In a prospective study of risk factors for ischaemic heart disease 792 54 year old men selected by year of birth (1913) and residence in Gothenburg agreed to attend for questioning and a battery of anthropometric and other measurements in 1967. Thirteen years later these baseline findings were reviewed in relation to the numbers of men who had subsequently suffered a stroke, ischaemic heart disease, or death from all causes. Neither quintiles nor deciles of initial indices of obesity (body mass index, sum of three skinfold thickness measurements, waist or hip circumference) showed a significant correlation with any of the three end points studied. Statistically significant associations were, however, found between the waist to hip circumference ratio and the occurrence of stroke (p = 0.002) and ischaemic heart disease (p = 0.04). When the confounding effect of body mass index or the sum of three skinfold thicknesses was accounted for the waist to hip circumference ratio was significantly associated with all three end points. This ratio, however, was not an independent long term predictor of these end points when smoking, systolic blood pressure, and serum cholesterol concentration were taken into account. These results indicate that in middle aged men the distribution of fat deposits may be a better predictor of cardiovascular disease and death than the degree of adiposity.
High alcohol consumption is one of the major risk indicators for premature death in middle-aged men. An indicator of alcohol abuse--registration with the social authorities for alcoholic problems--was used to evaluate the role of alcohol in relation to general and cause-specific mortality in a general population sample. Altogether 1,116 men (11%) out of a total population of 10,004 men were registered for alcoholic problems. Total mortality during 11.8 years' follow-up was 10.4% among the non-registered men, compared to 20.5% among men with occasional convictions for drunkenness and 29.6% among heavy abusers. Fatal cancer as a whole was not independently associated with alcohol abuse, but oropharyngeal and oesophageal cancers together were seven times more common in the alcohol-registered groups. Total coronary heart disease (CHD) was significantly and independently associated with alcohol abuse, but nearly all the excess CHD mortality among the alcohol-registered men could be attributed to sudden coronary death. Cases with definite recent myocardial infarction were not more common in the alcoholic population. A combined effect of coronary arteriosclerosis and heart muscle damage secondary to alcohol abuse is suggested. Other causes of death strongly associated with registration for alcohol abuse include pulmonary embolism, pneumonia and peptic ulcer, as well as death from liver cirrhosis and alcoholism. Of the excess mortality among alcohol-registered subjects, 20.1% could be attributed to CHD, 18.1% to violent death, 13.6% to alcoholism without another diagnosis and 11.1% to liver cirrhosis.
The consequences of alcoholic intemperance and economic problems on CHD mortality and morbidity were studied among the participants in a large primary preventive trial. Official register data were used. Subjects registered with the Board of Social Welfare were categorised with respect to increasing load of alcoholic intemperance. Non-fatal CHD was not related to alcoholic problems. Fatal CHD, on the other hand, was strongly associated with registration for intemperance. This was especially pronounced for cases dying suddenly from CHD. A multivariate analysis was performed, controlling for smoking, systolic blood pressure and serum cholesterol, which showed that the association between intemperance and fatal CHD was independent of these factors.
During 1975-1977 twenty-nine males surviving acute myocardial infarction at an age between 40-44 years were registered in Gothenburg, Sweden. Twenty-five of these were studied and compared with two control groups. One group, the reference group (RG, n = 76), was randomly selected from the male population from which the acute myocardial infarction (AMI) group was derived. A second group, the matched control group (MC, n = 47), consisted of men with no history of coronary heart disease, matched with patients for age, serum cholesterol and body weight index. Serum triglyceride levels were higher and alphalipoprotein cholesterol lower in the AMI group than in RG. Prior to infarction, patients had a higher degree of physical activity at work and a higher tobacco consumption than RG. When AMI cases were compared with MC subjects lower alphalipoprotein cholesterol levels were found in AMI, and they also had a higher tobacco consumption prior to infarction. There was a negative correlation between alphalipoprotein cholesterol levels and tobacco consumption in the RG. The differences in alphalipoprotein cholesterol levels between AMI cases and controls could not attributed to smoking habits, but smoking may at least to some extent exert its effect as a risk factor through influence on alphalipoprotein cholesterol levels.
