Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

Reproducibility of Quantitative Arteriographic Assessment of Atherosclerosis in the Femoral Artery

Results from computer-analysed angiograms in the Probucol Quantitative Regression Swedish Trial (PQRST) were analysed to determine the reproducibility of the method and any drift in the analysing system. The precision index (P(μ)) for 2 angiography series, made at 10 min intervals, of the femoral artery in 276 patients was 10.5 for lumen volume and 21.9 for roughness (edge irregularity). No difference in reproducibility was found between patients with and without symptoms of peripheral atherosclerosis or when looking at the reproducibility over years. A drift of 0.67% per year in the radiographic equipment (but not in the analysis system) was found, confirmed by use of phantoms. Computer-based analysis of femoral atherosclerosis is a reliable method for follow-up trials, giving high reproducibility even if the trial spans over several years and involves different centres. The use of phantoms is essential for checking the method over time.

Quantitation of Atherosclerosis in Femoral Arteriography with Ecg Gated Exposures

Using a densitometric method introduced in 1977 by Crawford et coll. (6) the volumes of segments of the femoral artery were calculated from two angiographic series in each of 13 patients. ECG gated exposures were used to minimise the error of the method. The reproducibility of the method was found to be better than in a previous study in which ECG gating was not used. The method may therefore be of use in long term angiographic follow-up studies of atherosclerotic lesions, although the impact of different investigation parameters on methodologic precision is still not fully known.

Lifelong benefits on myocardial infarction mortality: 40-year follow-up of the randomized Oslo diet and antismoking study

BACKGROUND

The effects of saturated fat on atherosclerotic vascular disease are currently debated.

OBJECTIVES

In the Oslo cardiovascular study initiated in 1972/1973, a 5-year randomized intervention was conducted in healthy middle-aged men at high risk of coronary heart disease to compare the effects on coronary heart disease incidence of diet and antismoking advice versus control (no intervention). A significant reduction (47%) in first myocardial infarction incidence was observed. We have followed mortality up to 40 years to establish whether a lifelong benefit on mortality risk of myocardial infarction could be observed.

METHODS

In the present study, a total of 16 203 men (63% of those invited), aged 40-49 years, participated in a screening examination. Overall, 1232 men with total serum cholesterol levels of 6.9-8.9 mmol L(-1) (80% smokers) were included in the study. The dietary intervention consisted of mainly decreasing the intake of saturated fats and increasing fish and vegetable products, as well as weight reduction in overweight subjects. Smokers were advised to stop smoking. Cox regression analysis was used for statistical analyses.

RESULTS

The intervention group showed a sustained reduced risk of death at first myocardial infarction (hazard ratio 0.71, 95% confidence interval 0.51-1.00; P = 0.049), compared to control subjects up to 40 years. During follow-up, the beneficial effect developed gradually but proportionally up to about 15 years after randomization. Later, the curves were parallel. All-cause mortality decreased in the period 8-20 years after randomization, but not thereafter.

CONCLUSIONS

Receiving advice about a healthy lifestyle led to a long-term reduced risk of coronary mortality during the following 40 years. Our results suggest that systematically providing effective counselling for a healthy lifestyle for 5 years can lead to lifelong benefits.

Rosuvastatin-Induced Carotid Plaque Regression in Patients With Inflammatory Joint Diseases: The Rosuvastatin in Rheumatoid Arthritis, Ankylosing Spondylitis and Other Inflammatory Joint Diseases Study

OBJECTIVE

Patients with rheumatoid arthritis (RA) and carotid artery plaques have an increased risk of acute coronary syndromes. Statin treatment with the goal of achieving a low-density lipoprotein (LDL) cholesterol level of ≤1.8 mmoles/liter (≤70 mg/dl) is recommended for individuals in the general population who have carotid plaques. The aim of the ROsuvastatin in Rheumatoid Arthritis, Ankylosing Spondylitis and other inflammatory joint diseases (RORA-AS) study was to evaluate the effect of 18 months of intensive lipid-lowering treatment with rosuvastatin with regard to change in carotid plaque height.

METHODS

Eighty-six patients (60.5% of whom were female) with carotid plaques and inflammatory joint disease (55 with RA, 21 with AS, and 10 with psoriatic arthritis) were treated with rosuvastatin to obtain the LDL cholesterol goal. Carotid plaque height was evaluated by B-mode ultrasonography.

