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XXI Reunión Científica de la Sociedad Española de Epidemiología, conjunta con la
Federación Europea de Epidemiología de la Asociación Internacional de Epidemiología
Gac Sanit 2003;17(Supl 2):51-198
O18 - Comunicación Oral/Oral communication
Enfermedades cardiovasculares II
Cardiovascular diseases II
Viernes 3 de Octubre / Friday 3, October
9:00:00 a/to 11:00:00
Moderador/Chairperson:
Hans Werner Hense y Mª José Tormo
PATTERNS OF DIFFERENTIAL HYPERTENSION CONTROL IN THE
COMMUNITY - THE MONICA AUGSBURG PROJECT
Jan Heidrich*, Wazim Maziak*, Edith Siebert*, Angela Döring**, Ul-
rich Keil*, Hans-Werner Hense*
*Institute of Epidemiology & Social Medicine, University of Münster, Münster, Germany.
**Institute of Epidemiology, GSF-Research Centre, Neuherberg, Germany.
Introduction:
In recent years, importance has been attached to the distinction of sys-
tolic (SBP) and diastolic (DBP) blood pressure control among hypertensives. This
study aims to identify patterns and correlates of differential blood pressure control
in the community.
Methods:
We used data from three pooled survey samples of the the MONICA-Augs-
burg project 1984-95. Overall, 6910 men and 6908 women aged 25-74 years parti-
cipated in the study. Hypertension was defined as SBP/DBP >=140/90 mmHg or re-
ceiving antihypertensive drug therapy at the time of the survey. We determined the
age- and gender-stratified prevalence of three subtypes of hypertension based on
the presence of isolated SBP (SBP >=140 and DBP <90 mmHg), isolated DBP (SBP
<140 and DBP >=90 mmHg) elevation, or both. We assessed the proportion of con-
trol according to SPB (<140 mmHg) and DBP (<90 mmHg) among treated hyper-
tensives and identified factors related to poor SBP and DBP control using multiva-
riate analysis.
Results:
Among untreated hypertensives (N=3631), mean SBP increased with age
in men and women, while DBP decreased with age in both. In hypertensives aged
25-44 years, isolated SBP, isolated DBP, and joint SBP/DBP elevations contributed
in similar proportions to the total number of untreated hypertensives. In contrast, in
older hypertensives (age 65-74 years) isolated SBP constituted about two thirds of
the total number of untreated hypertensives. Among treated hypertensives (N=1700),
36% were controlled to SBP, 67% to DBP and only 32% to both, respectively. Age
was the only factor significantly associated with poor SBP control in the multivariate
analysis: poor SBP control was twice as common in the 45-64 years age group (OR
1.9; 95% CI 1.3-2.9) and three times in the 65-74 years age group (OR 2.8; 1.8-4.3),
as compared to the younger age group. On the other hand, poor DBP control was
less common in older age (OR 0.3; 0.2-0.5) and in diabetic patients (OR 0.5; 0.3-0.7).
Conclusions:
This study reveals a clear age-related pattern of hypertension con-
trol. Isolated systolic hypertension is predominating in older age. Poor SBP control
increases with age and constitutes most of poor overall hypertension control. SBP
control continues to be far more difficult to achieve than DBP control, putting older
hypertensives at particular risk. There is evidence from epidemiological and clinical
studies that DBP < 90 mmHg is achievable in 70-90%, whereas only 30-50% of hy-
pertensives attain a SBP < 140 mmHg. Achievement of systolic BP < 140 mmHg is
a medically reasonable and defendable goal but might be unrealistic in older age.
237
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Joint Scientific Meeting of the International Epidemiological Association European Epidemiology Federation (IEA EEF)
& the Spanish Society of Epidemiology (SEE)
Gac Sanit 2003;17(Supl 2):51-198
DETERMINANTS OF B-TYPE NATRIURETIC PEPTIDE VARIABILITY
IN THE POPULATION
Ana Azevedo*, Paulo Bettencourt**, Rui A. Rodrigues***, Pedro B Al-
meida***, Margarida Alvelos**, Fernando Frioes**, Paula Dias***, Cas-
siano A. Lima***, Henrique Barros*
*Hygiene and Epidemiology, University of Porto Medical School, Porto, Portugal. **Ser-
viço de Medicina B, Hospital de S. João, Porto, Portugal. ***Serviço de Cardiologia,
Hospital de S. João, Porto, Portugal.
