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Aims/hypothesis: The aim of this work was to investigate whether measurement of the mean common carotid intima-media thickness (CIMT) improves cardiovascular risk prediction in individuals with diabetes., Methods: We performed a subanalysis among 4,220 individuals with diabetes in a large ongoing individual participant data meta-analysis involving 56,194 subjects from 17 population-based cohorts worldwide. We first refitted the risk factors of the Framingham heart risk score on the individuals without previous cardiovascular disease (baseline model) and then expanded this model with the mean common CIMT (CIMT model). The absolute 10 year risk for developing a myocardial infarction or stroke was estimated from both models. In individuals with diabetes we compared discrimination and calibration of the two models. Reclassification of individuals with diabetes was based on allocation to another cardiovascular risk category when mean common CIMT was added., Results: During a median follow-up of 8.7 years, 684 first-time cardiovascular events occurred among the population with diabetes. The C statistic was 0.67 for the Framingham model and 0.68 for the CIMT model. The absolute 10 year risk for developing a myocardial infarction or stroke was 16% in both models. There was no net reclassification improvement with the addition of mean common CIMT (1.7%; 95% CI -1.8, 3.8). There were no differences in the results between men and women., Conclusions/interpretation: There is no improvement in risk prediction in individuals with diabetes when measurement of the mean common CIMT is added to the Framingham risk score. Therefore, this measurement is not recommended for improving individual cardiovascular risk stratification in individuals with diabetes.

Background: There are no data on directly measured cardiorespiratory fitness combined coronary risk evaluation with respect to death from cardiovascular diseases and all-causes. We investigated the prognostic significance of risk scores and cardiorespiratory fitness with respect to cardiovascular disease and all-cause mortality., Methods: Cardiorespiratory fitness (maximal oxygen uptake, VO2peak) was measured by exercise test with an electrically braked cycle ergometer. The study is based on a random population-based sample of 1639 men (42-60 years) without history of type 2 diabetes or atherosclerotic cardiovascular diseases., Results: During an average follow-up of 16 years, a total of 304 deaths occurred. Independent predictors for all-cause death were European Score (for 1% increment, RR 1.15, 95% CI 1.10-1.20), VO2peak (for 1 MET increment, RR 0.84, 95% CI 0.78-0.89), when adjusted for C-reactive protein, alcohol consumption, serum high-density lipoprotein, waist-to-hip ratio, family history of coronary heart disease, exercise-induced ST changes and the use of medications for hypertension, dyslipidaemia or aspirin. Also, Framingham risk score was related to the risk of death (RR 1.05, 95% CI 1.03-1.07, P < 0.001). Subjects with high European or Framingham score and low VO2peak represent the highest risk group., Conclusion: An important finding is that the risk scores can be used to identify men for whom low cardiorespiratory fitness predicts an especially high risk for death from cardiovascular and any other cause.

Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.

Objective: Based on case-control and prospective studies elevated blood total homocysteine (tHcy) has been suggested to be an independent risk factor for cardiovascular diseases (CVD). The purpose of the study was to explore the joint effect of increased serum tHcy concentration and other risk factors on the risk of CVD mortality in middle-aged men without a history of heart disease or stroke., Design: A prospective, population-based Kuopio Ischaemic Heart Disease Risk Factor (KIHD) Study., Setting: Eastern Finland. Subjects. A total of 802 men aged 46-64 years, examined in 1991-93., Main Outcome Measures: CVD mortality event., Results: The mean serum tHcy concentration was 10.8 micromol L(-1) (SD 3.3). During the average follow-up time of 10.8 years 50 men experienced a CVD death. The hazard rate ratio for CVD mortality was 1.80 (95% confidence interval: 1.02-3.19) in men in the highest serum tHcy third versus lower thirds after adjustment for cardiovascular risk factors. Furthermore, elevated serum tHcy concentration appeared to increase the risk of CVD death in men who smoke or who have high circulating concentrations of serum total or LDL cholesterol, apo-B apolipoprotein or plasma fibrinogen., Conclusion: We conclude that homocysteine may increase the risk of CVD mortality in middle-aged men from Eastern Finland, and it may especially increase the risk when present with other risk factors for CVD.

