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

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.

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.

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.

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

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.

Myocardial infarction events and cardiovascular risk factor levels in Finnish- and Swedish-speaking populations of Finland.

BACKGROUND. The Swedish-speaking minority of Finland is unique, because it has a higher socioeconomic status (SES) and longer life expectancy than the Finnish-speaking majority. We hypothesized that this minority may have a lower attack rate of coronary events and analysed whether this could be explained by their higher SES. METHODS. The population-based myocardial infarction (MI) registers recorded 4,845 MI events in Turku during 1988-1998. Individual-level indicators of SES were obtained from Statistics Finland. The population-based FINRISK surveys recorded cardiovascular risk factors and native languages of 10,432 people in 1987, 1997, and 2002. RESULTS. The age-standardized attack rate of MI was lower among the 35-64-year-old Swedish-speaking men than among Finnish-speaking men (rate ratio 0.66; 95% confidence interval 0.47-0.85) and the difference remained significant after adjustment for SES. The Swedish-speaking inhabitants had higher age-, sex-, and SES-adjusted high-density lipoprotein cholesterol, and lower triglycerides, body mass index, and diastolic blood pressure. Conclusion. The Swedish-speaking inhabitants of Turku had lower MI morbidity and coronary mortality than the Finnish-speaking inhabitants. After controlling for SES, these differences remained significant among men, suggesting that other factors, such as differences in the risk factor profiles may also play a role.

Visual assessment of [(11)C]PIB PET in patients with cognitive impairment.

PURPOSE: The aim of this study was to evaluate the visual assessment of positron emission tomography images of N-[methyl-11C]2-(4'-methylaminophenyl)-6-hydroxybenzothiazole ([11C]PIB) in a patient population with mild to moderate memory impairment or dementia. METHODS: We compared the visual ratings of two readers using kappa statistics and correlated the results of visual and quantitative region of interest (ROI) analyses. The one reader had good experience in evaluating PIB images and the other had little previous experience. The sensitivity and specificity of the visual assessment was determined using quantitative data from 18 healthy controls previously examined: [11C]PIB uptake was considered as abnormal if it was more than 2 SD above the mean of the healthy subjects. RESULTS: The evaluation of visual classification as "normal" or "abnormal" showed good interobserver agreement (kappa = 0.90). There was a clear correlation between visual and quantitative analysis (r = 0.47-0.79, p < 0.001). The most difficult visually assessed brain area was the putamen (kappa = 0.11; correlation with quantitative analysis: reader A r = 0.22; reader B r = 0.60). CONCLUSION: Our study shows that visual evaluation of [(11)C]PIB images conforms with quantitative analyses also in a clinical patient population supporting the feasibility of visual evaluation in clinical settings.

Stroke morbidity in Swedish- and Finnish-speaking populations of Turku, Finland.

OBJECTIVES: To examine differences in the morbidity and mortality of stroke between the Finnish- and Swedish-speaking populations in Turku, taking into account the socioeconomic differences between these groups. DESIGN: The population-based FINMONICA and FINSTROKE stroke registers recorded 5,135 stroke events among persons aged 25-99 years in Turku during 1988-1998. Events in persons aged > or =75 years were not registered in 1993-1995. Information on these persons' native language and socioeconomic status (SES) (measured by taxable income, profession and years of education) were obtained by record linkage with the files of Statistics Finland. RESULTS: Swedish-speaking men had a lower attack rate of ischaemic stroke than Finnish-speaking men (270, 95% Confidence Interval (CI) 214-326 versus 370, 95% CI 352-389, per 100,000 inhabitants per year) and the difference remained significant after adjustment for SES. Among women, the attack rates of ischaemic stroke were similar in both language groups. CONCLUSIONS: The attack rate of ischaemic stroke was lower among Swedish-speaking than among Finnish-speaking men. This difference was not totally explained by the higher SES of the Swedish-speaking population.

Lower recurrence risk through mammographic screening reduces breast cancer treatment costs.