Introduction:
There is wide overlap of B-type natriuretic peptide (BNP) plas-
ma levels between people with and without heart failure (HF) and/or left ventri-
cular systolic dysfunction (LVSD). Thus performance of BNP for detection of LVSD
at the community level is suboptimal. The aim of this study was to identify de-
terminants of plasma BNP levels at the populational level.
Methods:
In a cross-sectional study, we evaluated 559 participants selected from
the community-dwellers of Porto aged 45 years or older by random digit dialing.
Participants answered a questionnaire and were submitted to a clinical exami-
nation, ECG, echocardiogram and venous blood sample collection. BNP was
measured by the BIOSITE® Triage meter. The association between BNP and
independent variables was assessed by linear regression using the natural lo-
grithm of BNP plasma concentration as the dependent variable.
Results:
BNP levels were significantly higher in women than in men and this
association was not changed when taking into account other determinants of
BNP. Further analysis was stratified on gender. BNP increases with age, more
steeply in men than women (p<0.05 for the interaction). In univariate analysis,
BNP was associated in both men and women with LVSD, moderate-severe val-
vular abnormalities, left atrial diameter/body surface area, left ventricular mass
index, systolic blood pressure, lower creatinine clearance and jugular venous
distention on physical examination. In women it was also related with end-dias-
tolic left ventricular diameter/body surface area and in men with changes in the
segmental wall motion index. The final multivariable model includes as signifi-
cant independent determinants of BNP levels: age, LVSF and left atrial dimen-
sion among women, and age, LVSF and systolic blood pressure among men.
These models explain 17.2% and 32.3% of the variability of BNP, respectively
in women and men.
Conclusion:
The main determinants of BNP plasma levels in the population were
female gender; age and left ventricular systolic dysfunction in both genders; left
atrial size in women and systolic blood pressure in men. The association bet-
ween age and BNP was significantly stronger among men than women.
240
FAMILY HISTORY OF VENOUS DISEASES IN PATIENTS WITH VA-
RICOSIS - RESULTS OF A POPULATION-BASED CROSS-SEC-
TIONAL STUDY.
Katja Bromen
1
, Andreas Stang
1
, Eberhard Rabe
2
, Katrin Schuldt
1
, Su-
sanne Weber
1
, Eva Bock
1
, Felizitas Pannier-Fischer
2
, Karl-Heinz Jöckel
1
1
Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, Uni-
versity of Essen, Essen, Germany.
2
Department of Dermatology, University of Bonn,
Bonn, Germany.
Introduction:
Diseases of the venous system belong to the most frequent diseases
in the German population. However, the last comprehensive population-based Ger-
man data stem from a study conducted in Tübingen in 1979. Since then, diagnostic
methods have improved substantially. Also, the risk factor exposure has changed, e.g.
lack of exercise, sedentary occupations. Practical experience and scientific studies in-
dicate a familial predisposition to this disease. We examined this issue using actual
epidemiologic data.
Methods:
We conducted a population-based cross-sectional study in Bonn and its su-
rrounding rural area (Recruitment period: 11/2000-12/2001; response: 59%) funded by
the Federal Ministry of Health and the German Society of Phlebology. The study po-
pulation comprised 3072 participants, 18 to 79 years of age. The investigation consis-
ted of ascertaining a standardized medical history, physical examination, and duplex
sonography of veins of the legs. The definition of varicosis of the leg is based upon the
CEAP-Classification. 2 outcome definitions were used: 1) Participants were defined as
having varicose veins if the clinical classification was at least C2, 2) Symptomatic va-
ricose veins, i.e. clinical classification of at least C3. In both groups, those showing iso-
lated spider-bursts / telangiectasia exclusively and those with exclusive postthrombo-
tic etiology were excluded. Risk factors examined were family history of varicose veins
(VV), thrombophlebitis of the legs (TL), deep venous thrombosis of the leg (VT), and
crural ulcer (CU). Logistic regression, adjusted for age, sex and family size was used
for calculation of odds ratios (OR) and 95% confidence intervals (95%-CI).
