Bo Christensen

Myocardial Infarction and Risk of Suicide A Population-Based Case-Control Study

Background— Myocardial infarction (MI) is associated with an increased risk of anxiety, depression, low quality of life, and all-cause mortality. Whether MI is associated with an increased risk of suicide is unknown. We examined the association between MI and suicide. Methods and Results— We conducted a population-based case-control study by retrieving data from 5 nationwide longitudinal registers in Denmark. As cases, we selected all persons aged 40 to 89 years who died by suicide from 1981 to 2006. As controls, we randomly selected up to 10 persons per case matched by sex, day of birth, and calendar time. We identified 19 857 persons who committed suicide and 190 058 controls. MI was associated with a marked increased risk of suicide. The risk of suicide was highest during the first month after discharge for MI for patients with no history of psychiatric illness (adjusted rate ratio, 3.25; 95% confidence interval, 1.61 to 6.56) and for patients with a history of psychiatric illness (adjusted rate ratio, 64.05; 95% confidence interval, 13.36 to 307.06) compared with those with no history of MI or psychiatric illness. However, the risk remained high for at least 5 years after MI. Conclusions— MI is followed by an increased risk of suicide for persons with and without psychiatric illness. Our results suggest the importance of screening patients with MI for depression and suicidal ideation. # Clinical Perspective {#article-title-40}Background— Myocardial infarction (MI) is associated with an increased risk of anxiety, depression, low quality of life, and all-cause mortality. Whether MI is associated with an increased risk of suicide is unknown. We examined the association between MI and suicide. Methods and Results— We conducted a population-based case-control study by retrieving data from 5 nationwide longitudinal registers in Denmark. As cases, we selected all persons aged 40 to 89 years who died by suicide from 1981 to 2006. As controls, we randomly selected up to 10 persons per case matched by sex, day of birth, and calendar time. We identified 19 857 persons who committed suicide and 190 058 controls. MI was associated with a marked increased risk of suicide. The risk of suicide was highest during the first month after discharge for MI for patients with no history of psychiatric illness (adjusted rate ratio, 3.25; 95% confidence interval, 1.61 to 6.56) and for patients with a history of psychiatric illness (adjusted rate ratio, 64.05; 95% confidence interval, 13.36 to 307.06) compared with those with no history of MI or psychiatric illness. However, the risk remained high for at least 5 years after MI. Conclusions— MI is followed by an increased risk of suicide for persons with and without psychiatric illness. Our results suggest the importance of screening patients with MI for depression and suicidal ideation.

Prevalence of Hypertension in Member Countries of South Asian Association for Regional Cooperation (SAARC): Systematic Review and Meta-Analysis

AbstractHypertension is a leading attributable risk factor for mortality in South Asia. However, a systematic review on prevalence and risk factors for hypertension in the region of the South Asian Association for Regional Cooperation (SAARC) has not carried out before.The study was conducted according to the Meta-Analysis of Observational Studies in Epidemiology Guideline. A literature search was performed with a combination of medical subject headings terms, “hypertension” and “Epidemiology/EP”. The search was supplemented by cross-references. Thirty-three publications that met the inclusion criteria were included in the synthesis and meta-analyses. Hypertension is defined when an individual had a systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg, was taking antihypertensive drugs, or had previously been diagnosed as hypertensive by health care professionals. Prehypertension is defined as SBP 120–139 mm Hg and DBP 80–89 mm Hg.The overall prevalence of hypertension and prehypertension from the studies was found to be 27% and 29.6%, respectively. Hypertension varied between the studies, which ranged from 13.6% to 47.9% and was found to be higher in the studies conducted in urban areas than in rural areas. The prevalence of hypertension from the latest studies was: Bangladesh: 17.9%; Bhutan: 23.9%; India: 31.4%; Maldives: 31.5%; Nepal: 33.8%; Pakistan: 25%; and Sri Lanka: 20.9%. Eight out of 19 studies with information about prevalence of hypertension in both sexes showed that the prevalence was higher among women than men. Meta-analyses showed that sex (men: odds ratio [OR] 1.19; 95% confidence interval [CI]: 1.02, 1.37), obesity (OR 2.33; 95% CI: 1.87, 2.78), and central obesity (OR 2.16; 95% CI: 1.37, 2.95) were associated with hypertension.Our study found a variable prevalence of hypertension across SAARC countries, with a number of countries with blood pressure above the global average. We also noted that studies are not consistent in their data collection about hypertension and related modifiable risk factors.

