Symptoms at stroke onset as described by patients: a qualitative study.

BACKGROUND: Stroke is a common and severe disease that requires prompt care. Symptom expressions as one-sided weakness and speech difficulties are common and included in public stroke campaigns. For some patients stroke can present with subtle and less common symptoms, difficult to interpret. The symptom severity assessed by the National Institutes of Health Stroke Scale has decreased, and symptoms at onset may have changed. Therefore, we aimed to investigate how patients describe their symptoms at the onset of a first-time stroke. METHODS: The study used a qualitative descriptive design and conventional content analysis. Data were collected through recorded interviews with 27 patients aged 18 years and older hospitalised with a first-time stroke between October 2018 and April 2020. Data were analysed on a manifest level. RESULTS: Symptoms at stroke onset were presented in two themes: Altered Reality and Discomfort and Changed Body Functions and described in five categories. Various types of symptoms were found. All symptoms were perceived as sudden, persistent, and never experienced before and this appear as a "red thread" in the result. Regardless of symptom expressions, no specific symptom was described as more severe than another. CONCLUSIONS: Stroke symptoms were described with a variety of expressions. Many described complex symptoms not typical of stroke, which can make it difficult to recognise the symptoms as a stroke and delay medical care. Public stroke campaigns should emphasize the importance of seeking medical care at the slightest suspicion of stroke and could be designed to help achieve this.

Risk of Myocardial Infarction, Ischemic Stroke, and Mortality in Patients Who Undergo Gastric Bypass for Obesity Compared With Nonoperated Obese Patients and Population Controls.

OBJECTIVE: The aim of this study was to estimate risks of myocardial infarction, ischemic stroke, and cardiovascular-related and all-cause mortality after Roux-en-Y gastric bypass (RYGB) for obesity compared with nonop-erated obese patients and matched nonobese population controls. BACKGROUND: Few studies have assessed the influence of RYGB on fatal and non-fatal myocardial infarction and ischemic stroke, and the results vary between studies. METHOD: All patients aged 20 to 65 years with obesity diagnosis in the nationwide Swedish Patient Registry in 2001 to 2013 were included. These participants were divided into those who underwent RYGB within 2 years of obesity diagnosis (n = 28,204) and nonoperated (n = 40,827), and were matched for age, sex, and region with 2 nonobese population controls. Participants were followed until onset of outcome disease, death, or end of follow-up. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (95% CI). RESULTS: Compared with nonoperated patients with obesity, RYGB patients had a reduced risk of myocardial infarction [HR = 0.44 (95% CI 0.28-0.63)], similar risk of ischemic stroke [HR = 0.79 (95% CI 0.54-1.14)], and decreased risks of cardiovascular-related [HR = 0.47 (95% CI 0.35-0.65)] and all-cause mortality [HR = 0.66 (95% CI 0.54-0.81)] within the first 3 years of follow-up, but not later. Compared with nonobese population controls, RYGB patients had excess risks of ischemic stroke [HR = 1.57 (95% CI 1.08-2.29)], cardiovascular-related mortality [HR = 1.82 (95% CI 1.29-2.60)], and all-cause mortality [HR = 1.42 (95% CI 1.16-1.74)], but not of myocardial infarction [HR = 1.02 (95% CI 0.72-1.46)]. CONCLUSION: RYGB for obesity might not decrease the risk of ischemic stroke, but seems to decrease the risk of myocardial infarction back to population levels.

Body Mass Index in Young Women and Risk of Cardiomyopathy: A Long-Term Follow-Up Study in Sweden.

