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      Gender differences in trends of acute myocardial infarction events: The Northern Sweden MONICA study 1985 – 2004

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          Abstract

          Background

          The registration of non-fatal and fatal MI events initiated 1985 in the WHO MONICA project has been ongoing in northern Sweden since the end of the WHO project in 1995. The purpose of the present study was to analyze gender differences in first and recurrent events, case fatality and mortality in myocardial infarction (MI) in Northern Sweden during the 20-year period 1985 – 2004.

          Methods

          Diagnosed MI events in subjects aged 25–64 years in the Counties of Norrbotten and Västerbotten were validated according to the MONICA protocol. The total number of events registered up to January 1, 2005 was 11,763: 9,387 in men and 2,376 in women.

          Results

          The proportion of male/female events has decreased from 5.5:1 to 3:1. For males the reductions were 30% and 70% for first and recurrent MI, respectively, and for women 0% and 40% in the 55–64 year group. For both sexes a 50% reduction in 28-day case fatality was seen in the 25–64 year-group. Mortality was reduced by 69% and 45% in men and women, respectively.

          Conclusion

          First and recurrent events of myocardial infarction was markedly reduced in men over the 20-year observation period, but for women the reduction was seen only for recurrent infarctions. Case fatality, on the other hand, was markedly reduced for both sexes. As a result of the positive effects on incidence and case fatality a substantial reduction was seen in total mortality, most pronounced for men.

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          Most cited references32

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          Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA project populations. Monitoring trends and determinants in cardiovascular disease.

          The WHO MONICA (monitoring trends and determinants in cardiovascular disease) Project monitored, from the early 1980s, trends over 10 years in coronary heart disease (CHD) across 37 populations in 21 countries. We aimed to validate trends in mortality, partitioning responsibility between changing coronary-event rates and changing survival. Registers identified non-fatal definite myocardial infarction and definite, possible, or unclassifiable coronary deaths in men and women aged 35-64 years, followed up for 28 days in or out of hospital. We calculated rates from population denominators to estimate trends in age-standardised rates and case fatality (percentage of 28-day fatalities=[100-survival percentage]). During 371 population-years, 166,000 events were registered. Official CHD mortality rates, based on death certification, fell (annual changes: men -4.0% [range -10.8 to 3.2]; women -4.0% [-12.7 to 3.0]). By MONICA criteria, CHD mortality rates were higher, but fell less (-2.7% [-8.0 to 4.2] and -2.1% [-8.5 to 4.1]). Changes in non-fatal rates were smaller (-2.1%, [-6.9 to 2.8] and -0.8% [-9.8 to 6.8]). MONICA coronary-event rates (fatal and non-fatal combined) fell more (-2.1% [-6.5 to 2.8] and -1.4% [-6.7 to 2.8]) than case fatality (-0.6% [-4.2 to 3.1] and -0.8% [-4.8 to 2.9]). Contribution to changing CHD mortality varied, but in populations in which mortality decreased, coronary-event rates contributed two thirds and case fatality one third. Over the decade studied, the 37 populations in the WHO MONICA Project showed substantial contributions from changes in survival, but the major determinant of decline in CHD mortality is whatever drives changing coronary-event rates.
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            Estimation of contribution of changes in classic risk factors to trends in coronary-event rates across the WHO MONICA Project populations.

            From the mid-1980s to mid-1990s, the WHO MONICA Project monitored coronary events and classic risk factors for coronary heart disease (CHD) in 38 populations from 21 countries. We assessed the extent to which changes in these risk factors explain the variation in the trends in coronary-event rates across the populations. In men and women aged 35-64 years, non-fatal myocardial infarction and coronary deaths were registered continuously to assess trends in rates of coronary events. We carried out population surveys to estimate trends in risk factors. Trends in event rates were regressed on trends in risk score and in individual risk factors. Smoking rates decreased in most male populations but trends were mixed in women; mean blood pressures and cholesterol concentrations decreased, bodymass index increased, and overall risk scores and coronary-event rates decreased. The model of trends in 10-year coronary-event rates against risk scores and single risk factors showed a poor fit, but this was improved with a 4-year time lag for coronary events. The explanatory power of the analyses was limited by imprecision of the estimates and homogeneity of trends in the study populations. Changes in the classic risk factors seem to partly explain the variation in population trends in CHD. Residual variance is attributable to difficulties in measurement and analysis, including time lag, and to factors that were not included, such as medical interventions. The results support prevention policies based on the classic risk factors but suggest potential for prevention beyond these.
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              Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations.

              The revolution in coronary care in the mid-1980s to mid-1990s corresponded with monitoring of coronary heart disease (CHD) in 31 populations of the WHO MONICA Project. We studied the impact of this revolution on coronary endpoints. Case fatality, coronary-event rates, and CHD mortality were monitored in men and women aged 35-64 years in two separate 3-4-year periods. In each period, we recorded percentage use of eight treatments: coronary-artery reperfusion before, thrombolytics during, and beta-blockers, antiplatelet drugs, and angiotensin-converting-enzyme (ACE) inhibitors before and during non-fatal myocardial infarction. Values were averaged to produce treatment scores. We correlated changes across populations, and regressed changes in coronary endpoints on changes in treatment scores. Treatment changes correlated positively with each other but inversely with change in coronary endpoints. By regression, for the common average treatment change of 20, case fatality fell by 19% (95% CI 12-26) in men and 16% (5-27) in women; coronary-event rates fell by 25% (16-35) and 23% (7-39); and CHD mortality rates fell by 42% (31-53) and 34% (17-50). The regression model explained an estimated 61% and 41% of variance for men and women in trends for case fatality, 52% and 30% for coronary-event rates, and 72% and 56% for CHD mortality. Changes in coronary care and secondary prevention were strongly linked with declining coronary endpoints. Scores and benefits followed a geographical east-to-west gradient. The apparent effects of the treatment might be exaggerated by other changes in economically successful populations, so their specificity needs further assessment.
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                Author and article information

                Journal
                BMC Cardiovasc Disord
                BMC Cardiovascular Disorders
                BioMed Central
                1471-2261
                2008
                25 July 2008
                : 8
                : 17
                Affiliations
                [1 ]Department of Medicine, Sunderby Hospital, Luleå, Sweden
                [2 ]Department of Community Health, County Council of Norrbotten, Luleå, Sweden
                [3 ]Department of Medicine and Geriatrics, Skellefteå Hospital, Skellefteå, Sweden
                [4 ]Cardiology, Heart Centre, University Hospital, Umeå, Sweden
                [5 ]Department of Public Health and Clinical Medicine, University of Umeå, Umeå Sweden
                Article
                1471-2261-8-17
                10.1186/1471-2261-8-17
                2507701
                18655697
                d2ece086-e649-4ea5-86de-ef1e96cd6e74
                Copyright © 2008 Lundblad et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 8 January 2008
                : 25 July 2008
                Categories
                Research Article

                Cardiovascular Medicine
                Cardiovascular Medicine

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