Biomedical subjects

Birgitta Stegmayr

Publications and source records attributed to Birgitta Stegmayr.

At least 19 recordsLinked to original sources

PubMed2006

Genome-wide linkage scan of common stroke in families from northern Sweden.

BACKGROUND AND PURPOSE: Taking advantage of low genetic variations in northern Sweden, we performed a genome-wide linkage scan to investigate the susceptibility loci for common forms of stroke. METHODS: Fifty-six families, containing multiple cases of stroke and whose data had been previously used to replicate linkage to the phosphodiesterase 4D locus on chromosome 5q, were genotyped in a genome-wide scan. Fine mapping was performed, and subsequently 53 additional families from the same region were genotyped over the candidate regions. RESULTS: Linkage calculations were performed by using 3 different disease models, from a very broad (all stroke cases defined by World Health Organization MONICA criteria) to a narrower (ischemic stroke only) stroke phenotype. With all models, nonparametric multipoint linkage analysis yielded allele-sharing log of the odds (LOD) scores >1.2 at 9 locations: 1p34, 5q13, 7q35, 9q22, 9q34, 13q32, 14q32, 18p11, and 20q13. The highest allele-sharing LOD scores were obtained on chromosomes 5q (previously reported), 1p (LOD=2.09), and 18p (LOD=2.14). Fine mapping resulted in increased allele-sharing LOD scores for chromosome 5q (previously reported) and 9q22 (LOD=1.56), but all others decreased. Combining these initial results with a subsequent analysis of 53 additional families, we obtained the highest allele-sharing LOD scores on chromosomes 5q, 13q, and 18p, although none reached the initial genome-wide allele-sharing LOD scores. CONCLUSIONS: Genetic analysis of stroke in families from northern Sweden did not identify any new major stroke loci. This indicates that multiple minor susceptibility loci in addition to the previously known locus on chromosome 5 could contribute to the disease.

Aged↗

PubMed2006

Increased incidence of and impaired prognosis after acute myocardial infarction among patients with seropositive rheumatoid arthritis.

OBJECTIVE: To examine the incidence and outcome of acute myocardial infarction (AMI) in patients with rheumatoid arthritis compared with the general population, and to examine whether care and treatment of an AMI differs between patients and controls. METHODS: The Multinational Monitoring of Trends and Determinants of Cardiovascular Disease register for northern Sweden was used to compare those incidences of AMI in a cohort of patients with rheumatoid arthritis with that in the general population. 35 patients with rheumatoid arthritis who had also experienced an AMI were identified. For each patient with rheumatoid arthritis, three controls with a history of AMI but without rheumatoid arthritis were randomly selected from the same register, and matched for age, sex and year of the AMI for evaluation of case fatality and potential differences in treatment of AMI. RESULTS: The standardised incidence ratio for AMI was 2.9 in patients with rheumatoid arthritis compared with the general population (p<0.05). During the first 10 years after an AMI, patients with rheumatoid arthritis had a higher overall case fatality compared with controls (hazard ratio (HR) 1.67, 95% confidence interval (CI) 1.02 to 2.71). Survival time was decreased in the rheumatoid arthritis group compared with controls despite the same care and treatment. CONCLUSION: Both the incidence of and case fatality after an AMI were higher among patients with rheumatoid arthritis than among the general population. The results emphasise the necessity of optimising the preventive, diagnostic and caring strategies for AMI in rheumatoid arthritis.

Arthritis, Rheumatoid↗

PubMed2005

Time trends in burdens of cadmium, lead, and mercury in the population of northern Sweden.

The time trends of exposure to heavy metals are not adequately known. This is a worldwide problem with regard to the basis for preventive actions and evaluation of their effects. This study addresses time trends for the three toxic elements cadmium (Cd), mercury (Hg), and lead (Pb). Concentrations in erythrocytes (Ery) were determined in a subsample of the population-based MONICA surveys from 1990, 1994, and 1999 in a total of 600 men and women aged 25-74 years. The study took place in the two northernmost counties in Sweden. To assess the effect of changes in the environment, adjustments were made for life-style factors that are determinants of exposure. Annual decreases of 5-6% were seen for Ery-Pb levels (adjusted for age and changes in alcohol intake) and Ery-Hg levels (adjusted for age and changes in fish intake). Ery-Cd levels (adjusted for age) showed a similar significant decrease in smoking men. It is concluded that for Pb and maybe also Hg the actions against pollution during recent decades have caused a rapid decrease of exposure; for Hg the decreased use of dental amalgam may also have had an influence. For Cd, the decline in Ery-Cd was seen only in smokers, indicating that Cd exposure from tobacco has decreased, while other environmental sources of Cd have not changed significantly. To further improve the health status in Sweden, it is important to decrease the pollution of Cd, and actions against smoking in the community are important.

