Evaluation of Heart Size and Pulmonary Vasculature

Inter- and intraobserver variation and diagnostic accuracy in estimation of heart size and pulmonary vasculature were evaluated for conventional film-screen technique and image intensifier photofluorography. Interpretation of 218 p.a. and lateral chest films by both imaging techniques was performed independently by 4 readers. Heart size relative to body surface area measured from the plain chest films was used as the reference in cardiac size determination. Overall diagnostic accuracies of conventional radiography and image intensifier photofluorography for cardiomegaly were close to each other, 0.70 vs 0.68, respectively. Specificity of film-screen radiography was better than that of photofluorography (0.92 vs 0.84, p <0.05). Interobserver agreement was poor both in assessment of the heart size and pulmonary vasculature (range of kappa coefficients 0.18–0.59) while the intraobserver consistency (kappa coefficients 0.60–0.85) was good to excellent. The results suggest a limited usefulness of visual assessment of heart size and pulmonary vasculature in chest roentgenographs.

Low-grade systolic murmurs in healthy middle-aged individuals: innocent or clinically significant? A 35-year follow-up study of 2014 Norwegian men

OBJECTIVE

To determine whether a low-grade systolic murmur, found at heart auscultation, in middle-aged healthy men influences the long-term risk of aortic valve replacement (AVR) and death from cardiovascular disease (CVD). Setting and subjects.  During 1972-1975, 2014 apparently healthy men aged 40-59 years underwent an examination programme including case history, clinical examination, blood tests and a symptom-limited exercise ECG test. Heart auscultation was performed under standardized conditions, and murmurs were graded on a scale from I to VI. No men were found to have grade V/VI murmurs. Participants were followed for up to 35 years.

RESULTS

A total of 1541 men had no systolic murmur; 441 had low-grade murmurs (grade I/II) and 32 had moderate-grade murmurs (grade III/IV). Men with low-grade murmurs had a 4.7-fold [95% confidence interval (CI) 2.1-11.1] increased age-adjusted risk of AVR, but no increase in risk of CVD death. Men with moderate-grade murmurs had an 89.3-fold (95% CI 39.2-211.2) age-adjusted risk of AVR and a 1.5-fold (95% CI 0.8-2.5) age-adjusted increased risk of CVD death.

CONCLUSIONS

Low-grade systolic murmur was detected at heart auscultation in 21.9% of apparently healthy middle-aged men. Men with low-grade murmur had an increased risk of AVR, but no increase in risk of CVD death. Only 1.6% of men had moderate-grade murmur; these men had a very high risk of AVR and a 1.5-fold albeit non-significant increase in risk of CVD death.

A controlled study on the antihypertensive effect of a new beta-adrenergic receptor blocking drug, metoprolol, in combination with chlorthalidone

A double-blind crossover evaluation of the antihypertensive effect of metoprolol v. placebo was carried out in a series of twenty-three patients with mild or moderate essential hypertension who were receiving chlorthalidone (25 mg daily) as their basic treatment. An individually titrated metoprolol dosage (75-300 mg) was used. The double-blind crossover study consisted of two 3-month periods during which the patients received either metoprolol or placebo in addition to chlorthalidone. Metoprolol, as compared with placebo, produced a statistically significant reduction of blood pressure, both in supine and standing positions. Normotension was achieved during metoprolol-chlorthalidone treatment in twenty-two of the twenty-three patients, but during placebo-chlorthalidone treatment in only twelve of the twenty-three patients. During the double-blind crossover study mild side-effects occurred during metoprolol-chlorthalidone treatment in fourteen patients during first month, in twelve patients during second month and seven patients during third month. During placebo-chlorthalidone treatment side effects occurred in seven, six and seven patients, respectively. In conclusion, metoprolol caused a significant fall in blood pressure when given to patients already receiving chlorthalidone. Metoprolol in combination with chlorthalidone appears to be an effective and well-tolerated treatment for mild and moderate hypertension in those patients not responding to chlorthalidone alone.

Diabetes, prediabetes and cancer mortality

AIMS/HYPOTHESIS

We aimed to investigate the risk of cancer mortality in relation to the glucose tolerance status classified according to the 2 h OGTT.

METHODS

Data from 17 European population-based or occupational cohorts involved in the DECODE study comprising 26,460 men and 18,195 women aged 25-90 years were collaboratively analysed. The cohorts were recruited between 1966 and 2004 and followed for 5.9 to 36.8 years. Cox proportional hazards analysis with adjustment for cohort, age, BMI, total cholesterol, blood pressure and smoking status was used to estimate HRs for cancer mortality.

RESULTS

Compared with people in the normal glucose category, multivariable adjusted HRs (95% CI) for cancer mortality were 1.13 (1.00, 1.28), 1.27 (1.02, 1.57) and 1.71 (1.35, 2.17) in men with prediabetes, previously undiagnosed diabetes and known diabetes, respectively; in women they were 1.11 (0.94, 1.30), 1.31 (1.00, 1.70) and 1.43 (1.01, 2.02), respectively. Significant increases in deaths from cancer of the stomach, colon-rectum and liver in men with prediabetes and diabetes, and deaths from cancers of the liver and pancreas in women with diabetes were also observed. In individuals without known diabetes, the HR (95% CI) for cancer mortality corresponding to a one standard deviation increase in fasting plasma glucose was 1.06 (1.02, 1.09) and in 2 h plasma glucose was 1.07 (1.03, 1.11).

CONCLUSIONS/INTERPRETATION

Diabetes and prediabetes were associated with an increased risk of cancer death, particularly death from liver cancer. Mortality from all cancers rose linearly with increasing glucose concentrations.

Plasma insulin as coronary heart disease risk factor: relationship to other risk factors and predictive value during 9 1/2-year follow-up of the Helsinki Policemen Study population

In the Helsinki Policemen Study based on a cohort of 982 men aged 35-64 years and free of coronary heart disease (CHD) at entry plasma insulin level (fasting, 1-hour and 2-hour plasma insulin after oral glucose load) showed during a 9 1/2-year follow-up a non-linear association to the incidence of "hard criteria" CHD events (CHD death or non-fatal myocardial infarction) with highest incidence in the top decile of plasma insulin. Plasma insulin levels showed positive correlations, besides to blood glucose levels, to body mass index, plasma triglyceride level and blood pressure and inverse correlations to leisure time physical activity and objectively measured physical fitness. In multivariate analyses the predictive value of high plasma insulin with respect to CHD risk was found to be independent of other risk factors, including blood glucose levels.

