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Riva G, Boberg E, Ringh M, Jonsson M, Claesson A, Nord A, Rubertsson S, Blomberg H, Nordberg P, Forsberg S, Rosenqvist M, Svensson L, Andréll C, Herlitz J, Hollenberg J. Compression-Only or Standard Cardiopulmonary Resuscitation for Trained Laypersons in Out-of-Hospital Cardiac Arrest: A Nationwide Randomized Trial in Sweden. Circ Cardiovasc Qual Outcomes 2024; 17:e010027. [PMID: 38445487 DOI: 10.1161/circoutcomes.122.010027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 11/08/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND The ongoing TANGO2 (Telephone Assisted CPR. AN evaluation of efficacy amonGst cOmpression only and standard CPR) trial is designed to evaluate whether compression-only cardiopulmonary resuscitation (CPR) by trained laypersons is noninferior to standard CPR in adult out-of-hospital cardiac arrest. This pilot study assesses feasibility, safety, and intermediate clinical outcomes as part of the larger TANGO2 survival trial. METHODS Emergency medical dispatch calls of suspected out-of-hospital cardiac arrest were screened for inclusion at 18 dispatch centers in Sweden between January 1, 2017, and March 12, 2020. Inclusion criteria were witnessed event, bystander on the scene with previous CPR training, age above 18 years of age, and no signs of trauma, pregnancy, or intoxication. Cases were randomized 1:1 at the dispatch center to either instructions to perform compression-only CPR (intervention) or instructions to perform standard CPR (control). Feasibility included evaluation of inclusion, randomization, and adherence to protocol. Safety measures were time to emergency medical service dispatch CPR instructions, and to start of CPR, intermediate clinical outcome was defined as 1-day survival. RESULTS Of 11 838 calls of suspected out-of-hospital cardiac arrest screened for inclusion, 2168 were randomized and 1250 (57.7%) were out-of-hospital cardiac arrests treated by the emergency medical service. Of these, 640 were assigned to intervention and 610 to control. Crossover from intervention to control occurred in 16.3% and from control to intervention in 18.5%. The median time from emergency call to ambulance dispatch was 1 minute and 36 s (interquartile range, 1.1-2.2) in the intervention group and 1 minute and 30 s (interquartile range, 1.1-2.2) in the control group. Survival to 1 day was 28.6% versus 28.4% (P=0.984) for intervention and control, respectively. CONCLUSIONS In this national randomized pilot trial, compression-only CPR versus standard CPR by trained laypersons was feasible. No differences in safety measures or short-term survival were found between the 2 strategies. Efforts to reduce crossover are important and may strengthen the ongoing main trial that will assess differences in long-term survival. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02401633.
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Affiliation(s)
- Gabriel Riva
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden (G.R., E.B., M. Ringh, M.J., A.C., A.N., P.N., S.F., M. Rosenqvist, J. Hollenberg)
- Department of Cardiology, S:t Göran's Hospital, Stockholm, Sweden (G.R.)
| | - Erik Boberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden (G.R., E.B., M. Ringh, M.J., A.C., A.N., P.N., S.F., M. Rosenqvist, J. Hollenberg)
| | - Mattias Ringh
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden (G.R., E.B., M. Ringh, M.J., A.C., A.N., P.N., S.F., M. Rosenqvist, J. Hollenberg)
| | - Martin Jonsson
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden (G.R., E.B., M. Ringh, M.J., A.C., A.N., P.N., S.F., M. Rosenqvist, J. Hollenberg)
| | - Andreas Claesson
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden (G.R., E.B., M. Ringh, M.J., A.C., A.N., P.N., S.F., M. Rosenqvist, J. Hollenberg)
| | - Anette Nord
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden (G.R., E.B., M. Ringh, M.J., A.C., A.N., P.N., S.F., M. Rosenqvist, J. Hollenberg)
| | - Sten Rubertsson
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Uppsala University, Sweden (S.R., H.B.)
| | - Hans Blomberg
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Uppsala University, Sweden (S.R., H.B.)
| | - Per Nordberg
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Uppsala University, Sweden (S.R., H.B.)
