Cardiovascular event rate and death in high-risk secondary prevention patient cohort in Finland: A registry study.

BACKGROUND: A large number of patients are living with atherosclerotic cardiovascular (CV) disease and thus are at risk of life-threatening CV events. HYPOTHESIS: This study evaluated the risk for a recurrent CV event or death in Finnish real-world data. METHODS: Patients with an incident atherosclerotic CV event between 2012 and 2016 were included in this retrospective registry study and followed for recurrent CV events or death. The risk and risk factors of recurrent CV events or death and time from the first CV event to recurrence were assessed. RESULTS: A total of 48,405 patients were followed from their first CV event. The event rate was 14.34 events per 100 patient-years. Multistate models suggested that at 5 years post index CV event, 41.5% of the patients had died or suffered a recurrent CV event. Death was the most common type of subsequent event (61.5%). After the first CV event, there were rapid increases both in recurrent CV events and deaths during the next 6 months. The subsequent CV event was usually of the same type as the first, which was of the cardiac or cerebrovascular cluster. CONCLUSIONS: The incidence of recurrent CV events and all-cause mortality was high in patients suffering from their first CV event, particularly during the first 6 months after the index event. Death was the most common subsequent event. The event rate accelerated after each additional CV event. This suggests that the acute treatment of the index event should be followed by prompt secondary prevention measures to achieve guideline-recommended goals as soon as possible.

Prediction of recurrent event in patients with coronary heart disease: the EUROASPIRE Risk Model.

AIMS: Most patients with established atherosclerotic cardiovascular disease (CVD) are at very high risk for developing recurrent events. Since this risk varies a lot between patients there is a need to identify those in whom an even more intensive secondary prevention strategy should be envisaged. Using data from the EUROASPIRE IV and V cohorts of coronary heart disease (CHD) patients from 27 European countries, we aimed at developing and internally and externally validating a risk model predicting recurrent CVD events in patients aged < 75 years. METHODS AND RESULTS: Prospective data were available for 12 484 patients after a median follow-up time of 1.7 years. The primary endpoint, a composite of fatal CVD or new hospitalizations for non-fatal myocardial infarction (MI), stroke, heart failure, coronary artery bypass graft, or percutaneous coronary intervention (PCI), occurred in 1424 patients. The model was developed based on data from 8000 randomly selected patients in whom the association between potential risk factors and the incidence of the primary endpoint was investigated. This model was then validated in the remaining 4484 patients. The final multivariate model revealed a higher risk for the primary endpoint with increasing age, a previous hospitalization for stroke, heart failure or PCI, a previous diagnosis of peripheral artery disease, self-reported diabetes and its glycaemic control, higher non-high-density lipoprotein cholesterol, reduced renal function, symptoms of depression and anxiety and living in a higher risk country. The model demonstrated excellent internal validity and proved very adequate in the validation cohort. Regarding external validity, the model demonstrated good discriminative ability in 20 148 MI patients participating in the SWEDEHEART register. Finally, we developed a risk calculator to estimate risks at 1 and 2 years for patients with stable CHD. CONCLUSION: In patients with CHD, fatal and non-fatal rates of recurrent CVD events are high. However, there are still opportunities to optimize their management in order to prevent further disease or death. The EUROASPIRE Risk Calculator may be of help to reach this goal.

Potential for optimizing management of obesity in the secondary prevention of coronary heart disease.

