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Background The objectives of this study were to investigate the relation between coronary risk factors, exercise testing parameters, and the presence of angiographically significant coronary artery disease (CAD) (>50% luminal stenosis) in female patients previously hospitalized for an acute CAD event. Methods and Results All women younger than age 66 years in the greater Stockholm area in Sweden who were hospitalized for acute coronary syndromes during a 3-year period were recruited, Besides collection of clinical parameters, coronary angiography and a symptom-limited exercise test were performed in 228 patients 3 to 6 months after the index hospitalization. The mean age was 56 +/- 7 years. Angiographically nonsignificant CAD (stenosis <50%) was verified in 37% of the patients; significant CAD was found in 63%. The clinical parameters that showed the strongest relation with the presence of significant CAD after adjusting for age were history of myocardial infarction (odds ratio [OR] 4.91, 95% confidence interval [CI] 2.35 to 7.49), history of diabetes mellitus (OR 3.83, 95% Cl 1.63 to 14.31), serum high-density lipoprotein cholesterol <1.4 mmol/L (OR 2.11, 95% Cl 1.20 to 3.72), and waist-to-hip ratio >0.85 (OR 1.78, 95% Cl 1.02 to 3.10). A low exercise capacity and associated low change of rate-pressure product from rest to peak exercise were the only exercise testing parameters that were significantly related to angiographically verified significant CAD (<90% of the predicted maximal work capacity adjusted for age and weight, OR 1.91, 95% CI 1.04 to 3.50). Conclusions In female patients recovering from unstable CAD, exercise capacity was the only exercise testing parameter of value in the prediction of significant CAD. The consideration of certain clinical characteristics and coronary risk factors offer better or complementary information when deciding on further coronary assessment.

Plasma fibrinogen is an independent risk factor for coronary heart disease (CHD) in men; however, its role in women is less clear. We examined the ability of plasma fibrinogen to predict CHD in a community-based, case-control study of women aged 65 years or younger living in the greater Stockholm area. Cases were all patients hospitalized for an acute coronary event between February 1991 and February 1994. Controls were randomly selected from the city census and were matched to cases by age and catchment area. Plasma fibrinogen was measured 3 to 6 months after hospitalization by using a fibrinogen assay based on fibrinogen polymerization time measurement. Of the 292 consecutive cases, 110 (37%) were hospitalized for an acute myocardial infarction and 182 (63%) for angina pectoris. The mean age+/-SD in both patients and controls was 56+/-7 years. Mean levels of plasma fibrinogen in patients and controls were 3.66+/-0.81 and 3.25+/-0.64 g/L (P<0.0001), respectively. The age-adjusted odds ratio (OR) for CHD in the highest versus the lowest quartile of plasma fibrinogen was 6.0 (95% confidence interval [CI], 3.5 to 10.4). After adjustment for age, cigarette smoking, body mass index, systolic blood pressure, total cholesterol, high density lipoprotein cholesterol, triglycerides, and educational level, the OR was 3.0 (95% CI, 1.6 to 5.5). Further adjustment for C-reactive protein yielded the same result. In both premenopausal and postmenopausal women, the multivariate adjusted ORs were 7.0 (95% CI, 1.8 to 28.3) and 2.1 (95% CI, 1.0 to 4.4), respectively. These results provide evidence that plasma fibrinogen is associated with an excess risk of CHD in women.

