Behavioral factors predict all-cause mortality in female coronary patients and healthy controls over 26 years - a prospective secondary analysis of the Stockholm Female Coronary Risk Study.

OBJECTIVE: The prognosis of coronary artery disease (CAD) is related to its severity and cardiovascular risk factors in both sexes. In women, social isolation, marital stress, sedentary lifestyle and depression predicted CAD progression and outcome within 3 to 5 years. We hypothesised that these behavioral factors would still be associated with all-cause mortality in female patients after 26 years. METHODS: We examined 292 patients with CAD and 300 healthy controls (mean age of 56 ± 7 y) within the Fem-Cor-Risk-Study at baseline. Their cardiac, behavioral, and psychosocial risk profiles, exercise, smoking, and dietary habits were assessed using standardized procedures. Physiological characteristics included a full lipid profile, the coagulation cascade and autonomic dysfunction (heart rate variability, HRV). A new exploratory analysis using machine-learning algorithms compared the effects of social and behavioral mechanisms with standard risk factors. Results: All-cause mortality records were completed in 286 (97.9%) patients and 299 (99.7%) healthy women. During a median follow-up of 26 years, 158 (55.2%) patients and 101 (33.9%) matched healthy controls died. The annualized mortality rate was 2.1% and 1.3%, respectively. After controlling for all available confounders, behavioral predictors of survival in patients were social integration (HR 0.99, 95% CI 0.99-1.0) and physical activity (HR 0.54, 95% CI 0.37-0.79). Smoking acted as a predictor of all-cause mortality (HR 1.56, 95% CI 1.03-2.36). Among healthy women, moderate physical activity (HR 0.42, 95% CI 0.24-0.74) and complete HRV recordings (≥50%) were found to be significant predictors of survival. CONCLUSIONS: CAD patients with adequate social integration, who do not smoke and are physically active, have a favorable long-term prognosis. The exact survival times confirm that behavioral risk factors are associated with all-cause mortality in female CAD patients and healthy controls.

Association of rotating shift work schedules and the use of prescribed sleep medication: A prospective cohort study.

We examined whether working rotating shifts, with or without night work, is associated with the purchase of prescribed sleep medication, and whether the association is dependent on age. Data were obtained from a longitudinal cohort study of Finnish public sector employees who responded to questions on work schedule and background characteristics in 2000, 2004 and 2008. The data were linked to national register data on redeemed prescriptions of hypnotic and sedative medications, with up to 11 years of follow-up. Age stratified Cox proportional hazard regression models were computed to examine incident use of medication comparing two groups of rotating shift workers (those working shifts that included night shifts and those whose schedules did not include night shifts) with day workers who worked in a similar range of occupations. Shift work with night shifts was associated with increased use of sleep medication in all age groups, after adjustments for sex, occupational status, marital status, alcohol consumption, smoking and physical activity levels (hazard ratio [HR], [95% confidence interval, CI] 1.14 [1.01-1.28] for age group ≤39 years; 1.33 [1.19-1.48] for age group 40-49 years; 1.28 [1.13-1.44] for age group ≥50 years). Shift work without nights was associated with medication use in the two older age groups (HR [95% CI] 1.14 [1.01-1.29] and 1.17 [1.05-1.31] for age groups 40-49 years and >50 years, respectively). These findings suggest that circadian disruption and older age puts rotating shift workers, and especially those who work nights, at increased risk of developing clinically significant levels of sleep problems.

Job Strain as a Risk Factor for Peripheral Artery Disease: A Multi-Cohort Study.

Background Job strain is implicated in many atherosclerotic diseases, but its role in peripheral artery disease (PAD) is unclear. We investigated the association of job strain with hospital records of PAD, using individual-level data from 11 prospective cohort studies from Finland, Sweden, Denmark, and the United Kingdom. Methods and Results Job strain (high demands and low control at work) was self-reported at baseline (1985-2008). PAD records were ascertained from national hospitalization data. We used Cox regression to examine the associations of job strain with PAD in each study, and combined the study-specific estimates in random effects meta-analyses. We used τ2, I2, and subgroup analyses to examine heterogeneity. Of the 139 132 participants with no previous hospitalization with PAD, 32 489 (23.4%) reported job strain at baseline. During 1 718 132 person-years at risk (mean follow-up 12.8 years), 667 individuals had a hospital record of PAD (3.88 per 10 000 person-years). Job strain was associated with a 1.41-fold (95% CI, 1.11-1.80) increased average risk of hospitalization with PAD. The study-specific estimates were moderately heterogeneous (τ2=0.0427, I2: 26.9%). Despite variation in their magnitude, the estimates were consistent in both sexes, across the socioeconomic hierarchy and by baseline smoking status. Additional adjustment for baseline diabetes mellitus did not change the direction or magnitude of the observed associations. Conclusions Job strain was associated with small but consistent increase in the risk of hospitalization with PAD, with the relative risks on par with those for coronary heart disease and ischemic stroke.