Left ventricular function in newly diagnosed non-insulin-dependent (type 2) diabetics evaluated by systolic time intervals and echocardiography

Systolic time intervals (STI) and echocardiography were recorded in 133 (70 men, 63 women) newly diagnosed non-insulin-dependent diabetics aged 45-64 years and in 144 (62 men, 82 women) non-diabetic control subjects of the same age. Both male and female diabetics had significantly increased pre-ejection period/left ventricular ejection time ratio (PEP/LVET) in STI as compared with the respective non-diabetic control subjects. Male diabetics showed a reduced ejection fraction (EF) in echocardiography, but no significant difference was found in this respect between female diabetics and controls. A significant negative correlation was found between 2-hour postglucose serum insulin level and EF in male and female diabetics. After adjusting for the effect of age, coronary heart disease, hypertension, obesity and haemoglobin concentration, male diabetics still had a higher PEP/LVET ratio and a lower EF than male controls. In women, no significant differences were found between diabetics and controls in the PEP/LVET ratio or EF adjusted for the above factors. The results of this study are compatible with the view that impaired left ventricular function may be an early phenomenon in the clinical course of non-insulin-dependent diabetes.

Stopping insulin treatment in middle-aged diabetic patients with high postglucagon plasma C-peptide. Effect on glycaemic control, serum lipids and lipoproteins

We studied the successfulness of stopping insulin treatment in middle-aged diabetic patients aged 45-64 with a high postglucagon C-peptide level and the effects of this change on glycaemic control, serum lipids and lipoproteins. Insulin treatment was successfully stopped in 15 of our 22 patients who satisfied the inclusion criteria for the study and were selected on the basis of a computer file including practically all diabetic patients treated with insulin in the Kuopio University Central Hospital region (population base 250,000 inhabitants). Insulin therapy was restarted in seven patients during the first 3 months after discharge. During the following 9 months insulin therapy was restarted in another three patients so that after a 1-year follow-up period half of the diabetic patients whose insulin therapy was stopped had been switched back to insulin. Insulin therapy was seldom successfully stopped if the postglucagon C-peptide value was under the limit of 1.0 nmol/l. Glycaemic control did not change during the follow-up, although there was a significant weight loss in diabetic patients. No changes were observed in serum lipids or lipoproteins with the exception of LDL cholesterol, which showed a significant reduction during the 3-month follow-up. In conclusion, insulin therapy can often be successfully stopped in patients with postglucagon C-peptide over the limit of 1.0 nmol/l without worsening of glycaemic control and without unfavourable changes in serum lipid and lipoprotein levels.

Incidence of different manifestations of coronary heart disease in middle-aged Finnish men and women

The incidence of myocardial infarction and symptoms of coronary heart disease (CHD) were investigated in a prospective Finnish population study. Drawn from four geographical areas in Finland the study population comprised 5 438 men and 4 924 women aged 30-59 at entry. The results are based on a re-examination of the study population after a mean follow-up time of six years. The average annual incidence of coronary death was 3.8/1 000, and that of non-fatal infarction 6.5/1 000 in men and 0.4/1 000 and 2.1/1 000 in women. Ten per cent of all infarctions were silent, revealed only by ECG changes. Cases of new angina pectoris comprised 40% of all the new events in men but 80% in women. This descriptive report serves as the basis for subsequent analyses comprising risk factors for different CHD manifestations.

Efficacy of dietary instructions in newly diagnosed non-insulin-dependent diabetic patients. Comparison of two different patient education regimens

Eighty consecutive newly diagnosed non-insulin-dependent diabetic patients were randomly allocated into two groups to compare two different patient education regimens. One group received individual dietary instructions by a nurse and the other a short, written leaflet given by a doctor. The principal aim of the dietary instructions was weight reduction. A significant weight loss and improvement in the control of diabetes occurred in both groups, and these changes were similar in the two groups. At the end of one year's follow-up, however, only 25% of the patients were satisfactorily controlled (fasting blood glucose less than or equal to 6.0 mmol/l). The degree of weight loss correlated only weakly with the improvement in the metabolic control. The degree of obesity and insulin secretion capacity as measured at the beginning of the study did not predict the improvement of glycaemic control during the study. At the end of the study a significant improvement was observed in serum lipids of patients with good control (fasting blood glucose less than or equal to 6.0 mmol/l) or weight loss (greater than 5 kg). In conclusion, both brief, written and individual dietary instructions induced a significant weight loss as well as improved glucose and lipid metabolism in newly diagnosed non-insulin-dependent diabetic patients, but satisfactory metabolic control was achieved only in a minority of the patients.

Effect of correction of hyperglycemia on left ventricular function in non-insulin-dependent (type 2) diabetics

Systolic time intervals (STI) were recorded in 33 newly diagnosed non-insulin-dependent diabetics (19 men, 14 women, aged 44-64 years) before and after 3-8 months' dietary therapy. The mean (+/- SD) fasting blood glucose was 11.1 +/- 2.6 mmol/l before treatment and 7.8 +/- 1.8 at the second examination (p less than 0.001). Concomitantly with the decline in blood glucose concentration, the heart rate corrected pre-ejection period (PEP) decreased from 139 +/- 11.9 to 135 +/- 14.4 msec (mean +/- SD) (p less than 0.05), the heart rate corrected left ventricular ejection time (LVET) increased from 400 +/- 15.1 to 410 +/- 20.7 msec (p less than 0.0025) and the PEP/LVET ratio decreased from 0.39 +/- 0.06 to 0.36 +/- 0.06 (p less than 0.005). When the diabetics were divided into two groups according to the degree of the decline in blood glucose concentration, only those whose fasting blood glucose decreased by greater than or equal to 3 mmol/l showed significant changes in STI. No significant changes were observed in the mean heart rate or systolic blood pressure during the treatment. Cardiac dysfunction occurring in untreated non-insulin-dependent diabetics may be caused by metabolic factors and it may be reversed at least partially by correction of hyperglycemia.

