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Life-course influences on occurrence and outcome for stroke and coronary heart disease
Örebro University, School of Medical Sciences.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Although typical clinical onset does not occur until adulthood, cardiovascular disease (CVD) may have a long natural history with accumulation of risks beginning in early life and continuing through childhood and into adolescence and adulthood. Therefore, it is important to adopt a life-course approach to explore accumulation of risks, as well as identifying age-defined windows of susceptibility, from early life to disease onset. This thesis examines characteristics in adolescence and adulthood linked with subsequent risk of CVD. One area is concerned with physical and psychological characteristics in adolescence, which reflects inherited and acquired elements from childhood, and their association with occurrence and outcome of subsequent stroke and coronary heart disease many years later. The second area focuses on severe infections and subsequent delayed risk of CVD. Data from several Swedish registers were used to provide information on a general population-based cohort of men. Some 284 198 males, born in Sweden from 1952 to 1956 and included in the Swedish Military Conscription Register, form the basis of the study cohort for this thesis. Our results indicate that characteristics already present in adolescence may have an important role in determining long-term cardiovascular health. Stress resilience in adolescence was associated with an increased risk of stroke and CHD, working in part through other CVD factors, in particular physical fitness. Stress resilience, unhealthy BMI and elevated blood pressure in adolescence were also associated with aspects of stroke severity among survivors of a first stroke. We demonstrated an association for severe infections (hospital admission for sepsis and pneumonia) in adulthood with subsequent delayed risk of CVD, independent of risk factors from adolescence. Persistent systemic inflammatory activity which could follow infection, and that might persist long after infections resolve, represents a possible mechanism. Interventions to protect against CVD should begin by adolescence; and there may be a period of heightened susceptibility in the years following severe infection when additional monitoring and interventions for CVD may be of value.

Place, publisher, year, edition, pages
Örebro: Örebro University , 2017.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 156
Keyword [en]
cardiovascular disease, stroke, risk factors, adolescence, stress resilience, adult infections, life-course epidemiology, cohort study
National Category
Family Medicine
Identifiers
URN: urn:nbn:se:oru:diva-54254ISBN: 978-91-7529-177-2 (print)OAI: oai:DiVA.org:oru-54254DiVA: diva2:1061572
Public defence
2017-03-10, Örebro universitet, Campus USÖ, hörsal C3, Södra Grev Rosengatan 32, Örebro, 09:30 (Swedish)
Opponent
Supervisors
Available from: 2017-01-03 Created: 2017-01-03 Last updated: 2017-02-16Bibliographically approved
List of papers
1. Stress resilience in male adolescents and subsequent stroke risk: cohort study
Open this publication in new window or tab >>Stress resilience in male adolescents and subsequent stroke risk: cohort study
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2014 (English)In: Journal of Neurology, Neurosurgery and Psychiatry, ISSN 0022-3050, E-ISSN 1468-330X, Vol. 85, no 12, 1331-1336 p.Article in journal (Refereed) Published
Abstract [en]

Objective Exposure to psychosocial stress has been identified as a possible stroke risk, but the role of stress resilience which may be relevant to chronic exposure is uncertain. We investigated the association of stress resilience in adolescence with subsequent stroke risk.

Methods Register-based cohort study. Some 237 879 males born between 1952 and 1956 were followed from 1987 to 2010 using information from Swedish registers. Cox regression estimated the association of stress resilience with stroke, after adjustment for established stroke risk factors.

Results Some 3411 diagnoses of first stroke were identified. Lowest stress resilience (21.8%) compared with the highest (23.7%) was associated with increased stroke risk, producing unadjusted HR (with 95% CIs) of 1.54 (1.40 to 1.70). The association attenuated slightly to 1.48 (1.34 to 1.63) after adjustment for markers of socioeconomic circumstances in childhood; and after further adjustment for markers of development and disease in adolescence (blood pressure, cognitive function and pre-existing cardiovascular disease) to 1.30 (1.18 to 1.45). The greatest reduction followed further adjustment for markers of physical fitness (BMI and physical working capacity) in adolescence to 1.16 (1.04 to 1.29). The results were consistent when stroke was subdivided into fatal, ischaemic and haemorrhagic, with higher magnitude associations for fatal rather than non-fatal, and for haemorrhagic rather than ischaemic stroke.

Conclusions Stress susceptibility and, therefore, psychosocial stress may be implicated in the aetiology of stroke. This association may be explained, in part, by poorer physical fitness. Effective prevention might focus on behaviour/lifestyle and psychosocial stress.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2014
Keyword
stroke
National Category
Neurology Psychiatry Surgery
Identifiers
urn:nbn:se:oru:diva-35058 (URN)10.1136/jnnp-2013-307485 (DOI)000345276400010 ()2-s2.0-84896691316 (ScopusID)
Note

Funding Agency:

UK Economic and Social Research Council (ESRC) RES-596-28-0001 ES/J019119/1

Stiftelsen Olle Engqvist Byggmästare 

Örebro University 

Available from: 2014-05-15 Created: 2014-05-15 Last updated: 2017-03-14Bibliographically approved
2. Stress resilience and physical fitness in adolescence and risk of coronary heart disease in middle age
Open this publication in new window or tab >>Stress resilience and physical fitness in adolescence and risk of coronary heart disease in middle age
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2015 (English)In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 101, no 8, 623-629 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Psychosocial stress is a suggested risk for coronary heart disease (CHD). The relationship of stress resilience in adolescence with subsequent CHD risk is underinvestigated, so our objective was to assess this and investigate the possible mediating role of physical fitness.

