OP0277 PERSISTENT EXCESS OF STROKE EVENTS IN RHEUMATOID ARTHRITIS: A RETROSPECTIVE COHORT STUDY FROM HORDALAND, NORWAY FROM 1972 TO 2014

Background

Patients with rheumatoid arthritis (RA) have an excess risk of cardiovascular disease (CVD), including stroke [1]. After the introduction of biological DMARDs in 1999 and the treat to target strategy, more patients reach low disease activity and remission, which is associated with lower CVD risk [2]. Few previous studies have examined stroke occurrence in RA patients before and after these improvements in RA management.

Objectives

To investigate stroke events in RA patients diagnosed before and after 1999 compared with the total population.

Methods

We included 771 RA patients diagnosed during 1972-1998 and 1050 during 1999-2013 at the main rheumatological department of Hordaland county, Norway. The total population of the same county and time period were used as a comparison cohort. Data on stroke events were obtained from regional cardiovascular registries or hospital patient administrative systems during 1972-2014. Aggregated counts of stroke events and population counts from the comparison cohort were used to estimate expected counts of stroke hospitalisation in the RA cohort per 5-year age group, sex and calendar year. We then estimated standardised event ratios (SERs) by Poisson regression as a measure of excess stroke events in RA patients compared with the total population.

Results

In total, 152 stroke events occurred in 112 RA patients diagnosed during 1972-1998 over 15137 person-years of follow-up and 86 stroke events in 70 RA patients diagnosed during 1999-2013 over 8672 person-years of follow-up. RA patients diagnosed in the later period were on average 2.1 years older (56 years) at RA diagnosis, but the proportion of women was similar in both groups.

Both RA patients diagnosed before and after 1998 had an excess of stroke events compared with the total population (SER 1.20, 95% CI 1.00-1.44 and SER 1.22, 95% CI 1.05-1.42 respectively). RA patients younger than 60 years of age did not appear to have significant excess stroke events in either group.

Conclusion

These results indicate a similar excess of stroke events in RA patients diagnosed before and after 1999. This warrants continued awareness regarding stroke prevention in RA patients, even after the recent improvements in RA treatment.

References

[1]Wiseman SJ, Ralston SH, Wardlaw JM. Cerebrovascular Disease in Rheumatic Diseases: A Systematic Review and Meta-Analysis. Stroke 2016;47:943–50.

[2]Myasoedova E, Chandran A, Ilhan B, et al. The role of rheumatoid arthritis (RA) flare and cumulative burden of RA severity in the risk of cardiovascular disease. Ann Rheum Dis 2016;75:560–5.

Figure 1.

Standardised event ratios (SER) comparing stroke events in RA patients with the total population of Hordaland, Norway, given with 95% robust confidence intervals. Seperate estimates were calculated for the entire RA cohort and 6 RA subcohorts defined by age, sex, positive rheumatoid factor or ACPA and arthritis on x-ray during follow-up. ACPA, anti-citrullinated protein antibodies; ACR, American College of Rheumatology; EULAR, European League against Rheumatism; RA, rheumatoid arthritis; RF, rheumatoid factor.

Acknowledgements

This work was funded by the Western Norway Regional Health Authority, Marit Hansen’s Memorial fund and Aslaug Andersen’s Memorial fund.

Disclosure of Interests

Christian Lillebø Alsing: None declared, Jannicke Igland: None declared, Grethe S. Tell: None declared, Halvor Næss Speakers bureau: Pfizer, BMS, Tone Wikene Nystad: None declared, Bjørg Tilde Svanes Fevang Speakers bureau: Part of discussion board at UCB conference on spondyloarthritis, Consultant of: Part of advisory board Lilly

POS0580 TRENDS IN THE OCCURRENCE OF ISCHEMIC HEART DISEASE OVER TIME IN RHEUMATOID ARTHRITIS: A RETROSPECTIVE COHORT STUDY FROM NORWAY OF 1821 PATIENTS FROM 1972 TO 2014

Background

Previous studies have shown that rheumatoid arthritis is associated with a 1.5 to 2.0 times increased risk of acute myocardial infarction (AMI) and ischemic heart disease (IHD) compared with the general population [1,2]. RA treatment has improved vastly over the last two decades, due to the focus on early and aggressive treatment and the use of synthetic and biologic DMARDs. Several studies have documented higher rates of remission and better long-term outcomes in patients with early introduction of DMARDs [3]. This “window of opportunity” may also be a critical phase for intervention against the development of atherosclerosis in RA. There is little information about the occurrence of AMI and IHD in RA patients diagnosed after the introduction of modern RA treatment.

Objectives

To evaluate trends of AMI and IHD in RA patients compared with the general population over time.

Methods

We performed a retrospective cohort study of 1821 RA patients diagnosed from 1972 to 2013. The total population of Hordaland, Norway was used as a comparison cohort. Information on AMI and IHD events was obtained from hospital patient administrative systems or cardiovascular registries during 1972-2014. Aggregated counts of AMI, IHD and population counts of the comparison cohort were used to calculate expected counts of AMI and IHD in the RA cohort per 5-year age group, sex and calendar year. We then used Poisson regression with expected counts as an offset to estimate standardized event ratios (SER) as a measure of excess events.