AIMS: Prevention guidelines have identified the management of obese patients as an important priority to reduce the burden of incident and recurrent cardiovascular disease. Still, studies have demonstrated that over 80% of patients with coronary heart disease (CHD) fail to achieve their weight target. Here, we describe advice received and actions reported by overweight CHD patients since being discharged from hospital and how weight changes relate to their risk profile. METHODS AND RESULTS: Based on data from 10 507 CHD patients participating in the EUROASPIRE IV and V studies, we analysed weight changes from hospital admission to the time of a study visit ≥6 and <24 months later. At hospitalization, 34.9% were obese and another 46.0% were overweight. Obesity was more frequent in women and associated with more comorbidities. By the time of the study visit, 19.5% of obese patients had lost ≥5% of weight. However, in 16.4% weight had increased ≥5%. Weight gain in those overweight was associated with physical inactivity, non-adherence to dietary recommendations, smoking cessation, raised blood pressure, dyslipidaemia, dysglycaemia, and lower levels of quality of life. Less than half of obese patients was considering weight loss in the coming month. CONCLUSIONS: The management of obesity remains a challenge in the secondary prevention of CHD despite a beneficial effect of weight loss on risk factor prevalences and quality of life. Cardiac rehabilitation programmes should include weight loss interventions as a specific component and the incremental value of telehealth intervention as well as recently described pharmacological interventions need full consideration.

Risk factors for major adverse cardiovascular events after the first acute coronary syndrome.

AIMS: To evaluate risk factors for major adverse cardiac event (MACE) after the first acute coronary syndrome (ACS) and to examine the prevalence of risk factors in post-ACS patients. METHODS: We used Finnish population-based myocardial infarction register, FINAMI, data from years 1993-2011 to identify survivors of first ACS (n = 12686), who were then followed up for recurrent events and all-cause mortality for three years. Finnish FINRISK risk factor surveys were used to determine the prevalence of risk factors (smoking, hyperlipidaemia, diabetes and blood pressure) in post-ACS patients (n = 199). RESULTS: Of the first ACS survivors, 48.4% had MACE within three years of their primary event, 17.0% were fatal. Diabetes (p = 4.4 × 10-7), heart failure (HF) during the first ACS attack hospitalization (p = 6.8 × 10-15), higher Charlson index (p = 1.56 × 10-19) and older age (p = .026) were associated with elevated risk for MACE in the three-year follow-up, and revascularization (p = .0036) was associated with reduced risk. Risk factor analyses showed that 23% of ACS survivors continued smoking and cholesterol levels were still high (>5mmol/l) in 24% although 86% of the patients were taking lipid lowering medication. CONCLUSION: Diabetes, higher Charlson index and HF are the most important risk factors of MACE after the first ACS. Cardiovascular risk factor levels were still high among survivors of first ACS.

Lifestyle and impact on cardiovascular risk factor control in coronary patients across 27 countries: Results from the European Society of Cardiology ESC-EORP EUROASPIRE V registry.

AIMS: The aim of this study was to determine whether the Joint European Societies guidelines on secondary cardiovascular prevention are followed in everyday practice. DESIGN: A cross-sectional ESC-EORP survey (EUROASPIRE V) at 131 centres in 81 regions in 27 countries. METHODS: Patients (<80 years old) with verified coronary artery events or interventions were interviewed and examined ≥6 months later. RESULTS: A total of 8261 patients (females 26%) were interviewed. Nineteen per cent smoked and 55% of them were persistent smokers, 38% were obese (body mass index ≥30 kg/m2), 59% were centrally obese (waist circumference: men ≥102 cm; women ≥88 cm) while 66% were physically active <30 min 5 times/week. Forty-two per cent had a blood pressure ≥140/90 mmHg (≥140/85 if diabetic), 71% had low-density lipoprotein cholesterol ≥1.8 mmol/L (≥70 mg/dL) and 29% reported having diabetes. Cardioprotective medication was: anti-platelets 93%, beta-blockers 81%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75% and statins 80%. CONCLUSION: A large majority of coronary patients have unhealthy lifestyles in terms of smoking, diet and sedentary behaviour, which adversely impacts major cardiovascular risk factors. A majority did not achieve their blood pressure, low-density lipoprotein cholesterol and glucose targets. Cardiovascular prevention requires modern preventive cardiology programmes delivered by interdisciplinary teams of healthcare professionals addressing all aspects of lifestyle and risk factor management, in order to reduce the risk of recurrent cardiovascular events.

