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Stombaugh DK, Singh K, Malek A, Kleiman A, Walters S, Zaaqoq A, Dawson M, McNeil JS, Kern J, Mazzeffi M. Preoperative Alcohol Use, Postoperative Pain, and Opioid Use After Coronary Artery Bypass Surgery. J Cardiothorac Vasc Anesth 2024; 38:957-963. [PMID: 38310067 DOI: 10.1053/j.jvca.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/07/2024] [Accepted: 01/12/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVES Chronic alcohol use is associated with chronic pain and increased opioid consumption. The association between chronic alcohol use and acute postoperative pain has been studied minimally. The authors' objective was to explore the association among preoperative alcohol use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG). DESIGN A retrospective cohort study. SETTING At a single academic medical center. PARTICIPANTS Patients having isolated CABG. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics, comorbidities, and baseline alcohol consumption were recorded. Primary outcomes were mean pain score and morphine milligram equivalent (MME) consumption on postoperative day 0. Among 1,338 patients, there were 764 (57.1%) who had no weekly preoperative alcohol use, 294 (22.0%) who drank ≤1 drink per week, 170 (12.7%) who drank 2-to-7 drinks per week, and 110 (8.2%) who drank 8 or more drinks per week. There was no significant difference in mean pain score on postoperative day 0 in patients who consumed different amounts of alcohol (no alcohol = 5.3 ± 2.2, ≤1 drink = 5.2 ± 2.1, 2 to 7 drinks = 5.3 ± 2.3, 8 or more drinks = 5.4 ± 1.9, p = 0.66). There was also no significant difference in median MME use on postoperative day 0 in patients who consumed different amounts of alcohol (no alcohol = 22.5 mg, ≤1 drink = 21.1 mg, 2-to-7 drinks = 24.8 mg, 8 or more drinks = 24.5 mg, p = 0.14). CONCLUSIONS There is no apparent association among mild-to-moderate preoperative alcohol consumption and early postoperative pain and opioid use in patients who underwent CABG.
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Affiliation(s)
- D Keegan Stombaugh
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - Karen Singh
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - Amir Malek
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - Amanda Kleiman
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - Susan Walters
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - Akram Zaaqoq
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - Michelle Dawson
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - John Steven McNeil
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - John Kern
- University of Virginia, Department of Surgery, Division of Cardiothoracic Surgery, Charlottesville, VA
| | - Michael Mazzeffi
- University of Virginia, Department of Anesthesiology, Charlottesville, VA.
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Li R, Prastein DJ. Patients with alcohol abuse have higher risks of complications after coronary artery bypass grafting: a population-based study of National Inpatient Sample from 2015 to 2020. Alcohol 2024:S0741-8329(24)00038-7. [PMID: 38452863 DOI: 10.1016/j.alcohol.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 02/25/2024] [Accepted: 03/04/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Alcohol abuse (AA) has s high prevalence, affecting 10 to 15 million Americans. While AA was demonstrated to negatively impact cardiovascular health, limited evidence from existing studies presents conflicting findings regarding the effects of AA on coronary artery bypass grafting (CABG) outcomes. This study aimed to compare the in-hospital outcomes after CABG between AA and non-AA patients. METHODS Patients who underwent CABG were identified in National Inpatient Sample from Q4 2015-2020. Exclusion criteria included age<18 years and concomitant procedures. A 1:3 propensity-score matching was used to address differences in demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status between AA and non-AA patients. In-hospital outcomes after CABG were examined. RESULTS There were 5,694 (3.39%) AA patients who underwent CABG. After matching, 17,315 from 162,488 non-AA patients were matched to all AA patients. AA and non-AA patients had comparable mortality (1.64% vs 1.55%, p=0.67) and MACE (2.46% vs 2.56%, p=0.73). However, AA patients had higher cardiogenic shock (8.31% vs 7.43%, p=0.03), mechanical ventilation (11.51% vs 7.96%, p<0.01), hemorrhage/hematoma (57.49% vs 54.75%, p<0.01), superficial (0.99% vs 0.61%, p<0.01) and deep wound complications (0.37% vs 0.18%, p=0.02), reopen surgery for bleeding control (0.92% vs 0.63%, p=0.03), transfer out (21.00% vs 16.38%, p<0.01), longer time from admission to operation (p<0.01), longer length of stay (p<0.01), and higher hospital charge (p<0.01). CONCLUSION While AA was not found to be linked with in-hospital mortality or MACE after CABG, it was independently associated with postoperative complications. These findings could enhance preoperative risk stratification for AA patients and inform postoperative management following CABG.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Deyanira J Prastein
