Resting electrocardiographic abnormalities as predictors of coronary events and total mortality among elderly men.

PURPOSE: To examine the prognostic significance of electrocardiographic (ECG) abnormalities among the elderly. MATERIALS AND METHODS: The Finnish cohorts of the Seven Countries Study involved 697 men aged 65 to 84 years at baseline in 1984. A 5-year follow-up was made from 1984 to 1989. Fatal myocardial infarction, nonfatal myocardial infarction, and all-cause mortality were outcome measures. RESULTS: Seventy-four fatal myocardial infarctions (MI), 101 fatal or nonfatal Mis, and 207 deaths occurred. When electrocardiographic changes were analyzed one by one, men with Q waves (n = 98), high-amplitude R waves (n = 112), depressed ST-interval (n = 122) or T-wave changes (n = 263) had significantly (P < 0.05) higher risk of coronary events and all-cause mortality than men without these changes. Additionally, men with atrial fibrillation (n = 49) had significantly higher risk of death. Highest risk was observed among men with Q waves together with ST- or T-wave changes. Men with both ST depression and T flattening/inversions without Q waves had also increased risk, whereas this was not true for men with Q waves without concomitant ST- or T-wave changes. CONCLUSION: Electrocardiographic abnormalities suggestive of coronary heart disease are associated with a high risk for coronary events and total mortality among elderly men. Among the elderly, a reliable history of coronary heart disease may not be easily achievable, thus the ECG could potentially be used as an indicator of symptomless or atypical heart disease.

Comparison of multivariate predictive power of major risk factors for coronary heart diseases in different countries: results from eight nations of the Seven Countries Study, 25-year follow-up.

BACKGROUND: It was hypothesized that among eight national groups of men aged 40-59 years enrolled in the Seven Countries Study, the multivariate coefficients of major risk factors predicting coronary heart disease mortality over 25 years would be relatively similar. MATERIALS AND METHODS: Sixteen cohorts were located in eight nations and pooled, comprising one cohort in the USA, two in Finland, one in the Netherlands, three in Italy, two in Croatia (former Yugoslavia), three in Serbia (Yugoslavia), two in Greece and two in Japan, for a total of over 12000 subjects at entry. Coronary heart disease (CHD) mortality was defined as fatal myocardial infarction or sudden coronary death, and proportional hazard models were solved, for each country, with age, serum cholesterol level, systolic blood pressure and cigarette consumption as covariates. RESULTS: The relationships between risk factors and CHD mortality were statistically significant for all risk factors and for all countries, except for age in Croatia and Japan, cholesterol in Croatia and Japan, systolic blood pressure in Serbia and Greece, and cigarette-smoking in the Netherlands, Croatia, Serbia and Greece. When comparing all pairs of coefficients (28 comparisons for each factor) significant differences were found on four occasions for age, on six occasions for cholesterol, on no occasion for blood pressure and on four occasions for cigarette-smoking. Other tests suggested a substantial homogeneity among multivariate coefficients. Estimates for pooled coefficients were: age, in years, 0.0570 (95% confidence limits 0.0465 and 0.0673); relative risk for 5 years 1.33 (95% confidence limits 1.26 and 1.40); serum cholesterol level in mg/dl, 0.0057 (95% confidence limits 0.0045 and 0.0069); relative risk for 40 mg/dl 1.31 (95% confidence limits 1.20 and 1.31); systolic blood pressure in mmHg, 0.0160, (95% confidence limits 0.0134 and 0.0185), relative risk for 20 mmHg 1.38 (95% confidence limits 1.31 and 1.45); cigarettes per day, 0.0220 (95% confidence limits 0.0170 and 0.0272); relative risk for 10 cigarettes per day 1.25 (95% confidence limits 1.18 and 1.31). CONCLUSIONS: Great similarities were found in the multivariate coefficients of major coronary risk factors to CHD risk derived from population samples varying in CHD frequency.

Changes in serum cholesterol level and mortality: a 30-year follow-up. The Finnish cohorts of the seven countries study.

