http://repub.eur.nl/res/aut/1720/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/39995/ 2013-02-01T00:00:00Z Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular disease. Electrocardiography (ECG) carries information about cardiac disease and prognosis, but studies comparing ECG characteristics between patients with and without COPD are lacking. We related ECG characteristics of patients with COPD, to ECG characteristics of patients without COPD, and determined whether ECG abnormalities are related to COPD severity. A cross-sectional study was conducted within a cohort of 243 COPD patients, aged 65 years or older. All patients underwent extensive examinations, including resting 12-lead ECG and pulmonary function tests. The reference group (n = 293) was a sample from the general population, also aged 65 or older, without COPD. Abnormal ECGs were more prevalent in COPD patients (50%) than in patients without COPD (36%, p = 0.054). Conduction abnormalities were the most common ECG abnormality in COPD patients (28%) being significantly more prevalent than in patients without COPD (11%, p < 0.001). The mean heart rate was higher in COPD patients (72 bpm (SD 14)) compared to controls (65 bpm (SD 13), p < 0.001), and QTc prolongation was less frequent in COPD patients (9% versus 14%, p = 0.01). The prevalence of ECG abnormalities increased with severity of pulmonary obstruction. ECG abnormalities, especially conduction abnormalities are common in COPD patients, and the prevalence of ECG abnormalities increases with severity of COPD. This underlines the importance of an integrated-care approach for COPD patients, paying attention to early detection of unrecognized coexisting cardiac disorders. http://repub.eur.nl/res/pub/37844/ 2012-07-26T00:00:00Z http://repub.eur.nl/res/pub/26274/ 2011-06-01T00:00:00Z Background: Diagnosing early stages of heart failure with mild symptoms is difficult. B-type natriuretic peptide (BNP) has promising biochemical test characteristics, but its diagnostic yield on top of readily available diagnostic knowledge has not been sufficiently quantified in early stages of heart failure. Objectives: To quantify the added diagnostic value of BNP for the diagnosis of heart failure in a population relevant to GPs and validate the findings in an independent primary care patient population. Design: Individual patient data meta-analysis followed by external validation. The additional diagnostic yield of BNP above standard clinical information was compared with ECG and chest x-ray results. Patients and methods: Derivation was performed on two existing datasets from Hillingdon (n=127) and Rotterdam (n=149) while the UK Natriuretic Peptide Study (n=306) served as validation dataset. Included were patients with suspected heart failure referred to a rapid-access diagnostic outpatient clinic. Case definition was according to the ESC guideline. Logistic regression was used to assess discrimination (with the c-statistic) and calibration. Results: Of the 276 patients in the derivation set, 30.8% had heart failure. The clinical model (encompassing age, gender, known coronary artery disease, diabetes, orthopnoea, elevated jugular venous pressure, crackles, pitting oedema and S3 gallop) had a c-statistic of 0.79. Adding, respectively, chest x-ray results, ECG results or BNP to the clinical model increased the c-statistic to 0.84, 0.85 and 0.92. Neither ECG nor chest x-ray added significantly to the 'clinical plus BNP' model. All models had adequate calibration. The 'clinical plus BNP' diagnostic model performed well in an independent cohort with comparable inclusion criteria (c-statistic=0.91 and adequate calibration). Using separate cut-off values for 'ruling in' (typically implying referral for echocardiography) and for 'ruling out' heart failure - creating a grey zone - resulted in insufficient proportions of patients with a correct diagnosis. Conclusion: BNP has considerable diagnostic value in addition to signs and symptoms in patients suspected of heart failure in primary care. However, using BNP alone with the currently recommended cut-off levels is not sufficient to make a reliable diagnosis of heart failure. http://repub.eur.nl/res/pub/27861/ 2010-07-01T00:00:00Z Objective: Several guidelines for hypertension and cardiovascular risk management recommend an ECG in hypertensive patients to improve risk prediction. We estimated the prevalence of clinically relevant ECG abnormalities and the number needed