Favourable trends in the incidence and outcome of myocardial infarction in nondiabetic, but not in diabetic, subjects: findings from the MONICA myocardial infarction registry in northern Sweden in 1989-2000.

BACKGROUND: The aim of this study was to compare time trends in incidence, case fatality and mortality due to myocardial infarction (MI) in patients with or without diabetes. METHODS: This study was based on the Northern Sweden MONICA Project MI registry with a target population of about 200,000 inhabitants in the age group 35--64 years in the two northernmost counties of Sweden. During 1989--2000, 6254 patients who had had an MI according to MONICA criteria were included in this study: 4569 patients had a first MI and 1685 had a recurrent MI. Sixteen per cent of the men and 20% of the women had had diabetes mellitus diagnosed prior the MI. RESULTS: Over the 12-year period, there was a declining trend in incidence and case fatality in first MI. Also, the event rates (first ever and recurrent MI) declined in men without diabetes. In women without diabetes favourable time trends were seen in first ever MI, recurrent MI and in case fatality. There were no favourable time trends for any of these outcomes in patients with diabetes. CONCLUSION: In nondiabetic subjects below the age of 65, the incidence of, and case-fatality in, MI declined. This led to a decreased mortality over the 12-year period. These favourable trends over time were not observed in diabetic subjects.

Sudden cardiac death in the young in Sweden: electrocardiogram in relation to forensic diagnosis.

OBJECTIVES: To study electrocardiogram (ECG) in relation to forensic diagnosis in young persons who suffered a sudden cardiac death (SCD) in Sweden during 1992-99. DESIGN: A register study of a national database of forensic medicine in Sweden, selecting all cases of SCD 15-35 years of age. In this group, 12-lead ECGs and clinical data were searched for in military conscription and medical records. The ECGs were re-analysed and classified according to the Minnesota code criteria. SETTING: The whole nation of Sweden. SUBJECTS: Sudden cardiac death victims (66 individuals), 15-35 years of age, where it was possible to obtain an ECG recording. RESULTS: We observed major or minor ECG abnormalities in 82% of the subjects. The most common changes were T wave abnormalities (35%), ST segment changes (32%) and conduction defects (20%). The ECGs were evaluated as pathological in 50% of the cases, more often in arrhythmogenic right ventricular cardiomyopathy (88%) and hypertrophic cardiomyopathy (82%). Cardiac-related symptoms were seen in 76% of the total group and there was a family history of a similar cardiac condition in 18%. CONCLUSIONS: Pathological ECGs were common in young SCD victims, in spite of being taken many years before death. An ECG could help identify prospective victims of SCD, and should always be taken in cases with possible cardiac-related symptoms or a family history of SCD. The pathological ECGs were often found in connection with routine screening at military enlistment for men, which raises the question of a routine screening in the young, including women.

The Arctic Oscillation and incidence of acute myocardial infarction.

OBJECTIVES: To describe the relation between the Arctic Oscillation (AO) index and the incidence and mortality in acute myocardial infarction (AMI) in the northern, partly subarctic area of Sweden. DESIGN: Comparison of a time series of daily variations in the AO index and register data on the daily number of fatal and nonfatal AMIs. SETTING: The northernmost two Swedish counties, Norrbotten and Västerbotten. SUBJECTS: All inhabitants in the Norrbotten and Västerbotten counties were followed for the occurrence of an AMI between 1985 and 1999 within the framework of the WHO MONICA (multinational MONItoring of trends and determinants of CArdiovascular disease) Project. MAIN OUTCOME MEASURE: Fatal and nonfatal AMIs. RESULTS: There was a consistent positive relation between increasing AO index and an increase in AMI incidence and mortality. The maximum impact on AMI incidence of the AO came after a lag phase of 3 days. A one unit increase in AO index was associated with an increase in: the daily number of AMIs (+3.8%), the case fatality in AMI within 28 days (+5.1%), the number of nonfatal AMIs (+3.4%), and the number of sudden cardiac deaths (+8.3%). CONCLUSIONS: An AO index increase, bringing warmer weather over Scandinavia, was associated with an increase in the incidence and mortality in AMI in northern Sweden.

Trends in sudden cardiac death in the northern Sweden MONICA area 1985-99.