The association of past changes in serum cholesterol level with cause-specific mortality between 1974 and 1989 was examined in a cohort of 784 Finnish men aged 55-74 years who were free of symptomatic coronary heart disease in 1974. Changes in serum cholesterol level were computed based on measurements made in 1959, 1964, 1969, and 1974. Of the 405 deaths, 202 were due to cardiovascular diseases and 107 due to cancer. Men with a decline in serum cholesterol level between 1959 and 1974 also experienced greater than average declines in body mass index and tended to be more often current smokers in 1974. Among 339 men aged 65-74 years in 1974, men in the lowest tertile of serum cholesterol change, i.e., with greatest declines, had increased cardiovascular (hazard ratio, 1.58; 95% confidence interval 1.00-2.50) and all-cause (hazard ratio, 1.46; 95% confidence interval 1.06-2.02) mortality compared with men in the middle tertile of change, i.e., with least change, in multivariate analysis. Among 445 men aged 55-64 years in 1974, there was a significant U-shaped association between change in serum cholesterol level and coronary and all-cause mortality risk. The authors suggest that both the decline in serum cholesterol level and the associated high mortality may be caused by a third factor, such as increased prevalence of chronic diseases or other changes associated with aging. This would help to explain why several studies have not found an association of serum cholesterol with coronary risk among the elderly.

Short- and long-term association of serum cholesterol with mortality. The 25-year follow-up of the Finnish cohorts of the seven countries study.

The association of serum cholesterol with cause-specific and all-cause mortality was assessed in a cohort of 1,426 men aged 40-59 years who were free of clinically evident heart disease at baseline (1959). A total of 748 deaths (53 percent of the participants) occurred during the 25-year follow-up period. Men with high serum cholesterol levels at baseline had high mortality due to coronary heart disease during both the early and later parts of the follow-up period. In contrast, the association of serum cholesterol with mortality due to causes other than coronary heart disease changed during follow-up (interaction of cholesterol with follow-up period: p = 0.004). During the first 10 years of follow-up, despite their high coronary mortality, men with high cholesterol levels had lower all-cause mortality (age-adjusted relative risk = 0.71 for serum cholesterol above 5.79 mmol/liter vs. below 5.80 mmol/liter; p = 0.03) because of their low cancer mortality (relative risk = 0.55, p = 0.03) and residual mortality (relative risk = 0.49, p less than 0.01). During the last 15 years of follow-up, cholesterol at baseline was no longer associated with mortality due to causes other than coronary heart disease, and consequently, because of their high coronary mortality, men with high cholesterol levels also had higher all-cause mortality (relative risk = 1.22, p = 0.05). The results suggest that to fully analyze the association of serum cholesterol with all-cause mortality, the follow-up period should be sufficiently long--possibly more than 10 years--and the possibility of a change in the direction of the association studied should always be considered.

All cause mortality and its determinants in middle aged men in Finland, The Netherlands, and Italy in a 25 year follow up.

STUDY OBJECTIVE: The aims were (1) to compare all cause mortality in population samples of different cultures; and (2) to cross predict fatal event by risk functions involving risk factors usually measured in cardiovascular epidemiology. DESIGN: The study was a 25 year prospective cohort study. The prediction of all cause mortality was made using the multiple logistic equation as a function of 12 risk factors; the prediction of months lived after entry examination was made by the multiple linear regression using the same factors. POPULATION SAMPLES: There were five cohorts of men aged 40-59 years, from Finland (two cohorts, 1677 men), from The Netherlands (one cohort, 878 men), and from Italy (two cohorts, 1712 men). SETTING: The Finnish cohorts came from geographically defined rural areas, the Dutch cohort from a small town in central Holland, and the Italian cohorts from rural villages in northern and central Italy. MEASUREMENTS AND MAIN RESULTS: All cause mortality was highest in Finland (557 per 1000), and lower in The Netherlands (477) and in Italy (475). The solutions of the multiple logistic function showed the significant and almost universal predictive role of certain factors, with rare exceptions. These were age, blood pressure, cigarette smoking, and arm circumference (the latter with a negative relationship). Similar results were obtained when solving a multiple linear regression equation predicting the number of months lived after entry examination as a function of the same factors. The prediction of fatal events in each country, using the risk functions of the others, produced limited errors, the smallest one being -2% and the largest +11%. When solving the logistic model in the pool of all the cohorts with the addition of dummy variables for the identification of nationality, it also appeared that only a small part of the mortality differences between countries is not explained by 12 available risk factors. CONCLUSIONS: A small set of risk factors seems to explain the intercohort differences of 25 year all cause mortality in population samples of three rather different cultures.

