Lars Wilhelmsen

Self-perceived psychological stress and incidence of coronary artery disease in middle-aged men☆

Self-perceived psychological stress as a risk factor for coronary artery disease (CAD) was evaluated in a general population study comprising 6,935 men aged 47 to 55 years at baseline without previous myocardial infarction. In 1970 to 1973, the men answered a question about psychological stress defined as a feeling of tension, irritability or anxiety, or as having sleeping difficulties as a result of conditions at work or at home. Psychological stress was graded as follows: (1) never experienced stress; (2) greater than or equal to 1 period of stress; (3) greater than or equal to 1 period of stress during the last 5 years; (4) several periods of stress during the last 5 years; and (5 to 6) permanent stress during the last year or the last 5 years. After a mean follow-up of 11.8 years, 6% of the men with the lowest 4 stress ratings (n = 5,865) had either developed a nonfatal myocardial infarction or died from CAD, with no increase in risk from grade 1 to 4. The corresponding figure among the men with the highest 2 stress ratings (n = 1,070) was 10%; the odds ratio was 1.5 (95% confidence interval 1.2-1.9) after controlling for age and other risk factors. Similar, independent associations were seen with stroke, and with death from cardiovascular disease and from all causes, but not with death from cancer. With respect to CAD, no decrease in the effect of stress at baseline could be seen over time. No relation between life events and self-perceived psychological stress was found in another sample of 732 fifty-year-old men.

Association of Cardiometabolic Multimorbidity With Mortality.

IMPORTANCE The prevalence of cardiometabolic multimorbidity is increasing. OBJECTIVE To estimate reductions in life expectancy associated with cardiometabolic multimorbidity. DESIGN, SETTING, AND PARTICIPANTS Age- and sex-adjusted mortality rates and hazard ratios (HRs) were calculated using individual participant data from the Emerging Risk Factors Collaboration (689,300 participants; 91 cohorts; years of baseline surveys: 1960-2007; latest mortality follow-up: April 2013; 128,843 deaths). The HRs from the Emerging Risk Factors Collaboration were compared with those from the UK Biobank (499,808 participants; years of baseline surveys: 2006-2010; latest mortality follow-up: November 2013; 7995 deaths). Cumulative survival was estimated by applying calculated age-specific HRs for mortality to contemporary US age-specific death rates. EXPOSURES A history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction (MI). MAIN OUTCOMES AND MEASURES All-cause mortality and estimated reductions in life expectancy. RESULTS In participants in the Emerging Risk Factors Collaboration without a history of diabetes, stroke, or MI at baseline (reference group), the all-cause mortality rate adjusted to the age of 60 years was 6.8 per 1000 person-years. Mortality rates per 1000 person-years were 15.6 in participants with a history of diabetes, 16.1 in those with stroke, 16.8 in those with MI, 32.0 in those with both diabetes and MI, 32.5 in those with both diabetes and stroke, 32.8 in those with both stroke and MI, and 59.5 in those with diabetes, stroke, and MI. Compared with the reference group, the HRs for all-cause mortality were 1.9 (95% CI, 1.8-2.0) in participants with a history of diabetes, 2.1 (95% CI, 2.0-2.2) in those with stroke, 2.0 (95% CI, 1.9-2.2) in those with MI, 3.7 (95% CI, 3.3-4.1) in those with both diabetes and MI, 3.8 (95% CI, 3.5-4.2) in those with both diabetes and stroke, 3.5 (95% CI, 3.1-4.0) in those with both stroke and MI, and 6.9 (95% CI, 5.7-8.3) in those with diabetes, stroke, and MI. The HRs from the Emerging Risk Factors Collaboration were similar to those from the more recently recruited UK Biobank. The HRs were little changed after further adjustment for markers of established intermediate pathways (eg, levels of lipids and blood pressure) and lifestyle factors (eg, smoking, diet). At the age of 60 years, a history of any 2 of these conditions was associated with 12 years of reduced life expectancy and a history of all 3 of these conditions was associated with 15 years of reduced life expectancy. CONCLUSIONS AND RELEVANCE Mortality associated with a history of diabetes, stroke, or MI was similar for each condition. Because any combination of these conditions was associated with multiplicative mortality risk, life expectancy was substantially lower in people with multimorbidity.

