Equalization of four cardiovascular risk algorithms after systematic recalibration: individual-participant meta-analysis of 86 prospective studies.

AIMS: There is debate about the optimum algorithm for cardiovascular disease (CVD) risk estimation. We conducted head-to-head comparisons of four algorithms recommended by primary prevention guidelines, before and after 'recalibration', a method that adapts risk algorithms to take account of differences in the risk characteristics of the populations being studied. METHODS AND RESULTS: Using individual-participant data on 360 737 participants without CVD at baseline in 86 prospective studies from 22 countries, we compared the Framingham risk score (FRS), Systematic COronary Risk Evaluation (SCORE), pooled cohort equations (PCE), and Reynolds risk score (RRS). We calculated measures of risk discrimination and calibration, and modelled clinical implications of initiating statin therapy in people judged to be at 'high' 10 year CVD risk. Original risk algorithms were recalibrated using the risk factor profile and CVD incidence of target populations. The four algorithms had similar risk discrimination. Before recalibration, FRS, SCORE, and PCE over-predicted CVD risk on average by 10%, 52%, and 41%, respectively, whereas RRS under-predicted by 10%. Original versions of algorithms classified 29-39% of individuals aged ≥40 years as high risk. By contrast, recalibration reduced this proportion to 22-24% for every algorithm. We estimated that to prevent one CVD event, it would be necessary to initiate statin therapy in 44-51 such individuals using original algorithms, in contrast to 37-39 individuals with recalibrated algorithms. CONCLUSION: Before recalibration, the clinical performance of four widely used CVD risk algorithms varied substantially. By contrast, simple recalibration nearly equalized their performance and improved modelled targeting of preventive action to clinical need.

Glycated hemoglobin measurement and prediction of cardiovascular disease.

IMPORTANCE: The value of measuring levels of glycated hemoglobin (HbA1c) for the prediction of first cardiovascular events is uncertain. OBJECTIVE: To determine whether adding information on HbA1c values to conventional cardiovascular risk factors is associated with improvement in prediction of cardiovascular disease (CVD) risk. DESIGN, SETTING, AND PARTICIPANTS: Analysis of individual-participant data available from 73 prospective studies involving 294,998 participants without a known history of diabetes mellitus or CVD at the baseline assessment. MAIN OUTCOMES AND MEASURES: Measures of risk discrimination for CVD outcomes (eg, C-index) and reclassification (eg, net reclassification improvement) of participants across predicted 10-year risk categories of low (<5%), intermediate (5% to <7.5%), and high (≥ 7.5%) risk. RESULTS: During a median follow-up of 9.9 (interquartile range, 7.6-13.2) years, 20,840 incident fatal and nonfatal CVD outcomes (13,237 coronary heart disease and 7603 stroke outcomes) were recorded. In analyses adjusted for several conventional cardiovascular risk factors, there was an approximately J-shaped association between HbA1c values and CVD risk. The association between HbA1c values and CVD risk changed only slightly after adjustment for total cholesterol and triglyceride concentrations or estimated glomerular filtration rate, but this association attenuated somewhat after adjustment for concentrations of high-density lipoprotein cholesterol and C-reactive protein. The C-index for a CVD risk prediction model containing conventional cardiovascular risk factors alone was 0.7434 (95% CI, 0.7350 to 0.7517). The addition of information on HbA1c was associated with a C-index change of 0.0018 (0.0003 to 0.0033) and a net reclassification improvement of 0.42 (-0.63 to 1.48) for the categories of predicted 10-year CVD risk. The improvement provided by HbA1c assessment in prediction of CVD risk was equal to or better than estimated improvements for measurement of fasting, random, or postload plasma glucose levels. CONCLUSIONS AND RELEVANCE: In a study of individuals without known CVD or diabetes, additional assessment of HbA1c values in the context of CVD risk assessment provided little incremental benefit for prediction of CVD risk.

The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER): study design and progress.