to screen (NNS) with a routine ECG to prevent the occurrence of one death in the next 10 years conditional on adequate treatment and follow-up. Methods: The study population consisted of 866 hypertensive participants recruited from the Utrecht Health Project (UHP), a dynamic population study in Utrecht. Baseline measurements included an ECG and the risk factors that enable a Systematic COronary Risk Evaluation (SCORE) risk estimation for each participant. ECGs were interpreted using Modular ECG Analysis System for computerized recognition of ECG abnormalities. NNS to prevent one death was computed by the reciprocal of the prevalence of the ECG abnormalities multiplied by number needed to treat to prevent one death when the ECG abnormality is managed according to the prevailing clinical guidelines. Results: The population consisted of 54.2% men with a mean age of 53.2 years (SD 11.5). The prevalence of ECG abnormalities was 17.6 [n = 95% confidence interval (CI) 15.0-20.1]. Prevalence of atrial fibrillation or prior myocardial infarction was 2.1% (95%CI 1.1-3.0) and of other ECG abnormalities related to increased cardiovascular disease risk 15.4% (95%CI 13.1-17.9). NNS to prevent one death from cardiovascular disease within 10 years was estimated at 260 (95%CI 220-308). Conclusion: Our findings support the existing recommendations to routinely record an ECG in unselected hypertensive patients as the prevalence of relevant abnormalities is considerable and NNS to prevent one death is lower than that in other widely accepted tests. http://repub.eur.nl/res/pub/30300/ 2008-12-01T00:00:00Z Background: A RCT, conducted to examine the effectiveness of a structured collaboration in general practice to provide intensified preventive care in patients at high cardiovascular risk yielded no effect in the total group but differences across healthcare centres and ethnic groups become apparent. We conducted a process evaluation to explain these differences. Methods: We assessed the reach of the target group and whether key intervention components (individual educational sessions, structured team meetings, and risk assessments) were performed as planned (maximum score for protocol completion is 11). Results: The reach was initially 91%, but only a minority of patients completed the intervention activities as planned. The average score of the number of intervention components was low (5.66 out of 11 (sd 2.8)) and varied between centres (4.84 to 7.40) and ethnic groups (4.89 to 7.38), with team meetings as the least implemented activity conform plan. Conclusion: This study indicates that adding a practice nurse and a peer health educator to the general practice did not seem to result in the desired collaboration between the healthcare personnel. Further research is needed to investigate the reasons behind the low participation rate of the patients in the intervention. http://repub.eur.nl/res/pub/32379/ 2008-08-01T00:00:00Z Background: We examined the effectiveness of a structured collaboration in general practice between a practice nurse, a peer health educator, the general practitioner (GP) and a GP assistant in providing intensified preventive care for patients at high risk of developing cardiovascular diseases. DESIGN: A randomized controlled trial in three healthcare centres (18 GPs) in deprived neighbourhoods of two major Dutch cities. Methods: Two hundred seventy-five high-risk patients (30-70 years) from various ethnic groups were randomized to intervention (n=137) or usual care group (n=138). We determined group differences in outcomes [10-year absolute risk (Framingham risk equation), blood pressure, lipids and body mass index] at 12-month follow-up. Results: The 10-year absolute risk was reduced by 1.76% (standard error: 0.81) in intervention and by 2.27% (standard error: 0.69) in usual care group; the difference in mean change was 0.88% [95% confidence interval: -1.16 to 2.93]. In both groups significant reductions were observed in the following individual risk factors: total cholesterol, total cholesterol/high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol, with no relevance between group differences. Conclusion: The cardiovascular risk profile of intervention and control patients improved after 1-year follow-up. However, no extra effect of the structured preventive care on the risk for cardiovascular diseases was achieved. http://repub.eur.nl/res/pub/30395/ 2008-05-16T00:00:00Z This study compares the distribution of cardiovascular risk factors in different ethnic groups at high risk of developing cardiovascular diseases within general practices. A total of 430 patients (179 Dutch, 126 Turks, 50 Surinamese, 23 Moroccans, 23 Antilleans and 29 from other ethnic groups) were included in the study. Data collection consisted of questionnaires and physical and clinical examinations. 