RESULTS

The mean ± SD age of the patients was 60.8 ± 8.5 years, and the median compliance with rosuvastatin treatment was 97.9% (interquartile range [IQR] 96.0-99.4). At baseline, the median number and height of the carotid plaques were 1.0 (range 1-8) and 1.80 mm (IQR 1.60-2.10), respectively. The mean ± SD change in carotid plaque height after 18 months of treatment with rosuvastatin was -0.19 ± 0.35 mm (P < 0.0001). The mean ± SD baseline LDL cholesterol level was 4.0 ± 0.9 mmoles/liter (154.7 ± 34.8 mg/dl), and the mean reduction in the LDL cholesterol level was -2.3 mmoles/liter (95% confidence interval [95% CI] -2.48, -2.15) (-88.9 mg/dl [95% CI -95.9, -83.1]). The mean ± SD LDL cholesterol level during the 18 months of rosuvastatin treatment was 1.7 ± 0.4 mmoles/liter (area under the curve). After adjustment for age/sex/blood pressure, no linear relationship between a reduction in carotid plaque height and the level of LDL cholesterol exposure during the study period was observed. Attainment of the LDL cholesterol goal of ≤1.8 mmoles/liter (≤70 mg/dl) or the amount of change in the LDL cholesterol level during the study period did not influence the degree of carotid plaque height reduction.

CONCLUSION

Intensive lipid-lowering treatment with rosuvastatin induced atherosclerotic regression and reduced the LDL cholesterol level significantly in patients with inflammatory joint disease.

High-intensity training following lung cancer surgery: a randomised controlled trial

BACKGROUND

Many patients with lung cancer are deconditioned with poor physical fitness. Lung resection reduces physical fitness further, impairing the patient's ability to function in daily life.

METHODS

We conducted a single-blind randomised controlled trial of high-intensity endurance and strength training (60 min, three times a week, 20 weeks), starting 5-7 weeks after surgery. The control group received standard postoperative care. The primary outcome was the change in peak oxygen uptake measured directly during walking until exhaustion. Other outcomes included changes in pulmonary function, muscular strength by one-repetition maximum (1RM), total muscle mass measured by dual energy X-ray absorptiometry, daily physical functioning and quality of life (QoL).

RESULTS

The intention-to-treat analysis of the 61 randomised patients showed that the exercise group had a greater increase in peak oxygen uptake (3.4 mL/kg/min between-group difference, p=0.002), carbon monoxide transfer factor (Tlco) (5.2% predicted, p=0.007), 1RM leg press (29.5 kg, p<0.001), chair stand (2.1 times p<0.001), stair run (4.3 steps, p=0.002) and total muscle mass (1.36 kg, p=0.012) compared with the controls. The mean±SD QoL (SF-36) physical component summary score was 51.8±5.5 and 43.3±11.3 (p=0.006), and the mental component summary score was 55.5±5.3 and 46.6±14.0 (p=0.015) in the exercise and control groups, respectively.

CONCLUSIONS

In patients recently operated for lung cancer, high-intensity endurance and strength training was well tolerated and induced clinically significant improvements in peak oxygen uptake, Tlco, muscular strength, total muscle mass, functional fitness and QoL. This study may provide a basis for exercise therapy after lung cancer surgery.

TRIAL REGISTRATION NUMBER

NCT01748981.

Objectively recorded physical activity and the association with gestational diabetes

The aim of this population-based study was to assess the association between objectively recorded physical activity (PA) in early gestation and gestational diabetes mellitus (GDM) identified at 28 weeks of gestation in a multi-ethnic cohort of healthy pregnant women in Oslo, Norway. In total, 759 women were included. In early gestation (<20 weeks), light-, moderate-, and vigorous-intensity PA and number of steps were objectively recorded (SenseWear™ Armband Pro3), and self-reported PA, demographics, and anthropometrics were collected. The 75-g oral glucose tolerance test was performed at 28 weeks of gestation. Women with GDM had fewer objectively recorded steps (mean 7964 steps/day vs 8879 steps/day, P < 0.001) and minutes of moderate-to-vigorous-intensity PA (median 62 min/day vs 75 min/day, P = 0.004) in early gestation than women without GDM. Additionally, 30% of women with GDM compared with 44% (P < 0.001) of women without GDM self-reported regular PA before pregnancy. The significant inverse association between objectively recorded steps per day in early gestation and GDM persisted after adjustment for ethnic origin, weeks of gestation, age, parity, pre-pregnancy BMI, early life socioeconomic position, and self-reported regular PA before pregnancy. The adjusted odds ratio for GDM decreased 19% per standard deviation (3159 steps) increase in objectively recorded steps per day (P = 0.039). Daily life PA in early gestation measured as steps/day was associated with lower risk of GDM.

