Pulmonary embolism and deep venous thrombosis after COVID-19: long-term risk in a population-based cohort study

Background

Venous thromboembolism (VTE) (pulmonary embolism (PE) or deep venous thrombosis (DVT)) is common during acute COVID-19. Long-term excess risk has not yet been established.

Objective

To study long-term VTE risk after COVID-19.

Methods

Swedish citizens aged 18-84 years, hospitalized and/or testing positive for COVID-19 between January 1, 2020, and September 11, 2021 (exposed), stratified by initial hospitalization, were compared to matched (1:5) non-exposed population-derived subjects without COVID-19. Outcomes were incident VTE, PE or DVT recorded within 60, 60-<180, and ≥180 days. Cox regression was used for evaluation and a model adjusted for age, sex, comorbidities and socioeconomic markers developed to control for confounders.

Results

Among exposed patients, 48,861 were hospitalized for COVID-19 (mean age 60.6 years) and 894,121 were without hospitalization (mean age 41.4 years). Among patients hospitalized for COVID-19, fully adjusted hazard ratios (HRs) during 60-<180 days were 6.05 (95% confidence interval (CI) 4.80─7.62) for PE and 3.97 (CI 2.96─5.33) for DVT, compared to non-exposed with corresponding estimates among COVID-19 without hospitalization 1.17 (CI 1.01─1.35) and 0.99 (CI 0.86─1.15), based on 475 and 2,311 VTE events, respectively. Long-term (≥180 days) HRs in patients hospitalized for COVID-19 were 2.01 (CI 1.51─2.68) for PE and 1.46 (CI 1.05─2.01) for DVT while non-hospitalized had similar risk to non-exposed, based on 467 and 2,030 VTE events, respectively.

Conclusions

Patients hospitalized for COVID-19 retained an elevated excess risk of VTE, mainly PE, after 180 days, while long-term risk of VTE in individuals with COVID-19 without hospitalization was similar to the non-exposed.

Treatment response in recent-onset heart failure with reduced ejection fraction: non-ischaemic vs. ischaemic aetiology

AIMS

In heart failure (HF) with reduced left ventricular ejection fraction (HFrEF), the prognosis appears better in non-ischaemic than in ischaemic aetiology. Infrequent diagnostic work-up for ischaemic heart disease (IHD) in HF is reported. In this study, we compared short-term response to initiated guideline-directed medical treatment (GDMT) in recent-onset HFrEF of non-ischaemic (non-IHF) vs. ischaemic (IHF) aetiology and evaluated the frequency of coronary investigation.

METHODS AND RESULTS

Patients hospitalized with recent-onset HFrEF [left ventricular ejection fraction (LVEF) < 40%] between 1 January 2016 and 31 December 2019 were included. Treatment response was determined by use of a hierarchical clinical composite outcome classifying each patient as worsened, improved, or unchanged based on hard outcomes (mortality, heart transplantation, and HF hospitalization) and soft outcomes (± ≥10 unit change in LVEF, ± ≥30% change in N-terminal pro-B-type natriuretic peptide, and ± ≥1 point change in New York Heart Association functional class) during 28 weeks of follow-up. The associations between baseline characteristics and composite changes were analysed with multiple logistic regression. Among the 364 patients analysed, 47 were not investigated for IHD. Comparing non-IHF (n = 203) vs. IHF (n = 114), patients were younger (mean age 61.0 vs. 69.4 years, P < 0.001) with lower mean LVEF (26% vs. 31%, P < 0.001), but with similar male predominance (70.4% vs. 75.4%, P = 0.363). For non-IHF vs. IHF, the composite outcomes were worsened (19.1% vs. 43.9%, P < 0.001) and improved (74.2% vs. 43.9%, P < 0.001). After multivariable adjustments, IHF was associated with increased odds for worsening [odds ratio (OR) 2.94; 95% confidence interval (CI) 1.51-5.74; P = 0.002] and decreased odds for improvement (OR 0.35; 95% CI 0.18-0.65; P < 0.001). In cases without previous IHD or new-onset myocardial infarction (n = 261), a decision for coronary investigation was made in 69.0%.

CONCLUSIONS

In recent-onset HFrEF, patients with non-IHF responded better to GDMT than patients with IHF. Almost one-third of patients selected for follow-up at HF clinics were never investigated for IHD.

Prognostic differences in long-standing vs. recent-onset dilated cardiomyopathy

Aims

This study aimed to evaluate the outcome and prognostic factors in patients with dilated cardiomyopathy (DCM) and long‐standing heart failure (LDCM) vs. recent‐onset heart failure (RODCM).

Methods and results

We compared 2019 patients with RODCM (duration <6 months, mean age 58.6 years, 70.7% male) with 1714 patients with LDCM (duration ≥6 months, median duration 3.5 years, mean age 62.5 years, 73.7% male) included in the Swedish Heart Failure Registry in the years 2003–16. Outcome measures were all‐cause, cardiovascular (CV), and non‐CV death and hospitalizations; heart transplantation; and a combined outcome of all‐cause death, heart transplantation, or heart failure (HF) hospitalization. Multivariable risk factor analyses were performed for the combined endpoint. All outcomes were more frequent in LDCM than in RODCM. The multivariable‐adjusted hazard ratios (HRs) (95% confidence interval) for LDCM vs. RODCM were 1.56 (1.34–1.82), P < 0.0001, for all‐cause death over a median follow‐up of 4.2 and 5.0 years, respectively; 1.67 (1.36–2.05), P < 0.0001, for CV death; 2.12 (1.14–3.91), P < 0.0001, for heart transplantation; 1.36 (1.21–1.53), P < 0.0001, for HF hospitalization; and 1.37 (1.24–1.52), P < 0.0001, for the combined outcome. A propensity score‐matched analysis yielded similar results. CV death was the main cause of mortality in LDCM and was higher in LDCM than in RODCM (P < 0.0001). Almost all co‐morbidities were significantly more frequent in LDCM than in RODCM, and the mean number of co‐morbidities increased significantly with increased duration of disease, also after age adjustment. Age, New York Heart Association functional class, ejection fraction, and left bundle branch block were prognostically adverse. The only co‐morbidity associated with the combined outcome regardless of HF duration was diabetes, in LDCM [HR 1.34 (1.15–1.56), P = 0.0002] and in RODCM [HR 1.29 (1.04–1.59), P = 0.018]. Male sex [HR 1.38 (1.18–1.63), P < 0.0001] and aspirin use [HR 1.33 (1.14–1.55), P = 0.0004] carried increased risk only in RODCM. Heart rate ≥75 b.p.m. [HR 1.20 (1.04–1.37), P = 0.01], atrial fibrillation [HR 1.24 (1.08–1.42), P = 0.0024], musculoskeletal or connective tissue disorder [HR 1.36 (1.13–1.63), P = 0.0014], and diuretic therapy [HR 1.40 (1.17–1.67), P = 0.0002] were prognostically adverse only in LDCM.

Conclusions

This nationwide study of patients with DCM demonstrates that longer disease duration is associated with worse prognosis. Co‐morbidities are more common in long‐standing HF than in recent‐onset HF and are associated with worse outcome. With the increased survival seen in the last decades, our results highlight the importance of careful attention to co‐morbid conditions in patients with DCM.

Temporal trends in outcome and patient characteristics in dilated cardiomyopathy, data from the Swedish Heart Failure Registry 2003-2015

Background

Temporal trends in clinical composition and outcome in dilated cardiomyopathy (DCM) are largely unknown, despite considerable advances in heart failure management. We set out to study clinical characteristics and prognosis over time in DCM in Sweden during 2003–2015.

Methods

DCM patients (n = 7873) from the Swedish Heart Failure Registry were divided into three calendar periods of inclusion, 2003–2007 (Period 1, n = 2029), 2008–2011 (Period 2, n = 3363), 2012–2015 (Period 3, n = 2481). The primary outcome was the composite of all-cause death, transplantation and hospitalization during 1 year after inclusion into the registry.