Background and Purpose: There are few if any data on the prognostic importance of silent myocardial ischemia during exercise with regard to the risk of stroke and cardiovascular diseases (CVDs) among asymptomatic men. In this prospective study, we investigated the relation of silent myocardial ischemia and the risk of stroke and CVD death in men with and without conventional risk factors., Methods: The study sample included 1726 middle-aged men with no history of stroke, coronary heart disease, or atrial fibrillation at baseline. Silent myocardial ischemia was defined as a horizontal or downsloping ST-segment depression (>or=1 mm) during exercise electrocardiography. A total of 86 CVD-related deaths and 78 strokes occurred during an average follow-up of 10 years., Results: Men with silent ischemia during exercise had a 3.5-fold increased risk of CVD death and a 2.2-fold increased risk of stroke compared with men without silent ischemia, after adjusting for conventional risk factors. Silent ischemia during exercise was associated with a 3.8-fold (95% confidence interval [CI], 1.5 to 9.5) increased risk for CVD in smokers, a 3.9-fold (95% CI, 2.1 to 7.3) increased risk in hypercholesterolemic subjects, a 3.6-fold (95% CI, 1.9 to 6.8) increased risk in the hypertensives, and 3.8-fold (95% CI, 2.0 to 7.1) increased risk in overweight men. The respective relative risks for stroke were 3.8 (95% CI, 1.1 to 12.5), 3.5 (95% CI, 1.7 to 7.4), 3.4 (95% CI, 1.6 to 7.1), and 2.9 (95% CI, 1.4 to 6.1)., Conclusions: Exercise-induced silent myocardial ischemia is an important indicator of increased risk of stroke and CVD in men with other risk factors, such as smoking, hypercholesterolemia, hypertension, and being overweight.

Objective: To examine the relations of cardiorespiratory fitness, as measured by maximal oxygen uptake and exercise test duration at the initiation of the study, with overall, cardiovascular disease (CVD)-related, and non-CVD-related mortality., Methods: A population-based cohort study of 1294 men with no CVD, pulmonary disease, or cancer at baseline in Kuopio and surrounding communities in eastern Finland. During an average follow-up of 10.7 years, there were 124 overall, 42 CVD-related, and 82 non-CVD-related deaths., Results: The relative risk of overall death in unfit men (maximal oxygen uptake <27.6 mL/kg per minute) was 2.76 (95% confidence interval, 1.43-5.33) (P =.002), and the relative risk of CVD-related death was 3.09 (95% confidence interval, 1.10-9.56) (P =.05), compared with fit men (maximal oxygen uptake >37.1 mL/kg per minute) after adjusting for age, examination years, smoking, and alcohol consumption. The relative risk of non-CVD-related death in unfit men was almost the same magnitude as for overall death. Furthermore, adjustment for serum lipid levels, blood pressure, plasma fibrinogen level, diabetes, and fasting serum insulin level did not weaken these associations significantly. Exercise test duration also had a strong inverse relation to overall, CVD-related, and non-CVD-related mortality. Poor cardiorespiratory fitness was comparable with elevated systolic blood pressure, smoking, obesity, and diabetes in importance as a risk factor for mortality., Conclusions: Cardiorespiratory fitness had a strong, graded, inverse association with overall, CVD-related, and non-CVD-related mortality. Maximal oxygen uptake and exercise test duration represent the strongest predictors of mortality.

Objective: To test the hypothesis that low serum folate concentrations are associated with an increased risk of acute coronary events in men free of prior coronary heart disease., Setting: Research Institute of Public Health, University of Kuopio, Kuopio, Finland., Design: Prospective study in a cohort of 734 men aged 46-64 y examined in 1991-1993 as part of the Kuopio Ischaemic Heart Disease Risk Factor Study (KIHD) and followed for 5 y and 3 months., Intervention: Acute coronary events during the follow-up period were obtained by national hospital discharge registry. Baseline serum folate concentrations were measured by radioimmunoassay., Results: During the follow-up, six (2.5%) men with higher serum folate concentrations (highest third>11.3 nmol/1) and 28 (5.7%) men with lower serum folate (two lowest thirds) developed an acute coronary event (P=0.008). In a Cox model adjusting for age, examination years, and plasma lycopene concentration, in men with higher serum folate concentrations the relative risk for an acute coronary event was 0.31 (95% CI 0.11-0.90, P=0.031) when compared with men with lower serum folates., Conclusion: This prospective cohort study in middle-aged men from eastern Finland indicates that moderate-to-high levels of serum folate are associated with a greatly reduced incidence of acute coronary events.

