Changes in bicycle ergometer test performance and survival in men and women from 50 to 60 and from 70 to 80 years of age: two longitudinal studies in the Glostrup (Denmark) population.

BACKGROUND: During the aging process longitudinal changes for sustained work in humans are poorly understood. Only a few longitudinal follow-up studies have been published thus far, and most of them have been based on highly selected groups, such as physical education teachers or senior athletes. OBJECTIVE AND METHODS: On the basis of random samples of a general population, the purpose of this study was to analyze changes in bicycle test performance in two longitudinal designs: a 10-year follow-up period from 50 to 60 years of age, using a submaximal test protocol, and another 10-year follow-up period from 70 to 80 years of age, using indirect voluntary maximal tests. In addition, the preventive value of the bicycle test results for survival at different age levels was analyzed. The subjects in the first part of the study were members of a random sample of originally 514 men and 461 women living in the Glostrup area, close to Copenhagen, Denmark, in 1964. Of these, 367 men (71.4%) and 206 women (44.7%) were tested at the age of 50 years, and 309 men and 245 women were tested 10 years later. The subjects in the second part of the study came from the same original sample. At 70 years of age 171 men and 154 women and at 80 years of age 70 men and 68 women took part in the maximal test. RESULTS: The submaximal test results between the ages of 50 and 60 years showed a mean annual decline in body mass adjusted maximal power in sustained work (W/kg) of 0.54% in men and of 0.90% in women. Between the ages of 70 and 80 years, when the indirect maximal tests were applied, the annual decline in men was on average 1.79% and in women 3.03%. When the associations of submaximal test results at ages 50-60 years and the voluntary maximal test results at the higher ages were analyzed, a moderate positive correlation was observed with the results obtained at the age of 70 years. The survival analyses showed that the submaximal bicycle test results (W/kg body mass) at the age of 60 years had a predictive value for survival in women during the subsequent 10-year period. The same was true for the maximal test results obtained at the age of 70 years in men; a significantly larger proportion of men in the lowest quintile died during the subsequent 10 years than of those belonging to the higher quintiles. CONCLUSIONS: The changes in body mass related maximal power in sustained work observed in this population on the basis of longitudinal studies among the age groups 50-60 and 70-80 years indicated a steeper decline at the higher ages. The decline was relatively more pronounced in women than in men. However, differences in the test protocols employed at different times limit the possibilities for overall comparisons across the data. The results of the submaximal bicycle ergometer tests in middle-aged female subjects (60 years old) had a predictive value for survival over the 10 years immediately following the test; likewise, the voluntary maximal test results at higher ages predicted survival in men.

[Prognosis after primary acute myocardial infarction]. / Prognosen efter primaert akut myokardieinfarkt.

Results from many clinical trials have changed treatment strategies, but due to considerable selection caused by extensive inclusion- and exclusion criteria the results are only valid for smaller groups, while the majority of the patients still suffer from high mortality with conservative treatment. We have during eight years followed 933 patients with first myocardial infarction and found that the group who tolerated treatment with thrombolytic agents had a lower mortality than the rest. On the other hand, infarct patients are generally old, often with concomitant chronic diseases which affect mortality, and this in combination with heart-failure and cardiac arrhythmias determines outcome. Better prophylactic and treatment measures are needed to improve survival of ischaemic heart disease.

Prognostic implications of ventricular ectopy one week, one month, and sixteen months after an acute myocardial infarction. Danish Study Group on Verapamil in Myocardial Infarction.