Results

Over the three calendar periods patients were older (p = 0.022), the proportion of females increased (mean 22.5%, 26.4%, 27.6%, p = 0.0001), left ventricular ejection fraction was higher (p = 0.0014), and symptoms by New York Heart Association less severe (p < 0.0001). Device (implantable cardioverter defibrillator and/or cardiac resynchronization) therapy increased by 30% over time (mean 11.6%, 12.3%, 15.1%, p < 0.0001). The event rates for mortality, and hospitalization were consistently decreasing over calendar periods (p < 0.0001 for all), whereas transplantation rate was stable. More advanced physical symptoms correlated with an increased risk of a composite outcome over time (p = 0.0043).

Conclusions

From 2003 until 2015, we observed declining mortality and hospitalizations in DCM, paralleled by a continuous change in both demographic profile and therapy in the DCM population in Sweden, towards a less affected phenotype.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02124-0.

A negative T-wave in electrocardiogram at 50 years predicted lifetime mortality in a random population-based cohort

Background

Severe electrocardiographic (ECG) abnormalities in asymptomatic subjects correlate with cardiovascular risk.

Hypothesis

The role of minor ECG abnormalities is less well‐known. We evaluated the association between a negative T‐wave and mortality, as a possible marker for prognosis.

Methods

A prospective, population‐based cohort, examined at 50 years, and followed until death. Time to death (event rates) and predictive role of a negative T‐wave (Cox regression) were analyzed.

Results

Participants (n = 839) with a negative T‐wave (7.3%) had significantly higher blood pressure (BP) (mean systolic 157.9 mmHg vs 136.8 mmHg without negative T‐wave, P = <.0001). A negative T‐wave correlated with elevated risk (hazard ratio [HR] [95% CI] [confidence interval]) for all‐cause and cardiovascular (CV) death (1.59 (1.20‐2.11) P = .0012 vs 1.91 (1.34‐2.73) P = .0004). The association remained after excluding coexisting Q/QS patterns and ST‐junction/segment depression ECG abnormalities (1.66 [1.13‐2.44] P = .0098 for all‐cause vs 1.87 [1.13‐3.09] P = .015 for CV death). Death from other causes was not associated with a negative T‐wave. A major negative T‐wave carried higher risk than a minor (2.17 [1.25‐3.76] P = .0062 vs 1.78 [1.13‐2.79] P = .012) for CV death.

Conclusion

A negative T‐wave at 50 years, in asymptomatic individuals, carried an increased risk of all‐cause and CV death during lifetime follow‐up.

Prognostic impact over time of ischaemic heart disease vs. non-ischaemic heart disease in heart failure

Aims

The aim of this study is to investigate the prognostic impact of ischaemic heart disease (IHD) in heart failure (HF) and its association to age, sex, left ventricular ejection fraction (EF), and HF duration, and furthermore, to evaluate if the impact of IHD has changed over time, in light of improved therapy.

Methods and results

We studied 30 946 patients with non‐valvular HF, by accessing the Swedish Heart Failure Registry, from years 2000 to 2012. The mortality in 17 778 patients with clinical IHD was compared with 13 168 patients without IHD (non‐IHD). There was a significantly worse outcome in IHD, with the crude mortality of 41.1% and the event rate per 100 person‐years [95% confidence interval (CI)] of 14.8 (14.4–15.1), compared with 28.2% and 9.7 (9.4–10.0) in non‐IHD. After multivariable adjustment, the hazard ratio (HR) (95% CI) for mortality, IHD vs. non‐IHD, was 1.16 (1.11–1.22; P < 0.0001). Subgroup analyses showed significantly increased mortality in IHD, in all age subgroups, in all subgroups with EF < 50%, in both men and women, and regardless of heart failure duration more or less than 6 months. Analyses for the combination of age and EF showed the highest HR for time to death in the youngest with the lowest EF, HR (95% CI) 2.05 (1.59–2.64) for patients <60 years of age with EF < 30%. Although a numerical reduction of the HR for mortality was seen over time, the risk for mortality in IHD, compared with the non‐IHD group, was greater throughout the study period.

Conclusions

In non‐valvular heart failure, IHD was associated with significantly increased mortality, compared with non‐IHD, in groups of EF below 50%, in all age groups, and regardless of sex or HF duration. The risk increase associated with EF reduction diminished with increasing age. The mortality in IHD, compared with non‐IHD, remained significantly higher throughout the 13 year study period.

Revealed by degrees: Patients' experience of receiving information after in-hospital cardiac arrest

AIMS AND OBJECTIVES

To describe patients' experience of receiving information about the event after having a cardiac arrest in hospital.

BACKGROUND

In Sweden, approximately 2,600 people per year experience cardiac arrest in hospital. After a cardiac arrest, the patient is entitled to receive information about what has occurred. This information must be provided in a way that does not do the patient more harm than good. In order to provide information to patients in a satisfactory manner for them, knowledge about how patients react to information in this situation is valuable.

DESIGN

We used a qualitative approach with interviews and content analysis.

METHODS

Twenty patients participated in face-to-face interviews analysed by content analysis. Consolidated criteria for reporting qualitative studies were used.

RESULTS

The analysis resulted in three categories: Getting the information gradually, Understanding information received and Seeking clarity. The subcategories that emerged were as follows: Indirect information, Short and direct information, Explanatory information, Lack of information, Unsatisfactory information, Hard-to-understand information, Insight, Unanswered questions, Hard-to-formulate questions, Requesting information and Searching independently for knowledge.

CONCLUSIONS

The patients needed gradual and repeated information during their hospitalisation, and repeated information was continually required after their discharge from hospital. Whether or how the information was given varied. The patients' experience was that they sometimes lacked opportunities for conversation and asking questions, while they also found it hard to formulate questions. Patients who have a cardiac arrest in hospital appear to have similar information needs to patients whose cardiac arrest takes place outside the hospital context.

RELEVANCE TO CLINICAL PRACTICE

Information on the patient's cardiac arrest should be given in gradual stages, according to the patient's needs. The information needs to be repeated during the hospital stay and after discharge. Healthcare professional should gain insight into patients' responses and create information that is adapted to the individual.

Trends in Gender Differences in Cardiac Care and Outcome After Acute Myocardial Infarction in Western Sweden: A Report From the Swedish Web System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART)

BACKGROUND

Cardiovascular disease is the most common cause of death for both genders. Debates are ongoing as to whether gender-specific differences in clinical course, diagnosis, and management of acute myocardial infarction (MI) exist.

METHODS AND RESULTS

We compared all men and women who were treated for acute MI at cardiac care units in Västra Götaland, Sweden, between January 1995 and October 2014 by obtaining data from the prospective SWEDEHEART (Swedish Web-System for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry. We performed unadjusted and adjusted Cox proportional hazards and logistic regression analyses on complete case data and on imputed data sets. Overall, 48 118 patients (35.4% women) were diagnosed with acute MI. Women as a group had better age-adjusted prognosis than men, but this survival benefit was absent for younger women (aged <60 years) and for women with ST-segment elevation MI. Compared with men, younger women and women with ST-segment elevation MI were more likely to develop prehospital cardiogenic shock (adjusted odds ratio 1.67, 95% CI 1.30 to 2.16, P<0.001 and adjusted odds ratio 1.31, 95% CI 1.16 to 1.48, P<0.001) and were less likely to be prescribed evidence-based treatment at discharge (P<0.001 for β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, statins, and P2Y12 antagonists). Differences in treatment between the genders did not decrease over the study period (P>0.1 for all treatments).

CONCLUSIONS

Women on average have better adjusted prognosis than men after acute MI; however, younger women and women with ST-segment elevation MI have disproportionately poor prognosis and are less likely to be prescribed evidence-based treatment.

Association between glycometabolic status in the acute phase and 2½ years after an acute coronary syndrome

OBJECTIVES

To evaluate the association between glycometabolic status in the acute phase and 21/2 years later in patients with acute coronary syndrome (ACS).

METHODS

Non-diabetic patients (n = 762) presenting with ACS were prospectively followed up for 21/2 years. Patients were stratified by admission plasma glucose (<6.1 mmol/l, 6.1 - 6.9 mmol/l and >or=7.0 mmol/l) and HbA1c (<or=4.5%, 4.6 - 5.4% and >or=5.5%). The predictive value of glucose levels >or= 7.0 mmol/l and HbA1c >or= 5.5% for glycometabolic disturbance (i.e. diabetes or impaired fasting glycaemia (IFG)) was analysed.

