POPULÄRVETENSKAPLIG SAMMANFATTNING PÅ SVENSKA Hjärt- och kärlsjukdomar är den ledande dödsorsaken för världens kvinnor. Det

främ-sta syftet med det här projektet var att studera aktuella data om könsspecifi ka skill-nader i symptom, dödlighet och prognos efter kranskärlssjukdom. Det övergripande syftet är att öka kunskapen om kvinnor och hjärtkärlsjukdom, något som har betydelse för att planera sjukvård och förebyggande åtgärder. Data har hämtats från de svenska rikstäckande och personnummerbaserade Dödsorsaksregistret och Patientregistret.

Patientjournaler har använts för att studera symptom hos patienter i den populations-baserade INTERGENE-studien.

Bland 225 patienter som insjuknat med förstagångshjärtinfarkt var bröstsmärta det vanligaste symptomet både hos män och kvinnor. Kvinnor hade oftare illamående, ryggsmärta, yrsel och hjärtklappning och ett högre antal symptom än män. Mel-lan 1987-2009 har dödligheten i kranskärlssjukdom i Sverige minskat med ca två tredjedelar både hos män och kvinnor och i alla åldrar mellan 35 och 84 år. Bland patienter med en första hjärtinfarkt som ankom till sjukhus samt bland dem som avled av kranskärlssjukdom utanför sjukhus mellan 1987 och 2011 var kvinnorna i genomsnitt fyra år äldre än männen och hade fl er samtidiga andra sjukdomar. 28- dagars- och 1-årsöverlevnaden efter sjukhusvård för hjärtinfarkt har ökat de senaste två decennierna men prognosen för kvinnor har inte förbättrats lika mycket som för män. Kvinnor under 55 år som inkommer till sjukhus har fortfarande högre 28-dagars och 1-årsdödlighet än män. Fler män dör dock utanför sjukhus än bland de sjukhusin-lagda så när de som dog utanför sjukhus inkluderades i analysen så hade männen sämre korttidsprognos.

Bland 7229 yngre kvinnor och 30047 män 25-55 år som överlevt en första hjärtin-farkt mellan 1987-2006 förbättrades 4-årsöverlevnaden påtagligt under perioden men mindre för kvinnor än för män. Den årliga mortaliteten kan numera skattas till ca 1%

i denna grupp. Trots att detta är en låg siffra i absoluta tal är det betydligt mer än för populationen i samma åldrar i övrigt, särskilt för kvinnor som normalt har en mycket låg dödlighet i dessa åldrar.

ACKNOWLEDGEMENTS

I wish to express my sincere gratefulness to all who have been involved in this thesis.

In particular, I would like to thank:

Professor Annika Rosengren, my supervisor, for supporting the initial idea, for great encouragement, inspiration and advice both on research and clinical matters and for always helping me to strive towards precision in study design, analysis and language.

Thanks for an amazing journey through cardiovascular epidemiology and also for be-ing a great role-model.

Lena Björck, my co-supervisor for opening the door to the world of research and hav-ing patience with all my questions.

Georg Lappas, for all your time, guiding and discussions regarding the statistical challenges.

Kerstin Dudas, my co-author for life wisdom and mentorship.

Susanne Nielsen, my roommate and co-author for productive discussions and wise support.

Kok Wai Giang, my roommate and co-author for your contagious enthusiasm and statistical discussions.

Tatiana Zverkova Sandström, my roommate and co-author for interesting statistical discussions.

Professor Owe Johnson, for attracting my interest in the fascinating fi eld of Cardio-logy during my studies at Umeå University.

Eva Thydén, for expertise and great assistance during my PhD period and for help with publishing this book.

Ann-Britt Johansson, for always being a professional and guiding me in all adminis-trative issues.

All other welcoming colleagues at Sahlgrenska University Hospital.

Fredrik, my beloved husband for your endless love, patience and support.

My parents - Anders and Lena - for your incredible support throughout my life.

My mentorship group - for all your advice during my internship period.

The Medical Women´s International Association - for being role-models and sharing your strengths.

In memory of my grandfather Ove Berg- for your courage to follow your vision.

