Location-Based Augmented Reality for Cultural Heritage Communication and Education: The Doltso District Application

Location-based Augmented Reality applications are increasingly used in many research and commercial fields. Some of the fields that these applications are used are recreational digital games, tourism, education, and marketing. This study aims to present a location-based augmented reality (AR) application for cultural heritage communication and education. The application was created to inform the public, especially K12 students, about a district of their city with cultural heritage value. Furthermore, Google Earth was utilized to create an interactive virtual tour for consolidating the knowledge acquired by the location-based AR application. A scheme for evaluating the AR application was also constructed using factors suitable for location-based applications: challenge, educational usefulness (knowledge), collaboration, and intention to reuse. A sample of 309 students evaluated the application. Descriptive statistical analysis showed that the application scored well in all factors, especially in challenge and knowledge (mean values 4.21 and 4.12). Furthermore, structural equation modeling (SEM) analysis led to a model construction that represents how the factors are causally related. Based on the findings, the perceived challenge significantly influenced the perceived educational usefulness (knowledge) (b = 0.459, sig = 0.000) and interaction levels (b = 0.645, sig = 0.000). Interaction amongst users also had a significant positive impact on users' perceived educational usefulness (b = 0.374, sig = 0.000), which in turn influenced users' intention to reuse the application (b = 0.624, sig = 0.000).

Mid-life extrapyramidal symptoms predict cognitive impairment 23 years later

OBJECTIVES

The prevalence of dementia is growing rapidly worldwide. The early identification and treatment of cognitive decline could reduce the burden on the health care system. Our objective was to investigate whether factors measured at an examination at age 50 predict cognitive impairment (CI) 23 years later.

MATERIALS & METHODS

In 1993 we enrolled a randomly selected sample of 798 men, 50 years of age, from the general population. They all underwent a physical examination, provided blood samples and filled out questionnaires addressing lifestyle and psychosocial factors. Cognitive testing was offered to all participants still alive in 2016, at age 73.

RESULTS

A total of 333 men participated in the cognitive study, of which 80 (24.0%) performed at a level corresponding to mild cognitive impairment, and four (1.2%) at a level consistent with severe cognitive impairment. After the first step in the multivariable analysis, hypertension, heavy smoking, high intake of alcohol, financial stress, difficulty falling asleep, and cogwheel rigidity were associated with cognitive impairment. After further adjustment, only wide waist circumference measured in cm (OR 1.04, 95% CI 1.00-1.08, p = .04), leg pendulousness (OR 41.97, 95% CI 3.27-538.62, p = .004) and self-assessed hidden irritability (OR 2.18, 95% CI 1.10-4.32, p = .03) at baseline, remained as being associated with cognitive impairment 23 years later.

CONCLUSIONS

Extrapyramidal symptoms such as leg pendulousness, at the age of 50, may be an indicator for very early identification of future cognitive decline.

Cumulative incidence and predictors of acquired aortic stenosis in a large population of men followed for up to 43 years

Background

Acquired aortic stenosis (AS) increases with age and has high mortality without intervention. Factors predicting its development are unclear, although atherosclerotic factors are assumed to be involved. Our aim in this study is to estimate the lifetime cumulative incidence and predictors of AS in middle-aged men.

Methods

We included a random sample of men (n = 9998) born 1915–1925 in Gothenburg, Sweden. From them, 7,494 were examined and followed until a diagnosis of AS or death (maximum follow-up time 42.8 years). We identified AS diagnosis from the Swedish National Patient Registry and deaths from the Swedish Cause of Death Registry by using International Classification of Disease (ICD) diagnostic criteria. To study time-dependent relationships between AS and risk factors with death as the competing risk, we divided the cohort into three overlapping follow-up groups: 25–43, 30–43 and 35–43 years. We used age-adjusted Cox proportional hazards model to identify predictors of AS.

Results

The lifelong cumulative incidence of AS was 3.2%. At baseline, participants in the third group had a healthier lifestyle, lower body mass index (BMI), blood pressure, and serum cholesterol levels. Higher BMI, obesity, cholesterol, hypertension, atrial fibrillation, smoking and heredity for stroke were associated with AS. With BMI of 20–22.5 as a reference, hazard ratios of being diagnosed with AS for men with a baseline BMI of 25–27.5 kg/m², 27.5–30 kg/m² and > 30 kg/m² were 1.99 (95% CI 1.12–3.55), 2.98 (95% CI 1.65–5.40) and 3.55 (95% CI 1.84–6.87), respectively.

Conclusions

The lifetime cumulative incidence of AS in middle-aged male population was 3.2%. Multiple atherosclerotic risk factors, particularly high BMI might be associated with a higher risk of developing AS.

Automatic contouring of normal tissues with deep learning for preclinical radiation studies

Objective.Delineation of relevant normal tissues is a bottleneck in image-guided precision radiotherapy workflows for small animals. A deep learning (DL) model for automatic contouring using standardized 3D micro cone-beam CT (μCBCT) volumes as input is proposed, to provide a fully automatic, generalizable method for normal tissue contouring in preclinical studies.Approach.A 3D U-net was trained to contour organs in the head (whole brain, left/right brain hemisphere, left/right eye) and thorax (complete lungs, left/right lung, heart, spinal cord, thorax bone) regions. As an important preprocessing step, Hounsfield units (HUs) were converted to mass density (MD) values, to remove the energy dependency of theμCBCT scanner and improve generalizability of the DL model. Model performance was evaluated quantitatively by Dice similarity coefficient (DSC), mean surface distance (MSD), 95th percentile Hausdorff distance (HD_95p), and center of mass displacement (ΔCoM). For qualitative assessment, DL-generated contours (for 40 and 80 kV images) were scored (0: unacceptable, manual re-contouring needed - 5: no adjustments needed). An uncertainty analysis using Monte Carlo dropout uncertainty was performed for delineation of the heart.Main results.The proposed DL model and accompanying preprocessing method provide high quality contours, with in general median DSC > 0.85, MSD < 0.25 mm, HD_95p < 1 mm and ΔCoM < 0.5 mm. The qualitative assessment showed very few contours needed manual adaptations (40 kV: 20/155 contours, 80 kV: 3/155 contours). The uncertainty of the DL model is small (within 2%).Significance.A DL-based model dedicated to preclinical studies has been developed for multi-organ segmentation in two body sites. For the first time, a method independent of image acquisition parameters has been quantitatively evaluated, resulting in sub-millimeter performance, while qualitative assessment demonstrated the high quality of the DL-generated contours. The uncertainty analysis additionally showed that inherent model variability is low.

Inter-observer variability of organ contouring for preclinical studies with cone beam Computed Tomography imaging

Background and purpose

In preclinical radiation studies, there is great interest in quantifying the radiation response of healthy tissues. Manual contouring has significant impact on the treatment-planning because of variation introduced by human interpretation. This results in inconsistencies when assessing normal tissue volumes. Evaluation of these discrepancies can provide a better understanding on the limitations of the current preclinical radiation workflow. In the present work, interobserver variability (IOV) in manual contouring of rodent normal tissues on cone-beam Computed Tomography, in head and thorax regions was evaluated.

Materials and methods

Two animal technicians performed manually (assisted) contouring of normal tissues located within the thorax and head regions of rodents, 20 cases per body site. Mean surface distance (MSD), displacement of center of mass (ΔCoM), DICE similarity coefficient (DSC) and the 95th percentile Hausdorff distance (HD₉₅) were calculated between the contours of the two observers to evaluate the IOV.

Results

For the thorax organs, right lung had the lowest IOV (ΔCoM: 0.08 ± 0.04 mm, DSC: 0.96 ± 0.01, MSD:0.07 ± 0.01 mm, HD₉₅:0.20 ± 0.03 mm) while spinal cord, the highest IOV (ΔCoM:0.5 ± 0.3 mm, DSC:0.81 ± 0.05, MSD:0.14 ± 0.03 mm, HD₉₅:0.8 ± 0.2 mm). Regarding head organs, right eye demonstrated the lowest IOV (ΔCoM:0.12 ± 0.08 mm, DSC: 0.93 ± 0.02, MSD: 0.15 ± 0.04 mm, HD₉₅: 0.29 ± 0.07 mm) while complete brain, the highest IOV (ΔCoM: 0.2 ± 0.1 mm, DSC: 0.94 ± 0.02, MSD: 0.3 ± 0.1 mm, HD₉₅: 0.5 ± 0.1 mm).

Conclusions

Our findings reveal small IOV, within the sub-mm range, for thorax and head normal tissues in rodents. The set of contours can serve as a basis for developing an automated delineation method for e.g., treatment planning.

