Use of oral anticoagulants after ischaemic stroke in patients with atrial fibrillation and cancer.

BACKGROUND AND OBJECTIVES: The use of oral anticoagulants (OACs) amongst patients with atrial fibrillation (AF) has increased in the last decade. We aimed to describe temporal trends in the utilization of OACs for secondary prevention after ischaemic stroke amongst patients with AF and active cancer. METHODS: This is a cross-sectional and cohort study of patients with active cancer (n = 1518) and without cancer (n = 50 953) in the Swedish national register Riksstroke, including all patients with ischaemic stroke between 1 July 2005 and 30 December 2017, discharged with AF. Prescription and dispensation before and after the introduction of nonvitamin K OACs (NOACs) in late 2011 were compared. We used logistic and Cox regression to analyse associations with OAC use, adjusting for hospital clustering and the competing risk of death. RESULTS: The proportion of cancer patients with AF prescribed OACs at discharge after ischaemic stroke increased by 40.2% after 2011, compared with 69.3% in noncancer patients during the same period. Stroke and bleeding risk scores remained similar between patients with and without cancer. OAC dispensation during the following year did not increase as much in cancer patients (43.8% to 64.5%) as that in noncancer patients (46.0% to 74.9%), and the median time to OAC dispensation or censoring was significantly longer in cancer patients (94 vs. 30 days). CONCLUSION: OAC treatment in poststroke patients with AF and active cancer has increased after the introduction of NOACs. However, the growing treatment gap in these patients compared to that in noncancer patients raises the possibility of underutilization.

Impact of the Swedish National Stroke Campaign on stroke awareness.

BACKGROUND: Time delay from stroke onset to arrival in hospital is an important obstacle to widespread reperfusion therapy. To increase knowledge about stroke, and potentially decrease this delay, a 27-month national public information campaign was carried out in Sweden. AIMS: To assess the effects of a national stroke campaign in Sweden. METHODS: The variables used to measure campaign effects were knowledge of the AKUT test [a Swedish equivalent of the FAST (Face-Arm-Speech-Time)] test and intent to call 112 (emergency telephone number) . Telephone interviews were carried out with 1500 randomly selected people in Sweden at eight points in time: before, three times during, immediately after, and nine, 13 and 21 months after the campaign. RESULTS: Before the campaign, 4% could recall the meaning of some or all keywords in the AKUT test, compared with 23% during and directly after the campaign, and 14% 21 months later. Corresponding figures were 15%, 51%, and 50% for those remembering the term AKUT and 65%, 76%, and 73% for intent to call 112 when observing or experiencing stroke symptoms. During the course of the campaign, improvement of stroke knowledge was similar among men and women, but the absolute level of knowledge for both items was higher for women at all time points. CONCLUSION: The nationwide campaign substantially increased knowledge about the AKUT test and intention to call 112 when experiencing or observing stroke symptoms, but knowledge declined post-intervention. Repeated public information therefore appears essential to sustain knowledge gains.

Stroke unit care revisited: who benefits the most? A cohort study of 105,043 patients in Riks-Stroke, the Swedish Stroke Register.

BACKGROUND: Treatment at stroke units is superior to treatment at other types of wards. The objective of the present study is to determine the effect size of stroke unit care in subgroups of patients with stroke. This information might be useful in a formal priority setting. METHODS: All acute strokes reported to the Swedish Stroke Register from 2001 through 2005 were followed until January 2007. The subgroups were age (18-64, 65-74, 75-84, 85+ years and above), sex (male, female), stroke subtype (intracerebral haemorrhage, cerebral infarction and unspecified stroke) and level of consciousness (conscious, reduced, unconscious). Cox proportional hazards and logistic regression analyses were used to estimate the risk for death, institutional living or dependency. RESULTS: 105,043 patients were registered at 86 hospitals. 79,689 patients (76%) were treated in stroke units and 25,354 patients (24%) in other types of wards. Stroke unit care was associated with better long-term survival in all subgroups. The best relative effect was seen among the following subgroups: age 18-64 years (hazard ratio (HR) for death 0.53; 0.49 to 0.58), intracerebral haemorrhage (HR 0.61; 0.58 to 0.65) and unconsciousness (HR 0.70; 0.66 to 0.75). Stroke unit care was also associated with reduced risk for death or institutional living after 3 months. CONCLUSIONS: Stroke unit care was associated with better long-term survival in all subgroups, but younger patients, patients with intracerebral haemorrhage and patients who were unconscious had the best relative effect and may be given the highest priority to this form of care.