BACKGROUND: Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) is a multi-center, randomized, controlled trial ongoing in Finland. MATERIALS: Participants (1200 individuals at risk of cognitive decline) are recruited from previous population-based non-intervention studies. Inclusion criteria are CAIDE Dementia Risk Score ≥6 and cognitive performance at the mean level or slightly lower than expected for age (but not substantial impairment) assessed with the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological battery. The 2-year multidomain intervention consists of: nutritional guidance; exercise; cognitive training and social activity; and management of metabolic and vascular risk factors. Persons in the control group receive regular health advice. The primary outcome is cognitive performance as measured by the modified Neuropsychological Test Battery, Stroop test, and Trail Making Test. Main secondary outcomes are: dementia (after extended follow-up); disability; depressive symptoms; vascular risk factors and outcomes; quality of life; utilization of health resources; and neuroimaging measures. RESULTS: Screening began in September 2009 and was completed in December 2011. All 1200 persons are enrolled and the intervention is ongoing as planned. Baseline clinical characteristics indicate that several vascular risk factors and unhealthy lifestyle-related factors are present, creating a window of opportunity for prevention. The intervention will be completed during 2014. CONCLUSIONS: The FINGER is at the forefront of international collaborative efforts to solve the clinical and public health problems of early identification of individuals at increased risk of late-life cognitive impairment, and of developing intervention strategies to prevent or delay the onset of cognitive impairment and dementia.

Low respiratory function increases the risk of depressive symptoms in later life in men.

OBJECTIVE: To assess the risk of depressive symptoms with respect to respiratory function in middle-aged men. Chronic lung diseases are associated with a high prevalence of depression, but the association of poor respiratory function with depressive symptoms has not been established in prospective population-based cohort studies. METHODS: In a prospective, population-based cohort study with up to 30 years of follow-up, we included 1205 men aged 50 to 69 years from Finland (n = 663) and Italy (n = 542). Forced vital capacity (FVC) and forced expiratory flow in 0.75 sec (FEV(0.75)) in 1970 were analyzed in relationship to depressive symptoms (by Zung self-rating depression scale [SDS]) in 1985, 1990, 1995, and 2000, using multilevel regression models. Subsequent analyses were done separately in the strata with (n = 501) and without (n = 704) chronic diseases in 1970 (i.e., chronic lung diseases, cardiovascular diseases, or diabetes mellitus). RESULTS: Poor respiratory function was associated independently with steeper increases in depressive symptoms over time, both for FVC (p < .001) and FEV(0.75) (p = .004). In participants without chronic diseases, a standard deviation (SD) increase in FVC was associated with a 1.1-point decrease (standard error [SE] = 0.4) in Zung SDS (p = .01) and a 1.5-point decrease (SE = 0.4) (p < .001) in participants with chronic diseases (p = .27 for interaction). Low FEV(0.75) was associated with more depressive symptoms in participants with chronic diseases (1.7 SE 0.4 decrease per SD; p < .001), but not in participants without chronic diseases (0.6 SE 0.4 decrease per SD; p = .16; p = .008 for interaction). CONCLUSIONS: Small lung volumes were associated with an increased risk of subsequent depressive symptoms at old age, especially in persons with chronic lung diseases, cardiovascular diseases, or diabetes mellitus at baseline.

Apolipoprotein E genotype modifies the association between midlife lung function and cognitive function in old age.

BACKGROUND/AIMS: Because poor lung function may be a risk factor for cognitive decline, we aimed to test the association of respiratory function with cognitive function and dementia later in life, as well as potential effect modification by APOE epsilon4 carrier status. METHODS: In a prospective population-based cohort study, forced vital capacity and forced expiratory flow were measured around 1965 in 857 men aged 45-64 years (394 from Finland, 208 from The Netherlands, and 255 from Italy). The Mini-Mental State Examination scores around 1990, 1995 and 2000 were analyzed using multilevel regression models and the Clinical Dementia Rating score around 1990 using multinomial logistic regression analyses. RESULTS: Midlife lung function was positively associated with cognitive function in old age in APOE epsilon4 non-carriers, but not in carriers (p < 0.05 for interaction). In Finland and Italy, 18.6% had questionable to mild dementia and 2.8% moderate to severe dementia after 25 years of follow-up. Dementia was inversely related to midlife lung function in APOE epsilon4 non-carriers, but not in carriers (p < 0.05 for interaction). CONCLUSIONS: Small lung volumes were prospectively associated with an increased risk for poor cognitive function and dementia in non-carriers of the APOE epsilon4 gene.

Homogeneity in the relationship of serum cholesterol to coronary deaths across different cultures: 40-year follow-up of the Seven Countries Study.