54% was female. The mean age was 53.1 (sd 9.9) years. There were important ethnic differences in the distribution of cardiovascular risk factors. Compared to the Dutch, ethnic minorities had significantly greater odds of being diabetic (OR = 3.2-19.4); but were less likely to smoke (OR = 0.10-0.53). Turkish individuals had a lower prevalence of hypercholesterolemia but were 2.4 times more likely to be obese than the Dutch. Hypertension was very common in all ethnic groups and no significant ethnic differences were found. These findings provide additional evidence of the need for tailored interventions for different ethnic groups in general practices. http://repub.eur.nl/res/pub/36234/ 2007-12-01T00:00:00Z Objective: To assess whether the accuracy of self-reported diabetes, hypertension, and hypercholesterolemia in high-risk groups differs according to ethnicity. Study Design and Setting: We analyzed data of 430 patients at high risk of cardiovascular disease from different ethnic origin, including Turkish, Surinamese, and Dutch. Risk factors based on self-reports were compared with data from medical records and with a gold standard based on clinical measurements. Proportions of concordance between self-reports and other methods and kappa statistics (κ) were determined by ethnicity. Results: Concordance between self-reports and other data sources was highest in diabetes and lowest for hypercholesterolemia. Agreement of self-reports was substantial to almost perfect for diabetes (κ: 0.84-0.76), substantial to moderate for hypertension (κ: 0.63-0.51), and moderate for hypercholesterolemia (κ: 0.55-0.48). There was no statistically significant association between ethnicity and concordance, except for self-reporting of diabetes among Surinamese vs. Dutch indigenous patients (odds ratio = 0.37; 95% confidence interval: 0.14-0.97). Conclusion: There are no marked ethnic differences in the accuracy of self-reports of diabetes, hypertension, and hypercholesterolemia in high-risk populations. Larger studies including multiple ethnic groups are needed to confirm these findings. http://repub.eur.nl/res/pub/12933/ 2001-08-22T00:00:00Z AIMS: To determine the prognosis, cause of death, and its determinants in participants of the population-based Rotterdam Study who were found to have heart failure. METHODS AND RESULTS: In 5255 Rotterdam Study participants (aged 68.9+/-8.6 years, 3113 women) the presence of heart failure was determined. Data were analysed with Cox's proportional-hazards models. One hundred and eighty-one participants (age 77.3+/-7.9 years, 109 women) had heart failure. Of these 85 (47%) died during the 4.8-8.5 (mean 6.1) years of follow-up. One, 2 and 5 years' survival was 89%, 79%, and 59%, representing an age-adjusted mortality twice that of persons without heart failure (hazard ratio 2.1, 95% CI 1.8-2.7). The hazard ratio for sudden death was even more pronounced: 4.8, (95% CI 2.6-8.7). Diabetes mellitus, impairment of renal function and atrial fibrillation were associated with a poor outcome. A higher blood pressure and body mass index conferred a more favourable prognosis in those with heart failure. CONCLUSION: Heart failure generally afflicts older subjects in the community, carries a poor prognosis, especially in the presence of concomitant diseases, and confers a fivefold increase in the risk of sudden death. http://repub.eur.nl/res/pub/9343/ 2000-01-01T00:00:00Z OBJECTIVE: Investigators from several studies have reported a positive relationship between low cholesterol levels and death due to violent causes (eg, suicide and accidents), possibly mediated by depressive symptoms, aggression or hostility, or impulsivity. We set out to establish whether middle-aged men with chronically low cholesterol levels (< or =4.5 mmol/liter) have a higher risk of having depressive symptoms, according to scores on the Beck Depression Inventory, compared with a reference group of men with cholesterol levels between 6 and 7 mmol/liter. A similar comparison was also made for measures of anger, hostility, and impulsivity. METHODS: Cholesterol measurements