Primary risk factors influence risk of recurrent myocardial infarction/death from coronary heart disease: results from the Stockholm Heart Epidemiology Program (SHEEP)
Restricted accessResearch articleFirst published online August, 2007
Primary risk factors influence risk of recurrent myocardial infarction/death from coronary heart disease: results from the Stockholm Heart Epidemiology Program (SHEEP)
Prognosis after a first myocardial infarction (MI) is influenced by primary risk factors as well as secondary risk factors. There is still a lack of follow-up studies of well-characterized patient cohorts assessing the relative importance of these factors.
Design
A cohort of 1635 patients (aged 45-70 years) surviving at least 28 days after a first MI were followed for 6-9 years with regard to recurrent MI/fatal coronary heart disease (CHD). Data were collected through questionnaires, physical examinations, and medical records.
Methods
Hazard ratios (HR) with 95% confidence intervals (CI) for different risk factors were calculated using the Cox proportional hazard model.
Results
Of the primary risk factors, diabetes in both sexes was the most important predictor of recurrent MI/fatal CHD, multivariate-adjusted HR in men 1.6 (95% CI; 1.0-2.4) and in women 2.5 (95% CI; 0.9-6.9). Other primary risk factors with prognostic influence were job strain, HR 1.5 (95% CI; 1.0-2.1), and central obesity, HR 1.4 (95% CI; 1.0-2.0), in men and a low level of apolipoprotein A1, HR 2.3 (95% CI; 1.1-5.0), and high-density lipoprotein cholesterol, HR 1.9 (95% CI; 0.9-4.1), in women. The secondary risk factors most detrimental for prognosis were heart failure in men, HR 2.2 (95% CI; 1.2-4.0), and a high peak acute cardiac enzyme level in women, HR 4.4 (95% CI; 2.0-9.7).
Conclusions
Long-term follow-up of patients who survived at least 28 days after a first MI shows that several primary cardiovascular risk factors, particularly diabetes, contribute to the increased risk of recurrent MI/fatal CHD.
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2.
KaplanRHeckbertSFurbergCPsatyB.Predictors of subsequent coronary events, stroke, and death among survivors of first hospitalized myocardial infarction. J Clin Epidemiol2002; 55:654–664.
3.
UlvenstamGAbergABergstrandRJohanssonSPennertKVedinA.Long-term prognosis after myocardial infarction in men with diabetes. Diabetes1985; 34:787–792.
4.
ReaTHeckbertSKaplanRSmithNLemaitreRPsatyB.Smoking status and risk of recurrent coronary events after myocardial infarction. Ann Intern Med2002; 137:494–500.
5.
WongNCupplesAOstfeldALevyDKannelW.Risk factors for long-term coronary prognosis after initial myocardial infarction: the Framingham Study. Am J Epidemiol1989; 130:469–480.
6.
HaiderAChenLLarsonMEvansJChenMLevyD.Antecedent hypertension confers increased risk for advers outcomes after initial myocardial infarction. Hypertension1997; 30:1020–1024.
7.
SaitoDShirakiTOkaTKajiyamaATakamuraT.Risk factors indicating recurrent myocardial infarction after recovery from acute myocardial infarction. Circ J2002; 66:877–880.
8.
AlboniPAmadeiAScarfoSIppolitoFBaggioniG.In industrialized nations, a low socioeconomic status represents an independent predictor of mortality in patients with acute myocardial infarction. Ital Heart J2003; 4:551–558.
9.
HamstenAde FaireUWalldiusGDahlenGSzamosiALandouC.Plasminogen activator inhibitor in plasma: risk factor for recurrent myocardial infarction. Lancet1987; 2:3–9.
10.
AbbateABiondi-ZoccaiGBrugalettaSLiuzzoGBiasucciL.C-reactive protein and other inflammatory biomarkers as predictors of outcome following acute coronary syndromes. Semin Vasc Med2003; 3:375–384.
11.