BACKGROUND: The aim was to investigate whether multivariate coefficients of serum cholesterol in the prediction of coronary heart disease (CHD) deaths were similar across different cultures in a long-term follow-up. DESIGN: Thirteen cohorts for a total of 10,157 men aged 40-59 years at entry, enrolled in seven countries (USA, Finland, the Netherlands, Italy, Serbia, Greece, Japan) were repeatedly examined and followed up for 40 years. METHODS: Serum cholesterol measured at baseline, and then on repeated occasions, was studied, using multivariate models, in relation with the occurrence of CHD deaths during a 40-year follow-up. RESULTS: Homogeneity of multivariate serum cholesterol coefficients was found considering cholesterol levels at baseline, as average of up to three measurements during the first 10 years, as average of up to six measurements in 35 years, using the time-dependent technique with up to three measurements in 10 years, and with up to six measurement in 35 years. CONCLUSION: The strength of the association between serum cholesterol and CHD death seems homogeneous across different cultures characterized by different levels of serum cholesterol and different absolute risk of CHD death.

Coffee consumption and the incidence of antihypertensive drug treatment in Finnish men and women.

BACKGROUND: Only 2 prospective studies have previously investigated the association between coffee consumption and incident hypertension, and the findings are equivocal. OBJECTIVE: The objective was to determine the relation between coffee consumption and the incidence of antihypertensive drug treatment. DESIGN: We prospectively followed 24 710 Finnish subjects aged 25-64 y without a history of antihypertensive drug treatment, coronary heart disease, or stroke at baseline. Daily coffee consumption was assessed by questionnaires. RESULTS: During a mean follow-up period of 13.2 y, 2505 participants started antihypertensive drug treatment. The multivariate-adjusted (age, sex, study year, education, leisure-time physical activity, smoking, body mass index, high total cholesterol, history of diabetes, and alcohol, tea, fruit, vegetable, sausage, and bread consumption) hazard ratios for antihypertensive drug treatment associated with the amount of coffee consumed daily (0-1, 2-3, 4-5, 6-7, or >or=8 cups) were 1.00, 1.29 (95% CI: 1.09, 1.54), 1.26 (95% CI: 1.06, 1.49), 1.24 (95% CI: 1.04, 1.48), and 1.14 (95% CI: 0.94, 1.37) (P for trend = 0.024), respectively. This trend became marginally significant after additional adjustment for baseline systolic blood pressure (P for trend = 0.077). CONCLUSIONS: The results indicate that coffee drinking seems to increase the risk of antihypertensive drug treatment, and this risk was higher in subjects with low-to-moderate coffee intakes; however, there was no significantly increased trend in drinkers of approximately 1 cup (100 mL)/d or >or=8 cups/d.

Trends in lifestyle factors affecting blood pressure in hypertensive and normotensive Finns during 1982-2002.

OBJECTIVE: To assess the trends in blood pressure (BP) affecting lifestyle factors in hypertensive and normotensive Finns from 1982 to 2002. DESIGN AND SETTING: Five independent cross-sectional population surveys conducted in 1982, 1987, 1992, 1997 and 2002 in the provinces of North Karelia and Kuopio in eastern Finland and the region of Turku-Loimaa in southwestern Finland. PARTICIPANTS: Stratified random samples of men and women aged 25-64 years were drawn from the national population register. The participants (n = 28 235) were classified into four groups according to their BP level and treatment status: normotensive, unaware hypertensive, aware but untreated hypertensive, and treated hypertensive subjects. MAIN OUTCOME MEASURES: Alcohol intake, body mass index (BMI), 24-h urinary sodium and potassium excretion (a subsample of 5849 subjects) and the proportion of subjects with leisure-time physical activity (LTPA) at least three times a week. RESULTS: Mean BMI increased significantly in all groups except in untreated hypertensive women. Alcohol intake increased in all men but especially in hypertensive women (P < 0.001). The 24-h urinary sodium excretion decreased significantly in all BP groups. The proportion of subjects with a recommended level of LTPA increased significantly and similarly in all BP groups (P < 0.001). CONCLUSIONS: The unfavourable trends observed in mean BMI and alcohol intake in the entire population should be reversed in order to decrease the frequency of hypertension in Finland. The health behaviours of hypertensive subjects should be carefully monitored and modified in a more systematic and efficient way than at present.

Carotid intima-media thickness and cognitive function in elderly women: a population-based study.