Associations between shift work and use of prescribed medications for the treatment of hypertension, diabetes, and dyslipidemia: a prospective cohort study.

Objective This study examined the associations between shift work and use of antihypertensive, lipid-lowering, and antidiabetic medications. Methods Survey data from two cohorts of Finnish men (N=11 998) and women (N=49 944) working in multiple occupations where shift work was used were linked to national Drug Prescription Register data, with up to 11 years of follow-up. In each cohort, age-stratified Cox proportional hazard regression models were computed to examine any incident use of prescription medication for each of the three medical conditions, separately comparing each of two groups of rotating shift workers (those whose schedules included night shifts, and those whose schedules did not include night shifts) with day workers who worked in a similar range of occupations. Results In the larger cohort, among participants aged 40-49 at baseline, shift work without night shifts was associated with increased use of type-2 diabetes medication after adjustments for sex, occupational status, marital status, alcohol consumption, smoking, and physical activity [hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.01-1.62], while shift work with night shifts was associated with increased use of dyslipidemia medication after adjustments (HR 1.33, 95% CI 1.12-1.57). There were no such associations among younger and older shift workers. Also in the larger cohort, among those aged <50 years at baseline, both types of shift work were associated with increased use of hypertension medication after adjustments [up to HR 1.20 (95% CI 1.05-1.37)]. There were no positive associations in the smaller cohort. Conclusions There was mixed evidence regarding the use of medications for cardiovascular risk factors by shift workers. Selection effects may have affected the associations.

Obesity and loss of disease-free years owing to major non-communicable diseases: a multicohort study.

BACKGROUND: Obesity increases the risk of several chronic diseases, but the extent to which the obesity-related loss of disease-free years varies by lifestyle category and across socioeconomic groups is unclear. We estimated the number of years free from major non-communicable diseases in adults who are overweight and obese, compared with those who are normal weight. METHODS: We pooled individual-level data on body-mass index (BMI) and non-communicable diseases from men and women with no initial evidence of these diseases in European cohort studies from the Individual-Participant-Data Meta-Analysis in Working Populations consortium. BMI was assessed at baseline (1991-2008) and non-communicable diseases (incident type 2 diabetes, coronary heart disease, stroke, cancer, asthma, and chronic obstructive pulmonary disease) were ascertained via linkage to records from national health registries, repeated medical examinations, or self-report. Disease-free years from age 40 years to 75 years associated with underweight (BMI <18·5 kg/m2), overweight (≥25 kg/m2 to <30 kg/m2), and obesity (class I [mild] ≥30 kg/m2 to <35 kg/m2; class II-III [severe] ≥35 kg/m2) compared with normal weight (≥18·5 kg/m2 to <25 kg/m2) were estimated. FINDINGS: Of 137 503 participants from ten studies, we excluded 6973 owing to missing data and 10 349 with prevalent disease at baseline, resulting in an analytic sample of 120 181 participants. Of 47 127 men, 211 (0·4%) were underweight, 21 468 (45·6%) normal weight, 20 738 (44·0%) overweight, 3982 (8·4%) class I obese, and 728 (1·5%) class II-III obese. The corresponding numbers among the 73 054 women were 1493 (2·0%), 44 760 (61·3%), 19 553 (26·8%), 5670 (7·8%), and 1578 (2·2%), respectively. During 1 328 873 person-years at risk (mean follow-up 11·5 years [range 6·3-18·6]), 8159 men and 8100 women developed at least one non-communicable disease. Between 40 years and 75 years, the estimated number of disease-free years was 29·3 (95% CI 28·8-29·8) in normal-weight men and 29·4 (28·7-30·0) in normal-weight women. Compared with normal weight, the loss of disease-free years in men was 1·8 (95% CI -1·3 to 4·9) for underweight, 1·1 (0·7 to 1·5) for overweight, 3·9 (2·9 to 4·9) for class I obese, and 8·5 (7·1 to 9·8) for class II-III obese. The corresponding estimates for women were 0·0 (-1·4 to 1·4) for underweight, 1·1 (0·6 to 1·5) for overweight, 2·7 (1·5 to 3·9) for class I obese, and 7·3 (6·1 to 8·6) for class II-III obese. The loss of disease-free years associated with class II-III obesity varied between 7·1 and 10·0 years in subgroups of participants of different socioeconomic level, physical activity level, and smoking habit. INTERPRETATION: Mild obesity was associated with the loss of one in ten, and severe obesity the loss of one in four potential disease-free years during middle and later adulthood. This increasing loss of disease-free years as obesity becomes more severe occurred in both sexes, among smokers and non-smokers, the physically active and inactive, and across the socioeconomic hierarchy. FUNDING: NordForsk, UK Medical Research Council, US National Institute on Aging, Academy of Finland, Helsinki Institute of Life Science, and Cancer Research UK.

