Merete Appleyard

Very Low Levels of Microalbuminuria Are Associated With Increased Risk of Coronary Heart Disease and Death Independently of Renal Function, Hypertension, and Diabetes

Background—The aim of this study was to assess the level of urinary albumin excretion (microalbuminuria), which is associated with increased risk of coronary heart disease and death, in the population. Microalbuminuria has been suggested as an atherosclerotic risk factor. However, the lower cutoff level of urinary albumin excretion is unknown. It is also unknown whether impaired renal function confounds the association. Methods and Results—In the Third Copenhagen City Heart Study in 1992 to 1994, 2762 men and women 30 to 70 years of age underwent a detailed cardiovascular investigation program, including a timed overnight urine sample. The participants were then followed up prospectively by registers until 1999 with respect to coronary heart disease and until 2001 with respect to death. During follow-up, 109 incident cases of coronary heart disease and 276 deaths were traced. A urinary albumin excretion above the upper quartile, ie, 4.8 μg/min, was associated with increased risk of coronary heart disease (RR, 2.0; 95% CI, 1.4 to 3.0; P <0.001) and death (RR, 1.9; 95% CI, 1.5 to 2.4; P <0.001) independently of age, sex, renal creatinine clearance, diabetes mellitus, hypertension, and plasma lipids. Lower levels of urinary albumin excretion were not associated with increased risk. Conclusions—Microalbuminuria, defined as urinary albumin excretion >4.8 μg/min (corresponding to ≈6.4 μg/min during daytime), is a strong and independent determinant of coronary heart disease and death. Our suggestion is to redefine microalbuminuria accordingly and perform intervention studies.

Spirometric findings and mortality in never-smokers

The relation of ventilatory function to overall mortality has been studied in 662 male and 2048 female never-smokers who during the period 1976-1978 participated in the Copenhagen City Heart Study, a prospective community study of more than 14,000 men and women randomly selected from the general population of the City of Copenhagen. Until the end of 1986, 195 subjects who said they were never-smokers died. Mortality was analyzed using the proportional hazards model of Cox. In addition to measures of ventilatory function, the mortality analysis included age, sex, body-mass index, alcohol consumption, school education, diabetes mellitus, heart disease and bronchial asthma as confounding factors. Forced expiratory volume in 1 second (FEV1) as a percentage of that predicted, forced vital capacity (FVC) as a percentage of that predicted and the ratio of FEV1 to FVC were significant risk factors for mortality among both sexes. The relative risk of death associated with a 50% decrease in FEV1 and FVC as a percentage of a predicted value was 1.65 and 1.81, respectively. This study confirms that lowered ventilatory function is a strong risk factor for mortality among never-smokers of both sexes.

Chronic obstructive lung disease in Copenhagen: cross-sectional epidemiological aspects

Abstract Lange P, Groth, S, Nyboe J, Appleyard M, Mortensen J, Jensen G, Schnohr P (Copenhagen City Heart Study, Medical Department B and Department of Clinical Physiology and Nuclear Medicine KF, Rigshospitalet, and Medical Department P, Bispebjerg Hospital, Copenhagen, Denmark). Chronic obstructive lung disease in Copenhagen: cross‐sectional epidemiological aspects.

Gray hair, baldness, and wrinkles in relation to myocardial infarction : the Copenhagen City Heart Study

To investigate a possible relation between aging signs such as graying of the hair, baldness, and facial wrinkling and myocardial infarction (MI), we analyzed data from The Copenhagen City Heart Study. During the 12-year follow-up, 750 cases of first-time MI were observed. After statistical adjustment for possible confounders, we found a correlation between graying of the hair, facial wrinkling, and frontoparietal baldness and crown-top baldness and MI in men. For example, the relative risk was 1.4 (95% CI, 0.9 to 2.0) for men with moderately gray hair compared with men with no gray hair and 1.9 (1.2 to 2.8) for men with completely gray hair (p < 0.001). With regard to gray hair, a similar although weaker and not statistically significant trend was seen in women. We conclude that, in addition to established coronary risk factors, aging signs like graying of the hair, male baldness, and facial wrinkling indicate an additional risk of MI.