RESULTS

Of 762 patients, 13% had a diagnosis of diabetes and 16% had IFG at follow-up. The prevalence of glycometabolic disturbance at follow-up increased with increasing plasma glucose at admission, from 19% in patients with < 6.1 mmol/l to 42% in patients with >or= 7.0 mmol/l. Sixty-one percent of patients with HbA1c >or= 5.5% had glycometabolic disturbance after 21/2 years compared to only 25% of those with HbA1c < 5.5%.

CONCLUSION

Non-diabetic patients with ACS and hyperglycaemia are at high risk for developing glycometabolic disturbance. HbA1c may be an even stronger predictor of glycometabolic disturbance than plasma glucose.

Mortality, risk indicators for death, and mode of death in younger and elderly patients during five years after coronary artery bypass graft

BACKGROUND

The number of elderly patients who may be candidates for coronary artery bypass graft (CABG) for severe coronary artery disease has increased. Cardiac surgery in the elderly is a high-risk procedure because many of these patients have concomitant systemic disease and other disabilities.

HYPOTHESIS

The study was undertaken to evaluate mortality, risk indicators for death, and mode of death in younger and elderly patients during 5 years after CABG.

METHODS

The study included all patients in western Sweden who underwent CABG without concomitant valve surgery and without previously performed CABG between June 1988 and June 1991. In all, 2,000 patients, of whom 953 (48%) were > or = 65 years, were divided into two age groups (< 65 years and > or = 65 years).

RESULTS

Compared with the younger patients, the elderly had a relative risk of death of 2.3 (95% confidence interval 1.8-3.0). The increased risk of death in the elderly was significantly more marked in men, in patients with more severe angina pectoris, and in patients without a history of cerebrovascular diseases. The mode and place of death appeared similar regardless of age; neither was there marked difference in symptoms of angina pectoris among survivors 5 years after CABG.

CONCLUSION

Compared with patients < 65 years, the elderly have more than twice as high a risk of death during the subsequent 5 years, and this risk is higher in men, in patients with severe symptoms of angina pectoris, and in those with no history of cerebrovascular disease.

Patients with a history of diabetes have a lower survival rate after in-hospital cardiac arrest

AIM

To describe the association between a history of diabetes and outcome among patients suffering an in-hospital cardiac arrest.

METHOD

All patients suffering an in-hospital cardiac arrest in whom cardiopulmonary resuscitation (CPR) was attempted at Sahlgrenska University Hospital in Göteborg between 1994 and 2006 and at nine further hospitals in Sweden between 2005 and 2006.

RESULTS

In all, 1810 patients were included in the survey, 395 (22%) of whom had a previous history of diabetes. Patients with a history of diabetes differed from those without such a history by having a higher prevalence of previous myocardial infarction, stroke, heart failure and renal disease. They were more frequently treated with anti-arrhythmic drugs during resuscitation. Whereas immediate survival did not differ between groups (51.7% and 53.1%, respectively), patients with diabetes were discharged alive from hospital (29.3%) less frequently compared with those without diabetes (37.6%). When correcting for dissimilarities at baseline, the adjusted odds ratio for being discharged alive (diabetes/no diabetes) was 0.57 (95% CL 0.40-0.79).

CONCLUSION

Among patients suffering an in-hospital cardiac arrest in Sweden in whom CPR was attempted, 22% had a history of diabetes. These patients had a lower survival rate, which cannot simply be explained by different co-morbidity.

Lack of Very Strong Association between Pre-Treatment Fibrinogen and PAI-1 with Long-Term Mortality after Coronary Bypass Surgery

AIM

To explore the association between the coagulation protein fibrinogen and the fibrinolytic biomarker plasminogen activator inhibitor-1 (PAI-1) and the long-term mortality after coronary artery bypass grafting (CABG).

PATIENTS AND METHODS

In 729 patients undergoing CABG at Sahlgrenska University Hospital, a blood sample for fibrinogen and PAI-1 was collected prior to the procedure. Patients were followed for 10 years.

RESULTS

Among patients with high levels of fibrinogen (>3.6 g/l; median), the 10-year mortality was 32.3 vs. 20.7% among patients with fibrinogen levels below the median (p = 0.0005). However, patients with higher levels of fibrinogen were older and had an adverse risk factor pattern. When adjusting for these differences, pre-operative fibrinogen levels did not clearly appear as an independent predictor of long-term mortality. The 10-year mortality was similar in patients with high (25.3%) and low (26.5%) levels of PAI-1.

CONCLUSION

Our results do not suggest that fibrinogen and PAI-1, when evaluated prior to the operative procedure, are strongly associated with increased mortality in the long-term after CABG, when other co-morbidity factors are simultaneously considered.

Increase of SUMO-1 expression in response to hypoxia: direct interaction with HIF-1alpha in adult mouse brain and heart in vivo

The present study investigates the regulation of small ubiquitin-related modifier-1 (SUMO-1) expression in response to hypoxia in adult mouse brain and heart. We observed a significant increase in SUMO-1 mRNAs and proteins after hypoxic stimulation in vivo. Because SUMO-1 interacts with various transcription factors, including hypoxia-inducible factor-1beta (HIF-1beta) in vitro, we not only demonstrated that the HIF-1alpha expression is increased by hypoxia in brain and heart, but also provided evidence that SUMO-1 co-localizes in vivo with HIF-1alpha in response to hypoxia by demonstrating the co-expression of these two proteins in neurons and cardiomyocytes. The specific interaction between SUMO-1 and HIF-1alpha was additionally demonstrated with co-immunoprecipitation. These results indicate that the increased levels of SUMO-1 participate in the modulation of HIF-1alpha function through sumoylation in brain and heart.

Relief of symptoms and improvement of health-related quality of life five years after coronary artery bypass graft in women and men

BACKGROUND

Severe coronary artery disease can be successfully treated with coronary artery bypass graft (CABG), with considerable improvement in the symptoms of angina pectoris. Approximately three of four patients are free of ischemic events for 5 years; however, increased survival is demonstrated only in selected subgroups with advanced coronary artery disease, and this effect has not been established in elderly patients.

HYPOTHESIS

The study was undertaken to determine the relief of symptoms and improvement in other aspects of health-related quality of life (QoL) during 5 years after CABG in women and men.

METHODS

Patients who underwent CABG in western Sweden were approached prior to and 5 years after surgery. Health-related QoL was estimated with Physical Activity Score (PAS), Nottingham Health Profile, and Psychological General Well-Being Index.

RESULTS

Women (n = 381) had a 5-year mortality of 17% compared with 13% for men (n = 1,619; NS). After 5 years, 1,719 patients (survivors) were available for the survey; of these, 876 (51%) answered the inquiry both prior to and after 5 years. Both women and men improved markedly and highly significantly, both with respect to symptoms and other aspects of health-related QoL. Women suffered more than men in terms of limitation of physical activity, dyspnea, chest pain, and others aspects of health-related QoL. There was a significant interaction between time and gender, with more improvement in men with regard to chest pain when walking uphill or quickly on level ground, when walking on level ground at the speed of other persons their own age, when under stress, and in windy and cold weather. For those parameters as well as for PAS, improvement was more marked in men than in women. In the other aspects of health-related QoL, there was no interaction between time and gender.

CONCLUSION

Five years after CABG, limitation of physical activity, symptoms of dyspnea, and chest pain were reduced, and various aspects of health-related QoL had improved in both women and men. In general, women suffered more than men both prior to and after CABG; however, in some aspects the improvement was more pronounced in men. Because of the limited response rate, the results may not be applicable to a nonselected population who had undergone CABG.

Physical activity, symptoms of chest pain and dyspnea in patients with ischemic heart disease in relation to age before and two years after coronary artery bypass grafting

BACKGROUND

To describe limitation of physical activity, cause of limitation of physical activity and symptoms of dyspnea and chest pain in relation to age before and 2 years after coronary artery bypass grafting (CABG).

