Maria Rosvall

Prediction of Clinical Cardiovascular Events With Carotid Intima-Media Thickness A Systematic Review and Meta-Analysis

Background— Carotid intima-media thickness (IMT) is increasingly used as a surrogate marker for atherosclerosis. Its use relies on its ability to predict future clinical cardiovascular end points. We performed a systematic review and meta-analysis of data to examine this association. Methods and Results— Using a prespecified search strategy, we identified 8 relevant studies and compared study design, measurement protocols, and reported data. We identified sources of heterogeneity between studies. The assumption of a linear relationship between IMT and risk was challenged by use of a graphical technique. To obtain a pooled estimate of the relative risk per IMT difference, we performed a meta-analysis based on random effects models. The age- and sex-adjusted overall estimates of the relative risk of myocardial infarction were 1.26 (95% CI, 1.21 to 1.30) per 1–standard deviation common carotid artery IMT difference and 1.15 (95% CI, 1.12 to 1.17) per 0.10-mm common carotid artery IMT difference. The age- and sex-adjusted relative risks of stroke were 1.32 (95% CI, 1.27 to 1.38) per 1–standard deviation common carotid artery IMT difference and 1.18 (95% CI, 1.16 to 1.21) per 0.10-mm common carotid artery IMT difference. Major sources of heterogeneity were age distribution, carotid segment definition, and IMT measurement protocol. The relationship between IMT and risk was nonlinear, but the linear models fitted relatively well for moderate to high IMT values. Conclusions— Carotid IMT is a strong predictor of future vascular events. The relative risk per IMT difference is slightly higher for the end point stroke than for myocardial infarction. In future IMT studies, ultrasound protocols should be aligned with published studies. Data for younger individuals are limited and more studies are required.

Common Carotid Intima-Media Thickness Measurements in Cardiovascular Risk Prediction: A Meta-analysis

CONTEXT The evidence that measurement of the common carotid intima-media thickness (CIMT) improves the risk scores in prediction of the absolute risk of cardiovascular events is inconsistent. OBJECTIVE To determine whether common CIMT has added value in 10-year risk prediction of first-time myocardial infarctions or strokes, above that of the Framingham Risk Score. DATA SOURCES Relevant studies were identified through literature searches of databases (PubMed from 1950 to June 2012 and EMBASE from 1980 to June 2012) and expert opinion. STUDY SELECTION Studies were included if participants were drawn from the general population, common CIMT was measured at baseline, and individuals were followed up for first-time myocardial infarction or stroke. DATA EXTRACTION Individual data were combined into 1 data set and an individual participant data meta-analysis was performed on individuals without existing cardiovascular disease. RESULTS We included 14 population-based cohorts contributing data for 45,828 individuals. During a median follow-up of 11 years, 4007 first-time myocardial infarctions or strokes occurred. We first refitted the risk factors of the Framingham Risk Score and then extended the model with common CIMT measurements to estimate the absolute 10-year risks to develop a first-time myocardial infarction or stroke in both models. The C statistic of both models was similar (0.757; 95% CI, 0.749-0.764; and 0.759; 95% CI, 0.752-0.766). The net reclassification improvement with the addition of common CIMT was small (0.8%; 95% CI, 0.1%-1.6%). In those at intermediate risk, the net reclassification improvement was 3.6% in all individuals (95% CI, 2.7%-4.6%) and no differences between men and women. CONCLUSION The addition of common CIMT measurements to the Framingham Risk Score was associated with small improvement in 10-year risk prediction of first-time myocardial infarction or stroke, but this improvement is unlikely to be of clinical importance.

Incident coronary events and case fatality in relation to common carotid intima‐media thickness

Objectives.  To evaluate the incidence of coronary events (CE) and case fatality in relation to common carotid intima‐media thickness (IMT) and carotid plaque over a median follow up of 7 years.

Prevalence of Asymptomatic Carotid Artery Stenosis in the General Population: An Individual Participant Data Meta-Analysis

Background and Purpose— In the discussion on the cost-effectiveness of screening, precise estimates of severe asymptomatic carotid stenosis are vital. Accordingly, we assessed the prevalence of moderate and severe asymptomatic carotid stenosis by age and sex using pooled cohort data. Methods— We performed an individual participant data meta-analysis (23 706 participants) of 4 population-based studies (Malmö Diet and Cancer Study, Tromsø, Carotid Atherosclerosis Progression Study, and Cardiovascular Health Study). Outcomes of interest were asymptomatic moderate (≥50%) and severe carotid stenosis (≥70%). Results— Prevalence of moderate asymptomatic carotid stenosis ranged from 0.2% (95% CI, 0.0% to 0.4%) in men aged <50 years to 7.5% (5.2% to 10.5%) in men aged ≥80 years. For women, this prevalence increased from 0% (0% to 0.2%) to 5.0% (3.1% to 7.5%). Prevalence of severe asymptomatic carotid stenosis ranged from 0.1% (0.0% to 0.3%) in men aged <50 years to 3.1% (1.7% to 5.3%) in men aged ≥80. For women, this prevalence increased from 0% (0.0% to 0.2%) to 0.9% (0.3% to 2.4%). Conclusions— The prevalence of severe asymptomatic carotid stenosis in the general population ranges from 0% to 3.1%, which is useful information in the discussion on the cost-effectiveness of screening.