| | - Sune Forsberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden (G.R., E.B., M. Ringh, M.J., A.C., A.N., P.N., S.F., M. Rosenqvist, J. Hollenberg)
| | - Mårten Rosenqvist
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden (G.R., E.B., M. Ringh, M.J., A.C., A.N., P.N., S.F., M. Rosenqvist, J. Hollenberg)
| | - Leif Svensson
- Department of Medicine, Solna Karolinska Institutet, Stockholm, Sweden (L.S.)
| | - Cecilia Andréll
- Department of Anesthesiology and Intensive Care, Lund University, Sweden (C.A.)
| | - Johan Herlitz
- Department of Caring Science, University of Borås, Sweden (J. Herlitz)
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Stockholm, Sweden (G.R., E.B., M. Ringh, M.J., A.C., A.N., P.N., S.F., M. Rosenqvist, J. Hollenberg)
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Lapidus O, Jonsson M, Svensson L, Hollenberg J, Berglund E, Riva G, Claesson A, Nordberg P, Rosenqvist M, Forsberg S, Nord A, Ringh M. Effects of a volunteer responder system for out-of-hospital cardiac arrest in areas of different population density - A retrospective cohort study. Resuscitation 2023; 191:109921. [PMID: 37543160 DOI: 10.1016/j.resuscitation.2023.109921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/26/2023] [Accepted: 07/26/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Volunteer responder dispatch to nearby out-of-hospital cardiac arrests using a smartphone application can increase the proportion of patients receiving cardiopulmonary resuscitation. It is unknown how population density is related to the efficacy of a volunteer responder system. This study aimed to compare the response time of volunteer responders and EMS dispatched to suspected OHCAs in areas of different population density. METHODS A total of 2630 suspected OHCAs in Stockholm County during 2018-2020 where at least one dispatched volunteer responder reached the patient were identified through the HeartRunner™ application database. Study outcome was the proportion of cases where volunteer responders arrived at the scene before EMS, as well as the difference in time between the arrival of volunteer responders and EMS. RESULTS Volunteer responders arrived before EMS in 68% of examined cases (n = 1613). Higher population density was associated with a lower proportion of cases where volunteer responders arrived at the scene before EMS. Time on scene before arrival of EMS was highest in areas of low population density and averaged 4:07 (mm:ss). Response time was significantly shorter for volunteer responders compared to EMS across all population density groups at 4:47 vs 8:11 (mm:ss) (p < 0.001); the largest difference in response time was found in low population density areas. CONCLUSION Volunteer responders have significantly shorter response time than EMS regardless of population density, with the greatest difference in low population density areas. Although their impact on clinical outcome remains unknown, the benefits of dispatching volunteer responders to OHCAs may be greatest in rural areas.
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Affiliation(s)
- Oscar Lapidus
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
| | - Martin Jonsson
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Leif Svensson
- Department of Medicine, Karolinska Institutet, Solna, Sweden
| | - Jacob Hollenberg
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Ellinor Berglund
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Gabriel Riva
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Andreas Claesson
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Per Nordberg
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Mårten Rosenqvist
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
| | - Sune Forsberg
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Anette Nord
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Mattias Ringh
- Center for Resuscitation Science, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
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Scorza R, Jonsson M, Corander JM, Rosenqvist M, Frykman V. Prognostic impact of morphology and duration of premature ventricular contractions in a population without structural heart disease. Ann Noninvasive Electrocardiol 2023:e13067. [PMID: 37326286 DOI: 10.1111/anec.13067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 05/03/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Premature ventricular contractions (PVCs) are a common form of arrhythmia associated with an unfavorable prognosis in patients with structural heart disease. It is unclear whether PVCs site of origin and QRS-width has a prognostic significance in patients without structural heart disease. The aim of this study was to assess the prognostic importance of PVCs morphology and duration in this patient group. METHODS We included 511 consecutive patients without a history of previous heart disease. They were examined with echocardiography and exercise test with normal findings. We categorized the PVCs from a 12 lead ECG according to morphology and width of the QRS-complex and analyzed the outcome in terms of a composite endpoint of total mortality and cardiovascular morbidity. RESULTS During a median follow-up time of 5.3 years, 19 patients (3.5%) died and 61 (11.3%) met the composite outcome. Patients with PVCs originating from the outflow tracts had a significantly lower risk for the composite outcome compared to patients with non-OT-PVCs. Similarly, patients with PVC originating from the right ventricle had a better outcome than patients with left ventricular PCVs. No difference in outcome depending on QRS-width during PVCs was noticed. CONCLUSION In our cohort of consecutively included PVC patients without structural heart disease PVCs from the outflow tracts were associated with a better prognostic outcome than non-OT PVCs; the same was true for right ventricular PVCs when compared to left ventricular ones. The classification of the origin of the PVCs was based on 12-lead ECG morphology. QRS-width during PVC did not seem to have prognostic significance.
