Geographic patterns of incidence of ischemic stroke and acute myocardial infarction in Finland during 1991-2003.

PURPOSE: To examine geographic variation in the incidence of ischemic stroke (IS) and acute myocardial infarction (AMI) in Finland during 1991-2003. METHODS: Data included all cases of first IS (n = 115,383) and AMI (n = 205,213) in persons aged 35-84 years. We used full Bayesian spatial shared component disease models for mapping the geographic risk patterns. RESULTS: The risk component shared by IS and AMI explained 73% (95% credible interval [CI]; 59%, 87%) of the geographic variation in IS risk and 68% (41%, 91%) in AMI risk. The spatial variation was similar in men and women. In the northeastern part of Finland, annual age-adjusted IS incidence was 356.4/100,000 (95% CI; 350.3, 362.6) in men and 231.2 (226.9, 235.4) in women. Annual AMI incidence was 855.6 (846.1, 865.2) in men and 351.4 (346.2, 356.5) in women. In the southwestern part of the country, annual IS incidence was 334.7 (331.6, 337.8) in men and 210.6 (208.5, 212.6) in women. Annual AMI incidence was 707.3 (702.8, 711.8) in men and 278.3 (276.0, 280.7) in women. CONCLUSION: A marked part of the spatial variation in IS and AMI incidence was disease specific, even though these diseases share a similar atherosclerotic background. Further studies are warranted for understanding the reasons for the different geographic variation.

Ankle blood pressure as a predictor of total and cardiovascular mortality.

BACKGROUND: The ankle blood pressure is commonly used as a ratio to the brachial blood pressure, called ankle-brachial index (ABI). Very few studies have considered the independent value of the ankle blood pressure without indexing it to the brachial blood pressure. We examined the value of ankle blood pressure, together with the exercise blood pressure, as a predictor of cardiovascular (CVD) and total mortality. METHODS: A prospective follow-up study of 3,858 consecutive ambulatory patients (mean age 51 years, 65,9% male) referred to a symptom-limited exercise test between August 1989 and December 1995. The cohort was followed up for all-cause and CVD mortality until December 31, 2004, by record linkage with the National Causes-of-Death Register. The independent value of ankle blood pressure as a predictor of cardiovascular and total mortality was assessed using Cox proportional hazards modelling. RESULTS: The average follow-up time was 14 years, during which 346 persons died, 108 of them due to CVD. Persons with normal (<140 mmHg) resting brachial blood pressure, ankle blood pressure < 175 mmHg and exercise blood pressure at moderate exercise level < or =215 mmHg at baseline investigation, had the best prognosis and were taken as the reference category. Among persons with elevated ankle blood pressure (> or =175 mmHg) but normal or borderline resting brachial pressure and normal exercise blood pressure (< or =215 mmHg) at moderate exercise level the multivariate-adjusted hazard ratios (HR, 95% confidence interval) for CVD and total mortality were 2.70 (1.52 - 4.80) and 2.13 (1.58 - 2.85), respectively. Similar and equally significant HRs were observed in persons with both elevated ankle blood pressure and elevated exercise blood pressure, as well as in those persons with elevated exercise blood pressure but ankle blood pressure < 175 mmHg. CONCLUSION: These results suggest that the ankle blood pressure has an independent value as a marker of arterial stiffness or subclinical atherosclerosis and a risk of future mortality in middle-aged, asymptomatic persons.

Trends in fatal and nonfatal strokes among persons aged 35 to > or =85 years during 1991-2002 in Finland.

