Publications by authors named "Seppo Lehto"

54 Publications

Potential for optimizing management of obesity in the secondary prevention of coronary heart disease.

Eur Heart J Qual Care Clin Outcomes 2021 Jul 27. Epub 2021 Jul 27.

Department of Medicine, Solna, Karolinska Institutet, FoU - Tema Hjärta och Kärl, S1:02, Karolinska Universitetssjukhuset/Solna, SE-171 76, Stockholm, Sweden.

Aims: Prevention guidelines have identified the management of obese patients as an important priority to reduce the burden of incident and recurrent cardiovascular disease. Still, studies have demonstrated that over 80% of patients with coronary heart disease (CHD) fail to achieve their weight target. Here, we describe advice received and actions reported by overweight CHD patients since being discharged from hospital and how weight changes relate to their risk profile.

Methods And Results: Based on data from 10 507 CHD patients participating in the EUROASPIRE IV and V studies, we analysed weight changes from hospital admission to the time of a study visit ≥6 and <24 months later. At hospitalization, 34.9% were obese and another 46.0% were overweight. Obesity was more frequent in women and associated with more comorbidities. By the time of the study visit, 19.5% of obese patients had lost ≥5% of weight. However, in 16.4% weight had increased ≥5%. Weight gain in those overweight was associated with physical inactivity, non-adherence to dietary recommendations, smoking cessation, raised blood pressure, dyslipidaemia, dysglycaemia, and lower levels of quality of life. Less than half of obese patients was considering weight loss in the coming month.

Conclusions: The management of obesity remains a challenge in the secondary prevention of CHD despite a beneficial effect of weight loss on risk factor prevalences and quality of life. Cardiac rehabilitation programmes should include weight loss interventions as a specific component and the incremental value of telehealth intervention as well as recently described pharmacological interventions need full consideration.
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http://dx.doi.org/10.1093/ehjqcco/qcab043DOI Listing
July 2021

Risk factors for major adverse cardiovascular events after the first acute coronary syndrome.

Ann Med 2021 12;53(1):817-823

Finnish Institute for Health and Welfare, Helsinki, Finland.

Aims: To evaluate risk factors for major adverse cardiac event (MACE) after the first acute coronary syndrome (ACS) and to examine the prevalence of risk factors in post-ACS patients.

Methods: We used Finnish population-based myocardial infarction register, FINAMI, data from years 1993-2011 to identify survivors of first ACS ( = 12686), who were then followed up for recurrent events and all-cause mortality for three years. Finnish FINRISK risk factor surveys were used to determine the prevalence of risk factors (smoking, hyperlipidaemia, diabetes and blood pressure) in post-ACS patients ( = 199).

Results: Of the first ACS survivors, 48.4% had MACE within three years of their primary event, 17.0% were fatal. Diabetes (p = 4.4 × 10), heart failure (HF) during the first ACS attack hospitalization (p = 6.8 × 10), higher Charlson index (p = 1.56 × 10) and older age ( = .026) were associated with elevated risk for MACE in the three-year follow-up, and revascularization ( = .0036) was associated with reduced risk. Risk factor analyses showed that 23% of ACS survivors continued smoking and cholesterol levels were still high (>5mmol/l) in 24% although 86% of the patients were taking lipid lowering medication.

Conclusion: Diabetes, higher Charlson index and HF are the most important risk factors of MACE after the first ACS. Cardiovascular risk factor levels were still high among survivors of first ACS.
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http://dx.doi.org/10.1080/07853890.2021.1924395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183550PMC
December 2021

Prediction of recurrent event in patients with coronary heart disease: the EUROASPIRE Risk Model.

Eur J Prev Cardiol 2020 Dec 29. Epub 2020 Dec 29.

Department of Public Health and Primary Care, Ghent University, C. Heymanslaan 10, 9000 Gent, Belgium.

Aims: Most patients with established atherosclerotic cardiovascular disease (CVD) are at very high risk for developing recurrent events. Since this risk varies a lot between patients there is a need to identify those in whom an even more intensive secondary prevention strategy should be envisaged. Using data from the EUROASPIRE IV and V cohorts of coronary heart disease (CHD) patients from 27 European countries, we aimed at developing and internally and externally validating a risk model predicting recurrent CVD events in patients aged < 75 years.

Methods And Results: Prospective data were available for 12 484 patients after a median follow-up time of 1.7 years. The primary endpoint, a composite of fatal CVD or new hospitalizations for non-fatal myocardial infarction (MI), stroke, heart failure, coronary artery bypass graft, or percutaneous coronary intervention (PCI), occurred in 1424 patients. The model was developed based on data from 8000 randomly selected patients in whom the association between potential risk factors and the incidence of the primary endpoint was investigated. This model was then validated in the remaining 4484 patients. The final multivariate model revealed a higher risk for the primary endpoint with increasing age, a previous hospitalization for stroke, heart failure or PCI, a previous diagnosis of peripheral artery disease, self-reported diabetes and its glycaemic control, higher non-high-density lipoprotein cholesterol, reduced renal function, symptoms of depression and anxiety and living in a higher risk country. The model demonstrated excellent internal validity and proved very adequate in the validation cohort. Regarding external validity, the model demonstrated good discriminative ability in 20 148 MI patients participating in the SWEDEHEART register. Finally, we developed a risk calculator to estimate risks at 1 and 2 years for patients with stable CHD.

Conclusion: In patients with CHD, fatal and non-fatal rates of recurrent CVD events are high. However, there are still opportunities to optimize their management in order to prevent further disease or death. The EUROASPIRE Risk Calculator may be of help to reach this goal.
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http://dx.doi.org/10.1093/eurjpc/zwaa128DOI Listing
December 2020

Lifestyle and impact on cardiovascular risk factor control in coronary patients across 27 countries: Results from the European Society of Cardiology ESC-EORP EUROASPIRE V registry.

Eur J Prev Cardiol 2019 05 10;26(8):824-835. Epub 2019 Feb 10.

32 Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Krakow, Poland.

Aims: The aim of this study was to determine whether the Joint European Societies guidelines on secondary cardiovascular prevention are followed in everyday practice.

Design: A cross-sectional ESC-EORP survey (EUROASPIRE V) at 131 centres in 81 regions in 27 countries.

Methods: Patients (<80 years old) with verified coronary artery events or interventions were interviewed and examined ≥6 months later.

Results: A total of 8261 patients (females 26%) were interviewed. Nineteen per cent smoked and 55% of them were persistent smokers, 38% were obese (body mass index ≥30 kg/m), 59% were centrally obese (waist circumference: men ≥102 cm; women ≥88 cm) while 66% were physically active <30 min 5 times/week. Forty-two per cent had a blood pressure ≥140/90 mmHg (≥140/85 if diabetic), 71% had low-density lipoprotein cholesterol ≥1.8 mmol/L (≥70 mg/dL) and 29% reported having diabetes. Cardioprotective medication was: anti-platelets 93%, beta-blockers 81%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75% and statins 80%.

