Evaluación de la validez de las funciones SCORE de bajo riesgo y calibrada para población española en las cohortes FRESCO / Validity assessment of low-risk SCORE function and SCORE function calibrated to the Spanish population in the FRESCO cohorts

Introducción y objetivos. Estudiar la validez de la función SCORE original de bajo riesgo sin y con colesterol unido a lipoproteínas de alta densidad y SCORE calibrada en población española. Métodos. Análisis agrupado con datos individuales de 12 estudios de cohorte de base poblacional. Se incluyó a 30.919 participantes de 40-64 años sin enfermedades cardiovasculares en el momento del reclutamiento, que se siguieron durante 10 años para la mortalidad cardiovascular contemplada en el proyecto SCORE. La validez de las funciones se analizó mediante el área bajo la curva ROC (discriminación) y el test de Hosmer-Lemeshow (calibración), respectivamente. Resultados. Se dispuso de 286.105 personas/año. La mortalidad a 10 años por causas cardiovasculares fue del 0,6%. La razón de casos esperados/observados fue de 9,1, 6,5 y 9,1 en varones y de 3,3, 1,3 y 1,9 en mujeres con las funciones SCORE original de bajo riesgo sin y con colesterol unido a lipoproteínas de alta densidad y SCORE calibrada, respectivamente; diferencias estadísticamente significativas con el test de calibración de Hosmer-Lemeshow entre la mortalidad predicha con SCORE y la observada (p < 0,001 en ambos sexos y en todas las funciones). Las áreas bajo la curva ROC con SCORE original fueron 0,68 en varones y 0,69 en mujeres. Conclusiones. Todas las versiones de las funciones SCORE disponibles en España sobreestiman significativamente la mortalidad cardiovascular observada en la población española. A pesar de la aceptable capacidad de discriminación, la predicción del número de acontecimientos cardiovasculares mortales (calibración) fue significativamente imprecisa (AU)

Introduction and objectives. To assess the validity of the original low-risk SCORE function without and with high-density lipoprotein cholesterol and SCORE calibrated to the Spanish population. Methods. Pooled analysis with individual data from 12 Spanish population-based cohort studies. We included 30 919 individuals aged 40 to 64 years with no history of cardiovascular disease at baseline, who were followed up for 10 years for the causes of death included in the SCORE project. The validity of the risk functions was analyzed with the area under the ROC curve (discrimination) and the Hosmer-Lemeshow test (calibration), respectively. Results. Follow-up comprised 286 105 persons/y. Ten-year cardiovascular mortality was 0.6%. The ratio between estimated/observed cases ranged from 9.1, 6.5, and 9.1 in men and 3.3, 1.3, and 1.9 in women with original low-risk SCORE risk function without and with high-density lipoprotein cholesterol and calibrated SCORE, respectively; differences were statistically significant with the Hosmer-Lemeshow test between predicted and observed mortality with SCORE (P < .001 in both sexes and with all functions). The area under the ROC curve with the original SCORE was 0.68 in men and 0.69 in women. Conclusions. All versions of the SCORE functions available in Spain significantly overestimate the cardiovascular mortality observed in the Spanish population. Despite the acceptable discrimination capacity, prediction of the number of fatal cardiovascular events (calibration) was significantly inaccurate (AU)

Interaction between cardiovascular risk factors and body mass index and 10-year incidence of cardiovascular disease, cancer death, and overall mortality.

