Cardiovascular Disease In Norway Research Articles

Hypertensive disorders of pregnancy among women with cardiovascular disease in Norway: A historical cohort study.

Women with cardiovascular disease may be at increased risk of hypertensive disorders of pregnancy (HDP). We aimed to: (1) Investigate the occurrence of HDP in a cohort of pregnant women with cardiovascular disease and compare it with the occurrence in the general population. (2) Assess the association between maternal cardiovascular risk and risk of HDP. We reviewed clinical data on a cohort of 901 pregnancies among 708 women with cardiovascular disease who were followed at the National Unit for Pregnancy and Heart Disease and gave birth at Oslo University Hospital between 2003 and 2018. The exposure under study was maternal cardiovascular risk, classified as low, moderate, or high based on a modified classification by the World Health Organization. The main outcome of interest was HDP, which included pre-eclampsia and gestational hypertension. The proportion of HDP cases in the general population in the same period was extracted from the Medical Birth Registry of Norway. We used logistic regression to estimate crude and adjusted odds ratios (OR) of HDP, with associated 95% confidence intervals (CIs), for women with moderate- and high cardiovascular risk compared to women with low risk. The occurrence of HDP in the study cohort was 12.1% (95% CI: 10.0%-14.4%) and varied between 8.7% (95% CI: 6.5%-11.3%) in the low-risk group, 15.7% (95% CI: 11.1%-21.4%) in the moderate-risk group, and 22.2% (95% CI: 15.1%-30.8%) in the high-risk group. By contrast, the nationwide occurrence of HDP was 5.1% (95% CI: 5.1%-5.2%). In the study cohort, the proportions of pregnancies with gestational hypertension and pre-eclampsia were similar (6.3% and 5.8%, respectively). Compared to pregnancies with low cardiovascular risk, the adjusted OR of HDP was 2.04 (95% CI: 1.21-3.44) in the moderate-risk group and 2.99 (95% CI: 1.73-5.18) in the high-risk group. The occurrence of hypertensive disease of pregnancy in the study cohort was more than doubled compared to the general population in Norway. The risk of HDP increased with maternal cardiovascular risk group. We recommend taking into account maternal cardiovascular risk group when assessing risk and prophylaxis of HDP.

Education Level and Self-Reported Cardiovascular Disease in Norway-The Tromsø Study, 1994-2016.

Cardiovascular disease (CVD) is a leading source of morbidity and mortality, and research has shown education level to be a risk factor for the disease. The aim of this study was to investigate the association between education level and self-reported CVD in Tromsø, Norway. This prospective cohort study included 12,400 participants enrolled in the fourth and seventh surveys of the Tromsø Study (Tromsø4 and Tromsø7) in 1994-1995 and 2015-2016, respectively. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs). For every 1-level increase in education, the age-adjusted risk of self-reported CVD decreased by 9% (OR = 0.91, 95% CI: 0.87-0.96), but after adjustment for covariates, the association was weaker (OR = 0.96, 95% CI: 0.92-1.01). The association was stronger for women (OR = 0.86, 95% CI: 0.79-0.94) than men (OR = 0.91, 95% CI: 0.86-0.97) in age-adjusted models. After adjustment for covariates, the associations for women and men were similarly weak (women: OR = 0.95, 95% CI: 0.87-1.04; men: OR = 0.97, 95% CI: 0.91-1.03). In age-adjusted-models, higher education level was associated with a lower risk of self-reported heart attack (OR = 0.90, 95% CI: 0.84-0.96), but not stroke (OR = 0.97, 95% CI: 0.90-1.05) or angina (OR = 0.98, 95% CI: 0.90-1.07). There were no clear associations observed in the multivariable models for CVD components (heart attack: OR = 0.97, 95% CI: 0.91-1.05; stroke: OR = 1.01, 95% CI: 0.93-1.09; angina: OR = 1.04, 95% CI: 0.95-1.14). Norwegian adults with a higher education level were at lower risk of self-reported CVD. The association was present in both genders, with a lower risk observed in women than men. After accounting for lifestyle factors, there was no clear association between education level and self-reported CVD, likely due to covariates acting as mediators.