Adult↗

PubMed2005

Linkage of ischemic stroke to the PDE4D region on 5q in a Swedish population.

BACKGROUND AND PURPOSE: Recent Icelandic studies have demonstrated linkage for common forms of stroke to chromosome 5q12 and association between phosphodiesterase4D (PDE4D) and ischemic stroke. Using a candidate region approach, we wanted to test the validity of these findings in a different population from northern Sweden. METHODS: A total of 56 families with 117 affected individuals were included in the linkage study. Genotyping was performed with polymorphic microsatellite markers with an average distance of 4.5 cM on chromosome 5. In the association study, 275 cases of first-ever stroke were included together with 550 matched community controls. Polymorphisms were tested individually for association of PDE4D to stroke. RESULTS: Maximum allele-sharing lod score in favor of linkage was observed at marker locus D5S424 (lod score=2.06; P=0.0010). Conditional logistic regression calculations revealed no significant association of ischemic stroke to the defined at-risk allele in PDE4D (odds ratio, 1.1; 95% confidence interval, 0.84 to 1.45). A protective effect may though be implied for 2 of the polymorphisms analyzed in PDE4D. CONCLUSIONS: Using a candidate region approach in a set of stroke families from northern Sweden, we have replicated linkage of stroke susceptibility to the PDE4D gene region on chromosome 5q. Association studies in an independent nested case-control sample from the same geographically located population suggested that different alleles confer susceptibility/protection to stroke in the Icelandic and the northern Swedish populations.

3',5'-Cyclic-AMP Phosphodiesterases↗

PubMed2005

Plasminogen activator inhibitor-1 4G/5G polymorphism and risk of stroke: replicated findings in two nested case-control studies based on independent cohorts.

BACKGROUND AND PURPOSE: Impaired fibrinolytic function secondary to elevated plasminogen activator inhibitor-1 (PAI-1) levels has been implicated in ischemic stroke. PAI-1 levels are determined by genetic factors and environmental factors, triglyceride levels in particular. The aim of this study was to investigate the common functional 4/5 guanosine (4G/5G) polymorphism in the promoter region of the PAI-1 gene and the risk of stroke. METHODS: A nested case-control study design was applied, using baseline data for 2 independent cohorts obtained at population-based surveys in northern Sweden. In study A, there were 113, and in study B, there were 275 individuals without major concomitant disease at baseline who later experienced a first-ever stroke. Blood samples obtained at baseline were analyzed for potential risk factors, including the 4G/5G polymorphism of the PAI-1 gene. RESULTS: The 4G allele of the PAI-1 polymorphism was associated with an increased risk of future ischemic stroke in both studies (odds ratio [OR] of 4G homozygosity, 1.87; 95% CI, 1.12 to 3.15 in study A; OR of 4G homozygosity, 1.56; 95% CI, 1.12 to 2.16 in study B). Individuals with the combination of hypertriglyceridemia and 4G homozygosity were at the greatest risk of developing stroke. Multiple logistic regression analysis identified 4G homozygosity, systolic blood pressure, and diabetes as independent predictors of ischemic stroke. CONCLUSIONS: Identical findings in 2 independent studies strongly suggest a true and clinically important association between PAI-1 4G/5G genotype and risk of future ischemic stroke. The observed modification of the genotype effect by triglycerides may be interpreted as a gene-environment interaction.

Adult↗

PubMed2005

Folate, vitamin B12, and risk of ischemic and hemorrhagic stroke: a prospective, nested case-referent study of plasma concentrations and dietary intake.