were obtained as part of a population-based cholesterol screening study in 1990-1991. These levels were remeasured in 1993-1994. Only those whose cholesterol level remained in the same range were included in the study. Depressive symptoms were assessed by using the Beck Depression Inventory; anger, by questionnaires based on the Spielberger Anger Expression Scale and State-Trait Anger Scale; hostility, by the Buss-Durkee Hostility Inventory; and impulsivity, by the Eysenck and Eysenck Impulsivity Questionnaire. RESULTS: Men with chronically low cholesterol levels showed a consistently higher risk of having depressive symptoms (Beck Depression Inventory score > or =15 or > or =17) than the reference group, even after adjusting for age, energy intake, alcohol use, and presence of chronic diseases. No differences in anger, hostility, and impulsivity were observed between the two groups. CONCLUSIONS: Men with a lower cholesterol level (< or =4.5 mmol/liter) have a higher prevalence of depressive symptoms than those with a cholesterol level between 6 and 7 mmol/liter. These data may be important in the ongoing debate on the putative association between low cholesterol levels and violent death. http://repub.eur.nl/res/pub/9064/ 1999-02-01T00:00:00Z AIMS: To examine the association between heart-rate corrected QT prolongation and cardiac and all-cause mortality in the population-based Rotterdam Study among men and women aged 55 years or older and to compare the prognostic value of the QT interval, using different formulas to correct for heart rate. METHODS AND RESULTS: After exclusion of participants with arrhythmias or bundle branch block on the ECG, the study population consisted of 2083 men and 3158 women. The QT interval was computed by the Modular ECG Analysis System (MEANS). Data were analysed using Cox' proportional hazards model. Participants in the highest quartile of the heart-rate corrected QT interval had about a 70% age- and sex-adjusted increased risk for both all-cause mortality (hazard ratio (HR) 1.8; 95% CI:1.3-2.4) and cardiac mortality (HR 1.7; 95% CI:1.0-2.7) compared to those in the lowest quartile. In women, the increased risk associated with prolonged QT for cardiac death was more pronounced than in men. These risk estimates did not change after adjustment for potential confounders, including history of myocardial infarction, hypertension and diabetes mellitus. CONCLUSION: A prolonged heart-rate corrected QT interval is an independent predictor for cardiac and all-cause mortality in older men and women. The risk associated with prolonged QT is hardly affected by the heart-rate correction formula used. http://repub.eur.nl/res/pub/22512/ 1999-01-01T00:00:00Z BACKGROUND: Elevated homocysteine level increases vascular disease risk. Most data are based on subjects younger than 60 years; data for the elderly are more limited. We examined the relationship of homocysteine level to incident myocardial infarction and stroke among older subjects in a nested case-control study. METHODS: Subjects were participants in the Rotterdam Study, a cohort study among 7983 subjects residing in the Ommoord district of Rotterdam, the Netherlands. Baseline examinations were performed from March 1, 1990, to July 31, 1993. The analysis is restricted to myocardial infarction and stroke that occurred before December 31, 1994. One hundred four patients with a myocardial infarction and 120 with a stroke were identified with complete data. Control subjects consisted of a sample of 533 subjects drawn from the study base, free of myocardial infarction and stroke. Nonfasting total homocysteine levels were measured. RESULTS: Results were adjusted for age and sex. The risk of stroke and myocardial infarction increased directly with total homocysteine. The linear coefficient suggested a risk increase by 6% to 7% for every 1-micromol/L increase in total homocysteine. The risk by quintiles of total homocysteine level was significantly increased only in the group with levels above 18.6 micromol/L (upper quintile): odds ratios were 2.43 (95% confidence interval, 1.11-5.35) for myocardial infarction and 2.53 (95% confidence interval, 1.19-5.35) for stroke. Associations were more pronounced among those with hypertension. CONCLUSIONS: The present study, based on a relatively short follow-up period, provides evidence that among elderly subjects an elevated homocysteine level is associated with an increased risk of cardiovascular