METHODS

All patients from Western Sweden who underwent CABG without concomitant procedures during 3 years in 1989-1991 answered questionnaires before, and 2 years after the operation. Patients were divided into 3 age groups of equal size i.e. 32-59 years, 60-67 years and > or = 68 years.

RESULTS

In total, 2121 patients participated in the evaluation. The overall 2 year mortality in the 3 age groups was 3.8%, 6.8% and 12.2% (p<0.001). Limitation of physical activity was significantly associated with age prior to surgery but not thereafter. Improvement in physical activity, following CABG, was significant in all age groups. The proportion of patients being free of dyspnea increased markedly regardless of age. The number of chest pain attacks was associated with age after CABG, i.e. fewer attacks in the elderly, but such an association was not found prior to surgery. Improvement in number of chest pain attacks was more marked in the elderly.

CONCLUSIONS

Physical activity improved similarly in all age groups after CABG. Attacks of chest pain, although significantly reduced in all age groups, seemed more effectively reduced in the elderly.

Relief of symptoms and improvement of quality of life five years after coronary artery bypass grafting in relation to preoperative ejection fraction

AIM

To describe the relief of symptoms and improvement in Quality of Life (QoL) 5 years after coronary artery bypass grafting (CABG) in relation to preoperative ejection fraction (EF).

METHODS

Patients who underwent CABG between 1988 and 1991 in western Sweden were approached with an inquiry prior to surgery and 5 years after the operation. Quality of Life was estimated with three different instruments: Physical activity score, Nottingham Health Profile and Psychological General Well-being Index.

RESULTS

Among all patients who underwent CABG (n = 1904) the 5-year mortality rate was 27% in those with EF < 0.40 and 12% in those with EF > or = 0.40 (p < 0.0001). In all, 849 patients, of whom 58 (7%) had EF < 0.40 participated in the evaluation. Neither physical activity, symptoms of chest pain, dyspnea nor any indices of QoL were significantly associated with preoperative EF. Improvement in physical activity, symptoms of chest pain and dyspnea and various estimates of QoL appeared similar and marked regardless of preoperative EF.

CONCLUSION

Among survivors there was no association between preoperative EF and symptoms or various estimates of QoL 5 years after CABG. Improvement in symptoms and QoL were not dependent on preoperative EF.

Impact of a history of diabetes on the improvement of symptoms and quality of life during 5 years after coronary artery bypass grafting

To describe the impact of a history of diabetes mellitus on the improvement of symptoms and various aspects of quality of life (QoL) during 5 years after coronary artery bypass grafting (CABG). Patients who underwent CABG between 1988 and 1991 in western Sweden were approached with an inquiry prior to surgery and 5 years after the operation. QoL was estimated with three different instruments: Physical Activity Score (PAS), Nottingham Health Profile (NHP) and Psychological General Well-Being (PGWB) index. 876 patients participated in the evaluation, of whom 87 (10%) had a history of diabetes. Symptoms of dyspnea and chest pain improved both in diabetic and non-diabetic patients. Diabetic patients scored worse than non-diabetic patients both prior to and 5 years after CABG, but without any major difference in improvement between the two groups with all three measures of QoL. PAS tended to improve more in non-diabetic than in diabetic patients, whereas improvement in NHP and PGWB was similar regardless of a history of diabetes. Diabetic patients differ from non-diabetic patients having an inferior QoL both prior to and 5 years after CABG. Both diabetic and non-diabetic patients improve in symptoms and QoL after the operation. In some aspects improvement tended to be less marked in the diabetic patients but on the whole improvement was similar compared to non-diabetic patients.

Impact of a history of hypertension on symptoms and quality of life prior to and at five years after coronary artery bypass grafting

AIM

To describe symptoms and other aspects of health-related quality of life (QoL) prior to and 5 years after coronary artery bypass grafting (CABG) in relation to a history of hypertension.

METHODS

Patients who underwent CABG in western Sweden were approached prior to surgery and 5 years after the operation. Health-related QoL was estimated with the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-Being Index.

RESULTS

In patients with a history of hypertension (n = 740) the 5-year mortality was 16.9% versus 12.4% among patients with no history (n = 1257; p = 0.004). Of 1717 patients available for the survey, 876 (51%) responded both prior to and 5 years after CABG. Of these, 36% had a history of hypertension. Compared with the situation prior to surgery there was an improvement in both hypertensive and non-hypertensive patients in terms of physical activity, symptoms of dyspnea and chest pain and other estimates of health-related QoL. However, physical activity and dyspnea improved less in hypertensive than in non-hypertensive patients.

CONCLUSION

Five years after CABG, a marked and significant improvement in terms of symptoms and other aspects of health-related QoL was observed among both hypertensive and non-hypertensive patients. However, improvement in physical activity was less marked in patients with a history of hypertension. Overall, a history of hypertension seemed to have a minor impact on improved well-being 5 years after coronary surgery. However, because of the limited response rate the results may not be applicable in a non-selected CABG population.

Limitation of physical activity, dyspnoea and chest pain before and two years after coronary artery bypass grafting in relation to preoperative ejection fraction

To investigate the relationships between limitation of physical activity and dyspnoea and chest pain before and 2 years after coronary artery bypass grafting (CABG) and preoperative left ventricular ejection fraction (LVEF), questionnaires were issued to all patients from Western Sweden who underwent CABG during 1988-1991. The analysis comprised 985 patients. Physical activity improved significantly after CABG regardless of the preoperative LVEF. No significant association was found between LVEF and degree of limitation of physical activity before or after surgery. Dyspnoea and chest pain improved markedly, irrespective of LVEF. There was significant association between freedom from dyspnoea and LVEF preoperatively (less dyspnoea with higher LVEF), but not after CABG. The frequency of chest-pain attacks was not related to LVEF, before or after the operation. Thus physical activity, dyspnoea and chest pain improved in the 2 years after CABG irrespective of preoperative LVEF. Absence of dyspnoea was related to LVEF before, but not after surgery, and there was no association between preoperative LVEF and frequency of anginal attacks before or after CABG.

Mortality, mode of death and risk indicators for death during 5 years after coronary artery bypass grafting among patients with and without a history of diabetes mellitus

OBJECTIVE

To describe mortality, mode of death, risk indicators for death and symptoms of angina pectoris among survivors during 5 years after coronary artery bypass grafting (CABG) among patients with and without a history of diabetes mellitus.

METHODS

All patients in western Sweden who underwent CABG without concomitant valve surgery and who had no previous CABG between June 1988 and June 1991 were entered prospectively in this study. After 5 years, information on deaths that had occurred was obtained for the analysis.

RESULTS

In all, 1998 patients were included in the analysis; 242 (12%) had a history of diabetes. Among the non-diabetic patients, 5-year mortality was 12.5%; the corresponding relative risk for diabetic patients was 2.1 (95% confidence interval 1.6 to 2.9). A history of diabetes was an independent risk indicator of death; there was no significant interaction between any other risk indicator and diabetes. Independent risk indicators for death among diabetic patients were: current smoking, renal dysfunction and left ventricular ejection fraction < 0.40. Compared with non-diabetic patients, those with diabetes more frequently died in hospital, died a cardiac death, or had death associated with the development of acute myocardial infarction and with symptoms of congestive heart failure. Among survivors, diabetic patients tended to have more angina pectoris 5 years after CABG than did those without diabetes.

CONCLUSION

During a period of 5 years after CABG, diabetic patients had a mortality twice that of non-diabetic patients. The increased risk included death in hospital, cardiac death and death associated with development of acute myocardial infarction and with symptoms of congestive heart failure.

Mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in men and women

AIM

To describe mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in women and men.

SAMPLE

All patients in western Sweden who underwent coronary artery bypass grafting without concomitant valve surgery and without previously performed coronary artery bypass grafting between June 1988 and June 1991.

RESULTS

In all, 2000 patients participated in the evaluation, 381 (19%) of whom were women. Compared to men, who had a 5-year mortality of 13.3%, women had a relative risk of death of 1.4 (95% CI 1.0-1.8; P = 0.03). Renal dysfunction interacted significantly (P = 0.048) with gender, in that the differences were more marked in patients without renal dysfunction. When adjusting for differences at baseline, the relative risk of death amongst women was 1.0 (95% CL 0.7-1.3). Compared to men, women had an increased risk of in-hospital death and death associated with stroke. However, amongst the patients who died, the place and mode of death appeared to be similar in women and men. Amongst survivors after 5 years, women had more symptoms of angina pectoris than men.