Effects of glucose, chloromercuribenzene-p-sulphonic acid and 4-acetamido-4'-isothiocyanostilbene-2,2'-disulphonic acid on phosphate efflux from pancreatic islets.

Collagenase-isolated pancreatic islets of non-inbred ob/ob mice, containing more than 90% beta-cells, were labelled with radioactive orthophosphate (32P or 33P) and then subjected to non-recirculating perifusion. The basal D-glucose concentration in the perifusion medium was 2.8 mM. When the concentration was suddenly raised to 5.6, 8.3 or 16.7 mM, D-glucose promptly elicited a transient and dose-dependent release of radiophosphate. In the presence of 2.8 mM D-glucose, 0.1 mM of the poorly permeating sulphydryl blocker, chloromercuribenzene-p-sulphonic acid, also evoked a phosphate flush resembling the one induced by D-glucose. The basal radiophosphate release was partially inhibited by 1 mM 4-acetamido-4-'-isothiocyanostilbene-2,2'-disulphonic acid. However, the phosphate flush induced by 16.7 mM D-glucose was not noticeably inhibited by 4-acetamido-4'-isothiocyanostilbene-2,2'-disulphonic acid. It is concluded that the phosphate flush emanates from beta-cells and that membrane sulphydryl groups may participate in its regulation. Although at least the basal phosphate release may in part represent transmembrane transport through 4-acetamido-4'-isothiocyanostilbene-2,2'-disulphonic acid-sensitive anion channels, other mechanisms are also likely to participate in the glucose-induced phosphate flush.

Phosphate metabolism and glucose-initiated efflux of phosphate ions in islets of fetal pancreas.

Elsewhere we have proposed that the rapid transient efflux of 32P orthophosphate that occurs when prelabeled pancreatic islets are exposed to nutrient secretagogues (the "phosphate flush") reflects one of the earliest steps in islet stimulus-secretion coupling. We have now shown that the "phosphate flush" is much smaller with islets from fetal rats 21 1/2 days old. This could be attributed to decreased cellular stores of radioactivity, especially inorganic orthophosphate (32P), at the onset of stimulation, which may have been due, in part, to the diminished ability of fetal islets to retain the radiophosphorus accumulated during the labeling period. Certain other differences in phosphate metabolism were also observed. With prelabeled islets from adult rats, exposure to 3.0 mg. per milliliter glucose effected acute increases in the tissue content of AT32P and GT32P. Comparable stimulation of prelabeled fetal islets with 3.0 mg. per milliliter glucose did not elicit detectable changes in the labeling of ATP or GTP. The findings indicate that selected aspects of phosphate metabolism may be immature in fetal islets and, perhaps, implicated in their obtunded secretion of insulin in response to stimulation with glucose.

Decreased cyclic AMP and insulin response to glucose in isolated islets of neonatal rats.

The (3H) cyclic AMP accumulation was measured in incubations of pancreatic islets from one-day, six-day, and thirty-five-day-old rats exposed to a low (0.6 mg./ml.) or a high (3.0 mg./ml.) glucose concentration with or without the addition of 0.1 mM. of the phosphodiesterase inhibitor 3-isobutyl- 1 -methylxanthine (IBMX). In the thirty-five-day-old rats, (3H) cyclic AMP accumulation was significantly enhanced after sixty minutes' incubation in a high glucose concentration and further increased by IBMX. These changes were paralleled by a stimulated insulin release, measured simultaneously. By contrast, in the one-day-old rats, no effect of glucose with or without IBMX was seen on (3H) cyclic AMP, while the minor insulin release due to high glucose alone was markedly potentiated by IBMX. Even in the presence of this agent the insulin response to glucose was, however, clearly inferior to that seen in the thirty-five-day-old animals. The stimulatory patterns of glucose-induced insulin release in the six-day-old animals was intermediate between the other two age groups. At this age, stimulation of (3H) cyclic AMP due to glucose was observed only in the presence of IBMX. Measurement of (3H) cyclic AMP after three minutes' incubation confirmed these different stimulatory patterns of glucose in the age groups studied. It is suggested that the inefficiency of glucose to stimulate the adenyl cyclase-cyclic AMP system of the beta cell from fetal and neonatal animals may be one important factor determining the insensitivity to the insulin-releasing action of glucose that exists at this stage of development.