Background: The role of hyperinsulinemia as a cardiovascular risk factor is controversial. We studied whether hyperinsulinemia is independently associated with increased cardiovascular morbidity and mortality., Methods: Fasting serum insulin level and other cardiovascular risk factors were determined in 1521 men in eastern Finland aged 42 to 60 years with neither cardiovascular disease nor diabetes at baseline. Forty-five cardiovascular deaths, 110 acute coronary events, 48 strokes, and 163 any cardiovascular events occurred during an average follow-up of 9.5 years. A total of 163 cardiovascular events (45 cardiovascular deaths, 110 acute coronary events, and 48 strokes) occurred during an average follow-up of 9.5 years., Results: In Cox regression analysis adjusting for age and examination years, fasting serum insulin level as a continuous variable was directly associated with the risk of cardiovascular death (P = .006), acute coronary events (P = .04), and stroke (P = .02). Men with insulin levels of 52 to 66 pmol/L, 67 to 89 pmol/L, and 90 pmol/L or more (3 highest quartiles) had 1.4-fold (95% confidence interval, 0.5-3.7), 1.4-fold (95% confidence interval, 0.5-3.7), and 2.5-fold (95% confidence interval, 1.0-5.9; P = .05) cardiovascular mortality, respectively, compared with men with insulin levels of less than 52 pmol/L (lowest quartile) (P = .04 for linear trend). Adjustment for serum lipid levels, blood pressure, and obesity reduced the excess cardiovascular mortality in the highest insulin quartile by 7%, 33%, and 67%, respectively. There were no statistically significant differences in the incidence of acute coronary events and stroke between the insulin quartiles., Conclusions: Hyperinsulinemia had a modest association with increased cardiovascular mortality in middle-aged men. This relationship was largely explained by obesity, hypertension, and dyslipidemia. Hyperinsulinemia had even weaker associations with the risk of acute coronary event and stroke.

Objective: To examine the association between beer binging (regular sessions of heavy beer drinking) and mortality., Design: Prospective population based study with the baseline assessment of level of alcohol intake (dose), by type of drink and drinking pattern, previous and existing diseases, socioeconomic background, occupational status, involvement in organisations during leisure time, physical activity in leisure time, body mass index, blood pressure, serum lipids and plasma fibrinogen concentration, during an average of 7.7 years' follow up of mortality., Setting: Finland., Subjects: A population sample of 1641 men who consumed beer who were aged 42, 48, 54, or 60 years at baseline., Main Outcome Measures: All cause mortality, cardiovascular mortality, death due to external causes, fatal myocardial infarctions., Results: The risk of death was substantially increased in men whose usual dose of beer was 6 or more bottles per session compared with men who usually consumed less than 3 bottles, after adjustment for age and total alcohol consumption (relative risk 3.01 (95% confidence interval 1.54 to 5.90) for all deaths; 7.10 (2.01 to 25.12) for external deaths; and 6.50 (2.05 to 20.61) for fatal myocardial infarction). The association changed only slightly when smoking, occupational status, previous diseases, systolic blood pressure, low density lipoprotein and high density lipoprotein cholesterol concentration, plasma fibrinogen concentration, body mass index, marital status, leisure time physical activity, and involvement in organisations were controlled for., Conclusion: The pattern of beer binging is associated with increased risk of death, independently of the total average consumption of alcoholic drinks. The relation is not explained by known behavioural, psychosocial, or biological risk factors. Death due to injuries and other external causes is overrepresented among beer bingers, but a strong association with fatal myocardial infarction suggests that the pathway may also involve other acute triggers of severe health events.

