Pär Hedberg

Waist circumference alone predicts insulin resistance as good as the metabolic syndrome in elderly women.

BACKGROUND Insulin resistance (IR) is a risk factor for diabetes and atherosclerotic diseases. The metabolic syndrome (MetS) reflects IR. Waist circumference (WC) is the most easily registered component of MetS. The objective was to compare WC alone with MetS as defined by the National Cholesterol Education Program (NCEP) and the International Diabetes Federation (IDF) for their abilities to predict IR in elderly without known diabetes. METHODS The study included 223 women and 210 men comprising 70% of a random sample of 75-year-olds from a general population. IR was conventionally defined as the gender-specific upper quartile of the Homeostasis Model Assessment-Insulin Resistance (HOMA-IR) index in individuals without known diabetes. RESULTS 1) The positive association between WC and IR is stronger in women than in men. 2) WC >88 cm alone is nearly as good as MetS, using NCEP criteria, in predicting IR in women. 3) According to the ROC curve, the optimal cut-off point for WC predicting IR was between 96 and 97 cm (men) and between 88 and 89 cm (women). The relative risk of IR was 5.6 (95% CI: 3.1-11.9) for women with WC >88 cm and 1.9 (1.5-2.8) for men with WC >96 cm. 4) The NCEP criteria predicts IR significantly better than the IDF criteria. CONCLUSION WC >88 cm in women indicates a high likelihood of IR and is almost as good as MetS defined using the NCEP criteria in predicting IR. MetS defined using the NCEP criteria predicts IR better than MetS defined using the IDF criteria.

Augmented blood pressure response to exercise is associated with improved long-term survival in older people

Objective: Studies on the prognostic importance of the systolic blood pressure (SBP) response during exercise report ambiguous results. Most research focuses on younger and middle-aged selected patient groups and rarely includes women. We investigated the prognostic value of SBP response during exercise testing in 75-year-olds. Design: Prospective observational cohort study. Setting: A community-based random sample of 75-year-old men and women (n = 382). Main outcome measures: The prognostic value of SBP change from rest to peak exercise during a symptom-limited cycle test was evaluated for the endpoints all-cause mortality and cardiovascular mortality during long-term follow-up. Results: After a median follow-up of 10.6 years, 140 (37%) of the participants had died, 64 (17%) from cardiovascular causes. The all-cause mortalities for exercise SBP changes of ⩽30 mm Hg, 31–55 mm Hg and >55 mm Hg were 5.1, 4.2 and 2.6 per 100 person-years, respectively (logrank 9.6; p = 0.008). For every 10 mm Hg increase in SBP during exercise the relative hazard for all-cause mortality was reduced by 13% (p = 0.030) and for cardiovascular mortality by 26% (p = 0.004) after adjustment for sex, smoking, waist circumference, total/HDL cholesterol ratio, prevalent ischaemic heart disease, hypertension, diabetes, cardiovascular medication, pre-exercise SBP, exercise capacity, resting left ventricular ejection fraction and left ventricular mass index. Conclusions: Our findings suggest that an augmented SBP response during exercise is associated with an improved long-term survival among community-living 75-year-old individuals.

Echocardiographic doppler assessments of left ventricular filling and ejection during upright exercise in endurance athletes

Doppler echocardiography was used to describe left ventricular filling and ejection during upright bicycle exercise in 24 healthy male endurance athletes. The transmitral pressure gradient was estimated and isovolumetric relaxation, filling and ejection time and transmitral and aortic flow velocities were measured at rest and during exercise. From rest to peak exercise (at a heart rate of 160 bpm), the mean left ventricular filling time was shortened by 73%, the ejection time by 31%, while the isovolumetric relaxation time was shortened by 62%. At peak exercise, the maximum aortic flow velocity almost doubled and the maximum transmitral flow velocity more than doubled, with a tenfold increase in the mean transmitral pressure gradient. The increase was significant (P<0·001) at each level of exercise. The left ventricular filling rate measured as volume per time was 185 ± 62 ml s−1 at rest and it increased to 986 ± 192 ml s−1 at peak exercise. This study demonstrates large changes in diastolic filling indices during upright exercise and it shows that the heart is able to increase its filling rate five times from rest to peak exercise.

Left ventricular systolic dysfunction in outpatients with peripheral atherosclerotic vascular disease: prevalence and association with location of arterial disease.