Smokeless tobacco as a possible risk factor for myocardial infarction: a population-based study in middle-aged men.

OBJECTIVES: To explore whether the use of snuff affects the risk of myocardial infarction (MI). BACKGROUND: Snuff and other forms of smokeless tobacco are widely used in some populations. Possible health hazards associated with the use of smokeless tobacco remain controversial. METHODS: In a population-based study within the framework of the Northern Sweden center of the World Health Organization Multinational Monitoring of Trend and Determinants in Cardiovascular Disease (WHO MONICA) Project, tobacco habits were compared in 25- to 64-year-old men with first-time fatal or nonfatal MI and referent subjects matched for age and place of living (687 cases, 687 referents). RESULTS: The unadjusted odds ratio (OR) for MI in regular cigarette smokers as compared with men who never used tobacco was 3.65 (95% confidence interval [CI] 2.67 to 4.99). When nonsmoking regular snuff dippers were compared with never-users of tobacco, the unadjusted OR was 0.96 (0.65 to 1.41). After adjustment for multiple cardiovascular risk factors, the OR was 3.53 (95% CI 2.48 to 5.03) for regular smoking and 0.58 (95% CI 0.35 to 0.94) for regular snuff dipping. Restricting the analyses to fatal cases of myocardial (including sudden death) showed a tendency towards increased risk among snuff dippers 1.50 (95% CI 0.45 to 5.03). CONCLUSIONS: The risk of MI is not increased in snuff dippers. Nicotine is probably not an important contributor to ischemic heart disease in smokers. A possible small or modest detrimental effect of snuff dipping on the risk for sudden death could not be excluded in this study due to a limited number of fatal cases.

Acupuncture for acute stroke.

BACKGROUND: Acupuncture-like sensory stimulation activates multiple efferent (nerve) pathways leading to altered activity in numerous neural systems. Acupuncture is widely accepted by Chinese people and it is increasingly requested by patients and their relatives in Western countries. OBJECTIVES: To assess the effectiveness and safety of acupuncture in patients with acute stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group trials register (last searched August 2003), the Chinese Stroke Trials Register (August 2003) and the Chinese Acupuncture Trials Register (August 2003). Electronic searches were performed in the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2003), MEDLINE (1966 to 2003), EMBASE (1980 to 2003), Alternative Medicine Database (1985 to 2003), CINAHL (1982 to 2003) and the Chinese Biological Medicine Database (1981 to 2003). Reference lists of systematic reviews and identified trials were handsearched. SELECTION CRITERIA: Randomised and quasi-randomised trials of acupuncture started within 30 days of stroke onset, compared with placebo/sham acupuncture or open control in patients with acute ischaemic and/or haemorrhagic stroke. Needling into skin was required for acupuncture. DATA COLLECTION AND ANALYSIS: Two reviewers selected trials for inclusion, assessed trial quality, and extracted the data independently. Authors of trials were contacted for missing data. MAIN RESULTS: Fourteen trials involving 1208 patients were included. Ten trials included patients with only ischaemic stroke. When acupuncture was compared with sham acupuncture or open control, there was a borderline significant trend towards fewer patients being dead or dependent (Odds ratio (OR) 0.66, 95% confidence interval (CI) 0.43 to 0.99), and significantly fewer being dead or needing institutional care (OR 0.58, 95% CI 0.35 to 0.96) in the acupuncture group after three months or more. There was also a significant difference favouring acupuncture in the mean change of global neurological deficit score during the treatment period (standardized mean difference (SMD) 1.17, 95% CI 0.30 to 2.04). Comparison of acupuncture with sham acupuncture only showed a statistically significant difference on death or requiring institutional care (OR 0.49, 95% CI 0.25 to 0.96), but not on death or dependency (OR 0.67, 95% CI 0.40 to 1.12), or change of global neurological deficit score (SMD 0.01, 95% CI -0.55 to 0.57). Severe adverse events with acupuncture (dizziness, intolerable pain and infection of acupoints) were rare (6/386, 1.55%). AUTHORS' CONCLUSIONS: Acupuncture appeared to be safe but without clear evidence of benefit. The number of patients is too small to be certain whether acupuncture is effective for treatment of acute ischaemic or haemorrhagic stroke. Larger, methodologically-sound trials are required.

