Mette Bjerrum Koch

Increasing prevalence despite decreasing incidence of ischaemic heart disease and myocardial infarction. A national register based perspective in Denmark, 1980–2009

Aims Mortality from ischaemic heart disease (IHD) including acute myocardial infarction (AMI) in Denmark peaked around 1977, after which a marked decline has occurred as a result of decreasing incidence and increasing effect of treatment. IHD is a chronic, relapsing condition, and the effect of these changes on the prevalence of IHD is not known. Methods and results Changes in incidence and prevalence in 2000–2009 are presented, using nationwide data from public registers. An incident case is defined as a subject registered with a diagnosis of IHD/AMI and without a prior diagnosis for the past 20 years (beginning in 1980). A prevalent case is defined as a subject surviving the first year after the incident diagnosis. Regarding IHD, age-standardised incidence rates declined significantly from 2000 to 2009 for both sexes (females 445 to 340/100,000, males 822 to 678/100,000), reflecting a reduction in the annual number of new cases from 19.345 to 16.757. In contrast, prevalence rates increased slightly (females 2389 to 2616/100,000, males 5447 to 5579/100,000). Due to an increased proportion of elderly in the population, the number of prevalent cases increased from 125,000 in 2000 to 150,000 in 2009. The number of subjects having survived an AMI increased from 67,000 to 72,000. About 3% of the Danish population is afflicted by IHD. Conclusion Decreasing incidence, reduced case fatality and demographic development result in an increased prevalence of IHD, since the decline in incidence is more than offset by a larger decline in case fatality. The epidemic of IHD is far from over, in spite of the marked success of prevention and treatment.

Educational inequality in cardiovascular disease depends on diagnosis: A nationwide register based study from Denmark.

Background Social inequality is present in the morbidity as well as the mortality of cardiovascular diseases. This paper aims to quantify and compare the level of educational inequality across different cardiovascular diagnoses. Design Register based study. Methods Comparison of the extent of inequality across different cardiovascular diagnoses requires a measure of inequality which is comparable across subgroups with different educational distributions. The slope index of inequality and the relative index of inequality were applied for measuring inequalities in incidence of six cardiovascular diagnoses: ischaemic heart disease, acute myocardial infarction, valvular heart disease, congestive heart failure, atrial fibrillation and stroke in the period 2005–2009. All individuals in the general Danish population aged 35–84 years were followed in national registers regarding hospitalisation, death and education from 1985 to 2009 (annual average of 2.9 million people) to define incident cases. Results Marked educational inequality was found in the incidence of ischaemic heart disease, acute myocardial infarction, heart failure and stroke (relative index of inequality: 0.37 (95% confidence interval 0.34; 0.40) to 0.60 (0.57; 0.63), absolute index of inequality: −241 (−254.4; −227.4) to −37 (−42.7; −31.1)) while inequality in atrial fibrillation and, in particular, in valvular heart disease was small and insignificant (relative index of inequality: 0.57 (0.49; 0.65) to 0.97 (0.88; 1.08), absolute index of inequality: −29 (−35.1; −21.9) to −1 (−4.8; −3.8)). Conclusion The degree of educational inequality in cardiovascular diseases depends on the diagnosis, with the highest inequality in ischaemic heart disease, acute myocardial infarction, heart failure and stroke. Small differences were found between men and women.

What is the association of smoking and alcohol use with the increase in social inequality in mortality in Denmark? A nationwide register-based study

Objectives The aim of this paper is to estimate the impact of smoking and alcohol use on the increase in social inequality in mortality in Denmark in the period 1985–2009. Design A nationwide register-based study. Setting Denmark. Participants The whole Danish population aged 30 years or more in the period 1985–2009. Primary and secondary outcome measures The primary outcome is mortality rates in relation to educational attainments calculated with and without deaths related to smoking and alcohol use. An absolute measure of inequality in mortality is applied along with a result on the direct contribution from smoking and alcohol use on the absolute difference in mortality rates. The secondary outcome is life expectancy in relation to educational attainments. Results Since 1985, Danish overall mortality rates have decreased. Alongside the improvement in mortality, the absolute difference in the mortality rate (per 100 000 persons) between the lowest and the highest educated quartile grew from 465 to 611 among men and from 250 to 386 among women. Smoking and alcohol use have caused 75% of the increase among men and 97% of the increase among women. Among men the increase was mainly caused by alcohol. In women the increase was mainly caused by smoking. Conclusions The main explanation for the increase in social inequality in mortality since the mid-1980s is smoking and alcohol use. A significant reduction in the social inequality in mortality can only happen if the prevention of smoking and alcohol use are targeted to the lower educated part of the Danish population.

Implantable cardioverter defibrillator specific rehabilitation improves health cost outcomes: Findings from the COPE-ICD randomized controlled trial

OBJECTIVE The Copenhagen Outpatient ProgrammE - implantable cardioverter defibrillator (COPE-ICD) trial included patients with implantable cardioverter defibrillators in a randomized controlled trial of rehabilitation. After 6-12 months significant differences were found in favour of the rehabilitation group for exercise capacity, general and mental health. The aim of this paper is to explore the long-term health effects and cost implications associated with the rehabilitation programme; more specifically, (i) to compare implantable cardioverter defibrillator therapy history and mortality between rehabilitation and usual care groups; (ii) to examine the difference between rehabilitation and usual care groups in terms of time to first admission; and (iii) to determine attributable direct costs. METHODS Patients with first-time implantable cardioverter defibrillator implantation (n = 196) were randomized (1:1) to comprehensive cardiac rehabilitation or usual care. Outcomes were measured by implantable cardioverter defibrillator therapy history from patient records and national register follow-up on mortality, hospital admissions and costs. RESULTS No significant differences were found after 3 years for implantable cardioverter defibrillator therapy or mortality between rehabilitation and usual care. Time to first admission did not differ. The cost of rehabilitation was 335 USD/276 Euro per patient enrolled in rehabilitation. The total attributable cost of rehabilitation after 3 years was -6,789 USD/-5,593 Euro in favour of rehabilitation. CONCLUSION No long-term health outcome benefits were found for the rehabilitation programme. However, the rehabilitation programme resulted in a reduction in total attributable direct costs.