Long-term survival in patients with isolated pulmonary valve stenosis: a not so benign disease?

Background and objectives

During the last decades, the survival rates in patients with congenital heart disease have increased dramatically, particularly in patients with complex heart malformations. However, the survival in patients with simple defects is still unknown. We aimed to determine the characteristics and the risk of mortality in patients with isolated pulmonary valve stenosis (PS).

Methods

Swedish inpatient, outpatient and cause of death registries were used to identify patients born between 1970 and 2017 with a diagnosis of PS, without any other concomitant congenital heart lesion. For each patient with PS, 10 control individuals without congenital heart disease were matched by birth year and sex from the total population registry. We used median-unbiased method and Kaplan-Meier survival analysis to examine the risk of mortality.

Results

We included 3910 patients with PS and 38 770 matched controls. The median age of diagnosis of PS was 0.7 years (IQR 0.3–7.0). During a median follow-up of 13.5 years (IQR 6.5–23.5), 88 patients with PS and 192 controls died; 500 patients with PS (12%) underwent at least one transcatheter or surgical valve intervention. The overall mortality rate was significantly higher in patients with PS compared with matched controls (HR 4.67, 95% CI 3.61 to 5.99, p=0.001). Patients with an early diagnosis of PS (0–1 year) had the highest risk of mortality (HR 10.99, 95% CI 7.84 to 15.45).

Conclusions

In this nationwide, register-based cohort study, we found that the risk of mortality in patients with PS is almost five times higher compared with matched controls. Patients with an early diagnosis of PS appears to be the most vulnerable group and the regular follow-up in tertiary congenital heart units may be the key to prevention.

Severe COVID-19 in people with type 1 and type 2 diabetes in Sweden: A nationwide retrospective cohort study

BACKGROUND

Whether infection with SARS-CoV-2 leads to excess risk of requiring hospitalization or intensive care in persons with diabetes has not been reported, nor have risk factors in diabetes associated with increased risk for these outcomes.

METHODS

We included 44,639 and 411,976 adult patients with type 1 and type 2 diabetes alive on Jan 1, 2020, and compared them to controls matched for age, sex, and county of residence (n=204,919 and 1,948,900). Age- and sex-standardized rates for COVID-19 related hospitalizations, admissions to intensive care and death, were estimated and hazard ratios were calculated using Cox regression analyses.

FINDINGS

There were 10,486 hospitalizations and 1,416 admissions into intensive care. A total of 1,175 patients with diabetes and 1,820 matched controls died from COVID-19, of these 53•2% had been hospitalized and 10•7% had been in intensive care. Patients with type 2 diabetes, compared to controls, displayed an age- and sex-adjusted hazard ratio (HR) of 2•22, 95%CI 2•13-2•32) of being hospitalized for COVID-19, which decreased to HR 1•40, 95%CI 1•34-1•47) after further adjustment for sociodemographic factors, pharmacological treatment and comorbidities, had higher risk for admission to ICU due to COVID-19 (age- and sex-adjusted HR 2•49, 95%CI 2•22-2•79, decreasing to 1•42, 95%CI 1•25-1•62 after adjustment, and increased risk for death due to COVID-19 (age- and sex-adjusted HR 2•19, 95%CI 2•03-2•36, complete adjustment 1•50, 95%CI 1•39-1•63). Age- and sex-adjusted HR for COVID-19 hospitalization for type 1 diabetes was 2•10, 95%CI 1•72-2•57), decreasing to 1•25, 95%CI 0•3097-1•62) after adjustment• Patients with diabetes type 1 were twice as likely to require intensive care for COVID-19, however, not after adjustment (HR 1•49, 95%CI 0•75-2•92), and more likely to die (HR 2•90, 95% CI 1•6554-5•47) from COVID-19, but not independently of other factors (HR 1•38, 95% CI 0•64-2•99). Among patients with diabetes, elevated glycated hemoglobin levels were associated with higher risk for most outcomes.

INTERPRETATION

In this nationwide study, type 2 diabetes was independently associated with increased risk of hospitalization, admission to intensive care and death for COVID-19. There were few admissions into intensive care and deaths in type 1 diabetes, and although hazards were significantly raised for all three outcomes, there was no independent risk persisting after adjustment for confounding factors.

Lifelong cumulative incidence of acquired aortic stenosis and its predictors in a large middle-aged men population followed up to 42 years

Background

Acquired aortic stenosis (AS) is the most common valvular disorder that rises exponentially with age; it has high mortality after symptoms appear. Factors that predict the development of AS are still unknown. Some studies imply that the atherosclerotic factors are involved in the development of AS, but the findings have been heterogeneous.

Purpose

To estimate lifelong cumulative incidence of AS and analyse its predictors.

Methods

We included a random sample of men, born 1915–1925 in Gothenburg, Sweden, and examined them in 1970–1973 (participation rate 75%). They were between 47 and 55 years in the beginning and 57–65 years when the examination-period ended. Out of 7493 men 57 were excluded due to myocardial infarction prior to baseline; 7436 were thus followed from the inclusion date until a discharge diagnosis of AS or death, with a maximum follow up time of 42 years and mean follow-up time 26.8 years. Men with AS were identified from the Swedish National Patient Register and those who died from the Swedish Cause of Death Register. We used machine learning to identify the most important factors that predict AS. For these factors, we then estimated hazard ratios for the risk to acquire AS through Cox proportional hazards model.

Results

The lifelong cumulative incidence to acquire AS was 2.66% (198 out of 7436 individuals). For men with measurements approximately at the quartiles of the pulse pressure distribution, more specifically 44, 52, 62 mm Hg, the estimated cumulative risk were 1.97%, 2.74% and 3.07% respectively. For the body mass index (BMI) we had accordingly for measurements around 23, 25 and 27 kg/m2 estimated cumulative risk 2.52%, 2.80%, 2.79% respectively. For cholesterol values of 5, 6 and 7 mmol/l (approximately at quartile divisions) the estimated cumulative risk was 1.77%, 1.79% and 3.20% respectively. The estimated cumulative risks for the younger, with age around 47 and the older participants, with age around 55 were 1.76% and 2.68 respectively. Men with family history of infarction in a sibling had an estimated cumulative risk at 4.66% level whereas those with not at 2.51%.

The factors that were significantly associated with the development of AS in the Cox proportional model are: cholesterol level (HR=1.24, CI 95% 1.11–1.39, p=0.0001), pulse pressure (HR=1.01, CI 95% 1.01–1.02, p=0.0037), BMI (HR=1.06, CI 95% 1.02–1.11, p=0.0089), age (HR=1.11, CI 95% 1.04–1.19, p=0.0010) and family history of myocardial infarction in a sibling (HR=2.38, CI 95% 1.50–3.79, p=0.0002).

Conclusion

Lifelong cumulative incidence of acquired AS is approximately 2.7%. Multiple factors known also to be associated with arteriosclerosis were identified to increase the life-long risk of developing AS.

Funding Acknowledgement

Type of funding source: None

Association of anthropometry and weight change with risk of dementia and its major subtypes: A meta-analysis consisting 2.8 million adults with 57 294 cases of dementia

Uncertainty exists regarding the relation of body size and weight change with dementia risk. As populations continue to age and the global obesity epidemic shows no sign of waning, reliable quantification of such associations is important. We examined the relationship of body mass index, waist circumference, and annual percent weight change with risk of dementia and its subtypes by pooling data from 19 prospective cohort studies and four clinical trials using meta-analysis. Compared with body mass index-defined lower-normal weight (18.5-22.4 kg/m² ), the risk of all-cause dementia was higher among underweight individuals but lower among those with upper-normal (22.5-24.9 kg/m² ) levels. Obesity was associated with higher risk in vascular dementia. Similarly, relative to the lowest fifth of waist circumference, those in the highest fifth had nonsignificant higher vascular dementia risk. Weight loss was associated with higher all-cause dementia risk relative to weight maintenance. Weight gain was weakly associated with higher vascular dementia risk. The relationship between body size, weight change, and dementia is complex and exhibits non-linear associations depending on dementia subtype under scrutiny. Weight loss was associated with an elevated risk most likely due to reverse causality and/or pathophysiological changes in the brain, although the latter remains speculative.

Mortality burden in patients born with Ebstein’s anomaly: a 40-year nationwide cohort study

Aims 

Survival rates for unoperated patients with Ebstein’s anomaly (EA) are unknown. We estimated overall long-term mortality in operated and unoperated EA patients, compared with the general population in Sweden.

