Axel C. Carlsson

Blood pressure course in patients with acute stroke and matched controls.

The natural course of blood pressure (BP) was studied after emergency hospitalization in 209 consecutive stroke patients and as many age and sex matched controls. Histories of hypertension were more common among patients than controls (46% vs 26%). On admission 69% of the stroke group and 36% of the controls had BP greater than or equal to 170/100 mm Hg. In the first four days there was a spontaneous BP decline, which was greater the higher the initial values. During the whole hospitalization though, stroke patients with previous hypertension had the highest BP levels and previously normotensive controls the lowest. Even if WHO as well as the Joint Committee for Stroke have recommended cautious antihypertensive therapy in stroke patients with extreme hypertension, such therapy is not evaluated. If this is to be done, the present findings have to be taken into consideration. Stroke controls, matched according to the initial BP level, will thus be required.

Higher fibroblast growth factor-23 increases the risk of all-cause and cardiovascular mortality in the community

Fibroblast growth factor-23 (FGF23), a regulator of mineral metabolism, has been linked to cardiovascular disease in chronic kidney disease. As community-based data of the longitudinal association between FGF23 and cardiovascular events are lacking, we investigated a possible relationship in 727 men of the Uppsala Longitudinal Study of Adult Men population-based cohort (mean age 77 years). During a median follow-up of 9.7 years, 110 participants died of cardiovascular causes. In Cox regression models adjusted for age and established cardiovascular risk factors, higher serum FGF23 was associated with a significantly increased risk for cardiovascular mortality (hazard ratio (HR) per increased s.d. of 1.36). This relationship remained significant, albeit attenuated, after adjustment for glomerular filtration rate (GFR) (HR 1.21). FGF23 was also associated with all-cause mortality, although the association was weaker than that with cardiovascular mortality, and it was nonsignificant in fully adjusted multivariate models. Spline analysis suggested a log-linear relationship between FGF23 and outcome. Participants with a combination of high FGF23 (>60 pg/ml), low GFR (<60 ml/min), and micro-/macro-albuminuria (albumin/creatinine ratio above 3 mg/ml) had an almost eightfold increased risk compared with participants without these abnormalities. Thus, a higher FGF23 level is associated with an increased cardiovascular mortality risk in the community. Clinical trials are needed to determine whether FGF23 is a modifiable risk factor.

Serum FGF23 and Risk of Cardiovascular Events in Relation to Mineral Metabolism and Cardiovascular Pathology

BACKGROUND AND OBJECTIVES Circulating fibroblast growth factor-23 is associated with adverse cardiovascular outcomes in CKD and non-CKD individuals, but the underlying mechanism remains unclear. This study tested whether this association is independent of mineral metabolism and indices of subclinical cardiovascular pathology. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The prospective association between fibroblast growth factor-23 and major cardiovascular events (a composite of hospital-treated myocardial infarction, hospital-treated stroke, or all-cause mortality) was investigated in the community-based Prospective Investigation of the Vasculature in Uppsala Seniors (n=973; mean age=70 years, 50% women) using multivariate logistic regression. Subjects were recruited between January of 2001 and June of 2004. RESULTS During follow-up (median=5.1 years), 112 participants suffered a major cardiovascular event. In logistic regression models adjusted for age, sex, and estimated GFR, higher fibroblast growth factor-23 was associated with increased risk for major cardiovascular events (odds ratio for tertiles 2 and 3 versus tertile 1=1.92, 95% confidence interval=1.19-3.09, P<0.01). After additional adjustments in the model, adding established cardiovascular risk factors, confounders of mineral metabolism (calcium, phosphate, parathyroid hormone, and 25(OH)-vitamin D), and indices of subclinical pathology (flow-mediated vasodilation, endothelial-dependent and -independent vasodilation, arterial stiffness, and atherosclerosis and left ventricular mass) attenuated this relationship, but it remained significant (odds ratio for tertiles 2 and 3 versus tertile 1=1.69, 95% confidence interval=1.01-2.82, P<0.05). CONCLUSIONS Fibroblast growth factor-23 is an independent predictor of cardiovascular events in the community, even after accounting for mineral metabolism abnormalities and subclinical cardiovascular damage. Circulating fibroblast growth factor-23 may reflect novel and important aspects of cardiovascular risk yet to be unraveled.

