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Cardiovascular risk factors in elderly: With special emphasis on atrial fibrillation, hypertension and diabetes
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

The part of the population that belongs to the oldest-old (ages 80 years or older) increases rapidly, worldwide. Cardiovascular disease (CVD) is the leading cause of death and disease burden globally. Multimorbidity is common in old age and stroke, diabetes mellitus (DM) and atrial fibrillation (AF) are strongly associated with age. Cardiovascular risk factors are well studied and documented in younger and middle ages, but not as well in old and frail individuals. Therefore, preventive treatment choices are mostly based on evidence for younger patients. The aim of this thesis was to explore age and other aspects of cardiovascular risk factors; AF, hypertension and DM, in relation to comorbidity, cardiovascular outcome and mortality.

Methods

This thesis was based on four different studies:

  • The ELSA85 study of 85 years old in Linköping, Sweden
  • The international, multicentre, randomised controlled INTERACT2 trial of spontaneous intracranial haemorrhage (ICH), mean age 64 years.
  • The prospective SHADES study of nursing home residents, mean age 85 years.
  • The prospective, national SWE-diadep study of dispensed antidiabetics, antidepressantsand prevalent myocardial infarction (MI) in 45-84 years old.

Data was obtained from questionnaires (ELSA85, INTERACT2), medical records and medical examination (ELSA85, INTERACT2, SHADES), and national registers (SWE-Diadep).

Results

The ELSA85 study showed that 16% (n=53) had an ECG showing AF. There was an increased hazard ratio (HR) for all-cause mortality in participants with AF at baseline, at 90 years of age (HR 1.59, 95% [Confidence Interval] CI 1.04-2.44) adjusted for sex. This increase in HR did not persist when adjusted for congestive heart failure (CHF). In the INTERACT2 study, increasing age was associated with increasing frequency of death or dependency (odds ratio [OR] 4.36, 95% [CI] 3.12-6.08 for >75 years vs <52 years, p value for trend <0.001). The SHADES study showed that participants with Systolic blood pressure (SBP) <120 mmHg had an increased HR for mortality (1.56, 95% CI, 1.08–2.27; p=0.019) but there were no differences between SBP groups 140–159 mmHg and ≥160 mmHg compared with the reference group SBP 120–139 mmHg. SBP decreased during the prospective study period. In the SWE-diadep study, individuals with antidiabetics and antidepressants combined had a greater HR for MI compared to the reference of no antidiabetics or antidepressants, mostly so in women aged 45-64 years (HR 7.4, 95% CI: 6.3-8.6).

Conclusion

Risk factors for CVDs in elderly differ from cardiovascular risk factors in middle aged individuals an

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. , 78 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1466
National Category
Public Health, Global Health, Social Medicine and Epidemiology Other Health Sciences Family Medicine
Identifiers
URN: urn:nbn:se:liu:diva-121286DOI: 10.3384/diss.diva-121286ISBN: 978-91-7519-030-3 (print)OAI: oai:DiVA.org:liu-121286DiVA: diva2:853106
Public defence
2015-10-09, Belladonna, ingång 78, Campus US, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-09-11 Created: 2015-09-11 Last updated: 2015-09-18Bibliographically approved
List of papers
1. Atrial fibrillation (AF) and co-morbidity in elderly. A population based survey of 85 years old subjects.
Open this publication in new window or tab >>Atrial fibrillation (AF) and co-morbidity in elderly. A population based survey of 85 years old subjects.
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2011 (English)In: Archives of gerontology and geriatrics (Print), ISSN 0167-4943, E-ISSN 1872-6976, Vol. 52, no 3, e170-e175 p.Article in journal (Refereed) Published
Abstract [en]

The occurrence of AF increases sharply with age. The aim of this study was to explore and compare prevalent co-morbidity and self-estimated health-related quality of life (HRQoL) in subjects with AF versus subjects with sinus rhythm or pacemaker in 85 years old subjects. We analyzed data from a population of 336 eighty-five years old subjects participating in the Elderly in Linköping Screening Assessment (ELSA-85) study. Medical history was obtained from postal questionnaire, medical records and during medical examination that included a physical examination, cognitive tests, non-fasting venous blood samples and electrocardiographic (ECG) examination. 19% had an ECG showing AF. There were very few significant differences regarding medical history, self-estimated quality of life (QoL), laboratory- and examination findings and use of public health care between the AF group and the non-AF group. The study showed that the population of 85 years old subjects with AF was surprisingly healthy in terms of prevalent co-existing medical conditions, healthcare contacts and overall HRQoL. We conclude that elderly patients with AF do not in general have increased co-morbidity than subjects without AF.