These studies were supported by the Swedish Heart and Lung Foundation, The Swedish Research Council, the Swedish Council for Working Life and Social Research (Epilife), the Sahlgrenska University Hospital Foundation of Cardiology, Sahlgrenska University Hospital Research Internship and Anna Cederbergs Foundation.

REFERENCES

1. World Health Organization. The global burden of disease: 2004 update.: WHO Library Cataloguing-in-Publication Data;2004.

2. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. Third univer-sal defi nition of myocardial infarction. Eur Heart J 2012;33:2551-2567.

3. Swedish National Board of Health and Welfare. Statistic database for myocardial infarc-tions. 2013; http://www.socialstyrelsen.se/statistik/statistikdatabas/hjartinfarkter.

4. McGill HC, Jr., McMahan CA, Zieske AW, et al. Association of Coronary Heart Disease Risk Factors with microscopic qualities of coronary atherosclerosis in youth. Circulation 2000;102:374-379.

5. Bugiardini R, Bairey Merz CN. Angina with “normal” coronary arteries: a changing philosophy. JAMA 2005;293:477-484.

6. Rosengren A, Wallentin L, A KG, Behar S, Battler A, Hasdai D. Sex, age, and clinical presentation of acute coronary syndromes. Eur Heart J 2004;25:663-670.

7. Vaccarino V, Badimon L, Corti R, et al. Ischaemic heart disease in women: are there sex differences in pathophysiology and risk factors? Position paper from the working group on coronary pathophysiology and microcirculation of the European Society of Cardiol-ogy. Cardiovasc Res 2011;90:9-17.

8. Bjorck L, Wallentin L, Stenestrand U, Lappas G, Rosengren A. Medication in relation to ST-segment elevation myocardial infarction in patients with a fi rst myocardial infarction:

Swedish Register of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS-HIA). Arch Intern Med 2010;170:1375-1381.

9. Bjorck L, Rosengren A, Wallentin L, Stenestrand U. Smoking in relation to ST-segment elevation acute myocardial infarction: fi ndings from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions. Heart 2009;95:1006-1011.

10. Rosengren A, Wallentin L, Simoons M, et al. Cardiovascular risk factors and clinical presentation in acute coronary syndromes. Heart 2005;91:1141-1147.

11. Ravn-Fischer A, Karlsson T, Santos M, Bergman B, Herlitz J, Johanson P. Inequali-ties in the early treatment of women and men with acute chest pain? Am J Emerg Med 2012;30:1515-1521.

12. Isaksson RM, Holmgren L, Lundblad D, Brulin C, Eliasson M. Time trends in symptoms and prehospital delay time in women vs. men with myocardial infarction over a 15-year period. The Northern Sweden MONICA Study. Eur J Cardiovasc Nurs 2008;7:152-158.

13. Canto JG, Rogers WJ, Goldberg RJ, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA 2012;307:813-822.

14. Everts B, Karlson BW, Wahrborg P, Hedner T, Herlitz J. Localization of pain in sus-pected acute myocardial infarction in relation to fi nal diagnosis, age and sex, and site and type of infarction. Heart Lung 1996;25:430-437.

15. Goldberg R, Goff D, Cooper L, et al. Age and sex differences in presentation of symp-toms among patients with acute coronary disease: the REACT Trial. Rapid Early Action for Coronary Treatment. Coron Artery Dis 2000;11:399-407.

16. Goldberg RJ, O’Donnell C, Yarzebski J, Bigelow C, Savageau J, Gore JM. Sex differenc-es in symptom prdifferenc-esentation associated with acute myocardial infarction: a population-based perspective. Am Heart J 1998;136:189-195.

17. Maynard C, Litwin PE, Martin JS, Weaver WD. Gender differences in the treatment and outcome of acute myocardial infarction. Results from the Myocardial Infarction Triage and Intervention Registry. Arch Intern Med 1992;152:972-976.

18. Meischke H, Larsen MP, Eisenberg MS. Gender differences in reported symptoms for acute myocardial infarction: impact on prehospital delay time interval. Am J Emerg Med 1998;16:363-366.

19. Penque S, Halm M, Smith M, et al. Women and coronary disease: relationship between descriptors of signs and symptoms and diagnostic and treatment course. Am J Crit Care 1998;7:175-182.