HIGH-NORMAL BLOOD PRESSURE IS PARTICULARLY ASSOCIATED WITH INCREASED RISK FOR ACUTE CORONARY SYNDROMES IN WOMEN: THE HORDALAND HEALTH STUDY

Abstract Objective: Hypertension is a major risk factor for acute coronary syndromes (ACS). Less is known about whether high-normal blood pressure (BP) carries a different risk for ACS in women and men. We tested associations of high-normal BP with incident ACS in women and men participating in the community-based Hordaland Health Study (HUSK). Design and method: We followed 8262 participants aged 42 years (52% women) in HUSK from 1992/93 through 2009 by coupling them to the Cardiovascular Disease in Norway (CVDNOR) project and Cause of Death Registry. BP was measured at baseline in triples at after at least 2 minutes rest in seated position with calibrated sphygmomanometers in 1992/93. The average of the two last measurements was taken as the clinic BP measure. The cohort was divided according to BP class: normal BP (BP < 130/85 mmHg), high-normal BP (BP130–139/85–89) and hypertension (BP > 140/90 or use of antihypertensive drugs). ACS was defined as hospitalization or death with an acute myocardial infarction or unstable angina pectoris diagnosis (ICD-9 codes 410, 411 and ICD-10 codes I20.0, I21 and I22) in the period 1994–2009. The association between BP category and ACS was tested in sex-specific Cox regression analyses adjusted for diabetes, smoking and total cholesterol. Normal BP was used as the reference group. Results: At baseline, 17% women and 27% men had high-normal BP and 16% women and 32% men had hypertension (both p < 0.001 between sexes). During follow-up, 1.4% of women and 6.1% of men experienced an ACS (p < 0.001). In multivariable analyses in women, both hypertension and high-normal BP were associated with incident ACS (hazard ratio (HR) 2.79, 95% confidence interval (CI) 1.36–5.72 and HR 2.22, 95 % CI 1.05–4.71, respectively). In men, hypertension but not high-normal BP was associated with incident ACS (HR 1.63, 95 % CI 1.16–2.30 and HR 1.20, 95 % CI 0.81–1.77 respectively). Conclusions: In the Hordaland Health Study, high-normal BP was a stronger risk factor for ACS in middle-aged women than men. Our findings suggest that sex-specific diagnosis of high-normal BP and hypertension may be warranted.

Time trends in incidence rates of atrial fibrillation-related strokes in Norway 2001–2014: a nationwide analysis using data from the cardiovascular disease in Norway (CVDNOR) project

Abstract Background Stroke incidence rates declined in Norway during 2001 to 2014. Atrial fibrillation (AF) incidence rates were stable in the same period. Purpose We aimed to study time trends in incidence (first time) of acute stroke hospitalizations and stroke deaths associated with AF in Norway in the period 2001–2014. Methods Nationwide hospital discharge diagnoses in the Cardiovascular Disease in Norway (CVDNOR) database and in the National Patient Registry were linked to the National Cause of Death Registry. All hospitalizations with acute stroke (including ischemic stroke, intracerebral bleeding and unspecified stroke) and out-of-hospital deaths with stroke as underlying cause in individuals 25 years and older were obtained during 1994–2014. Incident stroke was defined as the first hospitalization or out-of-hospital death due to stroke with no hospitalization for acute stroke or stroke sequela the past 7 years. Stroke was defined as AF-related if AF was registered during a hospitalization the past 7 years, or as underlying or contributing cause of death up to 28 days after the stroke hospitalization. Age-standardized incidence rates with 95% confidence intervals (CIs) were calculated using direct standardization to the age-distribution in the Norwegian population per 2001. Age-adjusted average yearly incidence rate ratios (IRR) with 95% CIs were estimated by negative binomial regression analyses. Results From 2001 to 2014 we identified 157 580 incident stroke cases of which 38 317 were AF-related. The proportion of incident strokes that were related to AF increased from 20.6% in 2001 to 26.3% in 2014. Age-standardized incidence rates of AF-related strokes per 100,000 person years were stable at 88 (85, 92) in 2001 and 79 (76, 83) in 2014, corresponding to a 0% average yearly change, IRR 1.00 (0.99, 1.00). The age-standardized incidence rates of non-AF-related strokes per 100,000 person years decreased from 334 (328, 341) in 2001 to 214 (209, 219) in 2014, corresponding to a 3% average yearly decrease, IRR 0.97 (0.97, 0.97). Conclusion The favourable trend in total stroke incidence rates from 2001 to 2014 does not include AF-related strokes. This may suggest that AF has become accountable for a higher proportion of incident strokes or that AF detection improved over this period. Figure 1. Age-standardized incidence rates of stroke hospitalizations or out-of-hospital deaths per 100,000 person years (py) by year, illustrated as all strokes (blue horizontal line) and AF-related strokes (red horizontal line/height of red area). The height of the blue area illustrates the rate for non-AF related strokes. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Vestre Viken Hospital Trust (public hospital research fund)