BACKGROUND: Incidence rates of cardiomyopathies, which are a common cause of heart failure in young people, have increased during the last decades. An association between body weight in adolescence and future cardiomyopathy among men was recently identified. Whether or not this holds true also for women is unknown. The aim was therefore to determine whether for young women being overweight or obese is associated with a higher risk of developing cardiomyopathy. METHODS: This was a registry-based national prospective cohort study with data collected from the Swedish Medical Birth Register, 1982 to 2014, with up to 33 years of follow-up. Included women were of childbearing age (18-45 years) during the initial antenatal visit in their first or second pregnancy (n=1 393 346). We obtained baseline data on body mass index (BMI), smoking, education, and previous disorders. After exclusions, mainly because of previous disorders, the final sample was composed of 1 388 571 women. Cardiomyopathy cases were identified by linking the Medical Birth Register to the National Patient and Cause of Death registers. RESULTS: In total, we identified 1699 cases of cardiomyopathy (mean age at diagnosis, 46.2 [SD 9.1] years) during the follow-up with an incidence rate of 5.9 per 100 000 observation years. Of these, 481 were diagnosed with dilated cardiomyopathy, 246 had hypertrophic cardiomyopathy, 61 had alcohol/drug-induced cardiomyopathy, and 509 had other forms. The lowest risk for being diagnosed with a cardiomyopathy was detected at a BMI of 21 kg/m2, with a gradual increase in risk with higher BMI, particularly for dilated cardiomyopathy, where a hazard ratio of 4.71 (95% CI, 2.81-7.89) was found for severely obese subjects (BMI ≥35 kg/m2), as compared with BMI 20 to <22.5. CONCLUSIONS: Elevated BMI among young women was associated with an increased risk of being diagnosed with a subsequent cardiomyopathy, especially dilated cardiomyopathy, starting already at mildly elevated body weight, whereas severe obesity entailed an almost 5-fold increase in risk. With the increasing numbers of persons who are overweight or obese, higher rates of cardiomyopathy can be expected in the future, along with an altered disease burden related to adiposity.

Atrial fibrillation and risk of venous thromboembolism: a Swedish Nationwide Registry Study.

AIMS: Atrial fibrillation (AF) is associated with arterial thromboembolism, mainly ischaemic stroke, while venous thromboembolism (VTE) in AF is less well studied. The aim of this study, therefore, was to examine the relationship between AF and VTE, including pulmonary embolism (PE) and deep venous thrombosis (DVT). METHODS AND RESULTS: AF cases without previous VTE, ischaemic stroke or pulmonary arterial hypertension were identified from the Swedish Inpatient Registry between 1987 and 2013 and compared to two population controls per case without AF matched for age, sex, and county with respect to the incidence of VTE, PE, and DVT. In total, 463 244 AF cases were compared to 887 336 population controls. In both men and women, VTE rates were higher among AF patients the first 30 days after an AF diagnosis [40.2 vs. 5.7 in men and 55.7 vs. 6.6 in women per 1000 person-years at risk, respectively; hazard ratios 6.64 (95% confidence interval, 5.74-7.69) and 7.56 (6.47-8.83)]; and then decreasing, simultaneously with an increasing number of AF patients being treated with oral anticoagulation. VTE risk was similar to controls after 9 months in men but remained slightly elevated in women. CONCLUSION: AF is strongly associated with an increased risk of VTE during the first months after diagnosis. Introduction of anticoagulant therapy soon after AF diagnosis might reduce the risk of VTE as well as of ischaemic stroke.

Determinants of suboptimal long-term secondary prevention of acute myocardial infarction: the structural interview method and physical examinations.

BACKGROUND: Secondary prevention after an acute myocardial infarction (AMI) reduces morbidity and mortality, but suboptimal secondary prevention of cardiovascular disease is common. Therefore, the present study aimed to identify potential underlying factors for suboptimal secondary prevention 2 years after an AMI event. METHODS: Patients aged 18-85 years at the time of their index AMI and hospitalized between July 2010 and December 2011, were identified retrospectively and consecutively from hospital discharge records. All patients who agreed to participate underwent a structured interview, physical examinations and laboratory analysis 2 years after their index AMI. The secondary preventive goals included are; blood pressure < 140/90 mmHg, LDL < 1.8 mmol/L, HbA1c < 48 mmol/mol, regular physical activity that causes sweating at least twice a week, non-smoking and BMI < 25 kg/m2. Multivariable and univariable logistic regression models were applied to identify independent predictors of different secondary prevention achievements. RESULTS: Of the 200 patients (mean age 63.3 ± 9.7 years) included in the study, 159 (80%) were men. No common determinants were found in patients who failed to achieve at least six secondary prevention guideline-directed goals. For individual secondary prevention goals, several determinants were defined. Patients born in Sweden were less likely to achieve optimal lipid control [odds ratio (OR) 0.28 (95% confidence interval, CI 0.12-0.63)]. Younger (≤ 65 years) [OR 0.24 (95% CI 0.07-0.74)] and unemployed patients [OR 0.23 (95% CI 0.06-0.82)] were less likely to be non-smokers. Patients with diabetes mellitus [OR 0.21 (95% CI 0.04-0.98)] or with a walking aid [OR 0.23 (95% CI 0.07-0.71)] were less likely to achieve an optimal body mass index (BMI < 25). Living alone was an independent predictor of achieving regular physical activity [OR 1.94 (95% CI 1.02-3.69)]. CONCLUSION: Long-term secondary prevention remained suboptimal 2 years after an AMI. Causes are likely multifactorial, with no single determinant for all six guideline-recommended preventive goals. Therefore a tailored comprehensive assessment should be requested and updated and treatment of risk factors should be applied.

