Veikko Kallio

Reduction in sudden deaths by a multifactorial intervention programme after acute myocardial infarction.

375 consecutive patients below 65 years who had an acute myocardial infarction (AMI) took part in a randomised rehabilitation and secondary prevention trial (part of a W.H.O.-coordinated project) designed to study the effects of a multifactorial intervention programme on morbidity, mortality, return to work, &c. After three years follow-up the cumulative coronary mortality was significantly smaller in the intervention group than in the controls (18.6% versus 29.4%, p = 0.02). This difference was mainly due to a reduction of sudden deaths in the intervention group (5.8% versus 14.4%, p less than 0.01). The reduction was greatest during the first six months after AMI. 18.1% in the intervention group and 11.2% in the controls (p less than 0.10) presented with non-fatal reinfarctions. The number of patients with new Q-QS findings at the end of the three years was, however, almost the same in both groups. The results suggest that organised aftercare during the first six months after AMI with special emphasis on optimum medical control and health education contributes significantly to a reduction in the number of sudden deaths.

Atherosclerotic Vascular Disease and Its Risk Factors in Non-Insulin-Dependent Diabetic and Nondiabetic Subjects in Finland

A cross-sectional study on the prevalence of atherosclerotic vascular disease (ASVD) and its risk factors in non-insulin-dependent diabetic and nondiabetic subjects was carried out from 1982 to 1984 in East Finland (Kuopio)and West Finland (Turku), two areas known to differ markedly in prevalence ofASVD in the nondiabetic population. A total of 510 diabetic and 649 nondiabetic subjects aged 45–64 yr were examined in East Finland and 549 diabetic and 724 nondiabetic subjects of the same age in West Finland. In both areas and in both sexes the prevalence of coronary heart disease (CHD), stroke, and intermittent claudication was higher in diabetic than in nondiabetic subjects. Both in diabetic and nondiabetic subjects the prevalence of ASVD was higher in East Finland than in West Finlandase (CHD), stroke, and intermittent claudication was higher in diabetic than in nondiabetic subjects. Both in diabetic and nondiabetic subjects the prevalence of ASVD was higher in East Finland than in West Finland. In men, the East-West difference in the prevalence of symptomatic CHD and claudication was greater in diabetic than in nondiabetic subjects. In both areas and in both sexes the serum lipid pattern was more atherogenic and hypertension was more frequent in diabetic than in nondiabetic subjects. In both diabetic and nondiabetic subjects, serum total-cholesterol level was somewhat higher and hypertension was more frequent in East Finland than in West Finland. The East-West difference in serum total-cholesterol was greater in diabetic than in nondiabetic subjects. In multiple logistic analyses including cardiovascular risk factors, diabetes status, and area of residence, residence in East Finland was found to be, in addition to diabetes, a strong independent factor associated with CHD, particularly in men.

High fasting plasma insulin is an indicator of coronary heart disease in non-insulin-dependent diabetic patients and nondiabetic subjects.

The association between fasting plasma insulin level and coronary heart disease (CHD) was studied in 909 non-insulin-dependent diabetic (NIDDM) patients, aged 45-64 years, and in 1,373 nondiabetic control subjects. Both diabetic and nondiabetic subjects with various manifestations of CHD had higher plasma insulin levels than did subjects free of CHD. By plasma insulin quintiles formed according to values in nondiabetic subjects, the age-adjusted prevalence of CHD defined by symptoms and/or electrocardiographic changes in diabetic men was 48.2% in quintiles I + II (lowest), 54.8% in quintiles III + IV, and 65.7% in quintile V (highest) (p = 0.006). The respective prevalences in diabetic women were 53.5%, 59.1%, and 73.3% (p = 0.004); in nondiabetic men, 28.1%, 33.7%, and 43.3%, respectively (p = 0.016); and in nondiabetic women, 28.1%, 34.9%, and 44.3%, respectively (p = 0.007). An essentially similar association was observed between plasma insulin level and definite or possible myocardial infarction (MI). In diabetic subjects, a positive association between plasma insulin level and CHD manifestations was also found when insulin strata were formed using quintile cutoff points determined separately from diabetic subjects. The association between plasma insulin level and the prevalence of CHD or MI disappeared or was weaker, especially in men, when adjustment was made for body mass index, hypertension, and triglyceride or high density lipoprotein (HDL) cholesterol level. The association between high plasma insulin level and CHD was significant in diabetic subjects with a body mass index greater than 27 kg/m2 but not in those diabetics with a body mass index less than or equal to 27 kg/m2. A significant clustering of hypertension, high triglyceride values, and low HDL cholesterol levels was observed in diabetic subjects in the highest insulin quintiles. The results suggest that hyperinsulinemia is an indicator of CHD in both NIDDM patients and nondiabetic subjects. Hyperinsulinemia may be directly atherogenic, but it is more probable that hyperinsulinemia reflects insulin resistance, which may be a factor enhancing atherogenesis by causing adverse changes in many CHD risk factors.

