[Considerable differences in the management of stroke. A study of structured vs. conventional care].
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Biomedical subjects
B Fagerberg
Publications and source records attributed to B Fagerberg.
Multiple risk intervention in high-risk hypertensive patients. A 3-year ultrasound study of intima-media thickness and plaques in the carotid artery. Risk Intervention Study (RIS) Group.
In spite of optimal blood pressure control, available data indicate that the risk of coronary heart disease remains high in many patients with hypertension. Multifactorial risk intervention programs have therefore been advocated. The aim of the present randomized study was to analyze whether a favorable change in risk factors caused by a comprehensive risk factor modification program (focused mainly on nonpharmacological intervention) might beneficially affect ultrasound-assessed far-wall common carotid intima-media thickness or plaques in the carotid artery in high-risk hypertensive patients (n=81) in comparison with those undergoing usual care (n=83). A further aim was to analyze whether risk factors measured at baseline or follow-up were related to the change recorded in intima-media thickness during follow-up. The results showed in the intervention group a favorable change in LDL cholesterol (-9%), in smoking habits (32% of smokers quit smoking), and in HbA1c (-17% in patients with diabetes mellitus) over the 3.5-year observation period. However, no difference between the two randomization groups could be observed for far-wall common carotid intima-media thickness or plaque status during follow-up. Of all tested potential risk factors, only fasting insulin at baseline (available in nondiabetic patients) was significantly related to the change in mean intima-media thickness during follow-up (r=.25, n=92, P<.01). The relationship (negative) between follow-up serum HDL and change in mean intima-media thickness during the preceding follow-up was of borderline significance. Patients with moderate to large plaques in the carotid artery region at baseline had a significantly larger increase in common carotid artery intima-media thickness during follow-up than patients with no or only small plaques. The results are disappointing and may indicate that either the change in risk factors occurred too late in life or a considerably larger change in concomitant risk factors than we observed is needed to favorably affect intima-media thickness during an observation period of around 3 years in high-risk hypertensive patients.
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Atherosclerotic disease in the femoral artery in hypertensive patients at high cardiovascular risk. The value of ultrasonographic assessment of intima-media thickness and plaque occurrence. Risk Intervention Study (RIS) Group.
The aim of the present investigation was to examine the occurrence of ultrasound-assessed morphological changes in the right common femoral artery and relate these findings to the ankle-arm index and to symptoms of lower-extremity arterial disease in hypertensive men at high cardiovascular risk (n = 143). Comparisons were made with a healthy reference group consisting of age-matched men at low risk (n = 46). The results showed that it was possible to obtain high-quality measurements of intima-media thickness in about 80% of all men and that the intraobserver variability was satisfactory (14%). A normal mean intima-media thickness was defined, using data from the low-risk group. Plaque occurrence and mean intima-media thickness in the right common femoral artery were significantly associated with ankle-arm index both in the right and left leg. There were more and larger plaques, as well as thicker mean and maximum intima-media complexes, in the high-risk group than in the low-risk group. In the high-risk group, 11% suffered from symptoms of right lower-extremity artery disease, 20% had an ankle-arm index < or= 0.9, 62% had moderate or large plaques (compared with 28% in the low-risk group, P < .001), and 77% had an enlarged intima-media complex. The cumulative frequency of signs of atherosclerosis in the right leg was 81% among the 110 patients in whom complete results from all examinations were available. Our conclusion is that ultrasound measurement of the intima-media thickness of the common femoral artery is a valuable method to evaluate morphological changes related to atherosclerotic disease in the lower extremity.
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Does microalbuminuria predict cardiovascular events in nondiabetic men with treated hypertension? Risk Factor Intervention Study Group.
The aim of this study was to investigate the predictive value of microalbuminuria (overnight urinary albumin excretion rate 17 to 100 mg/12 h) as a risk factor for future major cardiovascular events in nondiabetic patients with treated hypertension in a prospective study with follow-up time of 3.3 years. Overnight urinary albumin excretion was measured in 345 nondiabetic treated hypertensive men, aged 50 to 72 years, either with a serum cholesterol of > or = 6.5 mmol/L or smokers, or both. Cardiovascular morbidity was closely recorded during the follow-up period. At entry, microalbuminuria was found in 84 patients (24.3%) and 12 patients had macroalbuminuria (3.5%). During the follow-up period there were no differences in new cardiovascular events between patients with microalbuminuria and those with normoalbuminuria. However, an increase in the risk of future major cardiovascular events occurred in patients with urinary albumin excretion above 100 mg/12 h (macroalbuminuria). In a Cox regression analysis urinary albumin excretion was not associated with the incidence of future major cardiovascular events unless a more detailed approach was used, showing that this was the case for urinary albumin excretion above 100 mg/12 h (macroalbuminuria). Calculations with an alternative definition of microalbuminuria and mortality as end-point did not change the principal result. In conclusion, microalbuminuria does not seem to be a predictor of future mortality and cardiovascular morbidity in nondiabetic men with treated hypertension and at high risk of coronary heart disease. However, macroalbuminuria was associated with future major cardiovascular events in this group of patients.