CONCLUSION

During 5 years after coronary artery bypass grafting, women had an increased mortality compared to men; renal dysfunction seemed to interact with female gender regarding mortality. Women had a higher risk of in-hospital death and death associated with stroke. However, the adjusted relative risk of death during 5 years was equal in women and men. Amongst survivors, women suffered more from angina pectoris than men.

Mortality, risk indicators, mode and place of death and symptoms of angina pectoris in the five years after coronary artery bypass grafting in patients with and without a history of hypertension

AIM

To describe mortality, risk indicators for death, place and mode of death, and symptoms of angina pectoris among survivors in the 5 years after coronary artery bypass grafting (CABG) in patients with and without a history of hypertension.

METHODS

All patients in western Sweden who underwent CABG without concomitant valve surgery and without previously performed CABG between June 1988 and June 1991.

RESULTS

A total of 1997 patients were included in the analysis, 740 (37%) of whom had a history of hypertension. Patients with no history had a 5-year mortality of 12.4%. The corresponding relative risk for hypertensives was 1.4 (95% CI 1.1-1.8). Risk factors for death appeared similar in patients with and without a history of hypertension. Patients with hypertension had an increased risk of death in hospital and an increased risk of a non-cardiac death. Among survivors after 5 years, patients with a history of hypertension tended to have a higher prevalence of symptoms equivalent to angina pectoris.

CONCLUSIONS

Patients with a history of hypertension have an increased risk of death in the 5 years after CABG. Risk factors for death appear similar in patients with and without a history of hypertension. Patients with hypertension have a particularly increased risk of death in hospital and of death judged as non-cardiac.

Impact of age on improvement in health-related quality of life 5 years after coronary artery bypass grafting

The aim of this study was to describe the relief of symptoms and improvement in other aspects of health-related quality of life 5 years after coronary artery by-pass grafting in relation to age. Patients in western Sweden were approached with an inquiry prior to surgery and 5 years after the operation. Health-related quality of life was estimated with 3 different instruments: Physical Activity Score (PAS), Nottingham Health Profile (NHP), Psychological General Well-Being Index (PGWB). Prior to surgery patients were approached either in the ward or by post and 5 years after surgery they were approached by post. A total of 1719 patients were available for the survey, of whom 876 (51%) responded to the survey both prior to and after 5 years. Among the 876 respondents 287 were <60 years, 331 were 60-67 years and 258 were >67 years. In terms of physical activity, chest pain and dyspnoea, a similar improvement was observed regardless of age. In terms of health-related quality of life questionnaires, there was an inverse association between age and improvement when using PAS and a similar trend was observed with NHP and PGWB. In conclusion, 5 years after coronary artery bypass grafting relief of symptoms and improvement in physical activity was not associated with age, whereas improvement in other aspects of health-related quality of life tended to be less marked in elderly people. Overall age seemed to have a small impact on the improved well-being 5 years after coronary surgery. However, due to the limited response rate the results may not be applicable to a non-selected coronary artery bypass grafting population.

Atherosclerosis progression in LDL receptor-deficient and apolipoprotein E-deficient mice is independent of genetic alterations in plasminogen activator inhibitor-1

Impaired fibrinolysis has been linked to atherosclerosis in a number of experimental and clinical studies. Plasminogen activator inhibitor type 1 (PAI-1) is the primary inhibitor of plasminogen activation and has been proposed to promote atherosclerosis by facilitating fibrin deposition within developing lesions. We examined the contribution of PAI-1 to disease progression in 2 established mouse models of atherosclerosis. Mice lacking apolipoprotein E (apoE-/-) and mice lacking the low density lipoprotein receptor (LDLR-/-) were crossbred with transgenic mice overexpressing PAI-1 (resulting in PAI-1 Tg(+)/apoE-/- and PAI-1 Tg(+)/LDLR-/-, respectively) or were crossbred with mice completely deficient in PAI-1 gene expression (resulting in PAI-1-/-/apoE-/- and PAI-1-/-/LDLR-/-, respectively). All animals were placed on a western diet (21% fat and 0.15% cholesterol) at 4 weeks of age and analyzed for the extent of atherosclerosis after an additional 6, 15, or 30 weeks. Intimal and medial areas were determined by computer-assisted morphometric analysis of standardized microscopic sections from the base of the aorta. Atherosclerotic lesions were also characterized by histochemical analyses with the use of markers for smooth muscle cells, macrophages, and fibrin deposition. Typical atherosclerotic lesions were observed in all experimental animals, with greater severity at the later time points and generally more extensive lesions in apoE-/- than in comparable LDLR-/- mice. No significant differences in lesion size or histological appearance were observed among PAI-1-/-, PAI-1 Tg(+), or PAI-1 wild-type mice at any of the time points on either the apoE-/- or LDLR-/- genetic background. We conclude that genetic modification of PAI-1 expression does not significantly alter the progression of atherosclerosis in either of these well-established mouse models. These results suggest that fibrinolytic balance (as well as the potential contribution of PAI-1 to the regulation of cell migration) plays only a limited role in the pathogenesis of the simple atherosclerotic lesions observed in the mouse.

Long term prognosis after CABG in relation to preoperative left ventricular ejection fraction

AIM

To evaluate the mortality rate, risk indicators for death, mode of death and symptoms of angina pectoris during 5 years after coronary artery by pass grafting (CABG) in relation to the preoperative left ventricular ejection fraction (LVEF).

PATIENTS

All patients in western Sweden who underwent CABG without concomitant valve surgery and without previously performed CABG between June 1988 and June 1991.

RESULTS

In all 1904 patients were included in the analysis, of whom 173 (9%) had a LVEF < 40%. Patients with LVEF > or = 40% had a 5-year mortality of 12.5%. LVEF < 40% was associated with an increased risk of death (RR 2.3; 95% cl 1.7-3.1). There was no significant interaction between age, sex or any other factor in terms of clinical history and LVEF. However, left main stenosis was a strong independent predictor of death among patients with LVEF < 40% but not in those with a higher LVEF. Patients with a low LVEF more frequently died a cardiac death and a death associated with myocardial infarction (AMI). Furthermore they more frequently died in association with congestive heart failure and ventricular fibrillation. Among survivors, symptoms of angina pectoris were similar regardless of the preoperative LVEF.

CONCLUSION

Patients with a low preoperative LVEF have a more than two-fold increased risk of death during 5 years after CABG. Their increased risk of death includes cardiac death, death associated with AMI, congestive heart failure and ventricular fibrillation.

Symptoms of chest pain and dyspnea and factors associated with chest pain after coronary artery bypass grafting

Patients in western Sweden who underwent CABG from 1988 to 1991 received prior to coronary angiography and 2 and 5 years after CABG a questionnaire, in which they were asked about symptoms of chest pain and dyspnea. In all, 1,226 patients answered the inquiry prior to CABG, 1,531 patients 2 years and 1,359 patients 5 years after surgery. Both in terms of chest pain and dyspnea there was a marked improvement 2 and 5 years after CABG as compared with prior to surgery. However, between 2 and 5 years after surgery there was a minor deterioration, both regarding chest pain and dyspnea. The most statistically significant preoperative predictors for the occurrence of chest pain more than twice a week 5 years after surgery were concomitant valvular heart disease and obesity.

Improvement in quality of life differs between women and men after coronary artery bypass surgery

OBJECTIVE

To study improvement in quality of life (QoL) after coronary artery bypass grafting (CABG) in relation to gender.

BACKGROUND

Women generally report worse QoL after CABG than men. However, women are older and more symptomatic prior to surgery, which should be considered in comparative analyses.

METHODS

We studied consecutive patients who underwent CABG between 1988 and 1991 [n = 2121] with a QoL questionnaire containing the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index prior to, 3 months, 1 year and 2 years after surgery.

