Pekka Jousilahti

Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project

AIMS The SCORE project was initiated to develop a risk scoring system for use in the clinical management of cardiovascular risk in European clinical practice. METHODS AND RESULTS The project assembled a pool of datasets from 12 European cohort studies, mainly carried out in general population settings. There were 20,5178 persons (88,080 women and 11,7098 men) representing 2.7 million person years of follow-up. There were 7934 cardiovascular deaths, of which 5652 were deaths from coronary heart disease. Ten-year risk of fatal cardiovascular disease was calculated using a Weibull model in which age was used as a measure of exposure time to risk rather than as a risk factor. Separate estimation equations were calculated for coronary heart disease and for non-coronary cardiovascular disease. These were calculated for high-risk and low-risk regions of Europe. Two parallel estimation models were developed, one based on total cholesterol and the other on total cholesterol/HDL cholesterol ratio. The risk estimations are displayed graphically in simple risk charts. Predictive value of the risk charts was examined by applying them to persons aged 45-64; areas under ROC curves ranged from 0.71 to 0.84. CONCLUSIONS The SCORE risk estimation system offers direct estimation of total fatal cardiovascular risk in a format suited to the constraints of clinical practice.

Sex, Age, Cardiovascular Risk Factors, and Coronary Heart Disease A Prospective Follow-Up Study of 14 786 Middle-Aged Men and Women in Finland

BACKGROUND Coronary heart disease (CHD) is markedly more common in men than in women. In both sexes, CHD risk increases with age, but the increase is sharper in women. We analyzed the extent to which major cardiovascular risk factors can explain the sex difference and the age-related increase in CHD risk. METHODS AND RESULTS The study cohort consists of 14 786 Finnish men and women 25 to 64 years old at baseline. The following cardiovascular risk factors were determined: smoking, serum total cholesterol, HDL cholesterol, blood pressure, body mass index, and diabetes. Risk factor measurements were done in 1982 or 1987, and the cohorts were followed up until the end of 1994. The Cox proportional hazards model was used to assess the relation between risk factors and CHD risk. CHD incidence in men compared with women was approximately 3 times higher and mortality was approximately 5 times higher. Most of the risk factors were more favorable in women, but the sex difference in risk factor levels diminished with increasing age. Differences in risk factors between sexes, particularly in HDL cholesterol and smoking, explained nearly half of the difference in CHD risk between men and women. Differences in serum total cholesterol level, blood pressure, body mass index, and diabetes prevalence explained about one-third of the age-related increase in CHD risk among men and 50% to 60% among women. CONCLUSIONS Differences in major cardiovascular risk factors explained a substantial part of the sex difference in CHD risk. An increase in risk factor levels was associated with the age-related increase in CHD incidence and mortality in both sexes but to a larger extent in women.

Urinary sodium excretion and cardiovascular mortality in Finland: a prospective study

BACKGROUND The evidence that high salt intake increases the risk of cardiovascular disease has been challenged. We aimed to find out whether salt intake, measured by 24 h urinary sodium excretion, is an independent risk factor for cardiovascular disease frequency and mortality, and all-cause mortality. METHODS We prospectively followed 1173 Finnish men and 1263 women aged 25-64 years with complete data on 24 h urinary sodium excretion and cardiovascular risk factors. The endpoints were an incident coronary and stroke event, and death from coronary heart disease, cardiovascular disease, and any cause. Each endpoint was analysed separately with the Cox proportional hazards model. FINDINGS The hazards ratios for coronary heart disease, cardiovascular disease, and all-cause mortality, associated with a 100 mmol increase in 24 h urinary sodium excretion, were 1.51 (95% CI 1.14-2.00), 1.45 (1.14-1.84), and 1.26 (1.06-1.50), respectively, in both men and women. The frequency of acute coronary events, but not acute stroke events, rose significantly with increasing sodium excretion. When analyses were done separately for each sex, the risk ratios were significant in men only. There was a significant interaction between sodium excretion and body mass index for cardiovascular and total mortality; sodium predicted mortality in men who were overweight. Correction for the regression dilution bias increased the hazards ratios markedly. INTERPRETATION High sodium intake predicted mortality and risk of coronary heart disease, independent of other cardiovascular risk factors, including blood pressure. These results provide direct evidence of the harmful effects of high salt intake in the adult population.

Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland.

Abstract Objectives: To estimate the extent to which changes in the main coronary risk factors (serum cholesterol concentration, blood pressure, and smoking) explain the decline in mortality from ischaemic heart disease and to evaluate the relative importance of change in each of these risk factors. Design: Predicted changes in ischaemic heart disease mortality were calculated by a ligistic regression model using the risk factor levels assessed by cross sectional population surveys, in 1972, 1977, 1982, 1987, and 1992. These predicted changes were compared with observed changes in mortality statistics. Setting: North Karelia and Kuopio provinces, Finland. Subjects: 14 257 men and 14 786 women aged 30–59 randomly selected from the national population register. Main outcome measures: Levels of the risk factors and predicted and observed changes in mortality from ischaemic heart disease. Results — The observed changes in the risk factors in the population from 1972 to 1992 predicted a decline in mortality from ischaemic heart disease of 44% (95% confidence interval 37% to 50%) in men and 49% (37% to 59%) in women. The observed decline was 55% (51% to 58%) and 68% (61 to 74) respectively. Conclusion: An assessment of the data on the risk factors for ischaemic heart disease and mortality suggests that most of the decline in mortality from ischaemic heart disease can be explained by changes in the three main coronary risk factors.

Body Weight, Cardiovascular Risk Factors, and Coronary Mortality 15-Year Follow-up of Middle-aged Men and Women in Eastern Finland

BACKGROUND Body weight is closely related to several known cardiovascular risk factors, but it may also have an independent effect on the risk of coronary heart disease (CHD). In this study, we analyzed the association between body mass index (BMI) and smoking, serum cholesterol, and blood pressure at baseline, as well as how BMI and the other risk factors are related to CHD mortality. METHODS AND RESULTS A total of 16 113 men and women aged 30 to 59 years were examined in eastern Finland in either 1972 or 1977. Serum cholesterol and blood pressure had a positive association and smoking had a negative association with BMI. During the 15-year prospective follow-up, mortality from CHD was positively associated with BMI. The BMI-associated risk ratio of CHD mortality, adjusted for age and study year, estimated from the Cox proportional hazards model was 1.04 (per kg/m2) (P < .001) among men. Inclusion of smoking in the model increased the risk ratio for BMI, whereas inclusion of serum cholesterol and blood pressure decreased it. In the model that included age, study year, and all three major cardiovascular risk factors, the BMI-associated risk ratio was 1.03 (P = .027). Among women, the BMI-associated risk ratio of CHD mortality adjusted for age and study year was 1.05 (P = .023) and the multifactorial adjusted risk ratio was 1.03 (P = .151). CONCLUSIONS Obesity is an independent risk factor for CHD mortality among men and also contributes to the risk of CHD among women. Part of the BMI-associated risk of CHD mortality is mediated through other known cardiovascular risk factors. By preventing overweight, a substantial part of CHD mortality may be prevented.

Relationship of Physical Activity and Body Mass Index to the Risk of Hypertension: A Prospective Study in Finland

