Birgitta Stegmayr

Hypertension Treatment and Control in Five European Countries, Canada, and the United States

Abstract—Levels of hypertension treatment and control have been noted to vary between Europe and North America, although direct comparisons with similar methods have not been undertaken. In this study, we sought to estimate the relative impact of hypertension treatment strategies in Germany, Sweden, England, Spain, Italy, Canada, and the United States by using sample surveys conducted in the 1990s. Hypertension was defined as a blood pressure of 160/95 mm Hg or 140/90 mm Hg, plus persons taking antihypertensive medication. “Controlled hypertension” was defined as a blood pressure less than threshold among persons taking antihypertensive medications. Among persons 35 to 64 years, 66% of hypertensives in the United States had their blood pressure controlled at 160/95 mm Hg, compared with 49% in Canada and 23% to 38% in Europe. Similar discrepancies were apparent at the 140/90 mm Hg threshold, at which 29% of hypertensives in the United States, 17% in Canada, and ≤10% in European countries had their blood pressure controlled. At the 140/90 mm Hg cutpoint, two thirds to three quarters of the hypertensives in Canada and Europe were untreated compared with slightly less than half in the United States. Although guidelines vary among countries, resulting in different case definitions, this does not account entirely for the varying success of different national control efforts. Low treatment and control rates in Europe, combined with a higher prevalence of hypertension, could contribute to a higher burden of cardiovascular disease risk attributable to elevated blood pressure compared with that in North America.

Sex Differences in Stroke Epidemiology : A Systematic Review

Background and Purpose— Epidemiological studies, mainly based on Western European surveys, have shown that stroke is more common in men than in women. In recent years, sex-specific data on stroke incidence, prevalence, subtypes, severity and case-fatality have become available from other parts of the world. The purpose of this article is to give a worldwide review on sex differences in stroke epidemiology. Methods— We searched PubMed, tables-of-contents, review articles, and reference lists for community-based studies including information on sex differences. In some areas, such as secular trends, ischemic subtypes and stroke severity, noncommunity-based studies were also reviewed. Male/female ratios were calculated. Results— We found 98 articles that contained relevant sex-specific information, including 59 incidence studies from 19 countries and 5 continents. The mean age at first-ever stroke was 68.6 years among men, and 72.9 years among women. Male stroke incidence rate was 33% higher and stroke prevalence was 41% higher than the female, with large variations between age bands and between populations. The incidence rates of brain infarction and intracerebral hemorrhage were higher among men, whereas the rate of subarachnoidal hemorrhage was higher among women, although this difference was not statistically significant. Stroke tended to be more severe in women, with a 1-month case fatality of 24.7% compared with 19.7% for men. Conclusions— Worldwide, stroke is more common among men, but women are more severely ill. The mismatch between the sexes is larger than previously described.

Poststroke Fatigue A 2-Year Follow-Up Study of Stroke Patients in Sweden

Background and Purpose— Fatigue is common among stroke patients. This study determined the prevalence of fatigue among long-term survivors after stroke and what impact fatigue had on various aspects of daily life and on survival. Methods— This study was based on Riks-Stroke, a hospital-based national register for quality assessment of acute stroke events in Sweden. During the first 6 months of 1997, 8194 patients were registered in Riks-Stroke, and 5189 were still alive 2 years after the stroke. They were followed up by a mail questionnaire, to which 4023 (79%) responded. Patients who reported that they always felt depressed were excluded. Results— To the question, “Do you feel tired?” 366 (10.0%) of the patients answered that they always felt tired, and an additional 1070 (29.2%) were often tired. Patients who always felt tired were on average older than the rest of the study population (74.5 versus 71.5 years, P <0.001); therefore, all subsequent analyses were age adjusted. Fatigue was an independent predictor for having to move into an institutional setting after stroke. Fatigue was also an independent predictor for being dependent in primary activities of daily living functions. Three years after stroke, patients with fatigue also had a higher case fatality rate. Conclusions— Fatigue is frequent and often severe, even late after stroke. It is associated with profound deterioration of several aspects of everyday life and with higher case fatality, but it usually receives little attention by healthcare professionals. Intervention studies are needed.