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The cost-effectiveness of a cardiovascular multiple-risk-factor intervention programme in treated hypertensive men.
OBJECTIVES: The aim of this study was to carry out a cost-effectiveness analysis of a multifactorial intervention programme in treated hypertensive patients. DESIGN: A cost-effectiveness analysis based on 3 years of follow-up in an open, randomized, parallel-group study with allocation either to a comprehensive, multiple-risk factor modification programme or to conventional treatment. SETTING: An outpatient clinic of a city hospital. SUBJECTS: Inclusion criteria were: male sex, age 50-72 (mean 66.4) years, treated hypertension and at least one of the following: serum cholesterol > or = 6.5 mmol L-1, and/or smoking and/or diabetes mellitus. A total of 508 patients were included in the study. INTERVENTIONS: Advice given to individuals, and group meetings based on nutritional advice and behavioural treatment principles. If necessary, drug therapy could be instituted to achieve the treatment goals in the intervention group: serum total cholesterol of < 6.0 mmol L-1, no smoking, HbAlc < 6.0% and diastolic blood pressure < 90 mmHg in both groups. MAIN OUTCOME MEASURE: Incremental cost per life-year gained of the intervention programme. RESULTS: The cost per life-year gained was SEK 4000 in an estimation based on the observed risk reduction and ranged between SEK 62,000 and SEK 163,000 in three estimations based on the risk factor changes. CONCLUSIONS: The analysis indicates that the intervention programme is cost-effective in the studied patient population.
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Microalbuminuria, insulin sensitivity and haemostatic factors in non-diabetic treated hypertensive men. Risk Factor Intervention Study Group.
OBJECTIVE: To examine whether microalbuminuria in non-diabetic, treated hypertensive men is associated with insulin resistance and measures of endothelial function, thrombogenesis and fibrinolysis. DESIGN: Cross-sectional study. SETTING: Outpatient clinic in city hospital. PATIENTS: Ninety-two treated hypertensive men, aged 57-77 years, either with a serum cholesterol of > or = 6.5 mmol L-1 or smokers, or both. Patients with diabetes mellitus or overnight urinary albumin excretion of > 100 mg 12 h-1 were excluded. MAIN OUTCOME MEASURES: Overnight urinary albumin excretion, insulin-mediated glucose disposal (hyperinsulinaemic euglycaemic clamp), blood glucose and plasma insulin during oral glucose tolerance test, fibrinogen, von Willebrand factor and plasminogen activator inhibitor activity. RESULTS: Microalbuminuric patients had increased blood glucose concentrations during the oral glucose tolerance test and higher plasma fibrinogen levels compared with the normoalbuminuric patients. In a randomly selected subgroup (n = 36), insulin-mediated glucose disposal was lower in microalbuminuric than in normoalbuminuric patients, and an inverse relationship between insulin sensitivity and albuminuria (r = -0.37; P = 0.028) was found. This relationship was not significant after adjustment for body-mass index (P = 0.098). In the univariate analyses including all patients, albuminuria was associated with blood glucose, serum creatinine, body-mass index, systolic blood pressure, fibrinogen, von Willebrand factor and cholesterol (negatively). In a multiple regression analysis, only the body-mass index was independently related to urinary albumin excretion. CONCLUSIONS: Microalbuminuria was associated with insulin resistance but obesity was a confounding factor. Relationships between microalbuminuria and fibrinogen as well as von Willebrand factor were found, but only in univariate analysis.
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Carotid artery wall intima-media thickness is associated with insulin-mediated glucose disposal in men at high and low coronary risk.
BACKGROUND AND PURPOSE: The aim of this investigation was to examine the relationship between insulin sensitivity and intima-media thickness in the common carotid artery. METHODS: Ultrasound examinations of the common carotid artery and hyperinsulinemic euglycemic clamp examinations were performed in a group (n = 25) of men aged 57 to 77 years at high risk for atherosclerotic disease (hypertension and at least one of the following factors: hypercholesterolemia and/or smoking) and in an age-matched low-risk group (n = 23) with no cardiovascular risk factors. Subjects with cardiovascular disease or diabetes mellitus were excluded. RESULTS: A significant negative relationship between insulin sensitivity index and common carotid maximum intima-media thickness was observed in both the high-risk group (r = -.45, P < .05) and in the low-risk group (r = -.59, P < .01). CONCLUSIONS: Our results suggest that an increase in intimamedia thickness, as a possible expression of early atherosclerosis, is negatively related to insulin sensitivity.