WooKSWhiteHD.Factors affecting outcome after recovery from myocardial infarction. Annu Rev Med1994; 45:325–339.
12.
BiggerJCoromilasJWeldFReiffelJRolnitzkyL.Prognosis after recovery from acute myocardial infarction. Annu Rev Med1984; 35:127–147.
13.
MaggioniAZuanettiGFranzosiMRovelliFSantoroEStaszewskyL.Prevalence and prognostic significance of ventricular arrhythmias after acute myocardial infarction in the fibrinolytic era: GISSI-2 results. Circulation1993; 87:312–322.
14.
PizzettiFTurazzaFMFranzosiMGBarleraSLeddaAMaggioniAP.Incidence and prognostic significance of atrial fibrillation in acute infarction: the GISSI-3 data. Heart2001; 86:527–532.
15.
HammarNAlfredssonLRosénMSpetzC-LKahanTYsbergA-S.A national record linkage to study acute myocardial infarction incidence and case fatality in Sweden. Int J Epidemiol2001; 30 (Suppl 1):S30–S34.
16.
ReuterwallCHallqvistJAhlbomAde FaireUDiderichsenFHogstedtC.Higher relative but lower absolute risk of myocardial infarction in women than in men for some major risk factors in the SHEEP study. J Int Med1999; 246:161–174.
17.
HamstenAWalldiusGDahlenGJohanssonBde FaireU.Serum lipoproteins and apolipoproteins in young male survivors of myocardial infarction. Atherosclerosis1986; 59:223–235.
18.
LeanderKWimanBHallqvistJSten-LinderMde FaireU.PAI-1 level and the PAI-1 4G/5G polymorphism in relation to risk of non-fatal myocardial infarction: results from the Stockholm Heart Epidemiology Program (SHEEP). Thromb Haemost2003; 89:1064–1071.
19.
VermylenCde VrekerRAVerstraeteM.A rapid enzymatic method for assay of fibrinogen fibrin polymerization time (FTP test). Clin Chim Acta1963; 8:418–424.
20.
BennetAMPrinceJAFeiG-ZLyrenasLHuangYWimanB.Interleukin-6 serum levels and genotypes influence the risk for myocardial infarction. Atherosclerosis2003; 171:359–367.
21.
LeanderKHallqvistJReuterwallCAhlbomAde FaireU.Family history of coronary heart disease, a strong risk factor for myocardial infarction interacting with other cardiovascular risk factors: results from the Stockholm Heart Epidemiology Program (SHEEP). Epidemiology2001; 12:215–221.
22.
KillipTKimballJ.Treatment of myocardial infarction in a coronary care unit. Am J Cardiol1967; 20:457–464.
23.
HuxleyRBarziFWoodwardM.Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ2006; 332:73–78.
24.
MalmbergKRydenLWedelHBirkelandKBootsmaADicksteinK.Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity. Eur Heart J2005; 26:650–661.
25.
LundstamUHerlitzJKarlssonTLindenTWiklundO.Serum lipids, lipoprotein(a) level, and apolipoprotein(a) isoforms as prognostic factors in patients with coronary heart disease. J Int Med2002; 251: 111–118.
26.
HoffmannAPfiffnerDHornungRNiederhauserH.Psychosocial factors predict outcome following a first myocardial infarction. Working group on cardiac rehabilitation of the Swiss Society of Cardiology. Coron Artery Dis1995; 6:147–152.
27.
RubermanWWeinblattEGoldbergJDChaudharyBS.Psychosocial influences on mortality after myocardial infarction. N Engl J Med1984; 311:552–559.
28.
De BacquerDDe BackerGöstörESimonJPyöräläK.Predictive value of classical risk factors and their control in coronary patients: a follow-up of the EUROSPIRE I cohort. Eur J Cardiovasc Prev Rehab2003; 10: 289–295.
29.
MartinCThompsonPArmstrongBHobbsMde KlerkN.Long-term prognosis after recovery from myocardial infarction: a nine year follow-up of the Perth Coronary Register. Circulation1983; 68:961–969.