Effect of “motivational interviewing” on quality of care measures in screen detected type 2 diabetes patients: A one-year follow-up of an RCT, ADDITION Denmark

Abstract Objective. “Motivational interviewing” (MI) has shown to be broadly applicable in the management of behavioural problems and diseases. Only a few studies have evaluated the effect of MI on type 2 diabetes treatment and none has explored the effect of MI on target-driven intensive treatment. Methods. Patients were cluster-randomized by GPs, who were randomized to training in MI or not. Both groups received training in target-driven intensive treatment of type 2 diabetes. The intervention consisted of a 1½-day residential course in MI with half-day follow-up twice during the first year. Blood samples, case record forms, national registry files, and validated questionnaires from patients were obtained. Results. After one year significantly improved metabolic status measured by HbA1c (p < 0.01) was achieved in both groups. There was no difference between groups. Medication adherence was close to 100% within both treatment groups. GPs in the intervention group did not use more than an average of 1.7 out of three possible MI consultations. Conclusion. The study found no effect of MI on metabolic status or on adherence of medication in people with screen detected type 2 diabetes. However, there was a significantly improved metabolic status and excellent medication adherence after one year within both study groups. An explanation may be that GPs in the control group may have taken up core elements of MI, and that GPs trained in MI used less than two out of three planned MI consultations. The five-year follow-up of this study will reveal whether MI has an effect over a longer period.

No long-term psychological reaction to information about increased risk of coronary heart disease in general practice:

Background Randomised, controlled trials focusing on long-term psychological reactions to information about increased risk of coronary heart disease are scarce. Design A population-based randomised, controlled, 5-year follow-up trial was conducted in general practice. Methods In 1991, invitations were sent to 2,000 middle-aged people registered in the general practices in the district of Ebeltoft, Denmark. A total of 1,507 (75.4%) agreed to participate and were randomised into a control group and two intervention groups: one included health screening, a written feedback and an optional follow-up visit with the general practitioner; the other included health screening, written feedback and a planned 45-min follow-up visit with the general practitioner. The participants were informed at screening about their risk of developing coronary heart disease. Psychological distress was measured by the GHQ-12 before screening and at the 1 and the 5-year follow-up. Results Before the screening (0 year), 1 and 5 years after there were no significant differences in the GHQ-12 score between the control group and the two intervention groups. Nor were there any differences related to information about increased risk of coronary heart disease between scores obtained at the 1 and the 5-year follow-up. Conclusion Middle-aged persons had no long-term psychological reaction after information about increased risk of developing coronary heart disease following a health screening in general practice evaluated by the GHQ-12,1 year and 5 years after the examinations.

Intervention among frequent attenders of the out-of-hours service: A stratified cluster randomized controlled trial

Objective – To investigate whether the number of frequent attenders (FA) contacts with the out-of-hours service can be reduced by deploying a combination of intervention strategies. Design – A stratified cluster randomized controlled trial, each cluster containing a general practice and all its listed patients. Setting – The out-of-hours service in the county of Northern Jutland (490 000 inhabitants), Denmark. Interventions – The following intervention strategies were deployed: predisposition, individual instruction, economic incitement, continuing medical education meetings, feedback/reminder, and patient-mediated intervention. Subjects – An intervention group of 3500 patients and a control group of 4635 patients. Main outcome measures – Absolute and relative fall in the number of contacts with the out-of-hours service per patient after 6 and 12 months. Results – Analysed by group, intervention patients saw a more pronounced decline in the number of contacts than controls, except for two outcomes. However, this difference was only significant after 12 months. For women aged 17–66 years with 5–9 contacts during the previous 12 months, the decrease was significantly more pronounced in the intervention group for all outcomes (p=0.004–0.042). However, for the rest of the subgroups the effect varied more, and in several cases it was more distinct in the control group. Conclusion – The data collected point towards an effect of intervention on the use of out-of-hours services even if the responses obtained were not uniform and unequivocal. However, one has to consider the problems of multiple comparisons and in conclusion no convincing effect of the intervention was found.