Results:
713 study participants (23%) had varicose veins with clinical classification
of at least C2 (20% of all men, 26% of all women). 295 study participants (10%) sho-
wed symptomatic varicose veins as defined above (8% of all men, 11% of all women).
Prevalences of family history (parents and siblings) were as follows: VV: 52%, TL: 14%,
VT: 13%, CU: 8%. Results of the logistic regression were as follows: 1) Varicose veins:
VV: OR=2.2 (95%-CI:1.8-2.6), TL: OR=1.9 (95%-CI:1.5-2.4), VT: OR=1.6 (95%-CI:1.2-
2.0), CU: OR=2.0 (95%-CI:1.5-2.7). 2) Symptomatic varicose veins: VV: OR=1.7 (95%-
CI:1.3-2.2), TL: OR=1.5 (95%-CI:1.1-2.1), VT: OR=1.4 (95%-CI:1.0-2.0), CU: OR=1.8
(95%-CI:1.2-2.5). Including the information on grandparents did not lead to relevant
changes in results.
Conclusions:
The association between family history of various forms of venous di-
seases and varicosis was confirmed by the results of this study.
241
DISEASE-RELATED COSTS IN PATIENTS WITH HYPERCHOLES-
TEROLEMIA
Jacqueline Müller-Nordhorn
1
, Heike Englert
1
, Frank Sonntag
2
, Heinz
Völler
3
, Eberhard Windler
4
, Wolfgang Meyer-Sabellek
5
, Hugo Katus
6
,
Karl Wegscheider
4
, Stefan N Willich
1
1
Institute of Social Medicine, Epidemiology, Health Economics, Charité Hospital, Ber-
lin, Germany.
2
Cardiologist, Henstedt-Ulzburg, Germany.
3
Rehabilitation Centre for Car-
diovascular Diseases, Rüdersdorf, Germany.
4
University of Hamburg, Germany.
5
As-
traZenaca GmbH, Wedel, Germany.
6
University of Heidelberg, Germany.
Introduction:
Hypercholesterolemia (HC) is a major risk factor for cardiovascu-
lar diseases. In a cost-of-illness analysis we aimed to assess direct and indirect
costs of patients withHC.
Methods:
The present analysis is part of the ongoing ORBITAL study, a rando-
mised controlled trial evaluating the long-term cost-effectiveness of a complian-
ce enhancing programme in 8000 patients with HC requiring statin therapy ac-
cording to Joint European Guidelines. At baseline patients were asked
retrospectively about their medical resource use and employment status in the
six months preceding enrolment. Direct cost data (including for the present analy-
sis costs for ambulatory, hospital, rehabilitative and nursing care, physiotherapy
and transportation) were calculated by multiplying medical resource units used
with cost factors per unit. Indirect cost data (productivity loss) were calculated
by multiplying days off work due to illness or disease-related early retirement with
the average cost factor per day (societal perspective).
Results:
Among a total of 2500 patients (mean age 61 ± 11 years, 44% fema-
le) included in the present analysis, 32% were employed at the time of inclusion,
19% had a history of myocardial infarction, 8% a history of stroke, 61% had hy-
pertension and 28% diabetes. Disease-related direct costs amounted to a mean
of 655 Euros ± 2293 per patient in the six months period, indirect costs to a mean
of 1495 Euros ± 4124 per patient. Direct costs included mainly costs for hospi-
tal stays (433 Euros ± 2098), primary care consultations (111 Euros ± 118), out-
patient therapeutic measures (54 Euros ± 200), and rehabilitation (43 Euros ±
367). Indirect costs due to days off work amounted to 303 Euros ± 1485, due to
early retirement to 1191 Euros ± 3940. Of all patients, 11% (n=287) reported days
off work (median 14 days) and 9% (n=214) reported disease-related early reti-
rement.