- The George Washington University Hospital, Department of Surgery, Washington, DC
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Kaveshnikov VS, Kuzmichkina MA, Serebryakova VN. Predictors of Long-Term Outcomes after Surgical Myocardial Revascularization. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2023. [DOI: 10.20996/1819-6446-2022-12-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
High mortality from cardiovascular diseases (CVD) requires improved approaches to the treatment of this socially significant pathology. Wide implementation of surgical myocardial revascularization makes it possible to improve significantly both life quality and expectancy in patients with coronary heart disease. The aim of this work was to analyze the literature on the impact of preoperative, operative and postoperative factors on the long-term prognosis after coronary artery bypass grafting (CABG). The review refers to both recent and earlier informative works. The target groups for this article are therapists, cardiologists, rehabilitologists, who work with patients in the short and long term after CABG. Data of Russian and foreign literature show that the long-term prognosis after CABG is largely determined by preoperative factors, in particular – age, set of cardiovascular risk factors (RF) and comorbidity, specifically – severity of coronary and systemic atherosclerosis, incident cardiovascular complications, structural and functional state of the heart. In the aggregate these factors reflect the cumulative effect and further potential of actual cardiovascular RFs, affect longterm risk of adverse events, and determine the therapeutic targets of secondary prevention. Priority of arterial conduits and completeness of revascularization are the main operative factors that determine the course of the long-term period after CABG. Among the postoperative factors, the efficiency of secondary CVD prevention is of paramount importance, in particular – achievement of target RF levels, compensation of cardiac and extracardiac pathology, adherence to the long-term medical therapy, known to improve outcomes based on specific comorbidity. Efficiency of secondary CVD prevention largely depends on patient's health attitudes, the key influence on which beyond attending physician can be provided by participation in rehabilitation programs, teaching patients the meaning and essentials of lifestyle modification and cardiovascular RFs’ control.
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Affiliation(s)
- V. S. Kaveshnikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - M. A. Kuzmichkina
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences
| | - V. N. Serebryakova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences
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Krittanawong C, Isath A, Rosenson RS, Khawaja M, Wang Z, Fogg SE, Virani SS, Qi L, Cao Y, Long MT, Tangney CC, Lavie CJ. Alcohol Consumption and Cardiovascular Health. Am J Med 2022; 135:1213-1230.e3. [PMID: 35580715 PMCID: PMC9529807 DOI: 10.1016/j.amjmed.2022.04.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Studies evaluating alcohol consumption and cardiovascular diseases have shown inconsistent results. METHODS We performed a systematic review of peer-reviewed publications from an extensive query of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception to March 2022 for all studies that reported the association between alcohol consumption in terms of quantity (daily or weekly amounts) and type of beverage (wine, beer or spirit) and cardiovascular disease events. RESULTS The study population included a total of 1,579,435 individuals based on 56 cohorts from several countries. We found that moderate wine consumption defined as 1-4 drinks per week was associated with a reduction in risk for cardiovascular mortality when compared with beer or spirits. However, higher risk for cardiovascular disease mortality was typically seen with heavier daily or weekly alcohol consumption across all types of beverages. CONCLUSIONS It is possible that the observational studies may overestimate the benefits of alcohol for cardiovascular disease outcomes. Although moderate wine consumption is probably associated with low cardiovascular disease events, there are many confounding factors, in particular, lifestyle, genetic, and socioeconomic associations with wine drinking, which likely explain much of the association with wine and reduced cardiovascular disease events. Further prospective study of alcohol and all-cause mortality, including cancer, is needed.
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Affiliation(s)
- Chayakrit Krittanawong
- The Michael E. DeBakey VA Medical Center, Houston, Texas; Section of Cardiology, Baylor College of Medicine, Houston, Texas.