OBJECTIVE: Several vascular risk factors have been linked to cognitive decline. However, little is known about the association between the atherosclerotic process and cognitive impairment. We investigated whether carotid intima-media thickness (IMT) predicts the risk of cognitive impairment and whether the putative impairment is specific for some cognitive domains. METHODS: A 12-year population-based follow-up study was performed for a total of 91 women, aged 60-70 years at baseline. Ultrasonographically assessed carotid artery IMT and the Mini-Mental State Examination test were performed at baseline and 12-year follow-up. A detailed cognitive evaluation for memory and cognitive speed was performed in 2003. The mean of left and right carotid bifurcation IMT was used in the analyses for association with the risk for poor cognitive speed and memory. RESULTS: Increased IMT at baseline was an independent predictor for poor memory (beta = -5.004, 95% confidence interval = -7.74 to -2.27; p = 0.001) and cognitive speed (beta = 2.562, 95% confidence interval = 1.19-4.94; p = 0.035) at 12-year follow-up after adjustment for age, education, depression, plasma LDL cholesterol, systolic blood pressure, cardiovascular disease, hormone replacement therapy, smoking, alcohol consumption and physical activity. The risk for poor memory (p = 0.023 for linear trend) and cognitive speed (p = 0.070 for linear trend) increased with increasing IMT tertiles. CONCLUSIONS: Carotid IMT predicts an increased risk for cognitive impairment, particularly poor memory and cognitive speed, in elderly women.

Physical inactivity, depression, and risk of cardiovascular mortality.

PURPOSE: Studies indicate that depression may increase risk of cardiovascular disease (CVD) in addition to classical risk factors. One of the hypotheses to explain this relation is that depressed subjects become physically inactive. We set out to determine the role of physical inactivity in the relation between depressive symptoms and cardiovascular mortality. METHODS: Data were used from the population-based prospective Finland, Italy, and the Netherlands Elderly (FINE) Study. Depressive symptoms were measured with the Zung Self-Rating Depression Scale in 909 elderly men, aged 70-90 yr, free of CVD and diabetes at baseline in 1990. Physical activity was assessed with a questionnaire for retired men. Hazard ratios (HR) for 10-yr cardiovascular mortality were calculated, adjusting for demographics and cardiovascular risk factors. RESULTS: At baseline, men with more depressive symptoms were less physically active (722 min.wk; 95% confidence interval (CI), 642-802) than men with few depressive symptoms (919 min.wk; 95% CI, 823-1015). During 10 yr of follow-up, 256 (28%) men died from CVD. The adjusted HR of cardiovascular mortality for a decrease of 30 min.d in physical activity was 1.09 (95% CI, 1.04-1.14). An increase in depressive symptoms with one standard deviation was associated with a higher cardiovascular mortality risk (HR = 1.42; 95% CI, 1.26-1.60). After additional adjustment for physical activity the risk decreased (9%), but an independent risk remained (HR = 1.37; 95% CI, 1.21-1.56). The excess risk on cardiovascular mortality attributable to the combined effect of depressive symptoms with inactivity was 1.47 (95% CI, -0.17 to 3.11). CONCLUSIONS: In the present study, the increased risk of depressive symptoms on cardiovascular mortality could not be explained by physical inactivity. However, our results suggest that depressive symptoms and physical inactivity may interact to increase cardiovascular mortality risk.

Metabolic syndrome and the progression of carotid intima-media thickness in elderly women.

BACKGROUND: Although the metabolic syndrome can predict cardiovascular events in middle-aged individuals, data on its association with the progression of subclinical atherosclerosis, particularly in elderly women, are limited. We investigated the association of the metabolic syndrome with the progression of carotid intima-media thickness (IMT) in elderly women. METHODS: We performed a 12-year follow-up study in a population-based sample of 101 women (age range at baseline, 60-70 years). All study variables were measured at baseline and 12 years later. We used the National Cholesterol Education Program definition for metabolic syndrome (> or =3 of 5 risk factors) and quantified carotid IMT noninvasively by ultrasonography. RESULTS: The prevalence of metabolic syndrome increased from 13% at baseline to 46% after 12 years of follow-up (P<.001). The mean +/- SD IMT increased by 21% (from 1.05 +/- 0.31 mm to 1.27 +/- 0.38 mm) during 12 years (P<.001). Among the individuals without metabolic syndrome at baseline, the increase in carotid IMT was greater in 34 women who developed metabolic syndrome during 12 years (0.31 +/- 0.37 mm) than in 54 women who did not (0.16 +/- 0.25 mm) after adjustment for age, prevalent cardiovascular diseases, physical activity, smoking, alcohol intake, serum low-density lipoprotein cholesterol level, use of cholesterol-lowering medication, carotid IMT, and National Cholesterol Education Program metabolic risk score at baseline (P = .04 for difference). CONCLUSION: Incident metabolic syndrome is associated with accelerated progression of carotid IMT in elderly women.