Prevalence and incidence rates of atrial fibrillation in Norway 2004–2014

ObjectiveTo study time trends in incidence of atrial fibrillation (AF) in the entire Norwegian population from 2004 to 2014, by age and sex, and to estimate the prevalence of AF...

Association of dietary vitamin K and risk of coronary heart disease in middle-age adults: the Hordaland Health Study Cohort

ObjectiveThe role of vitamin K in the regulation of vascular calcification is established. However, the association of dietary vitamins K1 and K2 with risk of coronary heart disease (CHD) is...

Heart failure in Norway, 2000-2014: analysing incident, total and readmission rates using data from the Cardiovascular Disease in Norway (CVDNOR) Project.

To examine trends in heart failure (HF) hospitalization rates and risk of readmissions following an incident HF hospitalization. During 2000-2014, we identified in the Cardiovascular Disease in Norway Project 142 109 hospitalizations with HF as primary diagnosis. Trends of incident and total (incident and recurrent) HF hospitalization rates were analysed using negative binomial regression models. Changes over time in 30-day and 3-year risk of HF recurrences or cardiovascular disease (CVD)-related readmissions were analysed using Fine and Grey competing risk regression, with death as competing events. Age-standardized rates declined on average 1.9% per year in men and 1.8% per year in women for incident HF hospitalizations (both Ptrend < 0.001) but did not change significantly in either men or women for total HF hospitalizations. In men surviving the incident HF hospitalization, 30-day and 3-year risk of a HF recurrent event increased 1.7% and 1.2% per year, respectively. Similarly, 30-day and 3-year risk of a CVD-related hospitalization increased 1.5% and 1.0% per year, respectively (all Ptrend < 0.001). No statistically significant changes in the risk of HF recurrences or CVD-related readmissions were observed among women. In-hospital mortality for a first and recurrent HF episode declined over time in both men and women. Incident HF hospitalization rates declined in Norway during 2000-2014. An increase in the risk of recurrences in the context of reduced in-hospital mortality following an incident and recurrent HF hospitalization led to flat trends of total HF hospitalization rates.

P6563Time trends in incidence rates of atrial fibrillation in Norway 2004–2014. A CVDNOR project

Abstract Background The reported incidence and prevalence of atrial fibrillation (AF) has been inconsistent among studies. Purpose We aimed to study time trends in incidence (first time) of AF hospitalizations or AF deaths in Norway in the period 2004–2014 by age and sex. Methods Nationwide hospital discharge diagnoses in the Cardiovascular Disease in Norway (CVDNOR) database and in the National Patient Registry were linked to the National Cause of Death Registry. All hospitalizations with AF as primary or secondary diagnosis and out-of-hospital deaths with AF as underlying cause (ICD-9: 427.3 or ICD 10: I48; AF or atrial flutter) in individuals ≥18 years were obtained during 1994–2014. Incident AF was defined as first hospitalization or out-of-hospital death due to AF with no previous hospitalization for AF the past 10 years. Age-standardized incidence rates with 95% confidence intervals (CIs) were calculated using direct standardization to the age-distribution in the Norwegian population per Jan 1st 2004. Age-adjusted average yearly incidence rate ratios (IRR) with 95% CIs were estimated by Poisson regression analyses. Accumulated prevalence during 1994–2014 was assessed in Norwegian residents 18 years and older per Dec 31st 2014. Results During 39,865,498 person years of follow up from 2004 to 2014 we identified 175,979 incident AF cases of which 30% were registered with AF as primary diagnosis, 69% as secondary diagnosis and 1% as out-of-hospital cause of death. The age-standardized incidence rate of AF hospitalization or out-of-hospital death per 100,000 person years was stable at 433 (426–440) in 2004 and 440 (433–447) in 2014. IRR were stable or declining across age groups of both sexes, except for the youngest age group 18–44 years, where incidence rates of AF hospitalization or out-of-hospital death increased by 2% per year, IRR 1.02 (1.01, 1.03). By 2014, the prevalence of AF assessed from hospital or death records was 2.9% in the adult population 18 years and older. Conclusion We found overall stable incidence rates of AF from 2004 to 2014 in the adult Norwegian population. Increased incidence rates of AF in the population 18–44 years are worrying and need further investigation. Acknowledgement/Funding The Norwegian Atrial Fibrillation Reseach Network