Incidence of cardiovascular events in patients with stabilized coronary heart disease: the EUROASPIRE IV follow-up study.

The EUROASPIRE surveys (EUROpean Action on Secondary Prevention through Intervention to Reduce Events) demonstrated that most European coronary patients fail to achieve lifestyle, risk factor and therapeutic targets. Here we report on the 2-year incidence of hard cardiovascular (CV) endpoints in the EUROASPIRE IV cohort. EUROASPIRE IV (2012-2013) was a large cross-sectional study undertaken at 78 centres from selected geographical areas in 24 European countries. Patients were interviewed and examined at least 6 months following hospitalization for a coronary event or procedure. Fatal and non-fatal CV events occurring at least 1 year after this baseline screening were registered. The primary outcome in our analyses was the incidence of CV death or non-fatal myocardial infarction, stroke or heart failure. Cox regression models, stratified for country, were fitted to relate baseline characteristics to outcome. Our analyses included 7471 predominantly male patients. Overall, 222 deaths were registered of whom 58% were cardiovascular. The incidence of the primary outcome was 42 per 1000 person-years. Comorbidities were strongly and significantly associated with the primary outcome (multivariately adjusted hazard ratio HR, 95% confidence interval): severe chronic kidney disease (HR 2.36, 1.44-3.85), uncontrolled diabetes (HR 1.89, 1.50-2.38), resting heart rate ≥ 75 bpm (HR 1.74, 1.30-2.32), history of stroke (HR 1.70, 1.27-2.29), peripheral artery disease (HR 1.48, 1.09-2.01), history of heart failure (HR 1.47, 1.08-2.01) and history of acute myocardial infarction (HR 1.27, 1.05-1.53). Low education and feelings of depression were significantly associated with increased risk. Lifestyle factors such as persistent smoking, insufficient physical activity and central obesity were not significantly related to adverse outcome. Blood pressure and LDL-C levels appeared to be unrelated to cardiovascular events irrespective of treatment. In patients with stabilized CHD, comorbid conditions that may reflect the ubiquitous nature of atherosclerosis, dominate lifestyle-related and other modifiable risk factors in terms of prognosis, at least over a 2-year follow-up period.

Type 2 diabetic patients on renal replacement therapy: Probability to receive renal transplantation and survival after transplantation.

BACKGROUND: Type 2 diabetic (T2DM) patients on renal replacement therapy (RRT) seldom receive a kidney transplant, which is partly due to age and comorbidities. Adjusting for case mix, we investigated whether T2DM patients have equal opportunity for renal transplantation compared to other patients on dialysis, and whether survival after transplantation is comparable. METHODS: Patients who entered RRT in Finland in 2000-2010 (n = 5419) were identified from the Finnish Registry for Kidney Diseases and followed until the end of 2012. Of these, 20% had T2DM, 14% type 1 diabetes (T1DM) and 66% other than diabetes as the cause of ESRD. Uni-/multivariate survival analysis techniques were employed to assess the probability of kidney transplantation after the start of dialysis and survival after transplantation. RESULTS: T2DM patients had a relative probability of renal transplantation of 0.18 (95% CI 0.15-0.22, P<0.001) compared to T1DM patients: this increased to 0.51 (95% CI 0.36-0.72, P<0.001) after adjustment for case mix (age, gender, laboratory values and comorbidities). When T2DM patients were compared to non-diabetic patients, the corresponding relative probabilities were 0.25 (95% CI 0.20-0.30, P<0.001) and 0.59 (95% CI 0.43-0.83, P = 0.002). After renal transplantation when adjusted for age and gender, relative risk of death was 1.25 (95% CI 0.64-2.44, P = 0.518) for T1DM patients and 0.72 (0.43-1.22, P = 0.227) for other patients compared to T2DM patients. CONCLUSIONS: T2DM patients had a considerably lower probability of receiving a kidney transplant, which could not be fully explained by differences in the patient characteristics. Survival within 5 years after transplantation is comparably good in T2DM patients.