20. Cunningham MA, Lee TH, Cook EF, et al. The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain: a report from the Multicenter Chest Pain Study Group. J Gen Intern Med 1989;4:392-398.

21. Maynard C, Beshansky JR, Griffi th JL, Selker HP. Infl uence of sex on the use of cardiac procedures in patients presenting to the emergency department. A prospective multi-center study. Circulation 1996;94(9 Suppl):II93-98.

22. Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarc-tion: infl uence of sex, age, and risk factors. Am Heart J 2002;144:1012-1017.

23. Tunstall-Pedoe H, Morrison C, Woodward M, Fitzpatrick B, Watt G. Sex differences in myocardial infarction and coronary deaths in the Scottish MONICA population of Glasgow 1985 to 1991. Presentation, diagnosis, treatment, and 28-day case fatality of 3991 events in men and 1551 events in women. Circulation 1996;93:1981-1992.

24. Rosengren A, Spetz CL, Koster M, Hammar N, Alfredsson L, Rosen M. Sex differences in survival after myocardial infarction in Sweden; data from the Swedish National Acute Myocardial Infarction Register. Eur Heart J 2001;22:314-322.

25. Wenger NK, Shaw LJ, Vaccarino V. Coronary heart disease in women: update 2008. Clin Pharmacol Ther 2008;83:37-51.

26. Gorodeski GI. Impact of the menopause on the epidemiology and risk factors of coro-nary artery heart disease in women. Exp Gerontol 1994;29:357-375.

27. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefi ts of estrogen plus pro-gestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA 2002;288:321-333.

28. Chlebowski RT, Hendrix SL, Langer RD, et al. Infl uence of estrogen plus progestin on breast cancer and mammography in healthy postmenopausal women: the Women’s Health Initiative Randomized Trial. JAMA 2003;289:3243-3253.

29. Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifi able risk factors associ-ated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364:937-952.

30. Anand SS, Islam S, Rosengren A, et al. Risk factors for myocardial infarction in women and men: insights from the INTERHEART study. Eur Heart J 2008;29:932-940.

31. Schenck-Gustafsson K, Rees M. Cardiology for gynecologists-A minireview. Maturitas 2013;75:386-391.

32. Sullivan SD, Umans JG, Ratner R. Gestational diabetes: implications for cardiovascular health. Curr Diab Rep 2012;12:43-52.

33. Collen AC, Hellgren M, Gustafsson H, Johansson MC, Manhem K. Cardiovascular and metabolic characteristics 40 years after hypertensive pregnancies: a long-term follow-up study of mothers. J Hypertens 2013;31:758-765.

34. Huang G, Coviello A. Clinical update on screening, diagnosis and management of meta-bolic disorders and cardiovascular risk factors associated with polycystic ovary syn-drome. Curr Opin Endocrinol Diabetes Obes 2012;19:512-519.

35. Wang HX, Leineweber C, Kirkeeide R, et al. Psychosocial stress and atherosclerosis:

family and work stress accelerate progression of coronary disease in women. The Stock-holm Female Coronary Angiography Study. J Intern Med 2007;261:245-254.

36. Orth-Gomer K, Wamala SP, Horsten M, Schenck-Gustafsson K, Schneiderman N, Mit-tleman MA. Marital stress worsens prognosis in women with coronary heart disease: The Stockholm Female Coronary Risk Study. JAMA 2000;284:3008-3014.

37. Rose G. Strategy of prevention: lessons from cardiovascular disease. Br Med J (Clin Res Ed) 1981;282:1847-1851.

38. Omran AR. The epidemiologic transition. A theory of the epidemiology of population change. Milbank Mem Fund Q 1971;49:509-538.

39. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urban-ization. Circulation 2001;104:2746-2753.

40. Asplund K, Eliasson M, Janlert U, Stegmayr B. [What the MONICA project has taught us about cardiovascular diseases--society, public health and health care]. Lakartidningen 2006;103:3006-3011.

41. Mirzaei M, Truswell AS, Taylor R, Leeder SR. Coronary heart disease epidemics: not all the same. Heart 2009;95:740-746.

42. Bjorck L, Rosengren A, Bennett K, Lappas G, Capewell S. Modelling the decreas-ing coronary heart disease mortality in Sweden between 1986 and 2002. Eur Heart J 2009;30:1046-1056.