Smoking and the risk of first acute myocardial infarction

When analyzing risk factors for first acute myocardial infarction in the Copenhagen City Heart Study, a large prospective population study of 20,000 men and women, smoking was found to influence risk significantly in a dose-dependent manner, the risk increasing 2% to 3% for each gram of tobacco smoked daily. Risk was particularly associated with inhalation, the risk for inhalers being almost twice that of noninhalers. No difference in risk could be demonstrated between various types of tobacco (pipe, cigar/cheroots, or plain and filtered cigarettes). The risk seemed associated with current smoking only, inasmuch as the duration of the smoking habit was not important. Ex-smokers had the same risk as those who had never smoked regardless of duration of smoking and time elapsed since quitting. Relative excess risk was significantly higher in female smokers than in male smokers, and daily alcohol intake appeared to have some protective effect on the risk of first acute myocardial infarction among heavy smokers.

Risk Stratification after Acute Myocardial Infarction by Means of Echocardiographic Wall Motion Scoring and Killip Classification

In order to perform risk stratification, 195 consecutive, unselected patients with acute myocardial infarction (AMI) underwent independent echocardiographic and clinical evaluation of their left ventricular function by means of the wall motion index (WMI) and Killip classification 5 days after AMI. The patients were prospectively allocated to a low, medium or high risk class depending on WMI alone, and the 1-year mortality in these classes was 2, 34 and 37%, respectively (p < 0.0001). The 1-year mortality of the patients in Killip class I, II, or III and IV was 6, 26 and 48%, respectively (p < 0.00001). The number of patients allocated to the low risk group by means of WMI was 87, and the number of patients in Killip class I was 86. Since these groups were not identical, a total of 103 patients, i.e. 53% of the study population, could be identified as low risk patients regarding 1-year mortality 5 days after AMI, when WMI and Killip classification were used in combination. We conclude that the combination of echocardiographic and clinical evaluation of left ventricular function after AMI provides a strong and yet very simple procedure to identify low risk patients, which could be easily implemented in the routine work of coronary care units.

Neuropsychological Functioning in Danish Gulf War Veterans

Research has shown that Danish Gulf War (GW) veterans reported a significantly higher prevalence of neuropsychological symptoms than did military controls 6 years after GW deployment. To explore the possible central nervous system determinants of these complaints, neuropsychological tests were administered to stratified, random samples of the Danish cohort of 916 GW-deployed veterans and 236 non–GW-deployed participants. Multivariate analyses of covariance were used to analyze neuropsychological test outcomes among the 215 male participants (143 GW-deployed and 72 non–GW-deployed soldiers). No significant differences in neuropsychological test performances were found between the GW-deployed and non–GW-deployed groups. Troops deployed to the GW reported significantly more mood complaints (i.e., fatigue and confusion) than their nondeployed counterparts. Because they were assigned to the Gulf region during the postcombat phase, Danish GW soldiers differed from the majority of American GW-deployed troops in military assignments and possible toxicant exposures.

Sensitivity and specificity of echocardiographic identification of patients eligible for safe early discharge after acute myocardial infarction