Conclusion: A large majority of coronary patients have unhealthy lifestyles in terms of smoking, diet and sedentary behaviour, which adversely impacts major cardiovascular risk factors. A majority did not achieve their blood pressure, low-density lipoprotein cholesterol and glucose targets. Cardiovascular prevention requires modern preventive cardiology programmes delivered by interdisciplinary teams of healthcare professionals addressing all aspects of lifestyle and risk factor management, in order to reduce the risk of recurrent cardiovascular events.
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http://dx.doi.org/10.1177/2047487318825350DOI Listing
May 2019

Incidence of cardiovascular events in patients with stabilized coronary heart disease: the EUROASPIRE IV follow-up study.

Eur J Epidemiol 2019 Mar 23;34(3):247-258. Epub 2018 Oct 23.

Department of Epidemiology and Population Studies, Faculty of Health Sciences, Jagiellonian University Medical College, Kracow, Poland.

The EUROASPIRE surveys (EUROpean Action on Secondary Prevention through Intervention to Reduce Events) demonstrated that most European coronary patients fail to achieve lifestyle, risk factor and therapeutic targets. Here we report on the 2-year incidence of hard cardiovascular (CV) endpoints in the EUROASPIRE IV cohort. EUROASPIRE IV (2012-2013) was a large cross-sectional study undertaken at 78 centres from selected geographical areas in 24 European countries. Patients were interviewed and examined at least 6 months following hospitalization for a coronary event or procedure. Fatal and non-fatal CV events occurring at least 1 year after this baseline screening were registered. The primary outcome in our analyses was the incidence of CV death or non-fatal myocardial infarction, stroke or heart failure. Cox regression models, stratified for country, were fitted to relate baseline characteristics to outcome. Our analyses included 7471 predominantly male patients. Overall, 222 deaths were registered of whom 58% were cardiovascular. The incidence of the primary outcome was 42 per 1000 person-years. Comorbidities were strongly and significantly associated with the primary outcome (multivariately adjusted hazard ratio HR, 95% confidence interval): severe chronic kidney disease (HR 2.36, 1.44-3.85), uncontrolled diabetes (HR 1.89, 1.50-2.38), resting heart rate ≥ 75 bpm (HR 1.74, 1.30-2.32), history of stroke (HR 1.70, 1.27-2.29), peripheral artery disease (HR 1.48, 1.09-2.01), history of heart failure (HR 1.47, 1.08-2.01) and history of acute myocardial infarction (HR 1.27, 1.05-1.53). Low education and feelings of depression were significantly associated with increased risk. Lifestyle factors such as persistent smoking, insufficient physical activity and central obesity were not significantly related to adverse outcome. Blood pressure and LDL-C levels appeared to be unrelated to cardiovascular events irrespective of treatment. In patients with stabilized CHD, comorbid conditions that may reflect the ubiquitous nature of atherosclerosis, dominate lifestyle-related and other modifiable risk factors in terms of prognosis, at least over a 2-year follow-up period.
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http://dx.doi.org/10.1007/s10654-018-0454-0DOI Listing
March 2019

Type 2 diabetic patients on renal replacement therapy: Probability to receive renal transplantation and survival after transplantation.

PLoS One 2018 15;13(8):e0201478. Epub 2018 Aug 15.

Finnish Registry for Kidney Diseases, Helsinki, Finland.

Background: Type 2 diabetic (T2DM) patients on renal replacement therapy (RRT) seldom receive a kidney transplant, which is partly due to age and comorbidities. Adjusting for case mix, we investigated whether T2DM patients have equal opportunity for renal transplantation compared to other patients on dialysis, and whether survival after transplantation is comparable.

Methods: Patients who entered RRT in Finland in 2000-2010 (n = 5419) were identified from the Finnish Registry for Kidney Diseases and followed until the end of 2012. Of these, 20% had T2DM, 14% type 1 diabetes (T1DM) and 66% other than diabetes as the cause of ESRD. Uni-/multivariate survival analysis techniques were employed to assess the probability of kidney transplantation after the start of dialysis and survival after transplantation.

Results: T2DM patients had a relative probability of renal transplantation of 0.18 (95% CI 0.15-0.22, P<0.001) compared to T1DM patients: this increased to 0.51 (95% CI 0.36-0.72, P<0.001) after adjustment for case mix (age, gender, laboratory values and comorbidities). When T2DM patients were compared to non-diabetic patients, the corresponding relative probabilities were 0.25 (95% CI 0.20-0.30, P<0.001) and 0.59 (95% CI 0.43-0.83, P = 0.002). After renal transplantation when adjusted for age and gender, relative risk of death was 1.25 (95% CI 0.64-2.44, P = 0.518) for T1DM patients and 0.72 (0.43-1.22, P = 0.227) for other patients compared to T2DM patients.

Conclusions: T2DM patients had a considerably lower probability of receiving a kidney transplant, which could not be fully explained by differences in the patient characteristics. Survival within 5 years after transplantation is comparably good in T2DM patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0201478PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6093678PMC
January 2019

Case fatality of acute coronary events is improving even among elderly patients; the FINAMI study 1995-2012.

Ann Med 2018 02 3;50(1):35-45. Epub 2017 Oct 3.

c Department of Health , National Institute for Health and Welfare (THL) , Helsinki , Finland.

Aim: To examine trends in incidence and 28-day case fatality of myocardial infarction (MI) in persons aged 75-99 years in four areas of Finland.

Methods And Results: The Finnish Acute Myocardial Infarction (FINAMI) register is a population-based MI register study, which during 1995-2012 recorded 30561 suspected acute coronary syndromes in persons aged ≥75 years. Of them, 16229 fulfilled the American Heart Association criteria for a definite, probable or possible MI or coronary death. This age-group contributed 56.8% of all MIs of which 62.7% occurred in women. The incidence of MI decreased by -3.3%/year (95% CI -4.2; -2.4) in women aged 75-84 years, and by -1.2%/year (-1.9; -0.5) in women aged 85-99 years, but among men in these age-groups, only a non-significant reduction occurred. The 28-day case fatality of MI was high. In the age-group 75-84 years, it decreased non-significantly by -1.6%/year in men, and significantly by -2.4%/year (-3.9; -0.8) in women. In the age-group 85-99 years, the decrease was more remarkable: -5.1%/year (-7.8; -2.3) and -3.9%/year (-5.5; -2.2), respectively.

Conclusions: In Finland, more than half of MIs occur in the age-group 75-99 years, and most of them in women. The incidence of MI decreased significantly in elderly women but non-significantly in elderly men. The 28-day case fatality decreased especially in the age-group 85-99 years. Key Messages In Finland, more than one half of all myocardial infarctions (MIs) occur in the age-group of 75 years or older. Furthermore, 62.7% of MIs among elderly patients occur among women, although 58.0% of the elderly population are women. The incidence of MI decreased significantly in elderly women but not in elderly men. The 28-day case fatality in elderly patients was high but decreased significantly during the study period 1995-2012. This study provides population-based data on treatment strategies and trends in incidence, event rate, mortality and case fatality of MI in elderly individuals. Elderly patients with acute coronary syndromes still present a remarkable burden to the healthcare system in Finland as well as in many other developed countries. Especially considering the modern trend of reducing hospital resources and shifting patient care to outpatient clinics, the epidemiology of MI in elderly patients remains an important issue for the future planning of the healthcare system.
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http://dx.doi.org/10.1080/07853890.2017.1382713DOI Listing
February 2018

Trends in long-term prognosis after acute coronary syndrome.

