Clinical importance of risk factors and exercise testing for prediction of significant coronary artery stenosis in women recovering from unstable coronary artery disease: the Stockholm Female Coronary Risk Study.
BACKGROUND: The objectives of this study were to investigate the relation between coronary risk factors, exercise testing parameters, and the presence of angiographically significant coronary artery disease (CAD) (> or =50% luminal stenosis) in female patients previously hospitalized for an acute CAD event. METHODS AND RESULTS: All women younger than age 66 years in the greater Stockholm area in Sweden who were hospitalized for acute coronary syndromes during a 3-year period were recruited. Besides collection of clinical parameters, coronary angiography and a symptom-limited exercise test were performed in 228 patients 3 to 6 months after the index hospitalization. The mean age was 56 +/- 7 years. Angiographically nonsignificant CAD (stenosis 0.85 (OR 1.78, 95% CI 1.02 to 3. 10). A low exercise capacity and associated low change of rate-pressure product from rest to peak exercise were the only exercise testing parameters that were significantly related to angiographically verified significant CAD (
AIMS: Several studies have reported that women with coronary heart disease have a poorer prognosis than men. Psychosocial factors, including social isolation and depressive symptoms have been suggested as a possible cause. However, little is known about these factors and their independent predictive value in women. Therefore, we investigated the prognostic impact of depression, lack of social integration and their interaction in the Stockholm Female Coronary Risk Study. METHODS AND RESULTS: Two hundred and ninety-two women patients aged 30 to 65 years and admitted for an acute coronary event between 1991 and 1994, were followed for 5 years from baseline assessments, which were performed between 3 and 6 months after admission. Lack of social integration and depressive symptoms, assessed at baseline by standardized questionnaires, were associated with recurrent events, including cardiovascular mortality, acute myocardial infarction and revascularization procedures (percutaneous transluminal coronary angioplasty and coronary artery bypass grafting). Adjusting for age, diagnosis at index event, symptoms of heart failure, diabetes mellitus, high density lipoprotein (HDL) cholesterol, history of hypertension, systolic blood pressure, smoking, sedentary lifestyle, body mass index, and severity of angina pectoris symptoms, the hazard ratio associated with low (lowest quartile) as compared to high social integration (upper quartile) was 2.3 (95% CI 1.2-4.5) and the hazard ratio associated with two or more (upper three quartiles) as compared to one or no depressive symptoms was 1.9 (95% CI 1.02-3.6). CONCLUSIONS: The presence of two or more depressive symptoms and lack of social integration independently predicted recurrent cardiac events in women with coronary heart disease. Women who were free of both these risk factors, had the best prognosis.
Comment In: Eur Heart J. 2000 Jul;21(13):1043-510843821
OBJECTIVE: The main objective was to examine the association between the metabolic syndrome and socioeconomic position (as indicated by education) among women. RESEARCH DESIGN AND METHODS: The study sample comprised healthy women (aged 30-65 years) in Sweden who were representative of the general population in a metropolitan area. Socioeconomic position was measured by educational level (mandatory [ or = 7.0 mmol/l; 2) arterial blood pressure > or = 160/90 mmHg; 3) fasting plasma triglycerides > or = 1.7 mmol/l and/or HDL cholesterol 0.85 and/or BMI > 30 kg/m2). RESULTS: After adjustment for age, the risk ratio for the presence of the metabolic syndrome comparing the lowest (
Estrogen replacement protects against cardiovascular morbidity and mortality in postmenopausal women. Conjugated estrogen is the main hormone used in these studies. However, the vascular effects of this type of estrogen are, to a large extent, unexplored. The objective of this study was to evaluate short-term endothelium-dependent vascular effects of intravenously conjugated estrogen at 2 dose levels. Eleven postmenopausal women were included. Each study subject was given 2.5 and 5 mg of conjugated estrogen or placebo in random order with at least 1 week between each investigation in a double-blind study design. The vascular reactivity of the brachial artery was studied using the duplex technique before and 30 minutes after the intravenous administration of study drug. Reactive hyperemia was used to study the flow-mediated vasodilation. Serum estradiol increased significantly and dose dependently 5 minutes after conjugated estrogen infusion. The flow-mediated vasodilation at baseline before drug administration was 1.8 +/- 2.0% (mean +/- SD) after an average 400% increase in local blood flow. Conjugated estrogen at a dose of 2.5 mg caused an increase in flow-mediated vasodilation from 1.8 +/- 2.1% at baseline to 5.4 +/- 2.8% after infusion (p