Results

The difference in events (excess events) in RA patients compared with the general population declined on average 1.3% per year for AMI and 2.3% for IHD from 1972 to 2014. There was no significant excess AMI (SER 1.05, 95% CI 0.82–1.35) and IHD events (SER 1.02, 95% CI, 0.89–1.16) for RA patients diagnosed after 1998 compared with the general population.

Conclusion

RA patients have historically had an excess risk of IHD compared with the general population. Our study did not find excess AMI or IHD events in RA patients diagnosed after 1998. Our findings may reflect improved management of RA, CVD prevention or changes in the case-mix of RA patients over time.

References

[1]Schieir O, Tosevski C, Glazier RH, et al. Incident myocardial infarction associated with major types of arthritis in the general population: a systematic review and meta-analysis. Ann Rheum Dis 2017;76:1396–404.

[2]Han C, Robinson DW, Hackett MV, et al. Cardiovascular Disease and Risk Factors in Patients With Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis. J Rheumatol 2006;33.https://pubmed.ncbi.nlm.nih.gov/16981296/ (accessed 2 Jul 2020).

[3]Monti S, Montecucco C, Bugatti S, et al. Rheumatoid arthritis treatment: the earlier the better to prevent joint damage. RMD Open 2015;1:e000057.

Figure 1.

Excess AMI and IHD events in RA patients compared with the general population. RA patients are divided into three groups by the time of RA diagnosis. End of follow-up was set to 1 year after the end of each diagnostic period (1986, -99 and 2014 respectively) to allow for equal RA duration between groups. Point estimates are standardized event ratios comparing the number of events in the RA cohort to the expected number of events calculated from reference rates in the general population and standardized for age, sex and year of the event. All estimates are given with robust 95% confidence intervals (CI). Both the RA and general population were obtained from Hordaland, Western Norway. AMI, acute myocardial infarction; IHD, ischemic heart disease.

Acknowledgements

This work was funded by the Western Norway Regional Health Authority, Marit Hansen’s Memorial fund and Aslaug Andersen’s Memorial fund.

Disclosure of Interests

Christian Lillebø Alsing: None declared, Tone Wikene Nystad: None declared, Jannicke Igland: None declared, Clara Gram Gjesdal: None declared, Helga Midtbø: None declared, Grethe S. Tell: None declared, Bjørg Tilde Svanes Fevang Speakers bureau: Part of discussion board at UCB conference on spondyloarthritis, Consultant of: Part of advisory board Lilly.

Trends in the occurrence of ischaemic heart disease over time in rheumatoid arthritis: 1821 patients from 1972 to 2017

OBJECTIVE

To evaluate trends of acute myocardial infarction (AMI) and ischaemic heart disease (IHD) in rheumatoid arthritis (RA) patients compared with the general population over time.

METHOD

We performed a retrospective cohort study of 1821 RA patients diagnosed from 1972 to 2013. Aggregated counts of the total population of the same county (Hordaland, Norway) and period were used for comparison. Information on AMI and IHD events was obtained from hospital patient administrative systems or cardiovascular registries. We estimated incidence rates and excess of events [standardized event ratio (SER) with 95% confidence interval (CI)] compared with the general population by Poisson regression.

RESULTS

There was an average annual decline of 1.6% in age- and gender-adjusted AMI incidence rates from 1972 to 2017 (p < 0.035). The difference in events (excess events) in RA patients compared with the general population declined on average by 1.3% per year for AMI and by 2.3% for IHD from 1972 to 2014. There were no significant excess AMI (SER 1.05, 95% CI 0.82-1.35) or IHD events (SER 1.02, 95% CI 0.89-1.16) for RA patients diagnosed after 1998 compared with the general population.

CONCLUSION

Incidence rates and excess events of AMI and IHD in RA patients declined from 1972 to 2017. There were no excess AMI or IHD events in RA patients diagnosed after 1998 compared with the general population.

Prevalence and incidence rates of atrial fibrillation in Denmark 2004–2018

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with substantial morbidity and mortality. Its prevalence is currently rising partly due to population ageing. However, reported trends in incidence rates are conflicting, and the comparability of existing reports is limited due to methodological inconsistencies across studies.

Purpose

The main purpose of the current study was to investigate the prevalence of AF in the Danish adult population and time trends in incidence rates from 2004 through 2018. As a secondary purpose, the prevalence and incidence were compared to corresponding Norwegian estimates from 2004 through 2014 derived using the same methodology.

Methods

A register-based study was conducted including all individuals aged ≥18 years in Denmark from 2004–2018. AF cases were identified in the National Patient Register and the Cause of Death Register, which comprise information on all hospital contacts and deaths in Denmark, respectively. The prevalence of AF was calculated as the number of individuals alive at the end of the study period with at least one registered diagnosis from 1994 through 2018 divided by the number of Danish residents aged ≥18 years. Incidence rates were calculated as the number of annual AF cases with no previous diagnosis noted in the past 10 years divided by the person-time contributed by the population free of AF on 1 January in the same calendar year. All incidence rates were standardized according to a Nordic standard population. The comparison of the Danish and Norwegian incidence estimates focused solely on AF hospitalizations and deaths from 2004 through 2014.

