Coronary Heart Disease In Finland Research Articles

Population-based health-economic evaluation of the secondary prevention of coronary heart disease in Finland

Objective:To evaluate the cost-effectiveness of generic atorvastatin 20 mg (A20), branded rosuvastatin 10 mg (R10), generic simvastatin 40 mg (S40) and the combination of generic S40 + branded ezetimibe 10 mg (S40 + EZ10) for the secondary prevention of coronary heart disease (CHD) in Finnish patients not meeting the target goal of low-density lipoprotein cholesterol (LDL-C) with S40.Research design and methods:A probabilistic Markov model was employed to evaluate the costs and health outcomes of the different therapies based on the cardiovascular events avoided. The model included Framingham risk equations, Finnish population characteristics, event rates, quality of life estimates, resource use and unit costs. The LDL-C lowering efficacies were gathered from a systematic literature review, based on a search of Medline carried out in June 2008 (no time limit).Main outcome measures:Incremental cost per quality-adjusted life year (QALY) gained and incremental cost per life year gained (LYG).Results:The efficacy (LDL-C decrease) gained from switching S40 to S40 + EZ10 was consistent in the literature review, whereas the LDL-C decrease gained from switching S40 to A20/R10 was uncertain. The incremental cost per QALY gained from switching generic S40 was lowest for S40 + EZ10 (€22,841 [€24,017] and €26,595 [€46,686] for diabetic and non-diabetic men [women], respectively). The respective incremental cost per QALY gained for S40 + EZ10 vs. A20 were €19,738 (€21,405) and €23,596 (€40,087). A20 dominated R10. Based on the cost-effectiveness acceptability frontier with a willingness-to-pay value of €30,000 per QALY gained, the probability of cost-effectiveness for switching generic S40 to S40 + EZ10 was 100% for men and diabetic women. Sensitivity analyses showed that results were robust.Conclusions:In the Finnish secondary prevention population that is not at goal on S40, switching generic S40 to S40 + EZ10 is more cost-effective than switching S40 to generic A20 or R10.

The feasibility of routine mortality and morbidity register data linkage to study the occurrence of acute coronary heart disease events in Finland. The Finnish Cardiovascular Diseases Registers (CVDR) Project.

Validated population-based data on the occurrence of coronary heart disease in Finland have previously been obtained from myocardial infarction (MI) registers. Such registers cannot, however, cover large areas. Therefore, the Finnish Cardiovascular Diseases Registers (CVDR) Project was set up to obtain data for the whole of Finland. The CVDR Project is based on routine mortality and morbidity data linkage. We report here the overall approach used in the project, the results of the feasibility study and the first main results. In Finland, data on all hospitalizations are registered in the nationwide Hospital Discharge Register. Also, data on all deaths are collected in the nationwide Causes of Death Register. The unique personal identification number assigned to all persons residing in Finland was used for data linkage. Data have been validated using the FINMONICA MI registers. Sensitivity analyses showed that the data were robust and consistent between different geographical areas. Coronary heart disease (CHD) mortality as well as the incidence and event rates showed the same very clear geographical pattern, dividing Finland to a southwest area with a lower occurrence and a northeast area with nearly twice higher occurrence. Case fatality did not differ much between the areas and did not follow this Southwest-Northeast division. The differences between northeast and southwest Finland may be related to differences in risk factor levels but also to socioeconomic and genetic differences. The CVDR Project data will be instrumental in further research addressing these issues.