Ginkgo biloba for acute ischaemic stroke.

BACKGROUND: Ginkgo biloba extract is widely used in the treatment of acute ischaemic stroke in China. We aimed to assess the evidence from randomised controlled trials and quasi-randomised controlled trials on the use of Ginkgo biloba extract in acute ischaemic stroke. OBJECTIVES: The primary objective was to determine whether Ginkgo biloba extract improves functional outcome without causing undue harm in patients with acute ischaemic stroke. Secondary objectives were to assess the effect of Ginkgo biloba extract on neurological impairment and quality of life. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched October 2004), the Trials Register of the Cochrane Complementary Medicine Field (last searched October 2004) and the Chinese Stroke Trials Register (last searched June 2004). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to August 2004), EMBASE (1980 to June 2004), AMED (1985 to May 2002) and the China Biological Medicine Database (CBM-disc, 1979 to August 2004). We searched relevant clinical trials and research registers and contacted pharmaceutical companies and researchers in an effort to identify further published and unpublished studies. SELECTION CRITERIA: Randomised controlled trials or quasi-randomised controlled clinical trials comparing Ginkgo biloba extract with placebo or open control (no placebo) in patients with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data. MAIN RESULTS: Fourteen trials were identified, of which 10 trials (792 patients) were included. Four trials are awaiting assessment. In the 10 included trials follow up was performed at 14 to 35 days after stroke. In all studies neurological outcome was assessed but none of them reported on disability (activities of daily living function) or quality of life. Only three trials reported adverse events. In nine trials, all of them assessed to be of inferior quality, significant improvement in neurological deficit at the end of the treatment was used as the outcome measure. When analysing these trials together, Ginkgo biloba extract was associated with a significant increase in the number of improved patients (Peto odds ratio (OR) 2.66; 95% confidence interval (CI) 1.79 to 3.94). One placebo-controlled trial, assessed to be of good quality, reported neurological outcome as a continuous variable. It failed to show an improvement of neurological deficit at the end of treatment (weighted mean difference (fixed) 0.81; 95% CI -8.9 to 10.52). No deaths or major adverse events were reported during the follow-up period. AUTHORS' CONCLUSIONS: There was no convincing evidence from trials of sufficient methodological quality to support the routine use of Ginkgo biloba extract to promote recovery after stroke. High-quality and large-scale randomised controlled trials are needed to test its efficacy.

The impact of nurses' opinion of client behaviour and level of social functioning on the amount of time they spend with clients.

The impact of nurses' opinion of client behaviour and level of social functioning on the amount of time they spend with clients For people afflicted with different kinds of psychiatric disorder, suffering is a common denominator. The time the nurses spend with psychiatric clients may mirror their attitudes towards and feelings for these clients. The aim of this study was to investigate the connections between the time spent together and the nurses' opinion of client behaviour and social functioning in community-based psychiatry. In this quantitative study, 29 clients were assessed by 30 nurses, who answered the Global Assessment of Functioning Scale (GAF) and the Positive and Negative Syndrome Scale (PANSS). At the same time, 11,200 non-participant observations of clients were registered using the Patient Activity Classification (PAC) to investigate how they spent their time at two psychiatric group dwellings. The PAC instrument revealed that clients spent an average of 60.8% of time alone, while only 20% of their daily time was spent with the nurses. Based on a factor analysis, indices were made by setting cut-off points for the PANSS and the GAF scores, and four small groups of clients were generated: a relatively high level of social functioning and a low degree of psychiatric symptoms (A); a relatively high level of social functioning and a high degree of psychiatric symptoms (B); a low level of social functioning and a low degree of psychiatric symptoms (C); and, finally, a low level of social functioning and a high degree of psychiatric symptoms (D). The clients judged as having a low level of social functioning in combination with high degrees of psychiatric symptoms, that is, the most vulnerable and dependent individuals, receive less staff attention (18%) and are the clients who spend the most time alone (71.4%). It might be possible to interpret the results of this study in the light of a process of dehumanization.

Screening for impaired glucose tolerance. Results from a population-based study in 21,057 individuals.