Place, publisher, year, edition, pages
Elsevier, 2011
Keyword
Atrial fibrillation; Co-morbidities of elderly; CHADS2 score; Oral anticoagulation; Health-related quality of life
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67143 (URN)10.1016/j.archger.2010.10.024 (DOI)000288989400015 ()
Note

Original Publication: Karin Rådholm, Carl Johan Östgren, Urban Alehagen, Magnus Falk, Eva Wressle, Jan Marcusson and Katarina Nägga, Atrial fibrillation (AF) and co-morbidity in elderly. A population based survey of 85 years old subjects., 2011, Archives of gerontology and geriatrics (Print), (52), 3, e170-e175. http://dx.doi.org/10.1016/j.archger.2010.10.024 Copyright: Elsevier Science B.V., Amsterdam. http://www.elsevier.com/

Available from: 2011-03-31 Created: 2011-03-31 Last updated: 2017-12-11
2. Older age is a strong predictor for poor outcome in intracerebral haemorrhage: the INTERACT2 study
Open this publication in new window or tab >>Older age is a strong predictor for poor outcome in intracerebral haemorrhage: the INTERACT2 study
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2015 (English)In: Age and Ageing, ISSN 0002-0729, E-ISSN 1468-2834, Vol. 44, no 3, 422-427 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND PURPOSE:: Global ageing contributes greatly to the burden of stroke. We investigated the influence of age on the baseline profile and on outcomes in acute intracerebral haemorrhage (ICH) among participants of the INTERACT2 study.

METHODS:: INTERACT2 was an international, randomised controlled trial in 2839 patients with spontaneous ICH within 6 h of onset and elevated systolic blood pressure (SBP; 150-220 mmHg) who were allocated to receive intensive (target SBP <140 mmHg within 1 h) or guideline-recommended (target SBP <180 mmHg) blood pressure lowering treatment. Stroke severity was assessed with the National Institutes of Health Stroke Scale. Poor outcome was defined as death or major disability ('dependency', modified Rankin Scale scores 3-6) at 90 days. Health-related quality of life (HRQoL) was assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire. Associations between age and outcomes were analysed in multivariable logistic regression models.

RESULTS:: Stroke severity increased in categories of older age (P-trend 0.002). Stroke patients over 75 years old were four times more likely to die or be disabled at 90 days than those <52 years when other confounders were accounted for (odds ratio 4.36, 95% confidence interval 3.12-6.08). Older age was also associated with decreasing HRQoL, across mobility, self-care, usual activities and depression (all P-trend <0.001), and pain or discomfort (P-trend 0.022).

CONCLUSION:: In the INTERACT2 cohort, older people had more severe ICH and worse outcomes (death, major disability and HRQoL). These data will help guide clinicians manage older people with haemorrhagic stroke. Clinical Trial Registration: http://www.clinicaltrials.gov (NCT00716079).

Place, publisher, year, edition, pages
Oxford University Press, 2015
National Category
Family Medicine
Identifiers
urn:nbn:se:liu:diva-115371 (URN)10.1093/ageing/afu198 (DOI)000355623100014 ()25497513 (PubMedID)
Available from: 2015-03-13 Created: 2015-03-13 Last updated: 2017-12-04
3. Blood pressure and all-cause mortality: a prospective study of nursing home residents
Open this publication in new window or tab >>Blood pressure and all-cause mortality: a prospective study of nursing home residents
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2016 (English)In: Age and Ageing, ISSN 0002-0729, E-ISSN 1468-2834, Vol. 45, no 6, 826-832 p.Article in journal (Refereed) Published
Abstract [en]

Aim: To explore the natural course of blood pressure development and its relation to mortality in a nursing home cohort.

