Relationship of socioeconomic status to the incidence and prehospital, 28-day, and 1-year mortality rates of acute coronary events in the FINMONICA myocardial infarction register study.

BACKGROUND: Low socioeconomic status (SES) is associated with increased coronary heart disease mortality rates. There are, however, very little data on the relation of SES to the incidence, recurrence, and prognosis of myocardial infarction (MI) events. METHODS AND RESULTS: The FINMONICA MI Register recorded detailed information on all MI events among men and women aged 35 to 64 years in 3 areas of Finland during the period of 1983 to 1992. We carried out a record linkage of the MI register data with files of Statistics Finland to obtain information on indicators of SES, such as taxable income and education, for each individual who is registered. In the analyses, income was grouped into 3 categories (low, middle, and high), and education was grouped into 2 categories (basic and secondary or higher). Among men with their first MI event (n=6485), the adjusted incidence rate ratios were 1.67 (95% CI 1.57 to 1.78) and 1.84 (95% CI 1.73 to 1.95) in the low- and middle-income categories compared with the high-income category. For 28-day mortality rates, the corresponding rate ratios were 3.18 (95% CI 2.82 to 3.58) and 2.33 (95% CI 2.03 to 2.68). Significant differentials were observed for prehospital mortality rates, and they remained similar up to 1 year after the MI. Findings among the women were consistent with those among the men. CONCLUSIONS: The excess coronary heart disease mortality and morbidity rates among persons with low SES are considerable in Finland. To bring the mortality rates of low- and middle-SES groups down to the level of that of the high-SES group constitutes a major public health challenge.

Decline in out-of-hospital coronary heart disease deaths has contributed the main part to the overall decline in coronary heart disease mortality rates among persons 35 to 64 years of age in Finland: the FINAMI study.

BACKGROUND: Out-of-hospital deaths constitute the majority of all coronary heart disease (CHD) deaths and are therefore of considerable public health significance. METHODS AND RESULTS: We used population-based myocardial infarction register data to examine trends in out-of-hospital CHD deaths in Finland during 1983 to 1997. We included in out-of-hospital deaths also deaths in the emergency room and all deaths within 1 hour after the onset of symptoms. Altogether, 3494 such events were included in the analyses. The proportion of out-of-hospital deaths of all CHD deaths depended on age and gender. In the age group 35 to 64 years, it was 73% among men and 60% among women. These proportions did not change during the study. The annual average decline in the age-standardized out-of-hospital CHD death rate was 6.1% (95% CI, -7.3, -5.0%) among men and 7.0% (-10.0, -4.0%) among women. These declines contributed among men 70% and among women 58% to the overall decline in CHD mortality rate. In all, 58% of the male and 52% of the female victims of out-of-hospital CHD death had a history of symptomatic CHD. Among men with a prior history of myocardial infarction, the annual average decline in out-of-hospital CHD deaths was 5.3% (-7.2, -3.2%), and among men without such history the decline was 2.9% (-4.4, -1.5%). Among women, the corresponding changes were -7.8% (-14.2, -1.5%) and -4.5% (-8.0, -1.0%). CONCLUSIONS: The decline in out-of-hospital CHD deaths has contributed the main part to the overall decline in CHD mortality rates among persons 35 to 64 years of age in Finland.

Impact of diabetes on mortality after the first myocardial infarction. The FINMONICA Myocardial Infarction Register Study Group.