Depressive Symptoms and Risk of New Cardiovascular Events or Death in Patients with Myocardial Infarction: A Population-Based Longitudinal Study Examining Health Behaviors and Health Care Interventions

Background Depressive symptoms is associated with adverse cardiovascular outcomes in patients with myocardial infarction (MI), but the underlying mechanisms are unclear and it remains unknown whether subgroups of patients are at a particularly high relative risk of adverse outcomes. We examined the risk of new cardiovascular events and/or death in patients with depressive symptoms following first-time MI taking into account other secondary preventive factors. We further explored whether we could identify subgroups of patients with a particularly high relative risk of adverse outcomes. Methods and Results We conducted a prospective population-based cohort study of 897 patients discharged with first-time MI between 1 January 2009 and 31 December 2009, and followed up until 31 July 2012. Depressive symptoms were found in 18.6% using the Hospital Anxiety and Depression Scale (HADS-D≥8). A total of 239 new cardiovascular events, 95 deaths, and 288 composite events (239 new cardiovascular events and 49 deaths) occurred during 1,975 person-years of follow-up. Event-free survival was evaluated using Cox regression analysis. Compared to the 730 patients without depressive symptoms (HADS-D<8), the 167 patients with depressive symptoms (HADS-D≥8) had age- and sex-adjusted hazard ratios [HR] (95% confidence interval [CI]) of 1.53 (95% CI, 1.14–2.05) for a new cardiovascular event, 3.10 (95% CI, 2.04–4.71) for death and 1.77 (95% CI, 1.36–2.31) for a composite event. The associations were attenuated when adjusted for disease severity, comorbid conditions and physical inactivity; HR = 1.17 (95% CI, 0.85–1.61) for a new cardiovascular event, HR = 2.01 (95% CI, 1.28–3.16) for death, and HR = 1.33 (95% CI, 1.00–1.76) for a composite event. No subgroups of patients had a particularly high risk of adverse outcomes. Conclusions Depressive symptoms following first-time MI was an independent prognostic risk factor for death, but not for new cardiovascular events. We found no subgroups of patients with a particularly high relative risk of adverse outcomes.

Rehabilitation status three months after first-time myocardial infarction

Objective. To describe the rehabilitation status three months after first-time myocardial infarction (MI) to identify focus areas for long-term cardiac rehabilitation (CR) in general practice. Design. Population-based cross-sectional study. Setting and subjects. Patients with first-time MI in 2009 from the Central Denmark Region. Data were obtained from patient questionnaires and from registers. Results. Of the 1288 eligible patients, 908 (70.5%) responded. The mean (SD) age was 67.1 (11.7) years and 626 (68.9%) were men. Overall, 287 (31.6%) of the patients lived alone and 398 (45.4%) had less than 10 years of education. Upwards of half (58.5%) of the patients stated that they had participated in hospital-based rehabilitation shortly after admission. A total of 262 (29.2%) were identified with anxiety or depressive disorder or both, according to the Hospital Anxiety and Depression Scale. Of these, 78 (29.8%) reported that they had participated in psychosocial support, and 55 (21.0%) used antidepressants. One in five patients smoked three months after MI although nearly half of the smokers had stopped after the MI. Regarding cardioprotective drugs, 714 (78.6%) used aspirin, 694 (76.4%) clopidogrel, 756 (83.3%) statins, and 735 (81.0%) beta-blockers. Conclusion. After three months, there is a considerable potential for further rehabilitation of MI patients. In particular, the long-term CR should focus on mental health, smoking cessation, and cardioprotective drugs.