Blood pressure changes as predictors of future mortality in the seven countries study.

Twelve cohorts of men aged 40-59 at entry, enrolled in six countries (Finland, The Netherlands, Italy, Yugoslavia, Greece and Japan), giving a total of 8,287 subjects, were examined for the measurement of cardiovascular risk factors and then followed-up for 20 years. Changes of systolic blood pressure (SBP) occurred over the first 10 years in 6,767 men and these values, computed by an integral-like procedure (Delta-SBP), were used as possible predictors of fatal events recorded in the second 10 years of follow-up. Men who had a relative increase of SBP in the first 10 years showed an excess risk of death as compared with those who had a relative decrease of SBP, after adjustment for age and entry levels of SBP. Such relative risks were greater than 1 in the cohorts pooled within each of the six countries, ranging from 1.07 to 1.79 for all causes of death and from 1.12 to 2.15 for atherosclerotic cardiovascular disease deaths (coronary, stroke and peripheral atherosclerotic disease). The Cox model was solved using the same two end-points as dependent variables and, as coviariates, six risk factors measured at entry examination (age, cigarettes smoked per day, body mass index, serum cholesterol, physical activity at work and systolic blood pressure). By adding Delta-SBP the predictive power of the models was significantly improved and the coefficients of Delta-SBP proved to be statistically significant.

Twenty-five-year mortality from coronary heart disease and its prediction in five cohorts of middle-aged men in Finland, The Netherlands, and Italy.

Five cohorts of men ages 40-59 (Finland: 2 cohorts of 1,677 men; Netherlands: 1 cohort of 878 men; Italy: 2 cohorts of 1,712 men) were examined and evaluated for cardiovascular risk factors in 1959-1960 and subsequently followed-up for mortality over the next 25 years. Age-adjusted death rates from coronary heart disease were highest in Finland (244 per 1,000), intermediate in The Netherlands (195 per 1,000), and lowest in Italy (122 per 1,000) with a twofold range between the extremes. The Cox proportional hazards model was used for single cohorts and for the pools of national cohorts with coronary heart disease deaths as endpoints and 12 risk factors as covariates. It showed the significant and almost universal predictive value of these factors (with some rare exceptions). The most highly predictive values were age, blood pressure, total serum cholesterol, cigarette smoking, and physical activity (negative relationship). The prediction of events within each country using the risk function of the others produced errors ranging from -19% to +51%. The largest errors were those involving the Italian cohorts whose experience tended to underpredict coronary heart disease mortality elsewhere and to be overpredicted by the risk functions of the other countries. Solving a Cox model which included all the cohorts, and adding dummy variables for the identification of nationality, it appears that the relative risk, everything else being equal, is 1.49 and 1.34 for a Finnish man, compared with Italian and Dutch men, respectively.

Predictors of high functional capacity and mortality in elderly Finnish men.

Factors predicting high functional capacity in old age and 25-year mortality were studied in 1711 men aged 40 to 59 years. The study population was that of the East-West Study, i.e. the Finnish part of the Seven Countries Study. After the 25-year follow-up (in 1984) 766 men were still alive. Nonsmoking and good pulmonary function in earlier middle-age and the absence of coronary heart disease, cerebrovascular disease or emphysema in later middle-age predicted high functional capacity in old age. High systolic blood pressure, low forced vital capacity, smoking, and the presence of coronary heart disease predicted mortality in the next 10 to 25 years. Although mortality rates were higher in eastern Finland, the predictors were similar in both the eastern and the southwestern parts of the country.