Eur J Prev Cardiol 2017 02 19;24(3):274-280. Epub 2016 Nov 19.

3 Department of Health, National Institute for Health and Welfare, Helsinki, Finland.

Background Coronary heart disease incidence, mortality and short-term case-fatality have improved substantially during the past decades. Recent changes in the long-term prognosis among survivors of acute coronary syndrome are less well known. Our aim was to investigate the long-term prognosis of acute coronary syndrome. Design An observational myocardial infarction register study. Methods Data was derived from the population based Finnish Myocardial Infarction register. Patients aged 35 or higher, who had their first acute coronary syndrome during 1993-2011 and survived the first 28 days, were included in the analysis ( n = 13,336). Endpoints were fatal and non-fatal cardiovascular disease events and all-cause mortality at one year and three years after the index event. We also compared the prognosis of acute coronary syndrome survivors with the prognosis of an apparently healthy population with the same age, sex and area of residence, derived from the FINRISK study. Results Significant declines over time were observed in the risk of a new cardiovascular disease event. At three year follow-up the age- and study area-adjusted hazard ratio per calendar year was 0.969 (95% confidence interval 0.960-0.977, p = 4.63 × 10) among men and 0.969 (95% confidence interval 0.961-0.978, p = 1.01 × 10) among women. Despite the improvement in prognosis, the age-standardized three year cardiovascular disease free survival of acute coronary syndrome patients was significantly lower than in the FINRISK control group (for men p = 6.64 × 10 and for women p = 2.11 × 10). Conclusion The prognosis of acute coronary syndrome survivors has improved during the 18-year period but is still much worse than the prognosis of comparable general population.
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http://dx.doi.org/10.1177/2047487316679522DOI Listing
February 2017

Time Trends in Lifestyle, Risk Factor Control, and Use of Evidence-Based Medications in Patients With Coronary Heart Disease in Europe: Results From 3 EUROASPIRE Surveys, 1999-2013.

Glob Heart 2017 12 16;12(4):315-322.e3. Epub 2016 Mar 16.

International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom.

Background: The EUROASPIRE (European Action on Secondary and Primary Prevention by Intervention to Reduce Events) cross-sectional surveys describe time trends in lifestyle and risk factor control among coronary patients between 1999 and 2013 in Belgium, Czech Republic, Finland, France, Ireland, the Netherlands, Poland, Slovenia, and the United Kingdom as part of the EuroObservational Research Programme under the auspices of European Society of Cardiology.

Objectives: This study sought to describe time trends in lifestyle, risk factor control, and the use of evidence-based medication in coronary patients across Europe.

Methods: The EUROASPIRE II (1999 to 2000), III (2006 to 2007), and IV (2012 to 13) surveys were conducted in the same geographical areas and selected hospitals in each country. Consecutive patients (≤70 years) after coronary artery bypass graft, percutaneous coronary intervention, or an acute coronary syndrome identified from hospital records were interviewed and examined ≥6 months later with standardized methods.

Results: Of 12,775 identified coronary patients, 8,456 (66.2%) were interviewed. Proportion of current smokers was similar across the 3 surveys. Prevalence of obesity increased by 7%. The prevalence of raised blood pressure (≥140/90 mm Hg or ≥140/80 mm Hg with diabetes) dropped by 8% from EUROASPIRE III to IV, and therapeutic control of blood pressure improved with 55% of patients below target in IV. The prevalence of low-density lipoprotein cholesterol ≥2.5 mmol/l decreased by 44%. In EUROASPIRE IV, 75% were above the target low-density lipoprotein cholesterol <1.8 mmol/l. The prevalence of self-reported diabetes increased by 9%. The use of evidence-based medications increased between the EUROASPIRE II and III surveys, but did not change between the III and IV surveys.

Conclusions: Lifestyle habits have deteriorated over time with increases in obesity, central obesity, and diabetes and stagnating rates of persistent smoking. Although blood pressure and lipid management improved, they are still not optimally controlled and the use of evidence-based medications appears to have stalled apart from the increased use of high-intensity statins. These results underline the importance of offering coronary patients access to modern preventive cardiology programs.
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http://dx.doi.org/10.1016/j.gheart.2015.11.003DOI Listing
December 2017

Patients with coronary artery disease and diabetes need improved management: a report from the EUROASPIRE IV survey: a registry from the EuroObservational Research Programme of the European Society of Cardiology.

Cardiovasc Diabetol 2015 Oct 1;14:133. Epub 2015 Oct 1.

European Society of Cardiology, Les Templiers, 2035 route des Colles, CS 80179 BIOT, 06903, Sophia Antipolis Cedex, France.

Background: In order to influence every day clinical practice professional organisations issue management guidelines. Cross-sectional surveys are used to evaluate the implementation of such guidelines. The present survey investigated screening for glucose perturbations in people with coronary artery disease and compared patients with known and newly detected type 2 diabetes with those without diabetes in terms of their life-style and pharmacological risk factor management in relation to contemporary European guidelines.

Methods: A total of 6187 patients (18-80 years) with coronary artery disease and known glycaemic status based on a self reported history of diabetes (previously known diabetes) or the results of an oral glucose tolerance test and HbA1c (no diabetes or newly diagnosed diabetes) were investigated in EUROASPIRE IV including patients in 24 European countries 2012-2013. The patients were interviewed and investigated in order to enable a comparison between their actual risk factor control with that recommended in current European management guidelines and the outcome in previously conducted surveys.

Results: A total of 2846 (46%) patients had no diabetes, 1158 (19%) newly diagnosed diabetes and 2183 (35%) previously known diabetes. The combined use of all four cardioprotective drugs in these groups was 53, 55 and 60%, respectively. A blood pressure target of <140/90 mmHg was achieved in 68, 61, 54% and a LDL-cholesterol target of <1.8 mmol/L in 16, 18 and 28%. Patients with newly diagnosed and previously known diabetes reached an HbA1c <7.0% (53 mmol/mol) in 95 and 53% and 11% of those with previously known diabetes had an HbA1c >9.0% (>75 mmol/mol). Of the patients with diabetes 69% reported on low physical activity. The proportion of patients participating in cardiac rehabilitation programmes was low (≈40 %) and only 27% of those with diabetes had attended diabetes schools. Compared with data from previous surveys the use of cardioprotective drugs had increased and more patients were achieving the risk factor treatment targets.

Conclusions: Despite advances in patient management there is further potential to improve both the detection and management of patients with diabetes and coronary artery disease.
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http://dx.doi.org/10.1186/s12933-015-0296-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4591740PMC
October 2015

EUROASPIRE IV: A European Society of Cardiology survey on the lifestyle, risk factor and therapeutic management of coronary patients from 24 European countries.