OBJECTIVES: To describe time trends in sudden cardiac death (SCD) occurrences between 1985 and 1999. DESIGN: Cohort study with analysis of a database of all symptomatic and/or fatal acute myocardial infarctions (AMI) in the two northernmost counties in Sweden, partly north of the Arctic Circle. SUBJECTS: A total of 1139 cases of SCD amongst men and women aged 35-64 years. MAIN OUTCOME MEASURE: Sudden cardiac death. RESULTS: Amongst men the proportion of SCD to all AMI deaths (within 28 days of an AMI) was 38% and for women 31%. The mean yearly incidence of SCD in this age group was 65 per 100,000 men and 12 per 100,000 women. Amongst men the mean yearly incidence decreased by 1.8% (95% confidence interval -3.2 to -0.3) and amongst women the decrease was 1.0% (95% confidence interval -4.4 to 2.4). Diabetes mellitus was more common in women compared with men (24% vs. 14%, P = 0.001). Men suffered an SCD more often around noon and on Saturdays, whereas women suffered their SCD on Mondays and Fridays. For season, men and women behaved similarly with a winter peak, although statistical significance was reached only for men. CONCLUSIONS: The SCD decreased amongst men between 1985 and 1999. There was also a decrease amongst women during the same time period but not to a statistically significant degree, possibly caused by lack of statistical power due to small numbers.

Sudden cardiac death in 15-35-year olds in Sweden during 1992-99.

OBJECTIVES: To study the incidence, pathogenesis and symptoms preceding sudden cardiovascular death amongst 15-35-year olds without substance abuse in Sweden during 1992-99. DESIGN: This was a register study of a national database of forensic medicine, Rattsbase. Clinical details were obtained from forensic, police and medical records and from interviews with family members. SETTING: The whole nation of Sweden. SUBJECTS: Individuals having suffered a sudden cardiac death. RESULTS: We found 181 cases of sudden cardiovascular death in a nationwide database, Rattsbase, in 15-35-year olds, of which 132 (73%) were male and 49 (27%) were female, and a rather stable incidence of 0.93 per 100,000 per year. Preceding symptoms were seen in half of the cases. The most common forensic diagnoses were: no structural abnormality (21.0%), coronary atherosclerosis (17.7%), dilated cardiomyopathy (12.2%), hypertrophic cardiomyopathy (10.5%) and myocarditis (10.5%). CONCLUSION: Sudden cardiovascular death was uncommon in the young, but the incidence was not decreasing. Postmortem diagnoses were often difficult to establish. There was a high frequency of structurally normal hearts. Because premortal cardiac-related symptoms are relatively common and treatment methods are developing, we should learn to recognize early symptoms of heart disease. To identify individuals at risk, further studies of preceding symptoms, life-style factors and electrocardiogram (ECG) changes are needed.

No covariation between the geomagnetic activity and the incidence of acute myocardial infarction in the polar area of northern Sweden.

This study was undertaken to investigate whether there was any relation between the aurora borealis (measured as the geomagnetic activity) and the number of acute myocardial infarctions (AMI) in the northern, partly polar, area of Sweden. The AMI cases were collected from The Northern Sweden MONICA (multinational MONItoring of trends and determinants of CArdiovascular disease) AMI registry between 1985 and 1998, inclusive, and the information on the geomagnetic activity from continuous measurements at the Swedish Institute of Space Physics, Kiruna. In the analyses, both the relation between the individual AMI case and ambient geomagnetic activity, and the relation between the mean daily K index and the daily number of AMI cases were tested. We found no statistically significant relation between the number of fatal or non-fatal AMI cases, the number of sudden deaths or the number of patients with chest pain without myocardial damage, and geomagnetic activity. Our data do not support a relation between the geomagnetic activity and AMI.

Cardiovascular drugs and the risk of death in acute myocardial infarction in northern Sweden MONICA patients.

PURPOSE: To quantify the impact of cardiovascular drugs used before the acute myocardial infarction (AMI) and given during the acute phase on reduction in the risk of death during the first 28 days after an AMI. METHODS: The Northern Sweden MONICA database on incident AMI was analysed with regard to drug use before and during the acute phase of the myocardial infarction and the risk of death within the first 28 days. All patients admitted to a hospital in this area with a suspected diagnosis of AMI were included in this database. RESULTS: No drugs used before and up to the acute myocardial infarction provided protection against death in the AMI in this analysis. Among drugs given during the acute phase, antiplatelet drugs and betablocking drugs reduced the risk of death in the AMI and to a lesser degree, anticoagulants and nitrates provided protection. CONCLUSIONS: The administration of antiplatelet drugs and betablockers in the acute phase of an AMI substantially reduces the risk of death during the first 28 days after an AMI for the individual.

Fatty acid composition in serum among males 4-16 years after myocardial infarction.