Results

The cumulative prevalence of AF was 3.0% in the Danish adult population. The incidence increased from 391 per 100,000 person-years in 2004 to 481 per 100,000 person-years in 2015, after which it declined to 367 per 100,000 person-years in 2018 (Figure 1). On average, the incidence increased by 1.7% annually until 2015 (IRR: 1.017 (95% CI: 1.016–1.018); p&lt;0.001) and then declined by 8.5% (IRR: 0.915 (95% CI: 0.909–0.921); p&lt;0.001). Although the incidence rates generally were higher among men and older individuals, a similar time trend was observed in both men and women irrespective of age. Focusing solely on AF hospitalizations and deaths did not change the interpretation of the results. The comparable Norwegian estimates will be presented at the conference.

Conclusions

The prevalence of AF is currently around 3.0% in the Danish adult population, but the incidence rate has declined steeply since 2015. The observed decline in new cases is promising from a public health perspective and its underlying causes warrant further investigation.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation Figure 1

Association of markers of vascular inflammation with blood pressure in midlife: the Hordaland Health Study

Background

Hypertension is a pro-inflammatory condition. A steeper rise in blood pressure (BP) has been observed in middle-aged women than men. However, sex-specific associations of vascular inflammation with midlife BP has not been much explored.

Purpose

To test the association of markers of vascular inflammation, including neopterin, kynurenin:tryptophan ratio (KTR) and high sensitive C-reactive protein (CRP) with BP.

Methods

Circulating levels of neopterin, KTR and CRP were measured in 2042 women and 1646 men aged 47–49 years from the community-based Hordaland Health study. The associations with systolic and diastolic BP were tested in sex-specific linear regression analyses and adjusted for body mass index, serum total- and high-density lipoprotein cholesterol, triglycerides, creatinine, physical activity, daily smoking and diabetes.

Results

Compared to men, women had lower average BP (124/72 vs. 131/78 mmHg, p&lt;0.001), higher plasma neopterin (7.5 vs 7.0 nmol/l, p&lt;0.001) and comparable plasma KTR and serum CRP (both p&gt;0.05). In multivariable analyses 1) higher neopterin was associated with higher diastolic BP in women, but not in men; 2) higher CRP was associated with higher systolic and diastolic BP in women, but not in men; 3) no association of higher KTR with BP was found in either sex (Table 1). A significant sex-interaction between neopterin and diastolic BP was found.

Conclusion

Among participants in the Hordaland Health study, higher circulating levels of neopterin and CRP with higher BP was found among women only, suggesting that vascular inflammation contributes to BP elevation in middle-aged women.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University of Bergen

Is high-normal blood pressure a more important risk factor for cardiovascular disease in women than in men? The Hordaland Health study

Background

Hypertension is a major risk factor for cardiovascular disease (CVD), but the definition of hypertension is currently debated. Little is known about whether high-normal blood pressure (BP) carries a different risk for CVD in women and men.

Purpose

The aim of the current study was to test associations of high-normal BP with CVD in women and men participating in the community-based Hordaland Health Study (HUSK).

Methods

Data from 8252 participants aged 40–43 years (52% women) participating in the HUSK survey in 1992–93 were coupled with hospitalization or death from CVD documented by ICD codes in national registries in the period 1994–2009. Attended BP was measured in accordance with current guidelines. The average of the two last measurements was taken as the clinic BP measure. The cohort was grouped into normal BP (BP&lt;130/85 mmHg), high-normal BP (BP 130–139/85–89 mmHg) and hypertension (BP≥140/90 mmHg or use of antihypertensive drugs). CVD was defined as hospitalization or death from any CVD diagnosis. The association between BP category and CVD was tested in sex-specific Cox regression analyses, using normal BP as the reference group and adjusting for diabetes, smoking, body mass index and total cholesterol.

Results

At baseline, 17% women and 27% men had high-normal BP and 16% women and 32% men had hypertension (both p&lt;0.001 between sexes). During 16 years follow-up, 15% of women and 22% of men experienced hospitalization or death from CVD (p&lt;0.001). A significant sex-interaction of BP group and outcome was found (p&lt;0.05). In multivariable analyses in women, both hypertension and high-normal BP were associated with incident CVD (both p&lt;0.01) independent of confounders (Table). In men, only hypertension was associated with incident CVD in the same model, while high-normal BP was not (p&lt;0.001 and p=0.53, respectively) (Table).

Conclusion

High-normal BP was a more important risk factor for CVD in middle-aged women than men. Our findings challenges whether hypertension-associated CVD risk is optimally detected in women by the current hypertension definition in European guidelines.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): University of Bergen

Time trends in incidence rates of atrial fibrillation-related strokes in Norway 2001–2014: a nationwide analysis using data from the cardiovascular disease in Norway (CVDNOR) project

Background

Stroke incidence rates declined in Norway during 2001 to 2014. Atrial fibrillation (AF) incidence rates were stable in the same period.