RESULTS

Females were older than men with more concomitant diseases preoperatively. QoL was improved on all postoperative occasions for both sexes. Improvement in the Physical Activity Score was somewhat, although not significantly, greater in males. Improvement in the Nottingham Health Profile was greater in females. General well-being showed no consistent pattern for improvement.

CONCLUSIONS

QoL is significantly improved after CABG in both sexes throughout follow-up. There is a complex association between improvement in various aspects of QoL and gender.

Determinants of an impaired quality of life five years after coronary artery bypass surgery

OBJECTIVE

To identify determinants of an inferior quality of life (QoL) five years after coronary artery bypass grafting (CABG).

SETTING

University hospital.

PARTICIPANTS

Patients from western Sweden who underwent CABG between 1988 and 1991.

MAIN OUTCOME MEASURES

Questionnaires for evaluating QoL before CABG and five years after operation. Three different instruments were used: the Nottingham health profile (NHP), the psychological general wellbeing index (PGWI), and the physical activity score (PAS).

RESULTS

2121 patients underwent CABG, of whom 310 died during five years' follow up. Information on QoL after five years was available in 1431 survivors (79%). There were three independent predictors for an inferior QoL with all three instruments: female sex, a history of diabetes mellitus, and a history of chronic obstructive pulmonary disease. Multivariate analysis showed that a poor preoperative QoL was a strong independent predictor for an impaired QoL five years after CABG. An impaired QoL was also predicted by previous disease.

CONCLUSIONS

Female sex, an impaired QoL before surgery, and other diseases such as diabetes mellitus are independent predictors for an impaired QoL after CABG in survivors five years after operation.

Improvement in quality of life during 5 years after coronary artery bypass grafting

OBJECTIVE

To describe the changes in various aspects of quality of life (QOL) from before coronary artery bypass grafting (CABG) to 5 years after the procedure.

PATIENTS AND METHODS

Patients who underwent CABG in the western region of Sweden in 1988-1991 were approached with questionnaires evaluating their QOL prior to and 3 months and 1, 2, and 5 years after the operation. Three different instruments were used: the Nottingham Health Profile, the Psychological General Well-Being Index, and the Physical Activity Score.

RESULTS

In all 2121 patients underwent CABG, of whom 310 died during 5 years of follow-up. With all three instruments QOL had improved 5 years after CABG compared with prior to the operation. However, all three instruments revealed a slight but significant deterioration in estimated QOL between 2 and 5 years after CABG.

CONCLUSIONS

QOL 5 years after CABG is better than that prior to the operation, but between 2 and 5 years after the operation a slight deterioration in QOL is observed.

Predictors of death and other cardiac events within 2 years after coronary artery bypass grafting

RESULTS

In 1,841 patients who underwent coronary artery bypass grafting (CABG) we evaluated risk indicators for death and other cardiac events during 2 years of follow-up. Independent predictors of death were: a history of congestive heart failure, diabetes mellitus and renal dysfunction prior to CABG. Independent predictors of death, acute myocardial infarction (AMI), CABG or percutaneous transluminal coronary angioplasty (PTCA) were: a small body surface area, a history of congestive heart failure, diabetes mellitus and smoking prior to CABG. Independent predictors of death, AMI, CABG, PTCA or rehospitalization for a cardiac reason were: angina functional class, previous AMI, a history of congestive heart failure and renal dysfunction prior to CABG.

CONCLUSION

When using various definitions of a cardiac event after CABG, various risk indicators for death or such an event can be found. Our data suggest that anamnestic information prior to CABG indicating a depressed myocardial function or severe myocardial ischemia are more important predictors of outcome than the information gained from cardioangiography.

Preoperative left-ventricular ejection fraction does not influence the improvement in quality of life after coronary artery bypass surgery

Coronary artery bypass grafting (CABG) is an established treatment for angina pectoris which conveys relief of chest pain and improved physical performance. However, increased survival has only been observed in selected subgroups of patients with advanced coronary artery disease, particularly in the presence of depressed left-ventricular ejection fraction (LVEF). It is therefore of interest to study whether the outcome in terms of quality of life (QoL) is also more favorable in candidates with depressed LVEF. All patients who underwent CABG without concomitant valve surgery in western Sweden between 6.1988 and 6.1991 (n = 2121) were sent questionnaires on QoL involving 3 different instruments, the Physical Activity Score, the Nottingham Health Profile, and the Psychological General Well-being Index. They were submitted before surgery and 3 times in the 2 years thereafter. QoL was improved on all postoperative occasions. The degree of improvement was not associated with preoperative LVEF for any of the instruments. The postoperative Physical Activity Score was associated with preoperative LVEF. The other instruments showed no such association with LVEF. The improvement in QoL during 2 years after CABG is not dependent on the LVEF determined prior to operation. Self-estimated physical abilities are postoperatively associated with preoperative LVEF whereas health-related QoL and general well-being are not.

The feeling of loneliness prior to coronary artery bypass grafting might be a predictor of short-and long-term postoperative mortality

OBJECTIVES

To evaluate the effect of different aspects of quality of life (QL) upon mortality during short-and long-term follow-up after coronary artery bypass grafting (CABG).

DESIGN

Prospective evaluation.

MATERIALS

Consecutive patients from western Sweden who during 3 years underwent CABG.

METHODS

They answered a questionnaire at the time of coronary angiography prior to CABG. Quality of life was measured with questions from the Nottingham Health Profile (NHP) part I.

RESULTS

In all, 1290 patients were included in the analyses. When accounting for various preoperative factors known to be independently associated with morality the NHP question "I feel lonely" was found to be associated with mortality, both at 30 days (RR 2.61; 95% CI 1.15-5.95; p = 0.02) and at 5 years (RR 1.78; 95% CI 1.17-2.71; p = 0.007) after the operation. Thirteen per cent reported they felt lonely. At 5 years was, in addition, the statement "I have difficulty climbing stairs" also independently associated with mortality (RR 1.50; 95% CI 1.02-2.22; p = 0.04).

CONCLUSION

Among the 38 statements in NHP as a judgment of QL prior to CABG, one of them, "I feel lonely" was independently associated with survival both at 30 days and 5 years after CABG.

Impact of a chest pain clinic on recurrency of symptoms and readmissions among patients early discharged from hospital after acute myocardial infarction was ruled out

This paper evaluates the impact of an early revisit including symptom evaluation and an exercise electrocardiogram on recurrency of symptoms and readmissions during 1 year of follow-up among patients coming to hospital with chest pain or an initial suspicion of acute myocardial infarction (AMI) but in whom the suspicion was quickly ruled out. Patients below the age of 65 admitted to the emergency department (ED) at Sahlgrenska Hospital due to chest pain or other symptoms raising a suspicion of AMI who were either directly discharged from the ED or discharged within 1 day after having AMI ruled out. Patients were allocated to two groups: (1) patients being re-evaluated in a chest pain clinic less than a week after discharge from hospital (intervention group) and (2) patients handled routinely with no formalized follow-up (control group). The intervention group (n=484) and the control group (n=374) were comparable at baseline. During 1 year of follow-up, patients in the intervention group had a lower rate of readmissions to the ED than patients in the control group (17.4% versus 24.9%, p < 0.05) and a lower rate of rehospitalizations (15.9% versus 23.3%, p < 0.05). The proportion of patients being on sick leave at any time during the follow-up did not differ and neither did the recurrency of symptoms. The introduction of a chest pain clinic for patients early discharged from hospital after having AMI ruled out indicated beneficiency in terms of a lower rate of readmissions to the ED and a lower requirement of rehospitalizations. However, a methodological weakness in the randomization procedure suggest carefulness in interpretation.

Impact of a history of diabetes mellitus on quality of life after coronary artery bypass grafting

AIM

To describe the improvement in various aspects of quality of life (QoL) after coronary artery bypass grafting (CABG), in relation to a previous history of diabetes mellitus.

PATIENTS

All patients from western Sweden who underwent CABG between 1988 and 1991 without simultaneous valve surgery.

METHODS

Patients were approached with three questionnaires: The Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index prior to surgery and 3 months, 1 and 2 years thereafter.