Mammographic screening is associated with a reduced risk of breast cancer recurrence. The objective of the study was to evaluate treatment costs due to breast cancer recurrence in relation to patients' use of mammographic screening, consecutively collected in a defined population. The study included 418 women exposed to screening and 109 women unexposed to screening diagnosed with stage I-III breast cancer. During the first eight years after primary diagnosis, 19% (N=80) of the exposed women and 33% (N=36) of the unexposed women developed recurrent disease, P=0.002. In the exposed group, 41% of the 8-year treatment costs were for the treatment of patients who developed recurrent disease, compared with 52% in the unexposed group, P=0.039. Among the relapsed patients, the mean post-recurrence costs were EUR14,950, accounting for 65% of their total 8-year costs. The mean post-recurrence costs were comparable for both exposure groups irrespective of the detection method.

Coronary events in persons aged 75 years or older in Finland from 1995 to 2002: the FINAMI study.

The authors used population-based myocardial infarction (MI) register data to examine trends in incidence, case fatality, treatment strategies of MI, and coronary heart disease (CHD) mortality in persons aged 75 to 99 years in 4 areas of Finland during 1995 through 2002. This age group contributed 53% (n=13,977) of all CHD events, and 65% occurred in women. CHD mortality declined among men annually by 3.5% and 1.0% in the 75- to 84-year-old and 85- to 99-year-old age groups, respectively. Among women, it declined by 2.2% per year in the 75- to 84-year-old age group but increased by 1.3% per year in the 85- to 99-year-old age group. MI attack rate did not change in men but increased significantly in women aged 85 to 99 years. Clinical management of MI in elderly patients was more conservative than in middle-aged patients. In conclusion, one-half of all CHD events occur among persons aged 75 years or older, and elderly patients with CHD represent an increasing burden to the health care system.

The validation of the Finnish Hospital Discharge Register and Causes of Death Register data on stroke diagnoses.

BACKGROUND AND PURPOSE: Administrative registers, like hospital discharge registers and causes of death registers are used for the monitoring of disease incidences and in the follow-up studies. Obtaining reliable results requires that the diagnoses in these registers are correct and the coverage of the registers is high. The purpose of this study was to evaluate the validity of the Finnish hospital discharge registers and causes of death registers stroke diagnoses against the population-based FINSTROKE register. METHODS: All first stroke events from the hospital discharge registers and causes of death registers from the areas covered by the FINSTROKE register were obtained for years 1993-1998 and linked to the FINSTROKE register. The sensitivity and positive predictive values were calculated. RESULTS: A total of 3633 stroke events, 767 fatal and 2866 non-fatal strokes, were included in the registers. The sensitivity for all first stroke events was 85%, for fatal strokes 86% and for non-fatal strokes 85%. The positive predictive values for all first strokes was 86%, for fatal strokes 92% and for non-fatal strokes 85%. The sensitivity as well as the positive predictive values for subarachnoid haemorrhage and intracerebral haemorrhage was higher than for cerebral infarctions. There were no marked differences in the sensitivity or positive predictive values between men and women. CONCLUSIONS: The sensitivity and the positive predictive values of the Finnish hospital discharge registers and causes of death registers are fairly good. Finnish administrative registers can be used for the monitoring of stroke incidence, but the number of cerebral infarctions should be interpreted with caution.

The effect of correcting for troponins on trends in coronary heart disease events in Finland during 1993-2002: the FINAMI study.

AIMS: The object of this study is to analyse the trends in coronary events in Finland during 1993-2002, correcting for the effect of troponins. METHODS AND RESULTS: A population-based myocardial infarction register recorded all coronary events (n=14 782) in four geographical areas of Finland during 1993-2002. Correction coefficients for the effect of troponins were calculated on the basis of 4359 coronary events, with simultaneous determination of troponins and the 'old' enzymatic markers of myocardial injury. Coronary mortality declined steeply, except in women aged > or = 75 years. The incidence of first coronary events declined 2.0% (95% confidence interval -3.0, -0.9%) per year among men and 1.0% (-2.7, 0.6%) per year among women aged 35-74 years. After correcting for the effect of troponins, also the decline among women became statistically significant: 2.7% (-4.5, -0.8%) per year. The effect of troponins tended to be stronger in women and older individuals than in men and younger individuals. The 28-day case fatality declined among men, but not among women. The effect of troponins on case fatality trends was weak. CONCLUSION: Declining trends in the incidence of coronary events in Finland during 1993-2002 were partly hidden by the effect of troponins. Both incidence and case fatality declines have contributed to the decline in mortality.