OBJECTIVE: To study diabetic and nondiabetic patients with their first myocardial infarction to determine overall 1-year mortality, out-of-hospital mortality, 28-day mortality of hospitalized patients, and 1-year mortality of 28-day survivors. RESEARCH DESIGN AND METHODS: This study--based on the FINMONICA Myocardial Infarction Register, a part of the Finnish contribution to the WHO MONICA Project (World Health Organization Multinational Monitoring of Trends and Determinants of Cardiovascular Disease)--covered coronary heart disease (CHD) deaths and acute CHD events occurring during hospitalization among residents of Finland aged 25-64 years in three geographically defined areas. The study population comprised 620 diabetic and 3,445 nondiabetic patients who had their first myocardial infarction during the years 1988-1992. RESULTS: The age- and area-adjusted mortality rates and hazard ratios (HRs) for diabetic versus nondiabetic patients (95% CI) were as follows: The 1-year mortality rate was 44.2% in diabetic men and 32.6% in nondiabetic men (HR, 1.38; 1.18-1.61) and 36.9% in diabetic women and 20.2% in nondiabetic women (HR, 1.86; 1.40-2.46); the out-of-hospital mortality rate was 28.3% in diabetic men and 22.4% in nondiabetic men (HR, 1.25; 1.03-1.52) and 10.4% in diabetic women and 11.0% in nondiabetic women (HR, 0.95; 0.58-1.54); the 28-day mortality rate of hospitalized patients was 14.4% in diabetic men and 8.8% in nondiabetic men (HR, 1.58; 1.15-2.18) and 21.7% in diabetic women and 7.8% in nondiabetic women (HR, 2.60; 1.71-3.95); and the 1-year mortality rate of 28-day survivors was 9.6% in diabetic men and 5.0% in nondiabetic men (HR, 1.97; 1.25-3.12) and 10.7% in diabetic women and 2.5% in nondiabetic women (HR, 4.17; 2.05-8.51). CONCLUSIONS: The high mortality rate of diabetic patients after their first myocardial infarction and the high proportion of out-of-hospital deaths in this group imply that vigorous primary and secondary preventive measures should become an integral part of their medical care.

Socioeconomic status and ischemic stroke: The FINMONICA Stroke Register.

BACKGROUND AND PURPOSE: It has been shown that low socioeconomic status is associated with death from stroke. More-detailed data have, however, remained scanty. The purpose of the present study was to examine the association of socioeconomic status with ischemic stroke. Besides mortality, we analyzed the incidence, case-fatality ratio, and prognosis of ischemic stroke events. METHODS: Our population-based study included 6903 first stroke events registered by the FINMONICA Stroke Register in 3 areas of Finland during 1983 to 1992. Indicators of socioeconomic status, such as taxable income and education, were obtained by record linkage of the stroke register data with files of Statistics Finland. RESULTS: Incidence, case-fatality ratio, and mortality rates for ischemic stroke were all inversely related to income. Furthermore, 28 days after the onset of symptoms, a greater proportion of patients with low income than of those with high income was still in institutionalized care and/or in need of help for their activities of daily living. Population-attributable risk of the incidence of first ischemic stroke due to low socioeconomic status was 36% for both sexes. For the death from first ischemic stroke, it was 56% for both sexes. CONCLUSIONS: Persons with low socioeconomic status have considerable excess rates of morbidity and mortality from ischemic stroke in Finland. A reduction in this excess could markedly decrease the burden of ischemic stroke to the society and thus constitute an important public health improvement.

Diagnosis of acute myocardial infarction by MONICA and FINMONICA diagnostic criteria in comparison with hospital discharge diagnosis.

WHO MONICA Project has suggested diagnostic criteria for acute myocardial infarction (AMI) for monitoring the trends of coronary heart disease (CHD). The aim of our study was to compare the diagnosis of AMI by the MONICA diagnostic criteria and by the modified criteria developed within the FINMONICA study with hospital discharge (clinical) diagnosis. In a series of 1565 suspected acute CHD events treated at Kuopio University Hospital in 1987-1990, a diagnosis of definite AMI was made clinically in 566 events and by the MONICA (and FINMONICA) criteria in 551 events. The comparability between clinical and MONICA (and FINMONICA) classifications was good (kappa 0.81, Ppos 0.88, Pneg 0.93). A diagnosis of definite or possible AMI was made clinically in 734 events, in 1249 events by the MONICA criteria (kappa 0.25, Ppos 0.69, Pneg 0.47) and in 934 events by the FINMONICA criteria (kappa 0.60, Ppos 0.81, Pneg 0.77). Of the 383 events classified as possible AMI by the FINMONICA criteria the clinical diagnosis was "prolonged angina pectoris attack" or "unstable angina" in 39%. The FINMONICA diagnostic criteria for AMI are closer to clinical diagnostic classification and offer a possibility for a more detailed classification of acute CHD events than the original MONICA criteria.

