Background: The aim of this study was to compare time trends in incidence, case fatality and mortality due to myocardial infarction (MI) in patients with or without diabetes.Methods: This study was based on the Northern Sweden MONICA Project MI registry with a target population of about 200 000 inhabitants in the age group 35-64 years in the two northernmost counties of Sweden. During 1989-2000, 6254 patients who had had an MI according to MONICA criteria were included in this study: 4569 patients had a first MI and 1685 had a recurrent MI. Sixteen per cent of the men and 20% of the women had had diabetes mellitus diagnosed prior the MI.Results: Over the 12-year period, there was a declining trend in incidence and case fatality in first MI. Also, the event rates (first ever and recurrent MI) declined in men without diabetes. In women without diabetes favourable time trends were seen in first ever MI, recurrent MI and in case fatality. There were no favourable time trends for any of these outcomes in patients with diabetes.Conclusion: In nondiabetic subjects below the age of 65, the incidence of, and case-fatality in, MI declined. This led to a decreased mortality over the 12-year period. These favourable trends over time were not observed in diabetic subjects.

Background The summarized importance of haemostatic and metabolic variables (insulin, lipids including lipoprotein (a) [Lp(a)] and leptin) in predicting first myocardial infarction, as well as possible interactions among these variables, have not been reported.Design A prospective case-control study nested within the Northern Sweden Health and Disease Cohort.Methods Sixty-two men diagnosed with a first myocardial infarction were sex- and age-matched with 124 controls. Conditional logistic regression was conducted including established risk factors, plasma levels of plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA) mass concentration, von Willebrand factor, insulin, proinsulin, specific insulin, apolipoprotein A-I (apo A-I), Lp(a), and leptin. Interaction analysis was also performed for tPA, apo A-I, Lp(a), leptin and proinsulin.Results Smoking, low plasma levels of apo A-I and high plasma levels of cholesterol, Lp(a), tPA, PAI-1, proinsulin and leptin were associated with myocardial infarction in univariate conditional logistic regression analysis. High tPA [odds ratio (OR), 21.3; 95% confidence interval (CI) 2.04-222] and Lp(a) (OR, 7.21; 95% CI, 1.31-39.8) and low apo A-I (OR, 0.15; 95% CI, 0.02-0.93) remained significant risk determinants in multivariate analysis with smoking habits, body mass index, hypertension, cholesterol, and diabetes included as covariates. There were non-significant synergic interactions between high Lp(a) and leptin and tPA, respectively, and between high Lp(a) and low apo A-I.Conclusion Plasma levels of tPA, Lp(a), and apo A-I are independently associated with subsequent development of a first myocardial infarction in men. (C) 2004 The European Society of Cardiology.

Objectives-Previous studies have shown differences in the main cardiovascular risk factors between communities of different sizes in northern Sweden, with serum cholesterol levels, systolic blood pressure and body mass index being higher, but with fewer smokers in the smallest communities. We wanted to see if there also were differences in the morbidity and 28-day case fatality in acute myocardial infarction (AMI) between communities of different sizes in this area.Design-The Northern Sweden MONICA Project database of AMI was examined for the years 1985 1999 for age-adjusted morbidity and 28-day case fatality for each sex in relation to the size of the community where each case lived.Results-The age standardized morbidity and 28-day case fatality were the lowest in the smallest communities where the risk factor burden previously was shown to be highest, and the highest in intermediate size communities.Conclusions-Other factors than conventional biomedical risk factors seem to either confer protection in the smallest communities or increase the AMI risk in larger communities.

Objectives. To describe time trends in sudden cardiac death (SCD) occurrences between 1985 and 1999.Design. Cohort study with analysis of a database of all symptomatic and/or fatal acute myocardial infarctions (AMI) in the two northernmost counties in Sweden, partly north of the Arctic Circle.Subjects. A total of 1139 cases of SCD amongst men and women aged 35-64 years.Main outcome measure. Sudden cardiac death.Results. Amongst men the proportion of SCD to all AMI deaths (within 28 days of an AMI) was 38% and for women 31%. The mean yearly incidence of SCD in this age group was 65 per 100 000 men and 12 per 100 000 women. Amongst men the mean yearly incidence decreased by 1.8% (95% confidence interval -3.2 to -0.3) and amongst women the decrease was 1.0% (95% confidence interval -4.4 to 2.4). Diabetes mellitus was more common in women compared with men (24% vs. 14%, P = 0.001). Men suffered an SCD more often around noon and on Saturdays, whereas women suffered their SCD on Mondays and Fridays. For season, men and women behaved similarly with a winter peak, although statistical significance was reached only for men.Conclusions. The SCD decreased amongst men between 1985 and 1999. There was also a decrease amongst women during the same time period but not to a statistically significant degree, possibly caused by lack of statistical power due to small numbers.