Aims Several studies have reported that women with coronary heart disease have a poorer prognosis than men. Psychosocial factors, including social isolation and depressive symptoms have been suggested as a possible cause. However. little is known; about these factors and their independent predictive value in women. Therefore, we investigated the prognostic impact of depression, lack of social integration and their interaction in the Stockholm Female Coronary Risk Study. Methods and Results Two hundred and ninety-two women patients aged 30 to 65 years and admitted for an acute coronary event between 1991 and 1994, were followed for 5 years from baseline assessments, which were performed between 3 and 6 months after admission. Lack of social integration and depressive symptoms, assessed at baseline by standardized questionnaires, were associated with recurrent events. including cardiovascular mortality, acute myocardial infarction and revascularization procedures (percutaneous transluminal coronary angioplasty and coronary artery bypass grafting). Adjusting for age, diagnosis at index event. symptoms of heart failure, diabetes mellitus, high density lipoprotein (HDL) cholesterol, history of hypertension, systolic blood pressure, smoking, sedentary lifestyle, body mass index, and severity of angina pectoris symptoms. the hazard ratio associated with low (lowest quartile) as compared to high social integration (upper quartile) was 2.3 (95% CI 1.2-4.5) and the hazard ratio associated with two or more (upper three quartiles) as compared to one or no depressive symptoms was 1.9 (95% CI 1.02-3 6). Conclusions The presence of two or more depressive symptoms and lack of social integration independently predicted recurrent cardiac events in women with coronary heart disease. Women who were free of both these risk factors, had the best prognosis. (C) 2000 The European Society of Cardiology.

Background Both social isolation and the metabolic syndrome are independently associated with greater than normal cardiovascular risk. Design A population-based cross-sectional study of middle-aged Swedish women. Methods The study group consisted of 300 healthy women (aged 31-65 years) who were representative of women living in the greater Stockholm area. Social isolation was measured by using a condensed Version of the Interpersonal Support Evaluation List. Health behaviours were assessed and a full serum-lipid-level and haemostatic profile was obtained by standardized methods, The metabolic syndrome was defined as the presence of two or more of these components: fasting serum level of glucose greater than or equal to 7.0 mmol/l, arterial blood pressure greater than or equal to 160/90 mmHg, fasting serum level of triglycerides greater than or equal to 1.7 mmol/l or high-density lipoprotein < 1.0 mmol/l, or both, and central obesity (waist:hip ratio > 0.85 or body mass index > 30 kg/m(2), or both), Results After adjustment for age, menopausal status, educational level, smoking, exercise habits and consumption of alcohol, the risk ratio for the metabolic syndrome for women in the lower compared with women in the upper social-support quartile was 3.5 (95% confidence interval 1.1-11.4), whereas that of women in the two middle quartiles was 2.2 (95% confidence interval 0.67-7.2; P for trend 0.02). Conclusions Social isolation was associated with the metabolic syndrome for these middle-aged women. The findings suggest that the metabolic syndrome and its components may be mediators of the reported association between social isolation and cardiovascular disease, (C) 1999 Lippincott Williams & Wilkins.

"Vital exhaustion," characterized by fatigue, irritability, and demoralization, precedes new and recurrent coronary events. Biological mechanisms explaining this association are not fully understood. The objective was to investigate the relationship between vital exhaustion, lifestyle, and lipid profile. Vital exhaustion, smoking, body mass index (BMI), alcohol consumption, exercise capacity, and serum lipids were determined in 300 healthy women, aged 56.4 +/- 7.1 years. No statistically significant associations were found between vital exhaustion and lifestyle variables. Divided into quartiles, vital exhaustion was inversely related to high-density lipoprotein cholesterol (HDL-C) and apolipoprotein A1 in a linear fashion after adjustment for age, BMI, exercise capacity, and alcohol consumption. A multivariate-adjusted vital exhaustion-score in the top quartile, as compared to one in the lowest, was associated with 12% lower HDL-C and 8% lower apolipoprotein A1 (p < .05). In conclusion, alterations in lipid metabolism may be a possible mediating mechanism between vital exhaustion and coronary heart disease. The impact of lifestyle variables was weak.

Aims Social relations have been repeatedly linked to coronary heart disease in men, even after careful control for standard risk factors. Women have rarely been studied and results have not been conclusive. We investigated the role of social support in the severity and extent of coronary artery disease in women. Methods and Results One hundred and thirty-one women, aged 30 to 65 years, who were hospitalized for an acute coronary event and were included in the Stockholm Female Coronary Risk Study, were examined with computer assisted quantitative coronary angiography. Angiographic measures included presence of stenosis greater than 50% in at least one coronary artery (severity) and the number of stenoses greater than 20% within the coronary tree (extent). Social factors included two measures of social support, which were previously shown to predict coronary disease in prospective studies of men. After adjustment for age, lack of social support was associated with both measures of coronary artery disease. With further adjustment for smoking, education, menopausal status, hypertension, high density lipoprotein and body mass index, the risk ratio for stenosis greater than 50% in women with poor as compared to those with strong social support was 2.5 (95% confidence interval 1.2 to 5.3; P=0.003). Also, women with poor social support had more stenoses obstructing at least 20% of the coronary lumen with multivariate adjustment, but the difference from women with strong support was only of borderline significance (P=0.09). Conclusion The findings suggest that lack of social support contributes to the severity of coronary artery disease in women, independent of standard risk factors.