Mortality following first-time hospitalization with acute myocardial infarction in Norway, 2001–2014: Time trends, underlying causes and place of death

BackgroundTrends on cause-specific mortality following acute myocardial infarction (AMI) are poorly described and no studies have analyzed where do AMI patients die.We analyzed trends in 28-day and one-year mortality following an incident AMI with focus on changes over time in the underlying cause and place of death. MethodsWe identified in the ‘Cardiovascular Disease in Norway’ Project all patients 25+ years, hospitalized with an incident AMI in Norway, 2001–2014. Information on date, underlying cause and place of death was obtained from the Cause of Death Registry. ResultsOf 144,473 patients included in the study, 11.4% died within first 28 days. The adjusted 28-day mortality declined by 5.2% per year (ptrend < 0.001).Of 118,881 patients surviving first 28 days, 10.1% died within one year. The adjusted one-year CVD mortality declined by 6.2% per year (ptrend < 0.001) while non-CVD mortality increased by 1.4% per year (ptrend < 0.001), mainly influenced by increased risk of dying from neoplasms.We observed a shift over time in the underlying cause of death toward more non-CVD deaths, and in the place of death toward more deaths occurring in nursing homes. ConclusionsWe observed a decline in 28-day mortality following an incident AMI hospitalization. One-year CVD mortality declined while one-year risk of dying from non-CVD conditions increased. The resulting shift toward more non-CVD deaths and deaths occurring outside a hospital need to be considered when formulating priorities in treating and preventing adverse events among AMI survivors.

Hypertensive pregnancy disorders increase the risk of maternal cardiovascular disease after adjustment for cardiovascular risk factors

Background and aimHypertensive pregnancy disorders are associated with subsequent cardiovascular disease (CVD), but the extent to which this association is explained by shared risk factors is unknown. We aimed to evaluate whether hypertensive pregnancy disorder in first pregnancy is associated with increased subsequent risk of maternal CVD after adjustment for established CVD risk factors measured after pregnancy. Methods and resultsA total of 20,075 women with a first delivery registered in the Medical Birth Registry of Norway (1980–2003) participated in Cohort of Norway (CONOR) health surveys a mean (standard deviation) of 10.7 (5.5) years after delivery. They were then followed (median 11.4 years) for an incident fatal or non-fatal CVD event through linkage to the Cardiovascular Disease in Norway (CVDNOR) database and the Norwegian Cause of Death Registry. Hypertensive pregnancy disorders were associated with an increased risk of CVD [Hazard ratio (HR) 2.3; 95% confidence interval (CI) 1.9–2.8], which remained significant after adjustment for established CVD risk factors including body mass index, smoking, hypertension, diabetes, serum glucose and lipid levels (HR 1.5; 95% CI 1.2–1.8). The population attributable fraction of CVD due to hypertensive pregnancy disorder was 4.3% (95% CI 1.9–6.6) after multivariable adjustment. ConclusionThe association between hypertensive pregnancy disorders and CVD risk was mediated in part by related CVD risk factors measured 10 years following delivery. These results underline the importance of post-pregnancy follow-up of women with hypertensive pregnancy disorders focusing on modifiable, lifestyle related risk factors to prevent future CVD.

Plasma Cystathionine and Risk of Incident Stroke in Patients With Suspected Stable Angina Pectoris.