METHODS: In this register-based study, 237 980 men born between 1952 and 1956 were followed from 1987 to 2010 using information from Swedish registers. Stress resilience was measured at a compulsory military conscription examination using a semistructured interview with a psychologist. Some 10 581 diagnoses of CHD were identified. Cox regression estimated the association of stress resilience with CHD, with adjustment for established cardiovascular risk factors.

RESULTS: Low-stress resilience was associated with increased CHD risk. The association remained after adjustment for physical fitness and other potential confounding and mediating factors, with adjusted HRs (and 95% CIs) of 1.17 (1.10 to 1.25), with some evidence of mediation by physical fitness. CHD incidence rates per 1000 person-years (and 95% CIs) for low-stress, medium-stress and high-stress resilience were 2.61 (2.52 to 2.70), 1.97 (1.92 to 2.03) and 1.59 (1.53 to 1.67) respectively. Higher physical fitness was inversely associated with CHD risk; however, this was attenuated by low-stress resilience, shown by interaction testing (p<0.001).

CONCLUSIONS: Low-stress resilience in adolescence was associated with increased risk of CHD in middle age and may diminish the benefit of physical fitness. This represents new evidence of the role of stress resilience in determining risk of CHD and its interrelationship with physical fitness.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2015
National Category
Cardiac and Cardiovascular Systems
Research subject
Epidemiology; Cardiology
Identifiers
urn:nbn:se:oru:diva-43425 (URN)10.1136/heartjnl-2014-306703 (DOI)000351755300009 ()25740818 (PubMedID)2-s2.0-84927665875 (ScopusID)
Note

Funding Agencies:

UK Economic and Social Research Council (ESRC) RES-596-28-0001  ES/JO19119/1

Stiftelsen Olle Engqvist Byggmästare, Folksam

Örebro University

Available from: 2015-03-06 Created: 2015-03-06 Last updated: 2017-03-14Bibliographically approved
3. Determinants in adolescence of stroke-related hospital stay duration in men: a national cohort study
Open this publication in new window or tab >>Determinants in adolescence of stroke-related hospital stay duration in men: a national cohort study
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2016 (English)In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 47, no 9, 2416-2418 p.Article in journal (Refereed) Published
Abstract [en]

Background and purpose: Physical and psychological characteristics in adolescence are associated with subsequent stroke risk. Our aim is to investigate their relevance to length of hospital stay and risk of second stroke.

Methods: Swedish men born between 1952 and 1956 (n=237 879) were followed from 1987 to 2010 using information from population-based national registers. Stress resilience, body mass index, cognitive function, physical fitness, and blood pressure were measured at compulsory military conscription examinations in late adolescence. Joint Cox proportional hazards models estimated the associations of these characteristics with long compared with short duration of stroke-related hospital stay and with second stroke compared with first.

Results: Some 3000 men were diagnosed with nonfatal stroke between ages 31 and 58 years. Low stress resilience, underweight, and higher systolic blood pressure (per 1-mm Hg increase) during adolescence were associated with longer hospital stay (compared with shorter) in ischemic stroke, with adjusted relative hazard ratios (and 95% confidence intervals) of 1.46 (1.08-1.89), 1.41 (1.04-1.91), and 1.01 (1.00-1.02), respectively. Elevated systolic and diastolic blood pressures during adolescence were associated with longer hospital stay in men with intracerebral hemorrhage: 1.01 (1.00-1.03) and 1.02 (1.00-1.04), respectively. Among both stroke types, obesity in adolescence conferred an increased risk of second stroke: 2.06 (1.21-3.45).

Conclusions: Some characteristics relevant to length of stroke-related hospital stay and risk of second stroke are already present in adolescence. Early lifestyle influences are of importance not only to stroke risk by middle age but also to recurrence and use of healthcare resources among stroke survivors.

Place, publisher, year, edition, pages
Philadelphia, USA: Lippincott Williams & Wilkins, 2016
Keyword
Adolescent, blood pressure, length of stay, psychological stress, risk factors
National Category
Cardiac and Cardiovascular Systems Neurology
Identifiers
urn:nbn:se:oru:diva-51591 (URN)10.1161/STROKEAHA.116.014265 (DOI)000383559300052 ()27491740 (PubMedID)2-s2.0-84982813061 (ScopusID)
Note

Funding Agencies:

UK Economic and Social Research Council RES-596-28-0001  ES/JO19119/1

Stiftelsen Olle Engqvist Byggmästare

Folksam

Örebro University

Available from: 2016-08-08 Created: 2016-08-08 Last updated: 2017-02-16Bibliographically approved
4. Severe infections and subsequent delayed cardiovascular disease: national cohort study
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(English)Manuscript (preprint) (Other academic)
National Category
Family Medicine
Identifiers
urn:nbn:se:oru:diva-55808 (URN)
Available from: 2017-02-16 Created: 2017-02-16 Last updated: 2017-02-16Bibliographically approved

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