Abstract—Prospective studies on physical activity in relation to the risk for hypertension are scant, particularly in women. This study aimed at finding out whether regular physical activity can reduce the risk of hypertension in both men and women, and in subjects with and without overweight. We prospectively followed 8302 Finnish men and 9139 women aged 25 to 64 years without a history of antihypertensive drug use, coronary heart disease, stroke, and heart failure at baseline. Both single and joint associations of physical activity and body mass index with the risk of hypertension were examined using Cox proportional hazard models. During a mean followup of 11 years, there were 1600 incident cases of drug-treated hypertension. Multivariate-adjusted hazards ratios of hypertension associated with light, moderate, and high physical activity were 1.00, 0.63, and 0.59 in men (Ptrend<0.001), and 1.00, 0.82, and 0.71 in women (Ptrend=0.005), respectively. This association persisted both in subjects who were overweight and in those who were not. Multivariate-adjusted hazards ratios of hypertension based at different levels of body mass index (<25, 25 to 29.9, and ≥30) were 1.00, 1.18, and 1.66 for men (Ptrend<0.001), and 1.00, 1.24, and 1.32 for women (Ptrend=0.007), respectively. Further adjustment for baseline systolic blood pressure did not affect the protective effect associated with physical activity, but it weakened markedly the association between body mass index and hypertension. The present study indicates that regular physical activity and weight control can reduce the risk of hypertension. The protective effect of physical activity was observed in both sexes regardless of the level of obesity.

Diabetes Mellitus as a Risk Factor for Death From Stroke: Prospective Study of the Middle-aged Finnish Population

BACKGROUND AND PURPOSE High blood pressure is the most important risk factor for stroke. It is also known that diabetic patients are at increased risk of both hypertension and stroke. The aim of this study was to assess the independent effect of diabetes as a risk factor for stroke. Results from the previous studies of this question have been somewhat inconclusive. METHODS We performed a prospective study (average follow-up, 16.4 years) of 8077 men and 8572 women who had participated in risk factor surveys in Eastern Finland in 1972 (20 years of follow-up) and 1977 (15 years of follow-up). Risk factors included in the current analyses were smoking, blood pressure, antihypertensive drug treatment, serum total cholesterol, and diabetes either at baseline or developed during the follow-up. Age- and risk factor-adjusted relative risks for death of stroke were determined with the Cox proportional hazards model. RESULTS Diabetes mellitus was the strongest risk factor for death from stroke among both men and women in univariate and multivariate analyses. In addition, smoking and systolic blood pressure appeared to be independent risk factors among both sexes, as did serum total cholesterol among men. Men with diabetes at baseline appeared to be at a sixfold increased risk of death from stroke, while relative risk for men who developed diabetes during the follow-up was 1.7. In women, those who were diabetic at baseline were at higher risk of stroke than women who developed diabetes later (relative risks, 8.2 and 3.7, respectively). Of stroke deaths, 16% in men and 33% in women were attributed to diabetes. CONCLUSIONS Diabetic subjects have a very high risk of death from stroke, particularly women. Our data also suggest that the duration of diabetes is an important factor contributing to the risk of stroke.

The effects of physical activity and body mass index on cardiovascular, cancer and all-cause mortality among 47 212 middle-aged Finnish men and women.

OBJECTIVE:To examine the association of physical activity and body mass index (BMI), and their combined effect, with the risk of total, cardiovascular disease (CVD) and cancer mortality.DESIGN:Prospective follow-up study.SUBJECTS:In all, 22 528 men and 24 684 women aged 25–64 y at baseline having 7394 deaths during a mean follow-up of 17.7 y.MEASUREMENT:A self-administered questionnaire data on smoking, socioeconomic factors, physical activity and medical history, together with measured height, weight, blood pressure and serum cholesterol using standardized protocol.RESULT:Physically active subjects had significantly lower age-adjusted mortality from cardiovascular, cancer and all causes compared with sedentary ones. Further adjustment for smoking, systolic blood pressure, cholesterol, BMI, diabetes and education affected the results only slightly. Obese subjects (BMI≥30 kg/m2) had significantly higher cardiovascular and total mortality than the normal weight (18.5≤BMI<25 kg/m2) subjects. Part of increased mortality among obese subjects was mediated through obesity-related cardiovascular risk factors. BMI had an inverse association with cancer mortality among men and almost significant direct association among women. Total mortality was also increased among the lean (BMI<18.5 kg/m2) subjects. However, less than 0.3% of deaths were attributed to low body weight, whereas in men 5.5% and in women 17.7% of deaths were attributed to obesity.CONCLUSION:Regular physical activity and normal weight are both important indicators for a decreased risk of mortality from all causes, CVD and cancer. Physical activity had a strong independent effect on mortality, whereas the effect of BMI was partly mediated through other obesity-related risk factors.

