Karin Manhem

Social Gradients in Cardiovascular Risk Factors and Symptoms of Swedish Men and Women: The Göteborg MONICA Study 1995

Background Even though coronary mortality in middle and old age is decreasing, social gradients may be increasing; but they need not necessarily be the same for men and women. In order to develop efficient preventive strategies more knowledge of the current distributions of risk factors both for men and for women is needed. Objective To investigate and to compare the socio-economic gradients for coronary risk factors of men and women. Design A cross-sectional study. Methods We studied 686 men and 825 women aged 25–64 years from a random population sample. Socio-economic status (SES) was classified according to the occupation-based Swedish Socio-economic Index. Results For women, high SES was associated with lower levels of total and low-density lipoprotein cholesterol, lower serum levels of triglycerides, higher levels of high-density lipoprotein cholesterol and lower blood pressure. For men, no relation between occupational status and levels of lipids and blood pressure was found. Obesity was associated with low SES both for men and for women. Socioeconomic differences in smoking habits were more pronounced for women than they were for men. The proportion of post-menopausal women was higher among the unskilled workers, despite there being no difference in age. Optimal risk factor status (non-smoker, total cholesterol level < 5 mmol/l, blood pressure < 140/90 mmHg without treatment and body mass index < 25 kg/m2) was unusual both among men and among women, but 34% of the higher officials among the women had optimal risk factor status, compared with 10% of the unskilled workers. Corresponding values for the men were 16 and 9% (P for interaction 0.09). The relation between low SES and level of low-density lipoprotein cholesterol was independent of smoking, post-menopausal state, use of oestrogen and waist: hip ratio (P = 0.04) and so was the relation between systolic blood pressure and low SES (P = 0.0003). Conclusions In Sweden, low SES exerts a stronger adverse influence on cardiovascular risk factors of women than it does on those of men.

Transdermal oestrogen reduces daytime blood pressure in hypertensive women

The aim of this study was to investigate the acute effects of transdermally administered 17-β-oestradiol on ambulatory blood pressure (BP) in hypertensive, postmenopausal women. Thirteen postmenopausal women with ongoing treatment for hypertension were included in this placebo-controlled, double-blind cross-over study. Ambulatory recordings of BP and heart rate were performed during 24 h on two occasions, separated by at least 1 week, after application of a patch containing either 100 μg per 24 h 17-β-oestradiol or placebo. Serum oestradiol was increased (P<0.001) during active treatment (139.2 ± 21.1 pg/ml) compared with the baseline postmenopausal levels recorded during placebo (40.5 ± 2.2 pg/ml). no rise in bp was found in office bp or during ambulatory recordings. daytime bp pressure was acutely reduced by approximately 3 mm hg during the 24 h of treatment with oestrogen (sbp n.s., dbp P<0.05), without any change in heart rate. nocturnal dipping in sbp and dbp was present during placebo conditions, and there were no signs of an increase in dipping during treatment with 17-β-oestradiol. this study supports previous evidence that hormone replacement therapy is safe in hypertensive women. the data in the present study also imply an acute, but small reduction of daytime bp due to transdermal oestrogen in hypertensive, postmenopausal women. furthermore oestrogen did not blunt or increase the dipping phenomena during the night in these women.

Depression, anxiety, stress, social interaction and health-related quality of life in men and women with unexplained chest pain

BackgroundUnexplained chest pain (UCP) is a common reason for emergency hospital admission and generates considerable health-care costs for society. Even though prior research indicates that psychological problems and impaired quality of life are common among UCP patients, there is lack of knowledge comparing UCP patients with a reference group from the general population. The aim of this study was to analyse differences between men and women with UCP and a reference group in terms of psychosocial factors as depression, anxiety, stress, social interaction and health-related quality of life (HRQOL).MethodsA self-administered questionnaire about psychosocial factors was completed by 127 men and 104 women with acute UCP admitted consecutively to the Emergency Department (ED) or as in-patients on a medical ward. A reference group from the general population, 490 men and 579 women, participants in the INTERGENE study and free of clinical heart disease, were selected.ResultsThe UCP patients were more likely to be immigrants, have a sedentary lifestyle, report stress at work and have symptoms of depression and trait-anxiety compared with the reference group. After adjustment for differences in age, smoking, hypertension and diabetes, these factors were still significantly more common among patients with UCP. In a stepwise multivariate model with mutual adjustment for psychosocial factors, being an immigrant was associated with a more than twofold risk in both sexes. Stress at work was associated with an almost fourfold increase in risk among men, whereas there was no independent impact for women. In contrast, depression only emerged as an independent risk factor in women. Trait-anxiety and a low level of social interaction were not independently associated with risk in either men or women. Patients with UCP were two to five times more likely to have low scores for HRQOL.ConclusionBoth men and women with UCP had higher depression scores than referents, but an independent association was only found in women. Among men, perceived stress at work emerged as the only psychosocial variable significantly associated with UCP.