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Urinary albumin excretion is associated with the intima-media thickness of the carotid artery in hypertensive males with non-insulin-dependent diabetes mellitus.
OBJECTIVE: To examine the relationship between urinary albumin excretion and ultrasonographically assessed morphology of the common carotid artery in hypertensive men with and without non-insulin-dependent diabetes mellitus. DESIGN: Cross-sectional study. SETTING: An outpatient clinic in a city hospital. PATIENTS: Hypertensive male patients (n = 25) with non-insulin-dependent diabetes mellitus and non-diabetic hypertensive male patients (n = 94) aged 50-72 years, randomly selected from a larger study group. MAIN OUTCOME MEASURES: Overnight urinary albumin excretion and B-mode ultrasound examinations of the carotid artery. RESULTS: Among the diabetic patients the logarithm of the overnight urinary albumin excretion was independently and significantly associated with the common carotid artery intima-media thickness, which was also true after adjustment for concomitant cardiovascular disease. In the non-diabetic group there was no association between intima-media thickness and urinary albumin excretion. No relationship between the occurrence of plaque and urinary albumin excretion was observed in any of the study groups. The results were reproducible at a re-examination after 3 years using the same methods. CONCLUSION: Among the hypertensive men with non-insulin-dependent diabetes mellitus, an independent and significant relationship, reproducible after 3 years, was found between urinary albumin excretion and the intima-media thickness of the common carotid artery. No such relationship was found in the group of non-diabetic hypertensive males.
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[Heart failure. Comparison between clinical practice and recommendations show that the treatment can be improved].
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Carotid artery wall morphology, haemostatic factors and cardiovascular disease. An ultrasound study in men at high and low risk for atherosclerotic disease.
The aim of this study was to examine whether there was a relationship between haemostatic factors and ultrasound-assessed morphology of the common carotid artery and cardiovascular disease in 57- to 77-year-old men at high risk for atherosclerotic disease (hypertension and at least one of the following risk factors: hypercholesterolaemia, smoking, diabetes mellitus). They were divided into one group with (n = 59) and one group without (n = 70) manifest cardiovascular disease. An age-matched reference group with no cardiovascular risk factors was used as a comparison (n = 51). Significant associations, independent of smoking, were found between plasma fibrinogen and both the maximal intima-media thickness and the occurrence of plaque in the high-risk group. High-risk patients with clinical signs of cardiovascular disease had higher levels of plasma fibrinogen and prothrombin 1 + 2 fragment compared with both high-risk patients without concomitant cardiovascular disease and low-risk subjects. Plasminogen activator inhibitor, von Willebrand factor and thrombin/antithrombin complex were increased in the high-risk group with signs of cardiovascular disease in comparison with the low-risk group. In conclusion the results indicate that plasma fibrinogen may be operative in the development of atherosclerosis. Clinical signs of cardiovascular disease were associated with increased plasma levels of fibrinogen, von Willebrand factor, plasminogen activator inhibitor, thrombin/antithrombin complex and prothrombin 1 + 2 fragment.
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The efficacy of multiple risk factor intervention in treated hypertensive men during long-term follow up. Risk Factor Intervention Study Group.
OBJECTIVE: To examine the feasibility and efficacy of a multifactorial intervention programme directed towards hypercholesterolaemia, smoking, and diabetes mellitus in treated hypertensive patients after more than 3 years' follow-up and to describe the incidence of cardiovascular complications. DESIGN: Open, randomized, parallel-group study with allocation either to a comprehensive multiple risk factor modification programme or to usual care. SETTING: Outpatient clinic in a city hospital. PATIENTS: A total of 508 male patients with treated hypertension, aged 50-72 years, with at least one of the following: serum cholesterol > or = 6.5 mmol L-1, smoking or diabetes mellitus. INTERVENTION: Individually given advice and group meetings based on nutritional advice and behavioral treatment principles. Drug therapy could be instituted to achieve the treatment goals in the intervention group: serum total cholesterol below 6.0 mmol L-1, no smoking, and HbA1c below 6.0%. Diastolic blood pressure below 90 mmHg was the treatment goal in both groups. MAIN OUTCOME MEASUREMENTS: Serum cholesterol, HbA1c, diastolic blood pressure, smoking. Cardiovascular end-points were recorded. RESULTS: The net changes were (change intervention--change usual care): serum cholesterol -5.0% (95% confidence interval, -7.6 to -2.3%), 17.6% more stopped smoking (P = 0.04); diastolic blood pressure and HbA1c remained unchanged. The incidence of stroke was lower in the intervention group compared with the usual-care group: 2.0 and 6.7%, respectively (P = 0.017). CONCLUSION: The intervention programme was comparatively successful with regards to the effects on hypercholesterolaemia and smoking habits. An unexpected decrease in the stroke incidence was observed in the intervention group compared with the usual-care group.
