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.

[Life after stroke--a new national study. Renewed follow-up of stroke patients shows increased dependency on the support from the next-of-kin]. / Livet efter stroke--ny nationell studie. Förnyad uppföljning av strokedrabbade visar okande beroende av anhöriga.

The National Board of Health and Welfare together with Riks-Stroke (the Swedish National Registry for Quality Assessment of Acute Stroke Care) initiated a follow-up 2 years after a stroke event in 10,303 individuals, registrated in Riks-Stroke during the first 6 months of 2001. The aim was to evaluate the health status of the patients and the burden and needs of the spouses. 6,695 patients (65 percent) were alive. 4,729 patients (71 percent) answered the questionnaire. 2,367 spouses answered a separate questionnaire. This study was compared with an almost identical study performed four years earlier. The results showed that more patients lived at home and were satisfied with help and support. Rehabilitation was still deficient for 30 percent, and more patients were highly dependent on support from next-of-kin. Thirty percent could stay alone less than half a day. These results will be used for improving rehabilitation for the stroke patients and support for their spouses.

Cardiovascular events in elderly patients with isolated systolic hypertension. A subgroup analysis of treatment strategies in STOP-Hypertension-2.

OBJECTIVE: To perform a subgroup analysis on those patients in STOP-Hypertension-2 who had isolated systolic hypertension. DESIGN AND METHODS: The STOP-Hypertension-2 study evaluated cardiovascular mortality and morbidity in elderly hypertensives comparing treatment with conventional drugs (diuretics, beta-blockers) with that of newer ones [angiotensin-converting enzyme (ACE) inhibitors, calcium antagonists]. In all, 6614 elderly patients with hypertension (mean age 76.0 years, range 70-84 years at baseline) were included in STOP-Hypertension-2. In the present subgroup analysis of STOP-Hypertension-2, isolated systolic hypertension was defined as systolic blood pressure at least 160 mmHg and diastolic blood pressure below 95 mmHg, in accordance with the Syst-Eur and Syst-China study criteria. In total, 2280 patients in STOP-Hypertension-2 met these criteria. In the study, patients were randomized to one of three treatment groups: "conventional" antihypertensive therapy with beta-blockers or diuretics (atenolol 50 mg, metoprolol 100 mg, pindolol 5 mg, or fixed-ratio hydrochlorothiazide 25 mg plus amiloride 2.5 mg daily); ACE inhibitors (enalapril 10 mg or lisinopril 10 mg daily); or calcium antagonists (felodipine 2.5 mg or isradipine 2.5 mg daily). Analysis was by intention to treat. RESULTS: The blood pressure lowering effect in patients with systolic hypertension was similar with all three therapeutic regimens: 35/13 mmHg in the conventional group (n=717), 34/12 mmHg in the ACE inhibitor group (n = 724), and 35/13 mmHg in the calcium antagonist group (n=708). Prevention of cardiovascular mortality, the primary endpoint of the study, did not differ between the three treatment groups. All stroke events, i.e. fatal and non-fatal stroke together, were significantly reduced by 25% in the newer-drugs group compared with the conventional group (95% CI 0.58-0.97; p=0.027). This difference was attributable to reduction of non-fatal stroke while fatal stroke events did not differ between groups. New cases of atrial fibrillation were significantly increased by 43% (95% CI 1.02-1.99; p=0.037) on "newer" drugs compared with "conventional" therapy, mainly attributable to the calcium antagonists. There were no significant differences between the three treatment groups with respect to the risks of myocardial infarction, sudden death or congestive heart failure. CONCLUSIONS: The analysis demonstrated that "newer" therapy (ACE inhibitors/calcium antagonists) was significantly better (25%) than "conventional" (diuretics/beta-blockers) in preventing all stroke in elderly patients with isolated systolic hypertension.

Large variations in the use of oral anticoagulants in stroke patients with atrial fibrillation: a Swedish national perspective.