Assessment of volar angulation and shortening in 5th metacarpal neck fractures: an inter- and intra-observer validity and reliability study

Four methods for measuring volar angulation in 5th metacarpal neck fractures were tested for validity and reliability. Mid-medullary canal measurement in the lateral view (method MC-90) has previously been proven valid in a cadaveric study, hence used as a reference to test validity of the latter three. These three yielded a significant different mean fracture angle compared with MC-90, with only minor enhancement in reliability. Therefore, none of these three methods is recommended as a better standard method than the MC-90, where reliability was found to be substantial (intraclass correlation coefficient 0.53-0.81). Two methods for measuring shortening in 5th metacarpal neck fractures were compared, and stipulation of shortening by drawing a line through the most distal point of the heads of the neighbouring 3rd and 4th metacarpals (method SH-Stip) is a simple method with excellent reliability (intraclass correlation coefficient 0.81-0.96) for estimating shortening, requiring only radiological examination of the injured hand.

Prognostic model for total mortality in patients with haemodialysis from the Assessments of Survival and Cardiovascular Events (AURORA) study

OBJECTIVES

Risk factors of mortality in patients with haemodialysis (HD) have been identified in several studies, but few prognostic models have been developed with assessments of calibration and discrimination abilities. We used the database of the Assessment of Survival and Cardiovascular Events study to develop a prognostic model of mortality over 3-4 years.

METHODS

Five factors (age, albumin, C-reactive protein, history of cardiovascular disease and diabetes) were selected from experience and forced into the regression equation. In a 67% random try-out sample of patients, no further factors amongst 24 candidates added significance (P < 0.01) to mortality outcome as assessed by Cox regression modelling, and individual probabilities of death were estimated in the try-out and test samples. Calibration was explored by calculating the prognostic index with regression coefficients from the try-out sample to patients in the 33% test sample. Discrimination was assessed by receiver operating characteristic (ROC) areas.

RESULTS

The strongest prognostic factor in the try-out sample was age, with small differences between the other four factors. Calibration in the test sample was good when the calculated number of deaths was multiplied by a constant of 1.33. The five-factor model discriminated reasonably well between deceased and surviving patients in both the try-out and test samples with an ROC area of about 0.73.

CONCLUSIONS

A model consisting of five factors can be used to estimate and stratify the probability of death for individuals The model is most useful for long-term prognosis in an HD population with survival prospects of more than 1 year.

Lipids, myocardial infarction and ischaemic stroke in patients with rheumatoid arthritis in the Apolipoprotein-related Mortality RISk (AMORIS) Study

Objectives

To examine the rates of acute myocardial infarction (AMI) and ischaemic stroke (IS) and to examine the predictive value of total cholesterol (TC) and triglycerides (TG) for AMI and IS in patients with rheumatoid arthritis (RA) and people without RA.

Methods

In the Apolipoprotein MOrtality RISk (AMORIS) Study 480 406 people (including 1779 with RA, of whom 214 had an AMI and 165 an IS) were followed for 11.8 (range 7–17) years. Cox regression analysis was used to calculate HR per SD increase in TC or TG with 95% CI. All values were adjusted for age, diabetes and hypertension.

Results

The levels of TC and TG were significantly lower in patients with RA than in people without RA. Despite this, the rate of AMI and IS per 1000 years was at least 1.6 times higher in RA than non-RA. TC was nearly significantly predictive for AMI (HR/SD 1.13 (95% CI 0.99 to 1.29), p=0.07) and significantly predictive for future IS in RA (HR/SD 1.20 (95% CI 1.03 to 1.40), p=0.02). TG had no relationship to development of AMI (1.07, 0.94 to 1.21, p=0.29), but was weakly related to IS (1.13, 0.99 to 1.27, p=0.06). In contrast, both TC and TG were significant predictors of AMI and IS in people without RA.