Eur J Prev Cardiol 2016 Apr 16;23(6):636-48. Epub 2015 Feb 16.

The European Society of Cardiology, Sophia Antipolis Cedex, France Federal Health Centre and Department of Chronic Noncommunicable Diseases Prevention, National Research Centre for Preventive Medicine, Moscow, Russia.

Aims: To determine whether the Joint European Societies guidelines on cardiovascular prevention are being followed in everyday clinical practice of secondary prevention and to describe the lifestyle, risk factor and therapeutic management of coronary patients across Europe.

Methods And Results: EUROASPIRE IV was a cross-sectional study undertaken at 78 centres from 24 European countries. Patients <80 years with coronary disease who had coronary artery bypass graft, percutaneous coronary intervention or an acute coronary syndrome were identified from hospital records and interviewed and examined ≥ 6 months later. A total of 16,426 medical records were reviewed and 7998 patients (24.4% females) interviewed. At interview, 16.0% of patients smoked cigarettes, and 48.6% of those smoking at the time of the event were persistent smokers. Little or no physical activity was reported by 59.9%; 37.6% were obese (BMI ≥ 30 kg/m(2)) and 58.2% centrally obese (waist circumference ≥ 102 cm in men or ≥88 cm in women); 42.7% had blood pressure ≥ 140/90 mmHg (≥140/80 in people with diabetes); 80.5% had low-density lipoprotein cholesterol ≥ 1.8 mmol/l and 26.8% reported having diabetes. Cardioprotective medication was: anti-platelets 93.8%; beta-blockers 82.6%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers 75.1%; and statins 85.7%. Of the patients 50.7% were advised to participate in a cardiac rehabilitation programme and 81.3% of those advised attended at least one-half of the sessions.

Conclusion: A large majority of coronary patients do not achieve the guideline standards for secondary prevention with high prevalences of persistent smoking, unhealthy diets, physical inactivity and consequently most patients are overweight or obese with a high prevalence of diabetes. Risk factor control is inadequate despite high reported use of medications and there are large variations in secondary prevention practice between centres. Less than one-half of the coronary patients access cardiac prevention and rehabilitation programmes. All coronary and vascular patients require a modern preventive cardiology programme, appropriately adapted to medical and cultural settings in each country, to achieve healthier lifestyles, better risk factor control and adherence with cardioprotective medications.
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http://dx.doi.org/10.1177/2047487315569401DOI Listing
April 2016

Prolonged P wave duration predicts stroke mortality among type 2 diabetic patients with prevalent non-major macrovascular disease.

BMC Cardiovasc Disord 2014 Nov 25;14:168. Epub 2014 Nov 25.

Department of Medicine, University of Turku and Turku University Hospital, Kiinamyllynkatu 10, 20520 Turku, Finland.

Background: Prolonged P wave duration is a marker of delayed inter-atrial conduction which may predict cardiovascular disease (CVD). Type 2 diabetes is a risk factor for all atherosclerotic manifestations including stroke. We evaluated the prognostic significance of prolonged P wave duration among middle-aged Finnish type 2 diabetes patients with and without prevalent non-major macrovascular disease (PNMMVD) with respect to total and stroke mortality.

Methods: We followed up for 18 years 739 type 2 diabetic patients without previous major CVD event at baseline. Participants were stratified according to P wave duration (<114 or ≥ 114 ms) and PNMMVD (i.e. coronary heart disease defined as ischaemic ECG changes and typical symptoms of angina pectoris, or claudication; yes or no). The Cox proportional hazards model was used to estimate the joint association between P wave duration, PNMMVD and the mortality risk.

Results: During the follow-up, 509 patients died, and 59 of them died from stroke. Those who had prolonged P wave duration had 2.45 (95% confidence interval: 1.11-5.37) increased stroke mortality among PNMMVD patients. In patients without PNMMVD, there was no relationship between P wave duration and stroke mortality.

Conclusions: As an easily measurable factor P wave duration merits further studies with higher number of patients to evaluate its importance in the estimation of stroke risk in type 2 diabetic patients with PNMMVD.
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http://dx.doi.org/10.1186/1471-2261-14-168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4280689PMC
November 2014

Effect of fatty and lean fish intake on lipoprotein subclasses in subjects with coronary heart disease: a controlled trial.

J Clin Lipidol 2014 Jan-Feb;8(1):126-33. Epub 2013 Sep 30.

Institute of Public Health and Clinical Nutrition, Kuopio Campus, University of Eastern Finland, Kuopio, Finland; Research Unit, Kuopio University Hospital, Kuopio, Finland.

Background: Fish oil intake reduces serum triglycerides; however, little is known about the effects of dietary fish intake on lipoprotein subclasses.

Objective: We aimed at assessing the effect of fatty and lean fish intake on the lipoprotein subclasses in an intervention study.

Methods: The intervention study included 33 patients with coronary heart disease, who were aged 61.0 ± 5.8 (mean ± SD) years. The subjects were randomly assigned to a fatty fish (n = 11), lean fish (n = 12), or control (n = 10) diet for 8 weeks. Fish diets included at least 4 fish meals per week. Subjects in the control group consumed lean beef, pork, and chicken. Lipoprotein subclasses and their lipid components were determined by nuclear magnetic resonance spectroscopy.

Results: Concentrations of n-3 fatty acids and docosahexaenoic acid increased in the fatty fish group. The concentrations of cholesterol, cholesterol esters, and total lipids in very large high-density lipoproteins (HDLs) increased in the fatty fish group (overall difference P = .005, P = .002, and P = .007, respectively; false discovery rate P = .04, P = .04, and P = .05, respectively). The mean size of HDL particles increased in the fatty fish group (9.8 ± 0.3 nm at baseline and 9.9 ± 0.4 nm at end of study; overall difference P = .004, false discovery rate P = .04). The fish diets did not affect very-low-density lipoprotein or low-density lipoprotein size.

Conclusion: Fatty fish intake at least 4 times per week increases HDL particle size which might have beneficial effect in patients with coronary heart disease.
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http://dx.doi.org/10.1016/j.jacl.2013.09.007DOI Listing
October 2014

Heart rate variability associates with asymptomatic coronary atherosclerosis.

Clin Auton Res 2014 Feb 30;24(1):31-7. Epub 2013 Nov 30.

Department of Neurology, Mikkeli Central Hospital, Porrassalmenkatu 35-37, 50100, Mikkeli, Finland,

Purpose: Heart rate variability (HRV) becomes impaired in symptomatic coronary artery disease (CAD), particularly, after myocardial infarction. The mechanism how CAD results in impairment of cardiac autonomic regulation is not known. Whether it results rather from coronary atherosclerosis itself than myocardial ischemia and myocardial injury has remained elusive.

Methods: Quantitative coronary angiography was performed in 30 subjects without history of myocardial ischemia, but with high familial risk for CAD. HRV was measured from 24-h ambulatory ECG recordings in time and frequency domain and also non-linear HRV variables SD1 and SD2 in Poincare plot were calculated. Myocardial ischemia was excluded by Tc-99m sestamibi scintigraphy at rest and during exercise.