Seven modifiable lifestyle factors predict reduced risk for ischemic cardiovascular disease and all-cause mortality regardless of body mass index: A cohort study

OBJECTIVES A healthy lifestyle has an impact on cardiovascular health. Yet, the importance of body mass index (BMI) and gender remains less clear. The aim of this study was to investigate whether healthy lifestyle factors can predict incident cardiovascular disease (CVD) and all-cause mortality. METHODS Representative population-based prospective cohort study of 60-year-old women (n=2193) and men (n=2039). The following factors related to a healthy lifestyle were assessed using a questionnaire: non-smoking, alcohol intake of 0.6-30 g/day, moderate physical activity at least once a week, low intake of processed meats, weekly intake of fish, daily intake of fruit, and daily intake of vegetables. These factors were combined to produce a total score of healthy lifestyle factors (0-7) and classified into four groups: unhealthy (0-2 lifestyle factors), intermediate (3), healthy (4-5), and very healthy (6-7). National registers enabled identification of incident CVD (n=375) and all-cause mortality (n=427) over a follow-up of 11 years. RESULTS Very healthy women and men exhibited a decreased risk for incident CVD compared with unhealthy individuals, with hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for educational level and BMI of 0.44 (0.26-0.75) and 0.39 (0.25-0.61), respectively. The corresponding HRs (95% CIs) for all-cause mortality for very healthy women and men were 0.25 (0.15-0.44) and 0.35 (0.23-0.54), respectively. CONCLUSION With seven healthy lifestyle factors, it was possible to identify men and women with substantially lower relative risks of incident CVD and death, regardless of BMI and educational level.

The association between BMI value and long-term mortality

Objectives:To study total mortality in different categories of BMI values, with adjustments for important covariates in a population-based 26-year mortality follow-up. Special interest will be given to gender differences and low BMI values.Methods:From a stratified sample in 1969 of 32 185 individuals aged 18–64 years from Stockholm County, 2422 underwent a health examination, with complete data obtained for 1020 subjects. BMI was classified as underweight (<20), normal (20–24.9), overweight (25–29.9) or obesity (⩾30). Participants were followed up in the National Cause of Death Register until the end of 1996. Multivariate analysis was performed by Cox regression for men and women separately, with different models, with step-wise adjustment for age, care need category, heart rate, hypertension, blood glucose, alcohol intake and smoking, with hazard ratios (HR) and 95% confidence interval (CI) and with normal weight as reference.Results:Among men, the age-adjusted HR was 1.68 (95% CI 1.10–2.57) for underweight and 1.62 (95% CI 1.08–2.43) for obesity, and among women it was 0.93 (95% CI 0.58–1.51) for underweight and 1.88 (95% CI 1.26–2.82) for obesity. In men, the significantly increased mortality remained when also adjusting for care need category, but not when adjusting for other factors, whereas the opposite was found regarding obesity. For women, underweight was significantly associated with decreased mortality when adjusting for smoking and for all factors together, whereas obesity was associated with increased mortality when adjusting for the different factors except for all factors together.Conclusions:Underweight was associated with higher mortality among men, but not when adjusting for covariates, whereas underweight was associated with lower mortality among women when adjusting for smoking.

Risk Factors Associated With Newly Diagnosed High Blood Pressure in Men and Women

BACKGROUND Hypertension is a major risk factor for cardiovascular diseases. Early diagnosis and prevention of hypertension are of great importance in reducing overall mortality. The objective was to determine which potential risk factors are associated with newly diagnosed high blood pressure in women and men. METHODS This study is part of a population-based, cross-sectional study including 4,228 women and men aged 60 years in Stockholm County, Sweden. Newly diagnosed high blood pressure was defined as systolic and/or diastolic blood pressure exceeding 140/90 measured on one occasion. Subjects with known hypertension were excluded, leaving 3,156 individuals. RESULTS Waist circumference > or =95 cm (quintiles 3-5) in men and > or =88.5 cm (quintiles 4-5) in women was associated with newly diagnosed high blood pressure. Secondary school was a protective factor in men (odds ratio (OR), men = 0.73, 95% confidence interval (CI) = 0.54-0.99) and university education was protective in both men (OR = 0.66, 95% CI = 0.52-0.85) and women (OR = 0.45, 95% CI = 0.34-0.59). Regular physical activity was negatively associated in women (OR = 0.77, 95% CI = 0.61-0.99), and high alcohol consumption (>30 g/day) was positively associated in men (OR = 1.60, 95% CI = 1.22-2.09). Women were negatively associated with newly diagnosed high blood pressure (OR = 0.50, 95% CI = 0.41-0.61). An interaction between college/university and gender was found in multivariate analysis (OR = 0.67, 95% CI = 0.47-0.97). CONCLUSION Gender differences in risk profile for newly diagnosed high blood pressure might explain part of the differences in hypertension found between men and women. These findings should be considered when planning preventive actions against hypertension at the community level.

Novel and established anthropometric measures and the prediction of incident cardiovascular disease: a cohort study