BACKGROUND: Ventricular ectopy early after an acute myocardial infarction (AMI) has previously been demonstrated to predict mortality. Less information is available about the prognostic implications of ventricular ectopy occurring late after an AMI, and no information is available about the prognostic implication of the development of ventricular ectopy during the first year after an AMI. HYPOTHESIS: The purpose of the present prospectively conducted trial, a part of the Danish Verapamil Infarction Trial II (DAVIT II), was to evaluate the prognostic implication of (1) ventricular premature complexes (VPCs) recorded by 24-h Holter monitoring 1 week, 1 month, and 16 months after an AMI; and (2) development of > 10 VPCs/h or of any complex ventricular ectopy, that is, pairs, more than two types of VPCs, ventricular tachycardia, or > 10 VPCs/h during follow-up after an AMI. METHODS: Patients were monitored 1 week (n = 250), 1 month (n = 210), and 16 months (n = 201) after AMI. RESULTS: Multivariate analyses based on history, clinical findings, and ventricular ectopy showed the following results: After 1 week, > 10 VPCs/h (p = 0.0006) and heart failure (p < 0.007); after 1 month, > 10 VPCs/h (p = 0.003) and resting heart rate (p < 0.02); and after 16 months, ventricular tachycardia (p = 0.002) independently predicted long-term mortality. Mortality was significantly predicted by the development of > 10 VPCs/h from 1 week to 1 month (p = 0.003) and 16 months (p = 0.03), and from 1 to 16 months (p = 0.007) after AMI, as well as by the development of any complex ventricular ectopy from 1 week to 1 month (p = 0.02) and 16 months (p = 0.01), and from 1 to 16 months (p = 0.04) after AMI. CONCLUSION: The present study demonstrated that 1 week and 1 month after an AMI the quantity of VPCs, that is, > 10 VPCs/h, predicted mortality, whereas 16 months after an AMI the quality of VPCs, that is, ventricular tachycardia, predicted mortality.

[Physical fitness of Danish men and women aged 50 to 80 years]. / Danske maend og kvinders fysiske arbejdsevne fra 50- til 80-års-alderen.

Maximal power in sustained work in originally randomly selected men and women, born in 1914, was studied five times between the ages of 50 and 80 years in a longitudinal design. Of the originally 514 men and 461 women in 1964 living in the Western suburbs of Copenhagen, 23 men and 18 women performed a bicycle test at age 50, 60, 70, 75 and 80. The mean annual decline in body mass adjusted maximal power in sustained work (W/kg) was 1.43% in the 18 men and 1.64% in the 23 women. Based on "cross-sectional" comparisons of all subjects tested at any age, the mean annual decline in men was 1.56%; in women the corresponding figure was 1.80%. When the results of the "longitudinal" and "cross-sectional" analyses were compared with each other, a rather similar picture of the age-related decline in maximal power was obtained, especially in women. In the longitudinal data only moderate (women) or zero (men) correlations were observed between the submaximal test results at the ages of 50 and 60 years and the maximal test results at higher ages. The physical work load at the age of 50 years had no significant correlation with maximal power at that age or thereafter. There were only minor changes in mean body height, body mass and BMI during the follow-up.

Treatment with verapamil and trandolapril in patients with congestive heart failure and angina pectoris or myocardial infarction. The DAVIT Study Group. Danish Verapamil Infarction Trial.

In a double-blind, randomized trial in a consecutive group of postinfarct patients in treatment with diuretic agents for congestive heart failure, the 3 month rate of cardiac events (i.e., death, repeat infarction, unstable angina pectoris, or repeat admission because of heart failure) was 14% in patients treated with verapamil and trandolapril and 35% in patients treated with trandolapril (p = 0.01). In another study of patients with angina pectoris and left ventricular ejection fraction less than 40%, trandolapril plus verapamil improved exercise duration and left ventricular ejection fraction. These findings indicate that combined treatment with verapamil and trandolapril may be beneficial in patients with congestive heart failure.

Treatment with verapamil and trandolapril in patients with congestive heart failure and myocardial infarction. The Danish Verapamil Infarction Trial (DAVIT Study Group).

UNLABELLED: EFFECTS OF VERAPAMIL AND TRANDOLAPRIL: Progression of heart failure, sudden death and death from re-infarction are the major cause of the increased mortality in postinfarct patients with congestive heart failure. Angiotensin converting enzyme (ACE) inhibitors such as trandolapril can prevent the progression of heart failure and thus improve survival. The calcium antagonist verapamil has been shown to prevent sudden death and re-infarction in postinfarct patients without congestive heart failure. HYPOTHESIS: The Danish Verapamil Infarction Trial (DAVIT) study group hypothesized the combined treatment with trandolapril and verapamil might prevent cardiac events in postinfarct patients with coronary heart disease. The first double-blind randomized trial included 100 patients and supported this hypothesis, as the cardiac event rate was significantly lower after 3 months in patients treated with the combination than in those treated with trandolapril alone (14 versus 35%, respectively; P = 0.01, hazard ratio 0.35, 95% confidence interval 0.15-0.85).

