Cluster of cardiovascular diseases and sequential risk increase for second events

Amelie Ohlrogge (Hamburg)1, H. Tunstall-Pedoe (Dundee)2, B. Geelhoed (Hamburg)1, F. M. Ojeda (Hamburg)1, S. Söderberg (Umeå)3, V. Salomaa (Helsinki)4, A. Linneberg (Copenhagen N)5, S. Blankenberg (Hamburg)1, K. Kuulasmaa (Helsinki)4, M.-L. Løchen (Tromsø)6, F. Kee (Belfast)7, L. Iacoviello (Pozzilli)8, T. J. Niiranen (Turku)9, R. Schnabel (Hamburg)10

1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 2University of Dundee Cardiovascular Epidemiology Unit, Institute of Cardiovascular Research Dundee, Großbritannien; 3Umeå University Department of Public Health and Clinical Medicine, and Heart Centre Umeå, Schweden; 4Finnish Institute for Health and Welfare Department of Public Health and Welfare Helsinki, Finnland; 5University of Copenhagen Department of Clinical Medicine, Faculty of Health and Medical Sciences Copenhagen N, Dänemark; 6UiT The Arctic University of Norway Department of Clinical Medicine Tromsø, Norwegen; 7Queens University Belfast Centre for Public Health Belfast, Großbritannien; 8Libera Università Mediterranea IRCCS Neuromed Pozzilli, Italien; 9Finnish Institute for Health and Welfare Department of Public Health and Welfare Turku, Finnland; 10Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland



Cardiovascular diseases (CVD) are highly prevalent and the leading cause of death in many parts of the world. Common CVD are myocardial infarction (MI), stroke, heart failure (HF), and atrial fibrillation (AF). These frequently occur together and reciprocally increase the risk of each other.


We analysed the occurrence of CVD in 89,975 participants of eight population-based cohorts of the MORGAM project carried out in six European countries. Hazard ratios were calculated for the onset of a second CVD event after the diagnosis of the first ever CVD event and depending on the time since diagnosis of the first CVD. Simultaneous co-occurence was defined as the onset of two or more CVD events within 30 days, for this analysis we excluded cases in which death occured on the same day as a CVD event.


During the median follow-up of 13.9 years, a total of 6,008 individuals developed an MI (6.7%), 5,398 individuals HF (6.0%), 4,430 individuals AF (4.9%) and 3,866 individuals a stroke (4.3%). The cluster of MI and HF was most frequent (1,761 individuals), followed by HF and AF (1,667 individuals), MI and stroke (788 indivdiuals) and AF and stroke (740 individuals). 114 individuals developed all four CVDs.

Simultaneous co-occurence of CVD was found in 340 individuals with MI and HF, in 325 individuals with HF and AF, in 125 individuals with stroke and AF, and in 116 individuals with MI and AF. Co-occurence of both MI and HF with stroke was less likely to appear within 30 days (69 and 38 indivdiuals, respectively).

The risk of developing HF after AF was highest (hazard ratio (HR) 8.03, 95% confidence interval (CI) 6.32 - 10.19, p-value <0.01), followed by the risk of developing HF after MI (HR 7.84, 95% CI 6.54 - 9.39, p-value <0.01) and the risk of developing AF after HF (HR 6.62, 95% CI 4.91 - 8.91, p-value <0.01). The HRs for any other combination of CVD were lower, ranging from 1.49 to 2.14. The risk increase after the occurrence of one CVD was particularly pronounced in the first year after diagnosis and decreased afterwards, with an HR of up to 18.42 (95% CI 15.31 - 22.16 <0.01) for HF in the first years after a MI.


CVDs are common in the general population and frequently occur in clusters. The risk for developing a second CVD largely varies, and is highest for HF after AF, followed by HF after MI. This risk is highest in the first year after the initial diagnosis and decreases afterwards. These findings highlight the need for tailored aftercare after a CVD diagnosis.


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