Case fatality of acute coronary events is improving even among elderly patients; the FINAMI study 1995-2012.

AIM: To examine trends in incidence and 28-day case fatality of myocardial infarction (MI) in persons aged 75-99 years in four areas of Finland. METHODS AND RESULTS: The Finnish Acute Myocardial Infarction (FINAMI) register is a population-based MI register study, which during 1995-2012 recorded 30561 suspected acute coronary syndromes in persons aged ≥75 years. Of them, 16229 fulfilled the American Heart Association criteria for a definite, probable or possible MI or coronary death. This age-group contributed 56.8% of all MIs of which 62.7% occurred in women. The incidence of MI decreased by -3.3%/year (95% CI -4.2; -2.4) in women aged 75-84 years, and by -1.2%/year (-1.9; -0.5) in women aged 85-99 years, but among men in these age-groups, only a non-significant reduction occurred. The 28-day case fatality of MI was high. In the age-group 75-84 years, it decreased non-significantly by -1.6%/year in men, and significantly by -2.4%/year (-3.9; -0.8) in women. In the age-group 85-99 years, the decrease was more remarkable: -5.1%/year (-7.8; -2.3) and -3.9%/year (-5.5; -2.2), respectively. CONCLUSIONS: In Finland, more than half of MIs occur in the age-group 75-99 years, and most of them in women. The incidence of MI decreased significantly in elderly women but non-significantly in elderly men. The 28-day case fatality decreased especially in the age-group 85-99 years. Key Messages In Finland, more than one half of all myocardial infarctions (MIs) occur in the age-group of 75 years or older. Furthermore, 62.7% of MIs among elderly patients occur among women, although 58.0% of the elderly population are women. The incidence of MI decreased significantly in elderly women but not in elderly men. The 28-day case fatality in elderly patients was high but decreased significantly during the study period 1995-2012. This study provides population-based data on treatment strategies and trends in incidence, event rate, mortality and case fatality of MI in elderly individuals. Elderly patients with acute coronary syndromes still present a remarkable burden to the healthcare system in Finland as well as in many other developed countries. Especially considering the modern trend of reducing hospital resources and shifting patient care to outpatient clinics, the epidemiology of MI in elderly patients remains an important issue for the future planning of the healthcare system.

Time Trends in Lifestyle, Risk Factor Control, and Use of Evidence-Based Medications in Patients With Coronary Heart Disease in Europe: Results From 3 EUROASPIRE Surveys, 1999-2013.

BACKGROUND: The EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events) cross-sectional surveys describe time trends in lifestyle and risk factor control among coronary patients between 1999 and 2013 in Belgium, Czech Republic, Finland, France, Ireland, the Netherlands, Poland, Slovenia, and the United Kingdom as part of the EuroObservational Research Programme under the auspices of European Society of Cardiology. OBJECTIVES: This study sought to describe time trends in lifestyle, risk factor control, and the use of evidence-based medication in coronary patients across Europe. METHODS: The EUROASPIRE II (1999 to 2000), III (2006 to 2007), and IV (2012 to 13) surveys were conducted in the same geographical areas and selected hospitals in each country. Consecutive patients (≤70 years) after coronary artery bypass graft, percutaneous coronary intervention, or an acute coronary syndrome identified from hospital records were interviewed and examined ≥6 months later with standardized methods. RESULTS: Of 12,775 identified coronary patients, 8,456 (66.2%) were interviewed. Proportion of current smokers was similar across the 3 surveys. Prevalence of obesity increased by 7%. The prevalence of raised blood pressure (≥140/90 mm Hg or ≥140/80 mm Hg with diabetes) dropped by 8% from EUROASPIRE III to IV, and therapeutic control of blood pressure improved with 55% of patients below target in IV. The prevalence of low-density lipoprotein cholesterol ≥2.5 mmol/l decreased by 44%. In EUROASPIRE IV, 75% were above the target low-density lipoprotein cholesterol <1.8 mmol/l. The prevalence of self-reported diabetes increased by 9%. The use of evidence-based medications increased between the EUROASPIRE II and III surveys, but did not change between the III and IV surveys. CONCLUSIONS: Lifestyle habits have deteriorated over time with increases in obesity, central obesity, and diabetes and stagnating rates of persistent smoking. Although blood pressure and lipid management improved, they are still not optimally controlled and the use of evidence-based medications appears to have stalled apart from the increased use of high-intensity statins. These results underline the importance of offering coronary patients access to modern preventive cardiology programs.