BACKGROUND AND PURPOSE: Declining trends in the incidence and mortality of stroke have been observed in Finland since the beginning of the 1980s until 1997. In this study we analyzed the trends in fatal and nonfatal strokes in Finland during 1991-2002. METHODS: The Finnish Hospital Discharge Register was linked to the National Causes of Death Register to produce a Cardiovascular Disease Register, which includes data on 410 760 cerebrovascular events (International Statistical Classification of Diseases, 10th Revision [ICD-10] codes I60-I69) in patients aged > or =35 years in 1991-2002. RESULTS: Age-standardized incidence of first-ever stroke (ICD-10 codes I60-I64, excluding I63.6) per 100 000 persons declined during 1991-2002 annually by 2.2% (95% CI, -2.4% to -1.9%) among men and 2.5% (-2.8% to -2.2%) among women aged 35 to 74 years. In patients aged 75 to 84 years, the change in the incidence of first-ever stroke was -2.6% per year (-3.0% to -2.2%) among men and -3.2% per year (-3.5% to -2.9%) among women. A similar trend was observed also in the oldest age group, in patients aged > or =85 years. Among patients aged 35 to 74 years, the 28-day case fatality of first-ever stroke declined annually by 3.2% (-3.9% to -2.5%) among men and by 3.0% (-3.8% to -2.2%) among women. A significant decrease was found in the 28-day case fatalities of all subtypes of stroke in this age group. CONCLUSIONS: The favorable development in stroke incidence, mortality, and case-fatality has continued in Finland during 1991-2002.

Ankle blood pressure and pulse pressure as predictors of cerebrovascular morbidity and mortality in a prospective follow-up study.

Background and Objective. We examined the association of elevated ankle blood pressure (ABP), together with exercise blood pressure, with incident cerebrovascular (CV) morbidity and mortality in a prospective follow-up study of 3,808 patients. The results were compared with pulse pressure, another indicator of arterial stiffness. Methods. Patients with normal ankle and exercise brachial blood pressures were taken as the reference group. Pulse pressure was considered as quartiles with the lowest quartile as the reference category. Results. A total of 170 subjects had a CV event during the follow-up. Multivariate adjusted hazard ratio of a CV event was 2.24 (95% CI 1.43-3.52, P < .0001) in patients with abnormal ABP. The pulse pressure was significant only in the model adjusted for age and sex. Conclusion. The risk of a future CV event was elevated already in those patients among whom elevated ABP was the only abnormal finding. As a risk marker, ABP is superior to the pulse pressure.

Prognosis of ischaemic stroke is improving similarly in patients with type 2 diabetes as in nondiabetic patients in Finland.

BACKGROUND: Case fatality of first ischaemic stroke has improved markedly during the past two decades. Aims To investigate whether stroke patients with type 2 diabetes have shared this favourable development. METHODS: Nation-wide registers were used to identify all patients with type 2 diabetes in Finland during 1988-2002. All first ischaemic strokes among them and also among all nondiabetic persons were identified from the National Hospital Discharge Register and the Causes of Death Register. Trends over time were calculated, for age-standardised case fatality of first stroke events, separately for two time periods: 0-27 and 28-364 days after the onset of stroke. These trends were compared between patients with type 2 diabetes and nondiabetic patients. RESULTS: Altogether, 23,097 first-ever ischaemic strokes were recorded among 222,940 persons with type 2 diabetes. The 28 day case fatality was 1.1-1.3 times higher, and the one-year case fatality of 28 day survivors was 1.4-2.2 times higher in patients with type 2 diabetes compared with nondiabetic patients. A significant decline in case fatality trends was observed, but the trends did not differ between type 2 diabetes and nondiabetic patients. CONCLUSIONS: The study revealed a positive development in survival after the first stroke event in persons with type 2 diabetes, similar to the development in nondiabetic persons. However, the level of case fatality has remained higher in patients with type 2 diabetes.

Association of variation in the interleukin-1 gene family with diabetes and glucose homeostasis.