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Ultrasound evaluation of atherosclerotic manifestations in the carotid artery in high-risk hypertensive patients. Risk Intervention Study (RIS) Group.
The aim of this study was to evaluate whether high-risk hypertensive patients (n = 137) had larger far-wall common carotid artery intima-media thickness than a control group (n = 37) and to study whether intima-media thickness was related to other signs of atherosclerotic disease. The results showed that intima-media thickness was significantly larger in the hypertension group than in the control group. Lumen diameter and mean cross-sectional area of the intima-media complex were larger both for hypertensive patients with a positive history of manifest clinical cardiovascular disease and for hypertensive patients with no such history than in the control group. There was a significant relationship between far-wall common carotid artery intima-media thickness and plaque status (visual scoring, no, small, moderate/large) in the carotid artery region. In univariate analyses, low diastolic blood pressure and high pulse pressure were both significantly related to plaque status. In multivariate analyses, pulse pressure was significantly and independently related both to common carotid artery intima-media thickness and to plaque status in the carotid artery region. In multivariate analyses, there was also an independent relationship between age and common carotid artery intima-media thickness, between smoking status and plaque status, and between a positive history of manifest clinical cardiovascular disease and plaque status. In conclusion, common carotid artery intima-media thickness and lumen diameter were increased in elderly high-risk hypertensive patients, in whom more than one third of the patients also had a moderate to large plaque in the carotid artery region.(ABSTRACT TRUNCATED AT 250 WORDS)
Arteriosclerosis↗
Carbohydrate-deficient transferrin is associated with insulin sensitivity in hypertensive men.
An elevated concentration of carbohydrate-deficient transferrin in serum (CDT) has been reported to indicate excessive ethanol consumption. However, in hypertensive men, we found low values for diagnostic sensitivity and specificity. Furthermore, in the individuals with high CDT values, the concentrations of serum triglycerides and blood glucose were low rather than high, indicating that factors related to insulin/glucose metabolism may be operative. The current study addresses this issue by examining 48 patients with treated hypertension and at least 1 of following: hypercholesterolemia, history of smoking, and diabetes mellitus. We determined serum CDT, fasting plasma insulin, and glucose disposal rate during hyperinsulinemic euglycemic clamp. Seven patients had elevated CDT concentrations. This group of patients had higher glucose disposal rates than the others (mean difference, 19 mumol/min.kg lean body mass; 95% confidence interval, 5-33 mumol/min.kg lean body mass; P = 0.0096), but did not differ in body mass index or alcohol intake. Serum CDT correlated positively with glucose disposal rate (r = 0.55; P = 0.0004) and negatively with fasting plasma insulin (r = -0.43; P = 0.0039). These relationships remained after exclusion of 8 patients with diabetes mellitus and adjustment for potentially confounding factors. We conclude that the serum CDT concentrations in our patients were associated with insulin sensitivity.
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Is carbohydrate-deficient transferrin in serum useful for detecting excessive alcohol consumption in hypertensive patients?
The aim of this study was to examine the diagnostic usefulness of carbohydrate-deficient transferrin (CDT) in serum in a cross-sectional study of 439 treated hypertensive men. We related the results to alcohol intake by questionnaire and to biochemical and hemodynamic measurements known to reflect excessive alcohol consumption. The diagnostic sensitivity and the specificity for high alcohol intake (> or = 24 g/day of ethanol) were 44% and 87%, respectively. The group with reported high alcohol intake (n = 32) was characterized by hemodynamic and biochemical changes typical of alcohol abuse. The corresponding profile for the patients with increased serum CDT concentrations (n = 70) was different in several respects, indicating a considerable number of false-positive tests. We conclude that serum CDT determination had low sensitivity and specificity for excessive alcohol consumption in this group of hypertensive patients. The results illustrate the importance of evaluating new laboratory methods in unselected patient populations before drawing any conclusions about their clinical value.
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Microalbuminuria in treated hypertensive men at high risk of coronary disease. The Risk Factor Intervention Study Group.