BACKGROUND AND PURPOSE: Folate metabolism has been implicated in stroke. However, the possibility of a role for folate and vitamin B12, independent of their effects on homocysteine status, remains to be explored. The aim of this prospective, nested case-referent study was to relate plasma and dietary intake levels of folate and vitamin B12 to risk of stroke, taking into consideration plasma homocysteine concentrations and methylenetetrahydrofolate reductase polymorphisms. METHODS: Subjects were 334 ischemic and 62 hemorrhagic stroke cases and matched double referents from the population-based Northern Sweden Health and Disease Cohort. RESULTS: Plasma folate was statistically significantly associated with risk of hemorrhagic stroke in an inverse linear manner, both in univariate analysis and after adjustment for conventional risk factors including hypertension (odds ratio [OR] for highest versus lowest quartile 0.21 (95% confidence interval [CI], 0.06 to 0.71; P for trend=0.008)). Risk estimates were attenuated by inclusion of homocysteine in the model (OR, 0.34; 95% CI, 0.08 to 1.40; P for trend=0.088). A similar pattern was observed for increasing folate intake (multivariate OR, 0.07; 95% CI, 0.01 to 0.55; P for trend=0.031 without homocysteine, and OR, 0.16, 95% CI, 0.02 to 1.23; P for trend=0.118 with homocysteine in the analysis). We found little evidence of an association between plasma or dietary folate and risk of ischemic stroke. Neither plasma nor dietary vitamin B12 was associated with risk of either stroke subtype. CONCLUSIONS: The results of this study suggest a protective role for folate, possibly in addition to its effects on homocysteine status, in hemorrhagic but not ischemic stroke.

Adult↗

PubMed2005

Food selection associated with sense of coherence in adults.

BACKGROUND: Favorable dietary habits promote health, whereas unfavorable habits link to various chronic diseases. An individual's "sense of coherence" (SOC) is reported to correlate with prevalence of some diseases to which dietary habits are linked. However, understanding what determines an individual's dietary preferences and how to change his/her behavior remains limited. The aim of the present study was to evaluate associations between dietary intake and SOC in adults. METHODS: Diet intake was recorded by an 84-item semi-quantitative food frequency questionnaire and SOC was measured by the 13-item Antonovsky questionnaire in 2,446 men and 2,545 women (25-74 years old) from the population based northern Sweden MONICA screening in 1999. RESULTS: Intakes of energy, total and saturated fat, ascorbic acid, sucrose, and servings of fruits, vegetables, cereals, and sweets correlated with SOC among women, whereas intakes of total and saturated fat, ascorbic acid, fiber, and alcohol, and servings of fruits, vegetables, bread, bread and cereals, fish, and potatoes correlated with SOC among men. With a few exceptions, intakes of these nutrients/foods were significantly explained by SOC quartile scores in linear GLM models. Both women and men classified into the highest SOC quartile had significantly higher age-BMI-education standardized mean intakes of vegetables than those in the lowest quartiles. Women in the highest SOC quartile also had higher intake of fruits but lower intakes of energy, total and saturated fat, sucrose, and sweets. Projection to latent structures (PLS) multivariate modeling of intakes of the 84 food items and food aggregates simultaneously on SOC scores supported low SOC to coincide with a presumably less health promoting dietary preference, e.g. intake of pizza, soft drinks, candies, sausages for main course, hamburgers, mashed potato, chips and other snacks, potato salad, French fries, whereas men and women with high SOC scores were characterized by e.g. high intake of rye crisp whole meal bread, boiled potato, vegetables, berries, and fruits. CONCLUSION: Both men and women in the highest, as compared with the lowest, SOC score quartile reported more "healthy" food choices. Dietary habits for individuals in the lowest SOC quartile therefore may render a higher risk for various endemic diseases.

Adult↗

PubMed2005

An international comparative study of blood pressure in populations of European vs. African descent.

BACKGROUND: The consistent finding of higher prevalence of hypertension in US blacks compared to whites has led to speculation that African-origin populations are particularly susceptible to this condition. Large surveys now provide new information on this issue. METHODS: Using a standardized analysis strategy we examined prevalence estimates for 8 white and 3 black populations (N = 85,000 participants). RESULTS: The range in hypertension prevalence was from 27 to 55% for whites and 14 to 44% for blacks. CONCLUSIONS: These data demonstrate that not only is there a wide variation in hypertension prevalence among both racial groups, the rates among blacks are not unusually high when viewed internationally. These data suggest that the impact of environmental factors among both populations may have been under-appreciated.

Black or African American↗

PubMed2005

Psychosocial factors, gender, and sleep.