Cardiac event rates after acute myocardial infarction in patients treated with verapamil and trandolapril versus trandolapril alone. Danish Verapamil Infarction Trial (DAVIT) Study Group.

Angiotensin-converting enzyme (ACE) inhibitors improve survival in patients with congestive heart failure (CHF) after an acute myocardial infarction (AMI), but mortality may be as high as 10% to 15% after 1 year. Verapamil prevents cardiac events after an AMI in patients without CHF. We hypothesized that in postinfarct patients with CHF already prescribed diuretics and an ACE inhibitor, additional treatment with verapamil may reduce cardiac event rate. In this multicenter, double-blind study, patients with CHF receiving diuretic treatment were consecutively randomized to treatment with trandolapril 1 mg/day for 1 month and 2 mg/day the following 2 months (n = 49), or to trandolapril as mentioned plus verapamil 240 mg/day for 1 month and 360 mg/day for 2 months (n = 51). Trial medication started 3 to 10 days after AMI. All patients were followed for 3 months. End points in the trandolapril/trandolapril-verapamil groups were death 1/1, reinfarction 7/1, unstable angina 9/3, and readmission for CHF 6/2. The 3-month first cardiac event rate was 35% in trandolapril-treated patients and 14% in trandolapril-verapamil-treated patients (hazard ratio 0.35, 95% confidence interval 0.15 to 0.85, p = 0.015). These data suggest that verapamil reduces cardiac event rates in post-AMI patients with CHF when added to an ACE inhibitor and a diuretic.

Effect of verapamil on the prognosis of patients with early postinfarction electrical or mechanical complications. The Danish Verapamil Infarction Trial II (DAVIT II).

The Danish Verapamil Infarction Trial II (DAVIT II) demonstrated from the second postinfarction week, that long term treatment with verapamil significantly improved reinfarction free survival after an acute myocardial infarction (AMI). The present post hoc analysis of DAVIT II was undertaken with the purpose of evaluating the effect of treatment with verapamil in patients with early electrical complications, i.e. ventricular or atrial fibrillation, ventricular tachycardia, or second or third degree atrioventricular block, with or without mechanical complication, i.e. heart failure, during the first post-AMI week. In the placebo group, the 18-month mortality rate was lowest (9.5%) in patients without electrical or mechanical complications, highest (24.6%) in patients with electrical events only, and in-between (17.5%) in patients with mechanical problems regardless of presence of electrical complications. Verapamil significantly reduced the 18-month mortality rate in patients with early electrical without mechanical complications (60% reduction, P = 0.02), and in patients without mechanical complications (35% reduction, P = 0.02). Verapamil did not change the mortality rate in patients with mechanical complications.

Short- and long-term prognostic implications of in-hospital postinfarction arrhythmias. DAVIT II Study Group.

The purpose of the present study was to evaluate, in patients surviving the first postinfarction week, the short- and long-term prognostic implications of arrhythmias, and their relation to easily obtained anamnestic and clinical parameters presented during hospitalisation. The study consisted of 897 placebo-treated patients of the Danish Verapamil Infarction Trial II (DAVIT II). In patients with and without supraventricular tachycardia mortality within 2 months was 9.2 and 3.7% (p = 0.004), respectively. By multivariate analysis supraventricular tachycardia independently predicted mortality within 2 months. Mortality within 5 years was predicted by the presence of supraventricular tachycardia, atrial fibrillation, advanced atrioventricular block, sinoatrial block, and of the combined arrhythmic parameter, i.e. ventricular and/or atrial fibrillation and/or advanced atrioventricular block. When easily obtained and assessed anamnestic and clinical parameters were included in a multivariate analysis, the presence of supraventricular tachycardia alone gave independent prognostic information on long-term mortality.