Psychosocial factors and venous thromboembolism: a long‐term follow‐up study of Swedish men

Summary.  Background: The link between psychosocial factors and coronary heart disease is well established, but although effects on coagulation and fibrinolysis variables may be implicated, no population‐based study has sought to determine whether venous thromboembolism is similarly related to psychosocial factors. Objective: To determine whether venous thromboembolism (deep vein thrombosis or pulmonary embolism) is related to psychosocial factors. Patients/methods:  A stress questionnaire was filled in by 6958 men at baseline from 1970 to 1973, participants in a cardiovascular intervention trial. Their occupation was used to determine socio‐economic status. Results: After a maximum follow‐up of 28.8 years, 358 cases of deep vein thrombosis and/or pulmonary embolism were identified through the Swedish hospital discharge and cause‐specific death registries. In comparison with men who, at baseline, had no or moderate stress, men with persistent stress had increased risk of pulmonary embolism [hazard ratio (HR)=1.80, 95% CI: 1.21–2.67]. After multivariable adjustment, the HR decreased slightly to 1.66 (95% CI: 1.12–2.48). When compared with manual workers, men with white‐collar jobs at intermediate or high level and professionals showed an inverse relationship between occupational class and pulmonary embolism (multiple‐adjusted HR=0.57, 95% CI: 0.39–0.83). Deep vein thrombosis was not significantly related to either stress or occupational class. Conclusion: Both persistent stress and low occupational class were independently related to future pulmonary embolism. The mechanisms are unknown, but effects on coagulation and fibrinolytic factors are likely.

Body Mass Index in Mid-Life Is Associated With a First Stroke in Men: A Prospective Population Study Over 28 Years

Background and Purpose— Data on the association between obesity and stroke are still limited. We examined the possible association between mid-life body mass index (BMI) and risk of stroke in the prospective Multifactor Primary Prevention Study in Göteborg, Sweden. Methods— 7402 apparently healthy men aged 47 to 55 at baseline were followed-up over a 28-year period. Incidence of fatal and nonfatal stroke was recorded in a local stroke registry through the Swedish National Register on Cause of Death and the Swedish Hospital Discharge Registry. Results— A total of 873 first strokes were recorded, including 495 ischemic, 144 hemorrhagic, and 234 unspecified strokes. Compared with men with low normal weight (BMI, 20.0 to 22.49 kg/m2), men with BMI >30.0 kg/m2 had a multiple adjusted hazard ratio of 1.93 (95% CI, 1.44 to 2.58) for total stroke, 1.78 (95% CI, 1.22 to 2.60) for ischemic stroke, and 3.91 (95% CI, 2.10 to 7.27) for unspecified stroke. There was no significant association between BMI and hemorrhagic stroke. Adjustment for potential mediators, eg, hypertension, diabetes and serum cholesterol levels, attenuated but did not eliminate the risk. Conclusion— In this prospective population-based study of men, increased BMI in mid-life was associated with an increased risk for total, ischemic, and unspecified stroke, but not with hemorrhagic stroke. The result supports the role of mid-life BMI as a risk factor for stroke later in life and suggests a differentiated effect on stroke subtypes.

Diabetes and Long-Term Risk of Mortality From Coronary and Other Causes in Middle-Aged Swedish Men: A general population study

OBJECTIVE To assess the relation between cardiovascular risk factors and long-term cause-specific mortality risk in middle-aged diabetic men, compared with men without diabetes. RESEARCH DESIGN AND METHODS This prospective study analyzes a large random population sample of men over a follow-up of 16 years. At baseline in 1974–1977, 249 men with diabetes and 6,851 men without diabetes, all aged 51–59 years, were identified. There were 2,126 deaths, 724 of which were due to coronary heart disease (CHD) and 1,001 deaths were due to any cardiovascular disease (CVD) cause. RESULTS After adjustment for age, serum cholesterol, systolic blood pressure, smoking, BMI, and coronary disease at baseline, the relative risk of dying from any cause was 2.50 (95% CI, 2.11–2.95) in men with diabetes, compared with nondiabetic men, and 2.87 (2.31–3.57) for cardiovascular death. Men with diabetes had no significant excessive risk of dying from cancer or violent causes, but the relative risk of dying from any other noncardiovascular cause was 3.69 (2.55–5.34). Most of these deaths were due to diabetes and its complications. Hypercholesterolemia, smoking, and elevated systolic blood pressure predicted both coronary and allcause mortality in diabetic as well as in nondiabetic men. Men with diabetes and serum cholesterol >7.2 mmol/1 had a risk of dying from coronary disease of 45.3 and from any cause of 76.1 per 1,000 observation-years. In men with diabetes, the relative risk of dying associated with serum cholesterol >7.2 mmol/1, as compared with <5.2 mmol/1, was 1.78 (95% CI, 1.05–3.02). The corresponding risk for nondiabetic men was 1.23 (1.04–1.46), and there was a statistically significant interaction between serum cholesterol and diabetes (P = 0.004). CONCLUSIONS In men with diabetes, hypercholesterolemia, smoking, and hypertension predict coronary mortality risk, as well as mortality risk from all causes. Men with both diabetes and hypercholesterolemia have severely compromised survival and should be targeted for intervention aimed at lowering their lipid levels.