Methods and results 

Using national medical registries, Swedish individuals born 1970–93 and diagnosed with EA between 1970 and 2011 were included. The hazard ratio for overall mortality for EA patients (n = 216) vs. the matched comparison cohort (n = 2160) was 43.7 [95% confidence interval (CI): 24.8–82.5]. Mortality risk for EA patients (vs. controls) decreased as birth period progressed, with hazard ratios declining from 63.6 (95% CI: 26.3–191.8) for those born in the 1970s to 34.4 (95% CI: 15.8–83.1) for those born in the 1980s and 20.2 (95% CI: 1.6–632.5) for those born at the beginning of 1990s. The overall mortality hazard ratios for unoperated and operated patients with EA (vs. controls) were 30.2 (95% CI: 13.8–73.3) and 63.7 (95% CI: 28.1–172.5), respectively. The risk of mortality among unoperated EA patients (vs. controls) declined with progressing birth period, with hazard ratios declining from 58.4 (95% CI: 15.1–415.2) in the 1970s to 22.9 (95% CI: 8.0–75.3) in the 1980s and 10.2 (95% CI: 0.3–395.9) in the 1990s.

Conclusion 

Overall all-cause mortality for patients with EA declined dramatically from 64 times to 20 times that of controls without EA, from the 1970s to the early 1990s. Unoperated patients with EA had better survival than did operated patients, possibly reflecting the higher severity of disease or more severe associated cardiac defects in patients undergoing surgery.

Risk of Cancer Among Children and Young Adults With Congenital Heart Disease Compared With Healthy Controls

IMPORTANCE

Adult patients with congenital heart disease (CHD) have an increased incidence of cancer, presumably owing to repeated radiation exposure, genetic predisposition, or repeated stress factors during heart interventions. However, there are limited data on the risk of cancer in children and young adults with CHD compared with the general population.

OBJECTIVE

To determine the risk of developing cancer from birth to age 41 years among patients with CHD compared with healthy matched controls.

DESIGN, SETTING, AND PARTICIPANTS

This registry-based, matched, prospective cohort study in Sweden used data from the Patient and Cause of Death Registers. Successive cohorts of patients with CHD born from 1970 to 1979, 1980 to 1989, and 1990 to 1993 were identified. Each patient (n = 21 982) was matched for birth year, sex, and county with 10 controls without CHD from the general population (n = 219 816). Follow-up and comorbidity data were collected from 1970 until 2011. Data analysis began in September 2018 and concluded in February 2019.

MAIN OUTCOMES AND MEASURES

Risk of cancer among children and young adults with CHD and among healthy controls.

RESULTS

Among 21 982 individuals with CHD and 219 816 healthy matched controls, 428 patients with CHD (2.0%) and 2072 controls (0.9%) developed cancer. Among patients with CHD, the mean (SD) age at follow-up was 26.6 (8.4) years, and 11 332 participants (51.6%) were men. Among healthy controls, the mean (SD) age at follow-up was 28.5 (9.1) years, and 113 319 participants (51.6%) were men. By the age of 41 years, 1 of 50 patients with CHD developed cancer. The overall hazard ratio (HR) for cancer was 2.24 (95% CI, 2.01-2.48) in children and young adults with CHD compared with controls. Risk increased by each successive birth cohort to an HR of 3.37 (95% CI, 2.60-4.35) among those born from 1990 to 1993. The risk of cancer was similar in men and women with CHD (men: HR, 2.41; 95% CI, 2.08-2.79; women: HR, 2.08; 95% CI, 1.80-2.41). The HR for cancer among patients with CHD who underwent surgery was 1.95 (95% CI, 1.58-2.33) compared with controls; for patients with CHD who had not undergone surgery, the HR was 2.43 (95% CI, 2.12-2.76). According to a hierarchical classification, a significantly increased risk of cancer was found among patients with complex heart lesions, such as conotruncal defects (HR, 2.29; 95% CI, 1.62-3.25), compared with healthy controls.

CONCLUSIONS AND RELEVANCE

Children and young adult patients with CHD had an increased risk of developing cancer compared with healthy matched controls, and the risk was significantly higher among patients with CHD from the most recent birth cohort. An increased risk of cancer in all CHD lesion groups was found, and a systematic screening for cancer could be considered for this at-risk group of patients.

Development of heart failure in young patients with congenital heart disease: a nation-wide cohort study

Objective

Heart failure (HF) is a common cause of hospitalisation and death in adults with congenital heart disease (CHD). However, the risk of HF in young patients with CHD has not been determined.

Methods

By linkage of national patient registers in Sweden, we identified 21 982 patients with CHD born between 1970 and 1993, and compared these with 10 controls per case. Follow-up data were collected from birth until 2011 or death.

Results

Over a mean follow-up of 26.6 years in patients with CHD and 28.5 years in controls, 729 (3.3%) and 75 (0.03%) developed HF, respectively. The cumulative incidence of HF in all CHD was 6.5% and in complex CHD 14.8% up to age 42 years. Thus, one patient in 15 with CHD runs the risk of developing HF before age 42 years, a risk that is 105.7 times higher (95 % CI 83.2 to 134.8) compared with controls. For patients with complex CHD (such as conotruncal defects, univentricular hearts, endocardial cushion defects), one in seven will develop HF, a HR of 401.5; 95% CI 298 to 601 as compared with controls. The cumulative probability of death in patients with CHD, after HF diagnosis, was 63.4% (95% CI 57.5 to 69.3).

Conclusions

An extremely high risk of developing HF (more than 100-fold) was found in patients with CHD, compared with matched controls, up to the age of 42 years. Patients with complex congenital heart malformations carried the highest risk and have to be considered as the main risk group for developing HF.

Association of diuretic treatment at hospital discharge in patients with heart failure with all-cause short- and long-term mortality: A propensity score-matched analysis from SwedeHF

AIMS

Diuretics are recommended for treating congestive symptoms in heart failure (HF). The short- and long-term prognostic effects of diuretic treatment at hospital discharge have not been studied in randomized clinical trials or in a Western world population. We aimed to determine the association of diuretic treatment at discharge with the risk of short-and long-term all-cause mortality in real-life patients in Sweden with HF irrespective of EF.

METHODS AND RESULTS

From a Swedish nationwide HF register 26,218 patients discharged from hospital were included in the present study. A total of 87% of patients were treated with and 13% were not treated with diuretics at hospital discharge. In a 1:1 propensity score-matched cohort of 6564 patients, the association of diuretic treatment at hospital discharge with the risk of 90-day all-cause mortality was neutral (HR 0.89, 95% CI 0.74-1.07, p=0.21) whereas the risk of long-term all-cause mortality (median follow-up: 2.85years) was increased (HR 1.15, 95% CI 1.06-1.24, p<0.001).

CONCLUSION

Diuretic treatment at hospital discharge was not associated with short-term mortality whereas it was associated with increased long-term mortality. Although we accounted for a wide range of clinical features, measured or unmeasured factors could still explain this increase in risk. However, our results suggest that diuretic treatment at hospital discharge may be regarded as a marker of increased long-term mortality.

Long-Term Risk of Hemorrhagic Stroke in Young Patients With Congenital Heart Disease

Supplemental Digital Content is available in the text.

Background and Purpose—

The risk of ischemic stroke is increased in patients with congenital heart disease (CHD); however, data on the risk of hemorrhagic stroke, including intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), are lacking.

Methods—

The Swedish Patient Register was used to identify all patients who were born with a diagnosis of CHD between 1970 and 1993. Each patient was compared with 10 randomly selected controls from the general population, matched for age, sex, and county. Follow-up data were collected until December 2011 for both cases and controls.

Results—

Of 21 982 patients with CHD, 70 developed ICH and 57 developed SAH up to the age of 42 years. CHD patients had more than an 8× higher risk (incidence rate ratio, 8.23; 95% confidence interval, 6–11.2) of developing ICH and almost an 8× higher risk of developing SAH (incidence rate ratio, 7.64; 95% confidence interval, 5.41–10.7) compared with controls. The absolute risk of ICH and SAH was low, with incidence rates of 1.18 and 0.96 cases per 10 000 person-years, respectively. Patients with severe nonconotruncal defects (incidence rate ratio, 16.5; 95% confidence interval, 5.63–51.2) or coarctation of the aorta (incidence rate ratio, 17.3; 95% confidence interval, 6.63–51.8) had the highest relative risk of developing hemorrhagic stroke, with incidence rates of 3.22 and 2.79 cases per 10 000 person-years, respectively.

Conclusions—

The relative risk of hemorrhagic stroke among children and young adults with CHD was almost 8× higher than that of matched controls from the general population, although the absolute risk was low. The highest risk of ICH and SAH occurred in patients with severe nonconotruncal defects and coarctation of the aorta.