Purpose

We aimed to study time trends in incidence (first time) of acute stroke hospitalizations and stroke deaths associated with AF in Norway in the period 2001–2014.

Methods

Nationwide hospital discharge diagnoses in the Cardiovascular Disease in Norway (CVDNOR) database and in the National Patient Registry were linked to the National Cause of Death Registry. All hospitalizations with acute stroke (including ischemic stroke, intracerebral bleeding and unspecified stroke) and out-of-hospital deaths with stroke as underlying cause in individuals 25 years and older were obtained during 1994–2014. Incident stroke was defined as the first hospitalization or out-of-hospital death due to stroke with no hospitalization for acute stroke or stroke sequela the past 7 years. Stroke was defined as AF-related if AF was registered during a hospitalization the past 7 years, or as underlying or contributing cause of death up to 28 days after the stroke hospitalization. Age-standardized incidence rates with 95% confidence intervals (CIs) were calculated using direct standardization to the age-distribution in the Norwegian population per 2001. Age-adjusted average yearly incidence rate ratios (IRR) with 95% CIs were estimated by negative binomial regression analyses.

Results

From 2001 to 2014 we identified 157 580 incident stroke cases of which 38 317 were AF-related. The proportion of incident strokes that were related to AF increased from 20.6% in 2001 to 26.3% in 2014. Age-standardized incidence rates of AF-related strokes per 100,000 person years were stable at 88 (85, 92) in 2001 and 79 (76, 83) in 2014, corresponding to a 0% average yearly change, IRR 1.00 (0.99, 1.00). The age-standardized incidence rates of non-AF-related strokes per 100,000 person years decreased from 334 (328, 341) in 2001 to 214 (209, 219) in 2014, corresponding to a 3% average yearly decrease, IRR 0.97 (0.97, 0.97).

Conclusion

The favourable trend in total stroke incidence rates from 2001 to 2014 does not include AF-related strokes. This may suggest that AF has become accountable for a higher proportion of incident strokes or that AF detection improved over this period.

Figure 1. Age-standardized incidence rates of stroke hospitalizations or out-of-hospital deaths per 100,000 person years (py) by year, illustrated as all strokes (blue horizontal line) and AF-related strokes (red horizontal line/height of red area). The height of the blue area illustrates the rate for non-AF related strokes.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Vestre Viken Hospital Trust (public hospital research fund)

Individuals with familial hypercholesterolemia have increased risk of re-hospitalization after acute myocardial infarction compared with controls

Background and aim

We have previously reported that individuals with familial hypercholesterolemia (FH) have a two-fold increased risk of acute myocardial infarction (AMI) compared with the general population. The consequences of having an AMI on re-hospitalization and mortality are however less known. The aim of the present study was to compare the risk of re-hospitalization with AMI and CHD and risk of mortality after incident (first) AMI-hospitalization between persons with and without FH (controls).

Methods

The original study population comprised 5691 persons diagnosed with FH during 1992–2014 and 119511 age and sex matched controls randomly selected from the general Norwegian population. We identified 221 individuals with FH and 1947 controls with an incident AMI registered in the Norwegian Patient Registry (NPR) or the Cardiovascular Disease in Norway Project during 2001–2017. Persons with incident AMI were followed until December 31st 2017 for re-hospitalization with AMI or coronary heart disease (CHD) registered in the NPR, and for mortality through linkage to the Norwegian Cause of Death Registry. Risk of re-hospitalization was compared with sub-hazard ratios (SHR) from competing risk regression with death as competing event, and mortality was compared using hazard ratios (HR) from Cox regression. All models were adjusted for age.

Results

Risk of re-hospitalization was 2-fold increased both for AMI [SHR=2.53 (95% CI: 1.88–3.41)] and CHD [SHR=1.82 (95% CI: 1.44–2.28)]. However, persons with FH did not have increased 28-day mortality following an incident AMI (HR=1.05 (95% CI: 0.62–1.78), but the longer-term (&gt;28 days) mortality after first AMI was increased in FH [HR=1.45 (95% CI: 1.07–1.95].

Conclusion

This study yields the important finding that persons with FH have increased risk of re-hospitalization of both AMI and CHD after incident AMI. These findings call for more intensive follow-up of individuals with FH after an AMI.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): University of Oslo and Oslo University Hospital

Effect of group treatment on physical inactivity among Syrian refugees. Randomized controlled trial

Background

Refugees in Norway show low levels of physical activity, and have relatively high prevalence of pain disorders and post-traumatic symptoms. Physical inactivity can be both a cause of and a consequence of physical and mental symptoms. In CHART study (Changing Health and health care needs Along the Syrian Refugees' Trajectories to Norway), two group interventions, one based on physiotherapy and body awareness (PAAI) and the other on Teaching Recovery Techniques (TRT), were developed to treat patients with pain disorders and/or post-traumatic symptoms.

Objective

As a secondary outcome of study, we assessed the effect of these group interventions on physical inactivity.