BackgroundCystathionine is an intermediate product in the transsulfuration pathway and formed during the B6‐dependent conversion of methionine to cysteine. Elevated plasma cystathionine has been related to atherosclerosis, which is a major etiological factor for ischemic stroke. However, the role of cystathionine in stroke development is unknown. Therefore, we prospectively assessed the association of circulating levels of cystathionine with risk of total and ischemic stroke.Methods and ResultsTwo‐thousand thirty‐six patients (64% men; median age, 62 years) undergoing coronary angiography for suspected stable angina pectoris were included. Stroke cases were identified by linkage to the CVDNOR (Cardiovascular Disease in Norway) project. Hazard ratios with confidence intervals (95% confidence interval) were estimated by using Cox‐regression analyses. During 7.3 years of median follow‐up, 124 (6.1%) incident strokes were ascertained, which comprised 100 cases of ischemic stroke. There was a positive association of plasma cystathionine with risk of total stroke and ischemic stroke. Comparing the fourth versus the first cystathionine quartiles, age‐ and sex‐adjusted hazard ratios (95% confidence interval) were 2.11 (1.19–3.75) and 2.56 (1.31–4.99) for total and ischemic stroke, respectively. Additional adjustment for major stroke risk factors only slightly attenuated the associations, which tended to be stronger in patients without previous or existing atrial fibrillation at baseline (hazard ratio [95% confidence interval], 2.43 [1.27–4.65] and 2.88 [1.39–5.98] for total and ischemic stroke, respectively).ConclusionsIn patients with suspected stable angina pectoris, plasma cystathionine was independently related to increased risk of total stroke and, in particular, ischemic stroke.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00354081.

Plasma Concentrations and Dietary Intakes of Choline and Betaine in Association With Atrial Fibrillation Risk: Results From 3 Prospective Cohorts With Different Health Profiles.

BackgroundAlthough choline metabolism has been associated with atherosclerotic heart disease, less research attention has been paid to the associations of choline and its oxidative metabolite betaine with cardiac arrhythmias.Methods and ResultsWe evaluated associations of plasma concentrations and dietary intakes of choline and betaine with long‐term atrial fibrillation (AF) risk in a community‐based cohort, HUSK ([the Hordaland Health Study] n=6949), and validated the findings in 2 patient cohorts: the Western Norway Coronary Angiography Cohort (n=4164) and the NORVIT (Norwegian B‐Vitamin) Trial (n=3733). Information on AF was obtained from the CVDNOR (Cardiovascular Disease in Norway) project. In HUSK, WECAC (Western Norway Coronary Angiography Cohort), and NORVIT, 552, 411, and 663 AF cases were identified during a median follow‐up time of 10.9, 7.3, and, 8.7 years, respectively. Plasma concentrations of choline and betaine were significantly positively associated with later AF risk after multivariable adjustments in HUSK. Such associations were independently replicated in the 2 external prospective patient cohorts. The pooled hazard ratio was 1.13 (95% confidence interval 1.08‐1.19, P<0.001) and 1.16 (95% confidence interval 1.10‐1.22, P<0.001) per SD increment for log‐transformed choline and betaine, respectively. Moreover, dietary intake of choline was marginally associated with AF risk (pooled hazard ratio 1.29, 95% confidence interval 1.01‐1.66, fifth versus first quintile), whereas no significant association was observed between dietary betaine and AF risk.ConclusionsOur findings indicate that plasma concentrations as well as dietary intake of choline, but not betaine, are associated with subsequent risk of AF, suggesting a potential role of choline metabolism in the pathogenesis of AF.Clinical Trial RegistrationURL: https://www.clinicaltrials.gov.Unique identifier: NCT00671346.

The PAr index, an indicator reflecting altered vitamin B-6 homeostasis, is associated with long-term risk of stroke in the general population: the Hordaland Health Study (HUSK)