The validity of the routine mortality statistics on coronary heart disease in Finland: comparison with the FINMONICA MI register data for the years 1983-1992. Finnish multinational MONItoring of trends and determinants in CArdiovascular disease.

We compared the diagnoses obtained from the routine mortality statistics with the standardized World Health Organization (WHO) MONICA (multinational MONItoring of trends and determinants in CArdiovascular disease) classification in suspect coronary heart disease (CHD) deaths registered in the FINMONICA myocardial infarction (MI) register during 1983-1992. All CHD deaths from routine mortality statistics (International Classification of Diseases codes 410-414) were registered in the MI register. Of the CHD deaths in routine mortality statistics 1.7% in men and 4.8% in women did not fulfill the MONICA criteria for CHD death (P<0.001 for the difference between the sexes). In men 4.7% and in women 7.3% (P=0.004) of the deaths registered in the MI Register and classified as CHD deaths by MONICA criteria had another underlying cause of death than CHD in routine mortality statistics; this proportion increased over time in both sexes (P=0.002 in men and P=0.77 in women). The CHD mortality trends obtained separately from the routine mortality statistics and from the FINMONICA MI Register were very similar. In conclusion, the high CHD mortality in Finland reported by the routine mortality statistics is real. It is possible that some CHD deaths have escaped registration, but the decline seen in the CHD mortality is also real.

Relation of socioeconomic position to the case fatality, prognosis and treatment of myocardial infarction events; the FINMONICA MI Register Study.

OBJECTIVE: To examine socioeconomic differences in case fatality and prognosis of myocardial infarction (MI) events, and to estimate the contributions of incidence and case fatality to socioeconomic differences in coronary heart disease (CHD) mortality. DESIGN: A population-based MI register study. METHODS: The FINMONICA MI Register recorded all MI events among persons aged 35-64 years in three areas of Finland during 1983-1992. A record linkage of the MI Register data with the files of Statistics Finland was performed to obtain information on socioeconomic indicators for each individual registered. First MI events (n=8427) were included in the analyses. MAIN RESULTS: The adjusted risk ratio of prehospital coronary death was 2.11 (95% CI 1.82, 2.46) among men and 1.68 (1.14, 2.48) among women with low income compared with those with high income. Even among persons hospitalised alive the risk of death during the next 12 months was markedly higher in the low income group than in the high income group. Case fatality explained 51% of the CHD mortality difference between the low and the high income groups among men and 38% among women. Incidence contributed 49% and 62%, respectively. CONCLUSIONS: Considerable socioeconomic differences were observed in the case fatality of first coronary events both before hospitalisation and among patients hospitalised alive. Case fatality explained a half of the CHD mortality difference between the low and the high income groups among men and more than a third among women.

Tetrahydro-beta-carbolines: effect on alcohol intake in rats.

Some beta-carbolines, such as tetrahydro-beta-carboline (THBC) and 6-methoxy-THBC, occur normally in mammalian tissues, and 1-methyl-THBC has been found in human blood after alcohol intake. Continuous intraventricular (ICV) infusion of THBC and 1-methyl-THBC for 14 days was shown to increase voluntary alcohol intake in rats during the second week of infusion. In this study the experimental arrangement was slightly modified. Alcohol was offered for 7 days before the start of the 14 days of ICV infusion with Alzet minipumps and alcohol concentration (3-30% v/v) was increased every second day. The rats consumed less alcohol in the second day with the same concentration. Also, the dose of 47 nmoles/hr of 1-Me-THBC increased the voluntary alcohol intake over the controls, but only during the last 7 days. The same dose of 6-MeO-THBC, a serotonergic beta-carboline, was ineffective. Neither drug changed the total fluid intake. This study suggests that the increased voluntary alcohol intake by THBC's is not due to their serotonergic effect. A hypothesis concerning a possible involvement of opiate receptors is presented.