RESULTS

All three questionnaires already showed a significant improvement in QoL after 3 months, remaining at a similar level 1 and 2 years after the operation. In terms of Physical Activity Score improvement was of similar magnitude in diabetic and non-diabetic patients. In terms of the Psychological General Well-Being Index significant and similar improvements were found in diabetic and non-diabetic patients at each evaluation. In terms of the Nottingham Health Profile there was a significant improvement both in diabetic and non-diabetic patients 3 months, 1 and 2 years after the operation. However, improvement was more marked in diabetic than in non-diabetic patients at each evaluation.

CONCLUSION

For 3 months, 1 and 2 years after CABG various aspects of QoL as estimated with three different instruments, improved significantly both in diabetic and in non-diabetic patients compared with the situation prior to the operation. However, the three instruments differed somewhat. Thus, whereas in the Physical Activity Score, diabetic patients tended to improve less markedly than non-diabetic patients, the opposite was found in the Nottingham Health Profile.

Limitation of physical activity, dyspnea and chest pain prior to and during two years after coronary artery bypass grafting in relation to a history of hypertension

AIM

To describe the limitation of physical activity, the cause of limitation of physical activity and symptoms of dyspnea and chest pain before and 2 years after coronary artery bypass grafting (CABG) in relation to a history of hypertension.

METHODS

All patients from western Sweden who underwent CABG between 1988 and 1991 were approached with a questionnaire--prior to, 3 months and 2 years after CABG--evaluating the issues raised above.

RESULTS

Of 2121 patients, 37% had a history of hypertension. By 3 months after CABG, physical activity tolerance had improved markedly and in a similar way for both hypertensive (p<0.001) and non-hypertensive patients (p<0.001); this level was sustained for 2 years. Absence of dyspnea increased markedly and similarly among both hypertensive and non-hypertensive patients (p < 0.001) after CABG. The presence of chest pain decreased markedly and similarly among hypertensive (p<0.001) and non-hypertensive patients (p<0.001), both 3 months and 2 years after compared to prior to the operation.

CONCLUSION

There was a marked improvement in terms of physical activity and cardiovascular symptoms 3 months and 2 years after CABG as compared with the situation prior to the operation. A previous history of hypertension did not seem to affect these results.

Impact of coronary artery bypass grafting on various aspects of quality of life

OBJECTIVE

To prospectively study the improvement in quality of life (QoL) after coronary artery bypass surgery (CABG).

PATIENTS AND METHODS

Consecutive patients (n = 2121) who underwent CABG at Sahlgrenska University Hospital between 1988 and 1991 received 3 questionnaires for the study of QoL: the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index, which were responded both before surgery and at 3 months (n = 1059), 1 year (n = 1045) and 2 years (n = 1027) postoperatively.

RESULTS

All differences were tested against baseline. The Physical Activity Score improved (mean 4.3 before CABG, 3.1, 3 months after (P < 0.0001), and 2.8, 2 years postoperatively (P < 0.0001)). The Nottingham Health Profile score improved (mean 20.5 before CABG, 11.4, 3 months (P < 0.0001), and 10.4, 2 years postoperatively (P < 0.0001)). The Psychological General Well-being Index improved (mean 91.1 before CABG, 103.8, 3 months (P < 0.0001), and 105.8 (P < 0.0001), 2 years after CABG). The subscale analyses of the Nottingham Health Profile and the Psychological General Well-being Index 2 years after CABG showed the greatest improvement in areas reflecting physical capacity and pain, to be followed by mental qualities. At 2 years after CABG only sexual problems were still markedly frequent, and independent predictors for sexual problems after surgery were preoperative problems (P < 0.00001), male sex (P < 0.0001), and diabetes mellitus (P = 0.0008).

CONCLUSION

QoL was markedly and significantly improved after CABG. The major improvement was seen already at 3 months, with further slight improvement observed 2 years after surgery. The major improvement was found in areas reflecting physical capacity and pain, which is consistent with symptomatic and objective measurements after CABG. In contrast to the overall improvement in QoL sexual problems were still markedly common 2 years after CABG. The mechanism for this is not fully understood and needs further investigation.

Limitation of physical activity, dyspnea and chest pain before and two years after coronary artery bypass grafting in relation to sex

AIM

To describe the limitation of physical activity and its causes, and symptoms of dyspnea and chest pain prior to and during two years after coronary artery bypass grafting (CABG) in relation to sex.

METHODS

All patients from western Sweden who underwent CABG between June 1988 and June 1991 were approached with a questionnaire prior to, three months and two years after CABG evaluating the issues raised above.

RESULTS

In all, 2121 patients were operated on, of which 81% were males. Physical activity was significantly improved and symptoms of chest pain and dyspnea were significantly reduced in both men and women after CABG. The improvement was significantly greater in males than in females even after adjustment for preoperative differences between the sexes.

CONCLUSION

There was an improvement for both men and women in terms of limitations for physical activity and cardiovascular symptoms three months and two years after CABG as compared with prior to the operation. Female patients suffered from significantly more symptoms of chest pain and dyspnea and limitations in physical activity after CABG than men, also when adjustment was made for preoperative differences between the sexes.

Improvement in various estimates of quality of life after coronary artery bypass grafting in patients with and without a history of hypertension

OBJECTIVE

To describe various estimates of the quality of life (QOL) prior to and for 2 years after coronary artery bypass grafting (CABG) for patients with a history of hypertension compared with nonhypertensives.

METHODS

Patients in western Sweden in whom CABG had been performed between 1988 and 1991 participated. Their QOL was estimated from the Physical Activity Score, the Nottingham Health Profile, and the Psychological General Well-being Index.

RESULTS

All three questionnaires detected a significant improvement in QOL already at 3 months, which persisted at 1 and 2 years both for hypertensive and for nonhypertensive patients. With the Physical Activity Score and the Psychological General Well-being Index the improvement in QOL of hypertension patients was less marked 3 months after the operation compared with that of nonhypertensives (P < 0.05). Two years after the CABG improvement was less marked for hypertensive patients than it was for nonhypertensive patients in terms of the Physical Activity Score (P < 0.01). With the Nottingham Health Profile the improvement was similar for hypertensive and nonhypertensive patients at each evaluation after the operation. With all three measures the results indicated that hypertensive patients had a worse QOL that did nonhypertensive patients. However, in a multivariate analysis considering other risk indicators simultaneously, a history of hypertension did not appear as an independent risk indicator for an adverse QOL 2 years after CABG.

CONCLUSION

There was a significant improvement in various QOL estimates after CABG both for hypertensive and for nonhypertensive patients. The degree of improvement tended to be less marked for hypertensive patients than it was for nonhypertensive patients, especially 3 months after the operation and concerning physical activities. Hypertensives had a worse QOL than did nonhypertensives. However, the differences were small and could mainly be explained in terms of factors other than hypertension.

Predictors for recurrent chest pain and relationship to myocardial ischaemia during long-term follow-up after coronary artery bypass grafting

OBJECTIVE

To describe the impact of coronary artery bypass grafting on chest pain during 2 years of follow-up after the operation and to identify predictors of chest pain and its relationship to myocardial ischaemia 2 years after the operation.

METHODS

Patients were approached with a questionnaire at the time of coronary angiography (1291) and 3 months (1664), 1 year (1638) and 2 years (1613) after coronary artery bypass grafting. Two years after the operation, a computerised 12-lead electrocardiogram was obtained during a standardised bicycle exercise test (618).

RESULTS

Prior to surgery, 37% of the patients were unable to perform physical activity compared with 6% after the operation (P < 0.0001 for change in degree of limitation). Only 3% had no chest pain at all prior to the operation, while 58% of the patients were free from chest pain 2 years after surgery (P < 0.0001). We found no correlation between patients reporting chest pain and signs of ischaemia at exercise test, but there was a highly significant correlation with chest pain during the exercise test (P < 0.0001). Independent predictors of chest pain were severity of preoperative angina (P < 0.0001), younger age (P = 0.0009), previous coronary artery bypass grafting (P = 0.003), duration of symptoms (P = 0.005), the need for prolonged cardiopulmonary bypass (P = 0.04) and the absence of left main stenosis (P = 0.04).