The effect of above-normal body mass index (BMI) on health outcomes is controversial because it is difficult to distinguish from the effect due to BMI-associated cardiovascular risk factors. The objective was to analyze the impact on 10-year incidence of cardiovascular disease, cancer deaths and overall mortality of the interaction between cardiovascular risk factors and BMI. We conducted a pooled analysis of individual data from 12 Spanish population cohorts with 10-year follow-up. Participants had no previous history of cardiovascular diseases and were 35-79years old at basal examination. Body mass index was measured at baseline being the outcome measures ten-year cardiovascular disease, cancer and overall mortality. Multivariable analyses were adjusted for potential confounders, considering the significant interactions with cardiovascular risk factors. We included 54,446 individuals (46.5% with overweight and 27.8% with obesity). After considering the significant interactions, the 10-year risk of cardiovascular disease was significantly increased in women with overweight and obesity [Hazard Ratio=2.34 (95% confidence interval: 1.19-4.61) and 5.65 (1.54-20.73), respectively]. Overweight and obesity significantly increased the risk of cancer death in women [3.98 (1.53-10.37) and 11.61 (1.93-69.72)]. Finally, obese men had an increased risk of cancer death and overall mortality [1.62 (1.03-2.54) and 1.34 (1.01-1.76), respectively]. In conclusion, overweight and obesity significantly increased the risk of cancer death and of fatal and non-fatal cardiovascular disease in women; whereas obese men had a significantly higher risk of death for all causes and for cancer. Cardiovascular risk factors may act as effect modifiers in these associations.

Validity Assessment of Low-risk SCORE Function and SCORE Function Calibrated to the Spanish Population in the FRESCO Cohorts.

INTRODUCTION AND OBJECTIVES: To assess the validity of the original low-risk SCORE function without and with high-density lipoprotein cholesterol and SCORE calibrated to the Spanish population. METHODS: Pooled analysis with individual data from 12 Spanish population-based cohort studies. We included 30 919 individuals aged 40 to 64 years with no history of cardiovascular disease at baseline, who were followed up for 10 years for the causes of death included in the SCORE project. The validity of the risk functions was analyzed with the area under the ROC curve (discrimination) and the Hosmer-Lemeshow test (calibration), respectively. RESULTS: Follow-up comprised 286 105 persons/y. Ten-year cardiovascular mortality was 0.6%. The ratio between estimated/observed cases ranged from 9.1, 6.5, and 9.1 in men and 3.3, 1.3, and 1.9 in women with original low-risk SCORE risk function without and with high-density lipoprotein cholesterol and calibrated SCORE, respectively; differences were statistically significant with the Hosmer-Lemeshow test between predicted and observed mortality with SCORE (P < .001 in both sexes and with all functions). The area under the ROC curve with the original SCORE was 0.68 in men and 0.69 in women. CONCLUSIONS: All versions of the SCORE functions available in Spain significantly overestimate the cardiovascular mortality observed in the Spanish population. Despite the acceptable discrimination capacity, prediction of the number of fatal cardiovascular events (calibration) was significantly inaccurate.

Risk of Cause-Specific Death in Individuals With Diabetes: A Competing Risks Analysis.

OBJECTIVE: Diabetes is a common cause of shortened life expectancy. We aimed to assess the association between diabetes and cause-specific death. RESEARCH DESIGN AND METHODS: We used the pooled analysis of individual data from 12 Spanish population cohorts with 10-year follow-up. Participants had no previous history of cardiovascular diseases and were 35-79 years old. Diabetes status was self-reported or defined as glycemia >125 mg/dL at baseline. Vital status and causes of death were ascertained by medical records review and linkage with the official death registry. The hazard ratios and cumulative mortality function were assessed with two approaches, with and without competing risks: proportional subdistribution hazard (PSH) and cause-specific hazard (CSH), respectively. Multivariate analyses were fitted for cardiovascular, cancer, and noncardiovascular noncancer deaths. RESULTS: We included 55,292 individuals (15.6% with diabetes and overall mortality of 9.1%). The adjusted hazard ratios showed that diabetes increased mortality risk: 1) cardiovascular death, CSH = 2.03 (95% CI 1.63-2.52) and PSH = 1.99 (1.60-2.49) in men; and CSH = 2.28 (1.75-2.97) and PSH = 2.23 (1.70-2.91) in women; 2) cancer death, CSH = 1.37 (1.13-1.67) and PSH = 1.35 (1.10-1.65) in men; and CSH = 1.68 (1.29-2.20) and PSH = 1.66 (1.25-2.19) in women; and 3) noncardiovascular noncancer death, CSH = 1.53 (1.23-1.91) and PSH = 1.50 (1.20-1.89) in men; and CSH = 1.89 (1.43-2.48) and PSH = 1.84 (1.39-2.45) in women. In all instances, the cumulative mortality function was significantly higher in individuals with diabetes. CONCLUSIONS: Diabetes is associated with premature death from cardiovascular disease, cancer, and noncardiovascular noncancer causes. The use of CSH and PSH provides a comprehensive view of mortality dynamics in a population with diabetes.