Evaluation of the Distribution of Paclitaxel After Application of a Paclitaxel-Coated Balloon in the Rabbit Urethra

INTRODUCTION

Urethral strictures are a common urologic problem that could require complex reconstructive procedures. Urethral dilatation represents a frequent practiced intervention associated with high recurrence rates. Drug-coated percutaneous angioplasty balloons (DCBs) with cytostatic drugs have been effectively used for the prevention of vascular restenosis after balloon dilatation. To reduce restenosis rates of urethral dilatation, these balloons could be used in the urethra. Nevertheless, the urothelium is different than the endothelium and these drugs may not be distributed to the outer layers of the urethra. Thus, an experiment was performed to evaluate the distribution of paclitaxel (PTX) in the rabbit urethra after the inflation of a PTX-coated balloon (PCB).

MATERIALS AND METHODS

Eleven rabbits underwent dilatation of the posterior urethra with common endoscopic balloons after urethrography. Nine of these rabbits were additionally treated with PCB. The urethras of the two control animals were removed along with three more dilated with PCB urethras immediately after the dilatation. The remaining of the urethras were removed after 24 (n = 3) and 48 hours (n = 3). The posterior segments of the urethras were evaluated with hematoxylin and eosin staining as well as with immunohistochemistry with polyclonal anti-PTX antibody.

RESULTS

The two control specimens showed denudation of the urothelium after balloon dilatations and no PTX was observed. All specimens from dilated PCB urethras showed distribution of PTX to all layers of the urethra. The specimens that were immediately removed exhibited denudation of the urothelium without any inflammation. The specimens removed at 24 and 48 hours showed mild acute inflammation.

CONCLUSION

PTX was distributed to the urothelial, submucosal, and smooth muscle layers of the normal rabbit urethra immediately after dilatation with a DCB. PTX and mild inflammation were present at the site 24 and 48 hours after the dilatation.

Sex differences in survival after myocardial infarction in Sweden, 1987-2010

Objective

In this nationwide study, we investigated age-specific and sex-specific trends in sex differences in survival after acute myocardial infarction (AMI), including deaths from coronary heart disease (CHD) that occurred outside hospital.

Methods

Observational study in Sweden of 28-day and 1-year mortality among 658 110 persons (35.7% women) aged 35–84 years with a first-time CHD event 1987–2010 with data retrieved from the national Swedish death and hospital registries.

Results

Age-adjusted 28-day case fatality decreased from 23.5% to 8.5% over the period (p<0.05). In hospitalised cases, short-term survival in women aged 35–54 years compared with men of the same age was poorer, not changing appreciably over time (HRs for women relative to men 1.63 (95% CI 1.28 to 2.08) at age 35–54 years and 1.28 (95% CI 1.12 to 1.46) at age 55–64 years in 2005–2010), but after adjustment for comorbidities, differences between men and women were no longer significant (HR 1.25 (95% CI 0.97 to 1.61) and 1.05 (95% CI 0.91 to 1.20)). When CHD deaths outside hospital were included, women had better prognosis regardless of age and period. In patients surviving the first 28 days, age-adjusted 1-year case fatality decreased from 15.3% to 7.7% (p<0.05) for both men and women. After adjustment for comorbidities, no significant sex differences persisted below the age of 75 years in the last period. Female 28-day survivors 75–84 years old had a consistently better prognosis than older men.

Conclusions

The worse short-term outcomes in women <55 years of age hospitalised with AMI did not persist after adjustment for comorbidities. When CHD deaths outside hospital were included, women had consistently better short-term prognosis. In 28-day survivors, women did not fare worse than men when differences in comorbidities were considered.

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.

Survivorship in Children and Young Adults With Congenital Heart Disease in Sweden

IMPORTANCE

Mortality in patients with congenital heart disease (CHD) has markedly decreased during recent decades because of advancement in pediatric care. However, there are limited data on survival trends in children and young adults with CHD compared with the general population.

OBJECTIVE

To determine survivorship in children and young adults with CHD compared with matched controls.

DESIGN, SETTING, AND PARTICIPANTS

A registry-based, prospective, matched-cohort study was conducted in Sweden. Data from the national patient and cause of death registers were linked to identify individuals with CHD born between January 1, 1970, and December 31, 1993, who were registered at or after birth. Follow-up and comorbidity data were collected until December 31, 2011. Survival analyses were performed with the Cox proportional hazards model; these analyses were performed from January 1, 1970, to December 31, 2011. A total of 21 982 patients with CHD in Sweden were identified. The mean (SD) follow-up time was 27.0 (8.86) years. Children serving as controls (n = 219 816) (10 for each patient), matched for birth year, sex, and county, were randomly selected from the general population.

MAIN OUTCOMES AND MEASURES

Survivorship in young patients with CHD and controls.

RESULTS

Of the 21 982 patients who were born between 1970 and 1993 and were registered with the diagnosis of CHD, 10 650 were female (48.4%). Median age at index registration was 4.22 years (interquartile range, 17.07 years). Survivorship among children younger than 5 years was increased from 96% in those born in 1970-1979 to 98% in those born in 1990-1993. Hazard ratios (HRs) of death in relation to that in control individuals decreased from 225.84 (95% CI, 136.84-372.70) to 33.47 (95% CI, 22.54-49.70). A substantial, but less pronounced, absolute and relative increase in survivorship was found in older patients (HRs ranged from 24.52; 95% CI, 11.72-51.26, at 5-9 years to 4.27; 95% CI, 2.29-7.95, at 18-29 years). According to a hierarchical CHD classification, the group of patients with the most severe complex defects (ie, common arterial trunk, transposition of the great vessels, double inlet ventricle, hypoplastic left heart syndrome, tetralogy of Fallot, and atrioventricular septal defect) had the highest risk for death (HR, 64.07; 95% CI, 53.39-76.89).

CONCLUSIONS AND RELEVANCE

Despite substantially increasing absolute and relative survivorship in children and young adults with CHD, the mortality risk remains high compared with the risk in matched controls. Further research on reducing the death rate in this vulnerable group is required.

Living alone predicts mortality in patients with ischemic stroke before 70 years of age: a long-term prospective follow-up study

Background

Living alone is associated with increased mortality after myocardial infarction but little data is available about whether this applies to prognosis after stroke. We aimed to examine the association between living situation and long-term mortality in patients with ischemic stroke and a control group, and to explore whether this association is modified by patient gender.

Methods

This is a prospective case-control study of 600 patients with ischemic stroke before 70 years of age and 600 age- and sex-matched controls who have been included in the Sahlgrenska Study on Ischemic Stroke. Mortality data were collected through national registers and medical records. We used Cox regression models for identifying predictors of mortality.

Results

In the entire sample, mean age was 57 years, proportion of males 64 %, proportion living alone 28 %, and median follow-up 8.6 years. Mortality rates were 36 % among patients living alone, 17 % among cohabitant patients, 15 % among controls living alone, and 9 % among cohabitant controls. Living alone was an independent predictor of all-cause mortality in cases after adjustment for stroke severity, stroke subtype, and vascular risk factors including physical activity, alcohol consumption, and socioeconomic status. A significant interaction was found between gender and living situation; the adjusted hazard ratio for mortality was 3.47 (95 % Confidence Interval 2.13–5.65) in male patients living alone, whereas no significant association was observed in women. Living alone was also a predictor of vascular mortality among cases and of all-cause mortality among controls.

Conclusions

Living alone is associated with increased long-term mortality after ischemic stroke in men. Further prospective studies are needed to confirm the observed gender difference and to identify modifiable factors underlying this increased risk.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0599-y) contains supplementary material, which is available to authorized users.

Ischemic Stroke in Children and Young Adults With Congenital Heart Disease

Background

Patients with congenital heart disease (CHD) may be at increased risk of ischemic stroke due to residual shunts, arrhythmias, and other cardiovascular abnormalities. We studied the relative risk and potential factors for developing ischemic stroke in children and young adults with CHD in Sweden.

Methods and Results

All patients in the Swedish Patient Register with a diagnosis of CHD, born between 1970 and 1993, were identified and compared with 10 controls for each patient, matched for age, sex, and county and randomly selected from the general population. Follow‐up data through 2011 were collected for both groups. Of 25 985 children and young adults with CHD (51.5% male, 48.5% female), 140 (0.5%) developed ischemic stroke. The hazard ratio for CHD patients developing ischemic stroke was 10.8 (95% CI, 8.5–13.6) versus controls. All major Marelli groups had significantly increased risk, but because of small CHD‐group sizes, only atrial septal defect/patent foramen ovale, double‐inlet ventricle, and aortic coarctation displayed significantly increased risk. In multivariate analysis of CHD patients, congestive heart failure carried the highest risk for developing ischemic stroke (hazard ratio 6.9 [95% CI, 4.7–10.3]), followed by hypertension and atrial fibrillation, which were also significantly associated with increased risk of ischemic stroke.