Neighborhood socioeconomic deprivation and residential instability - Effects on incidence of ischemic heart disease and survival after myocardial inforction

Background: Previous literature has shown that neighborhood socioeconomic position influences the risk of ischemic heart disease, but little is known about the mechanisms linking the residential context to ischemic heart disease incidence and mortality. We examined whether neighborhood socioeconomic position and neighborhood residential stability (as a determinant of social interaction patterns) have an influence on ischemic heart disease risk. Moreover, we investigated whether dissimilar contextual influences operate at different stages of the disease process, ie, on incidence, 1-day case-fatality, and long-term survival after acute myocardial infarction (MI). Methods: Using a large 27-year longitudinal cohort (baseline: 1 January 1996) defined in the Scania region, Sweden, we estimated multilevel survival models adjusted for individual sociodemographic factors and previous diseases of the persons. Results: After adjustment, multilevel survival models indicated that the incidence of ischemic heart disease increased with neighborhood socioeconomic deprivation but was only weakly associated with neighborhood residential instability (for high vs low residential instability, hazard ratio = 1.2; 95% credible interval = 1.0–1.4). Conversely, beyond effects of individual and contextual socioeconomic circumstances and distance to the hospital, we saw a markedly higher 1-day case-fatality (4.9; 1.8–15) and shorter survival time after MI among individuals still alive 28 days after MI (4.3; 1.2–17) in neighborhoods with a high versus low residential instability. Conclusions: Effects of residential instability on post-MI survival may be mediated by the lower availability of social support in residentially unstable neighborhoods, suggesting a new class of intermediate processes that should be taken into account when investigating contextual influences on ischemic heart disease. Moreover, dissimilar contextual effects may operate at various stages of the disease process (ie, on incidence, case-fatality, and survival after MI).

Stroke Incidence, Recurrence, and Case-Fatality in Relation to Socioeconomic Position A Population-Based Study of Middle-Aged Swedish Men and Women

Background and Purpose— Low socioeconomic status is associated with increased incidence of stroke. This study investigated stroke incidence, recurrence, and case-fatality after stroke among middle-aged Swedish men and women and whether this association differs by gender or stroke subtype. Methods— A total of 69 625 (49% men) citizens, aged 40 to 65 years, living in the city of Malmö in 1990 were studied in relation to total annual income and occupation class, ie, 2 indicators of socioeconomic status. Incidence of first-ever stroke, stroke recurrence, and case-fatality (death within 28 days or 1 year after stroke) were studied over 10 years of follow-up. Results— During the follow-up, a total of 1648 subjects developed a first-ever stroke of whom 275 also experienced a recurrent stroke. By using Cox regression model with covariate adjustments, the incidence of stroke was significantly increased (relative risk: 1.75, 95% CI:1.36 to 2.25) in women who were in the lowest quartile of income compared with the women being in the highest quartile. Corresponding relative risk in men was 1.29 (1.06 to 1.58). Both in men and women, income was significantly associated with ischemic, but not hemorrhagic, subtypes of stroke. Similar relationships were observed between occupation level and incidence of stroke. In addition, low income was associated with higher 28-day and 1-year fatality rates in men (relative risk: 3.13, 1.35 to 7.24 and 2.17, 1.18 to 4.00, respectively), but not in women. In contrast, recurrence of stroke was inversely associated with income only in women. Conclusions— Incidence of stroke, stroke recurrence, and case-fatality increased with decreasing socioeconomic status; however, this relationship differed by gender and subtype of events.

Neighbourhood social interactions and risk of acute myocardial infarction.