Risk of Heart Failure in Obese Patients With and Without Bariatric Surgery in Sweden-A Registry-Based Study.

BACKGROUND: Obesity is a known risk factor for heart failure. The prevalence of both conditions has increased in Sweden during the past several decades. Obesity surgery has been shown to improve cardiac function. We therefore investigated whether the risk of heart failure was lower in obese patients after bariatric surgery compared with obese patients without surgical intervention. METHODS AND RESULTS: From the Swedish National Patient Registry. we created a cohort including 47,859 patients aged 18-74 years with a primary diagnosis of obesity from 2000 to 2011. Of these, 22,295 (46.6%) underwent bariatric surgery (mean age 40.7 (standard deviation [SD] 10.7) years, 75.9% female). There were 25,564 (53.4%) nonsurgical obese patients (mean age 44.3 (SD 13.2) years, 66.8% female). Patients who underwent bariatric surgery had a markedly reduced risk of heart failure compared with nonsurgical obese patients (age- and sex-adjusted hazard ratio [HR] 0.37, 95% confidence interval [CI] 0.29-0.46). The lower risk persisted after further adjustment for baseline differences in known risk factors for heart failure (HR 0.37, 95% CI 0.30-0.46). CONCLUSION: Patients who underwent bariatric surgery had a reduced risk of heart failure after surgery compared with nonsurgical obese patients.

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.

FTO gene variation, macronutrient intake and coronary heart disease risk: a gene-diet interaction analysis.

PURPOSE: The fat mass and obesity-associated gene (FTO) is related to obesity and coronary heart disease (CHD). We studied interaction between macronutrient intake and FTO in association with CHD risk or body mass index (BMI). METHODS: The pooled population-based case-control studies, SHEEP and INTERGENE, included 1,381 first-time CHD patients and 4,290 population controls genotyped for FTO rs9939609 (T/A). Diet data were collected in self-administered food frequency questionnaires. Macronutrients were dichotomized into low/high energy percentages (E%) by median levels in controls. Association of FTO genotype (TA/AA vs. TT) with CHD risk was analysed by multiple logistic regression, and with BMI by multiple linear regression. Interaction between FTO and macronutrient was assessed by introducing an interaction term FTO × macronutrient. Interaction on CHD as deviation from additive effects was assessed by calculating relative excess risk due to interaction. RESULTS: No statistically significant interaction was found between FTO genotype and any macronutrient on CHD risk or BMI on either the multiplicative or additive scale. However, FTO genotype (TA/AA vs. TT) was associated with significantly increased CHD risk only in subjects with low E% from fat (OR 1.36, 95% CI 1.11-1.66) or saturated fatty acids (OR 1.36, 95% CI 1.10-1.69), or in subjects with high E% from carbohydrate (OR 1.32, 95% CI 1.07-1.61) or protein (OR 1.41, 95% CI 1.13-1.75). Mean BMI was 0.3-0.6 kg/m(2) higher in control subjects with TA/AA compared to TT, regardless of macronutrient E%. CONCLUSIONS: We found no evidence of interactions between FTO genotype and macronutrient intake on CHD risk or BMI.

Long-term secondary prevention of acute myocardial infarction (SEPAT) - guidelines adherence and outcome.