disease. http://repub.eur.nl/res/pub/9085/ 1999-01-01T00:00:00Z AIMS: To determine the prevalence of heart failure and symptomatic as well as asymptomatic left ventricular systolic dysfunction in the general population. METHODS AND RESULTS: In 5540 participants of the Rotterdam Study (age 68.9+/-8.7 years, 2251 men) aged 55-95 years, the presence of heart failure was determined by assessment of symptoms and signs (shortness of breath. ankle oedema and pulmonary crepitations) and use of heart failure medication. In 2267 subjects (age 65.7+/-7.4 years, 1028 men) fractional shortening was measured. The overall prevalence of heart failure was 3.9% (95% CI 3.0+/-4.7) and did not differ between men and women. The prevalence increased with age, with the exception of the highest age group in men. Fractional shortening was higher in women and did not decrease appreciably with age. The prevalence of left ventricular systolic dysfunction (fractional shortening <=25%) was approximately 2.5 times higher in men (5.5%, 95% CI 4.1-7.0) than in women (2.2%, 95% CI 1.4-3.2). Sixty percent of persons with left ventricular systolic dysfunction had no symptoms or signs of heart failure at all. CONCLUSIONS: The prevalence of heart failure is appreciable and does not differ between men and women. The majority of persons with left ventricular systolic dysfunction can be regarded as having asymptomatic left ventricular systolic dysfunction. http://repub.eur.nl/res/pub/9159/ 1999-01-01T00:00:00Z BACKGROUND: We studied whether the effectiveness of ultrasound screening for abdominal aortic aneurysms could be increased by preselecting high-risk subjects, based on the presence of risk indicators for the disease. METHODS: In a population-based screening programme for abdominal aortic aneurysms among 5328 subjects living in Rotterdam, The Netherlands, we studied four different strategies to select subjects for ultrasound screening of the abdominal aorta, based on risk indicators for abdominal aortic aneurysm disease. Risk indicators used in each strategy were entered in a logistic regression model to predict the probability of an individual having an abdominal aortic aneurysm. Using several cutoff values for the probability of a subject having an aneurysm for each strategy, we estimated the proportion of subjects that should be referred for ultrasound screening and the proportion of aneurysms that would be diagnosed by each strategy (sensitivity). RESULTS: When a probability of 1.5% of having an aneurysm is chosen as the cutoff point above which ultrasound screening is indicated, the proportion of subjects that would be referred for screening ranged from 36% (first strategy) to approximately 50% (other strategies), while 80% (first strategy) to approximately 94% (other three strategies) of all aneurysms would be detected. CONCLUSION: Effectiveness in screening for abdominal aortic aneurysms can be increased by selecting subjects by means of a short medical questionnaire, filled out by the screening candidates, including questions on medical history. http://repub.eur.nl/res/pub/9171/ 1999-01-01T00:00:00Z BACKGROUND: Prevention of cardiovascular disease in the elderly is becoming increasingly important. GPs are in a unique position to initiate preventive interventions in this age group. However, it is not clear which strategy a GP should follow to identify patients at increased cardiovascular risk-case finding or screening. OBJECTIVE: We aimed to assess the value of a single cardiovascular health check compared with a normal care case finding and to investigate the diagnostic or therapeutic consequences of detecting new cardiovascular risk indicators. METHODS: In 1991, 1002 persons aged 60 years and over, enlisted in one general practice, were invited. Of the 805 subjects who responded (80%), the cardiovascular risk profile was determined by a research physician. The proportion of newly detected cardiovascular risk indicators was the main outcome measure. A risk indicator was considered newly detected when it was not mentioned in the GP's summary of the patient record, which had been checked by the patient for its completeness. The patient records of participants with newly detected hypertension, diabetes or hypercholesterolaemia were systematically reviewed to detect diagnostic and therapeutic interventions by the GP. RESULTS: In 25.1% of the participants, one or more cardiovascular risk indicators were found which were previously unknown to the GP, including 