Current smoking and the risk of non-fatal myocardial infarction in the WHO MONICA Project populations.

BACKGROUND: Cohort studies have shown that smoking has a substantial influence on coronary heart disease mortality in young people. Population based data on non-fatal events have been sparse, however. OBJECTIVE: To study the impact of smoking on the risk of non-fatal acute myocardial infarction (MI) in young middle age people. METHODS: From 1985 to 1994 all non-fatal MI events in the age group 35-64 were registered in men and women in the WHO MONICA (multinational monitoring of trends and determinants in cardiovascular disease) project populations (18,762 events in men and 4047 in women from 32 populations from 21 countries). In the same populations and age groups 65,741 men and 66,717 women participated in the surveys of risk factors (overall response rate 72%). The relative risk of non-fatal MI for current smokers was compared with non-smokers, by sex and five year age group. RESULTS: The prevalence of smoking in people aged 35-39 years who experienced non-fatal MI events was 81% in men and 77% in women. It declined with increasing age to 45% in men aged 60-64 years and 36% in women, respectively. In the 35-39 years age group the relative risk of non-fatal MI for smokers was 4.9 (95% confidence interval (CI) 3.9 to 6.1) in men and 5.3 (95% CI 3.2 to 8.7) in women, and the population attributable fractions were 65% and 55%, respectively. CONCLUSIONS: During the study period more than half of the non-fatal MIs occurring in young middle age people can be attributed to smoking.

Short-term functional outcome of hospitalised first-ever strokes in Finnmark, Norway in 1998-1999. Results from the Finnmark Stroke Register.

Data on the functional outcome, prevalence of risk factors and comorbidity of stroke were collected in the population-based Finnmark Stroke Register in northern Norway. Findings for hospitalised first-ever strokes (n = 125) during the first registration year (1998-1999) are presented here. The median age of the patients was 70 years for men and 79 years for women. Cerebral infarctions comprised 81.6% of the strokes. Patients were severely handicapped: at discharge from hospital about 46% of those 75 years or older and about 21% of those younger than 75 years had severe disability by Rankin Scale. Women were more impaired than men. After hospitalisation, 45% of those 75 years or older and 21% of those younger than 75 years were sent to nursing home. The prevalence of risk factors and comorbidity was high: 29% of men (52% of women) had high blood pressure, 22% of men (25% of women) had atrial fibrillation, 22% of both men and women had diabetes, and 50% of men and 33% of women were current smokers. In conclusion, stroke victims in Finnmark were left with severe disability and need intensive rehabilitation. The prevalence of treatable risk factors was high; thus, primary and secondary prevention is the key to reduce the individual and social burden of stroke.

Modelling the burden of stroke in Finland until 2030.

BACKGROUND: It is well known that increasing age is the strongest risk factor of stroke. Therefore, it has been a common belief in many countries including Finland that the numbers of stroke patients will increase considerably during the next two decades because the population is rapidly ageing. METHODS: The FINMONICA and FINSTROKE registers operated in Finland in the Kuopio area and city of Turku from 1983 to 1997. The results showed that the incidence, mortality and case fatality of stroke declined significantly during that period. Importantly, it was established that the trends in incidence and mortality were also declining among the elderly (>74 years). We used these results to create a model for the entire country. The model was based on the trends present in these registers from Turku and Kuopio area and age-specific population projections up to the year 2030 that were obtained from Statistics Finland. RESULTS: In the year 2000, the number of new first stroke cases was estimated to be 11 500. If the declining trend were to level off totally after the year 2000, the number of new strokes would be 20 100 in the year 2030 due to the ageing of the population. It would be 12 100 if the trend continued as favourable as during the years 1983-1997. CONCLUSIONS: Ageing of the population will not inevitably increase the burden of stroke in Finland if the present declining trends are maintained, but the annual number of cases will almost double if the incidence remains at the level of the year 2000.