Serum Cholesterol Trends among Members of the Finnish Parliament

Background.Mortality from coronary heart disease in Finland has declined remarkably since the early 1970s. Most of the change has apparently been due to the active national strategy for reduction of serum cholesterol levels. This study was undertaken to estimate to what extent members of the Finnish parliament (MPs) have complied with the national recommendations.Methods.Serum total and HDL cholesterol values were measured from MPs of three subsequent parliaments elected in 1987, 1991, and 1995.Results.From 1987 to 1995, the Finnish MPs showed a reduction of serum total cholesterol that was significant among males (−5.2;%,P< 0.05) but not among females (−6.4%, NS) and was somewhat smaller than the reduction in the general population during 1987 to 1997 (−9.4% among males and −8.3% among females). The male MPs had a 14% rise in HDL cholesterol (P< 0.01), while among female MPs and in the general population it decreased by 3.1 to 3.8% (all NS). The cholesterol levels of female MPs were altogether a little lower than in the general population. The Finnish MPs tended to have lower total cholesterol levels compared with those reported from Hungarian MPs.Conclusion.The favorable change in the lipid profile of members of the Finnish parliament indicates that they have personally been involved in the national change process. Follow-up of risk factors in national decision-makers is a useful part of comprehensive monitoring of national coronary heart disease prevention activity.

The Validity of the Routine Mortality Statistics on Coronary Heart Disease in Finland: Comparison with the FINMONICA MI Register Data for the Years 1983–1992

We compared the diagnoses obtained from the routine mortality statistics with the standardized World Health Organization (WHO) MONICA (multinational MONItoring of trends and determinants in CArdiovascular disease) classification in suspect coronary heart disease (CHD) deaths registered in the FINMONICA myocardial infarction (MI) register during 1983–1992. All CHD deaths from routine mortality statistics (International Classification of Diseases codes 410–414) were registered in the MI register. Of the CHD deaths in routine mortality statistics 1.7% in men and 4.8% in women did not fulfill the MONICA criteria for CHD death (P < 0.001 for the difference between the sexes). In men 4.7% and in women 7.3% (P = 0.004) of the deaths registered in the MI Register and classified as CHD deaths by MONICA criteria had another underlying cause of death than CHD in routine mortality statistics; this proportion increased over time in both sexes (P = 0.002 in men and P = 0.77 in women). The CHD mortality trends obtained separately from the routine mortality statistics and from the FINMONICA MI Register were very similar. In conclusion, the high CHD mortality in Finland reported by the routine mortality statistics is real. It is possible that some CHD deaths have escaped registration, but the decline seen in the CHD mortality is also real.

Angiotensin‐converting enzyme genotypes in the high‐ and low‐risk area for coronary heart disease in Finland

The deletion/deletion genotype of the insertion (I)/deletion (D) polymorphism of the angiotensin-converting enzyme (ACE) gene has been suggested to be a risk factor for myocardial infarction (MI). The objective of this study was to evaluate whether genotype distributions of the I/D polymorphism of the ACE gene are different between individuals from high-risk and low-risk areas for coronary heart disease in the genetically isolated population of Finland and to assess the impact of this genetic risk factor by comparing individuals with different parental histories of MI. Representative population-based samples of middle-aged men (n = 363) and women (n = 358) from two areas of Finland were used. The area had a borderline significant effect on the prevalence of the genotype DD (beta = 0.35, SE = 0.16, X2 = 470, df = 1, P = 0.03), the DD genotype being more prevalent in eastern Finland (the high-risk area). The II genotype was more prevalent in women with parental history of MI, so we could not replicate the previous findings of the risk-increasing effect of DD genotype in this sample. Although the observed difference in the ACE DD genotype between the high-risk and low-risk areas for coronary heart disease might represent one of the genetic factors contributing to the difference in risk of coronary heart disease between eastern and southwestern Finland, the data emphasize the fact that also other risk factors, including other genes, contribute to this difference and the high incidence of MI in Finland.

Trends in the incidence of and mortality from coronary heart disease in Finland, 1983-1988.

