Atrial fibrillation in the elderly general population: a 30-year follow-up from 70 to 100 years of age.

Objectives. There is limited knowledge of atrial fibrillation (AF) incidence among the very old. Data from longitudinal cohort studies may give us a better insight. The aim of the study was to investigate the incidence rate and prevalence of AF, as well as the impact of AF on mortality, in the general population, from 70 to 100 years of age. Design. This was a population-based prospective cohort study where three representative samples of 70-year-old men and women (n = 2,629) from the Gerontological and Geriatric Populations Studies in Gothenburg (H-70) were included between 1971 and 1982. The participants were examined at age 70 years and were re-examined repeatedly until 100 years of age. AF was diagnosed according to a 12-lead electrocardiogram (ECG) recording at baseline and follow-up examinations, from the Swedish National Patient Register (NPR), or from the Cause of Death Register. Results. The cumulative incidence of AF from 70 to 100 years of age was 65.6% for men and 52.8% for women. Mortality was significantly higher in participants with AF compared with those without, rate ratio (RR) 1.92 (95% CI 1.73-2.14). In a subgroup analysis comprising only participants with AF diagnosed by ECG at screening, the RR for death was 1.29 (95% C.I: 1.03-1.63). Conclusions. Among persons surviving to age 70, the cumulative incidence of AF was over 50% during follow-up. Mortality rate was twice as high in participants with AF compared to participants without AF. Among participants with AF first recorded at a screening examination, the increased risk was only 29%.

Impact of changes in physical activity or BMI on risk of heart failure in women - the prospective population study of women in Gothenburg.

Objective: To longitudinally evaluate the impact of change in physical activity or change in body mass index (BMI) over time on the risk of developing heart failure (HF) in women without a previous diagnosis of HF.Design and setting: Longitudinal, observational, prospective study of women in Gothenburg, Sweden. Data on BMI and level of physical activity were collected from examinations 1968-1992 and hospital diagnoses and mortality data were ascertained from 1980 to 2012.Subjects: Data were obtained from 1749 women included in the Prospective Population Study of Women in Gothenburg.Main outcome measures: Hazard ratio (HR) for HF was calculated, using a Cox regression model.Results: Women with stable high physical activity during 1968-1980 and 1980-1992 reduced their risk of subsequent HF compared to the non-active women (for 1968-1980 HR 0.66, 95% Confidence Interval (CI) 0.44-0.99 and for 1980-1992 HR 0.47, 95% CI 0.29-0.74). Women with increasing levels of physical activity during 1980-1992 reduced their risk of HF compared to the non-active women (HR 0.40, 95% CI 0.22-0.72). Increase in BMI from overweight to obesity during 1968-1980 predicted increased risk of developing HF (HR 1.93, 95% CI 1.18-3.14).Conclusions: Reduced risk of future HF in healthy women may be achieved by remaining physically active from young middle age and throughout life or by increasing the level of physical activity. This is particularly important for sedentary women in middle age. The role of physical activity in preventing the development of obesity must be taken into account.Key pointsA sedentary lifestyle and obesity are risk factors for developing heart failure (HF) in women.The risk of developing HF may be reduced by increasing the level of activity in sedentary middle-aged women.For younger women, avoiding obesity is most important to reduce the risk of later HF.Primary care has a key role in guiding women towards the most effective lifestyle changes to prevent development of HF.

Drug Treatment, Postural Control, and Falls: An Observational Cohort Study of 504 Patients With Acute Stroke, the Fall Study of Gothenburg.