Subjects with essential hypertension are more sensitive to the inhibition of 11 β-HSD by liquorice

In this intervention study, we have investigated if hypertensive patients are more sensitive to liquorice-induced inhibition of 11 β-hydroxysteroid dehydrogenase (11 β-HSD) type 2 than normotensive (NT) subjects and if the response depends on gender. Healthy volunteers and patients with essential hypertension (HT), consumed 100 g of liquorice daily, for 4 weeks, corresponding to a daily intake of 150 mg glycyrrhetinic acid. Office, 24-h ambulatory blood pressure (BP) and blood samples were measured before, during and after liquorice consumption. Effect on cortisol metabolism was evaluated by determining the urinary total cortisol metabolites and urinary free cortisol/free cortisone quotient (Q). The mean rise in systolic BP with office measurements after 4 weeks of liquorice consumption was 3.5 mmHg (p<0.06) in NT and 15.3 mmHg (p=0.003) in hypertensive subjects, the response being different (p=0.004). The mean rise in diastolic BP was 3.6 mmHg (p=0.01) in NT and 9.3 mmHg (p<0.001) in hypertensive subjects, the response also being different (p=0.03). Liquorice induced more pronounced clinical symptoms in women than in men (p=0.0008), although the difference in the effect on the BP was not significant. The increase in Q was prominent (p<0.0001) and correlated to the rise in BP (p=0.02). The rise in BP was not dependant on age, the change in plasma renin activity or weight. We conclude that patients with essential HT are more sensitive to the inhibition of 11 β-HSD by liquorice than NT subjects, and that this inhibition causes more clinical symptoms in women than in men.

Gender differences in antihypertensive drug treatment: results from the Swedish Primary Care Cardiovascular Database (SPCCD)

There are gender differences in antihypertensive treatment. This study aimed to investigate if gender differences in treatment could be explained by comorbidities. In addition, we aimed to study whether blood pressure control is different in women and men, and whether women interrupt treatment more often with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) compared with men.This cohort study within the Swedish Primary Care Cardiovascular Database included 40,825 patients with hypertension attending primary health care from 2007 to 2008. Cardiovascular comorbidities, with the exception of heart failure, were more common in men. Women were more often treated with diuretics, and men with ACEI, as were hypertensive patients with diabetes. Comorbidities could not entirely explain gender differences in antihypertensive treatment in a regression model. Women had higher systolic and lower diastolic blood pressure; this was also true in subgroups with cardiovascular comorbidity. Men more often than women were prescribed ACEIs/ARBs and interrupted treatment. Women and men are treated with different antihypertensive drugs, and this is not fully explained by differences in comorbidities. Women have higher systolic blood pressures, irrespective of comorbidity. Men have interrupted treatment more often with ACEIs/ARBs. These gender differences could affect outcome and warrant further investigation.

Blood Pressure Response to Losartan and Continuous Positive Airway Pressure in Hypertension and Obstructive Sleep Apnea

RATIONALE Obstructive sleep apnea (OSA) is common in people with hypertension, particularly resistant hypertension. Treatment with an antihypertensive agent alone is often insufficient to control hypertension in patients with OSA. OBJECTIVES To determine whether continuous positive airway pressure (CPAP) added to treatment with an antihypertensive agent has an impact on blood pressure (BP) levels. METHODS During the initial 6-week, two-center, open, prospective, case-control, parallel-design study (2:1; OSA/no-OSA), all patients began treatment with an angiotensin II receptor antagonist, losartan, 50 mg daily. In the second 6-week, sex-stratified, open, randomized, parallel-design study of the OSA group, all subjects continued to receive losartan and were randomly assigned to either nightly CPAP as add-on therapy or no CPAP. MEASUREMENTS AND MAIN RESULTS Twenty-four-hour BP monitoring included assessment every 15 minutes during daytime hours and every 20 minutes during the night. Ninety-one patients with untreated hypertension underwent a home sleep study (55 were found to have OSA; 36 were not). Losartan significantly reduced systolic, diastolic, and mean arterial BP in both groups (without OSA: 12.6, 7.2, and 9.0 mm Hg; with OSA: 9.8, 5.7, and 6.1 mm Hg). Add-on CPAP treatment had no significant changes in 24-hour BP values but did reduce nighttime systolic BP by 4.7 mm Hg. All 24-hour BP values were reduced significantly in the 13 patients with OSA who used CPAP at least 4 hours per night. CONCLUSIONS Losartan reduced BP in OSA, but the reductions were less than in no-OSA. Add-on CPAP therapy resulted in no significant changes in 24-hour BP measures except in patients using CPAP efficiently. Clinical trial registered with www.clinicaltrials.gov (NCT00701428).​

Psychosocial profile in men and women with unexplained chest pain.