Trends in the incidence of and mortality from coronary heart disease during the period 1983-1988 were assessed in the population aged 35-64 years in three areas of Finland. The official mortality statistics and the FINMONICA (Finnish portion of the World Health Organization MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) project) Acute Myocardial Infarction Register were used as data sources. They both showed that coronary heart disease mortality declined steeply in Finnish men and women. This marked decline in coronary heart disease mortality was associated with a decline in the number of out-of-hospital coronary deaths. The changes in the incidence of acute myocardial infarction in men did not parallel the changes in mortality. No decline in incidence was seen in women in any of the study areas. These results suggest that the routine mortality statistics alone may give an overly favorable picture of coronary heart disease trends. Data on incidence are necessary to assess the need for the treatment and prevention of coronary heart disease.

Serum Lipids and Lipoproteins in Children, Adolescents and Young Adults in 1980–1986

A multicentre study on atherosclerosis precursors in young Finns aged three to 18 years was started in 1980 (3596 subjects) serum lipid concentrations (cholesterol, HDL (high density lipoprotein) cholesterol and triglycerides) were determined (n = 3554) and the apolipoproteins A-I and B measured (n = 1355). Two follow-up studies were carried out in 1983 (n = 2851) and 1986 (n = 2489), when HDL-subfractions (HDL-2-cholesterol and HDL-3-cholesterol) were also determined. Apolipoproteins A-I and B were measured again in 1986 (n = 1202). Serum total cholesterol concentration has fallen by about 1% annually during the 1980's from 5.07 mmol/l (1980) to 4.79 mmol/l (1986) in 9- to 18-year old children and adolescents. Mean values of serum triglycerides have slightly increased during the follow-up from 0.79 mmol/l to 0.84 mmol/l, respectively. In children and young adults (3-24 years) the mean cholesterol concentration was highest at the age of six and lowest during puberty. Concentrations of serum cholesterol, LDL (low density lipoprotein) cholesterol apoprotein B and triglycerides were higher in eastern than in western Finland in 1980 and 1983, but these differences were smaller in 1986, with the exception of serum triglycerides. Both in 1983 and in 1986 HDL-2-cholesterol was lower in the west than in the east, whereas HDL-3-cholesterol was higher in the former. The favourable changes in lipid levels should be reflected in future morbidity and mortality rates from coronary heart disease in Finland.

Prevention of Coronary Heart Disease in Finland—Application of the Population Strategy

The North Karelia Project was the first population-based cardiovascular disease prevention programme. Even though it achieved, as compared to the reference population, a sizeable reduction in smoking and small effect in blood pressure and serum cholesterol levels, the effect on coronary and cardiovascular mortality of the programme remains equivocal. This is mainly due to shortcomings in the original study design and unanticipated start of the national decline in coronary mortality at the same time with the programme. North Karelia Project contributed, however, to the initiation of national activities in the prevention of cardiovascular disease. These have produced a favourable trend in lipids in the whole Finnish population. The recommendations and activities by national authorities and organizations have suffered, until recently, from orientation towards screening and individual risk factors. The success in North Karelia in early 1970's in the reduction of smoking has still not occurred nationally. Further emphasis is needed in the population approach and in the integration of preventive activities into the community and legislation.

Apolipoprotein E phenotypes in Finnish youths: a cross-sectional and 6-year follow-up study.

Apolipoprotein E (apoE) polymorphism is a genetic determinant of plasma lipid levels and of coronary heart disease (CHD) risk. We determined the apoE phenotypes and plasma lipid levels in 1577 youths aged 3 to 18 years in 1980. The subjects were randomly selected from five areas of Finland. ApoE phenotyping was performed directly from plasma by isoelectric focusing and immunoblotting. The apoE allele frequencies in the population sample were epsilon 2 = 0.039, epsilon 3 = 0.767, and epsilon 4 = 0.194. There were no differences in the apoE phenotype distribution between East and West Finland or between sexes. The concentrations of serum total cholesterol, low density lipoprotein cholesterol, and apolipoprotein B increased with apoE phenotype in the order of E2/2, E3/2, E4/2, E3/3, E4/3, and E4/4. This increase was already seen in 3-year-old children; it was observed in both sexes, but was clearer in males than in females. The mean levels of high density lipoprotein (HDL) cholesterol, apolipoprotein A-I, triglyceride, Lp[a] lipoprotein, and the activity of lecithin:cholesterol acyltransferase did not differ between the apoE phenotypes. The observed differences in serum cholesterol remained fairly stable during the 6-year follow-up from 1980 to 1986, while the mean serum cholesterol concentration in the whole study population decreased by 6.3%. This study confirms the reported higher frequency of the epsilon 4 allele in Finns as compared to most other populations; this may contribute to the high rates of CHD in Finland as compared to most other populations. The results do not, however, explain the higher rate of CHD in East Finland in comparison to the western part of the country.