Derivation and validation of a set of 10-year cardiovascular risk predictive functions in Spain: the FRESCO Study.

OBJECTIVE: To derive and validate a set of functions to predict coronary heart disease (CHD) and stroke, and validate the Framingham-REGICOR function. METHOD: Pooled analysis of 11 population-based Spanish cohorts (1992-2005) with 50,408 eligible participants. Baseline smoking, diabetes, systolic blood pressure (SBP), lipid profile, and body mass index were recorded. A ten-year follow-up included re-examinations/telephone contact and cross-linkage with mortality registries. For each sex, two models were fitted for CHD, stroke, and both end-points combined: model A was adjusted for age, smoking, and body mass index and model B for age, smoking, diabetes, SBP, total and HDL cholesterol, and for hypertension treatment by SBP, and age by smoking and by SBP interactions. RESULTS: The 9.3-year median follow-up accumulated 2973 cardiovascular events. The C-statistic improved from model A to model B for CHD (0.66 to 0.71 for men; 0.70 to 0.74 for women) and the combined CHD-stroke end-points (0.68 to 0.71; 0.72 to 0.75, respectively), but not for stroke alone. Framingham-REGICOR had similar C-statistics but overestimated CHD risk. CONCLUSIONS: The new functions accurately estimate 10-year stroke and CHD risk in the adult population of a typical southern European country. The Framingham-REGICOR function provided similar CHD prediction but overestimated risk.

Cross-sectional associations of objectively measured physical activity, cardiorespiratory fitness and anthropometry in European adults.

OBJECTIVE: To quantify the independent associations between objectively measured physical activity (PA), cardiorespiratory fitness (CRF), and anthropometry in European men and women. METHODS: 2,056 volunteers from 12 centers across Europe were fitted with a heart rate and movement sensor at 2 visits 4 months apart for a total of 8 days. CRF (ml/kg/min) was estimated from an 8 minute ramped step test. A cross-sectional analysis of the independent associations between objectively measured PA (m/s(2)/d), moderate and vigorous physical activity (MVPA) (%time/d), sedentary time (%time/d), CRF, and anthropometry using sex stratified multiple linear regression was performed. RESULTS: In mutually adjusted models, CRF, PA, and MVPA were inversely associated with all anthropometric markers in women. In men, CRF, PA, and MVPA were inversely associated with BMI, whereas only CRF was significantly associated with the other anthropometric markers. Sedentary time was positively associated with all anthropometric markers, however, after adjustment for CRF significant in women only. CONCLUSION: CRF, PA, MVPA, and sedentary time are differently associated with anthropometric markers in men and women. CRF appears to attenuate associations between PA, MVPA, and sedentary time. These observations may have implications for prevention of obesity.

[Influence of double workload in perceived health and health services utilization of immigrants and Murcian natives, Spain]. / Influencia de la doble carga de trabajo en el estado de salud percibida y utilización de servicios sanitarios de las poblaciones inmigrante y autóctona de la región de Murcia.