BACKGROUND: A number of registry studies have reported suboptimal adherence to guidelines for cardiovascular prevention during the first year after acute myocardial infarction (AMI). However, only a few studies have addressed long-term secondary prevention after AMI. This study evaluates prevention guideline adherence and outcome of guideline-directed secondary prevention in patients surviving 2 years after AMI. METHODS: Patients aged 18-85 years at the time of their index AMI were consecutively identified from hospital discharge records between July 2010 and December 2011 in Gothenburg, Sweden. All patients who agreed to participate in the study (16.2%) were invited for a structured interview, physical examinations and laboratory analysis 2 years after AMI. Guideline-directed secondary preventive goals were defined as optimally controlled blood pressure, serum cholesterol, glucose, regular physical activity, smoking cessation and pharmacological treatment. RESULTS: The mean age of the study cohort (n = 200) at the index AMI was 63.0 ± 9.7 years, 79% were men. Only 3.5% of the cohort achieved all six guideline-directed secondary preventive goals 2 years after infarction. LDL < 1.8 mmol/L was achieved in 18.5% of the cohort, regular exercise in 45.5% and systolic blood pressure <140 mmHg in 57.0%. Anti-platelet therapy was used by 97% of the patients, beta-blockers by 83.0%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers by 76.5% and statins by 88.5%. During follow-up, non-fatal adverse cardiovascular events (cardiac hospitalization, recurrent acute coronary syndrome, angina pectoris, new percutaneous coronary intervention, new onset of atrial fibrillation, post-infarct heart failure, pacemaker implantation, stroke/transient ischemic attack (TIA), cardiac surgery and cardiac arrest) occurred in 47% of the cohort and readmission due to cardiac causes in 30%. CONCLUSIONS: Our data showed the failure of secondary prevention in our daily clinical practice and high rate of non-fatal adverse cardiovascular events 2 years after AMI.

Women's help-seeking behaviour during a first acute myocardial infarction.

Studies indicate that the time from onset of symptoms to medical treatment has decreased in acute myocardial infarction (AMI). However, there are still variations indicating that women wait longer than men before making the decision to seek medical care. Multidimensional factors hindering and facilitating the decision have been identified in previous studies, though few have fully explored how social context affects women's expectations, interpretations and actions and so influences the decision-making process. The aim of this study was therefore to identify how women's experiences interacted and influenced the decision to seek medical care at their first AMI. Seventeen women, aged 38-75 years, were interviewed, at home or in the hospital, between June 2011 and May 2012. Grounded theory was used as a method, and data collection and analysis were carried out simultaneously. The results showed that before deciding to seek medical care, these women went through three defined but interrelated processes that together hindered their normal activities and made them act according to existential needs. The women's experiences of the progression of the disease, in terms of both symptoms and time, were very different, so they sought medical care at different times, sometimes life-threateningly late and sometimes before developing an AMI. Three mechanisms had to coincide if the women were to receive medical care. First, the women had to acknowledge their symptoms as something more than common bodily changes. Second, the healthcare system had to be accessible when the women made their decision to seek care. Third, the women must have come into contact with healthcare providers when the heart muscle had taken enough damage to measure.

Body weight in midlife and long-term risk of developing heart failure-a 35-year follow-up of the primary prevention study in Gothenburg, Sweden.

BACKGROUND: This study aimed to determine whether midlife obesity predicts heart failure (HF) over an extended follow-up into old age. METHODS: We studied 7495 men (from a population sample of 9,998 men) without HF, who were 47-55 years old when investigated in 1970 to 1973. All participants were followed up for 35 years, or until death, using the Swedish National Inpatient Register (IPR) and the Cause of Death Register. Over follow-up, 1855 men (24.7%) were discharged from hospital or died with a diagnosis of HF. RESULTS: There was a strong relation between obesity and future risk of HF, which was accentuated over the last years of the long follow-up. After adjusting for age, the risk of HF increased stepwise with increasing body mass index (BMI), even in those with a normal BMI (22.5-24.9) The subdistribution hazard ratio (SHR) was 1.20 (95% CI: 1.02-1.39) in men with a normal BMI, 1.29 (95% CI: 1.11-1.50) for a BMI of 25-27.49, 1.50 (95% CI: 1.27-1.77) for a BMI of 27.5-29.99, and 1.62 (95% CI: 1.33-1.97) for a BMI >30. After adjusting for, age, smoking, occupational class, and physical activity, the results were unchanged. CONCLUSION: Obesity in midlife is strongly related to the long-term risk of developing HF extending into old age where the risk is highest. Even normal body weight (BMI <25) was related to an increased risk of developing HF during life. Because overweight and obesity are largely preventable, our findings further emphasize the importance of public health interventions against the development of obesity.