Four-year incidence of myocardial infarction and sudden coronary death in twelve Finnish population cohorts

The incidence of myocardial infarction (MI) and sudden coronary death in four years was studied in 6510 men and 5800 women, aged 30-59 years, derived from 12 Finnish population cohorts constituting the invited population to a prospective study. The incidence of all fatal coronary events in four years was 13.0/1 000 in men and 1.8/1 000 in women. The incidence of sudden coronary death was 7.8/1 000 in men and 0.7/1 000 in women. The incidence of non-fatal MI was 22.2/1 000 in men and 7.3/1 000 in women. Coronary mortality was significantly higher in non-participants in the initial survey than in participants. The incidence of MI was highest in men from eastern Finland (North Karelia), intermediate in men from central and western Finland and lowest in men from southwestern Finland. There were no significant regional differences in the incidence of MI in women. The incidence of MI in this study was in good agreement with that recorded in the myocardial community registers.

Fasting, postprandial and postprandial plus glucagon-stimulated plasma C-peptide levels in non-insulin-dependent diabetics and in control subjects

We have studied fasting, postprandial and postprandial plus glucagon-stimulated plasma C-peptide levels in 149 non-insulin-dependent diabetics treated either with diet or oral drugs and in 101 non-diabetic control subjects. Diet-treated diabetics showed the highest fasting, postprandial and post-glucagon C-peptide levels in both sexes. In men, diabetics treated with oral drugs showed lower postprandial and glucagon-stimulated C-peptide levels than control subjects, while in women C-peptide levels in this group of diabetics were similar to those in control subjects. The distribution of individual plasma C-peptide levels was wide in non-insulin-dependent diabetics and control subjects and there was considerable overlapping in plasma C-peptide distribution for diabetics and control subjects. Fasting and post-glucagon plasma C-peptide levels in diabetics showed an inverse association to plasma glucose levels and a positive association to degree of obesity, but no association with the known duration of diabetes.

Peripheral arterial disease and its relationship to cardiovascular risk factors and coronary heart disease in newly diagnosed non-insulin-dependent diabetics

The prevalence of peripheral arterial disease and its relationship to cardiovascular risk factors was investigated in 133 patients aged 45-64 years with newly diagnosed non-insulin-dependent diabetes and in 144 randomly selected non-diabetic subjects of the same age. History of intermittent claudication, absent foot pulses, decreased ankle-arm blood pressure ratio (less than 0.9) and radiologically detectable arterial calcifications of the lower limbs were used as indicators of the presence of peripheral arterial disease. Peripheral arterial disease tended to be somewhat more common in men with newly diagnosed non-insulin-dependent diabetes than in non-diabetic men, whereas no difference was found in prevalence of peripheral arterial disease between diabetic and non-diabetic women. The association of various indicators of peripheral arterial disease with cardiovascular risk factors and coronary heart disease was low or absent.

Long-term prognosis after coronary artery bypass surgery

OBJECTIVE

To analyse the risk of coronary heart disease (CHD) events and total mortality among patients who had coronary artery bypass graft (CABG) surgery during 1988-1992.

METHODS

A population-based myocardial infarction (MI) register included data on invasive cardiac procedures among residents of the study area. The subjects aged 35-64 years were followed-up for 12 years for non-fatal and fatal CHD events and all-cause mortality, excluding events within 30 days of the CABG operation. CABG was performed on 1158 men and 215 women.

RESULTS

The overall survival of men who underwent CABG was similar to the survival of the corresponding background population for about ten years but started to worsen after that. At twelve years of follow-up, 23% (n=266, 95% CI 234-298) of the men who had undergone the operation had died, while the expected proportion, based on mortality in the background population, was 20% (n=231, 95% CI 226-237). The CHD mortality of men who had undergone the operation was clearly higher than in the background population. Among women, the mortality after CABG was about twice the expected mortality in the corresponding background population. In Cox proportional hazards models age, smoking, history of MI, body mass index and diabetes were significant predictors of mortality.

CONCLUSIONS

The prognosis of male CABG patients did not differ from the prognosis of the corresponding background population for about ten years, but started to deteriorate after that. History of MI prior to CABG and major cardiovascular risk factors was a predictor of an adverse outcome.

Oral glucose tolerance test is needed for appropriate classification of glucose regulation in patients with coronary artery disease: a report from the Euro Heart Survey on Diabetes and the Heart

BACKGROUND

Patients with coronary artery disease (CAD) and abnormal glucose regulation (AGR) are at high risk for subsequent cardiovascular events, underlining the importance of accurate glucometabolic assessment in clinical practice.

OBJECTIVE

To investigate different methods to identify glucose disturbances among patients with acute and stable coronary heart disease.

METHODS

Consecutive patients referred to cardiologists were prospectively enrolled at 110 centres in 25 countries (n = 4961). Fasting plasma glucose (FPG) and glycaemia 2 h after a 75-g glucose load were requested in patients without known glucose abnormalities (n = 3362). Glucose metabolism was classified according to the World Health Organization and American Diabetes Association (ADA; 1997, 2004) criteria as normal, impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or diabetes.

RESULTS

Data on FPG and 2-h post-load glycaemia were available for 1867 patients, of whom 870 (47%) had normal glucose regulation, 87 (5%) had IFG, 591 (32%) had IGT and 319 (17%) had diabetes. If classification had been based on the ADA criterion from 1997, the proportion of misclassified (underdiagnosed) patients would have been 39%. The ADA 2004 criterion would have overdiagnosed 8% and underdiagnosed 33% of the patients, resulting in a total misclassification rate of 41%. For ethical concerns and practical reasons, oral glucose tolerance test (OGTT) was not conducted in 1495 of eligible patients. These patients were more often women, had higher age and waist circumference, and were therefore more likely to have AGR than those who were included. A model based on easily available clinical and laboratory variables, including FPG, high-density lipoprotein cholesterol, age and the logarithm of glycated haemoglobin A1c, misclassified 44% of the patients, of whom 18% were overdiagnosed and 26% were underdiagnosed.

CONCLUSION

An OGTT is still the most appropriate method for the clinical assessment of glucometabolic status in patients with coronary heart disease.

Proteinuria and metabolic syndrome as predictors of cardiovascular death in non-diabetic and type 2 diabetic men and women

AIMS/HYPOTHESIS

Proteinuria predicts cardiovascular disease (CVD), but it is unclear whether this is explained by the association of the metabolic syndrome with proteinuria. Therefore, we investigated proteinuria and the metabolic syndrome as independent predictors of CVD death in men and women.