Results: Coronary angiography revealed mean diameter stenosis of 32 ± 19 % in left anterior descending coronary artery, 26 ± 16 % in left circumflex coronary artery and 25 ± 20 % in right coronary artery. An inverse correlation was found between pNN50 and global severity of coronary artery diameter stenosis (r = -0.415, p < 0.05). Correspondingly, power of HF spectral component correlated negatively with global extent of coronary atherosclerosis (r = -0.366, p < 0.05). In Poincare plot, SD1/SD2 ratio correlated with global extent (r = -0.394, p < 0.05) and global burden (r = -0.388, p < 0.05) of coronary arteries.

Conclusions: The severity and extent of coronary atherosclerosis were related to a shift of cardiac autonomic regulation towards sympathetic predominance in asymptomatic subjects without evidence of myocardial ischemia.
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http://dx.doi.org/10.1007/s10286-013-0220-zDOI Listing
February 2014

Aging of the population may not lead to an increase in the numbers of acute coronary events: a community surveillance study and modelled forecast of the future.

Heart 2013 Jul 18;99(13):954-9. Epub 2013 Apr 18.

Department of Chronic Disease Prevention, THL-National Institute for Health and Welfare, PO Box 30, Helsinki FI-00271, Finland.

Objective: To examine the incidence, mortality and case fatality of acute coronary syndrome (ACS) in Finland during 1993-2007 and to create forecasts of the absolute numbers of ACS cases in the future, taking into account the aging of the population.

Design: Community surveillance study and modelled forecasts of the future.

Setting And Methods: Two sets of population-based coronary event register data from Finland (FINAMI and the National Cardiovascular Disease Register (CVDR)). Bayesian age-period-cohort (APC) modelling.

Participants: 24 905 observed ACS events in the FINAMI register and 364 137 in CVDR.

Main Outcome Measures: Observed trends of ACS events during 1993-2007, forecasted numbers of ACS cases, and the prevalence of ACS survivors until the year 2050.

Results: In the FINAMI register, the average annual declines in age-standardised incidence of ACS were 1.6% (p<0.001) in men and 1.8% (p<0.001) in women. For 28-day case fatality of incident ACS, the average annual declines were 4.1% (p<0.001) in men and 6.7% (p<0.001) in women. Findings in the country-wide CVDR data were consistent with the FINAMI register. The APC model, based on the CVDR data, suggested that both the absolute numbers of ACS events and the prevalence of ACS survivors reached their peak in Finland around 1990, have declined since then, and very likely will continue to decline until 2050.

Conclusions: The ACS event rates and absolute numbers of cases have declined steeply in Finland. The declining trends are likely to continue in the future despite the aging of the population.
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http://dx.doi.org/10.1136/heartjnl-2012-303216DOI Listing
July 2013

Does the clinical spectrum of incident cardiovascular disease differ between men and women?

Eur J Prev Cardiol 2014 Aug 12;21(8):964-71. Epub 2013 Mar 12.

National Institute for Health and Welfare (THL), Finland.

Background: Cardiovascular diseases (CVDs) are the main cause of death and disability in the western world. Women are known to be older at the time of first CVD event, but the main types of CVD events and their relative importance and differences compared with men are not well known. Our aim was to evaluate gender differences in the clinical presentation of incident major adverse cardiovascular events (MACE).

Design: A population-based study with prospective follow-up.

Methods: We used data from the population-based National FINRISK Surveys from years 1992, 1997, 2002 and 2007. People with prevalent cardiovascular disease were excluded. In total, 27,897 participants (53, 2% women) aged 25-74 years were included in the analyses.

Results: During the 292,316 person-years of follow-up, 2573 MACE were identified. MACE were more frequent in men than women (1318; 95% CI 1252-1388 in men vs. 736; 686-789 in women). Men had four times more fatal coronary heart disease (CHD) events (149; 126-174 vs. 39; 28-53) and three times more non-fatal CHD events (512; 471-555 vs. 164; 141-189) than women. Stroke incidence was higher in men than women (268; 238-301 vs. 169; 145-195). Heart failure (HF) incidence did not differ between genders. The relative proportions of MACE categories differed substantially between genders: HF was the most common type among women (50% vs. 30% in men), whereas the most common type among men was CHD (50% vs. 28% in women).

Conclusions: Incident MACE were more common in men than women. HF was the dominant type of MACE in women, whereas CHD dominated in men.
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http://dx.doi.org/10.1177/2047487313482284DOI Listing
August 2014

Prognosis of acute coronary events is worse in patients living alone: the FINAMI myocardial infarction register.

Eur J Prev Cardiol 2014 Aug 30;21(8):989-96. Epub 2013 Jan 30.

National Institute for Health and Welfare, Helsinki, Finland.

Background: Single living has been associated with a worse prognosis of acute coronary syndrome (ACS). We aimed to study the relation of sociodemographic characteristics to the morbidity, mortality, and case fatality (CF) of ACS in a large population-based ACS register.

Methods: The population-based FINAMI myocardial infarction register recorded 15,330 cases of ACS among persons aged 35-99 years in Finland in 1993-2002. Record linkage with the files of Statistics Finland provided information on sociodemographic characteristics (marital status, household size).

Results: ACS incidence and 28-day mortality rate were higher in unmarried men and women in all age groups. The prehospital CF of incident ACS was higher in single living and/or unmarried 35-64-year-old people. The 28-day CF was 26% (95% confidence interval, CI, 24-29%) in married men, 42% (95% CI 37-47%) in men who had previously been married, and 51% (95% CI 46-57%) in never-married men. Among women, the corresponding figures were 20% (95% CI 15-24%), 32% (95% CI 25-39%), and 43% (95% CI 31-56%). Most of these CF differences were apparent already at the prehospital phase. The only difference in treatment was that middle-aged men living alone or unmarried received thrombolysis less often. The disparities in ACS morbidity and mortality by marital status tended to widen during the study period.

Conclusions: Single living and/or being unmarried increases the risk of having a heart attack and worsens its prognosis both in men and women regardless of age. Most of the excess mortality appears already before the hospital admission and seems not to be related to differences in treatment of ACS.
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http://dx.doi.org/10.1177/2047487313475893DOI Listing
August 2014

Effect of vascular comorbidities on survival of type 2 diabetes patients on renal replacement therapy.

Am J Nephrol 2012 17;36(6):509-15. Epub 2012 Nov 17.

Department of Internal Medicine, Kuopio University Hospital, Kuopio, Finland.

Background: Atherosclerosis is an important predictor of mortality in patients with end-stage renal disease. The aim of this study was to determine how various vascular comorbidities such as coronary heart disease (CHD), peripheral vascular disease (PVD) or cerebrovascular disease (CeVD) affect survival of type 2 diabetic patients on renal replacement therapy (RRT).

Methods: Patients who entered RRT because of type 2 diabetes in 2000-2008 (n = 877) were identified within the Finnish Registry for Kidney Diseases. The patients were followed up until death or end of follow-up. Survival probabilities were calculated using Kaplan-Meier curves. Multivariate modeling was performed using Cox regression.