Association of smoking status with obesity and diabetes among elderly people.

The present study was aimed to examine associations of current and ex-smoking status with obesity and diabetes among elderly people. Nationwide study of Finnish elderly people based on biennial surveys from 1985 to 1995, were used to study 7482 people aged 65-79 years. Smoking status included non-, ex-light, ex-heavy, current light, and current heavy smokers. Obesity was set as body mass index (BMI) > or = 30. Information of smoking, BMI, and diabetes was based on self-reports. Logistic regression was used as the main method of analyses. Compared to non-smokers (reference category), ex-heavy smokers had higher (odds ratio, 1.42; 95% confidence interval: 1.09, 1.85) and current light smokers (OR, 0.46; 95% CI: 0.31, 0.69) lower relative risk of obesity. Current light smokers had also lower and ex-heavy smokers higher rate of diabetes than non-smokers. Ex-heavy smokers had a higher risk of obesity (OR, 1.75; 95% CI: 1.30, 2.36) and diabetes (OR, 1.48; 95% CI: 1.10, 2.01) than ex-light smokers. Same pattern for current smokers was found. Heavy ex- and current elderly smokers are at risk of obesity and diabetes. Thus, heavy smokers should be emphasized in programs promoting smoking cessation.

Training practitioners in evidence-based chronic disease prevention for global health.

Too often, public health decisions are based on short-term demands rather than long-term research and objectives. Policies and programmes are sometimes developed around anecdotal evidence. The Evidence-Based Public Health (EBPH) programme trains public health practitioners to use a comprehensive, scientific approach when developing and evaluating chronic disease programmes. Begun in 2002, the EBPH programme is an international collaboration. The course is organized in seven parts to teach skills in: 1) assessing a community's needs; 2) quantifying the issue; 3) developing a concise statement of the issue; 4) determining what is known about the issue by reviewing the scientific literature; 5) developing and prioritizing programme and policy options; 6) developing an action plan and implementing interventions; and 7) evaluating the programme or policy. The course takes an applied approach and emphasizes information that is readily available to busy practitioners, relying on experiential learning and includes lectures, practice exercises, and case studies. It focuses n using evidence-based tools and encourages participants to add to the evidence base in areas where intervention knowledge is sparse. Through this training programme, we educated practitioners from 38 countries in 4 continents. This article describes the evolution of the parent course and describes experiences implementing the course in the Russian Federation, Lithuania, and Chile. Lessons learned from replication of the course include the need to build a "critical mass" of public health officials trained in EBPH within each country and the importance of international, collaborative networks. Scientific and technologic advances provide unprecedented opportunities for public health professionals to enhance the practice of EBPH. To take full advantage of new technology and tools and to combat new health challenges, public health practitioners must continually improve their skills.

Trends in hypertension care in eastern and south-western Finland during 1982-2002.

OBJECTIVE: To assess the trends in blood pressure (BP) levels and the control of hypertension in eastern and south-western Finland during 1982-2002. DESIGN: Five independent cross-sectional population surveys conducted in 1982, 1987, 1992, 1997 and 2002. SETTING: The provinces of North Karelia and Kuopio in eastern Finland and the region of Turku-Loimaa in south-western Finland. PARTICIPANTS: Stratified random samples of men and women aged 25-64 years were selected from the national population register. The total number of participants was 29 127. MAIN OUTCOME MEASURES: Mean systolic blood pressure (SBP) and diastolic blood pressure (DBP), the prevalence and control of hypertension. The distribution of all subjects with no antihypertensive drug treatment in 2002 according to the modified risk stratification scheme introduced in 2003 European Society of Hypertension-European Society of Cardiology guidelines. RESULTS: Mean SBP and DBP and the prevalence of hypertension decreased significantly in all areas. The proportion of treated hypertensive subjects with adequately controlled BP (SBP < 140 mmHg and DBP < 90 mmHg) increased from 13.7 to 33.3% in men (P < 0.001) and from 11.4 to 32.0% in women (P < 0.001). The unsatisfactory treatment of hypertension was mainly a result of the lack of control of high SBP. According to the 2003 guidelines, 35.9% of the entire population currently not on antihypertensive drug treatment should have been prescribed such treatment within a year. CONCLUSIONS: Hypertension care has improved significantly in Finland during 1982-2002. However, the difference between the actual situation at the population level and the treatment goals presented by the hypertension guidelines remains vast.