Methods

We conducted a randomized controlled trial testing two group interventions. Syrian adults ≥16 years with pain and/or post-traumatic symptoms were randomized to either intervention group or control group. Effect of the intervention was measured after 8 (PAAI) and 6 (TRT) weeks, as relative risk (RR) with 95% confidence intervals for being inactive for intervention versus control groups, using log-binomial regression with adjustment for baseline inactivity and type of intervention (PAAI or TRT).

Results

177 Syrian refugees were recruited between July 2018-September 2019. 88 were randomized to the intervention group and 89 to the control group. Mean age was 35 years (SD 11) and 38% were women. Inactivity at recruitment was reported by 126 (71%) participants. The follow-up questionnaire was completed at 6/8 weeks by 116 (66%) participants. At that point, 39% in the intervention group were inactive as compared to 56% in the control group. RR for inactivity for the intervention group adjusted for inactivity at baseline was 0.68 (0.47-0.99) and remained 0.68 (0.48-0.99) when further adjusting for type of intervention (PAAI vs TRT).

Conclusions

PAAI and TRT group interventions reduced inactivity among refugees by 32%. Effect on physical inactivity was similar between PAAI and TRT interventions.

Key messages

Public health care should be aware of physical inactivity, especially in relation to pain disorders and post-traumatic symptoms among refugees. Group treatment interventions succeeded to encourage refugees to increase their physical activity.

Higher levels of bodily pain in people with long-term type 1 diabetes: associations with quality of life, depressive symptoms, fatigue and glycaemic control - the Dialong study

AIMS

To compare reported level of bodily pain, overall and health-related quality of life (QoL), depression and fatigue in people with long-term type 1 diabetes vs. a comparison group without diabetes. Further, to examine the associations of total bodily pain with QoL, depression, fatigue and glycaemic control in the diabetes group.

METHODS

Cross-sectional study of 104 (76% of eligible) people with type 1 diabetes of ≥ 45 years' duration attending the Norwegian Diabetes Centre and 75 persons without diabetes who completed questionnaires measuring bodily pain (RAND-36 bodily pain domain), shoulder pain (Shoulder Pain and Disability Index), hand pain (Australian/Canadian Osteoarthritis Hand Index), overall QoL (World Health Organization Quality of Life - BREF), health-related QoL (RAND-36), diabetes-specific QoL (Audit of Diabetes-Dependent Quality of Life; only diabetes group), depression (Patient Health Questionnaire) and fatigue (Fatigue questionnaire). For people with type 1 diabetes, possible associations between the bodily pain domain (lower scores indicate higher levels of bodily pain) and other questionnaire scores, were measured with regression coefficients (B) per 10-unit increase in bodily pain score from linear regression.

RESULTS

The diabetes group reported higher levels of bodily (P = 0.003), shoulder and hand pain (P < 0.001) than the comparison group. In the diabetes group, bodily pain was associated with lower overall and diabetes-specific QoL [B (95% confidence intervals)]: 0.2 (0.1, 0.2) and 0.2 (0.1, 0.3); higher levels of depression -1.0 (-1.3, -0.7) and total fatigue -1.5 (-1.9, -1.2); and worse glycaemic control HbA_1c (mmol/mol; %) -0.8 (-1.5, -0.1); -0.1 (-0.1, -0.01).

CONCLUSIONS

People with long-term type 1 diabetes experience a high level of bodily pain compared with a comparison group. Total bodily pain was associated with worse QoL and glycaemic control.

Access to healthcare and self-rated health among refugees in transit and after arrival in Norway

Background

Lack of basic infrastructure and poor provision of health services in conflict settings and during flight can have a negative impact on health. The overall health status of refugees seems to improve after arrival at a safe destination. This may be related to a safer environment and better access to health care services, but prior studies on this topic are limited. This study aims to assess self-perceived access to healthcare and its relationship with self-rated health (SRH) among refugees in transit and when settled in a host country.

Methods

We used data from the CHART study (Changing Health and health care needs Along the Syrian Refugees' Trajectories to Norway), which includes a cohort of 353 Syrian refugees who were contacted in 2017-2018 in Lebanon while waiting for relocation, and one year after their arrival to Norway. Information on self-perceived access to healthcare and its association with SRH was analyzed separately at each time-point. Data analysis was performed with STATA using logistic regression adjusting for age, gender, ethnicity and years of education and presented as adjusted odds ratios (AOR) with 95% CI.

Results

Fifteen percent reported good access to healthcare and 62% reported good SRH in Lebanon vs. 91% and 77% respectively, in Norway. Measures in Lebanon showed no association between access to healthcare and good SRH (AOR: 1.2 (0.6-2.2)), and men reported worse access to healthcare than women (AOR: 0.5 (0.3-1.0). In Norway, access to healthcare was strongly associated with good SRH (AOR: 4.7 (2.1-10.7) and was negatively associated with belonging to one specific minority group (AOR: 0.1 (0.0-0.3)).

Conclusions

Both SRH and perceived access to care improved from being in transit to being settled in Norway, the latter substantially more. There was a significant association between access to healthcare and good SRH after the refugees' arrival to a safe host country but not in transit.