Population-based mammography screening results in substantial savings in treatment costs for fatal breast cancer.

AIMS: The aim was to assess the effect of population-based mammography screening on treatment costs for fatal breast cancer in Turku, Finland. MATERIALS AND METHODS: The study included 556 women with invasive breast cancer, diagnosed at the age of 40-74 years in 1987-1993: 427 in the screened group (screen-detected or interval cancer) and 129 in the unscreened group (not yet invited or refused screening). Both groups were followed up for 8 years from diagnosis. RESULTS: In the unscreened group, 32 (25%) patients died of breast cancer versus 49 (12%) in the screened group (p < 0.001). The non-discounted mean treatment costs were 2.8-fold for those dying of breast cancer compared to survivors: 26,222 euros versus 9,434 euros; the difference between means was 16,788 euros (95% CI 14,915-18,660) (p<0.001). The mean costs for fatal cases were high, irrespective of the way cancer was detected: 23,800 euros in the unscreened group versus 27,803 euros in the screened group; the difference between means was -4,003 euros (-10,810 to 2802) (p=0.245). In the unscreened group, patients with fatal breast cancer accounted for 41% (0.76/1.87 million euros) of the total treatment costs versus 29% (1.36/4.76 million euros) in the screened group. It was estimated that about one third of costs for fatal breast cancer were avoided through mammography screening, accounting for 72-81% of the estimated total treatment cost savings achieved by screening. About 31-35% of the screening costs for 1987 to 1993 were offset by savings in treatment costs. CONCLUSIONS: Treatment costs for fatal breast cancer are high. Mammography screening results in substantial treatment cost savings, in which reduction of fatal disease is the key element.

Diabetes worsens the outcome of acute ischemic stroke.

OBJECTIVE: To characterize acute stroke events in diabetic patients in a population-based stroke register and to determine the influence of diabetes on the outcome of acute stroke. METHODS: Four thousand three hundred and ninety patients were recorded in the FINMONICA and FINSTROKE registers after their first ischemic stroke from 1990 to 1998. We followed mortality and stroke outcome for up to 4 weeks after the onset of acute stroke. RESULTS: Of the 4390 patients who had had an ischemic stroke, 43.6% were male and 25.1% (1103) had diabetes. Their mean age was 72.4 (S.D. 12.0) years and this was similar in patients with and without diabetes (72.9 years versus 72.3 years, p=0.18). Subjects with diabetes were more likely to be hypertensive (55% versus 38%, p<0.001) and have a history of myocardial infarction (20% versus 16%, p<0.001) than the non-diabetic stroke patients. Mortality at 4 weeks from the onset was higher in diabetic than in non-diabetic patients (20.0% versus 16.9% p=0.020). At day 28 after the stroke attack, diabetic patients were more likely to be disabled when compared with non-diabetic subjects (43.3% versus 33.5%, p<0.001). Using logistic regression analysis, adjusted for age-group, sex, previous medical history (MI, AF or TIA), diabetes was found to be a significant predictor of disability after stroke (OR=1.51, 95% CI 1.27-1.81). CONCLUSIONS: Diabetes, which affected one-fourth of the ischemic stroke patients on our register, was associated with a higher risk of death and disability after the onset of stroke. Preventing diabetes in the elderly population improves the short-term prognosis of acute ischemic stroke.

A new definition for myocardial infarction: what difference does it make?

AIMS: As a response to changing diagnostic tools of myocardial infarction (MI), new case definitions for acute coronary events were published in 2003 as the American Heart Association Scientific Statement. We assessed the new definition in hospitalized patients in a large population-based MI register study. METHODS AND RESULTS: We identified all suspected acute coronary syndromes with data either on troponin T or on troponin I and at least one of the enzymatic markers of myocardial injury (n=6104). The 2003 definition with the use of troponins identified 83% more definite MIs than the WHO MONICA definition using cardiac enzymes. The additional patients were older, had more often diabetes, and received less often thrombolysis and revascularization than those having MI by both definitions. Adjusting for age, sex, study area, and study year, the additional patients with their first MI aged 25-74 had a higher risk of cardiovascular death within 1 year than patients having definite MI by both definitions (hazard ratio 1.6, 95% CI 1.1-2.2). CONCLUSION: The changing diagnostic criteria present a considerable challenge for the assessment of long-term trends in MI events in the community as well as for longitudinal studies of the natural history of MI. The 2003 definition, when applied using troponins, identified a sizable new group of MI patients, among persons with suspected acute coronary syndrome, at high risk of a recurrent event.