Recent studies of men have shown that job stress is important in understanding the occupational gradient in coronary heart disease (CHD), but these relationships have rarely been studied in women. With increasing numbers of women in the workforce it is important to have a more complete understanding of how CHD risk may be mediated by job stress as well as other biological and behavioural risk factors. The objective of this study was to examine the occupational gradient in CHD risk in relation to job stress and other traditional risk factors in currently employed women. We used data from the Stockholm Female Coronary Risk Study, a population based case-control study, comprising 292 women with CHD aged 65 years or younger and 292 age-matched healthy women (controls). An inversely graded association was observed between occupational class and CHD risk. Compared with the highest (executive/professional), women in the lowest occupational class (semi/unskilled) had a four-fold (95% CI 1.75-8.83) increased age-adjusted risk for CHD. Simultaneous adjustment for traditional risk factors and job stress attenuated this risk to 2.45 (95% CI 1.01-6.14). Neither job control nor the Karasek demand-control model of job stress substantially explained the increased CHD risk of women in the lowest occupational classes. It is likely that lower occupational class working women face multiple and sometimes interacting sources of work and non-work stress that are mediated by behavioural and biological factors that increase their CHD risk.
STUDY OBJECTIVE: To examine the relationship between socioeconomic status (SES) and full lipid profile in middle aged healthy women. PARTICIPANTS: These comprised 300 healthy Swedish women between 30 and 65 years who constitute the control group of the Stockholm female coronary risk study, a population based, case-control study of women with coronary heart disease (CHD). The age matched control group, drawn from the census register of greater Stockholm, was representative of healthy Swedish women aged 30-65 years. Five measures of SES were used; educational level, occupation, decision latitude at work, annual income, and size of house or apartment. MAIN RESULTS: Swedish women with low decision latitude at work, low income, low educational level, blue collar jobs, and who were living in small houses or apartments had an unhealthy lipid profile, suggesting an increased risk of CHD. Part of this social gradient in lipids was explained by an unhealthy lifestyle, but the lipid gradients associated with decision latitude at work and annual income were independent of these factors. Decision latitude, educational level, and annual income had the strongest associations with lipid profile. These associations were independent of age, menopausal status, smoking, sedentary lifestyle, alcohol consumption, obesity, excess abdominal fat, and unhealthy dietary habits. Of the lipid variables, low high density lipoprotein cholesterol (HDL) levels were most consistently associated with low SES. CONCLUSIONS: Decision latitude at work was the strongest SES predictor of HDL levels in healthy middle aged Swedish women, after simultaneous adjustment for other SES measures, age, and all lifestyle factors in the multivariable regression model.
Erratum In: J Epidemiol Community Health 1998 May;52(3):340
In women as well as in men cardiovascular disease is common, and almost as many women as men suffer from myocardial infarction every year in Sweden. In spite of this, studies on female cardiovascular disease are few in number. Knowledge about differences in risk factors, prevention, treatment and management is not common. Female cardiovascular disease starts approximately ten years later than in men and consequently most women are excluded from studies because of low age limits for inclusion. Primary preventive effects of e.g. acetylsalicylic acid, lipid-lowering drugs, vitamins and exercise have only been studied in healthy men, but the conclusions have been applied on women as well. The effects of reducing triglyceride levels or abdominal obesity in women--important risk factors for cardiovascular disease--have not been studied in controlled randomized studies. In women, angina is a non-specific symptom, and false positive ECG's are much more frequent than in men. The fact that a woman has to present as a man in order to be treated professionally (the Yentl syndrome) is still at hand. There is a great need for spreading current knowledge regarding gender differences among colleagues and medical students.