In a case-control study we compared men who had suffered a myocardial infarction with age-matched controls free from clinically apparent ischemic heart disease. Our main interest were differences in serum lipid and apolipoprotein concentrations. We found no significant differences between these two populations. The fatty acid composition of the serum cholesterol esters was studied as an indirect measure of the dietary fat quality. There were rather small differences with regard to the fatty acid composition between the survivor cases and the controls suggesting that the quality of the dietary fat was not better among the cases after the myocardial infarction than among the average male in Kiruna. The cases had a significantly higher proportion of palmitoleic acid (16:1 n-7, p < 0.004) than the controls, also after controlling for other biomedical risk factors. A high content of palmitoleic acid may be a marker of increased risk for coronary heart disease.

Psycho-social risk factors for ischaemic heart disease among men in the subarctic area.

We analysed the psycho-social risk factors for acute myocardial infarction in Kiruna, a town about 150 km north of the Arctic Circle, with a high mortality in ischaemic heart disease. In a case-control study, 219 male patients aged 35 to 64 years admitted to Kiruna District Hospital, with a first acute myocardial infarction between 1973 and 1985, were compared to 438 age-matched male controls without coronary heart disease. After adjusting for main biomedical risk factors (diabetes, hypertension, number of smokers and family history) a combination of mental and physical stress at work (OR 3.5, 96% CI 1.6-7.8) and heavy physical work (OR 1.5, 95% CI 1.1-3.6) were associated with an increased risk of myocardial infarction, whereas good control over job tasks was associated with a reduced risk (OR 0.7, 95% CI 0.5-0.9). Migration into Kiruna, especially in the 15 years preceding the study compared to earlier migration, also appeared as an independent predictor of myocardial infarction. We conclude that subgroups of men in Kiruna are at particularly high risk of myocardial infarction because of adverse factors related to their work and their social life and thus enable to preventive measures.

Diet and dietary markers in Kiruna and Uppsala, Sweden--a comparison.

Because of a very high mortality in ischaemic heart disease in Kiruna, Sweden, a case-control study was undertaken to study risk factors (e.g. life style, hypertension, psycho-social factors, and diet and serum lipids). As part of this study the dietary habit, lipoproteins and composition of fatty acids in cholesterol esters in serum and adipose tissue triglycerides were studied in Kiruna and in an age-matched reference cohort in Uppsala. There were small, non-significant differences in these variables between cases and controls in Kiruna and between the Kiruna cohort and a reference cohort in Uppsala. Main differences in the inter-city comparison were low levels of gamma tocopherol in serum, high levels of palmitic acid (16:0) and low levels of linoleic acid (18:2 n-6) in serum cholesterol esters and adipose tissue triglycerides in Kiruna which suggest dietary differences and different anti-oxidative status in the two populations.

[Experience in applying legal conditions according to the nursing insurance regulation--ambulatory rehabilitation, nursing aids and nursing care eligibility]. / Erfahrung in der Umsetzung von Vorgaben nach dem Pflegeversicherungsgesetz--ambulante Rehabilitation, Hilfsmittel und Pflegeeinsatz.

UNLABELLED: The Statutory Health Care (Nursing) Insurance in Germany, called "Pflegeversicherung (PVG)", financially supports nursing care at home and in nursing homes. If suggested by an authorized examining person (MDK), it provides access to ambulatory rehabilitation and to various aids to facilitate nursing care of patients cared for at home. Also, the PVG mandatory requires the visit by a nurse every three to six months (nursing care checkup) if the patient is cared for by family members without support of professional nursing services. Little is known about the realisation of the suggestions given by the examining person from MDK and about the realisation of the nursing care checkup in actual practice. Our study tried to find answers to these questions. For this purpose, we visited 150 patients at home and asked them about rehabilitation efforts, whether the recommended additional aids had been supplied, and whether nursing care checkups had been successfully performed. RESULTS: For 41 patients, rehabilitatory exercises were suggested, but only 7 were actually realised. 89 patients were supposed to receive various aids, but only 31 were actually delivered. Whenever rehabilitation was performed, it was nearly without exception thanks to the initiative of relatives supported by their private doctor. Nursing care checkups should have been performed in 80 patients, but had been realised in only 11 cases. The care providing relatives considered such "care checkups" to be ineffective, costly and useless. CONCLUSION: The nonfinancial services granted by the PVG were not translated into reality in most instances, and if so, it was due to efforts of relatives and private doctors, not to efforts of the statutory bodies. Apparently this task was more than these bodies could handle during this early phase of services by the PVG. Therefore, the private doctors (family doctors) should be informed of the results of the examination done by MDK. The need for the nursing care checkup should be reconsidered.