Cardiovascular risk in young Finns, results from the second follow-up study.

A comprehensive study of coronary heart disease (CHD) risk factors and their determinants in children and adolescents in Finland was initiated in the late 1970's. The main cross-sectional study was undertaken in 1980, with 3596 subjects aged from 3 to 18 years participating. The first follow-up study was carried out in 1983, and the second in 1986. The present report describes briefly some findings in 2746 children and young adults, aged 9, 12, 15, 18, 21 and 24 years, participating in 1986. Serum total cholesterol concentrations, mean (SD), ranged between 4.31 (0.73) and 4.91 (0.81) mmol/l in boys, and between 4.73 (0.85) and 5.09 (0.82) mmol/l in girls, respectively. Mean serum cholesterol values had fallen from 1980 to 1986 by 5.4% in such age cohorts, which had been included in all three studies. Fat content in the diet remained unchanged (38 E %), whereas the mean P/S ratio increased from 0.24 in 1980 to 0.31 in 1986. Young Finns from East Finland had a higher somatic risk index than those from West Finland (P greater than 0.001). The clustering of somatic risk factors was stable between 1980 and 1986. Further follow-up of the cohorts will, we hope, provide the tools for implementing primary prevention of CHD in Finland.

Decline in mortality from coronary heart disease in Finland from 1969 to 1979.

The trends in mortality from coronary heart disease in the 1970s and the differences in trends between counties within Finland were calculated from official mortality statistics among the population aged 35 to 64 years. During this period coronary mortality declined by a mean of 1.1% for men and 2.3% for women annually in the whole of Finland. A community based cardiovascular control programme was started in 1972 in North Karelia, a county in the east of Finland. The decline in coronary mortality in this county between 1969 and 1979 was 24% in men and 51% in women. The decline in the rest of Finland over the same period was 12% in men and 24% in women. The decline in North Karelia was greater than that in other counties of Finland for both men and women and that difference exceeded random variation, with over 95% likelihood for both sexes. Even with adjustment for rates before 1974 with cross-county multiple regression analyses the difference persisted. Although further studies are needed, the changes in coronary mortality in North Karelia suggest that the preventive programme has been effective.

The high incidence of coronary heart disease in Finland and its probable causes

The mortality from coronary heart disease (CHD) in Finland is remarkably high; according to the vital statistics released by the World Health Organization it has for many years been the highest in the world. This, however, concerns only the male sex; in the females the mortality figures, though also relatively high, do not very markedly differ from those of many other populations. It is also noteworthy that the CHD mortality in the eastern provinces of Finland is higher than in the western provinces.

Subjects' recent life changes and coronary heart disease in Finland.

Data on recent life changes were gathered for 279 survivors of myocardial infarction and 226 victims of sudden coronary death in Helsinki, Finland. Subjects in both groups experienced a significant increase in recent life changes during the six months prior to infarction or death compared with the same six-month period one year earlier. Subjects were compared according to whether they had shown marked, moderate, or no increase in recent life changes. The authors point out the usefulness of including data on precipitating factors in prospective studies of coronary heart disease along with data on such physical risk factors as serum cholesterol levels and systolic blood pressure.