OBJECTIVE To report the age- and sex-specific prevalences of diabetes and impaired glucose regulation (IGR) according to the revised 1999 World Health Organization criteria for diabetes in Europe. RESEARCH DESIGN AND METHODS A total of 13 studies from nine European countries with 7,680 men and 9,251 women aged 30-89 years were included in the data analysis. RESULTS In most of the study populations, the age-specific prevalences of diabetes were <10% in subjects younger than 60 years and between 10 and 20% at 60-79 years of age. Mean 2-h plasma glucose (2hPG) concentration increased linearly with age, but fasting plasma glucose (FPG) concentration did not. The increase in the prevalence of undiagnosed diabetes and IGR in the elderly was mainly a result of the large increase in 2hPG rather than FPG. Diabetes and impaired fasting glycemia defined by isolated fasting hyperglycemia was more common in men than in women 30-69 years of age, whereas the prevalence of isolated postload hyperglycemia, particularly impaired glucose tolerance, was higher in women than in men, especially in the elderly (individuals >70 years of age). More than half of the diabetes was undiagnosed in subjects younger than 50 years of age. CONCLUSIONS Most European populations have a moderate to low prevalence of diabetes and IGR. Diabetes and IGR will be underestimated in Europe, particularly in women and in elderly men, if diagnoses are based on fasting glucose determination alone.

Aims: This study looks at trends in event rates of first and recurrent fatal and non-fatal acute myocardial infarction (AMI), and 28-day case fatality in AMI within the Northern Sweden MONICA area. Methods: The AMI event rate and 28-day case fatality in acute myocardial infarction were registered between 1985 and 1998 in the two northernmost counties in Sweden in men and women in the age groups 25-64 years. Results: Statistically significant mean annual decreases were found in fatal and non-fatal combined event rates (4% for men and 2.3%, for women), fatal event rate (7.1% for men and 5% for women), fatal first acute myocardial infarction (7.1% for men and 4.4% for women), and both non-fatal and fatal recurrent AMI for both sexes (5.5% for both men and women for non-fatal and, for fatal AMI, 7.1% for men and 5.7% for women). In addition, there were significant decreases for men in non-fatal event rate (2.4%), and non-fatal first AMI (1.4%). The decreases in case fatality were small, especially so for women. Conclusions: There is a trend of decreasing event rates in both fatal and non-fatal AMI, and first and recurrent AMI, most pronounced for men. The case fatality also decreased although to a lesser degree, suggesting that the decreasing mortality in ischaemic heart disease mainly is caused by reduced disease incidence.

AIM:To compare the levels of the main cardiovascular risk factors in communities of different sizes in northern Sweden. METHODS:Blood pressure, cholesterol, smoking habits, the prevalence of diabetes mellitus, and body mass index for 6167 men and women below age 65 were examined in the Northern Sweden MONICA surveys in 1986, 1990, 1994, and 1999. The size of the community where each individual lived and the levels of relevant confounders were also recorded. RESULTS:The proportion of persons with a higher educational level decreased gradually with decreasing community size. Total serum cholesterol, systolic blood pressure, the prevalence of diabetes mellitus and the body mass index were significantly higher in the smallest communities (<1000 inhabitants) as compared with the largest (>15000 inhabitants) but there were fewer smokers among men in the smallest communities. The time trends indicated an overall decreasing serum cholesterol level and increasing body mass index for both sexes and a decreasing proportion of smokers among men during the years surveyed. CONCLUSIONS:There are differences in levels of cardiovascular risk factors between communities of different sizes in the Northern Sweden MONICA area, mainly to the disadvantage of the smallest communities.