38 (4.7%) cases of hypertension, 82 (10%) cases of isolated systolic hypertension, 14 (1.7%) cases of diabetes mellitus and 63 (7.8%) cases of hypercholesterolaemia. On the basis of these findings, the GP initiated therapeutic interventions in almost all subjects with newly detected diabetes. However, reports of newly detected hypertension or high cholesterol levels were usually not followed by an intervention. CONCLUSION: A single cardiovascular health check in the elderly can detect a considerable number of risk indicators that are unknown to a patient's GP. In most cases, however, the detection of hypertension or cholesterol > or = 6.5 mmol/l did not lead to interventions by the GP. More efforts are needed to ensure that the beneficial effects of these interventions are not limited to participants in clinical trials but can be extended to patients in general practice. http://repub.eur.nl/res/pub/8780/ 1998-01-01T00:00:00Z To assess the age- and sex-specific prevalence of peripheral arterial disease (PAD) and intermittent claudication (IC) in an elderly population, we performed a population-based study in 7715 subjects (40% men, 60% women) aged 55 years and over. The presence of PAD and IC was determined by measuring the ankle-arm systolic blood pressure index (AAI) and by means of the World Health Organization/Rose questionnaire, respectively. PAD was considered present when the AAI was <0.90 in either leg. The prevalence of PAD was 19.1% (95% confidence interval, 18.1% to 20.0%): 16.9% in men and 20.5% in women. Symptoms of IC were reported by 1.6% (95% confidence interval, 1.3% to 1.9%) of the study population (2.2% in men, 1.2% in women). Of those with PAD, 6.3% reported symptoms of IC (8.7% in men, 4.9% in women), whereas in 68.9% of those with IC an AAI below 0.90 was found. Subjects with an AAI <0.90 were more likely to be smokers, to have hypertension, and to have symptomatic or asymptomatic cardiovascular disease compared with subjects with an AAI of 0.90 or higher. The authors conclude that the prevalence of PAD in the elderly is high whereas the prevalence of IC is rather low, although both prevalences clearly increase with advancing age. The vast majority of PAD patients reports no symptoms of IC. http://repub.eur.nl/res/pub/8785/ 1998-01-01T00:00:00Z BACKGROUND: Increased QTc dispersion has been associated with an increased risk for ventricular arrhythmias and cardiac death in selected patient populations. We examined the association between computerized QTc-dispersion measurements and mortality in a prospective analysis of the population-based Rotterdam Study among men and women aged > or = 55 years. METHODS AND RESULTS: QTc dispersion was computed with the use of the Modular ECG Analysis System as the difference between the maximum and minimum QTc intervals in 12 and 8 leads (ie, the 6 precordial leads, the shortest extremity lead, and the median of the 5 other extremity leads). After exclusion of those without a digitally stored ECG, the population consisted of 2358 men and 3454 women. During the 3 to 6.5 years (mean, 4 years) of follow-up, 568 subjects (9.8%) died. The degree of QTc dispersion was categorized into tertiles. Data were analyzed using the Cox proportional hazards model, with adjustment for age. For QTc dispersion in 8 leads, those in the highest tertile relative to the lowest tertile had a twofold risk for cardiac death (hazard ratio, 2.5; 95% confidence interval [CI], 1.6 to 4.0) and sudden cardiac death (hazard ratio, 1.9; 95% CI, 1.0 to 3.7) and a 40% increased risk for total mortality (hazard ratio, 1.4; 95% CI, 1.2 to 1.8). Additional adjustment for potential confounders, including history of myocardial infarction, hypertension, and overall QTc, did not materially change the risk estimates. Hazard ratios for QTc dispersion in 12 leads were comparable to those found for QTc dispersion in 8 leads. CONCLUSIONS: QTc dispersion is an important predictor of cardiac mortality in older men and women. http://repub.eur.nl/res/pub/9005/ 1998-01-01T00:00:00Z Relapse of congestive heart failure (CHF) frequently occurs and has serious consequences in terms of morbidity, mortality, and health care expenditure. Many studies have investigated the aetiological and prognostic factors of CHF, but there are only limited data on the role of precipitating factors that trigger relapse of CHF. Knowledge of potential precipitating factors may help to optimise treatment and provide guidance for patients