METHODS

The cohort comprised 574 non-diabetic men, 707 non-diabetic women, 371 diabetic men and 349 diabetic women, all free of CVD at baseline. Modified World Health Organization criteria were used to define the metabolic syndrome, and a urinary protein concentration of >or=0.1 g/l (or >or=0.2 g/l) to define proteinuria. The endpoint was CVD mortality during the 18-year follow-up.

RESULTS

Among non-diabetic men, CVD mortality per 1,000 person-years was as follows: no metabolic syndrome, no urinary protein group: 5.3; no metabolic syndrome, positive for urinary protein: 8.9; positive for metabolic syndrome, no urinary protein: 13.3; and positive for metabolic syndrome and urinary protein: 14.9. For non-diabetic women the corresponding values were: 0.9, 2.3, 4.9 and 7.9, respectively. Among diabetic men, CVD mortality per 1,000 person-years was 15.2, 32.5, 23.6 and 42.0 for the respective groups. Among diabetic women it was 25.3, 38.0, 26.3 and 40.3 (urinary protein in all cases defined as >or=0.1 g/l). In multivariate Cox models including both urinary protein and metabolic syndrome, the hazard ratios (HRs, 95% CI) of proteinuria for CVD mortality were 1.5 (0.9-2.4) in non-diabetic men, 1.8 (0.8-4.2) in non-diabetic women, 1.6 (1.0-2.6) in diabetic men and 1.6 (1.1-2.3) in diabetic women. Urinary protein as a continuous variable was associated with CVD mortality in all groups. The corresponding HRs for metabolic syndrome were: 1.6 (0.9-2.7), 4.0 (1.7-9.7), 1.5 (1.1-2.0) and 1.1 (0.8-1.5).

CONCLUSIONS/INTERPRETATION

Proteinuria predicted CVD mortality independently of the presence of metabolic syndrome in non-diabetic and diabetic subjects. Metabolic syndrome predicted CVD mortality in non-diabetic women and in diabetic men, independently of the presence of proteinuria.

Myocardial infarction in diabetic and non-diabetic persons with and without prior myocardial infarction: the FINAMI Study

AIMS/HYPOTHESIS

We compared the risk of acute coronary events in diabetic and non-diabetic persons with and without prior myocardial infarction (MI), stratified by age and sex.

METHODS

A Finnish MI-register study known as FINAMI recorded incident MIs and coronary deaths (n=6988) among people aged 45 to 74 years in four areas of Finland between 1993 and 2002. The population-based FINRISK surveys were used to estimate the numbers of persons with prior diabetes and prior MI in the population.

RESULTS

Persons with diabetes but no prior MI and persons with prior MI but no diabetes had a markedly greater risk of a coronary event than persons without diabetes and without prior MI. The rate of recurrent MI among non-diabetic men with prior MI was higher than the incidence of first MI among diabetic men aged 45 to 54 years. The rate ratio was 2.14 (95% CI 1.40-3.27) among men aged 50. Among elderly men, diabetes conferred a higher risk than prior MI. Diabetic women had a similar risk of suffering a first MI as non-diabetic women with a prior MI had for suffering a recurrent MI.

CONCLUSIONS/INTERPRETATION

Both persons with diabetes but no prior MI, and persons with a prior MI but no diabetes are high-risk individuals. Among men, a prior MI conferred a higher risk of a coronary event than diabetes in the 45-54 year age group, but the situation was reversed in the elderly. Among diabetic women, the risk of suffering a first MI was similar to the risk that non-diabetic women with prior MI had of suffering a recurrent MI.

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

AIM

To investigate the incidence of clinical diabetes as determined by the incidence of diabetes drug reimbursements within a 5-year period after the first myocardial infarction (MI) in patients who were non-diabetic at the time of their first MI.

RESEARCH DESIGN AND METHODS

A population-based MI register, FINMONICA/FINAMI, recorded all coronary events in persons of 35-64 years of age between 1988 and 2002 in four study areas in Finland. These records were used to identify subjects sustaining their first MI (n = 2632). Participants of the population-based risk factor survey FINRISK (surveys 1987, 1992, 1997 and 2002), who did not have diabetes or a history of MI, served as the control group (n = 7774). The FINMONICA/FINAMI study records were linked with the National Social Security Institute's drug reimbursement records, which include diabetes medications, using personal identification codes. The records were used to identify subjects who developed diabetes during the 5-year follow-up period (n = 98 in the MI group and n = 79 in the control group).

RESULTS

Sixteen per cent of men and 20% of women sustaining their first MI were known to have diabetes and thus were excluded from this analysis. Non-diabetic men having a first MI were at more than twofold {hazard ratio (HR) 2.3 [95% confidence interval (CI) 1.6-3.4]}, and women fourfold [HR 4.3 (95% CI 2.4-7.5)], risk of developing diabetes mellitus during the next 5 years compared with the control population without MI.

CONCLUSIONS

Many patients who do not have diabetes at the time of their first MI develop diabetes in the following 5 years.

Prediction of the risk of cardiovascular mortality using a score that includes glucose as a risk factor. The DECODE Study

AIMS/HYPOTHESIS

Risk scores have been developed to predict cardiovascular or coronary risk, and while most have included diabetes as a risk factor, none have included lower glucose concentrations, either at fasting or following a 2-h oral glucose tolerance test. This article develops 5- and 10-year risk scores for cardiovascular mortality that include glucose concentrations as well as known diabetes status.

METHODS

Data is from the DECODE cohort: 16,506 men and 8,907 women from 14 European studies. The risk factors studied were as follows: age, fasting and 2-h glucose (including cases of known diabetes), fasting glucose alone (including cases of known diabetes), cholesterol, smoking status, systolic blood pressure and BMI. For an absolute risk score the 1995 country- and sex-specific cardiovascular death rates were used.

RESULTS

In men, for both 5- and 10-year cardiovascular mortality, after adjusting for age and study centre, all studied risk factors, except BMI, were significantly associated with cardiovascular mortality (p<0.05). These results were unchanged in multivariate models with all factors included. In women, after adjusting for age and centre, glucose categories, systolic blood pressure and BMI were predictive of 5-year cardiovascular mortality. With all factors in the model, only age and glucose categories were predictive. In terms of 10-year cardiovascular mortality, smoking status and blood pressures were also predictive in the women. For men and women, the same scores were used for the risk factors, except for age and glucose categories where the hazard ratios differed significantly.