Conclusions

Patients with RA had 1.6 times higher rate of AMI and IS than people without RA. TC and TG were significant predictors of AMI and IS in people without RA, whereas the predictive value in RA was not consistent.

Cardiovascular outcomes and their relationships to lipoprotein components in patients with and without chronic kidney disease: results from the IDEAL trial

OBJECTIVES

In Incremental Decrease in Endpoints through Aggressive Lipid-lowering (IDEAL), we compared cardiovascular outcomes in patients with and without chronic kidney disease (CKD) (estimated glomerular filtration rate <60 mL min(-1) 1.73 m(-2)) and analysed relationships between lipoprotein components (LC) and major coronary events (MCE) and other cardiovascular (CV) events.

DESIGN

Exploratory analysis of CV endpoints in a randomized trial comparing high dose of atorvastatin to usual dose of simvastatin on MCE.

SETTINGS

Patients with CKD were compared with the non-CKD patients. Cox regression models were used to study the relationships between on-treatment levels of LC and incident MCE.

FINDINGS

Chronic kidney disease was strongly associated with cardiovascular end-points including total mortality. In patients with CKD, a significant benefit of high dose atorvastatin treatment was found for any CV events, stroke and peripheral artery disease, but not for MCE. However, all cardiovascular end-points except stroke and CV mortality were reduced in the non-CKD group. Differential changes in LC or relationships to LC could not explain the different treatment outcomes in MCE in the two groups.

INTERPRETATION

Chronic kidney disease was a powerful risk factor for all cardiovascular end-points. The reason why the significant reductions achieved by high-dose statin treatment in most CV end-points in the non-CKD group were only in part matched by similar reductions in the CKD patients is not apparent. This difference did not result from differential changes in or relations to LC, but limited power may have increased the possibility of chance findings.

Plant sterols from rapeseed and tall oils: effects on lipids, fat-soluble vitamins and plant sterol concentrations

BACKGROUND AND AIMS

Data comparing the impact of different sources of plant sterols on CVD risk factors and antioxidant levels is scarce. We evaluated the effects of plant sterols from rapeseed and tall oils on serum lipids, lipoproteins, fat-soluble vitamins and plant sterol concentrations.

METHODS AND RESULTS

This was a double-blinded, randomized, crossover trial in which 59 hypercholesterolemic subjects consumed 25 g/day of margarine for 4 weeks separated by 1 week washout periods. The two experimental margarines provided 2g/day of plant sterols from rapeseed or tall oil. The control margarine had no added plant sterols. The control margarine reduced LDL cholesterol by 4.5% (95% CI 1.4, 7.6%). The tall and rapeseed sterol margarines additionally reduced LDL cholesterol by 9.0% (95% CI 5.5, 12.4%) and 8.2% (95% CI 5.2, 11.4%) and apolipoprotein B by 5.3% (95% CI 1.0, 9.6%) and 6.9% (95% CI 3.6, 10.2%), respectively. Lipid-adjusted beta-carotene concentrations were reduced by both sterol margarines (P<0.017). alpha-Tocopherol concentrations were reduced by the tall sterol compared to the rapeseed sterol margarine (P=0.001). Campesterol concentrations increased more markedly with the rapeseed sterol versus tall sterol margarine (P<0.001). The rapeseed sterol margarine increased while the tall sterol margarine decreased brassicasterol concentrations (P<0.001).

CONCLUSIONS

Plant sterols from tall and rapeseed oils reduce atherogenic lipids and lipoproteins similarly. The rapeseed sterol margarine may have more favorable effects on serum alpha-tocopherol concentrations.

Effects of a low glycemic load diet versus a low-fat diet in subjects with and without the metabolic syndrome

BACKGROUND AND AIM

Although many studies report benefits of low glycemic diets, the clinical effects as a whole are mixed. The study aim was to compare a low glycemic load (LGL) diet versus a low-fat diet in a trial with a moderately intense dietary intervention in subjects with varying degrees of metabolic syndrome.