Job strain and tobacco smoking: an individual-participant data meta-analysis of 166,130 adults in 15 European studies.

BACKGROUND: Tobacco smoking is a major contributor to the public health burden and healthcare costs worldwide, but the determinants of smoking behaviours are poorly understood. We conducted a large individual-participant meta-analysis to examine the extent to which work-related stress, operationalised as job strain, is associated with tobacco smoking in working adults. METHODOLOGY AND PRINCIPAL FINDINGS: We analysed cross-sectional data from 15 European studies comprising 166,130 participants. Longitudinal data from six studies were used. Job strain and smoking were self-reported. Smoking was harmonised into three categories never, ex- and current. We modelled the cross-sectional associations using logistic regression and the results pooled in random effects meta-analyses. Mixed effects logistic regression was used to examine longitudinal associations. Of the 166,130 participants, 17% reported job strain, 42% were never smokers, 33% ex-smokers and 25% current smokers. In the analyses of the cross-sectional data, current smokers had higher odds of job strain than never-smokers (age, sex and socioeconomic position-adjusted odds ratio: 1.11, 95% confidence interval: 1.03, 1.18). Current smokers with job strain smoked, on average, three cigarettes per week more than current smokers without job strain. In the analyses of longitudinal data (1 to 9 years of follow-up), there was no clear evidence for longitudinal associations between job strain and taking up or quitting smoking. CONCLUSIONS: Our findings show that smokers are slightly more likely than non-smokers to report work-related stress. In addition, smokers who reported work stress smoked, on average, slightly more cigarettes than stress-free smokers.

Depressive symptoms, social isolation, and progression of coronary artery atherosclerosis: the Stockholm Female Coronary Angiography Study.

BACKGROUND: Although both depressive symptoms and social isolation in relation to coronary heart disease have been studied previously, few have examined their joint effects on coronary atherosclerosis progression in women. METHOD: Among the women enrolled in the Stockholm Female Coronary Angiography Study, Sweden, between 1991 and 1994, 102 were evaluated for coronary atherosclerosis progression using a computer-assisted standardized assessment, repeated quantitative coronary angiographic documentation, of the mean luminal diameter change over 3 years in 10 predefined coronary segments. Depressive symptoms and social isolation were assessed by standard questionnaires. RESULTS: Multivariable controlled mixed model ANOVAs revealed that women who were both depressed and socially isolated had the greatest disease progression: their absolute mean luminal diameter decreased by 0.18 mm [95% confidence interval (CI) = 0.11-0.24] and their percent narrowing was 5.5% (95% CI = 3.6-7.4), whereas in women who lacked both psychological risk factors, the mean luminal diameter decrease was 0.04 mm and their percent narrowing was 0.9%. These associations were independent of the baseline luminal diameter and standard risk factors, including age, smoking history, hypertension, and high-density lipoproteins. CONCLUSIONS: In women with coronary disease, depressive symptoms and social isolation in combination accelerated disease progression, suggesting a direct psychosocial effect on the atherosclerotic process. These findings provide an additional opportunity for therapeutic and preventive efforts against progression of coronary disease in women.

[Who can manage until the age of 65? Not the women--more than a half of all women stop working prematurely]. / Vem orkar anda till 65? Inte kvinnorna--mer an hälften avslutar arbetslivet i förtid.

We followed 300 Stockholm women, aged 30 to 65, for ten years to examine their health at the end of their working life and adaptation to retirement. Less than half of the initially healthy women were working until the retirement age of 65. More women left their working lives due to work related causes, than because of illness. Baseline assessments of stress at work and stress in the family were more important determinants of ill health than were life style (smoking, alcohol intake, exercise) and standard risk factors (lipid and hemostatic profile, blood pressure and obesity). The distribution of deaths and sickness pensions followed an expected social gradient with a higher frequency in women of lower social class, whereas the reverse was true for long-term sick leave (over 28 days). To stop working before the age of 65, with or without economic compensation, may be interpreted as an effective "coping-mechanism" available to well educated women, in order to avoid life-threatening illness.