CONTEXT: Psychosocial stress has been associated with incidence of coronary heart disease (CHD) in men, but the prognostic impact of such stress rarely has been studied in women. OBJECTIVE: To investigate the prognostic impact of psychosocial work stress and marital stress among women with CHD. DESIGN AND SETTING: Population-based, prospective follow-up study conducted in the city of Stockholm, Sweden. PARTICIPANTS: A total of 292 consecutive female patients aged 30 to 65 years (n = 279 working or cohabiting with a male partner) who were hospitalized for acute myocardial infarction or unstable angina pectoris between February 1991 and February 1994. Patients were followed up from the date of clinical examination until August 1997 (median, 4.8 years). MAIN OUTCOME MEASURES: Recurrent coronary events, including cardiac death, acute myocardial infarction, and revascularization procedures, by marital stress (assessed using the Stockholm Marital Stress Scale, a structured interview) and by work stress (assessed using the ratio of work demand to work control). RESULTS: Among women who were married or cohabiting with a male partner (n = 187), marital stress was associated with a 2.9-fold (95% confidence interval [CI], 1.3-6. 5) increased risk of recurrent events after adjustment for age, estrogen status, education level, smoking, diagnosis at index event, diabetes mellitus, systolic blood pressure, smoking, triglyceride level, high-density lipoprotein cholesterol level, and left ventricular dysfunction. Among working women (n = 200), work stress did not significantly predict recurrent coronary events (hazard ratio, 1.6; 95% CI, 0.8-3.3). CONCLUSIONS: Our results indicate that marital stress but not work stress predicts poor prognosis in women aged 30 to 65 years with CHD. These findings differ from previous findings in men and suggest that specific preventive measures be tailored to the needs of women with CHD.
Comment In: JAMA. 2001 Mar 14;285(10):1289-9011255378
Chronic periodontitis (CP) and atherosclerotic and aortic aneurysmal vascular diseases (VD) are inflammatory conditions that share a number of predisposing factors. They have a complex genetic heritability and may share genetic risk factors, but a well-defined relationship is still not determined. In addition, distinct genetic patterns of predisposition have been associated with these diseases. Here, we investigated the association of polymorphisms in the IL-1 gene locus with CP in a case-case study analysing VD patients with or without CP. Seventy-four patients with VD of whom 36 had CP were genotyped for single nucleotide polymorphisms in the IL1A -889 (rs1800587), IL1B +3954 (rs1143634) and IL1B at -511 (rs16944) genes and for VNTR polymorphisms in the IL1RN gene. A significantly higher frequency (17%) for allele 1 (four repeats) of the IL1RN VNTR gene was found among the VD patients with CP compared to those without CP. In addition, the frequency of the IL1RN VNTR genotypes 1/1 (4/4 repeats) and 2/2 (2/2 repeats) were significantly higher and lower, respectively, in VD patients with CP. These findings suggest an association of genetic polymorphisms in the IL1-gene locus with risk for CP in patients with VD. The carriage of the risk genotypes, the development and the subsequent influence of CP on systemic health may constitute an additional burden in the pathogenesis of VD. This emphasizes the importance of effective periodontal treatment in patients with VD.
The effect of increased nurse support on patients below 70 years of age attending an out-patient clinic following acute myocardial infarction was evaluated. Patients who saw a nurse 14 days after discharge (n = 56) were compared to a control group (n = 47) who, following the ordinary routines, were first seen 8 weeks after discharge. Increased nurse support had positive effects on psychosocial variables such as depressive feelings, expected quality of life in the future, and satisfaction with contact with the staff. However, no effects were found on any of the cardiac variables. Patients in the intervention group showed a decrease in depressive feelings during the 8 weeks follow-up period, whereas there was an increase for the control group. The patients in the intervention group also tended to have a better belief in the future compared to the control group. Patients in the intervention group were more satisfied with the staff contact than were the control group.