Conclusions

The risk of developing ischemic stroke was almost 11 times higher in young patients with CHD than in the general population, although absolute risk is low. Cardiovascular comorbidities were strongly associated with the development of ischemic stroke in young CHD patients.

Decline in Coronary Mortality in Sweden between 1986 and 2002: Comparing Contributions from Primary and Secondary Prevention

Background

The relative importance of risk factor reduction in healthy people (primary prevention) versus that in patients with coronary heart disease (secondary prevention) has been debated. We aimed to quantify the contribution of the two.

Methodology

We used the previously validated IMPACT model to estimate contributions from primary prevention (reducing risk factors in the population, particularly smoking, cholesterol and systolic blood pressure) and from secondary prevention (reducing risk factors in coronary heart disease patients) in the Swedish population.

Principal Findings

Between 1986 and 2002, about 8,690 fewer deaths were related to changes in the three major risk factors. Population cholesterol fell by 0.64 mmol/L, with approximately 5,210 fewer deaths attributable to diet changes (4,470 in healthy people740 in patients.) plus 810 to statin treatment (200 in healthy people, 610 in patients). Overall smoking prevalence decreased by 10.3%, resulting in 1,195 fewer deaths, attributable to smoking cessation (595 in healthy people, 600 in patients). Mean population systolic blood pressure fell by 2.6 mmHg, resulting in 900 fewer deaths (865 in healthy people, 35 in patients), plus 575 fewer deaths attributable to antihypertensive medication in healthy people. The majority of falls in deaths attributable to risk factors occurred in people without known heart disease: 6,705 fewer deaths compared with 1,985 fewer deaths in patients (secondary prevention), emphasizing the importance of promoting health interventions in the general population.

Conclusions

The largest effects on mortality came from primary prevention, giving markedly larger mortality reductions than secondary prevention.

Trends in mortality after first hospitalization with atrial fibrillation diagnosis in Sweden 1987 to 2006

BACKGROUND

To examine trends in 3-year mortality after a first hospitalization with diagnosed atrial fibrillation in a large cohort with and without important comorbidities.

METHODS

The Swedish Hospital Discharge and Cause of Death Registries were linked to investigate trends in mortality for all patients 35 to 84 years hospitalized for the first time with a discharge diagnosis (principal or contributory) of atrial fibrillation in Sweden during 1987 to 2006.We performed an analysis of temporal trends in mortality stratified for presence or absence of co-morbidities affecting survival.

RESULTS

Exactly 376,000 patients (56% male, mean age 72 years) with a first diagnosis of atrial fibrillation during 1987–2006 were identified and followed for 3 years. Patients with one or more of the prespecified comorbidities had the highest mortality and the largest absolute decline in mortality, but patients without these comorbidities had a slightly larger relative decline (absolute risk reduction in 3-year mortality (AAR) from 42.5 to 34.7%, Hazard Ratio (HR) 0.76; 95% confidence interval (95% CI) 0.74 to 0.77 versus ARR 16.2% to 11.7%, HR 0.71; 0.68 to 0.74. In patients aged below 65 years,with no comorbidities, there was minimal change inmortality, and they still had a 2 times increased mortality compared to the general population (SMR 1.95; 1.84-2.06).

CONCLUSIONS

Survival after a first hospitalization with a diagnosis of atrial fibrillation improved regardless comorbidities. Patients aged < 65 years old without diagnosed comorbidities still had a poor prognosis compared to the general population.

Incidence of Type 2 diabetes among occupational classes in Sweden: a 35-year follow-up cohort study in middle-aged men

AIMS

To assess if low occupational class was an independent predictor of Type 2 diabetes in men in Sweden over a 35-year follow-up, after adjustment for both conventional risk factors and psychological stress.

METHODS

A random population-based sample of 6874 men aged 47-56 years without a history of diabetes was divided into five occupational classes and the men were followed from 1970 to 2008. Diabetes cases were identified through the Swedish inpatient and death registers. Subdistribution hazard ratios (SHRs) and 95% CIs from competing risk regressions, cumulative incidence and conditional probabilities were calculated, after accounting for the risk of death attributed to other causes.

RESULTS

A total of 907 (13%) men with diabetes were identified over 35 years with a median follow-up of 27.9 years. The cumulative incidence of diabetes, when taking into account death as a competing event, was 11% in high officials, 12% in intermediate non-manual employees, 14% in assistant non-manual employees, 14% in skilled workers, and 16% in unskilled and semi-skilled workers. Men with unskilled and semi-skilled manual occupations had a significantly higher risk of diabetes than high officials (reference) after adjustment for age, BMI, hypertension, smoking and physical activity (SHR 1.39, 95% CI 1.08-1.78). Additional adjustment for self-reported psychological stress did not attenuate the results.

CONCLUSIONS

A low occupational class suggests a greater risk of Type 2 diabetes, independently of conventional risk factors and psychological stress.

Trends in prevalence from 1990 to 2007 of patients hospitalized with heart failure in Sweden

AIMS

To investigate trends in absolute numbers and prevalence from 1990 to 2007 of patients hospitalized with heart failure (HF) in Sweden.

METHODS AND RESULTS

National inpatient and cause-specific death registers were used to calculate age- and sex-specific trends in absolute numbers and prevalence from 1990 to 2007 of patients hospitalized with HF in Sweden. Absolute numbers increased from 105 449 in 1990 to 144 925 in 2007, with a 77% increase in patients aged 85-99 years. The overall age-adjusted prevalence in 1990 was 1.73%, and this increased with an estimated annual percentage change (EAPC) of 4.3% [95% confidence interval (CI) 3.6-4.9%] from 1990 to 1995, with no further significant change until 2002. The single year with the highest prevalence was 1998, when it peaked at 2.13%. The prevalence then declined slowly from 2002 (EAPC -1.1, 95% CI -1.5% to -0.6%) to 1.99% in 2007. The decrease in prevalence was not found in persons <65 years, where, instead, an increase was found throughout the period.

CONCLUSION

Fears of an impending HF 'epidemic' could not be confirmed in this analysis of trends in prevalence for the period 1990-2007 of patients hospitalized with HF in Sweden. An overall slight decrease in age-adjusted prevalence was observed from 2002. The prevalence in patients <65 years increased markedly. In absolute numbers, there was a substantial increase among the very old, consistent with demographic changes.

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.

Atrial natriuretic peptide as a predictor of atrial fibrillation in a male population study. The Study of Men Born in 1913 and 1923

BACKGROUND

Atrial fibrillation is one of the most common arrhythmias in clinical practice and it is often diagnosed after a complication occurs. The study aimed to evaluate the predictive value of atrial natriuretic peptide (ANP) for atrial fibrillation in a male population-based study.

METHODS AND RESULTS

This study is a part of the "Study of Men Born in 1913 and 1923", a longitudinal prospective cohort study of men, living in the city of Gothenburg in Sweden. A population-based sample of 528 men was investigated in 1988 when they were aged 65 years (n=134) and 75 years (n=394), and they were followed up for 16 years. Blood samples were collected from all 528 men at baseline and plasma ANP levels were analyzed by radioimmunoassay. Hazard ratios were estimated by competing-risk regression analysis. One hundred five participants were excluded because of a prior diagnosis of atrial fibrillation, congestive heart failure, severe hypertension, or severe chronic renal insufficiency. Of the remaining 423 participants, 90 men were diagnosed with atrial fibrillation over the 16-year follow-up. In multivariable analysis, men in the two highest quartiles of ANP levels had a significantly higher risk for atrial fibrillation compared with men in the lowest ANP quartile. The adjusted ratio was 3.14 (95% CI 1.59-6.20) for the third ANP quartile and 3.36 (95% CI 1.72-6.54) for the highest quartile of ANP level.

CONCLUSIONS

In this population-based longitudinal study, we found that elevated ANP levels at baseline predicted atrial fibrillation during a follow-up time of 16 years.

Heart failure in young adults: 20-year trends in hospitalization, aetiology, and case fatality in Sweden

AIMS

To describe trends in incidence and case fatality among younger (18-54 years) and older (55-84 years) Swedish patients with heart failure (HF).