Key messages

Refugee’s self-reported health and access to healthcare seem to improve shortly after arrival to a host country. To ensure that the UN’S Sustainable Development Goals concerning health equity are reached, refugees’ access to healthcare in transit and its impact on overall health needs to be addressed.

Changes in health among Syrian refugees along their migration trajectories from Lebanon to Norway: a prospective cohort study

OBJECTIVES

Conflict-driven displacement is an indisputable social determinant of health. Yet, data on changes in health along the migration trajectories of refugees are scarce. This study aims to assess the longitudinal changes in somatic and mental health and use of medication among Syrian refugees relocating from a conflict-near transit setting in the Middle East to a resettlement setting in Europe. Further, we examine different health status trajectories and factors that predict health in the early postmigration period.

STUDY DESIGN

This is a prospective cohort study.

METHODS

Survey data were collected during 2017-2018 among adult Syrian refugees in Lebanon selected for quota resettlement and at follow-up approximately one year after resettlement in Norway. Our primary outcomes were non-communicable disease (NCD), chronic impairment, chronic pain, anxiety/depression, post-traumatic stress symptoms, and daily use of drugs. We estimated longitudinal changes in prevalence proportions using generalized estimating equations and evaluated effect modification of health outcomes.

RESULTS

Altogether, 353 Syrians participated. NCDs declined (12%-9%), while the prevalence of chronic impairment, chronic pain, and use of drugs remained nearly unchanged (29%-28%, 30%-28%, and 20%-18%) between baseline and follow-up. Conversely, mental health outcomes improved (anxiety/depression 33%-11%, post-traumatic stress disorder 5%-2%). Effect modifiers for improvement over time included younger age, short length of stay, and non-legal status in the transit country before resettlement in Europe.

CONCLUSIONS

We find that mental health outcomes improve from a conflict-near transit setting in Lebanon to an early resettlement setting in Norway, while somatic health outcomes remain stable. Temporal changes in health among moving populations warrant attention, and long-term changes need further scrutiny.

P6563Time trends in incidence rates of atrial fibrillation in Norway 2004–2014. A CVDNOR project

Background

The reported incidence and prevalence of atrial fibrillation (AF) has been inconsistent among studies.

Purpose

We aimed to study time trends in incidence (first time) of AF hospitalizations or AF deaths in Norway in the period 2004–2014 by age and sex.

Methods

Nationwide hospital discharge diagnoses in the Cardiovascular Disease in Norway (CVDNOR) database and in the National Patient Registry were linked to the National Cause of Death Registry. All hospitalizations with AF as primary or secondary diagnosis and out-of-hospital deaths with AF as underlying cause (ICD-9: 427.3 or ICD 10: I48; AF or atrial flutter) in individuals ≥18 years were obtained during 1994–2014. Incident AF was defined as first hospitalization or out-of-hospital death due to AF with no previous hospitalization for AF the past 10 years. Age-standardized incidence rates with 95% confidence intervals (CIs) were calculated using direct standardization to the age-distribution in the Norwegian population per Jan 1st 2004. Age-adjusted average yearly incidence rate ratios (IRR) with 95% CIs were estimated by Poisson regression analyses. Accumulated prevalence during 1994–2014 was assessed in Norwegian residents 18 years and older per Dec 31st 2014.

Results

During 39,865,498 person years of follow up from 2004 to 2014 we identified 175,979 incident AF cases of which 30% were registered with AF as primary diagnosis, 69% as secondary diagnosis and 1% as out-of-hospital cause of death. The age-standardized incidence rate of AF hospitalization or out-of-hospital death per 100,000 person years was stable at 433 (426–440) in 2004 and 440 (433–447) in 2014. IRR were stable or declining across age groups of both sexes, except for the youngest age group 18–44 years, where incidence rates of AF hospitalization or out-of-hospital death increased by 2% per year, IRR 1.02 (1.01, 1.03). By 2014, the prevalence of AF assessed from hospital or death records was 2.9% in the adult population 18 years and older.

Conclusion

We found overall stable incidence rates of AF from 2004 to 2014 in the adult Norwegian population. Increased incidence rates of AF in the population 18–44 years are worrying and need further investigation.

Acknowledgement/Funding

The Norwegian Atrial Fibrillation Reseach Network

P818Incidence of coronary heart disease in patients with familiar hypercholesterolemia compared to age- and sex- matched controls

Background

Familial hypercholesterolemia (FH) is caused by mutations leading to high levels of low-density lipoprotein cholesterol (LDL-C) in the blood. The primary aim was to describe mutations in a large sample of individuals with FH, and compare risk of first-time hospitalization for coronary heart disease (CHD) and acute myocardial infarction (AMI) between FH mutation carriers and healthy controls. The secondary aim was to compare risk of death and re-hospitalization among FH mutation carriers and controls with a first event of CHD and AMI.