Trends in long-term prognosis after acute coronary syndrome.

Background Coronary heart disease incidence, mortality and short-term case-fatality have improved substantially during the past decades. Recent changes in the long-term prognosis among survivors of acute coronary syndrome are less well known. Our aim was to investigate the long-term prognosis of acute coronary syndrome. Design An observational myocardial infarction register study. Methods Data was derived from the population based Finnish Myocardial Infarction register. Patients aged 35 or higher, who had their first acute coronary syndrome during 1993-2011 and survived the first 28 days, were included in the analysis ( n = 13,336). Endpoints were fatal and non-fatal cardiovascular disease events and all-cause mortality at one year and three years after the index event. We also compared the prognosis of acute coronary syndrome survivors with the prognosis of an apparently healthy population with the same age, sex and area of residence, derived from the FINRISK study. Results Significant declines over time were observed in the risk of a new cardiovascular disease event. At three year follow-up the age- and study area-adjusted hazard ratio per calendar year was 0.969 (95% confidence interval 0.960-0.977, p = 4.63 × 10-13) among men and 0.969 (95% confidence interval 0.961-0.978, p = 1.01 × 10-11) among women. Despite the improvement in prognosis, the age-standardized three year cardiovascular disease free survival of acute coronary syndrome patients was significantly lower than in the FINRISK control group (for men p = 6.64 × 10-27 and for women p = 2.11 × 10-15). Conclusion The prognosis of acute coronary syndrome survivors has improved during the 18-year period but is still much worse than the prognosis of comparable general population.

EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries.

AIMS: To determine whether the Joint European Societies guidelines on cardiovascular prevention are being followed in everyday clinical practice of secondary prevention and to describe the lifestyle, risk factor and therapeutic management of coronary patients across Europe. METHODS AND RESULTS: EUROASPIRE IV was a cross-sectional study undertaken at 78 centres from 24 European countries. Patients <80 years with coronary disease who had coronary artery bypass graft, percutaneous coronary intervention or an acute coronary syndrome were identified from hospital records and interviewed and examined ≥ 6 months later. A total of 16,426 medical records were reviewed and 7998 patients (24.4% females) interviewed. At interview, 16.0% of patients smoked cigarettes, and 48.6% of those smoking at the time of the event were persistent smokers. Little or no physical activity was reported by 59.9%; 37.6% were obese (BMI ≥ 30 kg/m(2)) and 58.2% centrally obese (waist circumference ≥ 102 cm in men or ≥88 cm in women); 42.7% had blood pressure ≥ 140/90 mmHg (≥140/80 in people with diabetes); 80.5% had low-density lipoprotein cholesterol ≥ 1.8 mmol/l and 26.8% reported having diabetes. Cardioprotective medication was: anti-platelets 93.8%; beta-blockers 82.6%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75.1%; and statins 85.7%. Of the patients 50.7% were advised to participate in a cardiac rehabilitation programme and 81.3% of those advised attended at least one-half of the sessions. CONCLUSION: A large majority of coronary patients do not achieve the guideline standards for secondary prevention with high prevalences of persistent smoking, unhealthy diets, physical inactivity and consequently most patients are overweight or obese with a high prevalence of diabetes. Risk factor control is inadequate despite high reported use of medications and there are large variations in secondary prevention practice between centres. Less than one-half of the coronary patients access cardiac prevention and rehabilitation programmes. All coronary and vascular patients require a modern preventive cardiology programme, appropriately adapted to medical and cultural settings in each country, to achieve healthier lifestyles, better risk factor control and adherence with cardioprotective medications.

Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology.

BACKGROUND: In order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines. METHODS: A total of 6187 patients (18-80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012-2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys. RESULTS: A total of 2846 (46%) patients had no diabetes, 1158 (19%) newly diagnosed diabetes and 2183 (35%) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60%, respectively. A blood pressure target of <140/90 mmHg was achieved in 68, 61, 54% and a LDL-cholesterol target of <1.8 mmol/L in 16, 18 and 28%. Patients with newly diagnosed and previously known diabetes reached an HbA1c <7.0% (53 mmol/mol) in 95 and 53% and 11% of those with previously known diabetes had an HbA1c >9.0% (>75 mmol/mol). Of the patients with diabetes 69% reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (≈40 %) and only 27% of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets. CONCLUSIONS: Despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease.

Prolonged P wave duration predicts stroke mortality among type 2 diabetic patients with prevalent non-major macrovascular disease.

BACKGROUND: Prolonged P wave duration is a marker of delayed inter-atrial conduction which may predict cardiovascular disease (CVD). Type 2 diabetes is a risk factor for all atherosclerotic manifestations including stroke. We evaluated the prognostic significance of prolonged P wave duration among middle-aged Finnish type 2 diabetes patients with and without prevalent non-major macrovascular disease (PNMMVD) with respect to total and stroke mortality. METHODS: We followed up for 18 years 739 type 2 diabetic patients without previous major CVD event at baseline. Participants were stratified according to P wave duration (<114 or ≥ 114 ms) and PNMMVD (i.e. coronary heart disease defined as ischaemic ECG changes and typical symptoms of angina pectoris, or claudication; yes or no). The Cox proportional hazards model was used to estimate the joint association between P wave duration, PNMMVD and the mortality risk. RESULTS: During the follow-up, 509 patients died, and 59 of them died from stroke. Those who had prolonged P wave duration had 2.45 (95% confidence interval: 1.11-5.37) increased stroke mortality among PNMMVD patients. In patients without PNMMVD, there was no relationship between P wave duration and stroke mortality. CONCLUSIONS: As an easily measurable factor P wave duration merits further studies with higher number of patients to evaluate its importance in the estimation of stroke risk in type 2 diabetic patients with PNMMVD.

Effect of fatty and lean fish intake on lipoprotein subclasses in subjects with coronary heart disease: a controlled trial.

BACKGROUND: Fish oil intake reduces serum triglycerides; however, little is known about the effects of dietary fish intake on lipoprotein subclasses. OBJECTIVE: We aimed at assessing the effect of fatty and lean fish intake on the lipoprotein subclasses in an intervention study. METHODS: The intervention study included 33 patients with coronary heart disease, who were aged 61.0 ± 5.8 (mean ± SD) years. The subjects were randomly assigned to a fatty fish (n = 11), lean fish (n = 12), or control (n = 10) diet for 8 weeks. Fish diets included at least 4 fish meals per week. Subjects in the control group consumed lean beef, pork, and chicken. Lipoprotein subclasses and their lipid components were determined by nuclear magnetic resonance spectroscopy. RESULTS: Concentrations of n-3 fatty acids and docosahexaenoic acid increased in the fatty fish group. The concentrations of cholesterol, cholesterol esters, and total lipids in very large high-density lipoproteins (HDLs) increased in the fatty fish group (overall difference P = .005, P = .002, and P = .007, respectively; false discovery rate P = .04, P = .04, and P = .05, respectively). The mean size of HDL particles increased in the fatty fish group (9.8 ± 0.3 nm at baseline and 9.9 ± 0.4 nm at end of study; overall difference P = .004, false discovery rate P = .04). The fish diets did not affect very-low-density lipoprotein or low-density lipoprotein size. CONCLUSION: Fatty fish intake at least 4 times per week increases HDL particle size which might have beneficial effect in patients with coronary heart disease.