Conclusions:
Indirect costs due to a loss of productivity contributed markedly
to the disease-related costs in patients with HC. The considerable economic bur-
den of HC indicates the need to assess long-term effectiveness of health care
programmes in patients with the disorder.
238
HIGH SENSITIVITY C-REACTIVE PROTEIN AND THE FEATURES
OF THE METABOLIC SYNDROME
Ana C Santos*, João T Guimarãaes**, Mario Cerqueira-Gomes***, Hen-
rique Barros*
*Department of Hygiene and Epidemiology, University of Porto Medical School, Porto,
Portugal. **Department of Immunology, University of Porto Medical School, Porto, Por-
tugal. ***Unit of Cardiovascular Research and Development, University of Porto Me-
dical School, Porto, Portugal.
Introduction:
The metabolic syndrome components, including central obesity, high
blood pressure and glucose resistance, are major cardiovascular risk factors and
have recently been associated with elevated levels of the acute phase reactant,
C-reactive protein (CRP). We aimed to evaluate the association between the le-
vels of CRP and the features of the metabolic syndrome in an urban sample of
community dwellers.
Methods:
We evaluated 498 adult subjects (306 women and 192 men), 18-92 years,
recruited after random sampling of Porto in-habitants. All participants completed
a structured questionnaire comprising information on social, demographic, beha-
vioural and clinical aspects. Anthropometrics and blood pressure were recorded
and a fasting blood sample collected. Metabolic syndrome was defined according
to the Third Report of the Expert Panel on Detection, Evaluation, and Treatment
of High Blood Cholesterol in Adults, as the presence of 3 or more of the following
characteristics: waist circumference greater than 102 cm in men and 88 cm in women,
triglycerides levels
150mg/dL, high density lipoprotein cholesterol (HDL)
40 mg/dL
in men and
50mg/dL in women, blood pressure
130/85 mm Hg and serum glu-
cose
110mg/dL. High-sensitivity CRP was assessed by nephelometry. Means were
compared after log transformation using ANOVA.
Results:
Median CRP levels were significantly higher (p<0.05) in the presence of
central obesity (2.8mg/L vs. 1.2mg/L), high blood pressure (1.9mg/L vs. 1.0mg/L)
and hypertriglyceridemia (2.0mg/L vs. 1.4mg/L). In the presence of metabolic syn-
drome higher median levels of CRP (2.7 mg/L vs. 1.4 mg/L, p<0.001) were also
observed. We also found a significant increasing trend (p<0.001) in median levels
of CRP with increasing number of components of the metabolic syndrome.
Conclusions:
The present data supports the hypothesized role of inflammation
in the development of several features of the metabolic syndrome, namely obe-
sity and hypertension. Moreover it also seems that increasing severity of meta-
bolic syndrome is associated with increasing inflammation. The metabolic syndrome
seems to be associated with a systemic inflammatory response, which may re-
present an additional pathway for coronary heart disease in these subjects.
239
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XXI Reunión Científica de la Sociedad Española de Epidemiología, conjunta con la
Federación Europea de Epidemiología de la Asociación Internacional de Epidemiología
Gac Sanit 2003;17(Supl 2):51-198
STROKE PATIENTS AND CAREGIVERS. A SOCIAL INTERVENTION
RANDOMISED TRIAL
David Costa, Henrique Barros
Hygiene and Epidemiology, University of Porto Medical School, Porto, Portugal.
Introduction:
Stroke is a common disease with a well known psychosocial
impact both on surviving patients and their caring family. However, there is
no clear-cut information on the effectiveness of social support on patients’ and
caregivers outcome as measured through functional or psychosocial indices.
We did a randomized controlled trial to assess the impact of a social work in-
tervention on stroke patients and their informal carers.
Methods:
We identified 301 patients admitted for a first ischemic stroke at
the medical wards of a tertiary University Hospital, able to complete the ne-
eded questionnaires, and their carers. The patient-caregiver pairs were ran-
domly assigned to routine care procedures (n=149) or to the intervention group
(n=152). Intervention comprised two home visits at months 1 and 10 after dis-
charge. During the visits participants were fully informed about every social
support services in the community, needs assessed and orientation provided.