Effect of verapamil on arrhythmias and heart rate during 16 months following an acute myocardial infarction. The Danish Study Group on Verapamil in Myocardial Infarction.

The present study was a prospectively planned subset of the postinfarction, double blind, randomized, multicenter, placebo controlled trial of verapamil, DAVIT II. Patients had 24 hours of Holter monitoring before randomization, i.e., second week after infarction (placebo, n = 122; verapamil, n = 128), after 1 month (placebo, n = 108; verapamil, n = 94) and after 16 months (placebo, n = 75; verapamil, n = 63) of treatment. The purpose was to evaluate the effect of verapamil on the prevalence and changes over time of arrhythmias and heart rate. In patients monitored twice, a significant increase of average ventricular premature complexes (VPC) per hour from before to 1 month (p = 0.0007) and 16 months (p = 0.02) after was demonstrated in the placebo group, and from before to 1 months (p = 0.01) after in the verapamil group. Average VPC/hr did not change from 1 to 16 months of treatment. A significant increment of > 10 VPC/hr was found after 1 (p = 0.03) and 16 months (p = 0.05) compared to prerandomization in the placebo, but not in the verapamil group. A significant increase of supraventricular arrhythmias after 1 month compared with prerandomization was found in the placebo group (p = 0.003) but not in the verapamil group. The prevalence of VPC and supraventricular tachycardia was significantly lower in the verapamil compared with the placebo group after 1 month of treatment. At 16 months no significant difference was found between the two groups. The 24 hour mean heart rate was significantly lower, 3 beats/min, in the verapamil compared with placebo after 1 and 16 months of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[Smoking habits and risk of coronary heart disease, especially risk associated with low daily tobacco consumption]. / Rygevaner og risiko for koronar hjertesygdom, specielt risikoen ved lille dagligt tobaksforbrug.

The purpose of this study was to estimate the risk of acute myocardial infarction related to smoking habits, especially the risk among smokers with a daily tobacco consumption of five grams or less. The study is based on data from the 1914 population examined by the Glostrup Population Studies at the age of 50 and 60 in 1964 and 1974. Information concerning deaths and cases of hospitalisation has been obtained from national registers up to 1985. Blood pressure, lipids, body mass index and physical activity were used as confounders. It was not possible to make a definite conclusion for the group smoking five grams or less daily as a class, since both the size of the group and the number of myocardial infarctions within it were small. When tobacco consumption was used as a quantitative variable the risk of myocardial infarction was found to increase with increasing amount but the relation was found not to be non-linear. The best description of the tobacco-related risk of myocardial infarction was a logarithmically relation to daily tobacco consumption.

Exercise-provoked ST-segment depression and prognosis in patients recovering from acute myocardial infarction. Significance and pitfalls.

The importance of maximal versus submaximal exercise testing and the significance of heart failure on the prognostic value of exercise-provoked ST-segment depression > or = 0.1 mV was studied in 143 patients recovering from acute myocardial infarction. Patients were exercise tested prior to discharge and follow up lasted for up to 18 months (mean 17 months). End-point was first major event (i.e. first non-fatal reinfarction or death). A symptom-limited exercise test was superior to a heart-rate-limited test in detecting ST-segment depressions (27% vs. 20%: P < 0.5), and patients with ST-segment depression at lower heart rates did not have an increased risk of subsequent events compared with patients with ST-segment depression at higher heart rates (14% vs. 27%; NS). Heart failure surpassed ST-segment depression as a risk predictor (34% vs. 18%). Based on a meta-analysis including 13 studies (1987 patients) exercise-provoked ST-segment depression possessed an increased risk of subsequent major events (P < 0.0001; risk ratio = 1.90; 95% confidence limits 1.43,2.51). Thus, ST-segment depression provoked by a symptom-limited test selects patients with an increased risk of subsequent major events. In patients with a history of heart failure exercise-provoked ST-segment depression is of limited value.

Does exercise-induced ST-segment depression predict benefit of medical intervention in patients recovering from acute myocardial infarction? The Danish Study Group on Verapamil in Myocardial Infarction.