ABSTRACTBackgroundVitamin B-6 homeostasis is altered during inflammation and immune activation. It is unknown whether altered vitamin B-6 homeostasis is associated with the risk of stroke.ObjectiveWe investigated the relation between the ratio plasma 4-pyridoxic acid: (pyridoxal + pyridoxal-5′-phosphate) (PAr) as an indicator of altered vitamin B-6 homeostasis and the risk of stroke in the general population.DesignWe conducted a prospective analysis of the community-based Hordaland Health Study (HUSK) in 6891 adults (born during 1925–1927 and 1950–1951) without known stroke at baseline (1998–1999). Participants were followed via linkage to the CVDNOR (Cardiovascular Disease in Norway) project and the Cause of Death Registry. HRs and 95% CIs were calculated using Cox proportional hazards analyses.ResultsA total of 390 participants (193 men and 197 women) developed stroke over a median follow-up period of 11 y. Study participants with elevated PAr experienced a higher risk of incident stroke in an essentially linear dose-response fashion. The HR (95% CI) for the highest compared with the lowest quartile of PAr was 1.97 (1.42, 2.73; P-trend <0.001) for total stroke and 2.09 (1.42, 3.09; P-trend <0.001) for ischemic stroke after adjustment for age, sex, body mass index (BMI), smoking, education, physical activity, estimated glomerular filtration rate, hypertension, diabetes, total cholesterol, and statin use. PAr had greater predictive strength than did C-reactive protein, current smoking, diabetes, hypertension, estimated glomerular filtration rate, and physical activity. The associations were similar in subgroups stratified by age group, sex, BMI, current smoking, hypertension, diabetes, and statin use at baseline.ConclusionsHigher plasma PAr was independently associated with increased risk of incident stroke in all participants and across all subgroups stratified by conventional risk predictors. Our novel findings point to and expand the range of inflammation and immune activation processes that may be relevant for the pathogenesis and prevention of stroke. This trial was registered at clinicaltrials.gov as NCT03013725.

Smoking, plasma cotinine and risk of atrial fibrillation: the Hordaland Health Study.

Cigarette smoking has been identified as a major modifiable risk factor for coronary heart disease and mortality. However, findings on the relationship between smoking and atrial fibrillation (AF) have been inconsistent. Furthermore, findings from previous studies were based on self-reported smoking. To examine the associations of smoking status and plasma cotinine levels, a marker of nicotine exposure, with risk of incident AF in the Hordaland Health Study. We conducted a prospective analysis of 6682 adults aged 46-74 years without known AF at baseline. Participants were followed via linkage to the Cardiovascular Disease in Norway (CVDNOR) project and the Cause of Death Registry. Smoking status was assessed by both questionnaire and plasma cotinine levels. A total of 538 participants developed AF over a median follow-up period of 11 years. Using questionnaire data, current smoking (HR: 1.41, 95% CI: 1.09-1.83), but not former smoking (HR: 1.03, 95% CI: 0.83-1.28), was associated with an increased risk of AF after adjustment for gender, age, body mass index, hypertension, physical activity and education. Using plasma cotinine only, the adjusted HR (95% CI) was 1.40 (1.12-1.75) for participants with cotinine ≥85 nmol L-1 compared to those with cotinine <85 nmol L-1 . However, the risk increased with elevated plasma cotinine levels until 1199 nmol L-1 (HR: 1.55, 95% CI: 1.16-2.05 at the third group vs. the reference group) and plateaued at higher levels. Current, but not former smokers, had a higher risk of developing AF. Use of plasma cotinine measurement corroborated this finding.

Prognostic Impact of In-Hospital and Postdischarge Heart Failure in Patients With Acute Myocardial Infarction: A Nationwide Analysis Using Data From the Cardiovascular Disease in Norway (CVDNOR) Project.

BackgroundHeart failure (HF) is a serious complication of acute myocardial infarction (AMI). We explored the excess mortality associated with HF as an early or late complication of AMI and describe changes over time in such excess mortality.Methods and ResultsAll patients hospitalized with an incident AMI and without history of prior HF hospitalization were followed up to 1 year after AMI discharge for episodes of HF. New HF episodes were classified as in‐hospital HF if diagnosed during the AMI hospitalization or postdischarge HF if diagnosed within 1 year after discharge from the incident AMI. Logistic and Cox regression models were used to explore the excess mortality associated with HF categories. Changes over time in the excess mortality were assessed by testing the interaction between HF status and study year. In‐hospital HF increased in‐hospital mortality 1.79 times (odds ratio [OR], 1.79; 95% CI: 1.68–1.91). The excess mortality associated with HF increased by 4.3 times from 2001 to 2009 (P interaction<0.001) as a consequence of a greater decline of in‐hospital mortality among AMI patients without (9% per year) compared to those with in‐hospital HF (3% per year). Postdischarge HF increased all‐cause and CVD mortality 5.98 times (hazard ratio, 5.98; 95% CI: 5.39–6.64) and 7.93 times (subhazard ratio, 7.93; 95% CI: 6.84 –9.19), respectively. The relative excess 1‐year mortality associated with HF did not change significantly over time.ConclusionsDevelopment of HF—either as an early or late complication of AMI—has a negative impact on patients' survival. Changes in the excess mortality associated with HF are driven by modest improvements in survival among AMI patients with HF as compared to those without HF.