Hemostatic factors are reported to be associated with coronary heart disease (CHD). Socioeconomic status (SES) is 1 of the determinants of the hemostatic profile, but the factors underlying this association are not well known. Our aim was to examine determinants of the socioeconomic differences in hemostatic profile. Between 1991 and 1994, we studied 300 healthy women, aged 30 to 65 years, who were representative of women living in the greater Stockholm area. Fibrinogen, factor VII mass concentration (FVII:Ag), activated factor VII (FVIIa), von Willebrand factor (vWF), and plasminogen activator inhibitor-1 (PAI-1) were measured. Educational attainment was used as a measure of SES. Low educational level and an unfavorable hemostatic profile were both associated with older age, unhealthful life style, psychosocial stress, atherogenic biochemical factors, and hypertension. Levels of hemostatic factors increased with lower educational attainment. Independently of age, the differences between the lowest (mandatory) and highest (college/university) education in FVII:Ag levels were 41 mu g/L (95% confidence interval [CI] 15 to 66 mu g/L, P=0.001), 0.26 g/L (95% CI, 0.10 to 0.42 g/L, P=0.001) in fibrinogen levels, and 0.11 U/mL (95% CI, 0.09 to 0.12 U/mL, P=0.03) in levels of vWF. The corresponding differences in FVIIa and PAI-1 were not statistically significant. With further adjustment for menopausal status, family history of CHD, marital status, psychosocial stress, lifestyle patterns, biochemical factors, and hypertension, statistically significant differences between mandatory and college/university education were observed in FVII:Ag (difference=34 mu g/L; 95% CI, 2 to 65 mu g/L, P=0.05) but not in fibrinogen (difference 0.03 g/L; 95% CI, -0.13 to 0.19 g/L, P=0.92) or in VWF (difference=0.06 U/mL; 95% CI, -0.10 to 0.22 U/mL, P=0.45). An educational gradient was most consistent and statistically significant for FVII:Ag, fibrinogen, and VWF. Age, psychosocial stress, unhealthful life style, atherogenic biochemical factors, and hypertension mediated the association of low educational level with elevated levels of fibrinogen and vWF. Psychosocial stress and unhealthful life style were the most important contributing factors. There was an independent association between education and FVII:Ag, which could not be explained by any of these factors.

OBJECTIVE - The main objective was to examine the association between the metabolic syndrome and socioeconomic position las indicated by education) among women, RESEARCH DESIGN AND METHODS - The study sample comprised healthy women (aged 30-65 years) in Sweden who were representative of the general population in a metropolitan area. Socioeconomic position was measured by educational level (mandatory [less than or equal to 9 years], high school, or college/university). The metabolic syndrome was defined as the presence of two or mon: of the following components: 1) fasting plasma glucose level greater than or equal to 7.0 mmol/l; 2) arterial blood pressure greater than or equal to 160/90 mmHg; 3) fasting plasma triglycerides greater than or equal to 1.7 mmol/l and/or HDL cholesterol <1.0 mmol/l; and 4) central obesity (waist-to-hip ratio >0.85 and/or BMI >30 kg/m(2)), RESULTS - After adjustment for age, the risk ratio for the presence of the metabolic syndrome comparing the lowest (less than or equal to 9 years) with the highest (college/university) education was 2.7 (95% CI 1.1-6.8)1 This association persisted after controlling for menopausal status, family history of diabetes, and behavioral risk factors. CONCLUSIONS - Low education is associated with increased risk for metabolic syndrome in middle-aged women. These findings show that not only are women with low socioeconomic position at increased risk for individual risk factors that are associated with cardiovascular disease and type 2 diabetes, they are also at increased risk for the metabolic clustering of risk factors.