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Affiliation(s)
- Raffaele Scorza
- Cardiovascular Unit, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Martin Jonsson
- Department for Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - John-Martin Corander
- Cardiovascular Unit, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Cardiovascular Unit, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Viveka Frykman
- Cardiovascular Unit, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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Engdahl J, Gudmundsdottir KK, Rosenqvist M. Screening for atrial fibrillation: all invitees are equal, but some are more equal than others? Europace 2023:7163937. [PMID: 37191126 DOI: 10.1093/europace/euad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Affiliation(s)
- Johan Engdahl
- Karolinska Institutet, Department of Clinical Sciences, Danderyd University Hospital, Entrévägen, SE-18288 Stockholm, Sweden
| | - Katrin Kemp Gudmundsdottir
- Karolinska Institutet, Department of Clinical Sciences, Danderyd University Hospital, Entrévägen, SE-18288 Stockholm, Sweden
| | - Mårten Rosenqvist
- Karolinska Institutet, Department of Clinical Sciences, Danderyd University Hospital, Entrévägen, SE-18288 Stockholm, Sweden
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Berglund E, Hollenberg J, Jonsson M, Svensson L, Claesson A, Nord A, Nordberg P, Forsberg S, Rosenqvist M, Lundgren P, Högstedt Å, Riva G, Ringh M. Effect of Smartphone Dispatch of Volunteer Responders on Automated External Defibrillators and Out-of-Hospital Cardiac Arrests: The SAMBA Randomized Clinical Trial. JAMA Cardiol 2023; 8:81-88. [PMID: 36449309 PMCID: PMC9713680 DOI: 10.1001/jamacardio.2022.4362] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022]
Abstract
Importance Smartphone dispatch of volunteer responders to nearby out-of-hospital cardiac arrests (OHCAs) has emerged in several emergency medical services, but no randomized clinical trials have evaluated the effect on bystander use of automated external defibrillators (AEDs). Objective To evaluate if bystander AED use could be increased by smartphone-aided dispatch of lay volunteer responders with instructions to collect nearby AEDs compared with instructions to go directly to patients with OHCAs to start cardiopulmonary resuscitation (CPR). Design, Setting, and Participants This randomized clinical trial assessed a system for smartphone dispatch of volunteer responders to individuals experiencing OHCAs that was triggered at emergency dispatch centers in response to suspected OHCAs and randomized 1:1. The study was conducted in 2 main Swedish regions: Stockholm and Västra Götaland between December 2018 and January 2020. At study start, there were 3123 AEDs in Stockholm and 3195 in Västra Götaland and 24 493 volunteer responders in Stockholm and 19 117 in Västra Götaland. All OHCAs in which the volunteer responder system was activated by dispatchers were included. Excluded were patients with no OHCAs, those with OHCAs not treated by the emergency medical services, and those with OHCAs witnessed by the emergency medical services. Interventions Volunteer responders were alerted through the volunteer responder system smartphone application and received map-aided instructions to retrieve nearest available public AEDs on their way to the OHCAs. The control arm included volunteer responders who were instructed to go directly to the OHCAs to perform CPR. Main Outcomes and Measures Overall bystander AED attachment, including those attached by volunteer responders and lay volunteers who did not use the smartphone application. Results Volunteer responders were activated for 947 patients with OHCAs. Of those, 461 were randomized to the intervention group (median [IQR] age of patients, 73 [61-81] years; 295 male patients [65.3%]) and 486 were randomized to the control group (median [IQR] age of patients, 73 [63-82] years; 312 male patients [65.3%]). Primary outcome of AED attachment occurred in 61 patients (13.2%) in the intervention arm vs 46 patients (9.5%) in the control arm (difference, 3.8% [95% CI, -0.3% to 7.9%]; P = .08). The majority of AEDs were attached by lay volunteers who were not using the smartphone application (37 in intervention arm, 28 in control). There were no significant differences in secondary outcomes. Among the volunteer responders using the application, crossover was 11% and compliance to instructions was 31%. Volunteer responders attached 38% (41 of 107) of all AEDs and provided 45% (16 of 36) of all defibrillations and 43% (293 of 666) of all CPR. Conclusions and Relevance In this study, smartphone dispatch of volunteer responders to OHCAs to retrieve nearby AEDs vs instructions to directly perform CPR did not significantly increase volunteer AED use. High baseline AED attachement rate and crossover may explain why the difference was not significant. Trial Registration ClinicalTrials.gov Identifier: NCT02992873.