Results: 41% of the patients had CHD, 27% PVD and 16% CeVD at the start of RRT. Patients with PVD had a 1.9-fold (95% CI 1.6-2.3) risk of death compared to those without PVD when adjusting for age and gender, while patients with CHD had a 1.5-fold (95% CI 1.2-1.8) and those with CeVD a 1.4-fold (95% CI 1.1-1.8) risk compared to those without these diseases. The hazard ratio (HR) for death was highest in patients with the combination of PVD and either CHD (HR 2.8, 95% CI 2.1-3.8) or CeVD (HR 2.9, 95% CI 1.6-5.2) as compared to patients without any vascular comorbidities.

Conclusion: PVD is the vascular comorbidity that increases risk of death the most among patients with type 2 diabetes starting RRT. Prevention of PVD in this patient group would merit further studies.
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http://dx.doi.org/10.1159/000345143DOI Listing
June 2013

Residual risk of cardiovascular mortality in patients with coronary heart disease: the EUROASPIRE risk categories.

Int J Cardiol 2013 Sep 14;168(2):910-4. Epub 2012 Nov 14.

Department of Public Health, Ghent University, Belgium. Electronic address:

Background: The EUROASPIRE I, II and III surveys revealed high prevalences of modifiable risk factors in the high priority group of coronary patients all over Europe. The potential to further reduce coronary heart disease (CHD) morbidity and mortality rates is still considerable. We report here on the relative risk of cardiovascular disease (CVD) death associated with common modifiable risk factor levels based on the mortality follow-up of patients participating in the first two EUROASPIRE surveys. We also present a novel simple risk classification system (ERC) that can be used in the management of patients with existing CHD.

Methods: The study cohort consisted of a consecutive sample of CHD patients aged ≤ 70 years from 12 European countries. Baseline data gathered in 1995-2000 through standardized methods, were linked to cardiovascular mortality in 5216 patients according to an accelerated failure time model.

Results: During 28,143 person-years of follow-up, 332 patients died from cardiovascular disease denoting a CVD mortality risk of 12.3 per 1000 person-years in men and 10.2 per 1000 person-years in women. In multivariate analysis, fasting glucose, total cholesterol and smoking emerged as the strongest independent modifiable predictors of cardiovascular mortality.

Conclusions: The results of the mortality follow-up of the EUROASPIRE I and II CHD patients emphasize the continuing risk from elevated glucose and total cholesterol levels and underline the importance of smoking cessation in secondary prevention. The ERC risk tool that we developed may prove helpful to obtain these goals in the setting of secondary prevention.
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http://dx.doi.org/10.1016/j.ijcard.2012.10.051DOI Listing
September 2013

Cost-effectiveness of optimizing prevention in patients with coronary heart disease: the EUROASPIRE III health economics project.

Eur Heart J 2012 Nov 26;33(22):2865-72. Epub 2012 Jul 26.

Ghent University, Gent, Belgium.

Aims: The EUROASPIRE III survey indicated that the guidelines on cardiovascular disease prevention are poorly implemented in patients with established coronary heart disease (CHD). The purpose of this health economic project was to assess the potential clinical effectiveness and cost-effectiveness of optimizing cardiovascular prevention in eight EUROASPIRE III countries (Belgium, Bulgaria, Croatia, Finland, France, Italy, Poland, and the U.K.). METHODS AND RESULTS The individual risk for subsequent cardiovascular events was estimated, based on published Framingham equations. Based on the EUROASPIRE III data, the type of suboptimal prevention, if any, was identified for each individual, and the effects of optimized tailored prevention (smoking cessation, diet and exercise, better management of elevated blood pressure and/or LDL-cholesterol) were estimated. Costs of prevention and savings of avoided events were based on country-specific data. A willingness to pay threshold of €30,000/quality-adjusted life year (QALY) was used. The robustness of the results was validated by sensitivity analyses. Overall, the cost-effectiveness analyses for the eight countries showed mainly favourable results with an average incremental cost-effectiveness ratio (ICER) of €12,484 per QALY. Only in the minority of patients at the lowest risk for recurrent events, intensifying preventive therapy seems not cost-effective. Also, the single impact of intensified cholesterol control seems less cost-effective, possibly because their initial 2-year risk was already fairly low, hence the room for improvement is rather limited.

Conclusion: These results underscore the societal value of optimizing prevention in most patients with established CHD, but also highlight the need for setting priorities towards patients more at risk and the need for more studies comparing intensified prevention with usual care in these patients.
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http://dx.doi.org/10.1093/eurheartj/ehs210DOI Listing
November 2012

Myocardial (123) I-metaiodobenzylguanidine washout and heart rate variability in asymptomatic subjects.

Ann Noninvasive Electrocardiol 2012 Jan;17(1):8-13

Department of Neurology, Mikkeli Central Hospital, Mikkeli.

Background: Myocardial (123) I-metaiodobenzylguanidine (MIBG) kinetics reflect the integrity and function of cardiac presynaptic sympathetic nerve terminals. Heart rate variability (HRV) is an indicator of cardiac sympatho-vagal balance. However, the function of cardiac sympathetic nerve terminals as a modulator of HRV in asymptomatic subjects has remained elusive. In addition, the physiological background for different components of HRV is not fully established.

Methods: We evaluated the relationship between myocardial MIBG washout and HRV in 30 asymptomatic subjects with familial risk of coronary artery disease (CAD). Early and delayed myocardial MIBG uptakes as well as MIBG washout between these two scans were assessed. Myocardial perfusion at rest and during bicycle exercise was evaluated with (99m) Tc-sestamibi (MIBI). HRV was measured from 24-hour ambulatory ECG recordings.

Results: Myocardial MIBG washout averaged 40 ± 8%. The mean heart rate at rest was 76 ± 14 beats/min. Standard deviation of all normal RR intervals (SDNN) was 94 ± 22 ms and very low frequency (VLF) was 1625 ± 958 ms(2) on average. Myocardial MIBG washout correlated inversely with SDNN (r =-0.390; P < 0.05) and with VLF (r =-0.459; P < 0.01) component of HRV but not with heart rate at rest (r = 0.207, P = ns). All subjects had normal myocardial perfusion at rest and during exercise.

Conclusions: Increased cardiac presynaptic sympathetic nervous activity was related to reduced HRV in subjects with the risk of CAD but without evidence of myocardial ischemia or previous myocardial infarction. In addition, we found that VLF component of HRV includes information about sympathetic neural modulation of the heart rate.
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http://dx.doi.org/10.1111/j.1542-474X.2011.00475.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6931951PMC
January 2012

Socioeconomic inequalities in the morbidity and mortality of acute coronary events in Finland: 1988 to 2002.

Ann Epidemiol 2012 Feb;22(2):87-93

Turku University Hospital, Turku, Finland.

Purpose: To examine the changes in socioeconomic disparities in the incidence of coronary heart disease (CHD) and mortality in Finland and to analyze the effects of the severe economic recession of the early 1990s on these disparities.