Thirty-year cumulative incidence of chronic bronchitis and COPD in relation to 30-year pulmonary function and 40-year mortality: a follow-up in middle-aged rural men.

PURPOSE: To describe the 30-year cumulative incidence of chronic bronchitis and COPD in relation to smoking habits. The effect of chronic bronchitis on pulmonary function and mortality was also examined. METHODS: Middle-aged men belonging to two rural Finnish cohorts of the Seven Countries Study (n = 1,711 in 1959) were followed up for up to 40 years until 2000. Standard questionnaires were used to measure chronic bronchitis, and repeated spirometry was used to evaluate pulmonary function during the 30 years. Forty-year mortality data were examined. RESULTS: The cumulative incidence of chronic bronchitis and COPD was 42% and 32%, respectively, in continuous smokers, compared to 26% and 14% in ex-smokers and 22% and 12% in never-smokers. During the follow-up, subjects with chronic bronchitis had on average 252 mL (95% confidence interval, 211 to 293 mL) lower forced expiratory volume than those without it. The decrease in forced expiratory volume attributable to chronic bronchitis was most pronounced in those with persistent symptoms and in smokers. In subjects with chronic bronchitis, all-cause mortality was increased by a hazard ratio of 1.30 (95% confidence interval, 1.02 to 1.65). Smokers with chronic bronchitis who decreased their daily cigarette consumption increased their median life span by 2.4 years. CONCLUSIONS: The lifetime risk of chronic bronchitis among smokers is approximately two in five, and almost one half of smokers who have chronic bronchitis also acquire COPD. Chronic bronchitis is related to earlier death, also in never-smokers, probably partly through a rapid decline in pulmonary function.

Trends and educational disparities in functional capacity among people aged 65-84 years.

BACKGROUND: This study examined 10 year trends in functional capacity by gender, age, and education among elderly Finns aged 65-84 years, focusing on difficulties in basic activities of daily living (BADL). Educational disparities and their trends in the prevalence of these difficulties were also assessed. METHODS: Data were derived from nationally representative monitoring surveys conducted biennially from 1993 to 2003 by the National Public Health Institute (KTL). A total of 5740 men and 5746 women were included in the study (response rate 80%). Activities of daily living (ADL) measures were used to assess levels of functional capacity. Education was divided into two groups: low (0-8 years) and high (9+ years). Age-adjusted trends and logistic regression analyses were computed. RESULTS: A clear downward trend in BADL difficulties was observed in all age groups in both genders. 80-84 year olds had clearly poorer functional ability than 65-69 year olds, even when adjusted for chronic diseases. Despite the overall improvement in functional capacity in both educational groups, low educational status persistently predicted poorer functional capacity. When chronic diseases and survey period were controlled for, the educational disparities attenuated slightly but remained significant. CONCLUSIONS: The number of Finnish elderly with BADL difficulties has declined markedly over the past 10 years. However, persistent educational disparities continue to present a challenge to public health initiatives for reducing inequalities in health.

The relationship of age, blood pressure, serum cholesterol and smoking habits with the risk of typical and atypical coronary heart disease death in the European cohorts of the Seven Countries Study.