Experiences and actions during the decision making process among men with a first acute myocardial infarction.

BACKGROUND: Previous studies have shown that people hesitate to seek medical attention when experiencing the initial symptoms of acute myocardial infarction (AMI), but the reasons why and the events underpinning the decision-making process are unclear. The aim of this study was to describe the actions and experiences involved in the process of seeking medical attention in men with a first AMI. METHODS: We studied 21 men, aged 39-73 years, hospitalized with a first AMI between May 2011 and March 2013. All were interviewed in the coronary unit before discharge, with one exception. Data collection and analysis were carried out simultaneously in accordance with grounded theory methodology. RESULTS: Men diagnosed with a first AMI experienced a spectrum of insidious and vague symptoms, which they did not associate with an AMI. This caused uncertainty in how to interpret symptom severity and contributed to a reluctance to seek medical care. Participants also had difficulty interpreting online information when seeking to explain their symptoms. Weighing up and comparing the various experiences during the early stages of AMI proved to be the trigger that changed the men's perspectives and made them aware of the abnormality, the severity of their illness, and the need for action. CONCLUSION: Healthcare professionals should be aware that men experience a range of insidious and vague symptoms during their first AMI and must give greater emphasis to their narratives, particularly when objective clinical signs are limited or absent. Consideration should be given to the ways laypeople interpret online information when designing healthcare resources for the Internet.

Nitric oxide synthase (NOS) single nucleotide polymorphisms are associated with coronary heart disease and hypertension in the INTERGENE study.

OBJECTIVE: Nitric oxide synthase (NOS) exists in three distinct isoforms, each encoded by a specific gene: neuronal NOS (NOS1 gene), inducible NOS (NOS2 gene) and endothelial NOS (NOS3 gene). Single nucleotide polymorphisms (SNPs) in NOS genes have been associated with cardiovascular pathology. We aimed to comprehensively investigate which NOS gene variants are most strongly associated with coronary heart disease (CHD) and hypertension, using a set of tagging SNPs with good coverage across the 3 genes. METHOD AND RESULTS: CHD cases (n=560) and randomly selected population controls (n=2791) were genotyped at 58 SNPs in the NOS genes. Control individuals with systolic blood pressure ≥140, diastolic blood pressure ≥90 or on antihypertensive medication were defined as hypertensive. A structured stepwise logistic regression approach was used to select the SNPs most strongly associated with CHD and hypertension. NOS1 SNP rs3782218 showed the most consistent association with both phenotypes, odds ratio 0.59 (95% confidence interval 0.44-0.80) and 0.81 (0.67-0.97) per T-allele for CHD and hypertension respectively. For CHD, another NOS1 SNP (rs2682826) and a NOS3 SNP (rs1549758) also showed effect. For hypertension associations were seen for additional SNPs including NOS3 SNP rs3918226, previously associated with hypertension in genome-wide association study (GWAS) data. CONCLUSION: We found a previously unreported association between NOS1 SNP rs3782218 and both CHD and hypertension, and confirmed NOS1 as the most important NOS risk gene for CHD. In contrast, variants in all three NOS genes were seen to be associated with hypertension in the same source population.

Continuing decrease in coronary heart disease mortality in Sweden.

BACKGROUND: Deaths from coronary heart disease (CHD) have been decreasing in most Western countries over the last few decades. In contrast, a flattening of the decrease in mortality has been recently reported among younger age groups in some countries. We aimed to determine whether the decrease in CHD mortality is flattening among Swedish young adults. METHODS: We examined trends in CHD mortality in Sweden between 1987 and 2009 among persons aged 35 to 84 years using CHD mortality data from the Swedish National Register on Cause of Death. Annual percent changes in rates were examined using Joinpoint software. RESULTS: Overall, CHD mortality rates decreased by 67.4% in men and 65.1% in women. Among men aged 35-54 years, there was a modest early attenuation from a marked initial decrease. In the oldest women aged 75-84 years, an attenuation in the mortality decrease was observed from 1989 to 1992, followed by a decrease, as in all other age groups. CONCLUSIONS: In Sweden, coronary heart disease deaths are still falling. We were unable to confirm a flattening of the decline in young people. Death rates continue to decline in men and women across all age groups, albeit at a slower pace in younger men since 1991. Continued careful monitoring of CHD mortality trends in Sweden is required, particularly among young adults.

