Heart rate variability in long-term risk assessment in middle-aged women with coronary heart disease: The Stockholm Female Coronary Risk Study.

OBJECTIVES: Low heart rate variability (HRV) is associated with poor prognosis after acute coronary events in men. In women, the prognostic impact is not well documented. The objective of this study was to assess the long-term predictive power of HRV on mortality amongst middle-aged women with coronary heart disease (CHD). DESIGN, SETTINGS AND SUBJECTS: Consecutive women below 65 years hospitalized for an acute coronary syndrome during a 3-year period in Stockholm were examined for cardiovascular prognostic factors including HRV, and followed for a median of 9 years. An ambulatory 24-h electrocardiograph was recorded during normal activities, 3-6 months after hospitalization. SDNN index (mean of the standard deviations of all normal to normal intervals for all 5-min segments of the entire recording) and the following frequency domain parameters were assessed: total power, high-frequency (HF) power, low-frequency (LF) power, very-low frequency (VLF) power and LF/HF ratio. Using Cox proportional hazards regression, the hazard ratios (HR) for each 25% decrease of the HRV parameters were assessed. RESULTS: After controlling for the independent, significant predictors of mortality amongst the clinical variables, the following HRV parameters were found to be significant predictors of all-cause mortality: SDNN index [HR 1.56, 95% confidence intervals (CI) 1.19-2.05], total power (HR 1.21, 95% CI 1.08-1.35), VLF power (HR 1.22, 95% CI 1.09-1.36), LF power (HR 1.18 95%, CI 1.07-1.30) and HF power (HR 1.18, 95% CI 1.05-1.33). The results were essentially the same when cardiovascular mortality was used as end-points. The HRV parameters were stronger predictors of mortality in the first 5 years following the index event. CONCLUSION: Low HRV is a predictor of long-term mortality amongst middle-aged women with CHD when measured 3-6 months after hospitalization for an acute coronary syndrome, even after controlling for established clinical prognostic markers.

Short stature and prognosis of coronary heart disease in women.

OBJECTIVES: To investigate the effect of short stature on prognosis following an acute event of coronary heart disease (CHD) in women. SETTING: All women who were hospitalized for an acute event of CHD in any of the 10 cardiology clinics in greater Stockholm were investigated for the first time in the Stockholm Female Coronary Risk Study between 1991 and 1994, and were followed until August 1997 for recurrent coronary events. DESIGN: A follow-up study of women with either acute myocardial infarction (AMI) or unstable angina pectoris. Median follow-up period was 4.8 years. SUBJECTS: A total of 292 Swedish women. aged 65 years or younger. MAIN OUTCOME MEASURES: Recurrent AMI, death from CHD or revascularization procedure (percutaneous transluminal coronary angioplasty and coronary artery bypass grafting). RESULTS: Independent of the confounding effects of other risk factors of clinical importance for CHD (age, socioeconomic status, menopausal status, index event, congestive heart failure, angina severity, diabetes, hypertension, smoking, triglycerides and HDL cholesterol), the shortest 25% of women (< 160 cm) had a 2.1-fold (95% CI = 1.0-4.4) increased rate of developing adverse cardiac events (cardiovascular death, recurrent AMI or revascularization procedure) compared with the tallest 25% (> 165 cm). In addition, an increased rate was observed for each 10 cm difference in height (hazard ratio = 1.7, 95% CI = 1.4-2.7). Similar results were observed when analysing each outcome separately. CONCLUSIONS: These data indicate that short stature is a strong predictor of poor prognosis after an acute coronary event in women, independent of socioeconomic status and other risk factors for CHD.

Socioeconomic status and determinants of hemostatic function in healthy women.

Hemostatic factors are reported to be associated with coronary heart disease (CHD). Socioeconomic status (SES) is 1 of the determinants of the hemostatic profile, but the factors underlying this association are not well known. Our aim was to examine determinants of the socioeconomic differences in hemostatic profile. Between 1991 and 1994, we studied 300 healthy women, aged 30 to 65 years, who were representative of women living in the greater Stockholm area. Fibrinogen, factor VII mass concentration (FVII:Ag), activated factor VII (FVIIa), von Willebrand factor (vWF), and plasminogen activator inhibitor-1 (PAI-1) were measured. Educational attainment was used as a measure of SES. Low educational level and an unfavorable hemostatic profile were both associated with older age, unhealthful life style, psychosocial stress, atherogenic biochemical factors, and hypertension. Levels of hemostatic factors increased with lower educational attainment. Independently of age, the differences between the lowest (mandatory) and highest (college/university) education in FVII:Ag levels were 41 microg/L (95% confidence interval [CI], 15 to 66 microg/L, P=0.001), 0.26 g/L (95% CI, 0.10 to 0.42 g/L, P=0.001) in fibrinogen levels, and 0.11 U/mL (95% CI, 0.09 to 0.12 U/mL, P=0.03) in levels of vWF. The corresponding differences in FVIIa and PAI-1 were not statistically significant. With further adjustment for menopausal status, family history of CHD, marital status, psychosocial stress, lifestyle patterns, biochemical factors, and hypertension, statistically significant differences between mandatory and college/university education were observed in FVII:Ag (difference=34 microg/L; 95% CI, 2 to 65 microg/L, P=0.05) but not in fibrinogen (difference=0.03 g/L; 95% CI, -0.13 to 0.19 g/L, P=0.92) or in vWF (difference=0.06 U/mL; 95% CI, -0.10 to 0.22 U/mL, P=0.45). An educational gradient was most consistent and statistically significant for FVII:Ag, fibrinogen, and vWF. Age, psychosocial stress, unhealthful life style, atherogenic biochemical factors, and hypertension mediated the association of low educational level with elevated levels of fibrinogen and vWF. Psychosocial stress and unhealthful life style were the most important contributing factors. There was an independent association between education and FVII:Ag, which could not be explained by any of these factors.