OBJECTIVES: To explore nation-wide use of anticoagulation in stroke patients with atrial fibrillation, in routine clinical practice in Sweden. DESIGN: Cross-sectional cohort study. SETTING: Patients included in Riks-Stroke, the Swedish national quality register for stroke care, during 2001. SUBJECTS: Hospitals with incomplete coverage were excluded, leaving 4538 stroke patients with atrial fibrillation amongst 18 276 stroke patients from 75 hospitals in six health care regions. MAIN OUTCOME MEASURE: Treatment with oral anticoagulants. RESULTS: At stroke onset, the proportion of patients with atrial fibrillation and first-ever stroke, receiving oral anticoagulants as primary prevention was 11.0% (range 8.4-13.5% between regions and 2.5-24.4% between hospitals). Younger age, male sex and diabetes at stroke onset independently predicted primary prevention with oral anticoagulants. The proportion of stroke patients with atrial fibrillation receiving oral anticoagulants as secondary prevention at discharge was 33.5% (range 29.9-40.6% between regions and 16.4-61.9% between hospitals). Independent predictors for secondary prevention were younger age, male sex and independent activities of daily life (ADL) function before the stroke, being discharged to home, being fully conscious on admission and health care region. CONCLUSION: There were variations between hospitals and regions that differences in age, sex, functional impairments and comorbidities could not fully explain. This indicates that evidence-based primary and secondary prevention of embolic stroke is insufficiently practised. Local factors seem to determine whether patients with atrial fibrillation gain access to optimal prevention of stroke or not.

[Stroke--and then? Considerable need of assistance two year after stroke according to a large nation-wide study]. / Slaganfall--och sedan? Omfattande hjälpbehov två år efter slaganfallet, visar stor nationell studie.

The National Board of Health and Welfare together with Riks-Stroke (the Swedish National Registry for Quality Assessment of Acute Stroke Care) were commissioned by the government to study the circumstances of 4,023 stroke patients, two years after the event. Both physical and psychological impairments together with psychosocial consequences were common. Approximately one fifth of the patients did not receive enough help and support, and the most common reason for this was the high cost. Instead many were dependent upon next-of-kin. This indicates that the long-term care of stroke patients needs to be improved.

Differences in long-term outcome between patients treated in stroke units and in general wards: a 2-year follow-up of stroke patients in sweden.

BACKGROUND AND PURPOSE: The long-term beneficial effects of stroke unit care have been proved in several randomized trials. However, there is a question of large-scale applicability in routine clinical practice of interventions used by dedicated investigators in small randomized trials. The objective of this study was to compare, 21/2 years after stroke, patients who had been treated in stroke units and those treated in general wards in routine clinical practice. METHODS: This is a prospective cohort study based on 8194 patients who were included, during the first 6 months in 1997, in Riks-Stroke, the Swedish National Register for quality assessment of acute stroke. Two years after the event, 5189 patients were still alive and 5104 were followed up with a postal questionnaire to which 4038 responded. RESULTS: Among the group of patients who were independent in activities of daily living (ADL) functions before the stroke, patients who were treated in stroke units were less often dependent in ADL functions, after adjustment for case mix (OR, 0.79; CI, 0.66 to 0.94). If they also lived at home before the stroke, then they had a lower case-fatality rate 2 years after the stroke (OR, 0.81; CI, 0.72 to 0.92). CONCLUSIONS: Long-term beneficial effects of treatment in stroke units were shown for patients who were independent in ADL functions before the stroke. No benefits were shown for patients who were dependent on help for primary ADL before the stroke. Further studies on this group of patients with more detailed outcome measures are needed.

Comparison of antihypertensive treatments in preventing cardiovascular events in elderly diabetic patients: results from the Swedish Trial in Old Patients with Hypertension-2. STOP Hypertension-2 Study Group.

BACKGROUND: The benefits of treating hypertension in elderly diabetic patients, in terms of achieving reductions in cardiovascular morbidity and mortality, have been documented in several recent prospective trials. There has, however, been some controversy regarding the effect of different antihypertensive drugs on the frequency of myocardial infarction in this group of patients. DESIGN: STOP Hypertension-2 was a prospective, randomized, open trial with blinded endpoint evaluation. METHODS: We studied 6614 elderly patients aged 70-84 years; 719 of them had diabetes mellitus at the start of the study (mean age 75.8 years). Patients were randomly assigned to one of three treatment strategies: conventional antihypertensive drugs (diuretics or beta-blockers), calcium antagonists, or angiotensin converting enzyme (ACE) inhibitors. RESULTS: Reduction in blood pressure was similar in the three treatment groups of diabetics. The prevention of cardiovascular mortality was also similar; the frequency of this primary endpoint did not differ significantly between the three groups. There were, however, significantly fewer (P = 0.025) myocardial infarctions during ACE inhibitor treatment (n = 17) than during calcium antagonist treatment (n = 32; relative risk 0.51, 95% confidence interval 0.28-0.92); but a (non-significant) tendency to more strokes during ACE inhibitor treatment (n = 34 compared with n = 29; relative risk 1.16, 95% confidence interval 0.71-1.91). CONCLUSION: Treatment of hypertensive diabetic patients with conventional antihypertensive drugs (diuretics, beta-blockers, or both) seemed to be as effective as treatment with newer drugs such as calcium antagonists or ACE inhibitors.

Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study.

BACKGROUND: The efficacy of new antihypertensive drugs has been questioned. We compared the effects of conventional and newer antihypertensive drugs on cardiovascular mortality and morbidity in elderly patients. METHODS: We did a prospective, randomised trial in 6614 patients aged 70-84 years with hypertension (blood pressure > or = 180 mm Hg systolic, > or = 105 mm Hg diastolic, or both). Patients were randomly assigned conventional antihypertensive drugs (atenolol 50 mg, metoprolol 100 mg, pindolol 5 mg, or hydrochlorothiazide 25 mg plus amiloride 2.5 mg daily) or newer drugs (enalapril 10 mg or lisinopril 10 mg, or felodipine 2.5 mg or isradipine 2-5 mg daily). We assessed fatal stroke, fatal myocardial infarction, and other fatal cardiovascular disease. Analysis was by intention to treat. FINDINGS: Blood pressure was decreased similarly in all treatment groups. The primary combined endpoint of fatal stroke, fatal myocardial infarction, and other fatal cardiovascular disease occurred in 221 of 2213 patients in the conventional drugs group (19.8 events per 1000 patient-years) and in 438 of 4401 in the newer drugs group (19.8 per 1000; relative risk 0.99 [95% CI 0.84-1.16], p=0.89). The combined endpoint of fatal and non-fatal stroke, fatal and non-fatal myocardial infarction, and other cardiovascular mortality occurred in 460 patients taking conventional drugs and in 887 taking newer drugs (0.96 [0.86-1.08], p=0.49). INTERPRETATION: Old and new antihypertensive drugs were similar in prevention of cardiovascular mortality or major events. Decrease in blood pressure was of major importance for the prevention of cardiovascular events.

[Stroke unit care saves lives. The Swedish national quality assessment registry of stroke care is the first of its kind in the world]. / Vård på stroke-enhet räddar liv. Sverige först i världen med nationellt kvalitetsregister för slaganfall.

Meta-analyses of randomised trials of acute stroke treated in specialised stroke units have yielded convincing evidence of benefits in terms of reduced mortality rates, as compared with treatment in a general ward. However, no studies had been performed to ascertain whether the promising results could be reproduced in routine clinical practice. Accordingly, a comparison of routine care of acute stroke patients in stroke units (SUs) with that in general wards (GWs) was made on the basis of data for the 14,300 cases of acute stroke from 87 units in 80 Swedish hospitals registered in 1996 at the Swedish national stroke registry, the first of its kind in the world. Among patients capable of independent daily life and fully conscious at admission, the mortality rate was lower in the SU than in the GW subgroup, both at discharge from hospital and three months after the stroke event; and three months after stroke, a greater proportion of SU patients had been discharged to their homes, and a smaller proportion were in long-term care. However, no such subgroup differences were found among patients with impaired consciousness at admission. Thus, the promising results of the randomised trials of SU treatment would appear to be reproducible in routine clinical practice, though the beneficial effect is smaller in magnitude.

Efeito da inibicao da enzima conversora da angiotensina em comparacao com a terapeutica convencional sobre a morbidade e a mortalidade cardiovasculares na hipertensao: estudo randomizado Projeto Prevencao Captopril(CAPPP) / Effect of angiotensin-converting-enzime inhibition compared with conventional theraphy on cardiovascular morbidity and mortality in hypertension: the captopril Prevention Project(CAPPP) randomised trial

Os inibidores da enzima conversora da angiotensina (ECA) tem sido utilizados durante mais de uma decada para o tratamento do aumento da pressao arterial,apesar da ausencia de dados a aprtir de estudos randomizados de intervencao que tenham demosnstrado que esse tipo de tratamento afeta a morbidade e a mortalidade cardiovasculares.O trabalho denomnado Projeto Prevencao Captopril-Captopril Prevention Project(CAPPP) e um estudo randomizado de intervencao para comparacao dos efeitos da inibicao da ECA e da terapeutica convencional sobre a morbidade cardiovasculares em pacientes com hipertensao.O CAPPP foi um estudo prospectivo,randomizado de tipo aberto com avaliacao cega dos objetivos finais.Foram incluidos 10.985 pacientes em 536 centros de saude na Suecia e na Finlandia.Os pacientes com idades entre 25 e 66 anos cuja medicao da pressao arterial diastolica registrou 100 mmHg ou mais,em duas oportunidades,foram randomizados para o captopril ou para o tratamento antihipertensivo convencional(diureticos,beta-bloqueadores)

Stroke units in their natural habitat: can results of randomized trials be reproduced in routine clinical practice? Riks-Stroke Collaboration.