Cardiovascular responses to psychological events may mediate the influence of stress on cardiovascular disease. In this study the authors asked whether cardiovascular responses to psychological challenge changed with age and whether such changes were intrinsic to aging or could be attributed to the influence of disease and medications. Cardiovascular reactivity to mental challenge was examined in 902 men ranging in age from 46 to 64 years who participated in the Kuopio Ischemic Heart Disease Risk Factor Study. A battery of 4 tasks was used to induce cardiovascular responses. Current disease status, age, and medication use were entered into hierarchical regression analyses to assess their relation with measures of cardiovascular reactivity. Age and hypertension contributed independent, approximately equal, but small amounts of variance in the cardiac and vascular reactivity indexes. Medications also influenced reactivity independently of age and disease. Performance on the tasks was more consistently altered by age than by disease or medication. Cardiac and vascular reactivity increased with increasing age and the presence of hypertension. The authors conclude that both age and disease state must be considered when examining cardiovascular reactivity as a risk factor for disease.

We studied the relation between frequent hangovers and cardiovascular mortality in a representative population sample of middle-aged Finnish men who participated in the Kuopio Ischemic Heart Disease Risk Factor Study. Complete data on alcohol consumption, hangover frequency, prior cardiovascular diseases, and risk factors were obtained for 2,160 non-abstinent men. Frequent hangovers were rare in the three lowest alcohol consumption quartiles, but in the highest quartile, a total of 239 men (43.6%) reported having a hangover at least monthly. During an average follow-up time of 6.7 years, these men had a 2.36-fold (95% confidence interval = 1.02-5.48) risk of cardiovascular death compared with men with fewer hangovers, with adjustment for age and total alcohol consumption. The association was somewhat attenuated after adjustments for smoking, income, and prior cardiovascular diseases. Systolic blood pressure, body mass index, resting heart rate, or serum lipids had no appreciable role in the relation, but plasma fibrinogen concentration appeared as one possible pathway to increased risk of cardiovascular death in men who frequently experience hangovers. The findings underline the importance of preventive actions regarding not only the amount but also the way people consume alcohol.

Much remains to be understood about how low socioeconomic status (SES) increases cardiovascular disease and mortality risk. Data from the Kuopio Ischemic Heart Disease Risk Factor Study (1984-1993) were used to estimate the associations between acute myocardial infarction and income, all-cause mortality, and cardiovascular mortality in a population-based sample of 2,272 Finnish men, with adjustment for 23 biologic, behavioral, psychologic, and social risk factors. Compared with the highest income quintile, those in the bottom quintile had age-adjusted relative hazards of 3.14 (95% confidence interval (CI) 1.77-5.56), 2.66 (95% CI 1.25-5.66), and 4.34 (95% CI 1.95-9.66) for all-cause mortality, cardiovascular mortality, and AMI, respectively. After adjustment for risk factors, the relative hazards for the same comparisons were 1.32 (95% CI 0.70-2.49), 0.70 (95% CI 0.29-1.69), and 2.83 (95% CI 1.14-7.00). In the lowest income quintile, adjustment for risk factors reduced the excess relative risk of all-cause mortality by 85%, that of cardiovascular mortality by 118%, and that of acute myocardial infarction by 45%. These data show how the association between SES and cardiovascular mortality and all-cause mortality is mediated by known risk factor pathways, but full "explanations" for these associations will need to encompass why these biologic, behavioral, psychologic, and social risk factors are differentially distributed by SES.

Background: Even though previous studies have suggested an association between high fish intake and reduced coronary heart disease (CHD) mortality, men in Eastern Finland, who have a high fish intake, have an exceptionally high CHD mortality. We hypothesized that this paradox could be in part explained by high mercury content in fish., Methods and Results: We studied the relation of the dietary intake of fish and mercury, as well as hair content and urinary excretion of mercury, to the risk of acute myocardial infarction (AMI) and death from CHD, cardiovascular disease (CVD), and any cause in 1833 men aged 42 to 60 years who were free of clinical CHD, stroke, claudication, and cancer. Of these, 73 experienced an AMI in 2 to 7 years. Of the 78 decreased men, 18 died of CHD and 24 died of CVD. Men who had consumed local nonfatty fish species had elevated hair mercury contents. In Cox models with the major cardiovascular risk factors as covariates, dietary intakes of fish and mercury were associated with significantly increased risk of AMI and death from CHD, CVD, and any death. Men in the highest tertile (> or = 2.0 micrograms/g) of hair mercury content had a 2.0-fold (95% confidence interval, 1.2 to 3.1; P = .005) age- and CHD-adjusted risk of AMI and a 2.9-fold (95% CI, 1.2 to 6.6; P = .014) adjusted risk of cardiovascular death compared with those with a lower hair mercury content. In a nested case-control subsample, the 24-hour urinary mercury excretion had a significant (P = .042) independent association with the risk of AMI. Both the hair and urinary mercury associated significantly with titers of immune complexes containing oxidized LDL., Conclusions: These data suggest that a high intake of mercury from nonfatty freshwater fish and the consequent accumulation of mercury in the body are associated with an excess risk of AMI as well as death from CHD, CVD, and any cause in Eastern Finnish men and this increased risk may be due to the promotion of lipid peroxidation by mercury.