The present study tested the hypothesis that the increased risk in patients with exercise-provoked ST-segment depression recovering from acute myocardial infarction could by abolished by anti-ischaemic medical intervention. Prior to discharge a symptom-limited exercise test was carried out. Patients were then double-blindly randomized to treatment with either verapamil 120 mg t.i.d. or placebo, and observed for up to 18 months (mean 17 months). End-point was first major event; i.e. non-fatal reinfarction or death. Two-hundred-and-ninety-eight patients were included. Forty-four patients with and 111 without exercise-induced ischaemia were randomized to verapamil and 39 and 104 respectively, to placebo. The overall number of events was 12.5%. In patients without ST-segment depression, 12.5% in the placebo group (hazard = 1) and 12.6% in the verapamil group (hazard = 1.13) had an event (NS). In patients with ST-segment depression 15.4% in the placebo group (hazard = 1.20) and 9.1% in the verapamil group (hazard = 0.85) had an event (NS). The latter reduction (41%) supports the hypothesis that patients with ST-segment depression, i.e. residual myocardial ischaemia, are those who benefit from anti-ischaemic intervention after myocardial infarction.

Effect of verapamil on ischemia and ventricular arrhythmias after an acute myocardial infarction: prognostic implications. The Danish Verapamil Infarction Trial II Study Group.

This article is a review of presented subsets of the Danish Verapamil Infarction Trial II (DAVIT II) regarding the effect of verapamil on postinfarction ischemia, ventricular arrhythmias, and heart rate (HR), and the prognostic implications of these findings. Patients underwent Holter monitoring for 24-48 h at 1 week, i.e., before randomization to long-term treatment with placebo or verapamil, and after 1 month and about 1 year of study treatment. Ischemia: 18% of the patients had transient ST-segment deviation before randomization; 24% of the placebo- and 8% of the verapamil-treated patients (p = 0.04) showed ischemia after 1 month; and after 1 year, the figures were 26 and 4%, respectively (p = 0.02). The 18-month major event rate, i.e., first reinfarction or death, in patients with ischemia before randomization were 40 and 23.8% in patients without ischemia (p = 0.06). Arrhythmias: In the placebo group the prevalence and incidence of many ventricular ectopic beats (VEBs), i.e., more than 10 VEBs/h, increased significantly during the first years after infarction; this was not the case in the verapamil patients group. The mean HR was significantly reduced by verapamil treatment after 1 month and after 16 months of treatment. Multivariate analysis demonstrated the presence of more than 10 VEBs/h only early (i.e., 1 week) but not late (i.e., 1 month) after infarction, to be an independent predictor of major events during 18 months' follow-up observation. A HR above 80 beats/min independently predicted major events when appearing both early and late after infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

[Early retirement among the 1914 population in Glostrup. Significance of social and health problems in choosing early retirement]. / Efterløn blandt 1914-populationen i Glostrup. Sociale og helbredsmaessige faktorers betydning for valg af efterløn.

In the population investigation in Glostrup, the 1914 population was examined at the ages of 50, 60 and 67 years. A total of 141 participants at the 67 years examination (106 men and 35 women) stated that they had chosen early retirement prior to transition to old age pensions. The social and health circumstances of these early retirees at the ages of 50 and 60 years are compared with the circumstances in the 243 persons in the cohort (154 men and 89 women) who remained occupationally active until the age for old age pensioning. In the group of early retirees, unskilled men predominated. Out of those who found the occupational environment stressful at the ages of 50 or 60 years, a majority subsequently chose early retirement. Significantly more of the men with abnormal findings in the heart and lungs at the health examinations subsequently chose early retirement. Where the remaining health variables were concerned, no connection could be found with subsequent choice of early retirement. Where the health conditions at the age of 60 years were concerned, a tendency for more frequent choice of early retirement was observed in men with a series of abnormal conditions in the lungs and intestinal tract but no distinct tendency was observed in women. Where both sexes were concerned, an increasing tendency to subsequent choice of early retirement was observed with increasing incidense of cardiovascular risk factors at the age of 60 years. Data concerning low back pain at the age of 60 years did not reveal any connection with subsequent choice of early retirement but may suggest early elimination of persons with low back pain.