Stroke and coronary heart disease: predictive power of standard risk factors into old age--long-term cumulative risk study among men in Gothenburg, Sweden.

AIMS: The aim of this study was to examine the short-term and long-term cumulative risk of coronary heart disease (CHD) and stroke separately based on age, sex, smoking status, systolic blood pressure, and total serum cholesterol. METHODS AND RESULTS: The Primary Prevention Study comprising 7174 men aged between 47 and 55 free from a previous history of CHD, stroke, and diabetes at baseline examination (1970-73) was followed up for 35 years. To estimate the cumulative effect of CHD and stroke, all participants were stratified into one of five risk groups, defined by their number of risk factors. The estimated 10-year risk for high-risk individuals when adjusted for age and competing risk was 18.1% for CHD and 3.2% for stroke which increased to 47.8 and 19.6%, respectively, after 35 years. The estimates based on risk factors performed well throughout the period for CHD but less well for stroke. CONCLUSION: The prediction of traditional risk factors (systolic blood pressure, total serum cholesterol, and smoking status) on short-term risk (0-10 years) and long-term risk (0-35 years) of CHD of stroke differs substantially. This indicates that the cumulative risk in middle-aged men based on these traditional risk factors can effectively be used to predict CHD but not stroke to the same extent.

Body mass index and risk of cancer in young women.

It is unclear how increasing body mass index (BMI) influences risk of cancer in young women. We used data from the Medical Birth, Patient and Cause of Death registers collected between 1982 and 2014 to determine the risk of obesity-related cancer types, breast cancer, all cancer and cancer-related death in relation to BMI in 1,386,725 women, aged between 18 and 45 years, in Sweden. During a median follow-up of 16.3 years (IQR 7.7-23.5), 9808 women developed cancer. The hazard ratio (HR) of endometrial and ovarian cancer increased with higher BMI from 1.08 (95% CI 0.93-1.24) and 1.08 (95% CI 0.96-1.21) among women with BMI 22.5-< 25 to 2.33 (95% CI 1.92-2.83) and 1.48 (95% CI 1.24-1.77), respectively, among women with BMI ≥ 30. There were linear and positive associations between BMI and incident cancer in the ovary, colon, endometrium, pancreas, rectum, gallbladder, esophageal cancer and renal cell carcinoma, as well as death from obesity-related cancer forms. In conclusion, we found that elevated BMI in young women linearly associated with several obesity-related cancer forms, including death from these cancers.

Incidence of type 2 diabetes after gastric by-pass surgery in a Swedish controlled cohort study.

AIMS: To assess the long-term risk of developing type 2 diabetes in patients with obesity who have undergone gastric bypass surgery compared to non-operated patients with obesity and the general population. METHODS: This study included 71,495 patients aged 20-65 years with a principal diagnosis of obesity in the Swedish Patient Register in 2001-2013. Of these, 23,099 had undergone gastric bypass and 32,435 had not. Each patient was matched by age, sex and geographic region with two controls from the general population without obesity diagnosis, i.e., 44,735 controls for the gastric bypass cohort and 62,522 controls for the non-operated cohort with obesity. Operated and non-operated patients with obesity were also directly compared using Cox regression analysis, providing hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age, education, and sex. RESULTS: During a median follow-up of 4.3 years (interquartile range [IQR] 2.4, 7.0 years), 3792 (11.7%) non-operated patients with obesity developed type 2 diabetes (incidence rate 22.8/1000 person-years, 95% CI 22.1-23.6) compared to 394 (1.7%) among gastric bypass patients (incidence rate 4.0/1000 person-years, 95% CI 3.6-4.5). The latter incidence was comparable to population controls (3.5/1000 person-years, 95% CI 3.2-3.8). Gastric bypass patients had 85% lower risk of diabetes compared to non-operated patients with obesity during the first six years of follow-up (HR 0.15; 95% CI 0.13-0.17). CONCLUSION: Gastric bypass surgery for obesity seems to reduce the risk of developing type 2 diabetes to levels similar to that of the general population during the first six years of follow-up but not thereafter.

Comparison of associations between alcohol consumption and metabolic syndrome according to three definitions: The Swedish INTERGENE study.