Angina pectoris was studied in a representative series of male patients (n = 504) with a first myocardial infarction (MI) surviving the hospital stay. The prevalence of questionnaire angina before MI was 28% and of effort-induced chest pain alone 40%. Of the patients with effort-induced chest pain, 72% retained symptoms also after MI. No correlation with age was found. Three months after and one year after infarction the prevalence of effort-induced chest pain was 55% and 45%, respectively. The patients with effort-induced chest pain before MI had a somewhat more severe clinical course and a significantly higher death rate (15% versus 6%) than those without chest pain.
Angina pectoris, intermittent claudication and congestive heart failure in middle-aged male hypertensives. Development and predictive factors during long-term antihypertensive care. The Primary Preventive Trial, Göteborg, Sweden.
A group of middle-aged male hypertensives, derived from a random sample of a Swedish urban population, has been treated and followed for 10 years. The development of angina pectoris, intermittent claudication and congestive heart failure have been analysed. The initial prevalence and the average yearly incidence of angina pectoris was 3.9% and 1.3% p.a., of intermittent claudication 1.7% and 0.6% p.a. and of heart failure 1.0% and 0.8% p.a. ECG signs indicating subclinical heart disease (major Q wave, ST depression, T wave inversion) were risk factors for development of angina pectoris and congestive heart failure. Heart enlargement on chest X-ray was also a risk factor for development of congestive heart failure, as were a high serum creatinine, body mass index, serum uric acid and proteinuria. Smoking was found to be a strong and independent risk factor for any one of these cardiovascular disorders. After 10 years about one fourth of all patients, still attending the clinic, had at least one cardiovascular complication. Hence, the risk of developing cardiovascular disorders is substantial and seems to be potentiated by the same risk factors known to operate in the general population.
During recent decades we have seen an encouraging development of trial methodology. Less effort, however, has been devoted to the application of findings of trials to the practice of medicine. We cannot expect results of controlled trials alone to determine standard therapy, for clinical judgements are also required. Both beneficial and adverse effects are often only detectable on the group level. There are generally very few indications that drug effects differ qualitatively in subgroups of patients. It is important not only to prove or disprove effects, but also to find out how to implement a proper therapy for a majority of eligible patients. Four examples from treatment after myocardial infraction show that drug usage may not always be based upon results of clinical trials. The adoption of Swedish guidelines for thrombolytic therapy in acute myocardial infarction is taken as an example of an apparently optimal application of trial results in practice.
OBJECTIVE: Growth hormone deficiency (GHD) in adults has been associated with impaired health status and quality of life (QoL) in several studies using generic measures, and in a few studies using recently developed disease-specific measures. Theoretically, disease-specific measures may be more sensitive and succinct than generic measures, and hence prove convenient for general use in clinical practice. The present study sought to validate the scaling properties of the disease-specific QoL-AGHDA measure through the implementation of Rasch analysis. The study also sought to compare, by using the QoL-AGHDA, the QoL of a relatively large Swedish cohort of adults with untreated GHD with that of a reference population also from Sweden. PATIENTS: The QoL of 111 adults with untreated GHD from Stockholm and Göteborg was compared with that of 1448 adult subjects randomly selected from the population of Göteborg. MEASUREMENTS: The scaling properties of the QoL-AGHDA were assessed by investigating its fit to a dichotomous Rasch model. Rasch-transformed QoL scores from the QoL-AGHDA questionnaire were stratified by age and gender, and 95% confidence intervals were calculated. RESULTS: Rasch analysis of the QoL-AGHDA indicated the measure to be robust in terms of its unidimensionality and ordering properties, and lack of differential item functioning. The raw scores produced by the QoL-AGHDA are at the ordinal level. Non-overlapping 95% confidence intervals of Rasch-transformed interval scores in most age categories indicated that men and women with GHD had significantly lower QoL than the reference population. CONCLUSION: The Swedish QoL-AGHDA has good scaling properties, and hence can be considered a robust measure. It is suitable for assessing quality of life in adults with GH deficiency, and for making comparisons with adults who are not growth hormone deficient. Adult GH deficiency is associated with a significant impairment in QoL.
Comment On: Clin Endocrinol (Oxf). 2000 Feb;52(2):141-210671939