Mental disability among elderly men in Finland: prevalence, predictors and correlates.

Mental disability, variables associated with it and predictors of mental disability in late life were studied in 716 men from eastern and southwestern Finland in connection with the 25-year follow-up of the east-west study, which formed the Finnish part of the seven-countries study. The examinations were carried out in autumn 1984, when the men were 65-84 years of age. According to a 10-item mental status questionnaire, 95% of the men had normal mental capacities. There were no differences between the 2 areas. Old age, low educational level, low functional capacity, low body mass index, low serum cholesterol, low diastolic blood pressure, low alcohol or coffee consumption, low hemoglobin, low serum calcium, low serum triiodothyronine, high scores on the Zung Self-rating Depression Scale, and presence of transient ischemia or stroke were associated with mental disability in 1984. In the prospective analysis, low forced vital capacity, low forced expiratory volume in 0.75 s and high blood pressure in middle age predicted mental disability in old age.

Risk factors and 25 year risk of coronary heart disease in a male population with a high incidence of the disease: the Finnish cohorts of the seven countries study.

OBJECTIVE: To assess the efficacy of high serum cholesterol concentration, raised blood pressure, and smoking as predictors of coronary heart disease. DESIGN: Prospective cohort study of middle aged men conducted over 25 years. SETTING: Finish components of an ongoing international study (seven countries study). PARTICIPANTS: 1520 Men who at age 40-59 in 1959 were free of clinically evident heart disease. INTERVENTIONS: At each follow up visit a detailed medical examination including resting electrocardiography was performed, blood pressure and serum total cholesterol concentration were measured, and smoking was assessed. MEASUREMENTS AND MAIN RESULTS: 825 Deaths (54% of participants) occurred during follow up, of which 335 were due to coronary heart disease. The hazard ratio for death from coronary heart disease with respect to risk factors at entry were: for serum cholesterol concentrations above 8.4 mmol/l v below 5.2 mmol/l, 2.68 (95% confidence interval 1.62 to 4.42); for systolic blood pressure in the highest quintile v that in the lowest quintile, 2.46 (1.72 to 3.50); and for smoking 10 or more cigarettes daily v never smoking, 1.95 (1.36 to 2.79). The hazard ratios with respect to cholesterol concentrations and blood pressure remained constant during follow up but the ratio with respect to smoking diminished, mainly owing to men giving up the habit. The estimated conditional probability of a 50 year old man dying of coronary heart disease in the next 25 years ranged from 12% among those with the most favourable risk factor profile to 75% among those with the least favourable profile. CONCLUSIONS: High risk factor levels (as determined in this study) in middle aged men may greatly increase the absolute probability of death from coronary heart disease when the period of study is relevant to the human life span.

Serum cholesterol and risk of accidental or violent death in a 25-year follow-up. The Finnish cohorts of the Seven Countries Study.

In the two most recent cholesterol-lowering drug trials, the achieved reductions in coronary heart disease mortality were offset by increases in mortality due to accidents and violence. A possible biochemical explanation has been suggested for an association between low serum cholesterol level and increased risk of death due to injury. We, therefore, examined the association between serum cholesterol level and risk of death from accidents or violence in the 25-year follow-up of two cohorts of Finnish men (N = 1580). Although a statistically nonsignificant, negative association was observed in one cohort (hazard ratio, 0.84, with a 1 mmol/L increase in cholesterol), the other cohort showed a statistically significant, positive association in multivariate analysis (hazard ratio, 1.39). We conclude that the observed associations between serum cholesterol and deaths from injury in the present study and in cholesterol-lowering trials are probably determined by other, presently unknown factors, or by chance.

Risk factors for cardiovascular disease among 55 to 74 year-old Finnish men: a 10-year follow-up.