Recent studies of men have shown that job stress is important in understanding the occupational gradient in coronary heart disease (CHD), but these relationships have rarely been studied in women. With increasing numbers of women in the workforce it is important to have a more complete understanding of how CHD risk may be mediated by job stress as well as other biological and behavioural risk factors. The objective of this study was to examine the occupational gradient in CHD risk in relation to job stress and other traditional risk factors in currently employed women. We used data from the Stockholm Female Coronary Risk Study, a population based case-control study, comprising 292 women with CHD aged 65 years or younger and 292 age-matched healthy women (controls). An inversely graded association was observed between occupational class and CHD risk. Compared with the highest (executive/professional), women in the lowest occupational class (semi/unskilled) had a four-fold (95% CI 1.75-8.83) increased age-adjusted risk for CHD, Simultaneous adjustment for traditional risk factors and job stress attenuated this risk to 2.45 (95% CI 1.01-6.14). Neither job control nor the Karasek demand-control model of job stress substantially explained the increased CHD risk of women in the lowest occupational classes. It is likely that lower occupational class working women face multiple and sometimes interacting sources of work and non-work stress that are mediated by behavioural and biological factors that increase their CHD risk. (C) 2000 Elsevier Science Ltd. All rights reserved.

Objectives. To investigate the effect of short stature on prognosis following an acute event of coronary heart disease (CHD) in women. Setting. All women who were hospitalized for an acute event of CHD in any of the 10 cardiology clinics in greater Stockholm were investigated for the first time in the Stockholm Female Coronary Risk Study between 1991 and 1994, and were followed until August 1997 for recurrent coronary events. Design. A follow-up study of women with either acute myocardial infarction (AMI) or unstable angina pectoris, Median follow-up period was 4.8 years. Subjects. A total of 292 Swedish women, aged 65 years or younger. Main outcome measures. Recurrent AMI, death from CHD or revascularization procedure (percutaneous transluminal coronary angioplasty and coronary artery bypass grafting). Results. Independent of the confounding effects of other risk factors of clinical importance for CHD (age, socioeconomic status, menopausal status, index event, congestive heart failure, angina severity, diabetes, hypertension, smoking, triglycerides and HDL cholesterol), the shortest 25% of women (<160 cm) had a 2.1-fold (95% CI = 1.0-4.4) increased rate of developing adverse cardiac events (cardiovascular death, recurrent AMI or revascularization procedure) compared with the tallest 25% (>165 cm). In addition, an increased rate was observed for each 10 cm difference in height (hazard ratio = 1.7, 95% CI = 1.4-2.7). Similar results were observed when analysing each outcome separately. Conclusions. These data indicate that short stature is a strong predictor of poor prognosis after an acute coronary event in women, independent of socioeconomic status and other risk factors for CHD.

Objective: This study evaluated the ability of mental stress testing to discriminate between women with and without CHD, and among women with different disease manifestations, taking into account history of hypertension and beta -blocker use. Methods: Analyses were based on data from a community-based case-control study of women aged 65 years or younger. The study group consisted of 292 women who were hospitalized for an acute event of CHD, either AMI or unstable AP in Stockholm between 1991 and 1994. Controls were matched to cases by age and catchment area. Cardiovascular reactivity and emotional response to an anagram task solved under time pressure were measured 3 to 6 months after hospitalization. Results: Patients reacted with smaller increases in heart rate (4 bpm) than their controls (7 bpm). Results for the rate-pressure product were similar. Cardiovascular reactions did not distinguish patients with AP from those with AML History of hypertension (present in 50% of patients and 11% of controls) was related to enhanced diastolic blood pressure reactivity. Patients on beta -blockers (66%) had lower heart-rate levels throughout testing, but did not differ in their cardiovascular stress reactions when compared with the remaining participants. Conclusions: Women with heart disease have somewhat lower heart-rate responses to stress than healthy age-matched controls. History of hypertension is related to enhanced diastolic blood pressure reactivity to mental stress in both patients and controls.