CONCLUSION

Independent predictors of chest pain were identified 2 years after coronary artery bypass grafting. There was a dramatic improvement after coronary artery bypass grafting. However, almost half the patients complained of some kind of chest pain even after the operation. This chest pain correlated well with chest pain during the exercise test but not with signs of myocardial ischaemia.

Patients discharged from emergency care after acute myocardial infarction was ruled out: early follow-up in relation to gender

The aim of this research was to describe men and women who were discharged from the emergency department after having an initial suspicion of acute myocardial infarction ruled out in terms of patient characteristics, symptom reevaluation, electrocardiogram and exercise stress test. Consecutive patients below the age of 65 years who came to the emergency department of Sahlgrenska Hospital with acute chest pain or other symptoms raising suspicion of acute myocardial infarction for whom the suspicion was ruled out either directly in the emergency department or less than 1 day after hospital admission were included in the study. Four hundred and eighty-four patients participated, of whom 295 (61%) were men. Men had a higher prevalence of ischaemic heart disease. The cause of pain was judged similarly at reevaluation compared with in the emergency department in 53% of the cases. Only in 4.6% of the cases were the symptoms judged to be caused by myocardial ischaemia on both occasions. At the initial visit 36.0% of the patients were judged to have uncertain cause of the symptoms. This proportion was lowered to 26.4% at reevaluation. The exercise electrocardiogram at reevaluation revealed clinical and electrocardiographic signs indicating definite myocardial ischaemia in 2.6% of the cases. Early follow-up of patients discharged from the emergency department after acute myocardial infarction was ruled out revealed that a low proportion showed signs of myocardial ischaemia. In about half of the cases the judgement differed from that being made in the emergency department.

Prediction of left ventricular dysfunction in coronary artery disease from clinical and exercise test findings

We studied the ability to predict depressed left ventricular ejection fraction (LVEF) from clinical and exercise test findings prior to surgery in consecutive patients who underwent coronary artery bypass grafting (CABG) from 1988 to 1991 (n = 663). Multivariate analysis showed a history of myocardial infarction, pathological Q-wave in resting ECG, systolic blood pressure at maximal exercise and the degree of mitral regurgitation as significant independent predictors of impaired LVEF. The relative risk (RR) of depressed LVEF was markedly increased for a previous history of myocardial infarction (RR 3.3, p < 0.0001) and a pathological Q-wave in resting ECG (RR 2.4, p < 0.0001). All associations found between depressed LVEF and exercise test results were poor, and of little value for discriminating patients with depressed LVEF. Thus, clinical data appear to be better markers of low LVEF than the information obtained from the exercise test.

Improvement in quality of life and exercise capacity after coronary bypass surgery

BACKGROUND

Outcome after coronary artery bypass grafting is usually evaluated by exercise stress testing. Increased exercise capacity and reduced angina pectoris have been equated with improved quality of life, but this represents a limited view.

OBJECTIVE

To prospectively evaluate the effects of coronary artery bypass grafting on quality of life and exercise capacity and their interrelationship.

METHODS

In a consecutive series of patients (N = 2365) who underwent coronary artery bypass grafting, we administered a questionnaire to assess quality of life before and 2 years after surgery. A standardized exercise test was performed during the year before surgery and 2 years after. A preoperative exercise test was performed by 726 patients. Among these patients, 462 completed a quality-of-life questionnaire preoperatively and 578 did so postoperatively. Preoperative and postoperative exercise tests were obtained from 362 patients.

RESULTS

The improvement in quality of life was related to the severity of preoperative angina (P < .001) and female sex (P = .004) and was inversely related to preoperative exercise performance (P = .04). The improvement in exercise capacity was greater among men (P < .001) and was inversely related to preoperative exercise capacity (P < .001).

CONCLUSIONS

The greatest improvement in quality of life after coronary artery bypass grafting appeared in those patients with the most impaired exercise capacity, those with the most severe angina pectoris, and women. Improvement in exercise capacity was greatest in patients with the poorest preoperative exercise capacity and in men. These findings indicate that exercise testing is of limited value as a measure of quality of life and that assessment by a questionnaire has a complementary place.

Relationship between quality of life and exercise test findings after coronary artery bypass surgery

We studied the correlation between quality of life and exercise testing in 554 patients 2 years after coronary artery bypass surgery. Quality of life constitutes a person's perceptions of physical and mental functional capacity, health and symptoms. Traditionally, evaluations after coronary bypass surgery have focused on physical performance, medication and anginal symptoms, which cannot be said to represent quality of life. We used the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index for evaluation of quality of life. Significant correlations were found between quality of life and exercise capacity (P < 0.0001), and quality of life and chest pain at exercise for all questionnaires (P < 0.0001). Significant correlations, although of small or moderate magnitude, were found between exercise capacity, chest pain and most subscales of quality of life, with the highest correlation coefficients for dimensions reflecting physical abilities and pain. We conclude that quality of life correlates significantly with exercise capacity and chest pain during exercise 2 years after coronary bypass surgery. However, only dimensions of pain and physical performance are reasonably well correlated with exercise test results. Several aspects of quality of life are only weakly related to exercise test results and may escape identification in an exercise test.

Metoprolol treatment for two years after coronary bypass grafting: effects on exercise capacity and signs of myocardial ischaemia

OBJECTIVE

To evaluate whether prophylactic treatment with metoprolol for two years after coronary artery bypass grafting improves working capacity and reduces the occurrence of myocardial ischaemia in patients with coronary artery disease.

METHODS

After coronary artery bypass grafting, patients were randomised to treatment with metoprolol or placebo for two years. Two years after randomisation, a computerised 12-lead electrocardiogram was obtained during a standardised bicycle exercise test in 618 patients (64% of all those randomised).

RESULTS

The median exercise capacity was 140 W in the metoprolol group (n = 307) and 130 W in the placebo group (n = 311) (P > 0.20). An ST depression of > or = 1 mm at maximum exercise was present in 34% of the patients in the metoprolol group and 38% in the placebo group (P > 0.20) and an ST depression of > or = 2 mm at maximum exercise was present in 11% in the metoprolol group and 16% in the placebo group (P = 0.09). The median values for maximum systolic blood pressure were 200 mm Hg in the metoprolol group and 210 mm Hg in the placebo group (P < 0.0001), while the median values for maximum heart rate were 126 beats/min in the metoprolol group and 143 beats/min in the placebo group (P < 0.0001). The occurrence of cardiac and neurological clinical events two years postoperatively among exercised patients was comparable in the treatment groups.

CONCLUSIONS

Treatment with metoprolol for two years after coronary artery bypass grafting did not significantly change exercise capacity or electrocardiographic signs of myocardial ischaemia.

Influence of patient sex and clinical history on working capacity and myocardial ischemia after coronary artery bypass surgery

BACKGROUND

Coronary artery bypass grafting (CABG) is generally accepted as effective in relieving patients from angina pectoris, and in improving survival in subgroups. However, subset evaluations of myocardial ischemia and exercise capacity after CABG are scarce. The aim of this study was to determine the outcome of CABG in terms of exercise capacity and stress ECG findings in subgroups of patients.

METHODS

A stepwise bicycle exercise ECG (in most cases computerized) was performed on 362 patients within 1 year before and 2 years after CABG.

RESULTS

Exercise capacity increased from a median value of 90 to 130 W (P < 0.0001), more marked (P < 0.0001) in men (100-140 W) than in women (75-90 W). Improvement was not significantly related to age. Occurrence of ST-segment depression at exercise decreased, 76% showing ST-segment depression of at least 1 mm before the operation and 35% (P < 0.0001) 2 years after. Exercise-induced signs of ischemia on ECG did not differ between men and women. Maximum heart rate increased from a median value of 109 to one of 133 beats/min (P < 0.0001), and maximum systolic blood pressure from 170 to 210 mmHg (P < 0.0001). Termination of exercise because of chest pain decreased from 48 to 6% (P < 0.0001). Most subsets of patients improved exercise capacity with a reduction of ST-segment depression irrespective of their previous history and manifestations of cardiovascular disease.

CONCLUSIONS

CABG caused a marked increase in exercise capacity and reduced signs of myocardial ischemia. Although men increased their working capacity by a greater extent than women, reduction in signs of myocardial ischemia was similar in both sexes.