METHODS AND RESULTS

Men and women aged 30-65 years, with a BMI of 28-40 kg/m(2) (28-35 for women) and at least one criterion of metabolic syndrome were randomized to the two diets. A total of 202 subjects were included, of which 126 (62%) had metabolic syndrome (>or=3 criteria). The completion rate was 81%. At 3 months, weight loss was greater in the LGL group (-4.8+/-3.9 kg versus -3.8+/-3.5 kg; P=0.06) compared to the low-fat group. At 1 year, however, weight loss was similar in both groups (-4.0+/-5.5 kg versus -4.3+/-6.2 kg; n.s.), but waist circumference reduction was less in the LGL group (-3.9+/-5.3 cm versus -5.8+/-6.8 cm; P=0.03). In contrast, diastolic blood pressure decreased significantly more in the LGL group (-4.0+/-8.7 mmHg versus -1.1+/-8.5 mmHg; P=0.02). We also observed a significant interaction between the presence of the metabolic syndrome and the effect of the two diets on waist circumference, with a less favorable effect of the LGL diet in subjects without the syndrome (P=0.039).

CONCLUSION

After 12 months, both diets reduced body weight and the metabolic disturbances similarly, but the LGL diet appeared more suitable for subjects with metabolic syndrome, and was less effective in those without it.

Uric acid and risk of myocardial infarction, stroke and congestive heart failure in 417,734 men and women in the Apolipoprotein MOrtality RISk study (AMORIS)

OBJECTIVES

Few studies have simultaneously analysed the influence of elevated serum uric acid (UA) on acute myocardial infarction (AMI), ischaemic and haemorrhagic stroke (IS, HS) and congestive heart failure (CHF) in large healthy populations. We, here, examine UA as a risk factor for AMI, stroke and CHF by age and gender in the Apolipoprotein MOrtality RISk (AMORIS) Study.

DESIGN

Prospective study (11.8 years, range 7-17) of fatal and nonfatal acute myocardial infarction, stroke and CHF through linkage with Swedish hospital discharge and mortality registers.

SETTINGS

Measurements of uric acid in 417,734 men and women from health check-ups in Stockholm area.

RESULTS

There was a gradual increase in risk of AMI, stroke and CHF by increasing UA levels. Women had a stronger relationship between UA and both AMI and IS than men. Predictions of AMI were at least as powerful in the elderly as in the young, but not so for IS. Associations were markedly attenuated when adjusted for total cholesterol, triglycerides, hospital hypertension and diabetes status. The association between UA and HS was U-shaped in both genders. CHF was more strongly related to UA than AMI and stroke and less affected by the adjustment factors.

CONCLUSIONS

Already moderate levels of UA appear to be associated with an increased incidence of AMI, stroke and CHF in middle-aged subjects without prior cardiovascular disease. These associations seem to increase gradually from lower to higher levels of UA. UA may be an important complementary indicator of cardiovascular risk in the general population.

A 24-week multicenter double-blind study of doxazosin and hydrochlorothiazide in patients with mild to moderate essential hypertension

The new alpha1-adrenoceptor antagonist, doxazosin (DOX), was compared with hydrochlorothiazide (HCTZ), both drugs administered once daily, in a randomized double-blind study including 115 patients. The mean final daily doses used were DOX, 10.8 mg; HCTZ, 89.1 mg. There were no statistically significant differences between treatment groups for blood pressure (BP) changes except that HCTZ produced a significantly greater fall (p = 0.04) in supine systolic BP than DOX. The statistically significant mean differences in changes in lipid parameters (total cholesterol and total triglycerides) were in favour of DOX. The number of patients reporting side-effects were DOX, 27/57; HCTZ, 29/53, with two DOX- and five HCTZ-treated patients withdrawn due to side-effects. In the HCTZ-treated group, laboratory serum tests indicated 11 patients with abnormally low potassium and seven with abnormally high uric acid concentrations. The overall results suggest a benefit-to-risk ratio in favour of DOX.

Increased fibrinolytic potential after diet intervention in healthy coronary high-risk individuals

Twenty healthy individuals (15 men and 5 women) with initial fasting serum triglycerides greater than or equal to 1.80 mmol/l and euglobulin clot lysis time after venous occlusion greater than or equal to 60 min (upper normal limit 45 min) were tested for fibrinolytic response to venous occlusion and intravenous injection of desmopressin (DDAVP), serum lipids, serum glucose and relative body weight before and after a minimum of 3 to a maximum of 12 months' diet intervention. In order to be defined as a good diet responder, at least 20% reduction of the initial serum triglyceride concentration was required. At the end of the study, half of the participants (7 men and 3 women) met the criteria of good diet responders. All of these showed an improved fibrinolytic response to DDAVP injection, and 7 out of 10 had a normalized fibrinolytic response to venous occlusion. We conclude that, through dietary measures with substantial reduction of hypertriglyceridaemia, it is possible to improve and even normalize the fibrinolytic potential.