| | - Ameesh Isath
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla
| | - Robert S Rosenson
- Cardiometabolic Unit, Mount Sinai Hospital, Mount Sinai Heart, New York, NY; Mayo Clinic Evidence-based Practice Center, Rochester, Minn
| | - Muzamil Khawaja
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Zhen Wang
- Cardiometabolic Unit, Mount Sinai Hospital, Mount Sinai Heart, New York, NY; Mayo Clinic Evidence-based Practice Center, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minn
| | - Sonya E Fogg
- Library and Learning Resource Center, Texas Heart Institute, Houston
| | - Salim S Virani
- The Michael E. DeBakey VA Medical Center, Houston, Texas; Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Lu Qi
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, La
| | - Yin Cao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Michelle T Long
- Section of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Mass
| | - Christy C Tangney
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, Ill
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, La
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Aittokallio J, Kauko A, Palmu J, Niiranen T. Predictors and Outcomes of Coronary Artery Bypass Grafting: A Systematic and Untargeted Analysis of More Than 120,000 Individuals and 1,300 Disease Traits. J Cardiothorac Vasc Anesth 2021; 35:3232-3240. [PMID: 33934986 DOI: 10.1053/j.jvca.2021.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To perform an untargeted data-driven analysis on the correlates and outcomes of coronary artery bypass grafting (CABG). DESIGN FinnGen cohort study. SETTING The authors collected information on up to 1,327 disease traits before and after CABG from nationwide healthcare registers. PARTICIPANTS A mixed population and patient sample of 127,911 individuals including 3,784 CABG patients. INTERVENTIONS The authors assessed the association between (1) traits and incident CABG and (2) CABG and incident traits using multivariate-adjusted Cox models. MAIN RESULTS Patients who underwent CABG and were in the fourth quartile of a risk score based on the top predictors of mortality had 12.2-fold increased risk of dying (95% confidence interval [CI], 10.3-14.5) compared with those in the first quartile. Cardiovascular disease (CVD) and CVD risk factors were most strongly associated with incident CABG. However, CABG was associated with death due to cardiac causes (hazard ratio [HR], 3.7; 95% CI, 3.5-4.0) or other causes (HR, 2.5; 95% CI, 2.4-2.7). CABG also was related to increased risk of several non-CVD traits, including anemia (HR, 3.4; 95% CI, 2.8-4.1), gastrointestinal disorders (HR, 2.2; 95% CI, 1.8-2.6), acute renal failure (HR, 4.2; 95% CI, 3.5-5.1), septicemia (HR, 3.6; 95% CI, 3.1-4.1), lung cancer (HR, 2.3; 95% CI, 1.9-2.8), Alzheimer's disease (HR, 2.5; 95% CI, 2.2-2.7), and chronic obstuctive pulmonary disease (HR, 2.5; 95% CI, 2.2-2.9). CONCLUSIONS Known CVD risk factors associate most strongly with incident CABG. However, CABG is associated with increased risk of several, somewhat unexpected, non-CVD traits. More detailed study of these links is warranted to establish potential causality and pathogenesis.
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Affiliation(s)
- Jenni Aittokallio
- Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland; Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland.
| | - Anni Kauko
- Department of Internal Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Joonatan Palmu
- Department of Internal Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Teemu Niiranen
- Department of Internal Medicine, Turku University Hospital and University of Turku, Turku, Finland; Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland
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Callus E, Pagliuca S, Bertoldo EG, Fiolo V, Jackson AC, Boveri S, De Vincentiis C, Castelvecchio S, Volpe M, Menicanti L. The Monitoring of Psychosocial Factors During Hospitalization Before and After Cardiac Surgery Until Discharge From Cardiac Rehabilitation: A Research Protocol. Front Psychol 2020; 11:2202. [PMID: 33117210 PMCID: PMC7550819 DOI: 10.3389/fpsyg.2020.02202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 08/05/2020] [Indexed: 01/07/2023] Open
Abstract
Introduction: There is considerable evidence that psychosocial factors contribute to the etiology and prognosis of cardiac illness. Currently, in Italy, psychologists are only obligatory in the cardiac rehabilitation setting, although there are indications that patients could be experiencing distress also during other moments of hospitalization, such as on admission for cardiac surgery. Objective and Methods: The objective of this protocol is to gain more information about cardiac patients, specifically during the various moments of hospitalization for cardiac surgery, by collecting data at admission before cardiac surgery (t0), at admission to cardiac rehabilitation (t1), and at discharge (t2) at the Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato hospital. A psychosocial questionnaire was constructed after consulting the relevant national and international guidelines. Patients admitted for cardiac surgery and attending a rehabilitation program will be evaluated by acquiring data about their civil status, religiosity, education and work capacity, social condition (including the presence and quality of intimate relationships and support received), previous psychological and psychiatric histories, psychological status, lifestyle (including questions on nutrition, smoking, alcohol, and substance abuse), adherence to therapy, quality of life (QoL), health perception, anxiety, and depression at t0. Health perception, anxiety, and depression are also measured at t1 and t2. Discussion and Conclusion: This study is an attempt to identify the recommended psychosocial variables which need to be monitored during cardiac patients' hospitalization for cardiac surgery, through to the completion of cardiac rehabilitation. After implementing this study at the IRCCS Policlinico San Donato, attempts will be made to create studies on a national and international level to generate more evidence regarding these variables, in order to create tailor-made interventions for these patients during these specific and delicate moments.