30.
JorgensenSKoberLOttesenMTorp-PedersenCVidebaekJKjollerE.The prognostic importance of smoking status at the time of acute myocardial infarction in 6676 patients. TRACE Study Group. J Cardiovasc Risk1999; 6:23–27.
31.
WalleyTFolino-GalloPStephensPVan GanseE, On behalf of the EuroMedStat Group. Trends in prescribing and utilization of statins and other lipid lowering drugs across Europe 1997-2003. Br J Clin Pharmacol2005; 60:543–551.
32.
LylesRAllenAS.Estimating crude or common odds ratios in case-control studies with informatively missing exposure data. Am J Epidemiol2002; 155:274–281.
33.
GreenlandSFinkleW.A critical look at methods for handling missing covariates in epidemiologic regression analyses. Am J Epidemiol1995; 142:1255–1264.
34.
MukamalKJNestoRWCohenMCMullerJEMaclureMSherwoodJB.Impact of diabetes on long-term survival after acute myocardial infarction. Diabetes Care2001; 24:1422–1427.
35.
KaplanRHeckbertSFurbergCPsatyB.Predictors of subsequent coronary events, stroke, and death among survivors of first hospitalized myocardial infarction. J Clin Epidemiol2002; 55:654–664.
36.
UlvenstamGAbergABergstrandRJohanssonSPennertKVedinA.Long-term prognosis after myocardial infarction in men with diabetes. Diabetes1985; 34:787–792.
37.
ReaTHeckbertSKaplanRSmithNLemaitreRPsatyB.Smoking status and risk of recurrent coronary events after myocardial infarction. Ann Intern Med2002; 137:494–500.
38.
WongNCupplesAOstfeldALevyDKannelW.Risk factors for long-term coronary prognosis after initial myocardial infarction: the Framingham Study. Am J Epidemiol1989; 130:469–480.
39.
HaiderAChenLLarsonMEvansJChenMLevyD.Antecedent hypertension confers increased risk for advers outcomes after initial myocardial infarction. Hypertension1997; 30:1020–1024.
40.
SaitoDShirakiTOkaTKajiyamaATakamuraT.Risk factors indicating recurrent myocardial infarction after recovery from acute myocardial infarction. Circ J2002; 66:877–880.
41.
AlboniPAmadeiAScarfoSIppolitoFBaggioniG.In industrialized nations, a low socioeconomic status represents an independent predictor of mortality in patients with acute myocardial infarction. Ital Heart J2003; 4:551–558.
42.
HamstenAde FaireUWalldiusGDahlenGSzamosiALandouC.Plasminogen activator inhibitor in plasma: risk factor for recurrent myocardial infarction. Lancet1987; 2:3–9.
43.
AbbateABiondi-ZoccaiGBrugalettaSLiuzzoGBiasucciL.C-reactive protein and other inflammatory biomarkers as predictors of outcome following acute coronary syndromes. Semin Vasc Med2003; 3:375–384.
44.
WooKSWhiteHD.Factors affecting outcome after recovery from myocardial infarction. Annu Rev Med1994; 45:325–339.
45.
BiggerJCoromilasJWeldFReiffelJRolnitzkyL.Prognosis after recovery from acute myocardial infarction. Annu Rev Med1984; 35:127–147.
46.
MaggioniAZuanettiGFranzosiMRovelliFSantoroEStaszewskyL.Prevalence and prognostic significance of ventricular arrhythmias after acute myocardial infarction in the fibrinolytic era: GISSI-2 results. Circulation1993; 87:312–322.
47.
PizzettiFTurazzaFMFranzosiMGBarleraSLeddaAMaggioniAP.Incidence and prognostic significance of atrial fibrillation in acute infarction: the GISSI-3 data. Heart2001; 86:527–532.
48.