Low social support may contribute to poor sleep, more so than adverse aspects of demand and control and more so for women than men. This study on 1,179 working individuals, 623 women and 556 men, from the Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study investigated the association between sleep and psychosocial factors. Chi-square analyses investigated the associations among sleep and demand, control, social networks, and emotional support. A logit log-linear model analyzed interactions. More women reported poorer sleep when perceiving adverse psychosocial factors. Interactive effects were found between adverse scores on demand, control, and emotional support. A multivariate partial least square analysis showed that poorer health, pain, and adverse aspects of emotional support and social networks contributed significantly to the pattern of poor sleep.

Adult↗

PubMed2005

The decline of smoking in northern Sweden.

For decades men in Sweden have smoked at far lower rates than those in comparable countries. Previous studies showed that snus use played a major role in low smoking rates among men in northern Sweden; daily smoking declined from 19% (95% CI 16-22%) in 1986 to 11% (CI 8.9-14%) in 1999. The prevalence of smoking among all men is now 9% (CI 7.0-11%) and only 3% (CI 0.1-5.4%) among men age 25-34 years; the prevalence of exclusive snus use is 27% (CI 24-30%) and 34% (CI 27-42%) respectively. Combined smoking and snus use, an unstable and transient category, was under 5% in all surveys and was 2.2% (CI 1.4-3.4%) by 2004. For the first time snus use is also associated with a decrease in smoking prevalence among women. These patterns of tobacco use have implications for all smoking-dominated societies.

Adult↗

PubMed2004

Declining mortality from subarachnoid hemorrhage: changes in incidence and case fatality from 1985 through 2000.

BACKGROUND AND PURPOSE: Northern Sweden has one of the highest incidence rates of subarachnoid hemorrhage (SAH) among the populations covered by the WHO MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) Project, approximately twice as high as in the other populations in Europe. In this study, trends in incidence, 28-day case fatality (CF), and mortality in SAH were followed over a 16-year period. METHODS: Since 1985, all SAHs in northern Sweden among patients 25 to 74 years old have been validated using strict MONICA criteria. From 1985 through 2000, 392 men and 592 women had SAH. During 3 years, 1997 to 1999, SAH among those aged 75 and older were also included. RESULTS: The total incidence among those 25 years and older was 13.3 per 100 000 in men and 24.4 per 100 000 in women. During the 16 years of observation, age standardized incidence in the group aged 25 to 74 years decreased significantly in men (P for trend <0.0001) but remained essentially unchanged in women (P for trend=0.64). The 28-day CF for all years was 36.5% in men, with no significant trend (P=0.7). In women, average CF was 35%, with a significant decline (P=0.003). The annual mortality decreased significantly in both sexes (by 3.87 [95% CI+/-2.75 percentage points] in men and 3.97 [95% CI+/-2.29] in women). CONCLUSIONS: The decline in SAH mortality has different explanations in men (declining incidence) and in women (declining CF).

Adult↗

PubMed2004

Use of oral contraceptives and hormone replacement therapy in the WHO MONICA project.

AIMS: To compare menopausal age and the use of oral contraceptives (OC) and hormonal replacement therapy (HRT) between the 32 populations of the WHO MONICA Project, representing 20 different countries. METHODS: Using a uniform protocol, age at menopause and the use of OC and HRT was recorded in a random sample of 25-64 year-old women attending the final MONICA population cardiovascular risk factor survey between 1989 and 1997. A total of 39,120 women were included. RESULTS: There were wide variations between the populations in the use of OC and HRT. The use of OC varied between 0 and 52% in pre-menopausal women aged 35-44 years, Central and East Europe and North America having the lowest and West Europe and Australasia the highest prevalence rates. Among post-menopausal women between 45 and 64 years, the prevalence of HRT use varied from 0 to 42%. In general, the use of HRT was high in Western and Northern Europe, North America and Australasia and low in Central, Eastern and Southern Europe and China. With the exception of Canada (45 years), the mean age at menopause differed only little (ranging from 48 to 50 years) between the populations. CONCLUSION: The use of OC and HRT varies markedly between populations, in general following a regional pattern. Whereas, the prevalence rates are mostly similar within a country, there are remarkable differences even between neighbouring countries, reflecting nation-specific medical practice and public attitudes that are not necessarily based on scientific evidence.