CONCLUSIONS/INTERPRETATION

Including glucose concentrations as well as diabetic status provides quantitative information on cardiovascular risk prediction.

Risk factor management in diabetic and non-diabetic patients with coronary heart disease. Findings from the EUROASPIRE I AND II surveys

AIMS/HYPOTHESIS

We examined risk factor management in diabetic and non-diabetic patients with CHD based on data from EUROASPIRE surveys.

METHODS

Consecutive CHD patients aged 70 years or younger were interviewed and examined at least 6 months after hospitalisation for a revascularisation procedure or acute myocardial infarction or ischaemia. Of these patients, 3569 were from the EUROASPIRE I study, undertaken from 1995 to 1996 in nine countries, and 5556 were from the EUROASPIRE II study, conducted between 1999 and 2000 in 15 countries.

RESULTS

In EUROASPIRE I and II 18% and 20% of CHD patients respectively had been previously diagnosed with diabetes. Fasting glucose screening raised the prevalence of diabetes in EUROASPIRE II to 28%. In EUROSPIRE II the prevalence of risk factors (known diabetic/non-diabetic) was: current smoking 17%/22 % ( p=0.25); obesity (BMI >/=30 kg/m(2)) 43%/29% ( p<0.001); raised blood pressure (>/=140/90 mm Hg) 57%/49% ( p<0.001); and elevated total cholesterol (>/=5.0 mmol/l) 55%/59% ( p<0.001). The proportion of users of cardiovascular medication was: antiplatelet drugs 83%/86% (NS); beta-blockers 62%/63% (NS); ACE inhibitors 49%/35% ( p<0.001); and lipid-lowering drugs 62%/61% (NS). A comparison of both studies showed that for diabetic and non-diabetic patients the prevalence of smoking had increased somewhat and that the prevalence of obesity had increased clearly. There was no improvement in blood pressure control, but cholesterol control had improved, mainly explained by the increased use of lipid-lowering drugs.

CONCLUSIONS/INTERPRETATION

These European surveys show a high prevalence of adverse lifestyles and modifiable risk factors among diabetic and non-diabetic patients with CHD. The risk factor status was more adverse in diabetic patients.

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

BACKGROUND

Out-of-hospital deaths constitute the majority of all coronary heart disease (CHD) deaths and are therefore of considerable public health significance.

METHODS AND RESULTS

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

CONCLUSIONS

The decline in out-of-hospital CHD deaths has contributed the main part to the overall decline in CHD mortality rates among persons 35 to 64 years of age in Finland.

Serum and plasma as alternative sample types in analysis of cardiac markers in the clinical routine

There is an increasing demand for the results of cardiac markers (troponin I or T, creatine kinase MB mass and myoglobin) to be made available promptly after sample-taking. In order to shorten the turnaround time, the possibility of using EDTA- or heparin-plasma instead of serum was investigated. The study population comprised 391 patients with acute chest pain. Four different instruments and systems routinely used in Finland giving quantitative results were studied for the assays of creatine kinase isoenzyme MB mass, myoglobin, and troponin I or troponin T. In addition to serum samples, heparin-plasma seems to be useful for all three assays using the Access and Immulite systems, while EDTA-plasma seems to be useful for all three assays with the Access and Elecsys systems. For the AxSYM assays, serum samples seem to be the best alternative. In conclusion, it is possible to use a single EDTA- or heparin-plasma sample for Access, Elecsys and Immulite analysers, and thereby to shorten the turnaround time. In this way the quantitative analyses from plasma can be performed 30 min after taking the sample.

Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project

AIMS

The SCORE project was initiated to develop a risk scoring system for use in the clinical management of cardiovascular risk in European clinical practice.

METHODS AND RESULTS

The project assembled a pool of datasets from 12 European cohort studies, mainly carried out in general population settings. There were 20,5178 persons (88,080 women and 11,7098 men) representing 2.7 million person years of follow-up. There were 7934 cardiovascular deaths, of which 5652 were deaths from coronary heart disease. Ten-year risk of fatal cardiovascular disease was calculated using a Weibull model in which age was used as a measure of exposure time to risk rather than as a risk factor. Separate estimation equations were calculated for coronary heart disease and for non-coronary cardiovascular disease. These were calculated for high-risk and low-risk regions of Europe. Two parallel estimation models were developed, one based on total cholesterol and the other on total cholesterol/HDL cholesterol ratio. The risk estimations are displayed graphically in simple risk charts. Predictive value of the risk charts was examined by applying them to persons aged 45-64; areas under ROC curves ranged from 0.71 to 0.84.

CONCLUSIONS

The SCORE risk estimation system offers direct estimation of total fatal cardiovascular risk in a format suited to the constraints of clinical practice.

Trends in coronary events in Finland during 1983-1997. The FINAMI study

AIMS

To analyse the trends in incidence, recurrence, case fatality, and treatments of acute coronary events in Finland during the 15-year period 1983-97.

METHODS AND RESULTS

Population-based MI registration has been carried out in defined geographical areas, first as a part of the FINMONICA Project and then continued as the FINAMI register. During the study period, 6501 coronary heart disease (CHD) events were recorded among men and 1778 among women aged 35-64 years. The CHD mortality declined on average 6.4%/year (95% confidence interval -5.4, -7.4%) among men and 7.0%/year (-4.7, -9.3%) among women. The mortality from recurrent events declined even more steeply, 9.9%/year (-8.3, -11.4%) among men and 9.3%/year (-5.1, -13.4%) among women. The proportion of recurrent events of all CHD events also declined significantly in both sexes. Of all coronary deaths, 74% among men and 61% among women took place out-of-hospital. The decline in 28-day case fatality was 1.3%/year (-0.3, -2.3%) among men and 3.1%/year (-0.7, -5.5%) among women.

CONCLUSIONS

The study period was characterized by a marked reduction in the occurrence of recurrent CHD events and a relatively modest reduction in the 28-day case fatality. The findings suggest that primary and secondary prevention have played the main roles in the decline in CHD mortality in Finland.

Screening of family members of patients with premature coronary heart disease; results from the EUROASPIRE II family survey

AIMS

To determine whether the Joint European Societies' recommendations that first degree blood relatives of patients with premature coronary heart disease (CHD) should be screened for coronary risk factors is being followed and, if so, how effectively these relatives are being managed.