Research has suggested that social-class differences in adult health may be at least partly determined by conditions earlier in life. In 2636 Finnish men, we assessed impact of childhood and adult socioeconomic conditions on adult mortality risk by examining whether differing socioeconomic life-courses from early childhood to adulthood were associated with different risks of all-cause and cardiovascular mortality. Compared with high-income adults, those with low income had increased relative risks of all-cause (2.54, 95% CI 1.83-3.53) and cardiovascular (2.37, 1.51-3.7) mortality, but these increased risks were not related in either adult group to childhood socioeconomic conditions. Men who went from low-income childhood to high-income adulthood had the same mortality risks as those whose socioeconomic circumstances were good in both childhood and adulthood (1.14, 0.56-2.31, all causes; 0.99, 0.39-2.51, cardiovascular). By contrast, men who experienced poor socioeconomic circumstances as both children and adults were about twice as likely to die as those whose position improved (2.39, 1.28-4.44, all causes; 2.02, 0.9-4.54, cardiovascular). Our findings suggest that socioeconomic conditions in childhood are not important determinants of adult health. We caution against this interpretation--a life-course approach to socioeconomic differences in adult health requires understanding of the social and economic context in which individual life-courses are determined.

A case-control study was conducted to investigate the association between serum selenium and risk of death from acute coronary heart disease (CHD) as well as risk of fetal and non-fetal myocardial infarction (MI). Case-control pairs came from a population of 11,000 persons examined in 1972 from two counties in eastern Finland, an area with an exceptionally high mortality from cardiovascular diseases. Cases were aged 35-59 years and had died of CHD or other CVD or had a non-fetal MI during a seven-year follow-up. Controls were matched for sex, age, daily tobacco consumption, serum cholesterol, diastolic blood pressure, and history of angina pectoris. The mean serum selenium concentration for all cases was 51.8 micrograms/l and for all controls 55.3 micrograms/l (p less than 0.01). Serum selenium of less than 45 micrograms/l was associated with an adjusted relative risk of CHD death of 2.9 (p less than 0.01, 95% CI, 1.4-6.0), a relative risk of CVD death of 2.2 (p less than 0.01, 95% CI, 1.2-4.0), and a relative risk of fatal and nonfatal MI of 2.1 (p less than 0.001, 95% Ci, 1.4-3.1). 22% (95% CI, 8-35%) of contrary deaths were attributable to serum selenium in the whole study population.

The North Karelia Project in Finland illustrates the fundamental goals of health promotion. Specific activities of the project serve as examples of how concepts from the social and behavioral sciences can be applied to achieve estimated reductions in predicted risk of disease. The results in North Karelia are not conclusive, but they are encouraging, and the investigations conducted there is an essential reference for future research in health promotion and disease prevention.

In response to community demands to do something about the highest rates of cardiovascular diseases in the world that were found in the country of North Karelia, Finland, a comprehensive community control programme was set up in 1972. The main objective was to reduce the high rates by reducing level of smoking, serum cholesterol and blood pressure. The success of the programme was evaluated by examining independent representative population samples in 1972 and in 1977 in North Karelia and a matched control county. A decrease in the individual risk factors was found among the population aged 25-29 at the outset. This reduction was mainly based on favourable changes in lifestyle that took place through the whole community. In low as well as in high socioeconomic groups risk factor reductions occurred. At the same time morbidity and mortality from cardiovascular diseases fell in North Karelia. The intensified health education was not accompanied by adverse emotional or psychosomatic reactions that could be measured. Since there are results from a series of experimental and controlled studies on success of risk factor reduction, this evidence should be used in development and implementation of prevention programmes for cardiovascular diseases. Primary prevention of cardiovascular diseases today requires efficient programmes because they are forming the leading cause of death in majority of the countries where reliable mortality statistics are available.