Adult↗

PubMed2004

Self-reported depression and use of antidepressants after stroke: a national survey.

BACKGROUND AND PURPOSE: Depression after stroke is often described as underdiagnosed and undertreated. However, there are few data on self-reported depression and use of antidepressants in stroke patients at large. MATERIALS AND METHODS: In the Swedish national quality assessment register, Riks-Stroke, 15 747 stroke survivors are recorded. They were asked about depressive mood and antidepressant treatment 3 months after stroke. Age-specific prevalence of antidepressant use after stroke was calculated. RESULTS: At 3 months after stroke, 12.4% of male and 16.4% of female stroke survivors reported that they always or often felt depressed. In a multiple logistic regression model, female sex, age younger than 65 years, living alone, having had a recurrent stroke, being dependent on others, and institutional living 3 months after stroke were independent predictors of self-reported depression. Antidepressant medication was used by 22.5% of men and 28.1% of women who had had a stroke. Of patients using antidepressant drugs, 67.5% did not report depressive mood. However, 8.4% of the entire cohort reported depressive mood but no treatment with antidepressants. When compared with the general population, approximately twice as many of the stroke patients were using antidepressant treatment. CONCLUSIONS: In this national survey, 1 in 7 patients reported that they felt depressed and the use of antidepressant drugs after stroke was common. The widespread use of antidepressants challenges the contention that antidepressants are generally underused after stroke. However, the substantial proportion reporting depressive mood but not using treatment with antidepressants suggests that patient selection for treatment should be more precise.

Aged↗

PubMed2004

Hemostatic factors as risk markers for intracerebral hemorrhage: a prospective incident case-referent study.

BACKGROUND AND PURPOSE: Abnormalities in the hemostatic system may cause hemorrhagic complications. The aim of the present study was to examine whether total concentrations of tissue plasminogen activator (tPA), plasminogen inhibitor-1 (PAI-1), tPA/PAI-1 complex, von Willebrand factor (VWF), and soluble thrombomodulin were associated with a first-ever intracerebral hemorrhage (ICH). METHODS: This prospective study was an incident case-referent study nested within the Västerbotten Intervention Program and the Northern Sweden Monitoring Trends and Determinants in Cardiovascular Disease (MONICA) cohorts. By 2000, approximately 74 000 subjects had been screened, and 39 ICH cases were defined according to the World Health Organization MONICA criteria. A total of 78 matched controls were selected from the same cohort. RESULTS: The average time from screening to the ICH event was 5.1 years. tPA/PAI-1 complex, systolic and diastolic blood pressures, and hypertension were associated with ICH in the univariate analysis. In the multivariate model, only hypertension (odds ratio [OR], 3.96; 95% confidence interval [CI], 1.27 to 12.36) and the tertile with the highest level of VWF compared with the lowest tertile (OR, 0.27; 95% CI, 0.08 to 0.90) were independently associated with ICH. The OR for the combined exposure to hypertension and low levels of VWF was 8.95, indicating a possible synergistic interaction. No associations were observed for smoking, cholesterol, body mass index, PAI-1, tPA, and soluble thrombomodulin. CONCLUSIONS: This study showed that hypertension and low concentrations of VWF were independently associated with ICH. Furthermore, we observed a possible synergistic interaction between low levels of VWF and hypertension, suggesting 2 different pathways in the development of ICH.

Adult↗

PubMed2004

Depressive mood after a cardiac event: gender inequality and participation in rehabilitation programme.

BACKGROUND: Depressive mood after a cardiac event is common with serious consequences for the patient. AIMS: To compare gender in depressive mood during the first year after a cardiac event and to evaluate the effect of participating in a multidimensional secondary prevention program on depressive mood. METHODS: 166 men and 54 women, <73 years, consecutively answered a questionnaire concerning depressive mood at 2 weeks, 6 weeks, 5 months and 1 year after discharge after a cardiac event. At 2 weeks, each patient met a nurse, and was informed about the disease and received individual support about lifestyle changes. Of those invited to participate in a secondary prevention program, 127 patients accepted, and 93 declined participation. RESULTS: At each of the four follow-ups, women had significantly higher depression scores than men. Depressive mood in both women and men was significantly reduced at 6 weeks. Thereafter, it increased to the 2-week level in women and to above the 2-week level in men. No differences were seen in patients participating or not in secondary prevention programs. CONCLUSION: Women had higher depressive mood scores than men and secondary prevention programs failed to improve depressive mood in both women and men.