BACKGROUND: Gender inequalities in health have been largely documented. The main objective of this study is to assess whether there are gender differences in perceived health and health services utilization, and their relation with double workload in a representative sample of immigrants and Murcian natives. METHODS: We used data from the NHS 2006 and Health and Culture Study, 1,303 immigrants and 1,303 Spanish, both residents in the Region of Murcia. With the combination of reproductive work and paid work we built up the variable 'double workload' (DW). We estimated the prevalence ratio (PR) for positive self-perceived health, chronic morbidity, activity limitation, doctor's visits, hospitalization, emergency and drug use, by origin, using regression methods. Two models were constructed by adding double burden to the basic model adjusted by sociodemographic variables. Analyses were performed between and within sex. RESULTS: After adjusting for DW, no changes were seen in the differences by gender [RP women/men of positive perception health: 0.70 (0.54-0.89) East European; 0.87 (0.79-0.95) autochthonous / chronic morbidity: 1.44 (1.14-1.82) Hispanic; 1.36 (1.19-1.55) autochthonous / activity limitation: 2.23 (1.29-3.83) Hispanic; 1.45 (1.01-2.10) autochthonous / doctor's visits: 1.93 (1.50-2.48) Hispanic; 1.74 (1.06-2.86) Moroccan; 1.32 (1.09-1.59) autochthonous / hospitalization: 1.80 (1.02-3.17) Hispanic], almost the same than unadjusted. Women used more drugs than men. Within sexes, both autochthonous men (1.19; 1.06-1.33) and women (1.18; 1.01-1.40) with shared DW had more positive self-perceived health than those without DW. Hispanic men with DW without assistance: 0.67 (0.47-0.94). CONCLUSIONS: Women have worse health indicators and greater use of health services regardless of origin. Consideration of the double workload does not explain gender inequalities in health.

Infuencia de la doble carga de trabajo en el estado de salud percibida y utilización de servicios sanitarios de las poblaciones inmigrante y utóctona de la Región de Murcia / Influence of double workload in perceived health and health services utilization of immigrants and Murcian natives, Spain

Fundamentos: Las desigualdades de género en salud han sido ampliamente documentadas. El principal objetivo es evaluar si existen diferencias de género en salud percibida y utilización de servicios sanitarios, y su relación con la doble carga de trabajo, en una muestra representativa de población inmigrante y autóctona de la Región de Murcia (RM). Métodos: Se utilizaron datos de la ENS 2006 y el Estudio Salud y Culturas, 1.303 inmigrantes y 1.303 españoles residentes en la RM. La combinación del trabajo reproductivo y remunerado se consideró «doble carga» (DC). Se estimó la razón de prevalencia (RP) de la percepción positiva de salud, morbilidad crónica, limitación de actividad, visitas al médico, hospitalización, visitas a urgencias y consumo de fármacos, en cada grupo de origen, mediante métodos de regresión. Se construyeron dos modelos, añadiendo el ajuste por DC al modelo ajustado por variables sociodemográficas. Se realizó análisis inter e intrasexo. Resultados: Al ajustar por DC no se observaron cambios en las diferencias entre sexos [RP mujeres/hombres de percepción positiva salud: 0,70 (0,54-0,89) europeos Este; 0,87 (0,79-0,95) autóctonos / morbilidad crónica: 1,44 (1,14-1,82) hispanoamericanos; 1,36 (1,19-1,55) autóctonos / limitación actividad: 2,23 (1,29-3,83) hispanoamericanos; 1,45 (1,01-2,10) autóctonos / consulta médico: 1,93 (1,50-2,48) hispanoamericanos; 1,74 (1,06-2,86) marroquíes; 1,32 (1,09-1,59) autóctonos / hospitalización: 1,80 (1,02-3,17) hispanoamericanos], casi los mismos que sin ajustar. Las mujeres consumieron más fármacos que los hombres. Entre sexos, hombres (1,19; 1,06-1,33) y mujeres (1,18; 1,01-1,40) de la RM con DC compartida declararon mayor percepción positiva de salud que aquellos sin DC; hombres hispanoamericanos con DC sin ayuda: 0,67 (0,47-0,94). Conclusiones: Las mujeres presentan peores indicadores de salud y mayor uso de servicios sanitarios independientemente del origen. La doble carga no modifica las desigualdades de género en salud(AU)