Multimorbidity and Blood Pressure Control in 37 651 Hypertensive Patients From Danish General Practice

Background Patients with hypertension are primarily treated in general practice. However, major studies of patients with hypertension are rarely based on populations from primary care. Knowledge of blood pressure (BP) control rates in patients with diabetes and/or cardiovascular diseases (CVDs), who have additional comorbidities, is lacking. We aimed to investigate the association of comorbidities with BP control using a large cohort of hypertensive patients from primary care practices. Methods and Results Using the Danish General Practice Database, we included 37 651 patients with hypertension from 231 general practices in Denmark. Recommended BP control was defined as BP <140/90 mm Hg in general and <130/80 mm Hg in patients with diabetes. The overall control rate was 33.2% (95% CI: 32.7 to 33.7). Only 16.5% (95% CI: 15.8 to 17.3) of patients with diabetes achieved BP control, whereas control rates ranged from 42.9% to 51.4% for patients with ischemic heart diseases or cerebrovascular or peripheral vascular diseases. A diagnosis of cardiac heart failure in addition to diabetes and/or CVD was associated with higher BP control rates, compared with men and women having only diabetes and/or CVD. A diagnosis of asthma in addition to diabetes and CVD was associated with higher BP control rates in men. Conclusion In Danish general practice, only 1 of 3 patients diagnosed with hypertension had a BP below target. BP control rates differ substantially within comorbidities. Other serious comorbidities in addition to diabetes and/or CVD were not associated with lower BP control rates; on the contrary, in some cases the BP control rates were higher when the patient was diagnosed with other serious comorbidities in addition to diabetes and/or CVD.

Ambivalence related to potential lifestyle changes following preventive cardiovascular consultations in general practice: A qualitative study

BackgroundMotivational interviewing approaches are currently recommended in primary prevention and treatment of cardiovascular disease (CVD) in general practice in Denmark, based on an empirical and multidisciplinary body of scientific knowledge about the importance of motivation for successful lifestyle change among patients at risk of lifestyle related diseases. This study aimed to explore and describe motivational aspects related to potential lifestyle changes among patients at increased risk of CVD following preventive consultations in general practice.MethodsIndividual interviews with 12 patients at increased risk of CVD within 2 weeks after the consultation. Grounded theory was used in the analysis.ResultsAmbivalence related to potential lifestyle changes was the core motivational aspect in the interviews, even though the patients rarely verbalised this experience during the consultations. The patients experienced ambivalence in the form of conflicting feelings about lifestyle change. Analysis showed that these feelings interacted with their reflections in a concurrent process. Analysis generated a typology of five different ambivalence sub-types: perception, demand, information, priority and treatment ambivalence.ConclusionAmbivalence was a common experience in relation to motivation among patients at increased risk of CVD. Five different ambivalence sub-types were found, which clinicians may use to explore and resolve ambivalence in trying to aid patients to adopt lifestyle changes. Future research is needed to explore whether motivational interviewing and other cognitive approaches can be enhanced by exploring ambivalence in more depth, to ensure that lifestyle changes are made and sustained. Further studies with a wider range of patient characteristics are required to investigate the generalisability of the results.

Psychological reactions to information about risk of ischaemic heart disease in general practice

OBJECTIVE To examine the psychological reactions in 40-49 year old men diagnosed as having an increased risk for the development of ischaemic heart disease at a health examination in general practice. DESIGN A multipractice study including a questionnaire about the psychological well-being before and 6 months after a health examination aimed at finding an increased risk for ischaemic heart disease. SETTING General practice in the county of Aarhus, Denmark. Sixty five general practitioners. PARTICIPANTS 123 men with and 150 men without an increased risk of ischaemic heart disease. OUTCOME MEASURES Psychological well-being was measured by the General Health Questionnaire (12 item version). RESULTS No significant change in GHQ-scores after the screening examination. CONCLUSION Information about increased risk of IHD in 40-49 year old men at a health examination in general practice did not change the psychological well-being as measured by a General Health Questionnaire 6 months after the examination.