The importance of serum total cholesterol, systolic blood pressure, and smoking as predictors of cardiovascular (CVD) disease were studied in 867 men aged 55 to 74 years belonging to the Finnish cohorts of the Seven Countries Study. Men had no definite history of myocardial infarction nor any signs of cerebrovascular disease at baseline in 1974. During the 10-year follow-up 248 men either died from CVD or had non-fatal CVD event, including a total of 188 fatal and nonfatal coronary heart disease (CHD) events. Age-adjusted relative risk of CVD event for men aged 55 to 64 with cholesterol over 7.4 mmol/l compared to below 6.0 mmol/l was 2.6, with systolic blood pressure over 159 mmHg vs. below 135 mmHg 1.8, and smoking over 19 cigarettes per day vs. never smoker 1.7. Corresponding relative risks for men aged 65 to 74 were 1.0, 1.4 and 1.2, respectively. The results for CHD events were closely similar. The results indicate that, in terms of relative risk, systolic blood pressure retains its importance as risk factor for CVD and CHD from late middle age to old age, whereas the importance of smoking is diminished, and serum cholesterol is of little importance in old age.

Changes in alcohol consumption and mortality in aged Finnish men.

Drinking patterns and changes in alcohol consumption from 1974 to 1984 and associations between alcohol consumption in 1974 and ten-year mortality rates from cardiovascular, violent, cancer or all causes were studied among Finnish men born between 1900 and 1919. The overall absolute alcohol consumption was low in both 1974 and 1984. The average alcohol consumption and drinking pattern did not significantly change with increasing age, though some individual changes occured. Moderate or heavier alcohol consumption was a significant risk factor for cancer deaths among non-smoking men, but not in male smokers. Moderate or heavier alcohol consumption might also be a significant risk factor in violent death. Low, moderate or heavier alcohol consumption was not a significant risk factor for coronary deaths among the men in this rural Finnish population.

Association of physical activity with coronary risk factors and physical ability: twenty-year follow-up of a cohort of Finnish men.

The association of physical activity with coronary risk factors and self-reported physical ability was studied in a cohort of 331 healthy Finnish men aged 45-64 years at entry, representing the survivors of a 20-year longitudinal study from 1964 to 1984. Baseline physical activity was not significantly related to levels of coronary risk factors at subsequent 5-year, 10-year or 20-year follow-up examinations. The 72 who increased their physical activity during the study period smoked less at 20-year follow-up than those who remained sedentary (p = 0.03). No other significant associations between 20-year changes of physical activity and coronary risk factors were seen. Although baseline physical activity was not, physical activity and exercise at 20-year follow-up were positively related to indices of functional capacity assessed at the end of the study period, when the subjects had reached a mean age of 73 years. It is concluded from this long-term study that a relative increase of physical activity between middle and old age is associated with both less smoking and a maintained high level of physical ability.

Functional capacity and associated factors in elderly Finnish men.

Functional capacity and associated factors were studied in 321 men from eastern Finland and 395 men from southwestern Finland in connection with the 25-year follow-up survey of the East-West Study. The survey was carried out in autumn 1984, when the men were 65-84 years of age. In the measurement of different activities of daily living, 55 to 95% in the east and 62 to 97% in the south-west reported that they managed daily activities without another person's help. Both the mean age of the men and the mean of the sum index of functional capacity as stratified by age were in southwestern Finland significantly higher than in eastern Finland. Older age groups had lower functional capacity in both areas. Lowered functional capacity was associated with cardiovascular diseases, diabetes mellitus and impairments of vision in both areas, and with impairments of the locomotor system in the south-west. High pulmonary function was associated with high functional capacity. No connection was found between smoking and functional capacity, but heavier alcohol and coffee consumption were associated with high functional capacity.

Predictors of disability in elderly Finnish men--a longitudinal study.