Background: Gender inequalities in health have been largely documented. The main objective of this study is to assess whether there are gender differences in perceived health and health services utilization, and their relation with double workload in a representative sample of immigrants and Murcian natives. Methods: We used data from the NHS 2006 and Health and Culture Study, 1,303 immigrants and 1,303 Spanish, both residents in the Region of Murcia. With the combination of reproductive work and paid work we built up the variable “double workload” (DW). We estimated the prevalence ratio (PR) for positive self-perceived health, chronic morbidity, activity limitation, doctor’s visits, hospitalization, emergency and drug use, by origin, using regression methods. Two models were constructed by adding double burden to the basic model adjusted by sociodemographic variables. Analyses were performed between and within sex. Results: After adjusting for DW, no changes were seen in the differences by gender [RP women/men of positive perception health: 0.70 (0.54-0.89) East European; 0.87 (0.79-0.95) autochthonous / chronic morbidity: 1.44 (1.14-1.82) Hispanic; 1.36 (1.19-1.55) autochthonous / activity limitation: 2.23 (1.29-3.83) Hispanic; 1.45 (1.01-2.10) autochthonous / doctor’s visits: 1.93 (1.50-2.48) Hispanic; 1.74 (1.06-2.86) Moroccan; 1.32 (1.09-1.59) autochthonous / hospitalization: 1.80 (1.02-3.17) Hispanic], almost the same than unadjusted. Women used more drugs than men. Within sexes, both autochthonous men (1.19; 1.06-1.33) and women (1.18; 1.01-1.40) with shared DW had more positive self-perceived health than those without DW. Hispanic men with DW without assistance: 0.67 (0.47-0.94). Conclusions: Women have worse health indicators and greater use of health services regardless of origin. Consideration of the double workload does not explain gender inequalities in health(AU)

Validity of a short questionnaire to assess physical activity in 10 European countries.

To accurately examine associations of physical activity (PA) with disease outcomes, a valid method of assessing free-living activity is required. We examined the validity of a brief PA questionnaire (PAQ) used in the European Prospective Investigation into Cancer and Nutrition (EPIC). PA energy expenditure (PAEE) and time spent in moderate and vigorous physical activity (MVPA) was measured in 1,941 healthy individuals from 10 European countries using individually-calibrated combined heart-rate and movement sensing. Participants also completed the short EPIC-PAQ, which refers to past year's activity. Pearson (r) and Spearman (σ) correlation coefficients were calculated for each country, and random effects meta-analysis was used to calculate the combined correlation across countries to estimate the validity of two previously- and one newly-derived ordered, categorical PA indices ("Cambridge index", "total PA index", and "recreational index") that categorized individuals as inactive, moderately inactive, moderately active, or active. The strongest associations with PAEE and MVPA were observed for the Cambridge index (r = 0.33 and r = 0.25, respectively). No significant heterogeneity by country was observed for this index (I(2) = 36.3%, P = 0.12; I(2) = 0.0%, P = 0.85), whereas heterogeneity was suggested for other indices (I(2) > 48%, P < 0.05, I(2) > 47%, P < 0.05). PAEE increased linearly across self-reported PA categories (P for trend <0.001), with an average difference of approximately 460 kJ/d for men and 365 kJ/d for women, between categories of the Cambridge index. The EPIC-PAQ is suitable for categorizing European men and women into four distinct categories of overall physical activity. The difference in PAEE between categories may be useful when estimating effect sizes from observational research.

[Myocardial infarction. Population case-fatality in seven Spanish autonomous communities: the IBERICA Study]. / Mortalidad poblacional por infarto agudo de miocardio. Estudio IBERICA.