Methods: The population-based FINAMI Myocardial Infarction (MI) register recorded all suspected MI events among men and women ages 35 to 99 years in four geographical areas of Finland. Record linkage with the files of Statistics Finland provided us with detailed information on the indicators of socioeconomic status (SES; income, education, and profession). Rates were expressed per 100,000 inhabitants of each socioeconomic group per year and age-standardized to the European standard population. Poisson regression was used for analyzing rate ratios and time trends of coronary events in different socioeconomic groups.

Results: The mortality rate ratio of coronary events among 35- to 64 year-old men was 5.21 (95% confidence interval, 4.23-6.41) when the lowest income sixth to the highest income sixth were compared. Among women, the respective rate ratio was 11.13 (5.77-21.45). Significant differences in the incidence and 28-day mortality by SES were seen also in the older age groups. Some socioeconomic differences were found in the proportions of patients receiving thrombolysis or undergoing early revascularization. No substantial changes were observed in inequalities between the socioeconomic groups during the study period.

Conclusions: The excess CHD morbidity and mortality among persons with lower SES is still considerable in Finland, but the economic recession did not widen the differences.
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http://dx.doi.org/10.1016/j.annepidem.2011.10.012DOI Listing
February 2012

Benefits and safety of long-term fenofibrate therapy in people with type 2 diabetes and renal impairment: the FIELD Study.

Diabetes Care 2012 Feb 30;35(2):218-25. Epub 2011 Dec 30.

National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.

Objective: Diabetic patients with moderate renal impairment (estimated glomerular filtration rate [eGFR] 30-59 mL/min/1.73 m(2)) are at particular cardiovascular risk. Fenofibrate's safety in these patients is an issue because it may elevate plasma creatinine. Furthermore, guidelines regarding fenofibrate dosing in renal impairment vary internationally. We investigated fenofibrate's effects on cardiovascular and end-stage renal disease (ESRD) events, according to eGFR, in the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) Study.

Research Design And Methods: Type 2 diabetic patients (aged 50-75 years) with eGFR ≥30 mL/min/1.73 m(2) were randomly allocated to a fixed dose of fenofibrate (200 mg daily) (n = 4,895) or placebo (n = 4,900) for 5 years. Baseline renal function (Modification of Diet in Renal Disease equation) was grouped by eGFR (30-59, 60-89, and ≥90 mL/min/1.73 m(2)). The prespecified outcome was total cardiovascular events (composite of cardiovascular death, myocardial infarction, stroke, and coronary/carotid revascularization). Serious adverse events and instances of ESRD (plasma creatinine >400 μmol/L, dialysis, renal transplant, or renal death) were recorded. Analysis was by intention to treat.

Results: Overall, fenofibrate reduced total cardiovascular events, compared with placebo (hazard ratio 0.89 [95% CI 0.80-0.99]; P = 0.035). This benefit was not statistically different across eGFR groupings (P = 0.2 for interaction) (eGFR 30-59 mL/min/1.73 m(2): 0.68 [0.47-0.97], P = 0.035; eGFR ≥90 mL/min/1.73 m(2): 0.85 [0.70-1.02], P = 0.08). ESRD rates were similar between treatment arms, without adverse safety signals of fenofibrate use in renal impairment.

Conclusions: Patients with type 2 diabetes and moderate renal impairment benefit from long-term fenofibrate, without excess drug-related safety concerns compared with those with no or mild renal impairment. Fenofibrate treatment should not be contraindicated in moderate renal impairment, suggesting that current guidelines may be too restrictive.
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http://dx.doi.org/10.2337/dc11-1109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263870PMC
February 2012

Gender differences in the prevalence, causes and treatment of high cardiovascular risk: findings from the FINRISK Survey.

Eur J Prev Cardiol 2012 Oct 2;19(5):1153-60. Epub 2011 Sep 2.

University of Kuopio and Kuopio University Hospital, Department of Medicine, PO Box 1777, 70210 Kuopio, Finland.

Background: Concerns have been raised that high cardiovascular (CVD) risk is not always recognized in women and treated effectively enough. We aimed to analyze, whether there are differences between men and women in the prevalence, underlying causes and treatment of high CVD risk.

Design: A cross-sectional analysis of data from population-based health examination surveys was conducted.

Methods: Pooled data from the population-based National FINRISK Surveys from the years 1992, 1997, 2002 and 2007 were used. Subjects with any of the following were considered as having high-risk: history of a major CVD event, prevalent diabetes or 10-year risk of CVD ≥ 20% calculated according to the Framingham equation.

Results: We identified 835 (46.0% women) high-risk subjects in the age group 25-54 years and 3587 (27.3% women) in the age group 55-74 years. In the younger age group men had more often prevalent CVD (29.3% vs 7.8%, p < 0.001) and were more likely to be smokers (46.3% vs 21.4%, p < 0.001), whereas women had more diabetes (94.0 % vs 60.5%, p < 0.001). Younger women were less likely to achieve the recommended total cholesterol level of <4.5 mmol/l (14.3 % vs 17.3 %, p = 0.03) and had a lower rate of hypolipidaemic therapy (9.6% vs 21.2%, p < 0.001) and acetylsalicylic acid therapy (8.3% vs 27.7%, p < 0.001).

Conclusion: Among young individuals, high CVD risk was almost as common in women as in men. It appears that the high-risk situation is not always recognized and treated adequately in young women.
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http://dx.doi.org/10.1177/1741826711422454DOI Listing
October 2012

Sex differences in short- and long-term case-fatality of myocardial infarction.

Eur J Epidemiol 2011 Nov 30;26(11):851-61. Epub 2011 Jun 30.

Department of Medicine, University of Kuopio and Kuopio University Hospital, 70210, Kuopio, Finland.

Declining trends in case fatality (CF) of MI events have been generally reported in western countries. It is, however, not clear whether the development has been equally beneficial in both sexes. Data from two large population based registers, FINAMI and the Finnish National Cardiovascular Disease Register (CVDR) were used to determine whether the CF of incident MI events has declined less in women than in men. All patients aged 35 and over were included. CF was calculated for different time periods after the onset of the MI event, the main emphasis was in pre-hospital, 28-day, and 1-year CF. Figures were compared between two study periods: 1994-1996 and 2000-2002. A total of 6,342 incident MI events were recorded in FINAMI and 117,632 events in CVDR during the study periods. Comparison between the two study periods showed that the CF was generally declining. However, a slower decline in short-term CF was seen among young (aged<55 years) women (P for sex by study period interaction in pre-hospital CF=0.028 in FINAMI and 0.003 in CVDR, and for 28-day CF P=0.016 in FINAMI and <0.0001 in CVDR). In conclusion, the short and long-term prognosis of MI events has improved in both sexes. Pre-hospital CF has declined less among younger women than among men and among older women. This slower decline in early CF was responsible for the slower improvement in 28-day and 1-year prognosis in young women.
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http://dx.doi.org/10.1007/s10654-011-9601-6DOI Listing
November 2011

Physical activity, high-sensitivity C-reactive protein, and total and cardiovascular disease mortality in type 2 diabetes.

Diabetes Care 2011 Jul 20;34(7):1492-6. Epub 2011 May 20.