with CHF. The literature was reviewed to identify factors that may influence haemodynamic homeostasis in CHF. Precipitating factors that may offer opportunities for preventing relapse of CHF were selected. Potential precipitating factors are discussed in relation to the pathophysiology of CHF: alcohol, smoking, psychological stress, uncontrolled hypertension, cardiac arrhythmias, myocardial ischaemia, poor treatment compliance, and inappropriate medical treatment. Poor treatment compliance in particular is frequently encountered in patients with CHF. Furthermore, studies of medical treatment under everyday circumstances indicate that some aspects of the management of CHF can be improved. In conclusion, the identification of precipitating factors for relapse of CHF may strongly contribute to optimal treatment. Improvement of treatment compliance and optimalisation of medical treatment may offer important possibilities to clinicians to reduce the number of relapses in patients with CHF. http://repub.eur.nl/res/pub/22517/ 1997-09-01T00:00:00Z BACKGROUND: Noninvasive assessment of intima-media thickness (IMT) is widely used in observational studies and trials as an intermediate or proxy end point for cardiovascular disease. However, data showing that IMT predicts cardiovascular disease are limited. We studied whether common carotid IMT is related to future stroke and myocardial infarction. METHODS AND RESULTS: We used a nested case-control approach among 7983 subjects aged > or =55 years participating in the Rotterdam Study. At baseline (March 1990 through July 1993), ultrasound images of the common carotid artery were stored on videotape. Determination of incident myocardial infarction and stroke was predominantly based on hospital discharge records. Analysis (logistic regression) was based on 98 myocardial infarctions and 95 strokes that were registered before December 31, 1994. IMT was measured from videotape for all case subjects and a sample of 1373 subjects who remained free from myocardial infarction and stroke during follow-up. The mean duration of follow-up was 2.7 years. Results were adjusted for age and sex. Stroke risk increased gradually with increasing IMT. The odds ratio for stroke per standard deviation increase (0.163 mm) was 1.41 (95% CI, 1.25 to 1.82). For myocardial infarction, an odds ratio of 1.43 (95% CI, 1.16 to 1.78) was found. When subjects with a previous myocardial infarction or stroke were excluded, odds ratios were 1.57 (95% CI, 1.27 to 1.94) for stroke and 1.51 (95% CI, 1.18 to 1.92) for myocardial infarction. Additional adjustment for several cardiovascular risk factors attenuated these associations: 1.34 (95% CI, 1.08 to 1.67) and 1.25 (95% CI, 0.98 to 1.58), respectively. CONCLUSIONS: The present study, based on a short follow-up period, provides evidence that an increased common carotid IMT is associated with future cerebrovascular and cardiovascular events. http://repub.eur.nl/res/pub/5519/ 1996-01-01T00:00:00Z OBJECTIVE: To improve pre-hospital triage of patients with suspected acute cardiac disease. DESIGN: Prospective study. SUBJECTS. Patients with symptoms suggestive of acute cardiac pathology, who were seen by a general practitioner, for whom acute admission into hospital was requested, and in whom a pre-hospital electrocardiogram was recorded by the ambulance service. METHODS: The study consisted of two phases. In the first phase, a decision rule was developed based on clinical characteristics and electrocardiographic findings in 1005 patients with suspected acute cardiac pathology. In the second phase, the decision rule was prospectively validated. Symptoms were recorded by a standardized questionnaire by the general practitioner and a computerized electrocardiogram was made by the ambulance nurses at the patient's home. Three electrocardiographic outcomes were available: 'normal electrocardiogram', 'possible myocardial infarction' or 'extensive myocardial infarction'. By use of the predictive model, the general practitioner could decide if hospitalization was necessary or not. MAIN OUTCOME MEASUREMENTS: Identification of patients at low (stable angina, atypical chest pain, other pathology) and high (myocardial infarction, unstable angina) probability of acute cardiac pathology. RESULTS: Among 977 patients with a complete pre-hospital evaluation in the validation phase of the study, the decision rule recommended 'no hospitalization' in 227 patients (23%). The general