[Experiences in realization of guidelines of the nursing care insurance regulation--outcome in home care service after expert assessment by medical service personnel]. / Erfahrungen in der Umsetzung von Vorgaben nach dem Pflegeversicherungsgesetz--Erhebungen im häuslichen Bereich nach der Begutachtung durch den MDKN.

The German Pflegeversicherung is a new kind of insurance system for dependence on nursing care (Nursing Care Insurance). Grading into groups according to the intensity of help required, effected by physicians and nurses of the Medical Service of the statutory insurance bodies, as well as the grading system itself have been subjected to severe criticism. However, the emotions in this regard have recently calmed down considerably. The questions are: Do the benefits of the Pflegeversicherung result in improving the financial situation at home? Does it signify increase professional nursing at home? The purpose of our study is to find an answer to these and other questions. We interviewed 150 nursing care dependent persons receiving benefits according to the new system. Senile dementia was the most frequent diagnosis in groups II and III of the official grading scale. Despite of the financial support, a change to more professional nursing care was rarely observed; on the contrary, at times the costly professional services were no longer requested. Deterioration of physical health was seen in every second patient since the first rating by the Medical Service 4 to 6 months ago. Notification of grading and payments to the families took place without delay except in cases of "Kombinationsleistung" (financial support plus financing ambulatory professional nursing-care). We observed major deficits in the counselling of patients or their relatives; there were mostly no courses in nursing care for relatives. Patients and their care-providing relatives usually were satisfied by the benefits provided; relatives felt the financial benefits as an acknowledgement of their engagement. In summary, most care-providing relatives were satisfied by the benefits, but the lack of nonfinancial services (counselling, courses in nursing care, payments for social security) showed up major deficiencies.

Alcohol consumption and ischemic heart disease mortality in Sweden.

Most previous studies on the relationship between alcohol consumption and mortality from ischemic heart disease (IHD) have been conducted in countries with an alcohol consumption pattern different from that in Sweden (and other countries in the "Vodka Belt"), where irregular binge drinking of distilled spirits is common. Therefore, we carried out an ecological study in Sweden where cross-sectional, longitudinal, and time series analyses (1973-1986) were performed on consumption of spirits, wine and beer in relation to age-standardized mortality in IHD for males and females. There was a negative correlation in both cross-sectional and longitudinal analyses between wine consumption and mortality from IHD, especially strong for women, but no consistent relationship between the consumption of total ethanol, spirits and beer versus the mortality from IHD. In the time series analysis, only wine was negatively correlated with IHD mortality for women. We conclude that, on a population level, consumption of spirits and beer in a Swedish drinking pattern does not imply any protection against death from IHD. On the other hand, wine consumption in Sweden could be associated with a reduced risk of IHD death among women.

Clinical epidemiology of heart failure: experience in a rural hospital.

The prevalence of patients with heart failure is increasing in the population. This study was designed to find out whether this depends on increased survival or an increased incidence in the hospital catchment area. The hospital register of discharge diagnoses was searched for the diagnosis heart failure between 1987 and 1994. The vital status of each individual was checked in April 1995. For those deceased, survival time was calculated. The incidence increased gradually from 1.4/1,000 inhabitants in 1987 to 2.6/1,000 inhabitants in 1994, with the same incidence for men and women. There was no significant difference in survival for those treated in the beginning of the period compared to those treated late. Women had a 27% reduction in mortality compared to men. A one-decade age increase raised the hazard ratio by 35%. There has been an increase in incidence and demand for hospital beds for the diagnosis heart failure. The overall prognosis has not improved during the surveyed years. Being a man and being elderly carried a worse prognosis.

Risk factors for acute myocardial infarction among men in the subarctic area.

OBJECTIVE: To describe and quantify the main risk factors for acute myocardial infarction (AMI) among males in the subarctic region of Sweden. DESIGN: Case-control study comprising a questionnaire and a clinical examination. SETTING: Kiruna, a town about 100 miles north of the Arctic Circle with a very high mortality from ischaemic heart disease. SUBJECTS: 219 patients 35 to 64 years of age admitted to Kiruna District Hospital with a first myocardial infarction between 1973 and 1985, and 438 age-matched controls. RESULTS: The main risk factors for the whole group were hypertension (odds ratio [OR] 3.5), family history of AMI (OR 2.2), diabetes mellitus (OR 2.2), and smoking (OR 1.7). The distribution and strength of the risk factors differed between Kiruna-born and migrants into the community. CONCLUSION: Apart from the traditional risk factors, environmental and psycho-social factors and population dynamics must be taken into account when assessing the risk for a man in Kiruna of developing a myocardial infarction.