OBJECTIVE: To examine whether microalbuminuria is a marker of cardiovascular disease in treated hypertensive men without diabetes mellitus at high coronary risk and to examine the associations between microalbuminuria and recognized cardiovascular risk factors. DESIGN: Cross-sectional study. SETTING: Outpatient clinic in city hospital. PATIENTS: Three hundred and thirty-three treated hypertensive men, aged 50-72 years, either with a serum cholesterol of > or = 6.5 mmol/l or smokers, or both. The patients were recruited mainly from a population-based sample of hypertensive men. Patients with diabetes mellitus or overnight urinary albumin excretion of > 100 mg/12 h were excluded from the analyses. MAIN OUTCOME MEASURES: Overnight urinary albumin excretion, prevalence of microalbuminuria (defined as 17-100 mg/12 h) and organ damage (cardiovascular events or major electrocardiogram changes, or both), various well-established risk factor levels, blood glucose and plasma insulin responses to an oral glucose tolerance test. RESULTS: Microalbuminuria was found in 25% of the cohort. Among microalbuminuric patients, organ damage was significantly more common (47.6%) than in the normoalbuminuric group (30.9%). However, the sensitivity and specificity of microalbuminuria as a marker of organ damage were only 34 and 80%, respectively. Microalbuminuria was significantly related to body mass index and waist:hip ratio, age and plasma insulin during oral glucose tolerance testing. These relationships also persisted after adjustment for treatment with thiazides or beta-blockers. CONCLUSIONS: In treated hypertensive men without diabetes mellitus, microalbuminuria was associated with factors known to be related to insulin resistance. It had a low sensitivity as a marker of concomitant cardiovascular disease.
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Effects of alcohol intake and obesity on serum liver enzyme activity in obese men with mild hypertension.
OBJECTIVES: To examine the relationships between alcohol intake, obesity, plasma insulin concentration and serum activities of three liver enzymes in obese men with mild hypertension. DESIGN: A 6-week run-in period followed by randomization to either diet treatment or antihypertensive drug treatment, lasting for 1 year. Alcohol intake was estimated using questionnaires. Plasma insulin concentration, serum activities of gamma-glutamyl transferase, and aspartate and alanine aminotransferase, respectively, were measured at entry and after 1 year. SETTING: Out-patient clinic, city hospital. PATIENTS: Sixty-four men aged 40-69 years with a body mass index > or = 26 kg m-1 and with mild untreated hypertension. Exclusion criteria were alcoholism and diabetes mellitus. Sixty-one patients completed the study. INTERVENTIONS: Dietary treatment was based upon weight reduction and recommendations about a low alcohol intake. Drug treatment used a stepped-care approach with atenolol as the first-choice drug. MAIN OUTCOME MEASURES: Serum activities of the liver enzymes, body weight, body mass index, alcohol intake, plasma insulin concentration. RESULTS: Body weight decreased by 7.8 kg in the diet group and increased by 1.0 kg in the drug-treated group. Alcohol intake did not differ between the groups before or after 1 year. Serum gamma-glutamyl transferase activity correlated with alcohol consumption; it showed no significant change after weight loss. At entry, serum activities of aspartate and alanine aminotransferases correlated to plasma insulin concentration independent of body mass index. Weight reduction significantly lowered serum activities of these liver enzymes as well as plasma insulin concentrations and normalized elevated serum activity of alanine aminotransferase in a majority of the cases. CONCLUSION: Alcohol intake was an important determinant for elevated serum gamma-glutamyl transferase activity. The degree of obesity was a contributing factor for elevations of serum alanine aminotransferase activity. We speculate that insulin may play a role in this relationship.
Adult↗
Thyroid hormones, procollagen III peptide, body composition and basal metabolic rate in euthyroid individuals.
We examined 103 euthyroid men and women within a wide range of body weights and ages. Fat free mass (FFM) and body fat (BF) were determined with the total body potassium technique, basal metabolic rate (BMR) by indirect calorimetry and serum concentrations of thyroid hormones (free and total T3 and T4) and the aminoterminal propeptide of collagen III (pIIIp) by immunoassays. BMR was positively related to FFM, BF, total T3, the free T3/free T4 ratio and pIIIp, and negatively to free T4 (men) and to the ratios free T4/total T4 and free T3/total T3. pIIIp was as strongly related to BMR as to total T3. It is suggested that pIIIp may serve as an indicator of peripheral energy expenditure. The negative relationship between BMR and free T4 was unexpected and different to the situation in hypo- and hyperthyreosis where BMR and thyroid hormone are positively related. Our hypothesis is that euthyroid subjects with low serum free thyroid hormone concentrations and comparatively high BMR may have high intracellular thyroid hormone concentrations.
Adolescent↗