BACKGROUND AND PURPOSE: Meta-analyses of randomized controlled trials of acute stroke care have shown care in stroke units (SUs) to be superior to that in conventional general medical, neurological, or geriatric wards, with reductions in early case fatality, functional outcome, and the need for long-term institutionalization. This study examined whether these results can be reproduced in clinical practice. METHODS: A multicenter observational study of procedures and outcomes in acute stroke patients admitted to designated SUs or general medical or neurological wards (GWs), the study included patients of all ages with acute stroke excluding those with subarachnoid hemorrhage, who were entered into the Riks-Stroke (Swedish national quality assessment) database during 1996 (14 308 patients in 80 hospitals). RESULTS: Patients admitted to SUs who had lived independently and who were fully conscious on admission to the hospital had a lower case fatality than those cared for in GWs (relative risk [RR] for death, 0.87; 95% confidence interval [CI], 0.79 to 0.96) and at 3 months (RR, 0.91; 95% CI, 0.85 to 0.98). A greater proportion of patients cared for in an SU could be discharged home (RR, 1.06; 95% CI, 1.03 to 1.10), and fewer were in long-term institutional care 3 months after the stroke (RR, 0.94; 95% CI, 0.89 to 0.99). No difference was seen in outcome in patients cared for in SUs or GWs if they had impaired consciousness on admission. CONCLUSIONS: The improvement in outcomes after stroke care in SUs compared with care in GWs can be reproduced in the routine clinical setting, but the magnitude of the benefit appears smaller than that reported from meta-analyses.

Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPPP) randomised trial.

BACKGROUND: Angiotensin-converting-enzyme (ACE) inhibitors have been used for more than a decade to treat high blood pressure, despite the lack of data from randomised intervention trials to show that such treatment affects cardiovascular morbidity and mortality. The Captopril Prevention Project (CAPPP) is a randomised intervention trial to compare the effects of ACE inhibition and conventional therapy on cardiovascular morbidity and mortality in patients with hypertension. METHODS: CAPPP was a prospective, randomised, open trial with blinded endpoint evaluation. 10,985 patients were enrolled at 536 health centres in Sweden and Finland. Patients aged 25-66 years with a measured diastolic blood pressure of 100 mm Hg or more on two occasions were randomly assigned captopril or conventional antihypertensive treatment (diuretics, beta-blockers). Analysis was by intention-to-treat. The primary endpoint was a composite of fatal and non-fatal myocardial infarction, stroke, and other cardiovascular deaths. FINDINGS: Of 5492 patients assigned captopril and 5493 assigned conventional therapy, 14 and 13, respectively, were lost to follow-up. Primary endpoint events occurred in 363 patients in the captopril group (11.1 per 1000 patient-years) and 335 in the conventional-treatment group (10.2 per 1000 patient-years; relative risk 1.05 [95% CI 0.90-1.22], p=0-52). Cardiovascular mortality was lower with captopril than with conventional treatment (76 vs 95 events; relative risk 0.77 [0.57-1-04], p=0.092), the rate of fatal and non-fatal myocardial infarction was similar (162 vs 161), but fatal and non-fatal stroke was more common with captopril (189 vs 148; 1.25 [1-01-1-55]. p=0.044). INTERPRETATION: Captopril and conventional treatment did not differ in efficacy in preventing cardiovascular morbidity and mortality. The difference in stroke risk is probably due to the lower levels of blood pressure obtained initially in previously treated patients randomised to conventional therapy.

The Captopril Prevention Project (CAPPP) in hypertension--baseline data and current status.