OBJECTIVE: To study the distribution of fasting plasma glucose and impaired glucose tolerance (IGT) in a large general population and explore their possible implications for large-scale screening. The study focuses especially on the relation to age, obesity, and heredity background of diabetes. RESEARCH DESIGN AND METHODS: A total of 21,057 men and women aged 30-60 years were used for this cross-sectional study. Individuals with known diabetes and individuals with a fasting plasma glucose > or = 7 mmol/l were excluded. A physical examination, including blood sampling and an oral glucose tolerance test, was conducted. RESULTS: The relative risk for IGT increased more than fourfold among obese subjects compared with normal-weight subjects, yet only 25% of IGT subjects were obese. Similarly, IGT subjects more frequently reported having first-degree relatives with diabetes than did subjects with normal glucose tolerance. Nonetheless, > 70% of IGT subjects reported no heredity background of diabetes. Subjects with IGT showed higher mean values of BMI, blood pressure, and triglycerides. Only 13% of the men and 19% of the women having impaired fasting glucose (IFG) fulfilled the criteria of IGT. CONCLUSIONS: The present study shows that a high-risk screening strategy for IGT targeted solely toward subjects with obesity and/or heredity background of diabetes will fail to detect the majority of subjects with IGT in the general population. The new concept of IFG may not replace the concept of IGT as a risk marker for worsening to diabetes.

32P-labeling patterns in rat pancreatic islets: tissue source of the radiophosphate released after glucose stimulation.

Immediately after stimulation with glucose in vitro, isolated rat pancreatic islets prelabeled with [32P]orthophosphate release a pulse of [32P]orthophosphate into the media (the "phosphate flush"). Islets have been rapidly frozen before, during, and after this pulse to assess the concurrent changes in the distribution of tissue radioactivity. Under the present experimental conditions, approximately 90% of the islet radioactivity was soluble in perchloric acid (PCA-soluble) immediately before stimulation and slightly more than half of that was present as [32P]orthophosphate. The tissue pool of [32P]orthophosphate declined 55% and 62% after 7 and 14 min of stimulation which, respectively, incorporated the peak and the end of the heightened efflux of radioactivity. The net decrementa in tissue orthophosphate could account for all of the radioactivity which was released during the "phosphate flush." During the 14-min period of stimulation, labeled ATP and GTP (which had accounted for 13% and 4% of total PCA-soluble radioactivity before stimulation) increased 51% and 35%, respectively, and labeled ADP and AMP (which had accounted for 5.4% and 1.5% of PCA-soluble counts) fell 36% and 77%, respectively. Certain other PCA-soluble components, such as phosphorylcholine and phosphorylethanolamine, and total PCA-insoluble radioactivity were not demonstrably altered. The findings indicate that the "phosphate flush" originates from a labile pool of tissue orthophosphate. It remains to be established whether the simultaneous changes in the turnover of selected nucleotides are coupled to the translocation of orthophosphate or are mediated separately.

Does pretreatment with statins improve clinical outcome after stroke? A pilot case-referent study.

BACKGROUND AND PURPOSE: In primary and secondary prevention trials, statins have been shown to reduce the risk of stroke. In addition to lipid lowering, statins have a number of antiatherothrombotic and neuroprotective properties. In a preliminary observational study, we explored whether clinical outcome is improved in patients who are on treatment with statins when stroke occurs. METHODS: We conducted a population-based case-referent study of 25- to 74-year-old stroke patients with, for each case of a patient who was on statin treatment at the onset of stroke (n=125), 2 referent patients who were not treated with statins but were matched for age, gender, year of onset, and stroke subtype (n=250). RESULTS: The unadjusted odds ratio for early discharge to home (versus late discharge or death) was 1.41 (95% CI 0.91 to 2.17) when patients on statin treatment were compared with referent stroke patients not on statins. Prognostic factors were, in general, more unfavorable among patients on statins. When this was adjusted for in a logistic regression model, the use of statins was a moderately strong but statistically nonsignificant predictor of discharge to home (multiple-adjusted odds ratio 1.42, 95% CI 0.90 to 2.22). CONCLUSIONS: The statistical power of this case-referent study was such that only large beneficial effects of statins in acute stroke could be confirmed. However, the observed trend, together with experimental observations, is interesting enough to warrant a more detailed analysis of the relationship between statins and stroke outcome.

Acupuncture and transcutaneous nerve stimulation in stroke rehabilitation: a randomized, controlled trial.