practitioner followed this advice in 44% of these patients. Although seven of them developed a non-Q wave myocardial infarction, no complications occurred in patients not admitted. In addition, the general practitioner did not hospitalize 19 (2%) of 750 patients for whom the decision rule recommended admission. Pre-hospital triage by the general practitioner resulted in a 12% (118 of 977 patients) reduction of the number of patients admitted to the Coronary Care Units. CONCLUSIONS: Pre-hospital triage by the general practitioner was facilitated using a standardized questionnaire and pre-hospital electrocardiography, and resulted in a reduction in the number of patients admitted to the Coronary Care Unit, and proved to be safe. http://repub.eur.nl/res/pub/5516/ 1995-01-01T00:00:00Z OBJECTIVE: To assess the practical application, safety and long-term outcome of pre-hospital thrombolytic intervention with either alteplase or streptokinase in patients with extensive myocardial infarction. DESIGN: Prospective study. SUBJECTS: Patients with chest pain of more than 30 min duration, presenting within 6 h of symptom onset and with electrocardiographic evidence of extensive evolving myocardial infarction. METHODS: Eligibility of patients was established by the general practitioner or the ambulance nurse using a standardized questionnaire with (contra-) indications for thrombolytic therapy. Computerized ECG was recorded by ambulance nurses. In the presence of extensive ST segment elevation (sum ST deviation of at least 1.0 mV), eligible patients received either 100 mg alteplase (n = 246) or 50 mg alteplase in the ambulance followed by 0.75 x 10(6) IE streptokinase in hospital (n = 90), or 1.5 x 10(6) IE streptokinase intravenously (n = 193). MAIN OUTCOME MEASUREMENTS: Death and life-threatening complications (ventricular fibrillation, cardiac arrest) and side effects (hypotension, allergic reactions) during transportation to hospital and in the first 24 h following hospitalization, and survival up to 5 years follow-up. RESULTS: From 1988-1993, 529 patients received thrombolytic treatment initiated pre-hospital. The time gained by pre-hospital administration of thrombolysis amounted to 50 min. The rate of complications during transportation and during the first 24 h after hospitalization was low. Hospital mortality was 2% and 1-year mortality 3%. Cumulative survival at 5 years was 92%. This was superior to the 84% 5-year survival observed in a matched group of 239 patients with similar baseline characteristics treated with alteplase in hospital. CONCLUSIONS: Pre-hospital administration of either alteplase or streptokinase is feasible and safe and results in significant time gain. The long-term prognosis is excellent in spite of extensive evolving myocardial infarction upon admission. http://repub.eur.nl/res/pub/5821/ 1994-01-01T00:00:00Z To investigate the association of alcohol intake with mortality from all causes, cardiovascular disease (CVD), cancer and other causes (e.g., accidents, violence, suicide), we performed an analysis of data obtained in a prospective follow-up study conducted in the Netherlands since 1977. Causes of death were defined for a cohort of 1,620 persons (760 men and 860 women) examined in 1977. During the 10-year follow-up period, 123 (7.6%) of the participants died. Frequency of alcohol consumption was obtained separately for wine, beer and liquor by means of a questionnaire. Although no significant association could be established between alcohol consumption and all-cause mortality, all-cause mortality tended to be lower in alcohol consumers compared to abstainers. The age- and sex-adjusted risk estimates of death from CVD were 0.29 (0.11-0.74), 0.46 (0.21-0.96) and 0.32 (0.13-0.77) for subjects with occasional, frequent and daily alcohol use, respectively, compared with those who did not drink at baseline. The mortality risks of never-drinkers and ex-drinkers were similar. A J- or U-shaped relation between alcohol consumption and CVD mortality could not be confirmed in our data but the available information on the amount of alcohol consumed was limited. No significant influence on the risk estimates of death from cancer or other causes was found. However, mortality tended to be higher for those who consumed more alcohol. The protective effect of alcohol intake on CVD mortality found in our data persisted after excluding subjects with cardiovascular or other major diseases at baseline from the analysis.