A randomly sampled population aged from 25 to 59 years and examined in 1972 was monitored for 5 years. During that period, 126 deaths from cardiovascular causes occurred among subjects with no recent history of major cardiovascular diseases. A control matched for age, sex and the conventional cardiovascular risk factors was assigned to each of the deceased subjects from the same population at risk. Rheumatoid factors or antinuclear antibodies as determined from the baseline specimens were found among 21 of the deceased (20 in the discordant pairs), but only in 7 controls (6 in the discordant pairs). This corresponds to a relative risk of death due to cardiovascular causes of 3.3 (p less than 0.01).

Karelia project of the Minnesota Heart Health Program. International Journal of Epidemiology 1986, 15: 176-182. Community-based cardiovascular disease control studies represent an effort to change cardiovascular disease rates in entire communities. Communities, rather than individuals, are the primary units of analysis. The cross-community multiple time series model to estimate and test the effects is based on multiple communities that are evaluated at several points over time. Issues that influence the power of the analysis include: the number of communities to be studied, community size and composition, sample sizes of surveys, the decision to use cohorts or cross-sectional surveys, the number of surveys conducted in each community, and assumptions of latencies in the effects. These points are illustrated using the experiences of the North Karelia Project and the Minnesota Heart Health Program. The North Karelia Project was a community-based cardiovascular disease (CVD) prevention programme consisting of a five-year intervention period in 1972-7. It took place in two provinces in Finland. The Minnesota Heart Health Program is similar, taking place between 1980 and 1990 in six communities in the American Midwest.

Among the different approaches to the study of cardiovascular disease prevention are community-based programs. This type of program concerns a whole community and the intervention takes advantage of the existing service structure and community organization. The evaluation assesses the feasibility, effects on risk factor and disease reduction, costs, process, and other consequences associated with the program. Several such programs have recently been launched in the United States and some other countries. The first major community-based control program was the North Karelia project in Finland, started in 1972 and recently evaluated for its first five-year period. This paper discusses the problems in evaluating community-based CVD control programs on the experiences obtained in the North Karelia project.

To test whether the cardiovascular disease declines in North Karelia were accompanied by subjective improvements in health, we analyzed responses to two questions about perceived risk of heart disease and health status on independent random population samples surveyed 10 years apart. Age stratified perceived risk of heart disease declined significantly more (p less than .01) and age stratified perceived health status improved significantly more in North Karelia than in the reference area (p less than .005).

A cohort of 1019 male and 1232 female hypertensives, aged 25-59 years, based on a random population sample, was followed for five years during a community-based cardiovascular prevention programme. A small mean reduction in serum cholesterol level was found. The observed changes in casual serum cholesterol values were partly due to the regression to the mean. The reductions were most marked in elderly people and in those with high baseline serum cholesterol values. The partial regressions of the cholesterol change were computed in subgroups by age, sex and baseline serum cholesterol level. Changes in weight in men and in age in women were the strongest independent predictors of the change in serum cholesterol. Changes in dietary fat intake were also associated with the change in serum cholesterol. Only a small part of the total variation in the change in serum cholesterol was explained by the regression models. The results indicate that reduction of the serum cholesterol level among hypertensive persons, especially men, was caused by changes in their dietary habits.

The association between an a priori measure of social connections and five-year mortality from all causes, cardiovascular diseases (International Classification of Diseases, Eighth Revision (ICD-8) codes 390-458), and ischemic heart disease (ICD-8 codes 410-414) was studied in 13,301 men and women from eastern Finland who were first interviewed in 1972 or 1977. For men, there was a graded association between extent of social connections and mortality. In multivariate models with adjustment for age, smoking, serum cholesterol, mean weighted blood pressure, measures of prevalent illness, and other possible confounders, men who were in the two lowest quintiles of the social connections scale were at increased risk compared with those in the highest quintile (odds ratio (OR)all cause = 1.54, 95% confidence interval (CI) = 1.21-1.95; ORcardiovascular disease = 1.54, 95% CI = 1.11-2.13; ORischemic heart disease = 1.34, 95% CI = 0.94-1.90). No strong or consistent association was found for women. The association for men was modified by levels of blood pressure with the effect of low social connections greater at higher levels of blood pressure. In three separate analyses, there was no evidence for confounding or effect modification due to prevalent illness at baseline.