We aimed to determine the prevalence of left ventricular systolic dysfunction (LVSD) in outpatients with peripheral atherosclerotic vascular disease (PAVD). Further, the associations of stenotic internal carotid artery disease (SICAD) and lower extremity artery disease (LEAD) with LVSD were evaluated.

Survival of the fattest: unexpected findings about hyperglycaemia and obesity in a population based study of 75-year-olds.

Objective To study the relationship between body mass index (BMI) and mortality among 75-year-olds with and without diabetes mellitus type 2 (DM) or impaired fasting glucose (IFG). Design Prospective population-based cohort study with a 10-year follow-up. Participants A random sample of 618 of the 1100 inhabitants born in 1922 and living in the city of Västerås in 1997 were invited to participate in a cardiovascular health survey; 70% of those invited agreed to participate (432 individuals: 210 men, 222 women). Outcome measures All-cause and cardiovascular mortality. Results 163 of 432 (38%) participants died during the 10-year follow-up period. The prevalence of DM or IFG was 41% (35% among survivors, 48% among non-survivors). The prevalence of obesity/overweight/normal weight/underweight according to WHO definitions was 12/45/42/1% (14/43/42/1% among survivors, 9/47/42/2% among non-survivors). The hazard rate for death decreased by 10% for every kg/m2 increase in BMI in individuals with DM/IFG (HR 0.91, 95% CI 0.86 to 0.97; p=0.003). After adjustment for sex, current smoking, diagnosed hypertension, diagnosed angina pectoris, previous myocardial infarction and previous stroke/transient ischaemic attack, the corresponding decrease in mortality was 9% (HR 0.92, 95% CI 0.86 to 0.99; p=0.017). These findings remained after exclusion of individuals with BMI<20 or those who died within 2-year follow-up. In individuals without DM/IFG, BMI had no effect on mortality (HR 1.01, 95% CI 0.95 to 1.07; p=0.811). The HR for BMI differed significantly between individuals with and without DM/IFG (p interaction=0.025). The increased all-cause mortality in individuals with DM/IFG in combination with lower BMI was driven by cardiovascular death. Conclusion High all-cause and cardiovascular mortality was associated with lower BMI in 75-year-olds with DM/IFG but not in those without DM/IFG. Further studies on the combined effect of obesity/overweight and DM/IFG are needed in order to assess the appropriateness of current guideline recommendations for weight reduction in older people with DM/IFG.

Low Psychological General Well-Being (PGWB) is associated with deteriorated 10-year survival in men but not in women among the elderly

We studied Psychological General Well-Being (PGWB) and its relation to 10-year survival in 75-year-olds from the general population. The PGWB global score (sum of six subscale scores) and the subscale scores were transformed to 0-100 scales. Ten-year survival in relation to PGWB global and subscale scores was studied in a cohort of 204 men and 213 women. Global PGWB score (median) was 83 in men and 79 in women (for difference p=0.001). Significantly higher male scores were found for most PGWB subscales. Global PGWB score was significantly related to better 10-year survival in men (relative risk per ten points of score was 0.80; p=0.001 and 0.85; p=0.022 adjusting for chronic diseases and living alone) but not in women (relative risk 0.94; p=0.478 unadjusted). Among 75-year-olds, PGWB score was significantly higher for men. A high PGWB score was significantly related to better survival in men but not in women.

Mitral annulus motion compared with wall motion scoring index in the assessment of left ventricular ejection fraction.

The biplane disc summation method is the recommended echocardiographic procedure to determine left ventricular (LV) ejection fraction (EF). Assessment of mitral annulus motion (MAM) or wall motion scoring index (WMI) has been reported to be less dependent on image quality compared with the recommended method, and proposed as a surrogate to the disc summation method in calculation of LVEF. We aimed to compare MAM and WMI in the echocardiographic assessment of LVEF. In a randomly selected population-based sample of 75-year-old men and women in sinus rhythm (n = 409) MAM, as measured by M-mode, was compared with WMI, calculated as the mean value of wall motion scoring in 9 LV segments. LVEF, as measured by the biplane disc summation method was used as reference. The limits of agreement (mean difference +/- 1.96 SD) between LVEF and corresponding MAM values were -18 to +13 LVEF%, and between LVEF and corresponding WMI values were -12 to +13 LVEF%. The areas under the receiver operating characteristic curves for MAM and WMI to predict a LVEF < 50% were 0.892 and 0.998, respectively (95% confidence interval of the difference 0.062-0.149). The corresponding areas for MAM and WMI to predict a LVEF < 40% were 0.955 and 0.998, respectively (95% confidence interval of the difference 0.017-0.069). In conclusion, the ability of WMI to estimate LVEF was more favorable than MAM in this population-based sample of 75-year-old participants. The findings suggest that the WMI is preferable to MAM in estimating LVEF.