OBJECTIVE: To identify whether, and to what extent, treatment with cardiovascular drugs and neurotropic drugs are associated with postural control and falls in patients with acute stroke. DESIGN: Observational cohort study. SETTING: A stroke unit at a university hospital. PARTICIPANTS: A consecutive sample of patients (N=504) with acute stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Postural control was assessed using the modified version of the Postural Assessment Scale for Stroke Patients. Data including baseline characteristics, all drug treatments, and falls were derived from medical records. Univariable and multivariable logistic regression and Cox proportional hazards models were used to analyze the association of drug treatment and baseline characteristics with postural control and with falls. RESULTS: In the multivariable logistic regression analysis, factors significantly associated with impaired postural control were treatment with neurotropic drugs (eg, opioids, sedatives, hypnotics, antidepressants) with an odds ratio (OR) of 1.73 (95% confidence interval [CI], 1.01-2.97, P=.046); treatment with opioids (OR 9.23, 95% CI, 1.58-54.00, P=0.014); age (OR 1.09, 95% CI, 1.07-1.12, P<.0001), stroke severity, which had a high National Institutes of Health Stroke Scale-score (OR 1.29, 95% CI, 1.15-1.45, P<.0001), and sedentary life style (OR 4.32, 95% CI, 1.32-14.17, P=.016). No association was found between neurotropic drugs or cardiovascular drugs and falls. CONCLUSIONS: Treatment with neurotropic drugs, particularly opioids, in the acute phase after stroke, is associated with impaired postural control. Since impaired postural control is the major cause of falls in patients with acute stroke, these results suggest opioids should be used with caution in these patients.

Risk of falling in a stroke unit after acute stroke: The Fall Study of Gothenburg (FallsGOT).

OBJECTIVE: This study aimed to investigate incidence of falls and different baseline variables and their association with falling during hospitalization in a stroke unit among patients with acute stroke. DESIGN: Prospective observational study. SETTING: A stroke unit at a university hospital. SUBJECTS: A consecutive sample of stroke patients, out of which 504 were included, while 101 declined participation. METHODS: The patients were assessed a mean of 1.7 days after admission and 3.8 days after stroke onset. MAIN MEASURES: The primary end-point was any fall, from admission to the stroke unit to discharge. Factors associated with falling were analysed using univariable and multivariable Cox hazard regression analyses. Independent variables were related to function, activity and participation, as well as personal and environmental factors. RESULTS: In total, 65 patients (13%) fell at least once. Factors statistically significantly associated with falling in the multivariable analysis were male sex (hazard ratio (HR): 1.88, 95% confidence interval (CI): 1.13-3.14, P = 0.015), use of a walking aid (HR: 2.11, 95% CI: 1.24-3.60, P = 0.006) and postural control as assessed with the modified version of the Postural Assessment Scale for Stroke Patients (SwePASS). No association was found with age, cognition or stroke severity, the HR for low SwePASS scores (⩽24) was 9.33 (95% CI: 2.19-39.78, P = 0.003) and for medium SwePASS scores (25-30) was 6.34 (95% CI: 1.46-27.51, P = 0.014), compared with high SwePASS scores (⩾31). CONCLUSION: Postural control, male sex and use of a walking aid are associated with falling during hospitalization after acute stroke.

Obesity in Middle Age Increases Risk of Later Heart Failure in Women-Results From the Prospective Population Study of Women and H70 Studies in Gothenburg, Sweden.

OBJECTIVE: Obesity has been shown to be a risk factor for heart failure (HF), but whether the association varies by age is not understood. The aim was to examine the impact of obesity/overweight on the risk of developing heart failure in women of different ages by analysing prospective data from 2 population studies. METHODS: Data were obtained from the Population Study of Women in Gothenburg and the Gerontologic and Geriatric Population Studies concerning body mass index (BMI) collected in 1980 or later. Follow-up ended in 2006. Cox proportional hazard methods were used to determine associations between developing HF and BMI in 2574 women, 1243 aged 26-65 years and 1331 aged 66-76 years, at baseline. RESULTS: Women aged 26-65 years at baseline with BMI ≥30 kg/m2 had an increased risk of developing HF (hazard ratio [HR] 2.61, 95% confidence interval [CI] 1.56-4.35) even when controlling for age, glucose, smoking, alcohol consumption, serum triglycerides, and systolic blood pressure (reference group: women with BMI 18.5-22.4 kg/m2). Obese women aged 66-76 years at baseline did not show increased risk of developing HF (HR 0.55, 95% CI 0.23-1.29). CONCLUSIONS: Obesity in middle-age women increases their risk of developing HF later in life. In contrast, obesity later in life shows no association with HF.