43. Muller-Nordhorn J, Binting S, Roll S, Willich SN. An update on regional variation in cardiovascular mortality within Europe. Eur Heart J 2008;29:1316-1326.

44. Pearson TA. Cardiovascular disease in developing countries: myths, realities, and op-portunities. Cardiovasc Drugs Ther 1999;13:95-104.

45. Wilson A, Siskind V. Coronary heart disease mortality in Australia: is mortality starting to increase among young men? Int J Epidemiol 1995;24:678-684.

46. Tobias M, Sexton K, Mann S, Sharpe N. How low can it go? Projecting ischaemic heart disease mortality in New Zealand to 2015. N Z Med J 2006;119:U1932.

47. Ford ES, Capewell S. Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: concealed leveling of mortality rates. J Am Coll Cardiol 2007;50:2128-2132.

48. O’Flaherty M, Ford E, Allender S, Scarborough P, Capewell S. Coronary heart disease trends in England and Wales from 1984 to 2004: concealed levelling of mortality rates among young adults. Heart 2008;94:178-181.

49. O’Flaherty M, Bishop J, Redpath A, et al. Coronary heart disease mortality among young adults in Scotland in relation to social inequalities: time trend study. BMJ 2009;339:b2613.

50. Briffa T, Nedkoff L, Peeters A, et al. Discordant age and sex-specifi c trends in the in-cidence of a fi rst coronary heart disease event in Western Australia from 1996 to 2007.

Heart 2011;97:400-404.

51. Vaartjes I, O’Flaherty M, Grobbee DE, Bots ML, Capewell S. Coronary heart disease mortality trends in the Netherlands 1972-2007. Heart 2011;7:569-573.

52. Vaccarino V, Parsons L, Every NR, Barron HV, Krumholz HM. Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants. N Engl J Med 1999;341:217-225.

53. Dudas K, Lappas G, Rosengren A. Long-term prognosis after hospital admission for acute myocardial infarction from 1987 to 2006. Int J Cardiol 2012;155:400-405.

54. Langorgen J, Igland J, Vollset SE, et al. Short-term and long-term case fatality in 11 878 patients hospitalized with a fi rst acute myocardial infarction, 1979-2001: the Western Norway cardiovascular registry. Eur J Cardiovasc Prev Rehabil 2009;16:621-627.

55. Hardoon SL, Whincup PH, Petersen I, Capewell S, Morris RW. Trends in longer-term survival following an acute myocardial infarction and prescribing of evidenced-based medications in primary care in the UK from 1991: a longitudinal population-based study.

J Epidemiol Community Health 2011;65:770-774.

56. Fagring AJ, Lappas G, Kjellgren KI, Welin C, Manhem K, Rosengren A. Twenty-year trends in incidence and 1-year mortality in Swedish patients hospitalised with non-AMI chest pain. Data from 1987-2006 from the Swedish hospital and death registries. Heart 2010;96:1043-1049.

57. Gale CP, Cattle BA, Woolston A, et al. Resolving inequalities in care? Reduced mortality in the elderly after acute coronary syndromes. The Myocardial Ischaemia National Audit Project 2003-2010. Eur Heart J 2012;33:630-639.

58. Alpert JS, Thygesen K, Antman E, Bassand JP. Myocardial infarction redefi ned--a con-sensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefi nition of myocardial infarction. J Am Coll Cardiol 2000;36:959-969.

59. Cox D. Regression models and life-tables. J R Stat Soc Series B Stat Methodol 1972;34:187-220.

60. Allison P. Survival Analysis Using SAS: A Practical Guide. 2010.

61. Milner KA, Vaccarino V, Arnold AL, Funk M, Goldberg RJ. Gender and age differences in chief complaints of acute myocardial infarction (Worcester Heart Attack Study). Am J Cardiol 2004;93:606-608.

62. Paul SD, Eagle KA, Guidry U, et al. Do gender-based differences in presentation and management infl uence predictors of hospitalization costs and length of stay after an acute myocardial infarction? Am J Cardiol 1995;76:1122-1125.

63. Applegate WB, Graves S, Collins T, Vander Zwaag R, Akins D. Acute myocardial infarc-tion in elderly patients. South Med J 1984;77:1127-1129.