The Captopril Prevention Project (CAPPP) is an ongoing intervention study conducted in 11,019 hypertensive patients in Sweden and Finland. Patients have been randomized to receive either conventional antihypertensive therapy (diuretics and/or beta-blockers) or captopril-based treatment. A prospective, randomized, open, blinded-endpoint evaluation (PROBE) study design is used to compare these two therapeutic regimens as regards cardiovascular morbidity and mortality. The rationale for the CAPPP Study are the many observations of beneficial effects of ACE inhibition, as compared to diuretics and beta-blockers, on intermediary endpoints such as insulin sensitivity, serum lipoproteins, left ventricular hypertrophy and renal function. Captopril has also been shown to be markedly effective in the treatment of left ventricular dysfunction as well as congestive heart failure. The hypothesis is that these differences might result in improved risk reduction when ACE inhibitors are used in the treatment of hypertension. The present paper describes the baseline data and the changes in blood pressure during the first year in the total cohort. During the first year the average blood pressure was reduced by 11/8 mm Hg. A number of substudies have been conducted in the CAPPP Study. In one of these insulin sensitivity was compared in a subgroup of the patients using the euglycemic insulin clamp technique. In another substudy the ACE gene was sequenced and some new polymorphisms were discovered. Several other substudies are in progress or in the planning phase. The main results of the CAPPP Study should be available by mid-1998. Some of the intended anayses of the final results as well as other planned substudies are briefly described here.

The Swedish Trial in old patients with hypertension-2 (STOP-hypertension-2): a progress report.

OBJECTIVE: The Swedish Trial in Old Patients with Hypertension-2 (STOP-Hypertension-2) was designed by a project group of the Swedish Hypertension Society to test whether the "newer" treatment alternatives (ACE inhibitors and calcium antagonists) are as good as, better or less good than, the "older" ones (beta-blockers and diuretics) in terms of preventing cardiovascular morbidity and mortality in elderly hypertensives. The aim of the present paper is to report on the progress of the study. DESIGN: Prospective, open trial with blinded end-point committee and centralized randomization (PROBE design). STOP-Hypertension-2 may be regarded as a scientific follow-up of the previously published Swedish Trial in Old Patients with Hypertension (STOP-Hypertensioon-1) (6) using the same study organization. SUBJECTS: By the end of 1994 when recruitment was stopped, 6628 hypertensive men (34%) and women (66%) aged 70-84 (mean age 76) had been included at 312 Swedish health centres (out of approximately 850). In the whole cohort 11% are diabetics and 9% smokers. The mean total cholesterol value is 6.5 mmol/L. RESULTS: In the whole study cohort, blood pressure was lowered from 194/98 mmHg to 167/85 mmHg after one year. At the end of 1995, 319 fatal events (all-cause mortality) had been reported, corresponding to a mortality rate of 21.3 per 1000 person-years. CONCLUSION: In STOP-Hypertension-2, 6628 elderly hypertensive have been randomized to three different treatment regimes: beta-blocker+diuretics (the active treatment arm in STOP-Hypertension-1), ACE inhibitors, or calcium antagonists. Their average lowering of blood pressure was 27/13 mmHg and end-points have occurred at the expected rate. Thus, it should be possible to terminate STOP-Hypertension-2 within two to three years.

Magnesium therapy, fibrinolytic parameters and von Willebrand factor in acute myocardial infarction.

Sixty-one patients with non-thrombolytic treated acute myocardial infarction were randomised to open magnesium infusion or control. tPA activity, tPA mass, PAI-1 mass and von Willebrand factor (vWF) were measured in blood samples drawn at entrance and after on average 10 h and 18 h following inclusion in the trial. No differences for the hemostatic variables assay type were detected between the two groups. Fluctuations in the fibrinolytic parameters were maintained in the magnesium group, but blunted in the control group regarding PAI-mass and tPA-activity. This study gives no evidence that magnesium infusion in acute myocardial infarction influences fibrinolytic parameters or vWF.

Skeletal muscle magnesium and potassium in asthmatics treated with oral beta 2-agonists.

Dietary magnesium has been shown to be important for lung function and bronchial reactivity. Interest in electrolytes in asthma has so far mainly been focused upon serum potassium, especially linked to beta 2-agonist treatment. It is known that serum levels of magnesium and potassium may not correctly reflect the intracellular status. We therefore investigated whether asthmatics treated with oral beta 2-agonists had low magnesium or potassium in skeletal muscle and serum, and whether withdrawal of the oral beta 2-agonists would improve the electrolyte levels. Magnesium and potassium levels in skeletal muscle biopsies, serum and urine were analysed in 20 asthmatics before and 2 months after withdrawal of long-term oral beta 2-agonists, and for comparison in 10 healthy subjects. Skeletal muscle magnesium in the asthmatics was lower both before (3.62 +/- 0.69 mmol.100 g-1 (mean +/- SD)) and after (3.43 +/- 0.60 mmol.100 g-1) withdrawal of oral beta 2-agonists compared with the controls (4.43 +/- 0.74 mmol.100 g-1). Skeletal muscle potassium and serum magnesium did not differ between the groups. Serum potassium was significantly lower both before (4.0 +/- 0.2 mmol.L-1) and after (3.9 +/- 0.2 mmol.L-1) the withdrawal of oral beta 2-agonists compared with the control group (4.2 +/- 0.2 mmol.L-1). The asthmatics had lower skeletal muscle magnesium and lower serum potassium than the healthy controls, both with and without oral beta 2-agonists. Whether the findings are related to asthma pathophysiology or treatment is currently being investigated.