Salivary secretion and drug treatment in four 70-year-old Swedish cohorts during a period of 30 years.

OBJECTIVE: The aim was to examine the association between drug treatment and unstimulated and stimulated whole saliva in four 70-year-old Swedish cohorts, between 1971 and 2001. BACKGROUND: Both diseases and their medication can affect the salivary secretion rate. MATERIALS AND METHODS: The study was based on selected samples of four cohorts born in 1901/1902, 1906/1907, 1911/1912 and 1930/1931, respectively, a total of 1072 individuals. The response rate varied between 65% and 85%. RESULTS: The mean value for the stimulated salivary secretion rate was higher in men (1.3 ± 0.8 ml/min) than in women (1.0 ± 0.7 ml/min) (p < 0.001)). There was a significant association between the salivary secretion rate and the number of drugs among both women (p < 0.01) and men (p < 0.001). This influence was most pronounced in participants who were treated with cardiovascular drugs, mainly diuretics and non-selective ß-adrenoceptor blockers, but also with antipsychotics and antidepressants, even when adjusted for cohort, gender, number of teeth and other drugs. There was an increase in treatment with medicines during the three decades. CONCLUSION: In these four groups of 70-year-old participants, high drug consumption was associated with lower salivary flow. Unstimulated secretion was only affected in women and then, when taking four or more drugs. Pronounced hyposalivation was, however, uncommon. Cardiovascular drugs, antidepressants and antipsychotics were associated with low salivary secretion. In this age group, the frequently observed association between polypharmacy and a lower saliva secretion rate represents a risk of impaired dental health.

Cholesterol and triglyceride levels in midlife and risk of heart failure in women, a longitudinal study: the prospective population study of women in Gothenburg.

OBJECTIVE: To examine the association between triglycerides and cholesterol serum values and risk of developing heart failure in women. DESIGN: Longitudinal observational study of four cohorts 50-year-old women examined in 1968-1969, 1980-1981, 1992-1993 and 2004-2005, and followed until 2012. S-triglycerides and s-cholesterol were measured at baseline and heart failure morbidity and mortality data collected from 1980 to 2012. SETTING: Prospective population study Gothenburg, Sweden. Primary care. PARTICIPANTS: 1143 women 50 year old without history of heart failure or myocardial infarction. MAIN OUTCOME MEASURE: Association among s-triglycerides, s-cholesterol and heart failure expressed as HR for heart failure, adjusted for smoking, body mass index (BMI), physical activity and age. RESULTS: For 50-year-old women examined in 1968-1969, there was an independent association between level of s-triglycerides and heart failure and a significantly higher risk of developing heart failure (HR 1.8; CI 1.16 to 2.80, for each increment of 1.0 mmol/L in s-triglycerides), adjusted for smoking, BMI, physical activity and age. There was no significant association between s-cholesterol and risk of heart failure (HR 0.9; CI 0.77 to 1.15). In the cohorts of 50-year-old women examined in 1980 and 1992, there were no significant associations between neither s-triglycerides or s-cholesterol and the risk of heart failure. In the pooled analyses of the cohorts examined in 1968, 1980 and 1992, a significantly increased risk of heart failure was found (HR 1.49; CI 1.10 to 2.03) for s-triglycerides independently, but not for s-cholesterol. None of the 50-year-old women examined in 2004-2005 developed heart failure by 2012 and were excluded from further analyses. CONCLUSIONS: High levels of s-triglycerides but not s-cholesterol may be a risk marker for later development of heart failure in 50-year-old women.

SBP and antihypertensive treatment in the acute phase after stroke and its impact on the risk of falling.