Methods

This study is a prospective matched cohort study comprising a sample of 5691 persons with FH and 119 511 age- and sex- matched controls randomly selected from the general Norwegian population. Information on CHD and AMI were obtained from Norwegian Patient Registry, the Cardiovascular Disease in Norway project and the Norwegian Cause of Death Registry. Endpoints are defined according to the International Classification of Diseases, version 9 (ICD9) or version 10 (ICD10). Risk among persons with FH will be compared to healthy controls in terms of hazard ratios (HR) from Cox regression with follow-up time calculated from time of FH-diagnosis for the person with FH in each matched set.

Results

In total 51.8% (n=61866) of the combined sample were women with mean age 49.0±20.3 years, whereas 48.2% (n=57645) were men with mean age 46.8±19.6 years. There were 236 different FH mutations registered among the FH mutation carriers. The most frequent mutation was 313+1g>A, that accounted for 20.7% (n=1178) of the total, followed by C210G with 12.1% (n=690). Results for incidence of CHD, AMI, and mortality after CHD and AMI and readmission rates are not yet available but will be presented at the conference.

Acknowledgement/Funding

The study is funded by South-Eastern Norway Regional Health Authority

Diabetes prevalence among older people receiving care at home: associations with symptoms, health status and psychological well-being

AIMS

To determine the prevalence of diabetes among older people receiving care at home, and to explore differences in sociodemographic and clinical characteristics, symptoms, health status, quality of life and psychological well-being between diabetes categories defined as HbA_1c ≥ 48 mmol/mol (6.5%) and/or self-report.

METHODS

A community-based sample of 377 people receiving care at home in Western Norway participated in a cross-sectional survey. Instruments included the MMSE-NR, Symptom Check-List, WHO Quality of Life-BREF (WHOQOL-BREF, global items), EuroQol EQ-5D-5L/EQ-5D-VAS and WHO-Five Well-Being Index (WHO-5). Participants were grouped into four categories: no diabetes, self-report only, HbA_1c ≥ 48 mmol/mol (6.5%) and self-report, and HbA_1c ≥ 48 mmol/mol (6.5%) only.

RESULTS

Median age (IQR) was 86 (81-91) years and 34% of the sample were men. We identified 92 people (24%) with diabetes. Diabetes was more prevalent in men than women (34% vs. 20%, age-adjusted P = 0.005). Among people with diabetes, 14% were unaware of their diagnosis. There were significant differences in symptoms between the diabetes categories, with more symptoms (abnormal thirst, polyuria, genital itching, nausea, excessive hunger, perspiring, cold hands/feet, daytime sleepiness) among the groups with elevated HbA_1c . Significant differences in WHO-5, WHOQOL-BREF and EQ-5D-5L between diabetes categories were identified, with the poorest scores in the group with undiagnosed diabetes.

CONCLUSIONS

A high percentage of people with diabetes receiving care at home are unaware of their diagnosis. Diabetes deserves increased case-finding efforts and allocation of resources towards those receiving care at home to alleviate symptoms and the burden of inadequate diabetes care.

Gender differences in psychiatric comorbidity: a population-based study of 40 000 adults with attention deficit hyperactivity disorder

OBJECTIVE

We aimed at determining whether gender modified associations between ADHD and psychiatric comorbidities in adults.

METHOD

We identified adults with ADHD by linking Norwegian national registries and compared them with the remaining adult population (born 1967-1997, ADHD and bipolar during 2004-2015, other psychiatric disorders 2008-2015). Prevalence differences (PDs) and prevalence ratios (PRs) of psychiatric disorders were determined by Poisson regression. Interaction by gender was evaluated on additive (PDs) and multiplicative (PRs) scales. Proportions of psychiatric disorders attributable to ADHD were calculated.

RESULTS

We identified 40 103 adults with ADHD (44% women) and 1 661 103 adults (49% women) in the remaining population. PDs associated with ADHD were significantly larger in women than in men for anxiety, depression, bipolar and personality disorders, for example depression in women: 24.4 (95% CI, 23.8-24.9) vs. in men: 13.1 (12.8-13.4). PDs were significantly larger in men for schizophrenia and substance use disorder (SUD), for example SUD in men: 23.0 (22.5-23.5) vs. in women: 13.7 (13.3-14.0). Between 5.6 and 16.5% of psychiatric disorders in the population were attributable to ADHD.

CONCLUSION

The association between ADHD and psychiatric comorbidities differed significantly among men and women. Clinicians treating adults with ADHD should be aware of these frequent and gender-specific comorbidities, such that early treatment can be offered.

Smoking, plasma cotinine and risk of atrial fibrillation: the Hordaland Health Study

BACKGROUND

Cigarette smoking has been identified as a major modifiable risk factor for coronary heart disease and mortality. However, findings on the relationship between smoking and atrial fibrillation (AF) have been inconsistent. Furthermore, findings from previous studies were based on self-reported smoking.

OBJECTIVE

To examine the associations of smoking status and plasma cotinine levels, a marker of nicotine exposure, with risk of incident AF in the Hordaland Health Study.