BACKGROUND AND OBJECTIVE: The magnitude of the problem of myocardial infarction (MI) is better understood by assessing the population case-fatality than by analyzing only the number of patients attending hospitals. PATIENTS AND METHOD: Our data come from the IBERICA Study (Investigation, Specific Search and Registry of Acute Myocardial Ischemic Syndrome). Twenty eight-day MI population case-fatality is described in the population aged 25 to 74 years during 1997 and 1998 in the following Spanish autonomous communities: Castilla-La Mancha (Toledo and Albacete), Catalonia (Girona), Valencia Community (Valencia), Balearic Islands (Majorca), Murcia, Navarra and Basque Country. The relationship between case-fatality and other variables such as sex, age and geographic area is also analyzed. RESULTS: A total of 10,660 MI cases were registered, 4,106 of whom died within the period of 28 days following the onset of symptoms (38.5%; CI 95%, 37.6-39.4%). The overall case-fatality was 37.0% (CI 95%, 35.9-38.0%) in men and 44.3% (CI 95%, 42.3-46.4%) in women. Death occurred out of hospitals in 2,869 (69.9%) cases. An increased case-fatality in women was associated with a higher in-hospital case-fatality (45% higher than men). The proportion of patients who died before reaching a hospital was similar in both genders. Classical symptoms of MI were more common among men than women (82.7% vs. 77.6%, p < 0,001). The interval between symptoms' onset and hospitalization was 30 minute longer among hospitalized women as compared with men (p < 0,001). CONCLUSIONS: Population MI case-fatality is high in the seven Spanish autonomous communities studied. Approximately 2 out of 3 deaths occur without patients being able to reach a hospital. These results emphasize the importance of primary and secondary prevention measures and the necessity to design ready-access systems to defibrillation and resuscitation manoeuvres for patients with cardiopulmonary arrest.

Mortalidad poblacional por infarto agudo de miocardio. Estudio IBERICA / Myocardial infarction. Population case-fatality in seven Spanish autonomous communities: the IBERICA Study

FUNDAMENTO Y OBJETIVO: El estudio de la mortalidad poblacional del infarto agudo de miocardio (IAM), que incluye las muertes ocurridas antes de llegar al hospital, ofrece una visión más completa sobre la magnitud del problema que la obtenida estudiando únicamente la mortalidad de los casos que reciben atención hospitalaria. PACIENTES Y MÉTODO: Los datos provienen del estudio IBERICA (Investigación, Búsqueda Específica y Registro de Isquemia Coronaria Aguda). Se describe la mortalidad en los primeros 28 días desde el inicio de los síntomas de los episodios de IAM registrados, durante 1997 y 1998, en la población de 25 a 74 años residente en 7 comunidades autónomas españolas: Castilla-La Mancha (Toledo y Albacete), Cataluña (Girona), Comunidad Valenciana (Valencia), Islas Baleares (Mallorca), Murcia, Navarra y País Vasco. Además, se estudia la relación entre mortalidad y otras variables como el sexo, la edad y el área geográfica. RESULTADOS: Se registraron 10.654 casos de IAM de los que 4.105 fallecieron durante los 28 primeros días (38,5 por ciento; intervalo de confianza [IC] del 95 por ciento, 37,6-39,4 por ciento). La mortalidad fue del 37,0 por ciento (IC del 95 por ciento, 35,9-38,0 por ciento) en los varones y del 44,3 por ciento (IC del 95 por ciento, 42,3-46,4 por ciento) en las mujeres. La muerte se produjo fuera del hospital en 2.869 (69,9 por ciento) casos. La mayor mortalidad en mujeres estuvo relacionada fundamentalmente con una mayor mortalidad hospitalaria (45 por ciento superior a la registrada en los varones), siendo menor la diferencia en la proporción de casos que fallecieron fuera del hospital. La sintomatología típica de presentación del episodio fue más frecuente en varones (el 82,7 frente al 77,6 por ciento) (p < 0,001). Entre los pacientes que llegaron vivos al hospital, el tiempo transcurrido entre el comienzo de los síntomas y el inicio del tratamiento fue, en promedio, 30 min menor en los varones (p < 0,001). CONCLUSIONES: La mortalidad poblacional por IAM en estas 7 áreas españolas es muy elevada aunque inferior a la de otros países industrializados. Aproximadamente dos de cada tres muertes ocurren antes de llegar al hospital. Estos datos refuerzan el papel prioritario de la prevención primaria y secundaria, ya que los cuidados hospitalarios tienen un impacto limitado en el control de la mortalidad poblacional por IAM. También indican que una forma de reducir la mortalidad debería incluir el acceso rápido a la desfibrilación y a las maniobras de resucitación de los pacientes que presenten una muerte súbita (AU)

Los alimentos modificados genéticamente y la epidemiología actual / Gentically modified foods and the present-time epidemiology

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