Stroke and coronary heart disease in treated hypertension - a prospective cohort study over three decades

Objective.  To compare cardiovascular mortality and morbidity in middle‐aged hypertensive men with initially nonhypertensive men derived from the same random population sample, and to study stroke morbidity in these men in relation to cardiovascular risk factors during 25–28 years of follow‐up.

The Multifactor Primary Prevention Trial in Göteborg, Sweden

SummaryAll male inhabitants of the city of Göteborg, who were born between 1915–1922 and 1924–1925 were included in the trial, and were 47 to 55 years of age on entry to the study in 1970 to 1973. One-third of these men were randomly allocated to an intervention group, whilst the other two-thirds acted as controls. Men of all social classes, employed as wellas unemployed, health conscious as well as careless, were invited, with 75% of these responding to the invitation. The intervention group contained 10,000 men and the control group 20,000 men.The intervention group were given advice on diet, both individually and in groups, the type of advice depending upon serum cholesterol level. Smokers were advised to stop smoking, and men with elevated blood pressure were treated with antihypertensive drugs.Due to the large size of the groups and because they formed a random population sample, it was assumed that they had similar characteristics at the start of the trial. Risk factors were only measured in the intervention group at this time, followed by intervention. This design feature solved several ethical problems with regard to no treatment in the control group. These men were, however, subjected to health examinations and treatment as well as general health advice.Risk factor levels were measured in the intervention group, and also in random subsamples (11%) of the control group after 4 and 10 years. Serum cholesterol, blood pressure and smoking decreased among men in both groups, and only slightly more in the intervention group. Antihypertensive drug treatment was given to 26% of the intervention group and 20% of the control group participants after 10 years.No significant effect on total or cardiovascular mortality, or on the incidence of myocardial infarction or stroke was found. However, the effect of this intensive antihypertensive treatment on mortality and morbidity is indicated when the present results are compared to those of a previous population study in the same city.A markedly higher mortality in the group of non-participants diluted the results considerably, and some characteristics of this group will be discussed in view of future possibilities of prevention efforts in the whole community.

Low aerobic capacity in middle-aged men associated with increased mortality rates during 45 years of follow-up

Background Low aerobic capacity has been associated with increased mortality in short-term studies. The aim of this study was to evaluate the predictive power of aerobic capacity for mortality in middle-aged men during 45-years of follow-up. Design The study design was a population-based prospective cohort study. Methods A representative sample from Gothenburg of men born in 1913 was followed from 50–99 years of age, with periodic medical examinations and data from the National Hospital Discharge and Cause of Death registers. At 54 years of age, 792 men performed an ergometer exercise test, with 656 (83%) performing the maximum exercise test. Results In Cox regression analysis, low predicted peak oxygen uptake ( VO 2 max ), smoking, high serum cholesterol and high mean arterial blood pressure at rest were significantly associated with mortality. In multivariable analysis, an association was found between predicted VO 2 max tertiles and mortality, independent of established risk factors. Hazard ratios were 0.79 (95% confidence interval (CI) 0.71–0.89; p < 0.0001) for predicted VO 2 max , 1.01 (1.002–1.02; p < 0.01) for mean arterial blood pressure, 1.13 (1.04–1.22; p < 0.005) for cholesterol, and 1.58 (1.34–1.85; p < 0.0001) for smoking. The variable impact (Wald’s χ2) of predicted VO 2 max tertiles (15.3) on mortality was secondary only to smoking (31.4). The risk associated with low predicted VO 2 max was evident throughout four decades of follow-up. Conclusion In this representative population sample of middle-aged men, low aerobic capacity was associated with increased mortality rates, independent of traditional risk factors, including smoking, blood pressure and serum cholesterol, during more than 40 years of follow-up.

Incidence of Type 2 diabetes among occupational classes in Sweden: a 35-year follow-up cohort study in middle-aged men

To assess if low occupational class was an independent predictor of Type 2 diabetes in men in Sweden over a 35‐year follow‐up, after adjustment for both conventional risk factors and psychological stress.

Practical guidelines for drug therapy after myocardial infarction.

SummaryEffective management of the post infarction patient includes early assessment of direct complications such as angina pectoris, congestive heart failure and ventricular arrhythmias. Treatment of persistent ischaemia might call for early revascularisation. Early prevention of reocclusion with aspirin is recommended.It is advisable to correct blood lipid disturbances and to treat elevated blood pressure. β-Blocking drugs have shown worthwhile reductions of both non-fatal and fatal recurrences, whereas calcium blockers and antiarrhythmic drugs have not been found to be effective. Anticoagulants have not been definitely effective in reducing mortality but seem to have some effects on non-fatal recurrences. Platelet active drugs, among which aspirin is the best documented, reduce the incidence of both non-fatal and fatal recurrences.