BACKGROUND AND PURPOSE: In small trials with control groups that receive no intervention, acupuncture has been reported to improve functional outcome after stroke. We studied effects of acupuncture and transcutaneous electrical nerve stimulation on functional outcome and quality of life after stroke versus a control group that received subliminal electrostimulation. METHODS: In a multicenter randomized controlled trial involving 7 university and district hospitals in Sweden, 150 patients with moderate or severe functional impairment were included. At days 5 to 10 after acute stroke, patients were randomized to 1 of 3 intervention groups: (a) acupuncture, including electroacupuncture; (b) sensory stimulation with high-intensity, low-frequency transcutaneous electrical nerve stimulation that induces muscle contractions; and (c) low-intensity (subliminal) high-frequency electrostimulation (control group). A total of 20 treatment sessions were performed over a 10-week period. Outcome variables included motor function, activities of daily living function, walking ability, social activities, and life satisfaction at 3-month and 1-year follow-up. RESULTS: At baseline, patients in each group were closely similar in all important prognostic variables. At 3-month and 1-year follow-ups, no clinically important or statistically significant differences were observed between groups for any of the outcome variables. The 3 treatment modalities were all conducted without major adverse effects. CONCLUSIONS: When compared with a control group that received subliminal electrostimulation, treatment during the subacute phase of stroke with acupuncture or transcutaneous electrical nerve stimulation with muscle contractions had no beneficial effects on functional outcome or life satisfaction.

Randomized clinical trials of hemodilution in acute ischemic stroke.

The effects of hemodilution in acute ischemic stroke have been investigated, first in a single-center, then in a multicenter trial. Patients with hematocrit levels of 38-50% were randomized, within 48 h of onset of symptoms, to treatment with repeated venesections (total 250-1000 ml) and concomitant dextran 40 administration, or to a control group. The single-center study, performed in a research-oriented stroke unit, involved 102 patients. Case fatality rate was not grossly affected by hemodilution. In survivors, hemodilution improved neurological outcome. More hemodiluted patients were independent in walking and more were at home 3 months after the stroke. The ensuing multicenter trial involved 383 patients in 15 Scandinavian centers. Three-month case fatality rate was 16% in hemodiluted and 12% in control patients. Neurological scoring and ADL performance at 3 months was not improved by hemodilution. No subgroup with beneficial effects was discerned. It is concluded that the present standardized hemodilution regime cannot be recommended for general use in patients with ischemic stroke.

Relationship of cigarette smoking and snuff dipping to plasma fibrinogen, fibrinolytic variables and serum insulin. The Northern Sweden MONICA Study.

The influence of cigarette smoking and use of smokeless tobacco on plasma fibrinogen level, fibrinolytic variables, glucose tolerance and serum insulin was studied in a randomly selected population sample consisting of 604 men and 662 females between 25 and 64 years. Subjects were grouped according to tobacco habits as follows: regular smokers (> 1 cig/day), ex-smokers, snuff dippers, and non-tobacco users. An oral glucose tolerance test was performed on 54% of the participants. Tissue plasminogen activator (tPA) activity and plasminogen activator inhibitor type 1 (PAI-1) activity were used to study fibrinolysis. Men who smoked had 0.34 g/l (95% CI 0.17 to 0.49) higher fibrinogen level than non-tobacco users and numbers of cigarettes smoked correlated with plasma fibrinogen levels (r = 0.21, P = 0.006). Female smokers had significantly higher fibrinogen levels than ex-smokers but the difference compared with non-smokers was not significant. Snuff dipping did not affect fibrinogen levels. We found no relationship between tPA activity, PAI-1 activity and tobacco use. Post-load plasma glucose was lower in women who smoked, otherwise no influence of tobacco use on glucose levels was seen. Lower post-load insulin levels (-8.8 mU/ml, 95% CI -2.4 to -16.3) than in non-smokers were also found in women who smoked. This was only partially explained by a lower body mass index in smokers. We conclude that cigarette smoking is associated with increased fibrinogen levels, unaltered fibrinolysis, normal glucose tolerance and insulin levels. The use of smokeless tobacco, as moist oral snuff, does not appear to affect these potential cardiovascular risk factors.

Increased levels of tissue plasminogen activator antigen in essential hypertension. A population-based study in Sweden.