Snoring and progression of coronary artery disease: The Stockholm Female Coronary Angiography Study.

STUDY OBJECTIVES: Snoring is associated with a significant increased risk for acute myocardial infarction and stroke. However, our knowledge of mechanisms is still incomplete. The aim of the study was to investigate the influence of snoring in combination with feelings of tiredness on the 3-year progression of atherosclerosis in women with cardiovascular disease. DESIGN: Repeated quantitative coronary angiograms were carried out with an average time interval of 3.25 years. SETTING: Department of Thoracic Radiology at Karolinska Hospital, Stockholm, Sweden. PARTICIPANTS: The study sample comprised 103 women cardiac patients with repeated, valid, and comparable measurement of quantitative coronary angiograms. MEASUREMENTS AND RESULTS: Absolute luminal diameter (in mm) was measured in 10 predefined coronary segments. Mean segment diameter was calculated as the mean of all diameters measured along a given segment. The change over time was calculated by subtracting the first from the second measurement. Snoring and feelings of tiredness were measured by a short version of the Karolinska Sleep Questionnaire. We found that snoring women, after adjusting for age, waist-hip ratio, smoking, event at hospitalization, education, hypertension and alcohol intake, had a statistically significantly larger progression of atherosclerosis than did nonsnoring women (0.18 mm vs 0.07 mm change; P = .0006). CONCLUSION: Snoring contributes to the atherosclerotic process and should be taken into consideration when treating patients with cardiac disease.

Snoring and the metabolic syndrome in women.

OBJECTIVE: The main objective was to examine the association between metabolic syndrome, snoring and sleep quality among women. METHODS: The study sample comprised healthy women (30-65 years) from the greater Stockholm area. Snoring and sleep quality were measured by the Karolinska Sleep Questionnaire. The metabolic syndrome was defined as the presence of two or more of the following components: (1) fasting serum glucose level > or =7.0 mmol/L; (2) arterial blood pressure > or =140/90 mmHg; (3) fasting serum triglycerides > or =1.7 mmol/L and/or HDL cholesterol <1.05 mmol/L; and (4) obesity (waist-to-hip ratio >0.85 and/or BMI > or =28 kg/m2). RESULTS: After adjustment for age, the risk ratio of metabolic syndrome among snorers as compared to non-snorers was 4.50 (95% CI: 1.71-11.86; p=0.002). This association persisted after controlling for menopausal status, educational level, smoking, fatigue and exercise habits. Poor sleep quality showed a trend (OR: 3.31; 95% CI: 0.89-12.21; p=0.073) towards an increased risk for metabolic syndrome, but this did not reach statistical significance. CONCLUSIONS: Snoring may be a strong predictor for metabolic syndrome in middle-aged women. These findings show that snoring women are not only at increased risk for individual risk factors associated with cardiovascular disease and type 2 diabetes, but also for metabolic syndrome.

Depressive symptoms in relation to marital and work stress in women with and without coronary heart disease. The Stockholm Female Coronary Risk Study.

OBJECTIVE: The aim of this study was to investigate the effect of marital and job stress on depressive symptoms in middle aged women with coronary heart disease (CHD) and healthy women who were cohabiting and currently working. METHOD: Data were obtained from the Stockholm Female Coronary Risk (FemCorRisk) Study, a population-based case-control study, comprising all women aged 65 years or younger who were admitted for an acute event of CHD between 1991 and 1994. For each patient, an age-matched healthy control was recruited. Marital stress was assessed by a structured interview developed in our research laboratory and work stress by the Karasek demand-control questionnaire. Depressive symptoms were measured by a questionnaire derived from Pearlin et al. [J. Health Soc. Behav. 22 (1981) 337], which was validated by the Beck Depression Inventory. RESULTS: Depressive symptoms were twice as common in women with as in women without coronary disease: Marital stress was statistically significantly associated with depressive symptoms, even after controlling for age, educational level, menopausal status, body mass index (BMI), sedentary lifestyle, cigarette smoking and severity of heart failure symptoms. In both groups, depressive symptoms increased with increasing exposure to marital stress in a graded fashion. Work stress was not associated with depressive symptoms after multivariate adjustment. CONCLUSIONS: Marital stress but not work stress is independently related to depressive symptoms in women. Women with coronary disease react similarly to marital stress as healthy women, but depart from a higher level of depression, which may be explained by their poorer health status.