outcome-driven threshold for PWV, using 2 populations studies, respectively, for derivation IDCARS (International Database of Central Arterial Properties for Risk Stratification) and replication MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease Health Survey - Copenhagen). METHODS: A risk-carrying PWV threshold for CVE and TM was defined by multivariable Cox regression, using stepwise increasing PWV thresholds and by determining the threshold yielding a 5-year risk equivalent with systolic blood pressure of 140 mm Hg. The predictive performance of the PWV threshold was assessed by computing the integrated discrimination improvement and the net reclassification improvement. RESULTS: In well-calibrated models in IDCARS, the risk-carrying PWV thresholds converged at 9 m/s (10 m/s considering the anatomic pulse wave travel distance). With full adjustments applied, the threshold predicted CVE (hazard ratio [CI]: 1.68 [1.15-2.45]) and TM (1.61 [1.01-2.55]) in IDCARS and in MONICA (1.40 [1.09-1.79] and 1.55 [1.23-1.95]). In IDCARS and MONICA, the predictive accuracy of the threshold for both end points was ≈0.75. Integrated discrimination improvement was significant for TM in IDCARS and for both TM and CVE in MONICA, whereas net reclassification improvement was not for any outcome. CONCLUSIONS: PWV integrates multiple risk factors into a single variable and might replace a large panel of traditional risk factors. Exceeding the outcome-driven PWV threshold should motivate clinicians to stringent management of risk factors, in particular hypertension, which over a person's lifetime causes stiffening of the elastic arteries as waypoint to CVE and death.

Association of Midlife Inflammatory Markers With Cognitive Performance at 10-Year Follow-up.

BACKGROUND AND OBJECTIVES: Chronic low-grade inflammation, commonly associated with cardiovascular diseases and risk factors, has been associated inconclusively with cognitive decline and dementia. The aim of our study was to evaluate whether low-grade inflammation, measured in midlife, is associated with a decline in cognitive performance after a 10-year follow-up. We hypothesized that low-grade inflammation, estimated by interleukin-6 (IL-6), tumor necrosis factor alpha (TNF-α), and high-sensitivity CRP (hs-CRP), is a predictor of cognitive decline in the general population. METHODS: This prospective cohort study is based on a Finnish nationwide, population-based Health 2000 Examination Survey, its supplemental examinations in 2000-2001, and the follow-up Health 2011 Survey. Cognitive performance at baseline and at follow-up was assessed with categorical verbal fluency (VF), word-list learning (WLL), and word-list delayed recall (WLDR). Baseline low-grade inflammation was measured with IL-6, TNF-α, and hs-CRP in 2001. Associations between low-grade inflammation and cognitive performance were analyzed with multivariable linear models adjusted for age, sex, education, APOE ε4 genotype, type 2 diabetes, hypertension, hypercholesterolemia, body mass index, depressive symptoms, smoking, and baseline cognition. RESULTS: Nine hundred fifteen participants aged 45-74 years (median age 54 years, 55% women) were included in the analysis. Both higher IL-6 and TNF-α at baseline predicted poorer performance in VF and WLL at 10-year follow-up (VF: IL-6 ß: -1.14, p = 0.003, TNF-α ß: -1.78, p = 0.008; WLL: IL-6 ß: -0.61, p = 0.007, TNF-α ß: -0.86, p = 0.03). Elevated IL-6 also predicted a greater decline in VF and WLL after a 10-year follow-up (VF: ß: -0.81, p = 0.01; WLL: ß: -0.53, p = 0.008). Baseline TNF-α did not predict cognitive decline, and hs-CRP did not predict cognitive performance or decline after 10-years. DISCUSSION: Our results suggest that low-grade inflammation in midlife is an independent risk factor for poorer cognitive performance later in life. Of the studied markers, IL-6 and TNF-α seem to be stronger predictors for cognitive performance and decline than hs-CRP.

The International Database of Central Arterial Properties for Risk Stratification: Research Objectives and Baseline Characteristics of Participants.