The validity of the Finnish Hospital Discharge Register and Causes of Death Register data on coronary heart disease.

BACKGROUND AND DESIGN: The recent introduction of sensitive markers of myocardial injury is likely to affect the epidemiology of coronary heart disease (CHD). The American Heart Association together with other societies and research agencies have recently published a new definition on acute CHD to improve consistency in epidemiological and clinical studies (referred here as the '2003 definition'). METHODS: In this study we compare the data on CHD events in the Finnish National Hospital Discharge Register (HDR) and the Causes of Death Register (CDR) with the population-based myocardial infarction (MI) register, FINMONICA/FINAMI. The FINMONICA/FINAMI events were classified according to the 2003 definition. The relevant International Classification of Diseases (ICD) codes from the HDR and CDR were used. RESULTS: Using the 2003 definition as the reference, the overall sensitivity of the ICD codes for MI in the combined HDR and CDR was 83% and the positive predictive value (PPV) was 90%. When the ICD codes for unstable angina were added to the analyses, the sensitivity improved to 85% and the PPV declined to 83%. In the age group 35-74 the sensitivity of the MI codes improved over time, in men from 64% in 1988-1992 to 81% in 1998-2002, and in women from 61 to 78%, respectively. The oldest age group, 75 years or older, had sensitivity and PPV values comparable to those of the younger. CONCLUSION: Diagnoses of fatal and non-fatal CHD events in the Finnish HDR and Causes of Death register were reasonably valid indicators for hard CHD events when compared with the FINMONICA/FINAMI register data.

Liver echogenicity: relation to systemic blood pressure and other components of the metabolic syndrome.

We studied the impact of liver echogenicity among other potential predictors of systemic blood pressure (BP) and the metabolic syndrome. 38 persons (32 males, six females, aged 29 to 66) had their liver echogenicities scored, BPs measured and standard serum laboratory tests studied. There was a significant correlation between both systolic (r=0.438, p=0.006) and diastolic (r=0.498, p=0.001) BP and liver echogenicity. Liver echogenicity was the strongest predictor for systolic BP and the second strongest (after body mass index, BMI) for diastolic BP. Body height may modify the relation between liver echogenicity and systolic BP. Liver echogenicity also correlated significantly with BMI (r=0.527, p=0.001), serum triglycerides (r=0.472, p=0.003) and, to a lesser degree, with serum total cholesterol (r=0.305, p=0.066). Incidentally found increased liver echogenicity should alert the US performer and the clinician reading the report on the possibility of elevated BP or other features of the metabolic syndrome.

Mammographic screening reduces risk of breast carcinoma recurrence.

BACKGROUND: The current report is a long-term evaluation of breast carcinoma recurrence, factors predicting recurrence, and postrecurrence prognosis in relation to patients' use of service screening, which has been provided in Turku, Finland, since 1987 for women ages 40-74 years. METHODS: The current study included 527 invasive breast carcinomas: 418 in the screening group (which included screen-detected and interval malignancies) and 109 in the nonscreening group (which included breast carcinomas detected before initial screening and those detected in patients who chose not to undergo screening). These breast carcinomas were diagnosed among women ages 40-74 years between 1987 and 1993, with follow-up extending until the end of 2001. RESULTS: In the screening group, the risk of recurrence was only approximately half of the corresponding risk in the nonscreening group (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.39-0.83; P = 0.003). Five years after the primary diagnosis, 16% of patients in the screening group and 28% of patients in the nonscreening group (P = 0.001) had experienced recurrence; 10 years after diagnosis, the corresponding rates were 21% and 34%, respectively (P = 0.001). Postrecurrence prognosis was comparable for both detection groups (HR, 1.17; 95% CI, 0.70-1.94; P = 0.551), with approximately half of all patients dying of disease 5 years after recurrence. Detection of breast carcinoma via a method other than mammographic screening was associated with a high risk of recurrence on univariate analysis. On Cox multivariate analysis, risk factors for recurrence included lobular histologic type (HR, 2.23; 95% CI, 1.44-3.48; P < 0.001), poor histologic grade (HR, 2.02; 95% CI, 1.20-3.39; P = 0.008), and large tumor size (HR, 1.60; 95% CI, 1.07-2.37; P = 0.021). CONCLUSIONS: Long-term data from a population-based program demonstrated that mammographic screening reduced patients' risk of breast carcinoma recurrence. Specifically, the risk for patients with screen-detected disease was only approximately half of the risk for patients with non-screen-detected disease. Nonetheless, postrecurrence prognosis was comparable for patients in both detection groups.