64. Liau CS, Hahn LC, Tjung JJ, et al. The clinical characteristics of acute myocardial in-farction in aged patients. J Formos Med Assoc 1991;90:122-126.

65. Bayer AJ, Chadha JS, Farag RR, Pathy MS. Changing presentation of myocardial infarc-tion with increasing old age. J Am Geriatr Soc 1986;34:263-266.

66. Yang XS, Willems JL, Pardaens J, De Geest H. Acute myocardial infarction in the very elderly. A comparison with younger age groups. Acta Cardiol 1987;42:59-68.

67. Tucker MA, Andrew MF, Ogle SJ, Davison JG. Age-associated change in pain threshold measured by transcutaneous neuronal electrical stimulation. Age Ageing 1989;18:241-246.

68. Jones PP, Shapiro LF, Keisling GA, et al. Altered autonomic support of arterial blood pressure with age in healthy men. Circulation 2001;104:2424-2429.

69. Tsouna-Hadjis E, Kallergis G, Agrios N, et al. Pain intensity in nondiabetic patients with myocardial infarction or unstable angina. Its association with clinical and psychological features. Int J Cardiol 1998;67:165-169.

70. Legato MJ. Women’s health: not for women only. Int J Fertil Womens Med 1998;43:65-72.

71. Airaksinen KE, Ikaheimo MJ, Linnaluoto M, Tahvanainen KU, Huikuri HV. Gender difference in autonomic and hemodynamic reactions to abrupt coronary occlusion. J Am Coll Cardiol 1998;31:301-306.

72. Miller CL. A review of symptoms of coronary artery disease in women. J Adv Nurs 2002;39:17-23.

73. Vaartjes I, O’Flaherty M, Grobbee DE, Bots ML, Capewell S. Coronary heart disease mortality trends in the Netherlands 1972-2007. Heart 2011;97:569-573.

74. Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med 2007;356:2388-2398.

75. Unal B, Critchley J, Capewell S. Impact of smoking reduction on coronary heart disease mortality trends during 1981-2000 in England and Wales. Tob Induc Dis 2003;1:185.

76. Kabir Z, Perry IJ, Critchley J, O’Flaherty M, Capewell S, Bennett K. Modelling Coro-nary Heart Disease Mortality declines in the Republic of Ireland, 1985-2006. Int J Car-diol 2013. [Epub ahead of print]

77. Dudas K, Lappas G, Stewart S, Rosengren A. Trends in out-of-hospital deaths due to coronary heart disease in Sweden (1991 to 2006). Circulation 2011;123:46-52.

78. Lee DS, Chiu M, Manuel DG, et al. Trends in risk factors for cardiovascular disease in Canada: temporal, socio-demographic and geographic factors. CMAJ 2009;181:E55-66.

79. Rosengren A. Declining cardiovascular mortality and increasing obesity: a paradox.

CMAJ 2009;181:127-128.

80. Rosengren A, Eriksson H, Hansson PO, et al. Obesity and trends in cardiovascular risk factors over 40 years in Swedish men aged 50. J Intern Med 2009;266:268-276.

81. Abel ED, Litwin SE, Sweeney G. Cardiac remodeling in obesity. Physiol Rev 2008;88:389-419.

82. Diercks DB, Roe MT, Mulgund J, et al. The obesity paradox in non-ST-segment eleva-tion acute coronary syndromes: results from the Can Rapid risk stratifi caeleva-tion of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines Quality Improvement Initiative. Am Heart J 2006;152:140-148.

83. Johansson S, Wilhelmsen L, Welin C, Eriksson H, Welin L, Rosengren A. Obesity, smok-ing and secular trends in cardiovascular risk factors in middle-aged women: data from population studies in Goteborg from 1980 to 2003. J Intern Med 2010;268:594-603.

84. James WP. The epidemiology of obesity: the size of the problem. J Intern Med 2008;263:336-352.

85. Johansson G. Overweight and obesity in Sweden. A fi ve year follow-up, 2004-2008.

Scand J Public Health 2010;38:803-809.