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Affiliation(s)
- Ellinor Berglund
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Martin Jonsson
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Leif Svensson
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Claesson
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Anette Nord
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Per Nordberg
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Sune Forsberg
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Peter Lundgren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Prehospen–Centre for Prehospital Research, University of Borås, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Cardiology, Gothenburg, Sweden
| | - Åsa Högstedt
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
- Prehospen–Centre for Prehospital Research, University of Borås, Sweden
| | - Gabriel Riva
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Ringh
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
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Lyth J, Svennberg E, Bernfort L, Aronsson M, Frykman V, Al-Khalili F, Friberg L, Rosenqvist M, Engdahl J, Levin LÅ. Cost-effectiveness of population screening for atrial fibrillation: the STROKESTOP study. Eur Heart J 2022; 44:196-204. [PMID: 36349968 PMCID: PMC9839418 DOI: 10.1093/eurheartj/ehac547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 08/24/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Previous studies on the cost-effectiveness of screening for atrial fibrillation (AF) are based on assumptions of long-term clinical effects. The STROKESTOP study, which randomised 27 975 persons aged 75/76 years into a screening invitation group and a control group, has a median follow-up time of 6.9 years. The aim of this study was to estimate the cost-effectiveness of population-based screening for AF using clinical outcomes. METHODS AND RESULTS The analysis is based on a Markov cohort model. The prevalence of AF, the use of oral anticoagulation, clinical event data, and all-cause mortality were taken from the STROKESTOP study. The cost for clinical events, age-specific utilities, utility decrement due to stroke, and stroke death was taken from the literature. Uncertainty in the model was considered in a probabilistic sensitivity analysis. Per 1000 individuals invited to the screening, there were 77 gained life years and 65 gained quality-adjusted life years. The incremental cost was €1.77 million lower in the screening invitation group. Gained quality-adjusted life years to a lower cost means that the screening strategy was dominant. The result from 10 000 Monte Carlo simulations showed that the AF screening strategy was cost-effective in 99.2% and cost-saving in 92.7% of the simulations. In the base-case scenario, screening of 1000 individuals resulted in 10.6 [95% confidence interval (CI): -22.5 to 1.4] fewer strokes (8.4 ischaemic and 2.2 haemorrhagic strokes), 1.0 (95% CI: -1.9 to 4.1) more cases of systemic embolism, and 2.9 (95% CI: -18.2 to 13.1) fewer bleedings associated with hospitalization. CONCLUSION Based on the STROKESTOP study, this analysis shows that a broad AF screening strategy in an elderly population is cost-effective. Efforts should be made to increase screening participation.
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Affiliation(s)
- Johan Lyth
- Corresponding authors. Tel: +46739584822, (E.S.); Tel: +46 13 28 29 84, (J.L.)
| | - Emma Svennberg
- Corresponding authors. Tel: +46739584822, (E.S.); Tel: +46 13 28 29 84, (J.L.)