METHODS AND RESULTS

Using a postal questionnaire, 3322 relatives (siblings and children >/=18 years of age) of 1289 index patients in the EUROASPIRE II survey who had suffered from premature CHD (men under 55 years and women under 65 years) were asked whether screening for coronary risk factors had occurred and, if so, how they were being managed in terms of lifestyle advice and drug therapies. Overall, screening for coronary risk factors because of CHD in the family was only performed in 11.1% of siblings and 5.6% of children. However, prevalences of different cardiac risk factors were high both in relatives and offspring and a clear familial clustering could be documented. Less than 50% of siblings and 25% of children were given some general lifestyle advice regarding cardiac risk factors. Moreover, active interventions such as starting antihypertensive or lipid lowering drugs were rarely carried out, particularly in children of patients with premature CHD.

CONCLUSIONS

European physicians rarely screen family members of patients with premature CHD for cardiac risk factors. General lifestyle style advice or active treatment for these risk factors are also rarely given. However, since these family members have a high prevalence and familial clustering of cardiac risk factors, they form an ideal target population for primary prevention of CHD in high-risk patients.

Two-hour glucose is a better risk predictor for incident coronary heart disease and cardiovascular mortality than fasting glucose

AIMS

To assess the predictive value of fasting and 2-h glucose after a 75 g glucose load, with regard to incidence of coronary heart disease and cardiovascular mortality.

METHODS AND RESULTS

6766 subjects from five Finnish cohorts aged 30-89 years were followed up for 7-10 years. Hazards ratios associated with increasing glucose concentrations were homogeneous over studies. Multivariate Cox regression analyses showed that the hazards ratio for one standard deviation increase in 2-h glucose after logarithmic transformation was 1.17 (95% CI 1.05-1.30) for coronary heart disease incidence and 1.22 (1.09-1.37) for cardiovascular mortality. For fasting glucose, they were 1.05 (0.94-1.17) and 1.13 (1.01-1.25), respectively. Inclusion of 2-h glucose in the model based on fasting glucose significantly improved the prediction (P<0.005 for coronary heart disease incidence and P<0.025 for cardiovascular mortality), whereas fasting glucose did not add significant information to the model initially based on 2-h glucose (P>0.10 for both events).

CONCLUSION

In subjects without a prior history of diabetes the association of 2-h glucose with coronary heart disease incidence and cardiovascular morality is graded and independent. The results of our study indicate that 2-h glucose is superior to fasting glucose in assessing the risk of future cardiovascular disease events.

Variation in the fatty acid binding protein 2 gene is not associated with markers of metabolic syndrome in patients with coronary heart disease

BACKGROUND AND AIM

It has been suggested that the threonine (Thr) 54 allele of the intestinal fatty acid binding protein 2 (FABP2) gene is associated with insulin resistance and affects the fatty acid composition of serum lipids. Our aim was to investigate the frequency of the alanine (Ala) 54Thr polymorphism of the FABP2 gene in patients with coronary heart disease (CHD), and the association between the polymorphism and the markers of metabolic syndrome, serum lipid levels and the fatty acid profile of serum lipids.

METHODS AND RESULTS

A total of 414 CHD patients (mean age 61 years, range 33-74) participated in the cross-sectional EUROASPIRE (European Action on Secondary Prevention through Intervention to Reduce Events) Study. Markers of metabolic syndrome included fasting plasma glucose concentration, serum high-density lipoprotein cholesterol and triglycerides (TG), waist circumference, the waist/hip ratio, body mass index (BMI) and blood pressure (BP). The frequency of the Thr54 allele was similar in the CHD patients (27.2%) and control subjects from two independent studies (27.8% and 28.7%). There were no significant differences in plasma glucose, serum lipids, BP, BMI, waist circumference or waist/hip ratio among the genotypes. Genotype frequency was not associated with the prevalence of diabetes or metabolic syndrome, but metabolic syndrome (as defined by National Cholesterol Education Program criteria) tended to be more frequent in subjects with the Thr/Thr genotype (p = 0.095). There were no differences in the fatty acid profiles of serum cholesteryl esters, TG or phospholipids among the genotypes.

CONCLUSIONS

The Ala54Thr polymorphism of the FABP2 gene is not associated with CHD, markers of the metabolic syndrome, or the fatty acid profile of serum lipids in Finnish CHD patients.

Differences in the diagnosis of myocardial infarction by troponin T compared with clinical and epidemiologic criteria

We investigated the difference in the number of myocardial infarction (MI) diagnoses based on troponin T compared with clinical and epidemiologic (modified FINnish Multinational MONItoring of trends and determinants in CArdiovascular diseases) diagnoses, and the prognosis of patients with discordant diagnoses. Five hundred fifty-nine consecutive patients (315 men and 244 women, median age 69 years) were admitted to the hospital with a suspected acute coronary syndrome. Median follow-up time was 17 months. Of the 559 patients, 127 had a clinical and 137 an epidemiologic diagnosis of MI. When a diagnosis of MI was primarily based on troponin T (>0.10 microg/L), the number of MIs was 169, which increased by 33% compared with the number of MIs by clinical diagnosis, and by 23% compared with those by epidemiologic diagnosis. However, troponin T was not elevated in 13% of the 127 patients with the clinical diagnosis and in 14% of the 137 patients with the epidemiologic diagnosis of MI. Among patients in whom clinical diagnosis of MI was not made, the prognosis with regard to coronary death or nonfatal MI was not significantly worse in patients with troponin T >0.10 microg/L than < or =0.10 microg/L (hazard ratio 1.07; 95% confidence interval 0.62 to 1.84). In patients with a suspected acute coronary syndrome, troponin T-based diagnostics leads to an increase in the number of patients diagnosed with MI compared with clinical or epidemiologic diagnosis. The prognostic impact of troponin T in patients without clinical diagnosis of MI based on elevations in conventional enzyme activities needs further study in larger series of patients.

Ruling out myocardial infarction with troponin T and creatine kinase MB mass: diagnostic and prognostic aspects

OBJECTIVE

To investigate the time window for ruling out myocardial infarction (MI) with troponin T (TnT) and creatine kinase isoenzyme MB mass (CK-MBm) and the prognosis of patients with ruled-out MI diagnosis.

DESIGN

The study was based on 397 patients admitted with a suspected acute coronary syndrome but with relief of symptoms within 24 h.