Incident Coronary Heart Disease After Preeclampsia: Role of Reduced Fetal Growth, Preterm Delivery, and Parity

BackgroundPreeclampsia is a severe pregnancy disorder often complicated by reduced fetal growth or preterm delivery and is associated with long‐term maternal morbidity and mortality. We aimed to assess the association between preeclampsia phenotypes and risk of subsequent coronary heart disease and maternal cardiovascular mortality.Methods and ResultsWomen aged 16 to 49 years who gave birth during 1980–2002 and registered in the Medical Birth Registry of Norway were followed prospectively (1–29 years) for an incident major coronary event and mortality through linkage with the Cardiovascular Disease in Norway 1994–2009 (CVDNOR) project and the Norwegian Cause of Death Registry. Preeclampsia was subdivided based on the presence of a child born small for gestational age or preterm delivery. Among 506 350 women with 1 to 5 singleton births, there were 1275 (0.3%) occurrences of major coronary event, 468 (0.1%) cardiovascular deaths, and 5411 (1.1%) deaths overall. Compared with women without preeclampsia, the hazard ratio (95% CI) for major coronary event was 2.1 (1.73–2.65) after preeclampsia alone, 3.3 (2.37–4.57) after preeclampsia in combination with small for gestational age, and 5.4 (3.74–7.74) after preeclampsia in combination with preterm delivery. Analyses distinguishing women with 1 (n=61 352) or >1 (n=281 069) lifetime pregnancy and analyses with cardiovascular mortality as outcome followed the same pattern.ConclusionsThe occurrence of major coronary events was increased among women with preeclampsia and highest for preeclampsia combined with a child born small for gestational age and/or preterm delivery.

Time Trends and Educational Inequalities in Out-of-Hospital Coronary Deaths in Norway 1995-2009: A Cardiovascular Disease in Norway (CVDNOR) Project.

BackgroundRecent time trends and educational gradients characterizing out‐of‐hospital coronary deaths (OHCD) are poorly described.Methods and ResultsWe identified all deaths from coronary heart disease occurring outside the hospital in Norway during 1995 to 2009. Time trends were explored using Poisson regression analysis with year as the independent, continuous variable. Information on the highest achieved education was obtained from The National Education Database and classified as primary (up to 10 years of compulsory education), secondary (high school or vocational school), or tertiary (college/university). Educational gradients in OHCD were explored using Poisson regression, stratified by sex and age (<70 and ≥70 years), and results were expressed as incidence rate ratios (IRRs) and 95%CIs. Of 100 783 coronary heart disease deaths, 58.8% were OHCDs. From 1995 to 2009, age‐adjusted OHCD rates declined across all education categories (primary, secondary, and tertiary) in younger men (IRR=0.35; 95%CI 0.32‐0.38; IRR=0.38; 95%CI 0.35‐0.42; IRR=0.33; 95%CI 0.28‐0.40), younger women (IRR=0.47; 95% CI 0.40‐0.56; IRR=0.55; 95%CI 0.45‐0.67; IRR=0.28; 95% CI 0.16‐0.47), older men (IRR=0.20; 95%CI 0.19‐0.22; IRR=0.20; 95%CI 0.18‐0.22; IRR=0.20; 95%CI 0.17‐0.23), and older women (IRR=0.26; 95%CI 0.24‐0.28; IRR=0.25; 95%CI 0.23‐0.28; IRR=0.28; 95%CI 0.22‐0.34). Tertiary education was associated with lower risk of OHCD compared to primary education (IRR=0.37; 95%CI 0.35‐0.40 in younger men, IRR=0.26; 95%CI 0.22‐0.30 in younger women, IRR=0.52; 95%CI 0.49‐0.55 in older men, and IRR=0.61; 95%CI 0.57‐0.66 in older women). These gradients did not change over time (P interaction=0.25).ConclusionsAlthough OHCD rates declined substantially during 1995 to 2009, they displayed educational gradients that remained constant over time.