| | - Lars Bernfort
- Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 83 Linköping, Sweden
| | - Mattias Aronsson
- Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 83 Linköping, Sweden,AstraZeneca Nordics, SE-18257 Södertälje, Sweden
| | - Viveka Frykman
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Faris Al-Khalili
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Leif Friberg
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
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Scorza R, Jonsson M, Friberg L, Rosenqvist M, Frykman V. Prognostic implication of premature ventricular contractions in patients without structural heart disease. Europace 2022; 25:517-525. [PMID: 36261245 PMCID: PMC9935042 DOI: 10.1093/europace/euac184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 09/08/2022] [Indexed: 02/04/2023] Open
Abstract
AIMS Premature ventricular contractions (PVCs) are a common form of arrhythmia associated with an unfavourable prognosis in patients with structural heart disease. However, the prognostic significance in absence of heart disease is debated. With this study, we aim to investigate whether subjects with PVC, without structural heart disease, have a worse prognosis than the general population. METHODS AND RESULTS Patients evaluated for PVC at a secondary care centre in Stockholm County from January 2010 to December 2016 were identified. We included patients without history of previous heart disease who had undergone echocardiography and exercise test with normal findings. Based on sex and age, we matched the PVC cohort to a four times bigger control group from the general population and compared the outcome in terms of mortality and cardiovascular morbidity during a median follow-up time of 5.2 years. We included 820 patients and 3,264 controls. Based on a non-inferiority analysis, the PVC group did not have a higher mortality than the control group (0.44, CI 0.27-0.72). Sensitivity analysis with propensity score matching confirmed this result. CONCLUSIONS PVC patients, who after thorough evaluation showed no signs of structural heart disease, did not have a worse prognosis when compared to an age- and sex- control group based on the general population.
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Affiliation(s)
| | - Martin Jonsson
- Department for Clinical Science and Education, Karolinska Institutet,
Södersjukhuset, Center for Resuscitation Science,
Stockholm, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Karolinska Institutet, Cardiovascular
Unit, Danderyd University Hospital, Stockholm,
Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Karolinska Institutet, Cardiovascular
Unit, Danderyd University Hospital, Stockholm,
Sweden
| | - Viveka Frykman
- Department of Clinical Sciences, Karolinska Institutet, Cardiovascular
Unit, Danderyd University Hospital, Stockholm,
Sweden
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Scorza R, Shahgaldi K, Rosenqvist M, Frykman V. Evaluation of patients with high burden of premature ventricular contractions by comprehensive transthoracic echocardiography. IJC Heart & Vasculature 2022; 42:101124. [PMID: 36161233 PMCID: PMC9489744 DOI: 10.1016/j.ijcha.2022.101124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 09/05/2022] [Accepted: 09/12/2022] [Indexed: 11/28/2022]
Abstract
Background The prevalence and prognosis of premature ventricular contractions (PVCs) among individuals without structural heart disease are uncertain. Standard transthoracic echocardiography is a common method in evaluation of underlying cardiovascular disease and is recommended as a diagnostic method in PVC patients. However, it is unclear whether comprehensive echocardiographic examination can identify pathological findings in PVC patients with a normal standard echocardiogram. Method We included forty consecutive patients with a high PVC burden (>10,000 PVCs/day) and normal findings at a standard echocardiogram and exercise test. All subjects were investigated by a comprehensive echocardiographic examination using parameters usually not included in a routine work-up. We compared the results with 22 age and sex-matched controls. Results In six additional parameters–global longitudinal strain, right ventricular strain, septal-lateral delay, ventricular-arterial coupling, integrated backscatter and left atrial activation time–a statistically significant difference was shown between PVC patients and controls. Among these parameters, global longitudinal strain had a high reliability between operators. Conclusions Despite normal findings at standard echocardiography, the PVC group showed signs of impaired heart function when more comprehensive echocardiography parameters were used.
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Lee C, Rosenqvist M, Mandrola J. Screening for Atrial Fibrillation in Asymptomatic Older Adults. N Engl J Med 2022; 387:565-567. [PMID: 35947715 DOI: 10.1056/nejmclde2203726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Fernstad J, Svennberg E, Aberg P, Kemp-Gudmundsdottir K, Jansson A, Rosenqvist M, Engdahl J. Validation of a novel smartphone-based photoplethysmographic method for ambulatory heart rhythm diagnostics. Europace 2022. [DOI: 10.1093/europace/euac053.578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Vinnova - The Swedish Agency for Innovation Systems.
Region Stockholm Innovation Fund.