RESULTS

MI diagnosis was confirmed with elevated TnT (>0.10 microg/l) in 108 patients. in 91% within 12-24 h from the onset of symptoms, and in 99% within 12 h from admission. In 94 of these patients CK-MBm became elevated (>5.0 microg/l). in 95% within 10-12 h from the onset of symptoms, and in 99% within 6 h from admission. Among patients with ruled-out MI diagnosis, the 1-year incidence of recurrent coronary events was 29% in those with positive history of coronary heart disease (CHD) but only 7% in those without prior CHD (p < 0.001).

CONCLUSION

Using TnT or CK-MBm, MI can be ruled out within 12 h from admission in the majority of patients. Among patients with ruled-out MI diagnosis, positive history of CHD is an important determinant of prognosis.

Gender differences in recurrent coronary events; the FINMONICA MI register

BACKGROUND

Male gender is an established risk factor for first myocardial infarction, but some studies have suggested that among myocardial infarction survivors, women fare worse than men. Therefore, we examined the long-term prognosis of incident myocardial infarction survivors in a large, population-based MI register, addressing gender differences in mortality as well as the number of events and time intervals between recurrent events.

METHODS AND RESULTS

Study subjects included 4900 men and women, aged 25-64 years, with definite or probable first myocardial infarctions who were alive 28 days after the onset of symptoms. At first myocardial infarction, women were older and more likely to be hypertensive or diabetic than men, and had a greater proportion of probable vs definite events. After adjustment for age and geographic region, men had 1.74 times the risk of fatal coronary heart disease relative to women (hazard ratio=1.63 and 1.55 for cardiovascular disease and all-cause mortality, respectively) over an average of 5.9 years of follow-up. Number and time intervals between any recurrent event--fatal and non-fatal--did not differ by gender.

CONCLUSION

These data suggest that men are far more likely to have a fatal recurrent event than women despite comparable numbers of events.

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

OBJECTIVE

To examine socioeconomic differences in case fatality and prognosis of myocardial infarction (MI) events, and to estimate the contributions of incidence and case fatality to socioeconomic differences in coronary heart disease (CHD) mortality.

DESIGN

A population-based MI register study.

METHODS

The FINMONICA MI Register recorded all MI events among persons aged 35-64 years in three areas of Finland during 1983-1992. A record linkage of the MI Register data with the files of Statistics Finland was performed to obtain information on socioeconomic indicators for each individual registered. First MI events (n=8427) were included in the analyses.

MAIN RESULTS

The adjusted risk ratio of prehospital coronary death was 2.11 (95% CI 1.82, 2.46) among men and 1.68 (1.14, 2.48) among women with low income compared with those with high income. Even among persons hospitalised alive the risk of death during the next 12 months was markedly higher in the low income group than in the high income group. Case fatality explained 51% of the CHD mortality difference between the low and the high income groups among men and 38% among women. Incidence contributed 49% and 62%, respectively.

CONCLUSIONS

Considerable socioeconomic differences were observed in the case fatality of first coronary events both before hospitalisation and among patients hospitalised alive. Case fatality explained a half of the CHD mortality difference between the low and the high income groups among men and more than a third among women.

Risk factors for a major coronary event after myocardial infarction in the Scandinavian Simvastatin Survival Study (4S). Impact of predicted risk on the benefit of cholesterol-lowering treatment

AIMS

To analyse (1) the prognostic importance of clinical findings and lipids in patients with a previous myocardial infarction and (2) the relative and absolute benefit of simvastatin in patients at low, medium and high predicted risk.

METHODS

The 4S was a double-blind, randomized, clinical trial of long-term treatment with simvastatin or matching placebo in patients with myocardial infarction or angina pectoris, serum total cholesterol 5.5-8.0 mmol x l(-1), and serum triglycerides <or=2.5 mmol x l(-1). The present study only deals with those 3525 patients who had a previous myocardial infarction. End-points comprised coronary death, definite and probable hospital verified myocardial infarction, and resuscitated cardiac arrest. Because there were few women the primary analyses were performed among men.

RESULTS

A Cox model analysis in the placebo group identified the following independent predictors of coronary events: a history of hypertension (P=0.023), diabetes (P=0.0001), smoking after the myocardial infarction (P=0.010), total cholesterol (P=0.020), and HDL cholesterol (P=0.062). The relative reduction of risk by simvastatin treatment in patients at low, medium and high predicted risk was 38%, 39% and 42%, respectively, but the corresponding absolute benefit per 100 patients treated for 6 years increased from 7.9 to 16.2.

CONCLUSION

In addition to serum lipids, clinical variables contributed significantly to prediction. The relative benefit from simvastatin treatment was independent of predicted risk, but the absolute benefit increased from low to high risk.

Microbial etiology of community-acquired pneumonia in the adult population of 4 municipalities in eastern Finland

To determine the etiology of community-acquired pneumonia in the adult population of a defined area, specific antibody responses in paired serum samples, levels of circulating pneumococcal immune complexes in serum samples, and pneumococcal antigen in urine were measured. Samples (304 paired serum samples and 300 acute urine samples) were obtained from 345 patients > or =15 years old with community-acquired, radiologically confirmed pneumonia, which comprised all cases in the population of 4 municipalities in eastern Finland during 1 year. Specific infecting organisms were identified in 183 patients (including 49 with mixed infection), as follows: Streptococcus pneumoniae, 125 patients; Haemophilus influenzae, 12; Moraxella catarrhalis, 8; chlamydiae, 37 (of which, Chlamydia pneumoniae, 30); Mycoplasma pneumoniae, 30; and virus species, 27. The proportion of patients with pneumococcal infections increased and of those with Mycoplasma infections decreased with age, but for each age group, the etiologic profile was similar among inpatients and among outpatients. S. pneumoniae was the most important etiologic agent. The annual incidence of pneumococcal pneumonia per 1000 inhabitants aged > or =60 years was 8.0.

C-reactive protein, fibrinogen, interleukin-6 and tumour necrosis factor-alpha in the prognostic classification of unstable angina pectoris

BACKGROUND

Inflammatory process has been found to play an important role in the pathogenesis of coronary heart disease (CHD) and in the prognosis of CHD patients. AIM. The aim of this study was to investigate the prognostic value of C-reactive protein (CRP), fibrinogen, interleukin (IL)-6 and tumour necrosis factor-alpha (TNF-alpha) in patients with unstable angina pectoris (UAP), including factor analysis to assess their joint effects.