METHODS

We conducted a prospective analysis of 6682 adults aged 46-74 years without known AF at baseline. Participants were followed via linkage to the Cardiovascular Disease in Norway (CVDNOR) project and the Cause of Death Registry. Smoking status was assessed by both questionnaire and plasma cotinine levels.

RESULTS

A total of 538 participants developed AF over a median follow-up period of 11 years. Using questionnaire data, current smoking (HR: 1.41, 95% CI: 1.09-1.83), but not former smoking (HR: 1.03, 95% CI: 0.83-1.28), was associated with an increased risk of AF after adjustment for gender, age, body mass index, hypertension, physical activity and education. Using plasma cotinine only, the adjusted HR (95% CI) was 1.40 (1.12-1.75) for participants with cotinine ≥85 nmol L^-1 compared to those with cotinine <85 nmol L^-1 . However, the risk increased with elevated plasma cotinine levels until 1199 nmol L^-1 (HR: 1.55, 95% CI: 1.16-2.05 at the third group vs. the reference group) and plateaued at higher levels.

CONCLUSIONS

Current, but not former smokers, had a higher risk of developing AF. Use of plasma cotinine measurement corroborated this finding.

Zoonotic helminth exposure and risk of allergic diseases: A study of two generations in Norway

BACKGROUND

Animal and human studies indicate that definitive host helminth infections may confer protection from allergies. However, zoonotic helminths, such as Toxocara species (spp.), have been associated with increased allergies.

OBJECTIVE

We describe the prevalence of Toxocara spp. and Ascaris spp. seropositivity and associations with allergic diseases and sensitization, in 2 generations in Bergen, Norway.

METHODS

Serum levels of total IgG4, anti-Toxocara spp. IgG4 and Ascaris spp. IgG4 were established by ELISA in 2 cohorts: parents born 1945-1972 (n = 171) and their offspring born 1969-2003 (n = 264). Allergic outcomes and covariates were recorded through interviews and clinical examinations including serum IgEs and skin prick tests.

RESULTS

Anti-Ascaris spp. IgG4 was detected in 29.2% of parents and 10.3% of offspring, and anti-Toxocara spp. IgG4 in 17.5% and 8.0% of parents and offspring, respectively. Among offspring, anti-Toxocara spp. IgG4 was associated with pet keeping before age 15 (OR = 6.15; 95% CI = 1.37-27.5) and increasing BMI (1.16[1.06-1.25] per kg/m² ). Toxocara spp. seropositivity was associated with wheeze (2.97[1.45- 7.76]), hayfever (4.03[1.63-9.95]), eczema (2.89[1.08-7.76]) and cat sensitization (5.65[1.92-16.6]) among offspring, but was not associated with allergic outcomes among parents. Adjustment for childhood or current pet keeping did not alter associations with allergies. Parental Toxocara spp. seropositivity was associated with increased offspring allergies following a sex-specific pattern.

CONCLUSIONS & CLINICAL RELEVANCE

Zoonotic helminth exposure in Norway was less frequent in offspring than parents; however, Toxocara spp. seropositivity was associated with increased risk of allergic manifestations in the offspring generation, but not among parents. Changes in response to helminth exposure may provide insights into the increase in allergy incidence in affluent countries.

Trends in 28-day and 1-year mortality rates in patients hospitalized for a first acute myocardial infarction in Norway during 2001-2009: a "Cardiovascular disease in Norway" (CVDNOR) project

OBJECTIVE

The aim of this study was to investigate the trends in 28-day and 1-year mortality rates in patients hospitalized for a first acute myocardial infarction (AMI) in Norway during the period 2001-2009. Potential age group and gender differences in these trends were also examined.

DESIGN, SUBJECTS AND SETTING

In this retrospective nationwide cohort study, patients hospitalized for a first AMI between 2001 and 2009 were identified in the Cardiovascular Disease in Norway 1994-2009 (CVDNOR) project and followed for 1 year.

MAIN OUTCOME MEASURES

Trends in 28-day and 1-year mortality [both all-cause and cardiovascular disease (CVD) mortality] were investigated.

RESULTS

A total of 115,608 patients (60.6% men) were hospitalized for a first AMI during the study period. Mortality at 28 days was reduced annually by 3.8% overall and by 6.7%, 4.1% and 2.6% in patients aged 25-64, 65-84 and ≥85 years, respectively (all Ptrend < 0.001). In addition, 1-year all-cause mortality was reduced annually by 2.0% overall (Ptrend < 0.001) and by 3.7% (Ptrend = 0.02), 2.5% (Ptrend < 0.001) and 1.1% (Ptrend < 0.001) in patients aged 25-64, 65-84 and ≥85 years, respectively. Furthermore, 1-year CVD mortality was reduced overall by 6.2% annually; a reduction was observed in all age groups. Finally, 1-year non-CVD mortality increased annually overall by 3.9% due to an increase in patients aged ≥65 years.

CONCLUSION

Mortaity at 28 days after the first AMI declinedin Norway between 2001 and 2009 in both men and women and in all age groups. All-cause mortality at 1 year also declined both in men and women due to decreases in CVD mortality rates, whilst non-CVD mortality rates increased amongst patients ≥65 years of age.