Permanent and temporary disability pension award data and survey data were used to estimate the lower bound of earning losses related to cardiovascular disease during a community-based cardiovascular disease prevention program in Eastern Finland. Earning losses due to death totaled $39.94 million but were not affected by the project. Earning losses due to permanent disability totalled +29.01 million and were $4.25 million less than expected (p less than 0.025). Earning losses due to temporary disability were $10.91 million and were not affected by the project. Total earning losses attributable to cardiovascular disease during the project period were $79.86 million, and total decline in earning losses was +4.25 million. Project implementation costs were less than one per cent of total earning losses and were equal to approximately 17 per cent of the decline in these losses attributable to the project. The findings suggest that community-based heart disease prevention programs have the potential of more than paying for themselves through an associated decline in lost earnings.

A comprehensive community programme studying the control of cardiovascular diseases (CVD) was carried out in North Karelia, Finland, between 1972 and 1977. The main objective was to reduce the mortality and morbidity of CVD, particularly in middle-aged men. Changes in the mortality and incidence of CVD were monitored by community-based registers of cases of acute myocardial infarction (AMI) and stroke and data on death certificates. During the programme the total mortality in the area decreased by 5% and the mortality from CVD decreased by 13% among men and 31% among women aged 30-64 years. The incidence of AMI fell by 16% among men and 5% among women, while that of cerebral stroke fell by 38% among men and 50% among women. Changes in mortality in North Karelia were compared with those in a matched control area; the difference between the two areas was not significant. The true effect of the programme cannot be deduced from these results, but mortality from CVD and the incidence of AMI and stroke fell during the five years studied. Thus the changes in mortality and morbidity of CVD accorded with the initial objectives of the programme.

A comprehensive community-based program to control cardiovascular disease was carried out in North Karelia, Finland, in 1972--1977. Reductions in smoking, serum cholesterol and blood pressure (BP) levels were among the central intermediate objectives. The effect was evaluated by examining independent population samples at the outset and at the end, both in the program area and in a matched reference area. More than 10,000 subjects were studied each time (participation rate about 90%). This paper presents the analyses of the estimated effect of the program on the risk factor means by comparing the baseline and terminal situations among the population aged 30--59 years. The effect of the program among men was estimated to be a reduction of 13% in smoking, 4% in serum cholesterol and 3% in systolic and diastolic BP means. Among women, there was a net reduction of 5% in systolic BP and 4% in diastolic BP means. The net reductions in smoking (8%) and serum cholesterol (1%) among women were within sampling variation. It is concluded that the population means of the major coronary heart disease risk factors were reduced during the program more in the intervention area than in the reference area, and it seems likely that most of this difference was due to the program.

The trends in mortality from ischaemic heart disease, cerebrovascular stroke, and all cardiovascular diseases were analysed for the province of North Karelia and for the rest of Finland. Linear trends in mortality were computed for the population aged 35 to 64 for the period from 1969 to 1982, and changes in mortality between the three year means of 1969-71 and 1980-2 were calculated. In North Karelia, where a community based preventive programme has been carried out since 1972, the annual decline in mortality from ischaemic heart disease in men was on average 2.9%, whereas in the rest of Finland it was 2.0%. For women the respective average annual declines in mortality were 4.9% and 3.0%. The net decline from 1969-71 to 1980-2 in North Karelia was 100 deaths/100,000 men. The annual mortality from all cardiovascular disease in men decreased by 2.9% in North Karelia and by 2.6% in the rest of Finland; in women the decreases were 6.0% and 5.0% a year, respectively. The net decline in North Karelia was 71 deaths/100,000 men. The decline in mortality from all causes was also appreciable in both sexes in North Karelia, but it did not differ significantly from national trends.