HammarNAlfredssonLRosénMSpetzC-LKahanTYsbergA-S.A national record linkage to study acute myocardial infarction incidence and case fatality in Sweden. Int J Epidemiol2001; 30 (Suppl 1):S30–S34.
49.
ReuterwallCHallqvistJAhlbomAde FaireUDiderichsenFHogstedtC.Higher relative but lower absolute risk of myocardial infarction in women than in men for some major risk factors in the SHEEP study. J Int Med1999; 246:161–174.
50.
HamstenAWalldiusGDahlenGJohanssonBde FaireU.Serum lipoproteins and apolipoproteins in young male survivors of myocardial infarction. Atherosclerosis1986; 59:223–235.
51.
LeanderKWimanBHallqvistJSten-LinderMde FaireU.PAI-1 level and the PAI-1 4G/5G polymorphism in relation to risk of non-fatal myocardial infarction: results from the Stockholm Heart Epidemiology Program (SHEEP). Thromb Haemost2003; 89:1064–1071.
52.
VermylenCde VrekerRAVerstraeteM.A rapid enzymatic method for assay of fibrinogen fibrin polymerization time (FTP test). Clin Chim Acta1963; 8:418–424.
53.
BennetAMPrinceJAFeiG-ZLyrenasLHuangYWimanB.Interleukin-6 serum levels and genotypes influence the risk for myocardial infarction. Atherosclerosis2003; 171:359–367.
54.
LeanderKHallqvistJReuterwallCAhlbomAde FaireU.Family history of coronary heart disease, a strong risk factor for myocardial infarction interacting with other cardiovascular risk factors: results from the Stockholm Heart Epidemiology Program (SHEEP). Epidemiology2001; 12:215–221.
55.
KillipTKimballJ.Treatment of myocardial infarction in a coronary care unit. Am J Cardiol1967; 20:457–464.
56.
HuxleyRBarziFWoodwardM.Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ2006; 332:73–78.
57.
MalmbergKRydenLWedelHBirkelandKBootsmaADicksteinK.Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity. Eur Heart J2005; 26:650–661.
58.
LundstamUHerlitzJKarlssonTLindenTWiklundO.Serum lipids, lipoprotein(a) level, and apolipoprotein(a) isoforms as prognostic factors in patients with coronary heart disease. J Int Med2002; 251: 111–118.
59.
HoffmannAPfiffnerDHornungRNiederhauserH.Psychosocial factors predict outcome following a first myocardial infarction. Working group on cardiac rehabilitation of the Swiss Society of Cardiology. Coron Artery Dis1995; 6:147–152.
60.
RubermanWWeinblattEGoldbergJDChaudharyBS.Psychosocial influences on mortality after myocardial infarction. N Engl J Med1984; 311:552–559.
61.
De BacquerDDe BackerGöstörESimonJPyöräläK.Predictive value of classical risk factors and their control in coronary patients: a follow-up of the EUROSPIRE I cohort. Eur J Cardiovasc Prev Rehab2003; 10: 289–295.
62.
MartinCThompsonPArmstrongBHobbsMde KlerkN.Long-term prognosis after recovery from myocardial infarction: a nine year follow-up of the Perth Coronary Register. Circulation1983; 68:961–969.
63.
JorgensenSKoberLOttesenMTorp-PedersenCVidebaekJKjollerE.The prognostic importance of smoking status at the time of acute myocardial infarction in 6676 patients. TRACE Study Group. J Cardiovasc Risk1999; 6:23–27.
64.
WalleyTFolino-GalloPStephensPVan GanseE, On behalf of the EuroMedStat Group. Trends in prescribing and utilization of statins and other lipid lowering drugs across Europe 1997-2003. Br J Clin Pharmacol2005; 60:543–551.
65.
LylesRAllenAS.Estimating crude or common odds ratios in case-control studies with informatively missing exposure data. Am J Epidemiol2002; 155:274–281.
66.
GreenlandSFinkleW.A critical look at methods for handling missing covariates in epidemiologic regression analyses. Am J Epidemiol1995; 142:1255–1264.