Background: While prevalence estimates differ by definition of metabolic syndrome (MetS), it is less clear how different definitions affect associations with alcohol consumption. Methods: We included 3051 adults aged 25-77 from the baseline examination of the Swedish INTERGENE cohort (2001-2004). Using multiple logistic regression, we investigated cross-sectional associations between ethanol intake and MetS defined according to the Adult Treatment Panel III (ATP III), the International Diabetes Federation (IDF), and the Joint Interim Statement (JIS). Alcohol exposure categories comprised abstinence, and low, medium, and high consumption defined via sex-specific tertiles of ethanol intake among current consumers. Covariates included sociodemographics, health, and lifestyle factors. Results: MetS prevalence estimates varied between 13.9 % (ATP III) and 25.3 % (JIS), with higher prevalence in men than women. Adjusted for age and sex, medium-high alcohol consumption was associated with lower odds of MetS compared to low consumption, while no difference was observed for abstainers. Only the most specific (and thus severe) definition of MetS (ATP III) showed decreasing odds for ethanol intake when adjusted for all covariates. Conclusion: Our study shows that alcohol-related associations differ by definition of MetS. The finding that individuals with the most stringently defined MetS may benefit from alcohol consumption calls for further well-controlled studies.

Twenty-four-year trends in the incidence of ischemic stroke in Sweden from 1987 to 2010.

BACKGROUND AND PURPOSE: The incidence of stroke in Sweden increased between 1989 and 2000 among people aged ≤65 years, but more recent data on those aged >65 years are lacking. METHODS: Through the Swedish Hospital Discharge and Cause of Death registries, we identified all cases of nonfatal and fatal ischemic stroke (IS) among people aged 18 to 84 years during 1987-2010 in Sweden. RESULTS: Of the 391 081 stroke cases identified, 1.6% were 18 to 44 years, 16.7% were 45 to 64 years, and 81.7% were 65 to 84 years. Among people aged 18 to 44 years, there was a continuous increase in the incidence of stroke of 1.3% (95% confidence interval, 0.8%-1.8%) per year for men and 1.6% (1.0%-2.3%) per year for women. Among men and women aged 45 to 64 years, slightly declining rates were observed from the late 1990s, with a mean annual decrease of 0.4% (0.1%-0.7%) among men and 0.6% (0.2%-1.0%) among women. Among men aged 65 to 84 years, a decrease of 3.7% in IS (3.4%-4.0%) per year was observed from the late 1990s. This was more marked in women, where an initial decrease of 2.5% (2.1%-2.9%) per year was followed by an accelerated decrease of 5.1% (4.4%-5.8%) after 2005. Mortality from IS decreased markedly in all age groups. CONCLUSIONS: The incidence of IS in elderly people in Sweden is now decreasing, whereas the decline in IS incidence in the middle-aged people is much less steep. The increasing incidence of stroke in the young, particularly if carried forward to an older age, is concerning.

Twenty-year trends in long-term mortality risk in 17,149 survivors of ischemic stroke less than 55 years of age.

BACKGROUND AND PURPOSE: The purpose of the present study was to investigate the 4-year mortality risk among patients<55 years with a first ischemic stroke during 1987-2006. METHODS: A total of 17,149 cases (37.4% women) aged 18 to 54 years who survived≥28 days after a first ischemic stroke were identified in the Swedish Inpatient Register from 1987 to 2006. All patients were followed for 4 years or until death. The standardized mortality ratio was calculated by comparing the mortality rates with those of the general population of equivalent age, sex, and calendar year. RESULTS: During the period, there were 1265 deaths. Long-term survival improved over time in both men and women. Among men, the mortality risk decreased by 32% (hazard ratio=0.68 [95% confidence interval, 0.56-0.82]) from the first 5-year period to the last 5-year period (1987-1991 versus 2002-2006), and among women, the mortality risk decreased by 45% (0.55 [0.41-0.75]). Despite an overall decrease in mortality, the standardized mortality ratios for the last 5-year period remained high: 5.88 (95% confidence interval, 5.10-6.71) for men and 5.91 (4.68-7.29) for women with an absolute excess risk of 1.60 and 0.97 per 100 person-years, respectively, with nearly half of all deaths related to cardiovascular disease. CONCLUSIONS: During the 20-year period, 4-year mortality decreased by one third but was still 6-fold higher than that of the general population in the most recent period, emphasizing the importance of secondary prevention in young persons who have had a stroke.