Physical activity at work and at leisure in relation to coronary risk factors and social class. A 4-year mortality follow-up. The Oslo study

The association between physical activity at work and at leisure, coronary risk factors, social class and mortality has been studied in about 15000 Oslo men, aged 40-49, without known cardiovascular disease or diabetes at a screening examination for coronary risk factors. Four-year total and CHD mortality showed a decrease with increasing degree of leisure activity, and an increase with increasing work activity. The three conventional coronary risk factors--serum cholesterol, systolic blood pressure (SBP) and number of cigarettes--associated negatively with physical leisure activity, whereas they all associated positively with physical activity at work. Men in lower social classes were less active at leisure but more active at work than men in the higher classes. In a multivariate analysis of variance with coronary risk score (based on SBP, serum total cholesterol and number of cigarettes), social class and physical activity, the predictive power of physical leisure activity for future death was almost as good as the coronary risk score. Physical activity at work, on the other hand, was not an independent risk factor either for total or for CHD mortality.

Socio-economic status as a coronary risk factor: the Oslo study

The association between socioeconomic status, measured by a combination of income and education, and CHD mortality has been studied in a cohort of 40-49 year old Oslo men. Socio-economic status was significantly associated with CHD mortality. However, the lowest CHD mortality was found in social status Group III (middle class) and this could not be explained by the risk factor gradients seen among those studied. Although the number of fatalities is small (68 CHD deaths during 4.5 years) socio-economic status seems to be independently associated with coronary risk after adjusting for serum cholesterol, systolic blood pressure and cigarette smoking.

Five-year mortality in the city of Bergen, Norway, according to age, sex and blood pressure

The City of Bergen was covered by a Mass Miniature Radiology Survey in 1963-64. On the initiative of the University of Bergen, examinations of BP were included. The initial survey has been reported previously (1). This analysis concerns the relationship between the 5 1/4-year cause-specific mortality and BP. Non-attenders have excess mortality in relation to attenders and this is mostly explained by a generally high mortality among bedridden people. The age-specific total mortality shows a clear pattern of a general increase with increasing BP. At high systolic BP levels, the 5-year mortality is independent of whether the age is 45 or 75. The systolic age-adjusted curve for males increases quite linearly, while the diastolic curve is more U-shaped. Thus, when comparing the predictive power of BP, allowance must be made for this fact. Using a second order polynomial prediction function, this conclusion is reversed. The mortality from cerebral stroke shows a dramatic increase with increasing BP. The diastolic curve shows a bend-off for high values, above 110 mmHg. This may be due to the offer of treatment which such patients received after the screening. Also the CHD mortality curve flattens for high BP values, especially for diastolic BP.

A randomized, multicentre, double-blind, parallel-group study to assess the adverse event-related discontinuation rate with celecoxib and diclofenac in elderly patients with osteoarthritis

OBJECTIVE

To compare the adverse event (AE)-related discontinuation rate with celecoxib vs. diclofenac when given to reduce joint pain associated with knee or hip osteoarthritis (OA) in elderly patients.

METHODS

This was a double-blind, randomized, multicentre, parallel-group, 1-year comparison of celecoxib 200 mg once daily and diclofenac 50 mg twice daily in 925 patients with OA aged > or = 60 years. Study visits were at baseline and at 4, 13, 26, 39, and 52 weeks. At each visit, the Patient's and Physician's Global Assessment of Arthritis (PaGAA, PhGAA), the Patient's Assessment of Arthritis Pain--Visual Analogue Scale (PAAP-VAS), and AEs were assessed. A concomitant health economic analysis was conducted throughout.

RESULTS

The rate of study discontinuation due to AEs, laboratory abnormalities, and deaths was 27% for celecoxib and 31% for diclofenac (p = 0.22). The results of the arthritis/pain efficacy assessments were similar for celecoxib and diclofenac. Significantly fewer patients in the celecoxib group than the diclofenac group experienced cardiovascular/renal AEs (70/458 vs. 95/458, p = 0.039) or hepatic AEs (10/458 vs. 39/458, p<0.0001). Medication costs were higher for celecoxib than diclofenac but mean total treatment cost was slightly higher in the diclofenac group.