Symptoms of chronic bronchitis and the risk of coronary disease

BACKGROUND Experimental and epidemiological studies show a positive association between coronary disease and various infections in different organs, both viral and bacterial and both acute and chronic. Most attention has been paid to dental infections and infections in the respiratory tract. We have studied how chronic respiratory infection predicts coronary disease. METHODS We defined chronic respiratory infection by the occurrence of symptoms of chronic bronchitis. We also analysed whether any association with coronary disease incidence and mortality is independent of the known major cardiovascular risk factors and whether it is similar among persons in different occupations. Our cohort study was a 13-year follow-up of 19,444 randomly selected eastern Finnish men and women born between 1913 and 1947 and examined in either 1972 or 1977. FINDINGS During follow-up, there were 1419 first coronary events, either fatal or non-fatal, and 614 coronary deaths. Among men, the age-adjusted and study-year-adjusted risk ratio of long lasting-symptoms of chronic bronchitis (during as much as 3 months in a year) was 1.52 (95% CI 1.33-1.75) for coronary disease and 1.74 (CI 1.43-2.11) for coronary death. Among women the risk ratios were 1.38 (1.07-1.78) and 1.49 (0.98-2.27), respectively. Inclusion of smoking, serum cholesterol, and systolic blood pressure into the models decreased risk ratios to 1.36 (1.17-1.56) and 1.55 (1.26-1.90) in men and to 1.34 (1.04-1.74) and 1.41 (0.92-2.16) in women, respectively. The risk of coronary disease associated with the symptoms of chronic bronchitis was similar among blue-collar and white-collar workers but the association was not found among farmers. INTERPRETATION Symptoms of chronic bronchitis predicted the risk of coronary disease independently from the known major cardiovascular risk factors. If the observed association is causal, prevention and improved management of chronic infections may have played a role in the decrease in coronary disease mortality observed in eastern Finland in the past two decades.

Leisure Time, Occupational, and Commuting Physical Activity and the Risk of Stroke

Background and Purpose— The role of physical activity, especially that of occupational and commuting physical activity, in the prediction of stroke risk is not properly established. We assessed the relationship of different types of physical activity with total and type-specific stroke risk. Methods— We prospectively followed 47 721 Finnish subjects 25 to 64 years of age without a history of coronary heart disease, stroke, or cancer at baseline. Hazard ratios (HRs) for incident stroke were estimated for different levels of leisure time, occupational, and commuting physical activity. Results— During a mean follow-up of 19.0 years, 2863 incident stroke events were ascertained. The multivariate-adjusted (age, sex, area, study year, body mass index, systolic blood pressure, cholesterol, education, smoking, alcohol consumption, diabetes, and other 2 types of physical activity) HRs associated with low, moderate, and high leisure time physical activity were 1.00, 0.86, and 0.74 (Ptrend<0.001) for total stroke, 1.00, 0.87, and 0.46 (Ptrend=0.011) for subarachnoid hemorrhage, 1.00, 0.77, and 0.63 (Ptrend=0.024) for intracerebral hemorrhage, and 1.00, 0.87, and 0.80 (Ptrend=0.001) for ischemic stroke, respectively. The multivariate-adjusted HRs associated with none, 1 to 29, and ≥30 minutes of active commuting were 1.00, 0.92, and 0.89 (Ptrend=0.043) for total stroke, and 1.00, 0.93, and 0.86 (Ptrend=0.028) for ischemic stroke, respectively. Occupational activity had a modest association with ischemic stroke in the multivariate analysis (Ptrend=0.046). Conclusion— A high level of leisure time physical activity reduces the risk of all subtypes of stroke. Daily active commuting also reduces the risk of ischemic stroke.