OBJECTIVE: To explore whether "typical" coronary heart disease (CHD) such as fatal myocardial infarction and sudden death relate to major cardiovascular risk factors in the same way as the "atypical" CHD, such as fatal heart failure and chronic arrhythmias. DESIGN AND SETTING: Ten cohorts (6633 cardiovascular disease-free men, aged 40-59) in five European countries were examined, age and three major risk factors were measured (systolic blood pressure, serum cholesterol, and smoking habits) and 35-year mortality data were collected. Proportional hazard models were solved with typical and atypical CHD deaths treated separately. RESULTS: Death rates from typical and atypical CHD were inversely related among the five countries. Mean age at death was significantly higher for atypical than typical (75.8 versus 71.6 years; p < 0.001). In the multivariate analysis conducted on pools of 5 countries (adjusted for countries), the relationship of risk factors with typical CHD was direct and significant for age (hazard ratio-HR-for 5 years of age 1.44 (95% CI 1.36-1.52)), systolic blood pressure (HR for 20 mm Hg, 1.39 (95% CI 1.32-1.47)), serum cholesterol (HR for 1 mmol/l of 1.22 (95% CI 1.16-1.27)) and smoking habits (HR smokers versus non-smokers of 1.39 (95% CI 1.24-1.57)). For atypical CHD, age had a larger HR of 2.27 (95% CI 2.05-2.52), systolic blood pressure had a smaller HR of 1.28 (95% CI 1.16-1.41), serum cholesterol had an inverse non-significant HR of 0.90 (0.58-1.58) and smoking habits had a larger HR of 1.54 (95% CI 1.26-1.89). CONCLUSIONS: Age and serum cholesterol were differently related with typical and atypical CHD deaths, suggesting different etiologies for these coronary diseases.

Marital status and living situation during a 5-year period are associated with a subsequent 10-year cognitive decline in older men: the FINE Study.

We investigate the association between marital status and living situation (over 5 years) on 10-year subsequent cognitive decline. The study population consisted of 1,042 men aged 70-89 years in 1990, who participated in the longitudinal Finland, Italy, the Netherlands Elderly (known as FINE) Study. We measured cognition by using the Mini-Mental State Examination, and we assessed marital status (married vs unmarried) and living situation (living with others vs living alone) with a standardized questionnaire. We performed repeated measurement analyses and made adjustments for age, education, country, smoking, alcohol, chronic diseases, marital status or living situation, and baseline cognition. Men who lost a partner, who were unmarried, who started to live alone, or who lived alone during the 5-year period had at least a two times stronger subsequent cognitive decline compared with men who were married or who lived with someone in those years.

The relation between pulse pressure and cardiovascular mortality in 12,763 middle-aged men from various parts of the world: a 25-year follow-up of the seven countries study.

BACKGROUND: Hypertension is a dominant characteristic in the prediction of cardiovascular diseases (CVDs). We aimed to evaluate the association of blood pressure measurements with CVD mortality among different populations of the world. METHODS: A total of 12 763 men, aged 40 to 59 years, from 7 countries (United States, Japan, Italy, Greece, former Yugoslavia, Finland, and the Netherlands) were surveyed from 1958 to 1964. Follow-up for vital status and causes of death was carried out over 25 years. RESULTS: All baseline blood pressure measurements were the best predictors of CVD mortality, compared with age, physical activity, total serum cholesterol level, body mass index or height, and smoking. Moreover, pulse pressure and diastolic and systolic blood pressures were the best predictors for CVD death, followed by mean and mid blood pressures. The age-adjusted hazard ratio per 10-mm Hg increase in pulse pressure varied among cohorts from 1.19 in the United States (P = .04) to 1.29 in southern Europe (P = .01). Differences among cohorts were not significant. In the pooled cohorts, pulse pressure measurements were also a significant predictor for coronary heart disease (hazard ratio per 10-mm Hg increase, 1.15; P = .04) as well as stroke death (hazard ratio per 10-mm Hg increase, 1.32; P = .01). CONCLUSIONS: Pulse pressure followed by diastolic and systolic blood pressures were the best predictors for CVD mortality among other blood pressures, as well as age, physical activity, total serum cholesterol level, anthropometric indexes, and smoking habits. No significant differences were observed among the different populations studied.

Hierarchy levels, sum score, and worsening of disability are related to depressive symptoms in elderly men from three European countries.

OBJECTIVES: The objectives were to investigate the predictive value of hierarchy levels and sum score of disability and change in disability on depressive symptoms. METHOD: Longitudinal data of 723 men age 70 and older from the Finland, Italy, and the Netherlands Elderly Study were collected in 1990 and 1995. Self-reported disability was based on three disability domains (instrumental activities, mobility, and basic activities) and depressive symptoms on the Zung questionnaire. RESULTS: Severity levels of disability were positively associated with depressive symptoms. Men with no disability scored 5 to 17 points lower (p < .01) on depressive symptoms than did those with disability in all domains. Among men with mild disability, those who had worsening of disability status in the preceding 5 years scored 5 points higher (p = .004) on depressive symptoms than did men who improved. DISCUSSION: Hierarchic severity levels, sum score of disability, and preceding changes in disability status are risk factors for depressive symptoms.