OBJECTIVE: To address to what extent central hemodynamic measurements, improve risk stratification, and determine outcome-based diagnostic thresholds, we constructed the International Database of Central Arterial Properties for Risk Stratification (IDCARS), allowing a participant-level meta-analysis. The purpose of this article was to describe the characteristics of IDCARS participants and to highlight research perspectives. METHODS: Longitudinal or cross-sectional cohort studies with central blood pressure measured with the SphygmoCor devices and software were included. RESULTS: The database included 10,930 subjects (54.8% women; median age 46.0 years) from 13 studies in Europe, Africa, Asia, and South America. The prevalence of office hypertension was 4,446 (40.1%), of which 2,713 (61.0%) were treated, and of diabetes mellitus was 629 (5.8%). The peripheral and central systolic/diastolic blood pressure averaged 129.5/78.7 mm Hg and 118.2/79.7 mm Hg, respectively. Mean aortic pulse wave velocity was 7.3 m per seconds. Among 6,871 participants enrolled in 9 longitudinal studies, the median follow-up was 4.2 years (5th-95th percentile interval, 1.3-12.2 years). During 38,957 person-years of follow-up, 339 participants experienced a composite cardiovascular event and 212 died, 67 of cardiovascular disease. CONCLUSIONS: IDCARS will provide a unique opportunity to investigate hypotheses on central hemodynamic measurements that could not reliably be studied in individual studies. The results of these analyses might inform guidelines and be of help to clinicians involved in the management of patients with suspected or established hypertension.

Factors affecting the difference between morning and evening home blood pressure: the Finn-Home study.

OBJECTIVE: The aim of this study was to assess the determinants of home morning and evening blood pressure (BP) differences in general population. METHODS: We studied a representative sample of the general Finnish adult population with 1919 study subjects, aged 41-74 years. Study subjects underwent a clinical interview, clinical examination and home BP measurement (28 measurements performed twice in the morning and in the evening during 7 consecutive days). RESULTS: In untreated hypertensive subjects, systolic home BP was lower in the morning than in the evening while no difference was detected for diastolic home BP (137.7/85.1 vs 141.5/85.2 mmHg, p < 0.001/0.64). In treated hypertensive subjects, the difference between systolic morning and evening BP was smaller (136.2 vs 137.1 mmHg, p = 0.023) and diastolic morning BP was even higher than evening BP (83.3 vs 82.1 mmHg, p < 0.001). In the univariate analysis, higher home BP and higher body mass index were associated with relatively higher morning BP compared with evening BP. In addition, men, excessive alcohol users, subjects with cardiovascular disease, sleep apnea and subjects using antihypertensive medication had relatively higher morning BP compared with evening BP. In the multivariate analysis, male gender, excessive alcohol consumption, cardiovascular disease, sleep apnea and use of antihypertensive medication were independent determinants of elevated morning BP compared with evening BP. CONCLUSION: Knowledge of the underlying causes affecting morning and evening home BP difference in patients facilitates physicians to make rational antihypertensive medication and lifestyle adjustments, such as examining probable sleep disorder, and give alcohol and cardiovascular disease prevention counseling.

Association between self-reported hypertension onset age and electrocardiographic left ventricular hypertrophy.

Objectively defined early-onset hypertension, based on repeated blood pressure measurements, is associated with greater odds of organ damage and cardiovascular mortality than late-onset hypertension. In this study we examined the association between two factors that are easily available in primary care, self-reported hypertension onset age and electrocardiographic left ventricular hypertrophy (ECG-LVH), in a nationwide population sample of 2864 Finns aged ≥50 years. We observed that, in contrast to prior findings, the odds of ECG-LVH were similar between self-reported hypertension onset age groups, and thus self-reported early-onset hypertension does not seem to associate with ECG-LVH more strongly than simple presence of hypertension.

Positive change in the utilization of antihypertensive and lipid-lowering drugs among adult CHD patients in Finland: results from a large national database between 2000 and 2006.

AIM: To assess the changes in the utilization of antihypertensive, and lipid-lowering drugs among all adult Finnish coronary heart disease (CHD) patients between 2000 and 2006, and to evaluate the treatment and control of hypertension and dyslipidemia in a population-based sample of CHD patients. METHODS: From the databases of the Social Insurance Institution of Finland, 192,440 CHD patients aged 30 years or more in 2000 and 206,394 in 2006, respectively, were identified. Changes in the utilization of antihypertensive and lipid-lowering drugs were determined. In addition, from the Health 2000 Survey representing the whole Finnish population aged 30 years or more, 527 CHD patients were identified, to assess their characteristics and control of hypertension and dyslipidemia. RESULTS: Between the fall of 2000 and spring of 2001, 75% of the CHD patients were classified as hypertensives and 85% of these used antihypertensive medication. From 2000 to 2006, the utilization of lipid-lowering, and antihypertensive drugs increased from 33 to 52% and from 74 to 78%, respectively. Moreover, combination antihypertensive medication increased from 37 to 48%. Amidst the patients using antihypertensive drugs, the use of renin-angiotensin system blockers increased from 27 to 46% because of more than a three-fold increase in the use of angiotensin receptor blockers. CONCLUSION: Utilization of antihypertensive agents (especially angiotensin receptor blockers) and lipid-lowering drugs has increased remarkably by the end of 2006. However, the treatments are still far from optimal.