Objectives:The aim of this study was to compare novel and established anthropometrical measures in their ability to predict cardiovascular disease (CVD), and to determine whether they improve risk prediction beyond classical risk factors in a cohort study of 60-year-old men and women. We also stratified the results according to gender to identify possible differences between men and women. Furthermore, we aimed to replicate our findings in a large independent cohort (The Malmö Diet and Cancer study—cardiovascular cohort).Methods:This was a population-based study of 1751 men and 1990 women, aged 60 years and without CVD at baseline, with 375 incident cases of CVD during 11 years of follow-up. Weight, height, waist circumference (WC), hip circumference and sagittal abdominal diameter (SAD) were measured at baseline. Body mass index (BMI), waist–hip ratio (WHR), waist–hip-height ratio (WHHR), WC-to-height ratio (WCHR) and SAD-to-height ratio (SADHR) were calculated.Results:All anthropometric measures predicted CVD in unadjusted Cox regression models per s.d. increment (hazard ratios, 95% confidence interval), while significant associations after adjustments for established risk CVD factors were noted for WHHR 1.20 (1.08–1.33), WHR 1.14 (1.02–1.28), SAD 1.13 (1.02–1.25) and SADHR 1.17 (1.06–1.28). WHHR had higher increases in C-statistics, and model improvements (likelihood ratio tests (P<0.001)). In the replication study (MDC-CC, n=5180), WHHR was the only measure that improved Cox regression models in men (P=0.01).Conclusion:WHHR, a new measure reflecting body fat distribution, showed the highest risk estimates after adjustments for established CVD risk factors. These findings were verified in men but not women in an independent cohort.

Prevalence of hypertension in immigrants and Swedish-born individuals, a cross-sectional study of 60-year-old men and women in Sweden

Objective To estimate the prevalence of hypertension, defined as systolic or diastolic blood pressure or both of at least 140/90 mmHg measured on one occasion or being treated for hypertension or both, in 60-year-old men and women in groups of immigrants compared to Swedish-born. Design and method A population-based, cross-sectional study in Stockholm County including 4228 participants (77% participation rate), of whom 19% were immigrants. Outcome measures were prevalence of hypertension in immigrants compared to Swedish-born men and women with adjustments for various metabolic, lifestyle and socio-economic characteristics. Results The prevalence of hypertension among Swedish-born individuals (n = 3327) was 61% in men and 44% in women, among Finnish-born individuals (n = 327) it was 77% in men and 62% in women and among non-European immigrants (n = 123) it was 51% in men and 36% in women. The mean blood pressure in Finnish-born men was 149/90 (hypertensive). After adjustments for metabolic, lifestyle and socio-economic characteristics, the odds ratio for hypertension in immigrants from Finland was 2.02 (1.56–2.61) and the odds ratio in immigrants from non-European countries was 0.52 (0.34–0.80) using Swedish-born participants as reference. Conclusion About half of all 60-year-olds in Sweden had high blood pressure. The high prevalence of hypertension found in Finnish-born immigrants remained after adjustments for many factors and needs a genetic or environmental explanation. The high prevalence of hypertension in Sweden, especially in Finnish-born immigrants, calls for preventive actions.

Most common diseases diagnosed in primary care in Stockholm, Sweden, in 2011

BACKGROUND The most commonly reported diagnoses in primary care are useful to identify and meet health care needs in society. We estimated the rates of the most common diagnoses in primary health care in total and also by gender. METHODS This was a cross-sectional study including all 2.0 million inhabitants living in Stockholm County, Sweden, on 1 January 2009. Data on all health care appointments made in primary care in 2011 and during 2009-11 were extracted from the Stockholm County Council data warehouse VAL (Vårdanalysdatabasen; Stockholm regional health care data warehouse). Primary care data were analysed by underlying population and age. Appropriate specialist open care and inpatient data were used for comparison. RESULTS The five most common diagnoses in primary care (in 2011) were acute upper respiratory tract infections (6.0% of the population), essential hypertension (5.6%), coughing (2.6%), dorsalgia (2.6%) and acute tonsillitis (2.4%). Female-to-male ratios were higher for 27 of the 30 most common diagnoses, the exceptions being type 2 diabetes, unspecified types of diabetes and multiple wounds. CONCLUSIONS The 30 most common diagnoses in primary care reflect the complexity of disorders cared for in the first line of health care. Knowledge of these patterns is important when aiming at using primary health care resources in a proper way.

Time trends and gender differences in incidence and prevalence of type 1 diabetes in Sweden.

There are different opinions on a possible sex bias in diabetes. In Sweden we have access to data since the 1930s, making it an ideal model. We aimed to study gender differences and time trends in the incidence and prevalence of type 1 diabetes in Sweden. We found 31 articles on incidence and 8 on prevalence (6 overlapping). Times series on incidence were found regarding children 0-15 years of age (with the Swedish Childhood Diabetes Registry, SCDR, since 1977), with up to 14,721 children with diabetes and with a high degree of ascertainment. Incidence time series were also found for subjects aged 15-34 (Diabetes Incidence Study in Sweden, DISS, since 1983), with up to 7,369 subjects and with a lower degree of ascertainment compared to SCDR. Regarding age from 40 years and above fewer studies were found, and with a much lower number of subjects with type 1 diabetes. Diabetes incidence in children has had a relative increase of approximately 2% per year since 1938. Incidence rates in children 0-14 years of age show no gender differences, but in subjects aged 15-39 years a male preponderance up to twofold is found. Figures for subjects 40 years or older are more uncertain, but show a fairly equal incidence among men and women. The male preponderance in type 1 diabetes from age 15 up to 40-50 could be due to hormonal influence, with higher peripheral insulin resistance among men in young adults and younger middle age.