METHODS AND RESULTS

Through linking the Swedish national hospital discharge and the cause-specific death registries, we identified patients aged 18-84 years that were discharged 1987-2006 with a diagnosis of HF. Age-specific mean incidence rates per 100 000 person-years were calculated in four 5-year periods. Kaplan-Meier survival curves were plotted up to 3 years. From 1987 to 2006, there were 443 995 HF hospitalizations among adults 18-84 years. Of these, 4660 (1.0%) and 13 507 (3.0%) occurred in people aged 18-44 and 45-54 years (31.6% women), respectively. From the first to the last 5-year period, HF incidence increased by 50 and 43%, among people aged 18-34 and 35-44 years, respectively. Among people ≥45 years, incidence peaked in the mid-1990s and then decreased. Heart failure in the presence of cardiomyopathy increased more than two-fold among all age groups. Case fatality decreased for all age groups until 2001, after which no further significant decrease <55 years was observed.

CONCLUSION

Increasing HF hospitalization in young adults in Sweden opposes the general trend seen in older patients, a finding which may reflect true epidemiological changes. Cardiomyopathy accounted for a substantial part of this increase. High case fatality and lack of further case fatality reduction after 2001 are causes for concern.

Occupational status and incidences of ischemic and hemorrhagic stroke in Swedish men: a population-based 35-year prospective follow-up study

This study examined variations in stroke incidence across occupational classes over a 35-year follow-up period. We analyzed a random population-based sample of 6,994 men aged 47-56 years at baseline without prior history of stroke. Standardized incidence rates, subdistribution hazard ratios (SHRs) from competing risk regressions and cumulative incidence were calculated, after accounting for risk of death attributed to causes other than stroke. A total of 1,442 strokes were identified over the 35-year period with crude incidences of 5.50 (ischemic) and 1.16 (hemorrhagic) per 1,000 person-years. In the whole group, occupational class was not associated with either ischemic or hemorrhagic stroke. However, older men (≥51 years at baseline) with unskilled manual occupations had a significantly lower risk of ischemic stroke than those with high officials (referent). No association between occupation and stroke of either type was detected for men younger than 51 years. There was an inverse and graded risk of death from causes other than stroke; men in high official positions had the lowest cumulative risk and unskilled manual workers had the highest risk (P < 0.0001). The association between occupation and ischemic stroke in older men persisted after accounting for competing risks of death (SHR 0.62; 95 % CI 0.46-0.84). In conclusion, low socioeconomic status was not associated with an increased risk of incident hemorrhagic or ischemic stroke. Older men with the lowest occupational status i.e. unskilled manual had a significantly lower risk of ischemic stroke, even after controlling for other risk factors and competing risks of death.

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.

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.

Differences between acute myocardial infarction and unstable angina: a longitudinal cohort study reporting findings from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA)

OBJECTIVES

The aim of this study was to compare risk factors and comorbidities in patients with a first episode of acute coronary syndrome (ACS), being either acute myocardial infarction (AMI) or unstable angina pectoris (UAP).

DESIGN

Cross-sectional and prospective.

SETTING

The Swedish population.

PARTICIPANTS

A total of 145 346 consecutive patients aged 25-105 years included in the Swedish Register of Cardiac Intensive Care Admission (Register of Information and Knowledge about Swedish Heart Intensive Care) and admitted to hospital between 1 January 1996 and 30 June 2009 with a first episode of either AMI or UAP.

PRIMARY AND SECONDARY OUTCOME MEASURES

Type of ACS and 1-year outcome.

RESULTS

Compared with patients with UAP, AMI patients were more likely to be older; men; and former or current smokers; they were also more likely to have had diabetes and peripheral artery disease, but had lower rates of prior heart failure (HF) and fewer cardioprotective medications on admission. Among patients aged <65 years, 1.4% of men and 1.6% of women with UAP died within 1 year in 2003-2006 compared with 4.2% of men and 3.1% of women AMI patients (multiple-adjusted OR 3.54 (99% CI 2.29 to 5.48) in women and 2.65 (99% CI 2.11 to 3.34) in men). Corresponding proportions in patients aged ≥65 years was 7.5% in men and 7.6% in women with UAP and 21.5% in men and 17.8% in women with AMI.

CONCLUSIONS

In patients with a first-time ACS episode, male sex, slightly older age, smoking, diabetes and peripheral arterial disease (PAD), but fewer cardioprotective medications, were major determinants for presenting with AMI. Despite increasingly active treatment in AMI and more inclusive diagnostic criteria in recent years, persistently worse prognosis was observed in AMI patients.

High-normal blood pressure and long-term risk of type 2 diabetes: 35-year prospective population based cohort study of men

BACKGROUND

The link between type 2 diabetes and hypertension is well established and the conditions often coexist. High normal blood pressure, defined by WHO-ISH as systolic blood pressure (SBP) 130-139 mm Hg or diastolic blood pressure (DBP) 85-89 mm Hg, has been found to be an independent predictor for type 2 diabetes in studies, although with relatively limited follow-up periods of approximately 10 years. The aim of this study was to investigate whether hypertension, including mildly elevated blood pressure within the normal range, predicted subsequent development of type 2 diabetes in men over an extended follow-up of 35 years.

METHODS

Data were derived from the Gothenburg Primary Prevention Study where a random sample of 7 494 men aged 47-55 years underwent a baseline screening investigation in the period 1970-1973. A total of 7 333 men were free from previous history of diabetes at baseline. During a 35-year follow-up diabetes was identified through the Swedish hospital discharge and death registries. The cumulative risk of diabetes adjusted for age and competing risk of death was calculated. Using Cox proportional hazard models we calculated the multiple adjusted hazard ratios (HR) (95% confidence interval (CI)) for diabetes at different blood pressure levels.

RESULTS

During a 35-year follow-up, 956 men (13%) were identified with diabetes. The 35-year cumulative risk of diabetes after adjusting for age and competing risk of death in men with SBP levels <130 mm Hg, 130-139 mm Hg, 140-159 mm Hg and ≥160 mm Hg were 19%, 30%, 31% and 49%, respectively. The HR for diabetes adjusted for age, body mass index (BMI), cholesterol, antihypertensive treatment, smoking, physical activity and occupation were 1.43 (95% CI 1.12-1.84), 1.43 (95% CI 1.14-1.79) and 1.95 (95% CI 1.55-2.46) for men with SBP 130-139 mm Hg, 140-159 mm Hg, and ≥ 160 mm Hg, respectively (reference; SBP<130 mm Hg).

CONCLUSION

In this population, at mid-life, even high-normal SBP levels were shown to be a significant predictor of type 2 diabetes, independently of BMI and other conventional type 2 diabetes risk factors over an extended follow-up.

Self-reported leisure time physical activity: a useful assessment tool in everyday health care

Background

The individual physical activity level is an independent risk factor for cardiovascular disease and death, as well as a possible target for improving health outcome. However, today´s widely adopted risk score charts, typically do not include the level of physical activity. There is a need for a simple risk assessment tool, which includes a reliable assessment of the level of physical activity. The aim of this study was therefore, to analyse the association between the self-reported levels of physical activity, according to the Saltin-Grimby Physical Activity Level Scale (SGPALS) question, and cardiovascular risk factors, specifically focusing on the group of individuals with the lowest level of self-reported PA.

Methods

We used cross sectional data from the Intergene study, a random sample of inhabitants from the western part of Sweden, totalling 3588 (1685 men and 1903 women, mean age 52 and 51). Metabolic measurements, including serum-cholesterol, serum-triglycerides, fasting plasma-glucose, waist circumference, blood pressure and resting heart rate, as well as smoking and self-reported stress were related to the self-reported physical activity level, according to the modernized version of the SGPALS 4-level scale.

Results

There was a strong negative association between the self-reported physical activity level, and smoking, weight, waist circumference, resting heart rate, as well as to the levels of fasting plasma-glucose, serum-triglycerides, low-density lipoproteins (LDL), and self-reported stress and a positive association with the levels of high-density lipoproteins (HDL). The individuals reporting the lowest level of PA (SGPALS, level 1) had the highest odds-ratios (OR) for having pre-defined levels of abnormal risk factors, such as being overweight (men OR 2.19, 95% CI: 1.51-3.19; women OR 2.57, 95 % CI: 1.78-3.73), having an increased waist circumference (men OR 3.76, 95 % CI: 2.61-5.43; women OR 2.91, 95% CI: 1.94-4.35) and for reporting stress (men OR 3.59, 95 % CI: 2.34-5.49; women OR 1.25, 95% CI: 0.79-1.98), compared to the most active individuals, but also showed increased OR for most other risk factors analyzed above.