Study objective: Previous studies of neighbourhood effects on ischaemic heart disease (IHD) have used census or administrative data to characterise the residential context, most commonly its socioeconomic level. Using the ecometric approach to define neighbourhood social interaction variables that may be relevant to IHD, neighbourhood social cohesion and safety were examined to see how they related to acute myocardial infarction (AMI) mortality, after adjustment for individual and neighbourhood confounders. Design: To construct social interaction variables, multilevel models were used to aggregate individual perceptions of safety and cohesion at the neighbourhood level. Linking data from the Health Survey in Scania, Sweden, and the Population, Hospital, and Mortality Registers, multilevel survival models were used to investigate determinants of AMI mortality over a three year and nine month period. Participants: 7791 Individuals aged 45 years and over. Main results: The rate of AMI mortality increased with decreasing neighbourhood safety and cohesion. After adjustment for individual health and socioeconomic variables, low neighbourhood cohesion, and to a lesser extent low safety, were associated with higher AMI mortality. Neighbourhood cohesion effects persisted after adjustment for various neighbourhood confounding factors (income, population density, percentage of residents from low-income countries, residential stability) and distance to the hospital. There was some evidence that neighbourhood cohesion effects on AMI mortality were caused by effects on one-day case-fatality, rather than on incidence. Conclusions: Beyond commonly evoked effects of the physical environment, neighbourhood social interaction patterns may have a decisive influence on IHD, with a particularly strong effect on survival after AMI.

Job strain in men, but not in women, predicts a significant rise in blood pressure after 6.5 years of follow-up.

Background Job strain (high demands and low decision latitude) has been associated with hypertension and cardiovascular disease, especially in men. Most studies on job strain and hypertension have been cross-sectional, and prospective data are inconsistent. Objective To prospectively describe the effects of different psychosocial work characteristics on office blood pressure changes. Methods In total, 448 men and women, mean age 55 years, were followed for a mean of 6.5 years. At baseline, work characteristics and cardiovascular risk factors were assessed. Only employed subjects aged 63 years or younger were eligible for participation. Results Men with baseline job strain had a significantly greater increase in both systolic blood pressure (7.7 mmHg, P = 0.02), and diastolic blood pressure (5.6 mmHg, P = 0.003), compared to the group with low work demands and high decision latitude (‘relaxed’). These findings were significant also after adjustments for age, follow-up time, baseline blood pressure, blood pressure treatment at baseline and follow-up, and length of education. Work demands were more strongly correlated with blood pressure increase than decision latitude. For women, no significant associations between psychosocial work characteristics and blood pressure changes were found, apart from a weak trend of association between increasing decision latitude and increasing blood pressure. Conclusion Job strain significantly predicts an increase in office blood pressure in middle-aged men, but not in women. Work demands were more strongly correlated with blood pressure increase than decision latitude in men.

Assessment of the magnitude of geographical variations and socioeconomic contextual effects on ischaemic heart disease mortality: a multilevel survival analysis of a large Swedish cohort.

Background: In a public health perspective, it is of interest to assess the magnitude of geographical variations in ischaemic heart disease (IHD) mortality and quantify the strength of contextual effects on IHD. Objective: To investigate whether area effects vary according to the individual and contextual characteristics of the population, socioeconomic contextual influences were assessed in different age groups and within territories of differing population densities. Design: Multilevel survival analysis of a 28-year longitudinal database. Participants: 341 048 residents of the Scania region in Sweden, reaching age 50–79 years in 1996, followed up over 7 years. Results: After adjustment for several individual socioeconomic indicators over the adult age, Cox multilevel models indicated geographical variations in IHD mortality and socioeconomic contextual effects on the mortality risk. However, the magnitude of geographical variations and strength of contextual effects were modified by the age of individuals and the population density of their residential area: socioeconomic contextual effects were much stronger among non-elderly than among elderly adults, and much larger within urban territories than within rural ones. As a consequence, among non-elderly residents of urban territories, the socioeconomic contextual effect was almost as large as the effect of individual 20-year cumulated income. Conclusions: Non-elderly residents of deprived urban neighbourhoods constitute a major target for both contextual epidemiology of coronary disease and public health interventions aimed at reducing the detrimental effects of the social environment on IHD.

Work related and non-work related stress in relation to low leisure time physical activity in a Swedish population

Physical activity is regarded as an important component of a healthy lifestyle. Several social and environmental factors have systematically emerged as barriers to low leisure time physical activity (LTPA), for example, lack of money, low social support due to lack of supportive family or friends, and living in high crime rate areas. Low LTPA has been found to be strongly associated with low socioeconomic status groups where psychosocial stressors have been suggested to play a mediating part.1,2 The overall aim of this study was to investigate the association between work and non-work related stressors, respectively, in relation to low LTPA in a general population sample. Our main hypothesis was that psychosocial stressors would act as barriers to physical activity thus generating sedentary behaviour as measured by LTPA. The Scania health survey was conducted during the period of November 1999 through April 2000. After excluding refusals, non-contacts, and other non-responding groups, the final sample consisted of 13 715 persons, making the response rate 59% of the sample size. A self administered questionnaire provided information regarding health related behaviours, sociodemographic characteristic, and psychosocial factors. Our analysis was restricted to currently employed people (52% of the sample population) yielding a study population of 7169 subjects (3877 men and 3292 women). Odds ratios for low LTPA in relation to psychosocial variables were calculated using two logistic regression models, model one with adjustment for age, …