Epidemiology and Etiology of Ischemic Stroke in Young Adults Aged 18 to 44 Years in Northern Sweden

BACKGROUND AND PURPOSE The aim of this study was to conduct a population-based epidemiological survey among young adults aged 18 to 44 years in Northern Sweden and furthermore to gain further insight into the etiology of ischemic stroke in this age group. METHODS Two studies were done. In the first part, epidemiological data were collected to calculate incidence and mortality from 1991 through 1994. This was based on the World Health Organization Northern Sweden MONICA register of acute stroke events. Eighty-eight first-ever ischemic stroke patients were identified during that period. In the second part, 107 consecutive patients aged 18 to 44 years with ischemic stroke referred to a university hospital were studied prospectively during a 5-year period and were extensively evaluated according to a standardized protocol. On the basis of modified Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria, the patients were classified into eight subtypes of ischemic stroke. RESULTS The average population-based annual incidence rate for ischemic stroke (cases per 100,000 per year) was 11.3 (95% confidence interval, 6.7 to 16.1). The case-fatality rate was 5.7%. According to the modified TOAST criteria, a probable cause of ischemic stroke was identified in 36% and remained unexplained in 21% of cases. Spontaneous cervical arterial dissection was the leading probable etiology (13%). Patent foramen ovale or atrial septal aneurysm was a possible cause of stroke in 28% of cases. The percentages of ischemic stroke attributed to IgG anticardiolipin antibodies (4.7%), atherothrombotic vasculopathy (3.7%), oral contraceptive use (7%), and migraine (1%) were lower than reported in recent clinical series. CONCLUSIONS The incidence rate for ischemic stroke was higher than previously reported from most countries in Western Europe. The higher incidence was not explained by a higher prevalence of premature atherosclerotic vasculopathy. Without the additional diagnostic information derived from advanced cardiac imaging, the proportion of indeterminate cases would have constituted 37% of the patients.

Sex Differences in Management and Outcome After Stroke A Swedish National Perspective

Background and Purpose— It is disputed whether there are sex differences in management and outcome after stroke; early studies have shown inconsistent results. The objective of this study was to verify and explain differences between men and women in management and outcome after stroke in a national perspective. Methods— In 2001, 20 761 stroke patients were registered in Riks-Stroke, the national quality register for stroke care in Sweden in which all 84 hospitals participate. Data from 9 hospitals that had reported <70% of the estimated stroke events were excluded from analyses, leaving 19 547 patients (9666 women, 9881 men) at 75 hospitals for the present analyses. Results— Women were older than men (77.8 versus 73.2 years). After age adjustment, female patients were more often disabled, living at home with community support, or in institutions before the stroke. They also had a different cardiovascular risk factor profile. Case fatality ratios during the first 3 months were similar in men and women. After 3 months, more women were physically and mentally impaired and dependent on other persons. Female patients with atrial fibrillation received oral anticoagulants less often than men. Even after multiple adjustments for differences between sexes, female sex was independently associated with institutional living 3 months after the stroke (odds ratio, 1.2; 95% confidence interval, 1.0 to 1.4). Conclusions— Women have a worse prestroke condition. Except for case fatality ratios, they also have a worse outcome after stroke after adjustment for other prognostic factors. There are also sex differences in the medical management of stroke that need to be rectified.

The events registration and survey procedures in the Northern Sweden MONICA Project

Introduction: The WHO MONICA Project (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease) was initiated in 1982. The purpose was to evaluate to what extent mortality trends could be explained by changes over time in the population load of conventional cardiovascular risk factors. To test this hypothesis, time trends in cardiovascular event rates have been correlated with trends in levels of risk factors in 35- to 64-year-old men and women in 38 populations. In most MONICA populations, the study has covered a period of 10 years or more. Methods: All acute myocardial infarction and stroke events have been registered in a population-based setting in Norrbotten and Västerbotten counties from 1985 and onwards. The total population is approximately 510,000 inhabitants. In the frame of the WHO MONICA Project, the same strict criteria have been used in all years. Another part of the MONICA Project is population risk factor surveys. In Northern Sweden the first survey took place in 1986 and the following surveys were performed in 1990, 1994, and 1999, including the age group 25 - 74 years (the first two surveys were of the age range 25 - 64 years). Results: From 1985 to 2000, in total 18,105 suspected stroke events, aged 25 - 74 years, were scrutinized and validated at the central stroke office in Northern Sweden. Of these, 13,908 were found to fulfil the MONICA criteria of an acute stroke. During the period 1985 to 1998, in total 13,228 cases of suspected acute myocardial infarction, aged 25 - 64 years, were registered. Of these, 8,744 fulfilled the MONICA criteria for acute myocardial infarction. In the four surveys, in total 9,000 randomly selected men and women were invited for survey. Of these 6,952 (77%) participated in the surveys. Conclusion: From 1985 and onwards, the WHO MONICA project has been going on in Northern Sweden. During the whole time the same strict WHO criteria have been followed.