A comprehensive community programme to control cardiovascular diseases (CVD) in North Karelia, Finland, was carried out during 1972-7. The central intermediate objective of the programme was to reduce the prevalence of smoking, the serum cholesterol concentration, and raised blood-pressure values among the population of the area. The effect was evaluated by examining independent representative population samples in 1972 and 1977 in both the county of North Karelia and a matched control county. Over 10 000 subjects were studied each time, the participation rate being around 90%. The decrease that occurred in the risk factors, especially in men, was in general greater in North Karelia compared with the control county. When a multiple logistic function was used for the three risk factors an overall mean net reduction of 17% among men and 12% among women was observed in the estimated risk for coronary heart disease in North Karelia. This community programme effectively reduced the levels of the three main risk factors for CVD in the population, and thus mortality and morbidity from CVD should fall. This is assessed in further studies.

Aims/hypothesis: Type 2 diabetes is associated with a two- to seven-fold increase in cardiovascular morbidity and mortality. The aim of this study was to determine the relationships between intima-media thickness (IMT), an established marker of atherosclerosis, large artery function and other determinants of cardiovascular risk in type 2 diabetic patients. Methods: We studied 228 type 2 diabetic patients (75 women, aged 62±2 years [mean±SEM]). Carotid IMT was bilaterally measured using ultrasound technology. Applanation tonometry and pulse wave analysis were used to measure aortic systolic and diastolic blood pressures, central pressure augmentation (AG) and the augmentation index (AIx), a measure of systemic arterial stiffness. Conventional cardiovascular risk factors (lipids, HbA1c, smoking and diabetes duration) were also assessed. Results: Women had higher AG and AIx (p<0.0001), despite comparable systolic BP and heart rate in women and men. In women, AG (r=0.39, p<0.001), age (r=0.32, p<0.01), brachial systolic BP (r=0.34, p<0.01) and aortic systolic BP (r=0.34, p<0.01) correlated with IMT. In men, age (r=0.41, p<0.001), diabetes duration (r=0.25, p<0.01), AG (r=0.22, p<0.01), aortic systolic BP (r=0.21, p<0.01), brachial systolic BP (r=0.21, p<0.01) and body weight (r=0.16, p<0.05) correlated with IMT. In multiple linear regression analyses, AG and aortic systolic BP, but not brachial systolic BP, were age-independent determinants of IMT in men and women. In all patients, increased AG (adjusted for sex, age and heart rate) correlated with longer duration of diabetes, urinary albumin excretion and IMT. Conclusions/interpretation: Measures of central systolic pressure correlate with carotid IMT, independently of age and other risk markers. [ABSTRACT FROM AUTHOR]

Aims/hypothesis. Low-grade inflammation has been implicated in the development of Type 2 diabetes and cardiovascular disease, but its role in the pathogenesis of the metabolic syndrome is unclear. We investigated the association between C-reactive protein (CRP) levels and the development of the metabolic syndrome and diabetes in men. Methods. Serum CRP concentrations and factors related to insulin resistance were determined in middle-aged Finnish men who participated in a population-based cohort study and were free of diabetes at baseline. Results. At the 11-year follow-up, 143 of 680 men had developed the metabolic syndrome as defined by the National Cholesterol Education Program (NCEP) and 103 of 598 men had developed the metabolic syndrome as defined by the World Health Organization (WHO). Our analyses excluded men with the metabolic syndrome by the respective definition at baseline. In all, 78 of 762 men developed diabetes over the same period. Men with CRP concentrations ≥3 mg/l had a several-fold higher age-adjusted risk of developing the metabolic syndrome (NCEP definition: odds ratio [OR]=3.2, 95% CI 1.9–5.5; WHO definition: OR=3.4, 95% CI 2.0–6.1) or diabetes (OR=4.1, 95% CI 2.1–8.0) than men whose CRP levels were <1.0 mg/l. Even after further adjustment for potentially confounding lifestyle factors and factors related to insulin resistance, the risk of diabetes (OR=2.3, 95% CI 1.0–5.1) was still increased in men with CRP concentrations ≥3 mg/l, but the association with the metabolic syndrome was no longer significant. Conclusions/interpretation. Low-grade inflammation may increase the risk of the metabolic syndrome and diabetes in middle-aged men, but some of the risk is mediated through obesity and factors related to insulin resistance. [ABSTRACT FROM AUTHOR]