INTRODUCTION: Blood pressure development after acute stroke is inadequately studied. The objectives of this study were to describe SBP development among patients in the acute phase after stroke, and to investigate whether intensified antihypertensive treatment during this phase was associated with short-term prognosis regarding the risk of falling. PATIENTS AND METHODS: This observational study is a sub-study of the Fall Study of Gothenburg and included 421 consecutive patients admitted to a stroke unit. Medical records were studied for blood pressure measurements, antihypertensive treatment and falls. Random coefficient models for repeated measures data was used to study change in SBP. Univariable Cox proportional hazards model was used for estimation of predictors' effect on time to first fall within first 10 days. RESULTS: During the first two days after stroke onset, mean SBP for all stroke patients decreased by 14.9 mmHg (95% CI 12.3-17.4, P < 0.0001) and further 2.3 mmHg days 2-7 after onset (95% CI -0.1 to 4.7, P = 0.066). The decrease in SBP was statistically significant irrespective of the use of antihypertensive treatment. No association was found between intensified antihypertensive treatment in the first week after acute stroke and the risk of a fall. CONCLUSION: The findings show a spontaneous decrease of SBP during the first two days after acute stroke. This reduction in SBP seems to be present regardless of stroke type, age and use of antihypertensive treatment. No association between intensified antihypertensive treatment during the first 7 days after stroke and falls was found.

The clinical consequences of a pre-hospital diagnosis of stroke by the emergency medical service system. A pilot study.

BACKGROUND: There is still a considerable delay between the onset of symptoms and arrival at a stroke unit for most patients with acute stroke.The aim of the study was to describe the feasibility of a pre-hospital diagnosis of stroke by an emergency medical service (EMS) nurse in terms of diagnostic accuracy and delay from dialing 112 until arrival at a stroke unit. METHODS: Between September 2008 and November 2009, a subset of patients with presumed acute stroke in the pre-hospital setting were admitted by EMS staff directly to a stroke unit, bypassing the emergency department. A control group, matched for a number of background variables, was created. RESULTS: In all, there were 53 patients in the direct admission group, and 49 patients in the control group. The median delay from calling for an ambulance until arrival at a stroke unit was 54 minutes in the direct admission group and 289 minutes in the control group (p < 0.0001).In a comparison between the direct admission group and the control group, a final diagnosis of stroke, transient ischemic attack (TIA) or the sequelae of prior stroke was found in 85% versus 90% (NS). Among stroke patients who lived at home prior to the event, the percentage of patients that were living at home after 3 months was 71% and 62% respectively (NS). CONCLUSIONS: In a pilot study, the concept of a pre-hospital diagnosis of stroke by an EMS nurse was associated with relatively high diagnostic accuracy in terms of stroke-related diagnoses and a short delay to arrival at a stroke unit. These data need to be confirmed in larger studies, with a concomitant evaluation of the clinical consequences and, if possible, the level of patient satisfaction as well.

Nurse-led heart failure follow-up in primary care in Sweden.

BACKGROUND: Little or no knowledge is available about which service is offered to patients with heart failure in primary care. AIMS: To describe nurse-led follow-up of patients with heart failure in primary care in Sweden. METHODS AND RESULTS: A questionnaire was sent to all primary health care centres in Sweden and 610 of 939 centres returned the questionnaire. Special nurses had designated time for follow-up of heart failure patients at 18% (n=111) of the centres, compared to 93% and 78% for diabetes and obstructive lung disease. Centres with nurse-led follow-up of heart failure patients more frequently provided heart failure information (p<0.001), had more doctors interested in heart failure (p<0.001), more often had special care programmes (p<0.001) and had more co-operation with the hospitals around patients with heart failure (p<0.01), compared to centres without such follow-up (n=499). CONCLUSION: In primary care in Sweden, nurse-led follow-up is uncommon for patients with heart failure, despite being common for patients with diabetes and obstructive pulmonary disease. To improve this situation in primary care, an increased number of specially trained nurses is needed, together with further research to ensure a high quality follow-up in primary care.