Department of Medicine, University of Turku and Turku University Hospital, Turku, Finland.

Objective: Physical activity reduces high-sensitivity C-reactive protein (hs-CRP), cardiovascular disease (CVD), and total mortality in type 2 diabetic patients. However, it is not known whether the effects of physical activity on mortality depend on the levels of hs-CRP in patients with type 2 diabetes.

Research Design And Methods: We prospectively followed-up on 569 type 2 diabetic patients, aged 45-64 years, who were free of CVD at baseline. Participants were stratified according to the level of hs-CRP (<1.0, 1.0-3.0, or >3.0 mg/L) and the degree of physical activity (0-4 metabolic equivalent tasks [METs] or >4 METs). The Cox proportional hazards model was used to estimate the joint association between physical activity and hs-CRP levels and the risk of mortality.

Results: During an 18-year follow-up, 356 patients died, 217 of whom died of CVD. Those who were physically more active had significantly reduced total, CVD and coronary heart disease (CHD) mortality among patients with elevated hs-CRP levels (>3 mg/L). These findings persisted in multivariable analyses. However, in patients with an hs-CRP level<1 mg/L or between 1 and 3 mg/L, there was no statistically significant relationship between physical activity and CVD or CHD mortality.

Conclusions: Physical activity reduces total, CVD, and CHD mortality in type 2 diabetic patients with elevated hs-CRP levels. This suggests that the anti-inflammatory effect of physical activity may counteract increased CVD and CHD morbidity and mortality associated with high CRP levels.
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http://dx.doi.org/10.2337/dc11-0469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120189PMC
July 2011

Catheter-directed thrombolysis of proximal lower extremity deep vein thrombosis: a prospective trial with venographic and clinical follow-up.

Eur J Radiol 2012 Jun 16;81(6):1197-202. Epub 2011 Apr 16.

Department of Clinical Radiology, Kuopio University Hospital, Digital Imaging Centre, Kuopio, Finland.

Purpose: To prospectively evaluate the primary and long-term venographic and clinical results of catheter-directed thrombolysis in the treatment of proximal deep vein thrombosis (DVT) of lower extremity.

Materials And Methods: Fifty-six patients with mean age of 48 (range 15-81) years with acute DVT (symptom duration of less than 2 weeks), extending to high femoral (16 patients) or iliac vein (40 patients) were treated with selective catheter-directed thrombolysis. The mean total dose of 3.8 (range 1.0-8.1) million units of urokinase was administered during a mean of 39 (range 6-72) hours. Endovascular stenting was performed in 9 of the iliac DVT patients.

Results: Complete procedural venographic success was achieved in 79% of patients. Major complications were noted in 7% of patients and the total rate of complications was 13%. Mean venographic follow-up was 3.5 years (range 3 months to 9.6 years); well preserved femoral vein valves and fully recanalized deep crural veins were observed in 83% and 57% of patients. Normal clinical findings in the affected limb were noted during the latest follow-up visit in 67% of patients. Clinical post-thrombotic syndrome occurred in 9% of patients.

Conclusion: Catheter-directed thrombolysis achieves good primary success with acceptable complication rate and effectively reduces prevalence of post-thrombotic syndrome.
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http://dx.doi.org/10.1016/j.ejrad.2011.03.068DOI Listing
June 2012

Thoracoabdominal calcifications predict cardiovascular disease mortality in type 2 diabetic and nondiabetic subjects: 18-year follow-up study.

Diabetes Care 2010 Mar 15;33(3):583-5. Epub 2009 Dec 15.

Department of Medicine, Kuopio University Hospital, Kuopio, Finland.

OBJECTIVE To evaluate cardiovascular disease (CVD) and total mortality associated with thoracoabdominal calcifications. RESEARCH DESIGN AND METHODS Thoracoabdominal calcifications of native radiograms were evaluated in 833 subjects with type 2 diabetes and 1,292 subjects without diabetes, aged 45-64 years, without prior evidence of CVD. The type 2 diabetic and nondiabetic study cohorts were followed up for 18 years. RESULTS After adjustment for conventional risk factors, marked thoracoabdominal calcifications predicted CVD/total mortality with hazard ratio (HR) (95% CI) of 1.5 (0.8-3.0)/1.8 (1.1-2.9) in type 2 diabetic men, 3.0 (1.6-5.7)/3.1 (1.9-5.0) in type 2 diabetic women, 5.0 (2.2-12)/4.0 (2.2-7.4) in nondiabetic men, and 7.8 (1.8-34)/3.0 (1.3-7.0) in nondiabetic women and in the presence of C-reactive protein below/over 3 mg/l with HR of 2.4 (1.3-4.4)/3.0 (1.4-6.1) in type 2 diabetic subjects and 4.0 (1.5-10.8)/6.6 (2.7-16.0) in nondiabetic subjects. CONCLUSIONS Thoracoabdominal calcifications in native radiograms are significant predictors of CVD and total mortality, especially in type 2 diabetic and nondiabetic women with elevated high-sensitivity C-reactive protein level.
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http://dx.doi.org/10.2337/dc09-1813DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2827512PMC
March 2010

Improved survival of type 2 diabetic patients on renal replacement therapy in Finland.

Nephrol Dial Transplant 2010 Mar 21;25(3):892-6. Epub 2009 Oct 21.

Department of Internal Medicine, Kuopio University Hospital, Kuopio, Finland.

Background: Survival of type 2 diabetes mellitus patients on maintenance dialysis therapy is poor mainly due to cardiovascular events. The aim was to examine whether survival of type 2 diabetes patients on renal replacement therapy (RRT) in Finland has improved during 1995-2005.

Methods: Patients who entered RRT because of type 2 diabetes mellitus in 1995-99 (n = 314) and 2000-05 (n = 583) were identified within the Finnish Registry for Kidney Diseases. The two cohorts were followed up from start of RRT until death or end of follow-up on 31 December 2006. Survival probabilities and probabilities of receiving a kidney transplant were calculated using Kaplan-Meier curves. Multivariate modelling was performed using Cox regression.

Results: Patients who entered RRT in 2000-05 had lower risk of dying than those who entered in 1995-99; hazard ratio (HR) was 0.76 (95% CI 0.65-0.89) and 0.74 (95% CI 0.63-0.87) with adjustment for age and gender. The decreased risk of death was most obvious in age groups 55-64 (HR 0.67, 95% CI 0.49-0.92) and 65-74 years (HR 0.69, 95% CI 0.56-0.87). Adjustment for albumin in addition to age and gender only slightly weakened the effect of study periods (HR 0.83, 95% CI 0.69-1.01). The patients in 2000-05 were more obese, had lower total and LDL cholesterol and higher HDL cholesterol and albumin concentration in serum than patients in 1995-99. Patients' probability to receive a kidney transplant was low in both groups.

Conclusions: Survival of type 2 diabetes patients on RRT improved during the time period 1995-2005 in Finland while the probability of receiving a kidney transplant remained low and unchanged.
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http://dx.doi.org/10.1093/ndt/gfp555DOI Listing
March 2010
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