Angioplasty, Balloon, Coronary↗

PubMed2004

Polymorphisms in glutathione-related genes affect methylmercury retention.

Methylmercury is eliminated from the human body as glutathione (GSH) conjugates. GSH production is mediated by glutamyl-cysteine ligase (GCL) and conjugation by glutathione S-transferases (GST). In this study, the authors tested whether polymorphisms in GCL and GST genes modify methylmercury retention. Erythrocyte mercury concentration (EryHg), plasma polyunsaturated fatty acids (PPUFA), and genotype for GCLC, GCLM, GSTA1, GSTM1, GSTP1, and GSTT1 were determined in 365 individuals. A general linear model was developed for analyzing whether genotype modified the regression of EryHg on PPUFA. The presence of one variant allele for either GCLC-129 or GSTP1-114 was associated with higher EryHg and steeper regression slope. No similar trends were shown for GCLM, GSTA1, GSTM1, or GSTT1. These findings indicate that GCLC polymorphisms that affect GSH production also affect methylmercury retention, and that GSTP1 may play a role in conjugating methylmercury with GSH.

Adult↗

PubMed2003

High levels of tissue plasminogen activator (tPA) antigen precede the development of type 2 diabetes in a longitudinal population study. The Northern Sweden MONICA study.

BACKGROUND: Impaired fibrinolysis is found in impaired glucose tolerance and type 2 diabetes, associated with components of the metabolic syndrome. There are no data concerning fibrinolysis in subjects with normal glucose tolerance that convert to diabetes. METHODS: We studied the activities of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) and the levels of tPA antigen (a marker of endothelial dysfunction) in 551 subjects with normal glucose tolerance in 1990 in relation to incident diabetes during nine years of follow-up. RESULTS: Subjects with diabetes at follow-up (n = 15) had significantly lower baseline tPA activity and higher PAI-1 activity and tPA antigen than non-converters. The risk of diabetes increased linearly across quartiles of PAI-activity (p = 0.007) and tPA antigen (p < 0.001) and decreased across quartiles of tPA activity (p = 0.026). The risk of diabetes with low tPA activity or high PAI-1 activity persisted after adjustment for age and sex but diminished to a non-significant level after further adjustments. The odds ratio of diabetes for high tPA antigen was 10.4 (95% confidence interval 2.7-40) adjusted for age and sex. After further adjustment for diastolic blood pressure, waist circumference, insulin, triglycerides, fasting and post load glucose the odds ratio was 6.5 (1.3-33, p = 0.024). CONCLUSIONS: Impaired fibrinolysis and endothelial dysfunction are evident in subjects with normal glucose tolerance who later develop diabetes. High tPA antigen is predictive of future diabetes independent from the metabolic syndrome.

Journal Article↗

PubMed2003

Hypertension treatment and control in five European countries, Canada, and the United States.

Levels of hypertension treatment and control have been noted to vary between Europe and North America, although direct comparisons with similar methods have not been undertaken. In this study, we sought to estimate the relative impact of hypertension treatment strategies in Germany, Sweden, England, Spain, Italy, Canada, and the United States by using sample surveys conducted in the 1990s. Hypertension was defined as a blood pressure of 160/95 mm Hg or 140/90 mm Hg, plus persons taking antihypertensive medication. "Controlled hypertension" was defined as a blood pressure less than threshold among persons taking antihypertensive medications. Among persons 35 to 64 years, 66% of hypertensives in the United States had their blood pressure controlled at 160/95 mm Hg, compared with 49% in Canada and 23% to 38% in Europe. Similar discrepancies were apparent at the 140/90 mm Hg threshold, at which 29% of hypertensives in the United States, 17% in Canada, and </=10% in European countries had their blood pressure controlled. At the 140/90 mm Hg cutpoint, two thirds to three quarters of the hypertensives in Canada and Europe were untreated compared with slightly less than half in the United States. Although guidelines vary among countries, resulting in different case definitions, this does not account entirely for the varying success of different national control efforts. Low treatment and control rates in Europe, combined with a higher prevalence of hypertension, could contribute to a higher burden of cardiovascular disease risk attributable to elevated blood pressure compared with that in North America.

Adolescent↗