Cardiovascular End Points and Mortality Are Not Closer Associated With Central Than Peripheral Pulsatile Blood Pressure Components.

Pulsatile blood pressure (BP) confers cardiovascular risk. Whether associations of cardiovascular end points are tighter for central systolic BP (cSBP) than peripheral systolic BP (pSBP) or central pulse pressure (cPP) than peripheral pulse pressure (pPP) is uncertain. Among 5608 participants (54.1% women; mean age, 54.2 years) enrolled in nine studies, median follow-up was 4.1 years. cSBP and cPP, estimated tonometrically from the radial waveform, averaged 123.7 and 42.5 mm Hg, and pSBP and pPP 134.1 and 53.9 mm Hg. The primary composite cardiovascular end point occurred in 255 participants (4.5%). Across fourths of the cPP distribution, rates increased exponentially (4.1, 5.0, 7.3, and 22.0 per 1000 person-years) with comparable estimates for cSBP, pSBP, and pPP. The multivariable-adjusted hazard ratios, expressing the risk per 1-SD increment in BP, were 1.50 (95% CI, 1.33-1.70) for cSBP, 1.36 (95% CI, 1.19-1.54) for cPP, 1.49 (95% CI, 1.33-1.67) for pSBP, and 1.34 (95% CI, 1.19-1.51) for pPP (P<0.001). Further adjustment of cSBP and cPP, respectively, for pSBP and pPP, and vice versa, removed the significance of all hazard ratios. Adding cSBP, cPP, pSBP, pPP to a base model including covariables increased the model fit (P<0.001) with generalized R2 increments ranging from 0.37% to 0.74% but adding a second BP to a model including already one did not. Analyses of the secondary end points, including total mortality (204 deaths), coronary end points (109) and strokes (89), and various sensitivity analyses produced consistent results. In conclusion, associations of the primary and secondary end points with SBP and pulse pressure were not stronger if BP was measured centrally compared with peripherally.

ECG left ventricular hypertrophy as a risk predictor of sudden cardiac death.

BACKGROUND: Electrocardiographic (ECG) left ventricular hypertrophy (LVH) is an established risk factor for cardiovascular events. However, limited data is available on the prognostic values of different ECG LVH criteria specifically to sudden cardiac death (SCD). Our goal was to assess relationships of different ECG LVH criteria to SCD. METHODS: Three traditional and clinically useful (Sokolow-Lyon, Cornell, RaVL) and a recently proposed (Peguero-Lo Presti) ECG LVH voltage criteria were measured in 5730 subjects in the Health 2000 Survey, a national general population cohort study. Relationships between LVH criteria, as well as their selected composites, to SCD were analyzed with Cox regression models. In addition, population-attributable fractions for LVH criteria were calculated. RESULTS: After a mean follow-up of 12.5 ±â€¯2.2 years, 134 SCDs had occurred. When used as continuous variables, all LVH criteria except for RaVL were associated with SCD in multivariable analyses. When single LVH criteria were used as dichotomous variables, only Cornell was significant after adjustments. The dichotomous composite of Sokolow-Lyon and Cornell was also significant after adjustments (hazard ratio for SCD 1.82, 95% confidence interval 1.20-2.70, P = 0.006) and was the only LVH measure that showed statistically significant population-attributable fraction (11.0%, 95% confidence interval 1.9-19.2%, P = 0.019). CONCLUSIONS: Sokolow-Lyon, Cornell, and Peguero-Lo Presti ECG, but not RaVL voltage, are associated with SCD risk as continuous ECG voltage LVH variables. When SCD risk assessment/adjustment is performed using a dichotomous ECG LVH measure, composite of Sokolow-Lyon and Cornell voltages is the preferred option.