METHODS

The study comprised 263 consecutive patients (159 men, 104 women; median age 68 years) with UAP. Blood samples for the acute-phase protein and cytokine determinations were drawn on admission.

RESULTS

Coronary mortality during the median follow-up time of 17 months was 6-fold higher in the highest tertile for CRP and IL-6 and 3.5-fold higher in the highest tertile for fibrinogen and TNF-alpha than in the respective combined lower tertiles. Factor analysis produced two underlying factors, ie the 'inflammation' factor, including CRP, fibrinogen and IL-6, and the 'injury' factor, including troponin T, creatine kinase MB mass and TNF-alpha. In Cox models, both of these factors were independent predictors of the risk of coronary death and major coronary events (coronary death or nonfatal myocardial infarction).

CONCLUSIONS

Elevated levels of acute-phase proteins and cytokines, particularly CRP and IL-6, are strong predictors of the risk of serious coronary events in patients with UAP.

Potential for cholesterol lowering in secondary prevention of coronary heart disease in europe: findings from EUROASPIRE study. European Action on Secondary Prevention through Intervention to Reduce Events

We have examined the potential for cholesterol lowering in secondary prevention of coronary heart disease based on data from the European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE) study carried out in 1995-1996 in nine European centres (Czech Republic, Finland, France, Germany, Hungary, Italy, The Netherlands, Slovenia and Spain). Consecutive patients aged < or = 70 years in four diagnostic categories--coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, acute myocardial infarction, and acute myocardial ischaemia without infarction--were identified from hospital records and invited for an interview and risk factor assessment at least 6 months after hospital admission. Plasma lipid measurements were carried out in a central laboratory. Combining patients from all centres and diagnostic categories (n = 2749) the medians (interquartile ranges) for plasma lipids were: total cholesterol 5.36 (4.76-6.03) mmol/l, high density lipoprotein (HDL) cholesterol 1.19 (1.01-1.42) mmol/l, triglycerides 1.55 (1.15-2.24) mmol/l, and low density lipoprotein (LDL) cholesterol 3.32 (2.76-3.91) mmol/l. Only 33% of the patients received lipid-lowering drugs. If the therapeutic goal given in the 1998 European recommendations, total cholesterol < 5.0 mmol/l, were applied, 67% of these patients would have needed an intensified cholesterol-lowering action, and with an even stricter goal, total cholesterol < 4.5 mmol/l, this proportion would have been as high as 84%.

Depression after coronary heart disease events

OBJECTIVE

To study the prevalence of depression at least 6 months after various coronary heart disease (CHD) events (bypass grafting, coronary angioplasty, myocardial infarction, myocardial ischaemia without infarction) and the associations between depression and clinical variables.

DESIGN

In the course of the study 414 (284 males, 130 females) patients younger than 71 years (mean age for men 60.9 years and for women 63.6 years) were interviewed and examined. Smoking habits, body mass index, lipid levels and diabetic status were recorded. The New York Heart Association (NYHA) class was assessed. Depression was screened using a self-rated depression scale.

RESULTS

In the four diagnostic categories, one-sixth of the patients (14-19%) suffered from depression. Depression was associated with smoking (OR 1.7, 95% CI 1.2; 2.4) and poor NYHA class (OR 1.9, 95% CI 1.4; 2.6).

CONCLUSION

Depression is common after CHD events, and is associated with smoking and poor NYHA class. The identification and treatment of depression should be one of the elements in the rehabilitation of cardiac patients.

[Cardiovascular trials in diabetes: past and present. Invited lecture of the XXXVth National Congress of the Spanish Society of Cardiology]

The risk of coronary heart disease in subjects with Type2 diabetes is 2-4 times higher than in non-diabetic subjects of the same age. About 20% of patients with clinically established coronary heart disease have diabetes and the prognosis is much worse in diabetic than in non-diabetic patients. Trial evidence suggests that good blood glucose control reduces the risk of myocardial infarction in diabetic patients and improves prognosis after it. Trial evidence indicates that the benefit from antihypertensive treatment is at least as good in diabetic than in non-diabetic patients, and that diabetic patients with coronary heart disease or other form of atherosclerotic vascular disease should be treated with lipid-lowering drugs (usually with statins), if their LDL cholesterol levels on diet remain> 3.0 mmol/l (115 mg/dl). Trial evidence supports the use of aspirin in middle-aged or elderly diabetic patients. All diabetic patients should be advised to stop smoking.

Plasma insulin and all-cause, cardiovascular, and noncardiovascular mortality: the 22-year follow-up results of the Helsinki Policemen Study

OBJECTIVE

To investigate the association of plasma insulin with all-cause, cardiovascular, and noncardiovascular mortality.

RESEARCH DESIGN AND METHODS

We studied 22-year mortality data from the Helsinki Policemen Study The study population comprised 970 men, 34-64 years of age, who were free of coronary heart disease, other cardiovascular disease, and diabetes. Area under the insulin response curve (AUC insulin) during an oral glucose tolerance test was used to reflect plasma insulin levels.

RESULTS

During the follow-up period, 276 men died: 130 from cardiovascular and 146 from noncardiovascular causes. The hazard ratio (HR) for hyperinsulinemia (highest AUC insulin quintile vs. combined lower quintiles) with regard to all-cause mortality adjusting for age, was 1.94 (95% CI 1.20-3.13) during the first 10 years of the follow-up period and 1.51 (1.15-1.97) during the entire 22 years; adjusting for other risk factors, the HR was 1.88 (1.08-3.30) and 1.37 (1.00-1.87) during 10 and 22 years, respectively The corresponding HRs for cardiovascular mortality during 10 and 22 years were 2.67 (1.35-5.29) and 1.73 (1.19-2.53), respectively, for age-adjusted and 2.30 (1.03-5.12) and 1.39 (0.90-2.15), respectively, for multiple-adjusted HRs. A U-shaped association was observed between insulin and noncardiovascular mortality, multiple-adjusted HRs for lowest and highest versus middle AUC insulin quintiles were 1.85 (1.20-2.86) and 1.43 (0.91-2.24), respectively

CONCLUSIONS

Hyperinsulinemia was associated with increased all-cause and cardiovascular mortality in Helsinki policemen independent of other risk factors, although these associations weakened with the lengthening of the follow-up period. The association of insulin with noncardiovascular mortality was U-shaped.