Educational inequalities in mortality of patients with atrial fibrillation in Norway

Objectives: We explored the educational gradient in mortality in atrial fibrillation (AF) patients.Design: We prospectively followed patients hospitalized with AF as primary discharge diagnosis in the Cardiovascular Disease in Norway 2008-2012 project. The average length of follow-up was 2.4 years. Mortality by educational level was assessed by Cox proportional hazard models. Population attributable fractions (PAF) were calculated. Analyses stratified by age (≤75 and >75 years of age), and adjusted for age, gender, medical intervention, and Charlson Comorbidity Index.Results: Of 42,138 AF patients, 16% died by end of 2012. Among younger patients, those with low education (≤10 years) had a HR of 2.3 (95% confidence interval 2.0, 2.6) for all-cause mortality relative to those with any college or university education. Similar results were observed for cardiovascular mortality. Disparities in mortality were greater among younger than older patients. A PAF of 35.9% (95% confidence interval 27.9, 43.1) was observed for an educational level of high school/vocational school or less versus higher education in younger patients.Conclusions: Increasing educational level associated with better prognosis suggesting underlying education-related behavioral and medical determinants of mortality. A considerable proportion of mortality within 5 years following hospital discharge could be prevented.

Heart Failure Complicating Acute Myocardial Infarction; Burden and Timing of Occurrence: A Nation-wide Analysis Including 86 771 Patients From the Cardiovascular Disease in Norway (CVDNOR) Project.

BackgroundCoronary heart disease (CHD) represents often the underlying conditions for the development of heart failure (HF). We aimed at exploring the burden and timing of HF complicating an acute myocardial infarction (AMI), using the total population of AMI patients hospitalized during 2001–2009 in Norway.Methods and ResultsA total of 86 771 patients with a first AMI during 2001–2009 and without previous HF were identified in the “Cardiovascular Disease in Norway” project and followed until HF development, death, or December 31, 2009. In 16 219 patients (18.7%), HF was present on admission or developed during hospitalization for the incident AMI. HF occurrence varied according to age (8.9%, 15.2%, and 25.6% among men and 10.2%, 16.8%, and 27.1% among women ages 25–54, 55–74, and 75–85 years). Among 63 853 patients discharged alive without HF, 8058 (12.6%) were hospitalized with or died because of HF during a median follow‐up time of 3.2 years. HF incidence rates (IRs) per 1000 person‐years during follow‐up were 31 (95% CI, 30–32) for men and 46 (95% CI, 44–47) for women (P<0.01). IRs of HF were highest during the first 6 months of follow‐up, after which they leveled off and remained stable until the end of follow‐up.ConclusionsIn this nation‐wide cohort study, we observed that HF remains a frequent complication of the first AMI; both during the acute phase and shortly after the discharge from the hospital.

Ethnic inequalities in acute myocardial infarction and stroke rates in Norway 1994-2009: a nationwide cohort study (CVDNOR).

BackgroundImmigrants to Norway from South Asia and Former Yugoslavia have high levels of cardiovascular disease (CVD) risk factors. Yet, the incidence of CVD among immigrants in Norway has never been studied. Our aim was to study the burden of acute myocardial infarction (AMI) and stroke among ethnic groups in Norway.MethodsWe studied the whole Norwegian population (n = 2 637 057) aged 35–64 years during 1994–2009. The Cardiovascular Disease in Norway (CVDNOR) project provided information about all AMI and stroke hospital stays for this period, as well as deaths outside hospital through linkage to the Cause of Death Registry. The direct standardization method was used to estimate age standardized AMI and stroke event rates for immigrants and ethnic Norwegians. Rate ratios (RR) with ethnic Norwegians as reference were calculated using Poisson regression.ResultsThe highest risk of AMI was seen in South Asians (men RR = 2.27; 95 % CI 2.08–2.49; women RR = 2.10; 95 % CI 1.76–2.51) while the lowest was seen in East Asians (RR = 0.38 in both men (95 % CI 0.25–0.58) and women (95 % CI 0.18–0.79)). Immigrants from Former Yugoslavia and Central Asia also had increased risk of AMI compared to ethnic Norwegians. South Asians had increased risk of stroke (men RR = 1.26; 95 % CI 1.10–1.44; women RR = 1.58; 95 % CI 1.32–1.90), as did men from Former Yugoslavia, Sub-Saharan Africa and women from Southeast Asia.ConclusionsPreventive measures should be aimed at reducing the excess numbers of CVD among immigrants from South Asia and Former Yugoslavia.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-2412-z) contains supplementary material, which is available to authorized users.