In a prospective clinical trial of 195 consecutive unselected patients with acute myocardial infarction (AMI), systematic blinded clinical and echocardiographic examinations were performed by two observers on day 5. The purpose was to define low-risk patients with regard to in-hospital and 2-month mortality and predict the potential costs (lost patient lives) and benefits (saved in-patient days) if as a routine procedure these low-risk patients were discharged earlier. By design, low-risk patients as defined by clinical criteria were allocated to discharge on days 7 to 10 and by echocardiographic criteria on days 5 to 7 after AMI. The sensitivity of the echocardiographic low-risk identification procedure was more than twofold higher than the sensitivity of clinical low-risk identification (49% vs 24%). Both procedures were safe with a specificity of 100% for cardiac mortality. Optimal identification of low-risk patients was provided by combining data from echocardiographic and clinical evaluations (sensitivity 59%). Results of the study suggest that a bedside echocardiographic approach to estimation of global left ventricular function is more sensitive and equally specific and therefore more efficient for risk stratification on post-AMI day 5 than clinical examination alone. Thus echocardiographic examination allows identification of a larger subset of patients with AMI (greater than 40% of the population alive on day 5) who can be discharged earlier and safely, with a potential saving of in-patient days of 436 days in 87 low-risk patients minus the cost of echocardiographic studies in 195 patients. However, the best prediction was obtained by combining clinical and echocardiographic examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Phlegm production in plain cigarette smokers who changed to filter cigarettes or quitted smoking

Abstract. Data from a prospective epidemiological study that included 2025 plain cigarette smokers were analysed to investigate the effect on phlegm production of changing to filter cigarettes or quitting smoking. During a 5‐year follow‐up, 189 subjects quitted smoking, 312 changed to filter cigarettes, while 1524 continued to smoke plain cigarettes. Multiple logistic regression was used to adjust for age, duration of smoking, number of cigarettes smoked, socio‐economic status and alcohol consumption. Smokers with morning phlegm at enrolment, who changed to filter cigarettes during the follow‐up, had a probability ratio of 1.9 of phlegm production ceasing, compared with smokers who continued to smoke plain cigarettes (P < 0.05). However, the probability ratio of developing morning phlegm among smokers who changed to filter cigarettes compared to those who continued to smoke plain cigarettes was 1.6 (P < 0.05). The overall prevalence of morning phlegm at the end of the follow‐up was the same in smokers who changed to filter cigarettes as in persistent plain cigarette smokers. The trends for chronic phlegm were similar, although they did not reach statistical significance. The smokers who stopped smoking had a probability ratio of 0.4 of developing morning phlegm (P < 0.01) and a ratio of 7.7 for ceasing to produce it (P < 0.001) compared to the smokers who continued to smoke plain cigarettes. Our results suggest that changing from plain to filter cigarettes is associated with a higher frequency of cessation of phlegm production, but offers no protection against the development of phlegm.

Prognostic significance of electrocardiographic Q-waves in a low-risk population

AIMS In individuals without known heart disease, electrocardiographic Q-waves predict a poor prognosis. We aimed to examine whether prognostic information can be derived from the size and location of Q-waves in persons from the general population without known ischaemic heart disease (IHD) or heart failure (HF). METHODS AND RESULTS Electrocardiograms (ECGs) of 5381 persons without known IHD or HF from the 4th Copenhagen City Heart Study were reviewed and Q-waves were classified according to their size and location. Multivariate Cox proportional hazards regression models were used to examine the associations of Q-waves adjusted for age, hypertension, diabetes, and estimated glomerular filtration rate with the risk of the combined endpoint of death and hospitalization for IHD. During a median of 7.8 years of follow-up, 1003 persons reached the combined endpoint. One hundred and fourteen (2.1%) had pathological Q-waves, of whom 44% suffered from an event compared with 18% from the control group, P< 0.001. Persons with hypertension, diabetes, and impaired renal function were more likely to have Q-waves. Even small Q-waves (i.e. Minnesota code 1.2.x-1.3.x) were associated with a poor prognosis, hazard ratio (HR) 1.4 [95% confidence interval (CI): 1.0-2.0; P< 0.05], though not as grave as large Q-waves (i.e. Minnesota code 1.1.x) HR 2.8 (95%CI: 1.6-5.0; P< 0.001). Conversely, there was no difference in the outcome of patients with anteriorly HR 1.6 (95%CI: 1.1-2.4) vs. posteriorly HR 1.5 (95%CI: 0.9-2.4) located Q-waves (P= 0.85). CONCLUSION In the general population without known IHD or HF, even small Q-waves in the ECG are associated with a poor prognosis.