Prognosis of acute coronary events is worse in patients living alone: the FINAMI myocardial infarction register.

BACKGROUND: Single living has been associated with a worse prognosis of acute coronary syndrome (ACS). We aimed to study the relation of sociodemographic characteristics to the morbidity, mortality, and case fatality (CF) of ACS in a large population-based ACS register. METHODS: The population-based FINAMI myocardial infarction register recorded 15,330 cases of ACS among persons aged 35-99 years in Finland in 1993-2002. Record linkage with the files of Statistics Finland provided information on sociodemographic characteristics (marital status, household size). RESULTS: ACS incidence and 28-day mortality rate were higher in unmarried men and women in all age groups. The prehospital CF of incident ACS was higher in single living and/or unmarried 35-64-year-old people. The 28-day CF was 26% (95% confidence interval, CI, 24-29%) in married men, 42% (95% CI 37-47%) in men who had previously been married, and 51% (95% CI 46-57%) in never-married men. Among women, the corresponding figures were 20% (95% CI 15-24%), 32% (95% CI 25-39%), and 43% (95% CI 31-56%). Most of these CF differences were apparent already at the prehospital phase. The only difference in treatment was that middle-aged men living alone or unmarried received thrombolysis less often. The disparities in ACS morbidity and mortality by marital status tended to widen during the study period. CONCLUSIONS: Single living and/or being unmarried increases the risk of having a heart attack and worsens its prognosis both in men and women regardless of age. Most of the excess mortality appears already before the hospital admission and seems not to be related to differences in treatment of ACS.

Heart rate variability associates with asymptomatic coronary atherosclerosis.

PURPOSE: Heart rate variability (HRV) becomes impaired in symptomatic coronary artery disease (CAD), particularly, after myocardial infarction. The mechanism how CAD results in impairment of cardiac autonomic regulation is not known. Whether it results rather from coronary atherosclerosis itself than myocardial ischemia and myocardial injury has remained elusive. METHODS: Quantitative coronary angiography was performed in 30 subjects without history of myocardial ischemia, but with high familial risk for CAD. HRV was measured from 24-h ambulatory ECG recordings in time and frequency domain and also non-linear HRV variables SD1 and SD2 in Poincare plot were calculated. Myocardial ischemia was excluded by Tc-99m sestamibi scintigraphy at rest and during exercise. RESULTS: Coronary angiography revealed mean diameter stenosis of 32 ± 19 % in left anterior descending coronary artery, 26 ± 16 % in left circumflex coronary artery and 25 ± 20 % in right coronary artery. An inverse correlation was found between pNN50 and global severity of coronary artery diameter stenosis (r = -0.415, p < 0.05). Correspondingly, power of HF spectral component correlated negatively with global extent of coronary atherosclerosis (r = -0.366, p < 0.05). In Poincare plot, SD1/SD2 ratio correlated with global extent (r = -0.394, p < 0.05) and global burden (r = -0.388, p < 0.05) of coronary arteries. CONCLUSIONS: The severity and extent of coronary atherosclerosis were related to a shift of cardiac autonomic regulation towards sympathetic predominance in asymptomatic subjects without evidence of myocardial ischemia.

Does the clinical spectrum of incident cardiovascular disease differ between men and women?