Declining incidence and mortality of stroke in persons aged > or = 75 years in Finland; the FINSTROKE study.

BACKGROUND: The average life expectancy of a person aged 75 in Finland is approximately 10 years. A substantial threat to the quality of life during these years is stroke, which is common among the elderly, may hamper independent living and places a substantial burden on health care resources. The aim of the present study was to analyse the trends in incidence, mortality and prognosis of acute stroke events in persons aged > or = 75 years in Finland. DESIGN: A population-based stroke register study. METHODS: The FINSTROKE register recorded all stroke events in persons aged > or = 75 years (n=5493) among inhabitants of the town of Turku from 1982 to 1992 and again from 1996 to 1998, and in the Kuopio area from 1990 to 1997. RESULTS: At the end of the study period, the age group > or = 75 years constituted 3.8% of the population of study areas among men and 8.7% among women. This population segment contributed 35% of strokes among men and 66% among women. Of all strokes in this age group, 73% occurred among women. Data suggested that the mortality and incidence of acute stroke events were declining, but the 28-day case fatality did not change. At day 28 after the onset of stroke, only 26% of men and 19% of women had recovered well enough to be capable of independent living. CONCLUSIONS: Stroke mortality among the elderly is declining in Finland, which is mainly due to the decline in the incidence of stroke events.

Lower costs of hospital treatment of breast cancer through a population-based mammography screening programme.

BACKGROUND: The objective of this study was to evaluate the hospital treatment costs of invasive breast cancer in relation to the mode of detection, i.e. by mammography screening, between screenings or without screening during a population-based mammography screening programme, which started in 1987 among 36,000 women aged 40 to 74 years in the city of Turku, Southwest Finland. METHODS: The treatment costs and survival days of 556 women diagnosed with invasive breast cancer at the age of 40 to 74 years in 1987 to 1993 were followed up for five years from diagnosis or until death, whichever occurred first. RESULTS: Screen-detected cancers had the lowest average costs. The mean treatment costs per patient were 1.4-fold for clinical cancers and 1.3-fold for interval cancers compared to screen-detected cancers (p<0.001). The corresponding ratios in the mean treatment costs per survival day were 3.5 for clinical cancers and 1.9 for interval cancers (p<0.001). The mean treatment costs per patient were 1.3-fold for the non-screened group (clinical cancers) compared to the screened group (screen-detected and interval cancers) (p<0.001). The corresponding ratio was 3, when the mean treatment costs per survival day were compared (p<0.001). The estimated savings resulting from early treatment were 26-30% measured as a proportion of the screening costs for 1987 to 1993. CONCLUSION: The treatment costs of screen-detected cancers are lower than those of cancers detected by other methods. The study shows the potential for reducing treatment costs through early detection of breast cancer by mammography screening.

Secondary prevention of coronary heart disease is disappointing among patients of working age.

BACKGROUND: The risk factors underlying coronary heart disease (CHD) are well known. OBJECTIVE: The purpose of this study was to evaluate risk factors related to secondary prevention of working-age CHD patients. METHODS: CHD patients with (n = 139) and without (n = 203) myocardial infarction were selected from a postal questionnaire study (n = 21 101) of randomly selected Finns aged 20-54 years (HeSSup study). Four age- and sex-matched controls were chosen for every patient. RESULTS: CHD patients still smoke, are obese and suffer hangovers more frequently than the control population. CONCLUSION: The health care system has not succeeded in the secondary prevention of CHD.