Aims: The authors describe the occurrence of diabetes and obesity in the population of Northern Sweden and the role of diabetes in cardiovascular disease. Methods: Four surveys of the population aged 25 to 64 years were undertaken during a 14-year time span. Stroke events in subjects 35 - 74 years during 1985 - 92 and myocardial infarction in subjects 25 - 64 years 1989 - 93 were registered. Results: The prevalence of diagnosed diabetes was 3.1 and 2.0% in men and women, respectively, and 2.6 and 2.7% for previously undiagnosed diabetes. During the 13-year observation period, BMI increased 0.96 kg/m2 in men and 0.87 in women. The proportion of subjects with obesity (BMI≥30) increased from 10.3% to 14.6% in men and from 12.5% to 15.7% in women. Hip circumference increased substantially more than waist circumference, leading to a decreasing waits-to-hip ratio (WHR). The relative risk for stroke or myocardial infarction was four to six times higher in a person with diabetes than in those without diabetes. The 28-day case fatality for myocardial infarction, but not for stroke, was significantly higher in both men and women with diabetes. Population-attributable risk for diabetes and stroke was 18% in men and 22% in women and for myocardial infarction it was 11% in men and 17% in women. Conclusion: Obesity is becoming more common, although of a more distal than central distribution. The burden of diabetes in cardiovascular diseases in Northern Sweden is high.

Objectives. To describe the relation between the Arctic Oscillation (AO) index and the incidence and mortality in acute myocardial infarction (AMI) in the northern, partly subarctic area of Sweden.Design. Comparison of a time series of daily variations in the AO index and register data on the daily number of fatal and nonfatal AMIs.Setting. The northernmost two Swedish counties, Norrbotten and Vasterbotten.Subjects. All inhabitants in the Norrbotten and Vasterbotten counties were followed for the occurrence of an AMI between 1985 and 1999 within the framework of the WHO MONICA (multinational MONItoring of trends and determinants of CArdiovascular disease) Project.Main outcome measure. Fatal and nonfatal AMIs.Results. There was a consistent positive relation between increasing AO index and an increase in AMI incidence and mortality. The maximum impact on AMI incidence of the AO came after a lag phase of 3 days. A one unit increase in AO index was associated with an increase in: the daily number of AMIs (+3.8%), the case fatality in AMI within 28 days (+5.1%), the number of nonfatal AMIs (+3.4%), and the number of sudden cardiac deaths (+8.3%).Conclusions. An AO index increase, bringing warmer weather over Scandinavia, was associated with an increase in the incidence and mortality in AMI in northern Sweden.

Aims: To compare menopausal age and the use of oral contraceptives (OC) and hormonal replacement therapy (HRT) between the 32 populations of the WHO MONICA Project, representing 20 different countries.Methods: Using a uniform protocol, age at menopause and the use of OC and HRT was recorded in a random sample of 25-64 year-old women attending the final MONICA population cardiovascular risk factor survey between 1989 and 1997. A total of 39,120 women were included.Results: There were wide variations between the populations in the use of OC and HRT. The use of OC varied between 0 and 52% in pre-menopausal women aged 35-44 years, Central and East Europe and North America having the lowest and West Europe and Australasia the highest prevalence rates. Among post-menopausal women between 45 and 64 years, the prevalence of HRT use varied from 0 to 42%. In general, the use of HRT was high in Western and Northern Europe, North America and Australasia and low in Central, Eastern and Southern Europe and China. With the exception of Canada (45 years), the mean age at menopause differed only little (ranging from 48 to 50 years) between the populations.Conclusion: The use of OC and HRT varies markedly between populations, in general following a regional pattern. Whereas, the prevalence rates are mostly similar within a country, there are remarkable differences even between neighbouring countries, reflecting nation-specific medical practice and public attitudes that are not necessarily based on scientific evidence. (C) 2003 Elsevier Ireland Ltd. All rights reserved.

The authors give an overview of the quality assessments in the WHO MONICA project and compare the quality of the data from Northern Sweden with other reporting units. Methods and results: Standardized measurement procedures and routine checks were used to ensure good quality of the data. The quality has been evaluated by a scoring system. The results show that the data from Northern Sweden have good quality for all variables except total cholesterol in the initial Survey. In the subsequent surveys, the quality of cholesterol data was good. Conclusions: Great effort was put in to ensure good data quality and Northern Sweden is one of the MONICA units with very good quality of data.