Socioeconomic differences in health indices, social networks and mortality among Swedish men. A study of men born in 1933.

BACKGROUND: In previous survey we found large socioeconomic differences in mortality among urban Swedish men which remained unexplained after controlling for smoking and standard coronary risk factors. The present analysis was undertaken in order to investigate a broader set of possible explanatory factors in another cohort of Swedish men. STUDY POPULATION AND METHODS: Occupation was coded into five occupational classes for 717 of 776 participant men from a random population sample of 1016 men who were born in 1933. All were living in Göteborg and were 50 years old at the baseline examination. After 12 years' follow-up, 68 of the 717 men had died (9.5%). RESULTS: Low occupational class was associated with a higher prevalence of smoking at baseline, but no association was found with systolic blood pressure, body mass index, waist to hip ratio, serum triglycerides or serum cholesterol. Subjects from higher socioeconomic strata were taller, had higher maximum peak respiratory flow, lower plasma fibrinogen and lower body temperature. Low occupational class was associated with low social integration, low home activity levels, low levels of activity outside home and low social activity levels (p = 0.001 for all) and with low emotional support (p = 0.018). There were also associations between low occupational class and poor self-perceived health, as well as with several cardiovascular symptoms. During 12 years' follow-up, there was a graded and inverse relationship between occupational class and mortality from all causes. The highest mortality was found among the men who could not be classified (23 per 1,000 person years) Of the men in the lowest occupational class, 12 per 1,000 died, compared to 3 per 1,000 in the highest class (relative risk 3.7 (1.4-9.8)). After controlling for smoking, the relative risk decreased to 3.2 (1.2-8.6) and after further adjustment for emotional support, self-perceived health, activity level at home, and peak expiratory flow, the relative risk was still twofold but not significantly so (RR 2.1 (0.8-5.8)). CONCLUSION: We were able to confirm earlier results as to the wide mortality differentials in urban middle-aged men in Sweden. There were also large differences in several other factors, including constitutional factors, health variables, lifestyle and social support indices, which explained important parts of the social mortality gradient, the most prominent being smoking, respiratory function, social network factors and subjective health.

Lipid profile and socioeconomic status in healthy middle aged women in Sweden.

STUDY OBJECTIVE: To examine the relationship between socioeconomic status (SES) and full lipid profile in middle aged healthy women. PARTICIPANTS: These comprised 300 healthy Swedish women between 30 and 65 years who constitute the control group of the Stockholm female coronary risk study, a population based, case-control study of women with coronary heart disease (CHD). The age matched control group, drawn from the census register of greater Stockholm, was representative of healthy Swedish women aged 30-65 years. Five measures of SES were used; educational level, occupation, decision latitude at work, annual income, and size of house or apartment. MAIN RESULTS: Swedish women with low decision latitude at work, low income, low educational level, blue collar jobs, and who were living in small houses or apartments had an unhealthy lipid profile, suggesting an increased risk of CHD. Part of this social gradient in lipids was explained by an unhealthy lifestyle, but the lipid gradients associated with decision latitude at work and annual income were independent of these factors. Decision latitude, educational level, and annual income had the strongest associations with lipid profile. These associations were independent of age, menopausal status, smoking, sedentary lifestyle, alcohol consumption, obesity, excess abdominal fat, and unhealthy dietary habits. Of the lipid variables, low high density lipoprotein cholesterol (HDL) levels were most consistently associated with low SES. CONCLUSIONS: Decision latitude at work was the strongest SES predictor of HDL levels in healthy middle aged Swedish women, after simultaneous adjustment for other SES measures, age, and all lifestyle factors in the multivariable regression model.

Men who never married. A socio-medical study in northern Sweden.

In a population-based study 50 never-married men aged 40-64 years were compared with 503 similarly aged other men (married, co-habitant, divorced or widowed). The never-married had shorter education than other men, and had been unemployed more often. The never-married mens' emotional relationships were of lower quality. There was modest tendency towards higher blood pressures and higher serum cholesterol levels among the never-married men, but the differences did not reach statistical significance. In conclusion, never-married men were found to be worse off in terms of social support, education, employment status and health knowledge. Differences in health status, however, were small. It is possible that positive factors, not fully elucidated in this study, counterbalance the adverse socio-medical characteristics. Another possibility is that differences will become manifest at an older age which could be surveyed in a follow-up study.