BACKGROUND: Cardiovascular diseases (CVDs) are the main cause of death and disability in the western world. Women are known to be older at the time of first CVD event, but the main types of CVD events and their relative importance and differences compared with men are not well known. Our aim was to evaluate gender differences in the clinical presentation of incident major adverse cardiovascular events (MACE). DESIGN: A population-based study with prospective follow-up. METHODS: We used data from the population-based National FINRISK Surveys from years 1992, 1997, 2002 and 2007. People with prevalent cardiovascular disease were excluded. In total, 27,897 participants (53, 2% women) aged 25-74 years were included in the analyses. RESULTS: During the 292,316 person-years of follow-up, 2573 MACE were identified. MACE were more frequent in men than women (1318; 95% CI 1252-1388 in men vs. 736; 686-789 in women). Men had four times more fatal coronary heart disease (CHD) events (149; 126-174 vs. 39; 28-53) and three times more non-fatal CHD events (512; 471-555 vs. 164; 141-189) than women. Stroke incidence was higher in men than women (268; 238-301 vs. 169; 145-195). Heart failure (HF) incidence did not differ between genders. The relative proportions of MACE categories differed substantially between genders: HF was the most common type among women (50% vs. 30% in men), whereas the most common type among men was CHD (50% vs. 28% in women). CONCLUSIONS: Incident MACE were more common in men than women. HF was the dominant type of MACE in women, whereas CHD dominated in men.

Aging of the population may not lead to an increase in the numbers of acute coronary events: a community surveillance study and modelled forecast of the future.

OBJECTIVE: To examine the incidence, mortality and case fatality of acute coronary syndrome (ACS) in Finland during 1993-2007 and to create forecasts of the absolute numbers of ACS cases in the future, taking into account the aging of the population. DESIGN: Community surveillance study and modelled forecasts of the future. SETTING AND METHODS: Two sets of population-based coronary event register data from Finland (FINAMI and the National Cardiovascular Disease Register (CVDR)). Bayesian age-period-cohort (APC) modelling. PARTICIPANTS: 24 905 observed ACS events in the FINAMI register and 364 137 in CVDR. MAIN OUTCOME MEASURES: Observed trends of ACS events during 1993-2007, forecasted numbers of ACS cases, and the prevalence of ACS survivors until the year 2050. RESULTS: In the FINAMI register, the average annual declines in age-standardised incidence of ACS were 1.6% (p<0.001) in men and 1.8% (p<0.001) in women. For 28-day case fatality of incident ACS, the average annual declines were 4.1% (p<0.001) in men and 6.7% (p<0.001) in women. Findings in the country-wide CVDR data were consistent with the FINAMI register. The APC model, based on the CVDR data, suggested that both the absolute numbers of ACS events and the prevalence of ACS survivors reached their peak in Finland around 1990, have declined since then, and very likely will continue to decline until 2050. CONCLUSIONS: The ACS event rates and absolute numbers of cases have declined steeply in Finland. The declining trends are likely to continue in the future despite the aging of the population.

Residual risk of cardiovascular mortality in patients with coronary heart disease: the EUROASPIRE risk categories.

BACKGROUND: The EUROASPIRE I, II and III surveys revealed high prevalences of modifiable risk factors in the high priority group of coronary patients all over Europe. The potential to further reduce coronary heart disease (CHD) morbidity and mortality rates is still considerable. We report here on the relative risk of cardiovascular disease (CVD) death associated with common modifiable risk factor levels based on the mortality follow-up of patients participating in the first two EUROASPIRE surveys. We also present a novel simple risk classification system (ERC) that can be used in the management of patients with existing CHD. METHODS: The study cohort consisted of a consecutive sample of CHD patients aged ≤ 70 years from 12 European countries. Baseline data gathered in 1995-2000 through standardized methods, were linked to cardiovascular mortality in 5216 patients according to an accelerated failure time model. RESULTS: During 28,143 person-years of follow-up, 332 patients died from cardiovascular disease denoting a CVD mortality risk of 12.3 per 1000 person-years in men and 10.2 per 1000 person-years in women. In multivariate analysis, fasting glucose, total cholesterol and smoking emerged as the strongest independent modifiable predictors of cardiovascular mortality. CONCLUSIONS: The results of the mortality follow-up of the EUROASPIRE I and II CHD patients emphasize the continuing risk from elevated glucose and total cholesterol levels and underline the importance of smoking cessation in secondary prevention. The ERC risk tool that we developed may prove helpful to obtain these goals in the setting of secondary prevention.