Introduction: The WHO MONICA Project (Multinational Monitoring of Trends and Determinants in Cardiovascular Disease) was initiated in 1982. The purpose was to evaluate to what extent mortality trends could be explained by changes over time in the population load of conventional cardiovascular risk factors. To test this hypothesis, time trends in cardiovascular event rates have been correlated with trends in levels of risk factors in 35- to 64-year-old men and women in 38 populations. In most MONICA populations, the study has covered a period of 10 years or more. Methods: All acute myocardial infarction and stroke events have been registered in a population-based setting in Norrbotten and Västerbotten counties from 1985 and onwards. The total population is approximately 510,000 inhabitants. In the frame of the WHO MONICA Project, the same strict criteria have been used in all years. Another part of the MONICA Project is population risk factor surveys. In Northern Sweden the first survey took place in 1986 and the following surveys were performed in 1990, 1994, and 1999, including the age group 25 - 74 years (the first two surveys were of the age range 25 - 64 years). Results: From 1985 to 2000, in total 18,105 suspected stroke events, aged 25 - 74 years, were scrutinized and validated at the central stroke office in Northern Sweden. Of these, 13,908 were found to fulfil the MONICA criteria of an acute stroke. During the period 1985 to 1998, in total 13,228 cases of suspected acute myocardial infarction, aged 25 - 64 years, were registered. Of these, 8,744 fulfilled the MONICA criteria for acute myocardial infarction. In the four surveys, in total 9,000 randomly selected men and women were invited for survey. Of these 6,952 (77%) participated in the surveys. Conclusion: From 1985 and onwards, the WHO MONICA project has been going on in Northern Sweden. During the whole time the same strict WHO criteria have been followed.

This study was undertaken to investigate whether there was any relation between the aurora borealis (measured as the geomagnetic activity) and the number of acute myocardial infarctions (AMI) in the northern, partly polar, area of Sweden. The AMI cases were collected from The Northern Sweden MONICA (multinational MONItoring of trends and determinants of CArdiovascular disease) AMI registry between 1985 and 1998, inclusive, and the information on the geomagnetic activity from continuous measurements at the Swedish Institute of Space Physics, Kiruna. In the analyses, both the relation between the individual AMI case and ambient geomagnetic activity, and the relation between the mean daily K index and the daily number of AMI cases were tested. We found no statistically significant relation between the number of fatal or non-fatal AMI cases, the number of sudden deaths or the number of patients with chest pain without myocardial damage, and geomagnetic activity. Our data do not support a relation between the geomagnetic activity and AMI.

Objectives. To investigate sex differences in reaching diagnosis, medical management and case fatality (CF) in acute myocardial infarction (AMI) in the population aged 35-64 years in northern Sweden,Methods. Within the framework of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) Project, definite AMI was monitored in people aged 35-64 years from 1989 through 1995 (target population 510 000 in 1991). Setting. In a population based coronary register, all coronary events were recorded in nine hospitals in 1989-95.Results. The number of events included in the definite coronary myocardial infarction register was 2483 men and 669 women. On admission, a higher proportion of men with definite AMI had chest pain or ECG changes typical for AMI (P < 0.0001). Disagreement between clinical diagnosis and classification by MONICA criteria occurred more often in women (P = 0.008). A significantly higher proportion of men was admitted in the coronary care unit and they were significantly more often treated with thrombolytics, nitroglycerine, beta-blockers, or antiplatelet agents. Women received significantly more diuretics, inotropics or calcium antagonists. Diabetes, conferring a worse prognosis, was more common in women (20 vs. 15%; P = 0.003). Prehospital CF was significantly higher in men (24.1 vs. 18.3%; P = 0.005), but in patients treated in hospital, the CF was significantly lower in men (12.7 vs. 21.2%; P < 0.001). Total CF was equal in men and women.Conclusions. Several factors contributing to the excess in-hospital CF in women were identified, including greater problems in diagnosis of AMI in women which may be one of the reasons for less intensive treatment in women. Differences in co-morbidity, most notably diabetes and medical treatment between men and women with acute AMI may also have played a part.

Aims A global increase in diabetes is predicted due to higher body weight and less physical activity. Over the period 1986-1999, the body mass index (BMI) of the adult population of northern Sweden increased from 25.3 to 26.2 and the prevalence of obesity (BMI greater than or equal to 30) from 11% to 15%, although this was more distal than central adiposity. Our hypothesis was that this would lead to a higher prevalence of diabetes.Methods Four population surveys with new and independent cohorts of 2000 invited subjects, 25-64 years old, in 1986, 1990, 1994 and 1999. In the first three surveys an oral glucose tolerance test was carried out in 47%.Results Over the time period 1986-1999 there was no increase in the prevalence of known diabetes. No trends were noted in the finding of previously undiagnosed diabetes or impaired glucose tolerance over the period 1986-1994, although the confidence intervals are wide. Fasting, but not post-load, glucose levels increased with 0.040 mmol/year (95% CI 0.026; 0.055) in men and 0.033 mmol/year (0.023; 0.044) in women.Conclusion In spite of a marked increase in BMI, we found no increased prevalence of known diabetes over a 13-year observation period, although our data cannot exclude minor increases in undiagnosed diabetes. The development of more distal than abdominal obesity, a diet with less saturated fat and lower glycaemic index and fewer regular smokers in the population may contribute to this. The effects of obesity may thus be attenuated by other secular trends in society and highlight potential ways of curbing the worldwide increase in diabetes.