Long-term prognosis after coronary artery bypass surgery.

OBJECTIVE: To analyse the risk of coronary heart disease (CHD) events and total mortality among patients who had coronary artery bypass graft (CABG) surgery during 1988-1992. METHODS: A population-based myocardial infarction (MI) register included data on invasive cardiac procedures among residents of the study area. The subjects aged 35-64 years were followed-up for 12 years for non-fatal and fatal CHD events and all-cause mortality, excluding events within 30 days of the CABG operation. CABG was performed on 1158 men and 215 women. RESULTS: The overall survival of men who underwent CABG was similar to the survival of the corresponding background population for about ten years but started to worsen after that. At twelve years of follow-up, 23% (n=266, 95% CI 234-298) of the men who had undergone the operation had died, while the expected proportion, based on mortality in the background population, was 20% (n=231, 95% CI 226-237). The CHD mortality of men who had undergone the operation was clearly higher than in the background population. Among women, the mortality after CABG was about twice the expected mortality in the corresponding background population. In Cox proportional hazards models age, smoking, history of MI, body mass index and diabetes were significant predictors of mortality. CONCLUSIONS: The prognosis of male CABG patients did not differ from the prognosis of the corresponding background population for about ten years, but started to deteriorate after that. History of MI prior to CABG and major cardiovascular risk factors was a predictor of an adverse outcome.

Five-year risk of developing clinical diabetes after first myocardial infarction; the FINAMI study.

AIM: To investigate the incidence of clinical diabetes as determined by the incidence of diabetes drug reimbursements within a 5-year period after the first myocardial infarction (MI) in patients who were non-diabetic at the time of their first MI. RESEARCH DESIGN AND METHODS: A population-based MI register, FINMONICA/FINAMI, recorded all coronary events in persons of 35-64 years of age between 1988 and 2002 in four study areas in Finland. These records were used to identify subjects sustaining their first MI (n = 2632). Participants of the population-based risk factor survey FINRISK (surveys 1987, 1992, 1997 and 2002), who did not have diabetes or a history of MI, served as the control group (n = 7774). The FINMONICA/FINAMI study records were linked with the National Social Security Institute's drug reimbursement records, which include diabetes medications, using personal identification codes. The records were used to identify subjects who developed diabetes during the 5-year follow-up period (n = 98 in the MI group and n = 79 in the control group). RESULTS: Sixteen per cent of men and 20% of women sustaining their first MI were known to have diabetes and thus were excluded from this analysis. Non-diabetic men having a first MI were at more than twofold {hazard ratio (HR) 2.3 [95% confidence interval (CI) 1.6-3.4]}, and women fourfold [HR 4.3 (95% CI 2.4-7.5)], risk of developing diabetes mellitus during the next 5 years compared with the control population without MI. CONCLUSIONS: Many patients who do not have diabetes at the time of their first MI develop diabetes in the following 5 years.

Decreasing mortality from acute myocardial infarction: effect of incidence and prognosis.

Coronary heart disease (CHD) mortality rates have declined for the past 25 years in most western countries. During the 1970s and early 1980s, a decline in incidence was the main factor in the decline in mortality, but more recently, improvements in treatment and prognosis have played a larger role. Most of the change is a result of improvements in the treatment of risk factors among patients with chronic CHD, while the treatment of acute myocardial infarction has contributed a smaller part. CHD mortality has consistently decreased more than incidence, which may have led to an increased prevalence of CHD. Simultaneously, the treatment practice patterns and possibly also clinical presentation of CHD has changed so that hospitalizations as a result of CHD diagnoses other than myocardial infarction have increased, while definite myocardial infarctions have decreased. Furthermore, the stabilizing rates of incident myocardial infarction combined with the aging population tend to increase the numbers of CHD patients. Therefore, the total burden of CHD to the community has decreased less than one would expect on the basis of age-standardized mortality rates. There is a need to re-emphasize primary prevention, since heavy reliance on expensive treatments for the post-war baby-boom generation presents a major concern for public health resources.