Barthel index, the mini-mental state examination, the Nottingham health pro-
file (NHP) and Beck’s depressive inventory (BDI) were completed for the pa-
tients and NHP and BDI for caregivers, at discharge, 3 and 12 months. At ba-
seline, no significant differences were found between patients in the
intervention and the control group regarding social, demographic and clinical
variables. However, caregivers in the intervention group scored significantly
better in the mobility (p<0.01) and social isolation (p=0.02) scales of the NHP.
Results:
At three months only slight differences were found between the two
groups. However, at the 12 month evaluation patients in the intervention group
presented a significantly higher mean (standard deviation) amelioration in the
Barthel score - 19.7 (25.1) vs. 6.9 (29.3), p<0.001, and significantly higher
improvements in every scale of NHP. The same effect on health related qua-
lity of life and depressive symptoms scores were observed among caregivers.
The result observed was similar whether considering just the pairs with sur-
viving patients or all participants evaluated according to the intention to treat.
Conclusion:
A simple social service support intervention significantly incre-
ased stroke patients functional capacities and psychosocial indices, and the
same effect was evident for their informal caregivers.
242
A SYSTEMATIC REVIEW OF OBSERVATIONAL STUDIES OF FISH
INTAKE, N-3 FATTY ACIDS AND CORONARY HEART DISEASE
Ana Navas-Acien, Eliseo Guallar, Megan Jehn
Department of Epidemiology and Welch Center, Jonhs Hopkins Medical Institutions,
Baltimore, MD, USA.
Introduction:
Fish intake is currently recommended to reduce cardiovascular risk
and as part of a Mediterranean-type diet, based on the physiological effects of fish
oils (long-chain polyunsaturated n-3 fatty acids) and on the cardioprotective effect of
fish intake and fish oils in secondary prevention randomized trials. However, in ab-
sence of primary prevention trials, and due to the possibility that contaminants in fish
oppose the potential benefits of n-3 fatty acids, it is important to systematically eva-
luate the evidence from observational studies. In this study we undertook a com-
prehensive review of cohort and case-control studies of fish intake or n-3 fatty acid
levels and clinical cardiovascular outcomes.
Methods:
We performed a systematic literature search to identify studies presen-
ting associations of dietary fish intake or objective measures of n-3 fatty acids with
the risk of coronary heart disease (CHD), myocardial infarction (MI) or sudden car-
diac death (SCD). We excluded studies that mixed fish intake with other dietary pat-
terns, measured n-3 fatty acids not of marine origin, or were done in dialysis/trans-
plant patients. We searched articles in all languages using MEDLINE, and references
of published studies. For studies on fish intake, the adjusted relative risk (RR) for the
highest versus lowest category is presented. For studies of n-3 fatty acids, differen-
ces in levels between cases and non-cases were selected, as well as RRs if provi-
ded by the authors.
Results:
18 cohorts and 4 case-control studies investigated fish intake and CHD, MI
or SCD. For CHD mortality, 16 studies reported RRs for the highest vs. the lowest
category of fish intake in a range between 0.39 and 2.2. Heterogeneity of the fin-
dings precluded the estimation of meaningful combined RRs. The same heteroge-
neity was observed for CHD incidence. For fatal MI and SCD, RRs in 6 studies ran-
ged from 0.39 to 1.48, with a combined estimate of 0.65. For studies of fatal and non-fatal
MI, reported associations ranged from 0.42 to 1.87. Six nested case-control studies,
one cohort study, and 16 case-control studies measured n-3 fatty acid levels in human
tissue. A similar degree of heterogeneity was found, with RRs ranging from 0.10 to
1.26 when comparing the highest to the lowest level of n-3 exposure.
Conclusions:
Epidemiologic studies of fish intake or fish oil levels and CHD have
shown both inverse and positive associations. Although several factors may explain
this heterogeneity, including methodological differences among the studies, the pos-
sibility that fish intake may not be consistently protective deserves careful conside-
ration, especially when promoting fish as part of a healthy, cardioprotective diet for
the general population. Future research needs to investigate the reasons of these
conflicting results, particularly in relation to environmental contaminants.
243