OBJECTIVE: To investigate components of the haemostatic and fibrinolytic system in borderline hypertensives and hypertensives, drug-treated or not, from a defined population. DESIGN AND METHODS: A randomly selected sample of the population of northern Sweden, 1558 subjects aged 25-64 years, was studied. Eight per cent of them were being treated with antihypertensive drugs (trHT). Remaining subjects were classified according to their mean diastolic blood pressure (DBP). Normotension, DBP < 85 mmHg, was found in 63%, borderline hypertension (bHT), DBP 85-94 mmHg, in 21% and untreated hypertension (uHT), DBP > or = 95 mmHg, in 8% of the subjects. RESULTS: Mean age increased from the normotensive group through the bHT and uHT groups to the trHT group, members of which were the oldest. Age-adjusted values for the body mass index, waist: hip ratio, serum triglyceride and Phadeseph plasma insulin levels increased with each level of hypertension. Plasma fibrinogen levels and plasminogen activator inhibitor type 1 activity (in men) increased stepwise from normotensives through bHT and uHT to the highest values found in the trHT group. The tissue plasminogen activator (tPA) activity in men declined strongly across the groups, trHT having the lowest fibrinolytic activity (P < 0.001). tPA antigen levels increased strongly from normotensives through bHT to uHT, but then were lower in the trHT group. Even after adjustment for possible confounders, men in the uHT group had 21% higher (P = 0.027) tPA antigen levels than did the normotensives. In bHT men, the tPA antigen and plasminogen activator inhibitor type 1 activities were 14 and 24% respectively, higher (P < 0.01) than those in the normotensives. CONCLUSION: Hypertension is associated with multiple metabolic and fibrinolytic disturbances that are accentuated in drug-treated hypertensives and already discernible in subjects with borderline hypertension. Decreased fibrinolysis is associated with, and possibly secondary to, metabolic disturbances linked to the insulin-resistance syndrome. The independent increase in tPA antigen in hypertensive men might indicate an endothelial dysfunction.

Lipoprotein (a) in a randomly selected 25-64 year old population: the Northern Sweden Monica Study.

Lipoprotein (a) (Lp (a)) was determined in 1527 individuals participating in the Northern Sweden WHO MONICA project for monitoring of cardiovascular risk factors in the general population. Subjects were randomly selected and stratified according to sex and age. A weak but significant relation between Lp (a) and increasing age was found in both sexes (p < 0.01). Menopausal status was the strongest independent predictor of Lp (a) level in women (p = 0.010). Fibrinogen was independently related to Lp (a) in both men and women (p < 0.05). An inverse relation between waist-to-hip ratio and Lp (a) was found in men (p < 0.01). Hypertensive subjects treated with diuretics had significantly higher Lp (a) than hypertensives on other agents (p < 0.05). Only a minor proportion of Lp (a) variance could be explained by lifestyle factors, which supports the contention that genetic factors primarily control Lp(a) level.

Insulin resistance syndrome and fibrinolytic activity: the northern Sweden MONICA study.

BACKGROUND: Many studies have, in small and highly selected study populations, described how cardiovascular risk factors tend to cluster in subjects with insulin resistance. Recently, interest has focused on possible relationships between this insulin resistance syndrome and fibrinolysis, and the role of triglycerides in this association. The present study addresses these issues in a general population. METHODS: A subsample of participants in the population-based Northern Sweden MONICA (MONItoring of trends and determinants in CArdiovascular diseases) Study, consisting of 353 men and 403 women in the 25-64 year age range, was investigated. Insulin resistance was estimated indirectly from the fasting levels of insulin and glucose. Fibrinolytic activity was measured both as plasminogen activator inhibitor type 1 (PAI-1) activity and tissue plasminogen activator ((t)PA) activity. RESULTS: Insulin resistance was highly correlated with those cardiovascular risk factors that have been associated with the insulin resistance syndrome, and to the measures of fibrinolytic activity. Subjects in the upper tertile of insulin resistance had a PAI-1 activity that was three times higher than that of the lower third men and twice as high in women. There was a strong interaction between insulin resistance and serum triglycerides. Low versus high levels of both variables together were associated with a fivefold difference in PAI-1 activity in men and a threefold difference in women. The (t)PA activity was inversely correlated to both insulin resistance and serum triglycerides. CONCLUSIONS: In a general population, the 'insulin resistance syndrome' is closely associated with low fibrinolytic activity. Serum triglyceride levels interact with insulin resistance to predict fibrinolytic activity.