Methods: A cohort of 406 nursing home residents in south east Sweden was followed prospectively for 30 months. Participants were divided into four groups based on systolic blood pressure (SBP) at baseline. Data were analysed using a Cox regression model with all-cause mortality as the outcome measurement; paired Student t-tests were used to evaluate blood pressure development over time.

Results: During follow-up, 174 (43%) people died. Participants with SBP <120 mmHg had a hazard ratio for mortality of 1.56 (95% confidence interval, 1.08–2.27) compared with those with SBP 120–139 mmHg, adjusted for age and sex. Risk of malnutrition or present malnutrition was most common in participants with SBP <120 mmHg; risk of malnutrition or present malnutrition estimated using the Mini Nutritional Assessment was found in 78 (71%). The levels of SBP decreased over time independent of changes in anti-hypertensive medication.

Conclusions: In this cohort of nursing home residents, low SBP was associated with increased all-cause mortality. SBP decreased over time; this was not associated with altered anti-hypertensive treatment. The clinical implication from this study is that there is a need for systematic drug reviews in elderly persons in nursing homes, paying special attention to those with low SBP.

Place, publisher, year, edition, pages
Oxford University Press, 2016
Keyword
older people, prospective study, nursing home, hypertension, hypotension, all-cause mortality
National Category
Family Medicine Other Health Sciences
Identifiers
urn:nbn:se:liu:diva-121283 (URN)10.1093/ageing/afw122 (DOI)000392702200018 ()
Note

Funding agencies| Health Research Council in south east Sweden (FORSS-8888, FORSS-11636 and FORSS-31811); the County of Östergötland (LIO-11877, LIO-31321 and LIO-79951); the Family Janne Elgqvist Foundation; King Gustaf V and Queen Victoria Freemason Foundation.

At the time for thesis presentation publication was in status: Manuscript

Available from: 2015-09-11 Created: 2015-09-11 Last updated: 2017-12-04Bibliographically approved
4. Use of antidiabetic and antidepressant drugs is associated with increased risk of myocardial infarction: a nationwide register study
Open this publication in new window or tab >>Use of antidiabetic and antidepressant drugs is associated with increased risk of myocardial infarction: a nationwide register study
2016 (English)In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 33, no 2, 218-223 p.Article in journal (Refereed) Published
Abstract [en]

Aims

To explore the gender- and age-specific risk of developing a first myocardial infarction in people treated with antidiabetic and/or antidepressant drugs compared with people with no pharmaceutical treatment for diabetes or depression.

Methods

A cohort of all Swedish residents aged 45–84 years (n = 4 083 719) was followed for a period of 3 years. Data were derived from three nationwide registers. The prescription and dispensing of antidiabetic and antidepressant drugs were used as markers of disease. All study subjects were reallocated according to treatment and the treatment categories were updated every year. Data were analysed using a Cox regression model with a time-dependent variable. The outcome of interest was first fatal or non-fatal myocardial infarction.

Results

During follow-up, 42 840 people had a first myocardial infarction, 3511 of which were fatal. Women aged 45–64 years, receiving both antidiabetic and antidepressant drugs had a hazard ratio for myocardial infarction of 7.4 (95% CI 6.3–8.6) compared with women receiving neither. The corresponding hazard ratio for men was 3.1 (95% CI 2.8–3.6).

Conclusions

The combined use of antidiabetic and antidepressant drugs was associated with a higher risk of myocardial infarction compared with use of either group of drugs alone. The increase in relative risk was greater in middle-aged women than in middle-aged men.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2016
National Category
Public Health, Global Health, Social Medicine and Epidemiology Other Health Sciences Family Medicine
Identifiers
urn:nbn:se:liu:diva-121285 (URN)10.1111/dme.12822 (DOI)000370161800011 ()26036276 (PubMedID)
Note

Funding agencies: King Gustaf V and Queen Victoria Freemason Foundation

Available from: 2015-09-11 Created: 2015-09-11 Last updated: 2017-04-24Bibliographically approved

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