Factors predicting disability in late life were studied in 716 men from eastern or southwestern Finland in connection with the 25-year follow-up of the East-West Study, which is part of the Seven Countries Study, in 1984. In middle-aged men, low forced vital capacity, occurrence of diabetes, presence of intermittent claudication, high diastolic blood pressure, higher age and lower educational level showed the greatest predicting power for future disability 15-25 years later. In later middle age, low forced vital capacity, presence of intermittent claudication, cerebrovascular disease or coronary heart disease and higher age were the most powerful predictors for disability 10 years later. In order to lower disability in old age, it is important to prevent deterioration of ventilatory function and cardiovascular diseases in middle-aged populations and to treat chronic diseases adequately.

Vitamin A, vitamin E and selenium status in an aged Finnish male population.

Vitamin A (retinol), vitamin E (alpha-tocopherol) and selenium concentrations in serum were studied during the autumn season (October and November) in two Finnish male populations aged 65-84 years and living either in eastern or southwestern Finland. The mean vitamin A concentration was higher in south-western, but the mean selenium concentration was higher in eastern Finland. Mean vitamin A concentrations did not differ between age groups, but in the south-west highest vitamin E and selenium concentrations were found among the youngest population. A severe vitamin A deficiency (below 300 micrograms/l) was found only in 3 (1%) men in the east and 4 (1%) men in the south-west, and a mild deficiency (300-399 micrograms/l) in 11 (4%) men in the east and 16 (4%) men in the south-west. Vitamin E deficiency after the correction by serum total cholesterol (below 2 mg/l/g/l) was found only in 3 (1%) men in the east and 1 (0%) man in the south-west, and low values (2.0-2.9 mg/l/g/l) were found in 13 (4%) men in the east and 34 (9%) men in the south-west. A severe deficiency of selenium (below 46 micrograms/l) was found in 10 (3%) men in the east and 15 (4%) men in the south-west, while a mild deficiency (46-69 micrograms/l) was found in 140 (45%) men in the east and 197 (52%) men in the south-west. The overall vitamin A and vitamin E status of elderly Finnish men was relatively adequate, while severe or mild deficiencies of selenium were common.

Alcohol consumption and mortality in aging or aged Finnish men.

The association between alcohol consumption and 10-year mortality by death cause was studied in 1112 men aged 55-74 years and living either in eastern or south-western Finland. After adjustment for age, blood pressure, smoking, serum cholesterol, and other variables, the relative odds ratio of 10-year total mortality associated with consuming 1-273 g of absolute alcohol per month was 0.9 (95% confidence interval of 0.6-1.2) and with consuming more than 273 g per month due to violence was small, 15, but relative odds of violent death associated with consuming 1-273 and 274 or more grams of alcohol per month were 3.4 and 16.2, respectively (95% confidence intervals of 0.4-31.9 and 1.9-141.2).

Determinants and predictors of heavy alcohol consumption among aging Finnish men.

The aim was to identify socioeconomic, health behaviour, and health factors associated with or predicting heavy alcohol consumption in late middle age (55-74 years) or in old age (65-84 years). The material included a follow-up study of two cohorts of Finnish males resident either in eastern or south-western Finland. The main variables associated with heavy alcohol consumption in late middle age were: relatively young age and heavy smoking. The main associated variables in old age were good mental and physical capacity, occurrence of chronic bronchitis, the absence of certain cardiac diseases, and heavy smoking. Heavy smoking was the main predictor of heavy alcohol consumption 5-25 years later; alcohol consumption 10 years earlier was also an important predictor. Some regional differences were found in associated or predictive variables. The results suggest that, with the exception of alcohol consumption itself and heavy smoking, socioeconomic, health and other health behaviour factors are not very important in explaining or predicting heavy alcohol consumption among aging Finnish men. Drinking and smoking habits were closely related in these aging or aged men.

Changes in alcohol consumption during a ten-year follow-up among Finnish men aged 55-74 years.

Drinking patterns, changes in alcohol consumption from 1974 to 1984 and socioeconomic, social, health and health-related variables associated with changes were studied in a male cohort born 1900-1919 and living either in eastern or in southwestern Finland. The average alcohol consumption and drinking pattern did not change to any significant extent among these Finnish men with increasing age, though some individual changes happened. Most aging or aged Finnish men did not react to social stressors or worsening of health by changing alcohol consumption.