CONCLUSION

Treatment with celecoxib 200 mg once daily and diclofenac 50 mg twice daily resulted in similar rates of AE-related study discontinuation in elderly patients with OA. Celecoxib and diclofenac demonstrated comparable efficacy in relieving the signs and symptoms of OA. However, the proportion of patients with cardiorenal and hepatic AEs was significantly lower in the celecoxib group than the diclofenac group.

Relationships between lipoprotein components and risk of ischaemic and haemorrhagic stroke in the Apolipoprotein MOrtality RISk study (AMORIS)

OBJECTIVES

To compare lipoprotein components associated with ischaemic and haemorrhagic stroke by age and gender in the Apolipoprotein MOrtality RISk (AMORIS) Study (n=148 600).

DESIGN

Prospective follow-up study (11.8, range 7-17 years) of fatal and nonfatal ischaemic and haemorrhagic stroke through linkage with Swedish hospital discharge and mortality registers.

SETTING

Measurements of lipoprotein components from health check-ups in the larger Stockholm area.

RESULTS

Ischaemic stroke was more common than haemorrhagic stroke (5 :1), but case fatality was higher in haemorrhagic stroke. An elevated apoB/apoA-1 ratio and triglycerides, non-HDL cholesterol, low HDL cholesterol, and the total cholesterol to high-density cholesterol (TC/HDL-C) ratio were associated with increased incidence of nonfatal and fatal ischaemic stroke as well as all cerebrovascular events (n=7480) in both genders. The associations were somewhat stronger for nonfatal than fatal events. In ischaemic stroke the apoB/apoA-1 ratio was a stronger predictor than the TC/HDL-C ratio in all subjects, in those below 65 years of age and in those with LDL-C below 3 mmol L(-1). Haemorrhagic stroke was not associated with elevated atherogenic lipoproteins except for increased risk of fatal haemorrhagic stroke in women with a high apoB/apoA-I ratio.

CONCLUSIONS

Dyslipidaemia is associated with an increased risk of ischaemic stroke but few relations were seen in haemorrhagic stroke. Use of the apoB/apoA-I ratio as a marker of dyslipidaemia is at least as efficient as conventional lipids, for the identification of subjects at increased risk of stroke, especially ischaemic stroke. Practical advantages, fasting is not needed, speak in favour of using apoB and apoA-1 in stroke risk prediction.

Relationships between lipoprotein components and risk of myocardial infarction: age, gender and short versus longer follow-up periods in the Apolipoprotein MOrtality RISk study (AMORIS)

OBJECTIVES

Examine and compare lipoprotein components associated with fatal and nonfatal acute myocardial infarction (AMI) by time period in the Apolipoprotein MOrtality RISk (AMORIS) Study.

DESIGN

Prospective follow-up study of nonfatal and fatal myocardial infarction through linkage with Swedish hospital discharge and Swedish mortality registers.

SETTING

Measurements of lipoprotein components from health check-ups in the larger Stockholm area.

SUBJECTS

The AMORIS subjects (n = 149 121) free of AMI at blood sampling were followed from 1985 to 2002 with respect to n = 6794 first cases of AMI.

RESULTS

Hazard ratios of nonfatal and fatal AMI by lipoprotein parameters were highly significant and about equally strong in both genders. Apolipoprotein B (apoB), nonhigh density cholesterol and low density cholesterol predicted nonfatal AMI (NFAMI) better than fatal AMI, but high density cholesterol or apolipoprotein A-1 did not. Atherogenic components were weaker predictors after 1997 than before. In multivariate analyses apoB/apoA-1 was a better predictor than TC/HDL-C. ApoB/apoA-1 added clinically significant information to TC/HDL-C in men as reflected by a net reclassification improvement (NRI) of 9.4% (P < 0.0001).

CONCLUSION

ApoB, apoB/apoA-1 and non-HDL-C were found about equally predictive with LDL-C being slightly less, but multivariate analyses showed apoB/apoA-1 to be the strongest predictor. Attenuation of prediction ability between nonfatal and fatal AMI may be due to modern treatment of CHD after a NFAMI and attenuation of hazard ratios after 1997 may be due to selection of lower risk subjects surviving to 1997.