Conclusion

The self-reported PA-level according to the modernized Saltin-Grimby Physical Activity Level Scale, SGPALS, is associated with the presence of many cardiovascular risk factors, with the most inactive individuals having the highest risk factor profile, including self-reported stress. We propose that the present SGPALS may be used as an additional, simple tool in a routine risk assessment in e.g. primary care, to identify inactive individuals, with a higher risk profile.

Increasing evidence-based treatments to reduce coronary heart disease mortality in Sweden: quantifying the potential gains

OBJECTIVES

Between 1986 and 2002, coronary heart disease (CHD) mortality in Sweden fell by more than 50%. Approximately one-third (4800 fewer deaths) of this decline in age-adjusted CHD mortality could be attributed to treatments in patients with CHD and primary prevention medications. High treatment levels were achieved in some cases, but in others, only 50-80% of eligible patients received appropriate therapy. We therefore examined to what extent increasing the use of specific treatments in eligible patients might have reduced CHD mortality rates in Sweden.

DESIGN AND METHODS

We used the previously validated IMPACT CHD model to combine data on CHD patient numbers, medical and surgical uptake levels and treatment effectiveness. We estimated the number of deaths prevented or postponed for 2002 (baseline scenario) and for an alternative scenario (if at least 60% of eligible patients were treated).

RESULTS

If treatments were increased to consistently cover at least 60% of eligible patients, approximately 8900 deaths could have been postponed or prevented, representing a potential gain of approximately 4100 fewer deaths than actually occurred in 2002. Approximately 45% of the 4100 gain would have come from primary prevention with statins, 23% from acute coronary syndrome treatments, 15% from secondary prevention therapies and 15% from treatments for heart failure.

CONCLUSION

Increasing the proportion of eligible patients with CHD who receive evidence-based treatment could have resulted in approximately 4100 fewer deaths in 2002, almost doubling the actual mortality reduction. These findings further emphasize the importance of aggressively identifying and treating patients with CHD and high-risk individuals.

Twenty-year trends in incidence and 1-year mortality in Swedish patients hospitalised with non-AMI chest pain. Data from 1987-2006 from the Swedish hospital and death registries

OBJECTIVE

To study trends for 20 years in incidence and 1-year mortality in hospitalised patients who received a diagnosis of either angina or unexplained chest pain (UCP) in Sweden.

DESIGN AND SETTING

Register study of all patients aged 25-84 years identified from the Swedish National Hospital Discharge Register who were hospitalised with a first-time diagnosis of UCP or angina pectoris during 1987 to 2006.

PARTICIPANTS

A total of 378 454 patients, 235 855 with UCP and 142 599 with angina.

MAIN OUTCOME MEASURES

1-Year mortality and standardised mortality ratios (SMRs).

RESULTS

From the period 1987-1991 to 2002-2006, the observed 1-year mortality rate in men and women with UCP aged 25-74 years decreased from 2.19% to 1.45% and from 1.85% to 0.91%, respectively. SMRs decreased from 1.67 (95% CI 1.39 to 1.95) and 1.63 (1.27 to 2.00) to 1.09 (0.96 to 1.23) and 0.88 (0.75 to 1.00). Corresponding decreases in 1-year mortality for a discharge diagnosis of angina were from 6.50% to 2.49% in men and from 4.80% to 1.68% in women, with SMRs decreasing from 2.69 (2.33-3.05) and 2.59 (2.06-3.12) to 1.09 (0.93-1.25) and 1.05 (0.81-1.29), respectively. Similar changes occurred in patients aged 75-84 years. Only men with UCP aged 75-84 years still retained a slightly increased mortality (SMR 1.14 (1.01-1.28)).

CONCLUSIONS

The prognosis of patients admitted with chest pain in which acute myocardial infarction has been ruled out has improved for the past 20 years, such that the 1-year mortality of these patients is now similar to that in the general population.

Systematically missing confounders in individual participant data meta-analysis of observational cohort studies

One difficulty in performing meta-analyses of observational cohort studies is that the availability of confounders may vary between cohorts, so that some cohorts provide fully adjusted analyses while others only provide partially adjusted analyses. Commonly, analyses of the association between an exposure and disease either are restricted to cohorts with full confounder information, or use all cohorts but do not fully adjust for confounding. We propose using a bivariate random-effects meta-analysis model to use information from all available cohorts while still adjusting for all the potential confounders. Our method uses both the fully adjusted and the partially adjusted estimated effects in the cohorts with full confounder information, together with an estimate of their within-cohort correlation. The method is applied to estimate the association between fibrinogen level and coronary heart disease incidence using data from 154 012 participants in 31 cohorts.† Copyright © 2009 John Wiley & Sons, Ltd.

"Nonspecific" chest pain associated with high long-term mortality: results from the primary prevention study in Göteborg, Sweden

BACKGROUND

The syndrome angina pectoris with effort-related chest pain or discomfort is usually easy to recognize. However, vague and nonspecific symptoms may cause little reason for extensive evaluation. The prognosis of such patients in the general population has so far not been well described.

HYPOTHESIS

The study was undertaken to investigate long-term prognosis in men with chest pain considered to be nonspecific in comparison with men with typical angina pectoris (AP) or prior myocardial infarction (MI), and men without chest pain.

METHODS

At the second screening of the Göteborg Primary Prevention Study in 1974-1977, 6,488 men aged 51 to 59 years at baseline were available for the present analysis. Men who had responded positively to a postal questionnaire about chest pain during exercise or at rest were interviewed by a physician according to a Rose questionnaire at the screening examination. Those with typical or probable AP were further examined by single experienced physician. The following four groups were formed: Group 1: men who did not complain of chest pain (n = 5,545). Group 2: men who had not consulted any doctor because of chest pain, but who had chest pain according to a questionnaire (n = 441); these men were not considered to have AP according to a three-step examination by experienced physicians. Group 3: typical AP (n = 232). Group 4: men who had suffered an MI (n = 134).

RESULTS

During 16 years of follow-up, coronary heart disease (CHD) mortality for Groups 1-4 was 8.0, 19.5, 24.8, and 48.5%, respectively. Mortality from all cardiovascular diseases was 11.5, 24.5, 31.2, and 59.0%, respectively. Noncardiovascular disease mortality was 14.1, 17.7, 14.3, and 8.7%, respectively. Thus, the relative risk (RR) for CHD mortality among men with nonspecific chest pain (Group 2) was 2.77 [95% confidence interval (CI) 2.20, 3.50], for all cardiovascular disease mortality 2.46 (95% CI 2.00, 3.02), and for noncardiovascular disease mortality 1.60 (95% CI 1.28, 2.00). Total mortality in this group was as high (44%) as among those with typical AP (45%), but the highest mortality was found among men with a previous MI (68%). In men without chest pain it was 26%. Patients of Groups 2-4 had higher levels of cardiovascular risk factors than those in Group 1. Neither any specific questions in the Rose questionnaire, nor electrocardiographic changes at rest (uncommon) were of prognostic significance. Serum cholesterol, systolic blood pressure, diabetes, and smoking were significant predictors of outcome, both with respect to fatal CHD and to total mortality during the 16-year follow-up.

CONCLUSION

We found a high cardiovascular as well as noncardiovascular mortality among patients with chest pain who had not been considered to have AP at a three-step examination procedure. It is important to be suspicious of early CHD symptoms in men (and women?) with "nonspecific" chest symptoms and to analyze their cardiovascular risk factor pattern further because they are at considerably higher risk for future events than those in whom CHD is not suspected.

Survival trends in men and women with heart failure of ischaemic and non-ischaemic origin: data for the period 1987-2003 from the Swedish Hospital Discharge Registry

AIMS

To investigate gender-specific trends in long-term mortality in patients hospitalized for heart failure (HF).

METHODS AND RESULTS

The Swedish hospital discharge and cause-specific death registers were used to calculate age- and gender-specific trends for long-term prognosis in patients hospitalized with a principal diagnosis of HF from 1987 to 2003. Mortality decreased, mainly during 1987-95, with no further decrease after 2001. Survival in men improved more than in women (P-value for interaction 0.0003), particularly among patients aged <65 years (P-value for interaction: age, gender, and year of hospitalization 0.0003) and more for patients with ischaemic when compared with non-ischaemic HF (P-value for interaction <0.0001). Among men <65 years, the hazard ratio (HR) of dying within 3 years after discharge was 0.40 (95% confidence interval 0.36-0.45) during 1999-2001 when compared with 1987-89. The corresponding HR for women was 0.58 (0.48-0.69). For those discharged during 1999-2001, almost 20% of the patients aged 35-64 years and 40% of those aged 65-84 years died within 3 years.