86. Eliasson M, Lindahl B, Lundberg V, Stegmayr B. No increase in the prevalence of known diabetes between 1986 and 1999 in subjects 25-64 years of age in northern Sweden. Dia-bet Med 2002;19:874-880.

87. Jansson SP, Andersson DK, Svardsudd K. Prevalence and incidence rate of diabetes mel-litus in a Swedish community during 30 years of follow-up. Diabetologia 2007;50:703-710.

88. Swedish National Board of Health and Welfare. Public health report. Sweden 2009.

89. Mann J, Nye ER. Fad diets in Sweden, of all places. Lancet 2009;374:767-769.

90. Ng N, Johnson O, Lindahl B, Norberg M. A reversal of decreasing trends in population cholesterol levels in Vasterbotten County, Sweden. Glob Health Action 2012;5. [Epub ahead of print]

91. Gan SC, Beaver SK, Houck PM, MacLehose RF, Lawson HW, Chan L. Treatment of acute myocardial infarction and 30-day mortality among women and men. N Engl J Med 2000;343:8-15.

92. Heer T, Schiele R, Schneider S, et al. Gender differences in acute myocardial infarction in the era of reperfusion (the MITRA registry). Am J Cardiol 2002;89:511-517.

93. Dey S, Flather MD, Devlin G, et al. Sex-related differences in the presentation, treatment and outcomes among patients with acute coronary syndromes: the Global Registry of Acute Coronary Events. Heart 2009;95:20-26.

94. Lundberg V, Wikstrom B, Bostrom S, Asplund K. Exploring sex differences in case fa-tality in acute myocardial infarction or coronary death events in the northern Sweden MONICA Project. J Intern Med 2002;251:235-244.

95. Lawesson SS, Alfredsson J, Fredrikson M, Swahn E. Time trends in STEMI--improved treatment and outcome but still a gender gap: a prospective observational cohort study from the SWEDEHEART register. BMJ Open 2012;2:e000726.

96. Alfredsson J, Sederholm-Lawesson S, Stenestrand U, Swahn E. Although women are less likely to be admitted to coronary care units, they are treated equally to men and have better outcome. A prospective cohort study in patients with non ST-elevation acute coronary syndromes. Acute Card Care 2009;11:173-180.

97. Vaccarino V, Parsons L, Peterson ED, Rogers WJ, Kiefe CI, Canto J. Sex differences in mortality after acute myocardial infarction: changes from 1994 to 2006. Arch Intern Med 2009;169:1767-1774.

98. MacIntyre K, Stewart S, Capewell S, et al. Gender and survival: a population-based study of 201,114 men and women following a fi rst acute myocardial infarction. J Am Coll Cardiol 2001;38:729-735.

99. Capewell S, MacIntyre K, Stewart S, et al. Age, sex, and social trends in out-of-hospital cardiac deaths in Scotland 1986-95: a retrospective cohort study. Lancet 2001;358:1213-1217.

100. Swedish National Board of Health and Welfare. Public Health Report 2013.

101. Lawesson SS, Stenestrand U, Lagerqvist B, Wallentin L, Swahn E. Gender perspective on risk factors, coronary lesions and long-term outcome in young patients with ST-ele-vation myocardial infarction. Heart 2010;96:453-459.

102. Law MR, Watt HC, Wald NJ. The underlying risk of death after myocardial infarction in the absence of treatment. Arch Intern Med 2002;162:2405-2410.

103. Parikh NI, Gona P, Larson MG, et al. Long-term trends in myocardial infarction inci-dence and case fatality in the National Heart, Lung, and Blood Institute’s Framingham Heart study. Circulation 2009;119:1203-1210.

104. Myerson M, Coady S, Taylor H, Rosamond WD, Goff DC, Jr. Declining severity of myo-cardial infarction from 1987 to 2002: the Atherosclerosis Risk in Communities (ARIC) Study. Circulation 2009;119:503-514.

105. Goff DC, Jr., Howard G, Wang CH, et al. Trends in severity of hospitalized myocardial infarction: the atherosclerosis risk in communities (ARIC) study, 1987-1994. Am Heart

105. Goff DC, Jr., Howard G, Wang CH, et al. Trends in severity of hospitalized myocardial infarction: the atherosclerosis risk in communities (ARIC) study, 1987-1994. Am Heart

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