An international comparative study of blood pressure in populations of European vs. African descent

BackgroundThe consistent finding of higher prevalence of hypertension in US blacks compared to whites has led to speculation that African-origin populations are particularly susceptible to this condition. Large surveys now provide new information on this issue.MethodsUsing a standardized analysis strategy we examined prevalence estimates for 8 white and 3 black populations (N = 85,000 participants).ResultsThe range in hypertension prevalence was from 27 to 55% for whites and 14 to 44% for blacks.ConclusionsThese data demonstrate that not only is there a wide variation in hypertension prevalence among both racial groups, the rates among blacks are not unusually high when viewed internationally. These data suggest that the impact of environmental factors among both populations may have been under-appreciated.

Sense of coherence--stability over time and relation to health, disease, and psychosocial changes in a general population: a longitudinal study.

Aims: To explore the stability of sense of coherence (SOC) over time in a normal population and to examine its relation to gender and psychosocial factors. Methods: The Northern Sweden MONICA Project population surveys were performed in 1994 and 1999. A cohort of 1,254 subjects participating in both surveys answered questions about experiences of disease, perceived health, marital status, psychosocial factors, and Antonovskys SOC scale with 13 items. Results: The mean SOC score showed a decrease in the five-year follow-up and those with identified disease and the oldest age group (45 - 74 years) had the largest decrease of the SOC score. People with the lowest SOC scores in 1994 had the largest decrease during the period. Men and women shared a similar pattern regarding the decrease in SOC over time. The impact of individual social changes during the study period showed that both men and women who had experienced loss of perceived good health and high social support had the largest decrease. Furthermore, women seemed to be more affected by changes than men. Conclusions: We found that SOC was only stable for those with initially high levels of SOC. For other people, individual conditions and societal changes influenced their SOC. Further longitudinal studies in normal populations are needed to investigate the stability of SOC scores.

Cardiovascular disease and diabetes in the Northern Sweden Health and Disease Study Cohort - evaluation of risk factors and their interactions.

The purpose of this paper is, first, to describe the organization, sampling procedures, availability of samples/database, ethical considerations, and quality control program of the Northern Sweden Health and Disease Study Cohort. Secondly, some examples are given of studies on cardiovascular disease and diabetes with a focus on the biomarker programme. The cohort has been positioned as a national and international resource for scientific research.

Breast Cancer Survival Is Associated with Telomere Length in Peripheral Blood Cells

Telomeres are essential for maintaining chromosomal stability. Previous studies have indicated that individuals with shorter blood telomeres may be at higher risk of developing various types of cancer, such as in lung, bladder, and kidney. We have analyzed relative telomere length (RTL) of peripheral blood cells in relation to breast cancer incidence and prognosis. The study included 265 newly diagnosed breast cancer patients and 446 female controls. RTL was measured by real-time PCR, and our results show that the patient group displayed significantly longer telomeres compared with controls (P < 0.001). Age-adjusted odds ratios (OR) for breast cancer risk increased with increasing telomere length, with a maximal OR of 5.17 [95% confidence interval (95% CI), 3.09-8.64] for the quartile with the longest telomeres. Furthermore, RTL carried prognostic information for patients with advanced disease. Node positive (N+) patients with short telomeres (</=median) showed an increased survival compared with N+ patients with long telomeres (P = 0.001). For patients with ages <50 years with tumors >16 mm (median tumor diameter), short telomeres were associated with a significantly better outcome than longer telomeres (P = 0.006). Cox regression analysis showed that long RTL was a significant independent negative prognostic factor (hazards ratio, 2.92; 95% CI, 1.33-6.39; P = 0.007). Our results indicate that blood RTL may serve as a prognostic indicator in breast cancer patients with advanced disease.