Low serum testosterone and high serum estradiol associate with lower extremity peripheral arterial disease in elderly men. The MrOS Study in Sweden.

OBJECTIVES: This study sought to determine whether serum levels of testosterone and estradiol associate with lower extremity peripheral arterial disease (PAD) in a large population-based cohort of elderly men. BACKGROUND: Few studies have explored the relationship between serum sex steroids and lower extremity PAD in men. METHODS: The Swedish arm of the MrOS (Osteoporotic Fractures in Men) study (n = 3,014; average age 75.4 years) assessed ankle-brachial index (ABI) and defined lower extremity PAD as ABI <0.90. Radioimmunoassay measured serum levels of total testosterone, estradiol, and sex hormone-binding globulin, and we calculated free testosterone and free estradiol levels from the mass action equations. RESULTS: A linear regression model including age, current smoking, previous smoking, diabetes, hypertension, body mass index, free testosterone, and free estradiol showed that free testosterone independently and positively associates with ABI (p < 0.001), whereas free estradiol independently and negatively associates with ABI (p < 0.001). Logistic regression analyses showed that free testosterone in the lowest quartile (vs. quartiles 2 to 4; odds ratio [OR] 1.65, 95% confidence interval [CI] 1.22 to 2.23, p = 0.001) and free estradiol in the highest quartile (vs. quartiles 1 to 3; OR 1.45, 95% CI 1.09 to 1.94, p = 0.012) independently associate with lower extremity PAD. CONCLUSIONS: This cross-sectional study shows for the first time that low serum testosterone and high serum estradiol levels associate with lower extremity PAD in elderly men. Future prospective and interventional studies are needed to establish possible causal relationships between sex steroids and the development of lower extremity PAD in men.

Change in blood pressure in the age interval 70-90. Late blood pressure peak related to longer survival.

AIMS: To investigate longitudinal changes in systolic (SBP) and diastolic blood pressure (DBP) between age 70 and 90, and to analyse the relationship between blood pressure changes after 70 and survival in two representative population samples (n = 973 and n = 1036). MAJOR FINDINGS: In the total population sample, SBP increased up to age 75 and declined thereafter. In survivors up to 90, SBP increased up to age 79 and decreased thereafter. DBP decreased after 70. Up to age 82, women had higher SBP and DBP than men. Low SBP at 70 and 75 were correlated to longer survival in both sexes. The relation between blood pressure peak and survival up to age 90 was analysed in 424 men and 640 women, all examined at 70, 75 and 79 years. Twenty-six per cent of men and 44% of women with the highest SBP at 79 survived up to 90 years compared with 15% of men and 31% of women with the highest SBP at 70. SBP and DBP at age 90 were higher in survivors up to age 93 compared with non-survivors. PRINCIPAL CONCLUSION: Low blood pressure at 70 and late SBP peak were related to longer survival after age 79.

Exercise test in women and men aged 75-77 years.

The purpose of this study was to investigate the physiological response to an exercise test in 75- to 77-year-old women and men. Out of a systematically chosen and representative sample of 1,245 persons from a population at the age of 70, 649 individuals remained available at the age of 75-77 years. An exercise test was performed in 335 participants (52%), 174 women and 161 men. 180 (28%) were excluded because of morbidity. 131 (20%) refused to perform an exercise test. Three persons had to be excluded because of missing data. The maximal heart rate was about 140 beats/min. Heart rates at different submaximal workloads were higher in females than in males. In males there was a significant nonlinear increase in heart rate at increasing work loads while in females this was not significant. The systolic blood pressure increased more in females than in males while working on the loads 30-50 W and 50-75 W. There was a significant nonlinear increase in systolic blood pressure in men without cardiovascular drugs during exercise on 30-75 W, but the corresponding increase was not significant in women. The highest average work load for the whole group measured during at least 4 min of near-maximal exercise on a bicycle was in women 48 W and in men 66 W. Forty-four percent of the women and 22% of the men had a physical working capacity presumably interfering with their ability to perform activities of daily living.