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Affiliation(s)
- Edward Callus
- Clinical Psychology Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Silvana Pagliuca
- Clinical Psychology Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | - Valentina Fiolo
- Clinical Psychology Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | - Sara Boveri
- Scientific Directorate, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Carlo De Vincentiis
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | - Marianna Volpe
- Department of Cardiac Rehabilitation, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
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McCann M, Stamp N, Ngui A, Litton E. Cardiac Prehabilitation. J Cardiothorac Vasc Anesth 2019; 33:2255-2265. [DOI: 10.1053/j.jvca.2019.01.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 02/06/2023]
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Cromhout PF, Moons P, Thygesen LC, Nashef S, Damgaard S, Berg SK. Time to expand risk evaluation systems for cardiac surgery? Looking beyond physiological parameters. Eur J Cardiovasc Nurs 2018; 17:760-766. [DOI: 10.1177/1474515118783835] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Risk assessment in cardiac surgery traditionally consists of medical and physiological parameters. However, non-physiological factors have also been found to be predictive of poor outcomes following cardiac surgery. Therefore, the isolated focus on physiological parameters is questionable. This paper describes the emotional, behavioural, social and functional factors that have been established to play a role in outcomes following cardiac surgery. This forms a basis for future research, testing the value of these factors above and beyond the physiological parameters. By including such non-physiological factors, the accuracy of the existing risk scoring systems could potentially be improved.
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Affiliation(s)
- Pernille F Cromhout
- Department of Thoracic Anaesthesiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Philip Moons
- Department of Public Health and Primary Care, KU Leuven – University of Leuven, Belgium
- Institute of Health and Care Sciences, University of Gothenburg, Sweden
| | - Lau C Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Samer Nashef
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Sune Damgaard
- Department of Cardio-thoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Selina Kikkenborg Berg
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark
- Department of Public Health, University of Copenhagen, Denmark
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Quintana HK, Janszky I, Kanar A, Gigante B, Druid H, Ahlbom A, de Faire U, Hallqvist J, Leander K. Comorbidities in relation to fatality of first myocardial infarction. Cardiovasc Pathol 2017; 32:32-37. [PMID: 29175662 DOI: 10.1016/j.carpath.2017.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 10/18/2017] [Accepted: 11/08/2017] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Present knowledge concerning potential associations between comorbidities and the fatality of a first myocardial infarction (MI) is limited. AIM To identify comorbidities in 45-70-year-old individuals who suffered a first MI and died within 7 days in Stockholm County from 1992-1994. In addition, to assess how each of the comorbidities identified, as well as the number of hospitalizations during the 10-year period prior to the MI, was associated with MI fatality. METHODS The data collected on our inception cohort of 1984 first MI, of which 524 were fatal within 7 days, were primarily self-reported, proxy-reported by questionnaire and/or extracted from comprehensive national registers. Comorbidities among fatal cases with a prevalence >2% were identified. Risk ratios (with 95% confidence intervals) for the association of MI fatality with number of prior hospitalizations and specific comorbidities were calculated using binomial regression with log link. A structured review of autopsy reports on fatal cases was performed in order to identify additional indicators of comorbidities. RESULTS After adjusting for sex, age and disposable income, the number of previous hospitalizations was associated with 7-day MI fatality. Of the comorbidities identified as prevalent in fatal cases, the following were associated with 7-day fatality in crude analysis: epilepsy, heart failure, stroke, alcoholism, cancer, renal diseases, asthma, psychiatric diseases, diabetes, and rheumatoid arthritis. Indicators of comorbidities identified from autopsy data included a silent MI, severe atherosclerosis of the abdominal aorta, and hepatic steatosis. Adjustments for sex and age (although not possible for epilepsy and alcoholism), did not substantially alter results. CONCLUSIONS Our current findings indicate that in connection with a first MI, particular attention should be paid to those with repeated prior hospitalizations and/or epilepsy, heart failure, stroke, alcoholism, cancer, renal diseases, asthma, psychiatric diseases, diabetes and rheumatoid arthritis.
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Affiliation(s)
- Hedley Knewjen Quintana
- Unit of Cardiovascular Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Imre Janszky
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Alkass Kanar
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Unit of Cardiovascular Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Danderyd, Sweden
| | - Henrik Druid
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Anders Ahlbom
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ulf de Faire
- Unit of Cardiovascular Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Hallqvist
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Karin Leander
- Unit of Cardiovascular Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
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