Does NIDDM increase the risk for coronary heart disease similarly in both low- and high-risk populations?

SummaryFinland has marked regional differences in the occurrence of coronary heart disease (CHD). Although the causes for these differences in CHD mortality and morbidity in the Finnish population are unknown, it offers an excellent opportunity to investigate the effects of non-insulin-dependent diabetes mellitus (NIDDM) on CHD risk in two populations differing significantly with respect to the occurrence of CHD. Therefore, we carried out a 7-year prospective population-based study including a large number of patients with NIDDM (East Finland: 253 men and 257 women; West Finland: 328 men, 221 women) and corresponding non-diabetic subjects (East Finland: 313 men, 336 women; West Finland: 325 men, 399 women). In both study populations the presence of NIDDM increased significantly the risk for CHD events (CHD mortality or all CHD events including CHD mortality or non-fatal myocardial infarction). Diabetic men had 3–4 fold higher and diabetic women 8–11-fold higher risk for CHD than corresponding non-diabetic subjects. Both non-diabetic and diabetic subjects had odds ratios (East vs West) for CHD events of about 2 indicating a similar East-West difference in the CHD risk. Regional difference was quite similar in men and women. These results imply that factors related to NIDDM, independently of conventional risk factors and the occurrence of atherothrombosis in the background population, must play a major role in the pathogenesis of atherosclerotic vascular disease in NIDDM diabetes.

Rehabilitation after surgery for lumbar disc herniation: results of a randomized clinical trial.

The aim of this prospective study was to examine the one-year postoperative results in patients operated on for lumbar disc herniation randomized in two groups: one with comprehensive rehabilitation and the other taken care of by normal care facilities. A total of 212 patients without any previous spinal operations comprised the final study group. The physiatrist, the surgeon, the social worker, and the psychologist performed the handicap evaluation according to the occupation handicap scales of the WHO. The handicap was evaluated for two phases: before the onset of acute sciatica leading to operation and one year after operation. No significant differences in handicap distribution between the intervention and normal care groups were seen. The postoperative handicap correlated highly significantly with preoperative handicap for both groups. More than half (57%) of all the patients returned to work within two months of the operation. The amount of sick leaves did not differ significantly between the intervention and normal care groups. A total of 15 persons (7%) retired during the postoperative year.

Social support and physical and psychological recovery one year after myocardial infarction or coronary artery bypass surgery

The aim of this study was to evaluate the role of different support factors supposed to explain physical and psychological recovery after myocardial infarction (MI) or coronary artery bypass surgery (CABS). The subjects comprised 147 MI patients and 159 CABS patients. Support factors included formal services, semi-formal assistance, and informal social support. The outcome measures used for analysis were functional activities level (Duke Activity Status Index, DASI), physical working capacity, anxiety, and depression one year after MI or CABS. In general, support factors had a limited role in this study. The patients functional and psychological status at three months was the main determinant to recovery at one year. The outcome factors measured at three months explained 36-56% of their variance at one year, and the support factors increased the explanatory power by 0 -10%. The support model employed in this study revealed that some single factors may have a positive or negative role in the recovery after MI or CABS.