Interstudy heterogeneity of definitions of diastolic dysfunction severely affects reported prevalence

Aims The aim of this article is to examine how the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE) recommendations on the classification of diastolic dysfunction (DDF) are interpreted in the scientific community and to explore how variations in the DDF definition affect the reported prevalence. Methods and results A systematic review of studies citing the EACVI/ASE consensus document ‘Recommendations for the evaluation of left ventricular diastolic function by echocardiography’ was performed. The definition of DDF used in each study was recorded. Subsequently, several possible interpretations of the EACVI/ASE classification scheme were used to obtain DDF prevalence in a community-based sample (n = 714). In the systematic review, 60 studies were included. In 13 studies, no specification of DDF definition was presented, a one-level classification tree was used in 13, a two-level classification tree in 18, and in the remaining 16 studies, a DDF definition was presented but no grading of DDF was performed. In 17 studies, the DDF definition relied solely on early diastolic tissue velocity and/or left atrial size. In eight of these studies, a single parameter was used, in two studies the logical operator AND was used to combine two or more parameters, and the remaining seven studies used the logical operator OR. The resulting prevalence of DDF in the community-based sample varied from 12 to 84%, depending on the DDF definition used. Conclusion A substantial heterogeneity of definitions of DDF was evident among the studies reviewed, and the different definitions had a substantial impact on the reported prevalence of DDF.

Ten-Year Survival in 75-Year-Old Men and Women: Predictive Ability of Total Cholesterol, HDL-C, and LDL-C

Objective. The purpose of this study was to investigate prognostic impact of cholesterol and its subfractions among 75-year-old people from the general population. Methods and Results. The study comprised a random sample (222 women and 210 men) from the general population (participation rate 70%). During 10-year follow-up, 19% of women and 35% of men experienced a major cardiovascular event (MCVE). The all-cause mortality was 29% for women and 47% for men. After adjustment for cardiovascular risk factors, a low level of high-density lipoprotein cholesterol (HDL-C) was significantly associated with MCVE (P = .006) and mortality (P = .011) in men but not in women. The prognostic sex disparity was nearly significant (P = .051 for MCVE and .067 for mortality). The associations of adjusted HDL-C to MCVE and mortality were unchanged after excluding individuals with prevalent stroke or MI. Total cholesterol and low-density lipoprotein cholesterol (LDL-C) were not significantly related to prognosis in either sex. Main Conclusions. HDL-C was associated with dismal prognosis in men but not in women. Elderly men with HDL-C <40 mg/dL deserve particular attention for cardiovascular prevention.

White blood cell counts associate more strongly to the metabolic syndrome in 75-year-old women than in men : a population based study.

BACKGROUND A positive relation between the metabolic syndrome (MetS) and inflammatory activity has been reported. The purpose of this investigation was to study the relationships between 1) white blood cell (WBC) count and MetS, 2) WBC count and the individual components of MetS and 3) WBC count and insulin sensitivity in 75-year-old women and men from the general population. METHODS The study included 200 women and 196 men comprising 64% of the 75-year old people from the city of Västerås in Sweden. MetS was defined according to the National Cholesterol Education Program (NCEP). RESULTS WBC count (10(9)/L; median and interquartile range) was 5.7 (4.9-6.8) for women and 6.3 (5.4-7.2) for men, P < .001 for gender difference. For women with and without MetS, WBC count was 6.3 (5.3-7.3) and 5.4(4.7-6.3), respectively. For men the corresponding figures were 6.7 (5.9-7.6) and 6.1 (5.4-7.1).The difference in WBC count between individuals with and without MetS was significant (P < .001 for women; P = .014 for men). All individual components of MetS (with exception of blood pressure) were more strongly associated with WBC count for women than for men. Insulin sensitivity, measured as HOMA-IR (HOmeostasis Model Assessment-Insulin Resistance) index, was significantly associated with WBC count in women but not in men. CONCLUSIONS In this elderly population, individuals with MetS had a higher WBC count than those without. Women had a lower WBC count and stronger relationship between WBC count and insulin sensitivity than did men.