Objective.  The aim of this study was to compare men and women with unexplained chest pain (UCP) to a randomly selected population sample free of clinical heart disease with regard to sleep problems, mental strain at work, stress at home, negative life events and health‐related quality of life (HRQOL).

Antihypertensive treatment and control in a large primary care population of 21 167 patients.

The efficacy of antihypertensive drug therapy is undisputed, but observational studies show that few patients reach a target blood pressure <140/90 mm Hg. However, there is limited data on the drug prescribing patterns and their effectiveness in real practice. This retrospective observational survey of electronic patient records extracted data from 24 Swedish primary health-care centres, with a combined registered population of 330 000 subjects. We included all patients ⩾30 years with a recorded diagnosis of hypertension who consulted the centres in 2005 or 2006 (n=21 167). Main outcome measures were systolic and diastolic blood pressures, and prescribed antihypertensive drug classes. Only 27% had a blood pressure <140/90 mm Hg. The number of prescribed drugs increased with age, except among the oldest (⩾90 years). Only 29% of patients given monotherapy had a blood pressure <140/90 mm Hg. Women more often received diuretics (52 vs 42%), and less often angiotensin-converting enzyme inhibitors (22 vs 33%) and calcium channel blockers (26 vs 31%) than men. β-Blockers and diuretics were the most common drug classes prescribed, independent of comorbidity. In conclusion, one out of four primary care patients with hypertension reach target blood pressure. More frequent use of drug combinations may improve blood pressure control.

Central sympatholytic therapy has anti-inflammatory properties in hypertensive postmenopausal women.

Objective Postmenopausal phase expresses many unfavourable physiological changes that lead to increased risk for cardiovascular disease. We compared the effect of two sympatholytic antihypertensive drug treatments, the centrally acting imidazoline receptor-1 agonist moxonidine and peripherally acting β-blocking agent atenolol on sensitive inflammatory markers in overweight postmenopausal women with diastolic hypertension. Methods This was a multicentre, multinational double-blinded, prospective study comparing moxonidine (0.3 mg twice daily) with atenolol (50 mg once daily) in 87 hypertensive postmenopausal overweight women who were not taking hormone therapy. Sensitive C-reactive protein, IL-6, TNFα, TNFα-RII and adiponectin were determined in the beginning of the study and after 8 weeks of medical treatment. Results TNFα increased in atenolol and decreased in moxonidine group (P = 0.0004 between the groups). Adiponectin concentration decreased dramatically in atenonol but did not change in moxonidine treatment group (P < 0.0001 between the groups). In logistic regression analysis only treatment group showed an independent effect on changes in adiponectin and TNFα concentrations. Conclusion We believe that centrally acting sympatholytic agent moxonidine is beneficial in the treatment of postmenopausal women with hypertension by reducing inflammatory cytokine TNFα without changing protective adiponectin level.

Blood pressure and complications in individuals with type 2 diabetes and no previous cardiovascular disease: national population based cohort study.

Objectives To compare the risk associated with systolic blood pressure that meets current recommendations (that is, below 140 mm Hg) with the risk associated with lower levels in patients who have type 2 diabetes and no previous cardiovascular disease. Design Population based cohort study with nationwide clinical registries, 2006-12. The mean follow-up was 5.0 years. Setting 861 Swedish primary care units and hospital outpatient clinics. Participants 187 106 patients registered in the Swedish national diabetes register who had had type 2 diabetes for at least a year, age 75 or younger, and with no previous cardiovascular or other major disease. Main outcome measures Clinical events were obtained from the hospital discharge and death registers with respect to acute myocardial infarction, stroke, a composite of acute myocardial infarction and stroke (cardiovascular disease), coronary heart disease, heart failure, and total mortality. Hazard ratios were estimated for different levels of baseline systolic blood pressure with clinical characteristics and drug prescription data as covariates. Results The group with the lowest systolic blood pressure (110-119 mm Hg) had a significantly lower risk of non-fatal acute myocardial infarction (adjusted hazard ratio 0.76, 95% confidence interval 0.64 to 0.91; P=0.003), total acute myocardial infarction (0.85, 0.72 to 0.99; P=0.04), non-fatal cardiovascular disease (0.82, 0.72 to 0.93; P=0.002), total cardiovascular disease (0.88, 0.79 to 0.99; P=0.04), and non-fatal coronary heart disease (0.88, 0.78 to 0.99; P=0.03) compared with the reference group (130-139 mm Hg). There was no indication of a J shaped relation between systolic blood pressure and the endpoints, with the exception of heart failure and total mortality. Conclusions Lower systolic blood pressure than currently recommended is associated with significantly lower risk of cardiovascular events in patients with type 2 diabetes. The association between low blood pressure and increased mortality could be due to concomitant disease rather than antihypertensive treatment.