CONCLUSION

Long-term mortality in HF in Sweden decreased more for men than for women and more for ischaemic than non-ischaemic HF. There was no further decrease after 2001. Long-term mortality after a first hospitalization remained high.

Food patterns and cardiovascular disease risk factors: the Swedish INTERGENE research program

BACKGROUND

Analyzing the impact of the intake of many foods simultaneously provides additional knowledge about analyses of nutrients and might make it easier to implement recommendations for the public.

OBJECTIVE

The objective was to examine food patterns in a Swedish population and determine how they are related to metabolic risk factors for cardiovascular disease.

DESIGN

The study is based on data from the INTERGENE population study of women and men aged 25-74 y in western Sweden. Dietary patterns were identified with cluster analysis of 93 food frequencies reported by 3452 participants. Associations with features of the metabolic syndrome, including blood lipids, blood pressure, and anthropometric measures, were analyzed.

RESULTS

Five distinct food patterns were identified, of which one was interpreted as a "healthy" reference pattern. This healthy cluster was distinguished by more frequent consumption of high-fiber and low-fat foods and lower consumption of products rich in fat and sugar. The 4 other clusters differed significantly from the reference cluster with respect to prevalence of cardiovascular disease risk factors and the metabolic syndrome. For example, body mass index and waist-to-hip ratio were significantly higher in a cluster characterized by high consumption of energy-dense drinks and white bread and low consumption of fruit and vegetables (P < 0.0001 and P = 0.004, respectively).

CONCLUSIONS

It is possible to distinguish food patterns that are related to obesity and obesity-related cardiovascular disease risk factors in contrast with a more healthy pattern conforming with current dietary guidelines. Thus, the results indicate no reason for questioning the current recommendations.

The Emerging Risk Factors Collaboration: analysis of individual data on lipid, inflammatory and other markers in over 1.1 million participants in 104 prospective studies of cardiovascular diseases

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Role of oxidative stress in angiotensin II-induced enhanced expression of Gi(alpha) proteins and adenylyl cyclase signaling in A10 vascular smooth muscle cells

We have previously reported that angiotensin II (ANG II) treatment of A10 vascular smooth muscle cells (VSMCs) increased inhibitory G proteins (G(i) protein) expression and associated adenylyl cyclase signaling which was attributed to the enhanced MAP kinase activity. Since ANG II has been shown to increase oxidative stress, we investigated the role of oxidative stress in ANG II-induced enhanced expression of G(i)alpha proteins and examined the effects of antioxidants on ANG II-induced enhanced expression of G(i)alpha proteins and associated adenylyl cyclase signaling in A10 VSMCs. ANG II treatment of A10 VSMCs enhanced the production of O(2)(-) and the expression of Nox4 and P47(phox), different subunits of NADPH oxidase, which were attenuated toward control levels by diphenyleneiodonium (DPI). In addition, ANG II augmented the expression of G(i)alpha-2 and G(i)alpha-3 proteins in a concentration- and time-dependent manner; the maximal increase in the expression of G(i)alpha was observed at 1 to 2 h and at 0.1-1.0 microM. The enhanced expression of G(i)alpha-2 and G(i)alpha-3 proteins was restored to control levels by antioxidants such as N-acetyl-L-cysteine, alpha-tocopherol, DPI, and apocynin. In addition, ANG II also enhanced the ERK1/2 phosphorylation that was restored to control levels by DPI. Furthermore, the inhibition of forskolin-stimulated adenylyl cyclase activity by low concentrations of 5'-O-(3-triotriphosphate) (receptor-independent G(i) functions) and ANG II-, des(Glu(18),Ser(19),Glu(20),Leu(21),Gly(22))atrial natriuretic peptide(4-23)-NH(2) (natriuretic peptide receptor-C agonist), and oxotremorine-mediated inhibitions of adenylyl cyclase (receptor-dependent functions) that were augmented in ANG II-treated VSMCs was also restored to control levels by antioxidant treatments. In addition, G(s)alpha-mediated diminished stimulation of adenylyl cyclase by stimulatory hormones in ANG II-treated cells was also restored to control levels by DPI. These results suggest that ANG II-induced enhanced levels of G(i)alpha proteins and associated functions in VSMCs may be attributed to the ANG II-induced enhanced oxidative stress, which exerts its effects through mitogen-activated protein kinase signaling pathway.

Oxidative stress contributes to the enhanced expression of Gialpha proteins and adenylyl cyclase signaling in vascular smooth muscle cells from spontaneously hypertensive rats

OBJECTIVE

We have previously shown an enhanced expression of Gialpha proteins in spontaneously hypertensive rats (SHR) that precedes the development of hypertension. Since oxidative stress has been shown to be increased in SHR, the present studies were undertaken to examine the role of oxidative stress in enhanced expression of Gialpha proteins in SHR.

METHODS

Aortic vascular smooth muscle cells (VSMC) from 12-week-old SHR and Wistar-Kyoto (WKY) rats were used for the present studies. The levels of inhibitory guanine nucleotide regulatory proteins (Gialpha-2 and Gialpha-3) and stimulatory proteins (Gsalpha) were determined by western blotting techniques. Adenylyl cyclase activity was determined by measuring [32P]cAMP formation from [alpha-32P]ATP.

RESULTS

VSMC from SHR exhibited enhanced expression of Gialpha-2 and Gialpha-3 proteins as compared with age-matched WKY rats; however, the levels of Gsalpha proteins were not different between the two groups. The levels of superoxide anion (O2-) were also increased in SHR as compared with WKY rats, and losartan, an AT1 receptor antagonist, restored the enhanced levels to control WKY rat levels. Treatment of VSMC with antioxidants such as N-acetyl-L-cysteine (NAC) or diphenyleneiodonium (DPI) for 24 h decreased the enhanced expression of Gialpha-2 and Gialpha-3 proteins in a concentration-dependent manner in VSMC from SHR. In addition, the inhibition of forskolin-stimulated enzyme activity by low concentrations of GTPgammaS (receptor-independent Gi functions) and C-ANP4-23-mediated inhibition of adenylyl cyclase (receptor-dependent Gi functions) that were significantly enhanced in SHR were restored to WKY rat levels by NAC and DPI treatments. Similarly, diminished stimulation of adenylyl cyclase by GTPgammaS, isoproterenol and sodium fluoride in SHR was also restored towards control WKY rat levels by NAC and DPI treatments. Furthermore, PD98059, a selective inhibitor of mitogen-activated protein kinase, was able to restore the enhanced expression of Gialpha proteins in VSMC from SHR towards WKY rat levels. In addition, the enhanced activity of extracellular signal-regulated kinase 1/2 in SHR as compared with WKY rats, as demonstrated by enhanced phosphorylation of extracellular signal-regulated kinase 1/2, was also restored to WKY rat levels by NAC or DPI.

CONCLUSIONS

These results suggest that enhanced levels of Gialpha proteins and associated functions in SHR may be attributed to the enhanced oxidative stress present in SHR, which exerts its effects through the mitogen-activated protein kinase signaling pathway.

Trends in overweight and obesity from 1985 to 2002 in Göteborg, West Sweden

OBJECTIVE

To study secular trends in overweight and selected correlates in men and women in Göteborg, Sweden.

DESIGN

Cross-sequential population-based surveys.

SUBJECTS

A total of 2931 female and 2691 male subjects aged 25-64 y participated in WHO MONICA surveys (1985, 1990, 1995) and the INTERGENE study (2002).

MEASUREMENTS

Body mass index (BMI), waist-to-hip ratio (WHR), prevalence of overweight (BMI> or =25 kg/m(2)), and obesity (BMI> or =30 kg/m(2)).

RESULTS

Mean body weight increased by 3.3 kg for women and 5 kg for men, with a significant upward trend for BMI in men but not women over the 17-y observation period. The prevalence of overweight and obesity increased significantly in both sexes over the period. The largest increase was observed in men, and in women aged 25-34 y. In 2002, the prevalence of overweight was 38% in women and 58% in men, and the prevalence of obesity was 11% in women and 15% in men. No significant secular trends were observed for WHR, but there was an upward trend in prevalence of WHR>0.85 in women. A decreased prevalence of smoking in both sexes was observed together with an increase in reported leisure time physical activity. No significant secular trends were observed in rates of self-reported diabetes, although the risk of diabetes attributable to obesity was 24%.

CONCLUSION

The results indicate that 25-64-y-olds in the recent survey were more overweight and obese than earlier studied MONICA participants. The increase in BMI was more pronounced in men while abdominal obesity increased principally in women. Although obesity and overweight are clearly important risk factors for type 2 diabetes, the number of diabetics remains low and any secular increase is not yet apparent.