The feasibility of routine mortality and morbidity register data linkage to study the occurrence of acute coronary heart disease events in Finland. The Finnish Cardiovascular Diseases Registers (CVDR) Project.

Validated population-based data on the occurrence of coronary heart disease in Finland have previously been obtained from myocardial infarction (MI) registers. Such registers cannot, however, cover large areas. Therefore, the Finnish Cardiovascular Diseases Registers (CVDR) Project was set up to obtain data for the whole of Finland. The CVDR Project is based on routine mortality and morbidity data linkage. We report here the overall approach used in the project, the results of the feasibility study and the first main results. In Finland, data on all hospitalizations are registered in the nationwide Hospital Discharge Register. Also, data on all deaths are collected in the nationwide Causes of Death Register. The unique personal identification number assigned to all persons residing in Finland was used for data linkage. Data have been validated using the FINMONICA MI registers. Sensitivity analyses showed that the data were robust and consistent between different geographical areas. Coronary heart disease (CHD) mortality as well as the incidence and event rates showed the same very clear geographical pattern, dividing Finland to a southwest area with a lower occurrence and a northeast area with nearly twice higher occurrence. Case fatality did not differ much between the areas and did not follow this Southwest-Northeast division. The differences between northeast and southwest Finland may be related to differences in risk factor levels but also to socioeconomic and genetic differences. The CVDR Project data will be instrumental in further research addressing these issues.

A multinational comparison of subarachnoid hemorrhage epidemiology in the WHO MONICA stroke study.

BACKGROUND AND PURPOSE: By official, mostly unvalidated statistics, mortality from subarachnoid hemorrhage (SAH) show large variations between countries. Using uniform criteria for case ascertainment and diagnosis, a multinational comparison of attack rates and case fatality rates of SAH has been performed within the framework of the WHO MONICA Project. METHODS: In 25- to 64-year-old men and women, a total of 3368 SAH events were recorded during 35.9 million person-years of observation in 11 populations in Europe and China. Strict MONICA criteria were used for case ascertainment and diagnosis of stroke subtype. Case fatality was based on follow-up at 28 days after onset. RESULTS: Age-adjusted average annual SAH attack rates varied 10-fold among the 11 populations studied, from 2.0 (95% CI 1.6 to 2.4) per 100 000 population per year in China-Beijing to 22.5 (95% CI 20.9 to 24.1) per 100 000 population per year in Finland. No consistent pattern was observed in the sex ratio of attack rates in the different populations. The overall 28-day case fatality rate was 42%, with 2-fold differences in age-adjusted rates between populations but little difference between men and women. Case fatality rates were consistently higher in Eastern than in Western Europe. CONCLUSIONS: Using a uniform methodology, the WHO MONICA Project has shown very large variations in attack rates of SAH across 11 populations in Europe and China. The generally accepted view that women have a higher risk of SAH than men does not apply to all populations. Marked differences in outcome of SAH add to the wide gap in the burden of stroke between East and West Europe.

Monoclonal gammopathy with neurological signs and symptoms. A clinical, neurophysiological and muscle biopsy study.

Clinical, neurophysiological and muscle biopsy findings in ten patients with monoclonal gammopathy are reported. Three patients had polyneuropathy, one had hemiparkinsonism, one migraine and radicular symptoms and one paresthesiae and radicular symptoms. Amyloidosis was not found in muscle biopsy specimens. All but one patient with neurological findings also had positive immunofluorescence staining for tissue-bound immunoglobulins in muscle biopsy specimens. The tissue-bound immunoglobulins usually belonged to the same class as the M-component. None of the biopsies of patients without neurological findings were positive.