OBJECTIVE: Proinflammatory cytokine IL-1beta is capable of decreasing insulin-induced glucose transport. Therefore, we hypothesized that genetic variation in the IL-1 gene family is associated with measures of glucose homeostasis and diabetes. DESIGN AND OUTCOME MEASURES: Fifteen haplotype-tagging single-nucleotide polymorphisms in the IL-1alpha, IL-1beta, and IL-1 receptor antagonist genes were determined in a Finnish population survey (n = 6771). Glucose and insulin concentrations were measured, and indices of insulin resistance and beta-cell function were calculated using the homeostasis model assessment. Two-hour oral glucose tolerance tests were carried out on a subsample of 1390 participants. Associations with prevalent diabetes were tested for replication in a sample of European myocardial infarction survivors (n = 972). RESULTS: The minor allele of the IL-1beta rs1143634(G-->A) was associated with higher blood glucose than the major allele: 5.37, 5.41, and 5.48 mmol/liter for the GG, AG, and AA genotypes, respectively (multivariate adjusted P for trend <0.0001; Bonferroni corrected P = 0.00096). The 2-h glucose was also higher (6.45 and 7.20 mmol/liter for the GG vs. AA; P = 0.003, Bonferroni corrected P = 0.045). The haplotype ACG of rs1143634, rs3917356, and rs16944 associated with higher glucose, higher homeostasis model assessment for insulin resistance index, higher 2-h insulin, and prevalent diabetes (adjusted rate ratio = 1.54; 95% confidence interval = 1.03-2.30; P = 0.037). The association with prevalent diabetes was replicated among European myocardial infarction survivors (rate ratio = 2.09; 95% confidence interval = 1.17-3.76; P = 0.013). CONCLUSIONS: These results suggest that genetic variation in the IL-1 gene family is associated with measures of glucose homeostasis and prevalent diabetes.

Use of secondary preventive medications after the first attack of acute coronary syndrome.

BACKGROUND: It is not well-known to what extent evidence-based medications, such as beta-blockers, hypolipidemic medications, and angiotensin-converting enzyme inhibitors, are prescribed after an attack of acute coronary syndrome in the general healthcare setting and what is the compliance of patients with these prescriptions. DESIGN: We conducted a countrywide record linkage study. METHODS: We used record linkage of the National Hospital Discharge Register, Causes of Death Register, and Social Insurance Institution's drug reimbursement records to identify drug purchases of patients aged 35-74 years hospitalized for the first nonfatal acute coronary syndrome in Finland during 1995-2003 (n=53 353). RESULTS: In 2003 about 28 and 15% of the patients did not receive hypolipidemic medications or beta-blockers, respectively, after their acute coronary syndrome and a further 6 and 10% discontinued the use about 3 months later. Patients aged 65-74 years were less likely to receive hypolipidemic medications [odds ratio (OR) 0.55; 95% confidence interval (CI), 0.53-0.58] and beta-blockers (OR 0.77; 95% CI, 0.74-0.81) than younger patients. Diabetic patients received less hypolipidemic medications (OR 0.82; 95% CI, 0.78-0.86) and were more likely to discontinue the medication (OR 1.15; 95% CI, 1.05-1.26) than nondiabetic patients. In proportional hazards regression analyses the regular use of hypolipidemic medication or beta-blockers was associated with lower risk of cardiovascular death: adjusted hazard ratios 0.47 (95% CI, 0.41-0.53) and 0.54 (95% CI, 0.49-0.60), respectively. CONCLUSIONS: Our study showed that the evidence-based use of medications after acute coronary syndrome was suboptimal in Finland, particularly in elderly and diabetic patients. Consistent use of these medications, however, was associated with a better prognosis.

Trends in fatal and non-fatal coronary heart disease events in Finland during 1991-2001.

OBJECTIVE: To analyse the trends in fatal and non-fatal coronary heart disease (CHD) events in Finland during an 11-year period 1991-2001. DESIGN: Data on hospitalizations due to CHD in the Hospital Discharge Register were linked to the National Causes of Death Register in order to produce a Cardiovascular Disease Register including data on 271,771 events in 234,244 individuals. RESULTS: The annual average decline in the age-standardized CHD mortality rate was 5.2% (95% CI, -5.6, -4.8%) among men and 6.1% (-6.6, -5.6%) among women. The incidence of first myocardial infarction declined annually on average by 5.5% (-5.9, -5.1%) from 1991 to 1997 and by 2.4% (-3.0, -1.7%) from 1998 to 2001 among men. The respective changes among women were -5.9% (-6.5, -5.2%) and -1.7% (-2.7, -0.6%). The number of hospitalizations due to unstable angina pectoris increased between 1991 and 1996 (p = 0.0002) and remained stable for the rest of the study period. CONCLUSIONS: The Cardiovascular Disease Register is a powerful tool for epidemiological monitoring of cardiovascular diseases in Finland.