OBJECTIVES:The aim of this study was to analyse time trends in survival after acute myocardial infarction with special emphasis on sex differences.DESIGN:Within the framework of the population-based WHO MONICA Project, all acute myocardial infarction events were recorded in the age group 25-64 years in northern Sweden during the period 1985-94. All first-ever myocardial infarction patients were followed for information on vital status.SUBJECTS:A total of 3397 men and 860 women with acute myocardial infarction, during the period between 1985 and 1994.MAIN OUTCOME MEASURES:Case fatality rates after first-ever acute myocardial infarction.RESULTS:When compared with the 1985-86 cohort, the age-adjusted odds ratio for death within 1 year after acute myocardial infarction was 0.59 (95% CI 0.46-0.76) in the 1993-94 male cohort but 0.99 (95% CI 0.61-1.60) in the female 1993-94 cohort. Corresponding age-adjusted proportions of death within 1 year were 33.3% and 22.9% in men and 27.5% and 27.3% in women in 1985-86 and 1993-94, respectively. The odds ratio for 3-year case fatality amongst those who survived the first 28 days was 0.34 (95% CI 0.21-0.55) in 1991-92 compared with 1985-86 in men and 0.91 (0.43-1.94) in women.CONCLUSION:Both short- and long-term survival after AMI have improved markedly in men over the last decade. There is a disturbing sex difference in that, during the same period, survival in women with AMI has not improved at all. This sex difference was not explained by differences in conventional prognostic factors.

Cardiovascular disease morbidity and mortality rates show marked social patterning in industrialized countries. The aim of this study was to analyze if not only incidence but also survival after acute myocardial infarction (AMI) and stroke differ among socioeconomic groups. Within the framework of the population-based World Health Organization's Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Project, all first-ever AMI (ages 25-64 years) and stroke (ages 25-74 years) events were recorded in northern Sweden during the period 1985-1994. The numbers of first-ever AMI and stroke patients included in the study were 3,466 and 4,215, respectively. Incidence rates for both AMI and stroke showed a distinct social pattern, with high rates in workers and self-employed nonprofessionals and low rates in professionals. The pattern was similar in men and women. In men, early survival after an AMI follows the same socioeconomic pattern, whereas it is less clear if socioeconomic differences in survival contribute to explain differences in mortality in AMI among women and mortality in stroke (both sexes). The high case fatality among male workers and self-employed professionals with AMI is, in turn, attributed to a very marked increase in the risk for sudden death.

OBJECTIVES:To explore whether the use of snuff affects the risk of myocardial infarction (MI).BACKGROUND:Snuff and other forms of smokeless tobacco are widely used in some populations. Possible health hazards associated with the use of smokeless tobacco remain controversial.METHODS:In a population-based study within the framework of the Northern Sweden center of the World Health Organization Multinational Monitoring of Trend and Determinants in Cardiovascular Disease (WHO MONICA) Project, tobacco habits were compared in 25- to 64-year-old men with first-time fatal or nonfatal MI and referent subjects matched for age and place of living (687 cases, 687 referents).RESULTS:The unadjusted odds ratio (OR) for MI in regular cigarette smokers as compared with men who never used tobacco was 3.65 (95% confidence interval [CI] 2.67 to 4.99). When nonsmoking regular snuff dippers were compared with never-users of tobacco, the unadjusted OR was 0.96 (0.65 to 1.41). After adjustment for multiple cardiovascular risk factors, the OR was 3.53 (95% CI 2.48 to 5.03) for regular smoking and 0.58 (95% CI 0.35 to 0.94) for regular snuff dipping. Restricting the analyses to fatal cases of myocardial (including sudden death) showed a tendency towards increased risk among snuff dippers 1.50 (95% CI 0.45 to 5.03).CONCLUSIONS:The risk of MI is not increased in snuff dippers. Nicotine is probably not an important contributor to ischemic heart disease in smokers. A possible small or modest detrimental effect of snuff dipping on the risk for sudden death could not be excluded in this study due to a limited number of fatal cases.