Cardiac rehabilitation and return to work after coronary artery bypass surgery

The work situation of 66 male patients who underwent elective coronary artery bypass surgery (CABS) and who had been randomly allocated to receive cardiac rehabilitation (group R) was compared with the work situation of 59 similar patients allocated to receive only standard care (group H). The follow-up time was one year. The proportions of subjects working in groups R and H were 26% and 20% (p=ns) before the CABS, 45% and 34% (p=ns) 6 months and 56% and 38% (p=ns) 12 months after the CABS, repectively. The increase in proportion of subjects who worked was significant in both groups at both 6 and 12 months after the CABS (p<0.05 for all changes). The increases were not significantly different between the whole groups, but in patients younger than 55 years of age, return to work was more frequent in group R than in group H (at 12 months 60% vs. 35%, p for the difference in change=0.02). Stepwise logistic regression analysis of the factors influencing return to work showed that a patients judgement of his own working capacity as good 6 months after CABS (odds ratio (OR) 8.5, confidence interval (CI) 2.3–32.0), functional class 16 months after the CABS (OR 6.7, CI 1.8–24.5), his desire to work (OR 6.4, CI 1.6–26.0) and absence from work of less than 3 months before the CABS (OR 4.9, CI 1.2–20.2) were significant positive predictors of return to work 1 year after the CABS.

Atherosclerotic vascular disease in middle-aged, insulin-treated, diabetic patients. Association with endogenous insulin secretion capacity.

The prevalence of atherosclerotic vascular disease (ASVD) and Its risk factors were Investigated In 263 Insulin-treated diabetic patients, ages 45 to 64 years, who were older than 30 years when their diabetes was diagnosed. The patients were divided Into two groups based on the degree of endogenous Insulin secretion capacity: Group A: glucagon-stlmulated plasma C-peptlde <0.20 nmol/1 and Group B: C-peptlde >0.20 nmol/l. The age-adjusted prevalence of definite myocardlal Infarction was significantly higher In Group B than In Group A (16.8% vs. 5.2%, p<0.01). A similar difference between Groups A and B was found for definite or possible coronary heart disease(54.6% vs. 32.9%, p < 0.001) and stroke (9.3% vs. 2.0%, p<0.05). In multlvarlate analysis, high glucagon-stlmulated plasma C-peptlde level (a 0.20 nmol/1) was positively associated with definite or possible coronary heart disease Independently of other cardiovascular risk factors. Our results Indicate that among Insulin-treated patients with a late onset of diabetes, the prevalence of ASVD Is markedly higher In those with persistent endogenous Insulin secretion (nonlnsultn-dependent diabetes) than In those with low or no Insulin secretion (Insulin-dependent diabetes).

A Prospective Study of Patients with Sciatica: A Comparison Between Conservatively Treated Patients and Patients Who Have Undergone Operation, Part II: Results After One Year Follow-Up

The prospective study included 122 sciatica patients who had not undergone operation (NOPs) and 220 sciatica patients who had undergone operation (OPs); all had been examined by rhizography. The follow-up study was done on 110 (90%) of the NOPs and 212 (96%) of the OPs. The NOPs were divided into two groups: 30 patients with pathologic rhizography (PR) and 80 patients with negative rhizography (NR). Pain-, ADL-, and occupation-handicap indices showed that after the 1 year follow-up the OP group had the best result and the NR group the lowest result. The PR group had nearly as good a result as the OP group. Thus, sciatica patients are candidates for conservative therapy, even though they have pathologic findings in rhizography, if the symptoms are mild. To improve therapeutic outcome, more accurate diagnostic tools are needed to develop specific therapy especially for those sciatica patients with negative rhizography.

Clinical, social, and psychological factors and outcome in a 5-year follow-up study of 276 patients hospitalized because of suspected lumbar disc herniation

The study consisted of 276 patients who were hospitalized between 1980 and 1982 because of suspected lumbar disc herniation. No randomization of treatment was used. On the basis of clinical indications 179 patients were operated on and 97 had further conservative treatment. Results of physical, social, and psychological examinations performed after 1 year were related to the 5-year outcome defined by occupation handicap of the WHO system. For operated patients, subjective working incapacity, sensory deficit of leg, tightness of hamstrings, age, and pain in lumbar extension predicted a poor outcome. Predictive factors for non-operated patients were increased occurrence of occupational hazards and co-morbidity.