Changes in physical activity behavior and the development of body mass index during the last 30 years in Norway

Body mass index (BMI; kg/m(2)) has increased markedly in the last decades. We hypothesized that highly physically active persons both at work and at leisure would be resistant to weight gain. The hypothesis was tested by analyzing Norwegian cross-sectional data collected in the period 1972-2002. Participants were 214,449 men and 206,136 women (aged 20-70 years). During the last 30 years in men and the last 15 years in women, a systematic larger BMI increase per year was observed in the sedentary [regression coefficients (SE) in men 0.060 (0.004) kg/m(2) and women 0.137 (0.012) kg/m(2)] compared with highly physically active groups [regression coefficients (SE) in men 0.036 (0.00 4) kg/m(2), and in women -0.001 (0.039) kg/m(2)]. Analyses were robust to adjustments for age, smoking and education. There was a larger absolute net increase in the prevalence of obesity among the sedentary compared with persons performing light, moderate or heavy physical activity (PA) at leisure. PA level in women both at work and in leisure was not associated with weight gain during the last decades. This association was less evident among men. Men and women who were lightly, moderately or highly active at leisure were less likely to be obese compared with those who were sedentary.

Preventing injuries in female youth football--a cluster-randomized controlled trial

A set of exercises--the "11"--have been selected to prevent football injuries. The purpose of this cluster-randomized controlled trial was to investigate the effect of the "11" on injury risk in female youth football. Teams were randomized to an intervention (n=59 teams, 1091 players) or a control group (n=54 teams, 1001 players). The intervention group was taught the "11," exercises for core stability, lower extremity strength, neuromuscular control and agility, to be used as a 15-min warm-up program for football training over an 8-month season. A total of 396 players (20%) sustained 483 injuries. No difference was observed in the overall injury rate between the intervention (3.6 injuries/1000 h, confidence interval (CI) 3.2-4.1) and control group (3.7, CI 3.2-4.1; RR=1.0, CI 0.8-1.2; P=0.94) nor in the incidence for any type of injury. During the first 4 months of the season, the training program was used during 60% of the football training sessions, but only 14 out of 58 intervention teams completed more than 20 prevention training sessions. In conclusion, we observed no effect of the injury prevention program on the injury rate, most likely because the compliance with the program was low.

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.

ApoB but not LDL-cholesterol is reduced by exercise training in overweight healthy men. Results from the 1-year randomized Oslo Diet and Exercise Study

OBJECTIVES

(i) To estimate changes in apoB and apoB/apoA-I, reflecting the balance between atherogenic and anti-atherogenic lipoprotein particles, by exercise training and compare with changes in LDL-C and TC/HDL-C ratio, and (ii) To compare strengths of relationships between physical fitness and various lipoprotein variables.

DESIGN, SETTING, AND SUBJECTS

The study was a 1-year open randomized trial comprising 219 healthy middle-aged subjects aged 40-49 years who were allocated to exercise or no exercise, dietary advice or no advice in a 2 x 2 factorial design. This study includes 188 men who completed the trial, 45 to diet, 48 to exercise, 58 to diet + exercise and 37 to control.

INTERVENTIONS

Exercise; supervised endurance exercise three times a week. Diet; reduce weight, increase intake of fish and reduce total fat intake.

MAIN OUTCOME MEASURE

One-year change in apoB and apoB/apoA-I ratio.

RESULTS

Exercisers decreased their ApoB and ApoB/ApoA-I values significantly compared to non-exercisers. LDL-C was not, but LDL-C/HDL-C was marginally but statistically significantly reduced by exercise. One-year change in ApoB and ApoB/ApoA-I correlated more strongly to 1-year changes in physical fitness than LDL-C or LDL-C/HDL-C. Adjusting for changes in LDL-C or LDL-C/HDL-C did not influence the correlation between changes in fitness and ApoB or ApoB/ApoA-I. However, adjusting for changes in ApoB or ApoB/ApoA-I wiped out the correlation between change in fitness and LDL-C or LDL-C/HDL-C. Relationships weakened when adjusting for changes in waist circumference, but Apo B or ApoB/ApoA-I still correlated significantly to changes in fitness.

CONCLUSION

Physical exercise reduced the atherogenic burden as experienced by the reduction in apoB or apoB/apoA-I levels, but not by LDL-C in healthy middle-aged men. Possibly, regular physical activity might increase the LDL-C particle size, thereby making LDL less atherogenic. Monitoring of apolipoproteins rather than the cholesterol moiety of lipoproteins might improve the assessment of lipoprotein changes after exercise training.