Effects of intravenous magnesium sulphate in suspected acute myocardial infarction on acute arrhythmias and long-term outcome.

A total of 252 patients with suspected acute myocardial infarction were included in a double blind study and randomised to 50 mmol magnesium sulfate infusion under 20 h or corresponding placebo. Acute myocardial infarction was verified in 117 patients and 59% of these had concomitant treatment with thrombolysis. One-hundred ninety-four patients had Holter registrations during the first day in the coronary care unit. Intention-to-treat analysis showed an increase in long RR-intervals (> 3 s) in the magnesium treated group (P = 0.006) and a tendency toward a reduction in episodes of ventricular premature complexes in triplets (P = 0.09). During hospital stay and a mean of 22 months follow-up, 23 fatal events occurred in the magnesium allocated group and 31 fatal events among the placebo allocated group (P = 0.1). Mortality rate from cardiac disease was reduced by 54% (95% C.I. 30-99%, P < 0.05). Subgroup analysis on acute myocardial infarction patients showed a 48% mortality risk reduction in the magnesium treated acute myocardial infarction group compared to the placebo treated acute myocardial infarction group (95% C.I. 23-104%, P = 0.06). There was no significant interaction between the effects of magnesium and thrombolytic treatment on total mortality or cardiac events. This study supports the results of other small double blind placebo controlled studies regarding effects of magnesium therapy on mortality in acute myocardial infarction, but are in discordance to the conclusion from the ISIS-4 study. The reasons for these discrepancies cannot be elucidated by our data.

Costs of stroke in Sweden. A national perspective.

BACKGROUND AND PURPOSE: Cost-effectiveness analyses of stroke management are hampered by paucity of economic data. We made an update of the direct and indirect costs of stroke in Sweden (population, 8.5 million). METHODS: Direct costs (ie, the costs for hospital and outpatient care and social services) were estimated on the basis of two prospective population-based studies of stroke and of two nationwide cross-sectional inventories of bed-days and diagnoses. Indirect costs (ie, the costs for loss of productivity and early retirement) were based on official statistics. RESULTS: The direct annual costs of care for stroke patients in 1991 equaled 7836 million Swedish krona (SKr) ($1306 million in US dollars), and the indirect costs, 2430 million SKr ($405 million). The cost of stroke care was 1208 SKr ($201) per inhabitant in Sweden. The expected direct costs per patient from first stroke to death were 440,000 SKr ($73,333). When prestroke costs for other diseases and advanced age were subtracted, the sum was reduced to 180,000 SKr ($30,000). CONCLUSIONS: Costs for hospital and outpatient care and social services accounted for 76% of Swedish stroke costs and for 24% of costs for loss of production and early retirement. Only 41% of direct costs were stroke-related.

Nutritional magnesium supplementation does not change blood pressure nor serum or muscle potassium and magnesium in untreated hypertension. A double-blind crossover study.

The aim of this study was to evaluate if a nutritional dose of magnesium given orally changes the blood pressure in untreated hypertensive patients and if orally-given magnesium had any influence on serum and muscle magnesium and potassium. A randomized, double-blind crossover study design was followed with magnesium 15 mmol/day or placebo treatment for two months. Thirty-nine patients aged 20-59 years, were treated. Samples for magnesium and potassium in blood, muscle and urine were taken at entry time, after two months (crossover time) and after four months (end of study). Systolic and diastolic supine and standing blood pressures were measured at the same times. No significant change in blood pressure, serum or muscle concentrations of electrolytes were observed on magnesium treatment. Urine magnesium rose significantly on magnesium, and it decreased significantly on placebo. Therefore results suggest that 15 mmol magnesium/day, given to untreated mild-to-moderate hypertensives does not alter blood pressure nor the concentrations of magnesium and potassium in serum and muscle, in patients with normal magnesium turnover.