Introduction
Devices for long-term and ambulatory recording of heart rhythm have limited availability within health care systems worldwide, potentially leading to missed diagnoses and limitations in peri-procedural heart rhythm management. As smartphones are becoming ubiquitous the availability of heart rhythm diagnostics and management of atrial fibrillation (AF) using smartphone photoplethysmography (PPG) compared to electrocardiography (ECG) is increasing. Previous validation studies of smartphone-PPG applications have all been performed under supervision in healthcare settings. In addition, no previous study has validated smartphone-PPG compared to simultaneous ECG recordings, with manual heart rhythm interpretation of the PPG recordings nor have they included patients with atrial flutter (AFL).
Purpose
The aim of this study was to validate a novel smartphone-PPG method for heart rhythm diagnostics in patients with AF and/or AFL when in use unsupervised in an ambulatory setting.
Methods
Unselected patients undergoing direct current cardioversion at a University Hospital for treatment of AF or AFL were asked to perform one-minute heart rhythm recordings post-treatment at least twice daily for 30 days in their home environment. All included were provided with an unmodified iPhone 7 smartphone running the CORAI Heart Monitor PPG application simultaneously with a single-lead ECG recording (KardiaMobile). PPG and ECG recordings were interpreted independently by two readers.
Results
In total 280 patients, with median age of 69.0 years (31% women) were included from November 2018 to July 2020 and registered 18 005 simultaneous PPG and ECG recordings. Of the PPG recordings 96.9% had sufficient quality for diagnosis compared to 95.1% of the ECG recordings (p < 0.001). Precardioversion ECG recordings were interpreted as AF in 82.1%, AFL in 14.3% and as having insufficient quality for diagnosis in 3.6% of the patients. After removal of recordings with insufficient quality 69.7% of ECG recordings were interpreted as sinus rhythm, 28.2% as AF and 2.1 % as AFL. Manual interpretation of the PPG recordings diagnosed AF/AFL (sensitivity) in 97.7% and sinus rhythm (specificity) in 99.4% of the recordings compared to manually interpreted ECG recordings, with an overall accuracy of 98.9%. Results excluding recordings interpreted as AFL on ECG or PPG diagnosed AF (sensitivity) in 99.0% and sinus rhythm (specificity) in 99.7% of the recordings, with an overall accuracy of 99.5%.
Conclusion
A novel smartphone-PPG method can be used by patients unsupervised in their home environment for accurate heart rhythm diagnostics of AF and AFL with high sensitivity and specificity.
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Affiliation(s)
- J Fernstad
- Karolinska Institutet, Dept of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - E Svennberg
- Karolinska Institutet, Dept of Medicine, Huddinge, Karolinska University Hospital, Stockholm, Sweden
| | - P Aberg
- Karolinska Institutet, Dept of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - K Kemp-Gudmundsdottir
- Karolinska Institutet, Dept of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - A Jansson
- Karolinska Institutet, Dept of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - M Rosenqvist
- Karolinska Institutet, Dept of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - J Engdahl
- Karolinska Institutet, Dept of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
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Ghazal F, Aronsson M, Al-Khalili F, Rosenqvist M, Levin LÅ. Cost-effectiveness of screening for atrial fibrillation in a single primary care center at a 3-year follow-up. SCAND CARDIOVASC J 2022; 56:35-41. [PMID: 35389311 DOI: 10.1080/14017431.2022.2060523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The aim of this study was to estimate the cost-effectiveness of intermittent electrocardiogram (ECG) screening for atrial fibrillation (AF) among 70-74-year old individuals in primary care. We also aimed to assess adherence to anticoagulants, severe bleeding, stroke and mortality among screening-detected AF cases at three-year follow-up. METHODS A post hoc analysis based on a cross-sectional screening study for AF among 70-74-year old patients, who were registered at a single primary care center, was followed for three years for mortality. Data about adherence to anticoagulants, incidence of stroke and severe bleeding among screening-detected AF cases, were collected from patient's records. Markov model and Monte Carlo simulation were used to assess the cost-effectiveness of the screening program. RESULTS The mortality rate among screening-detected AF cases (n = 16) did not differ compared to the 274 individuals with no AF (hazard ratio 0.86, CI 0.12-6.44). Adherence to anticoagulants was 92%. There was no stroke or severe bleeding. The incremental cost-effectiveness ratio of screening versus no screening was EUR 2389/quality-adjusted life year (QALY) gained. The screening showed a 99% probability of being cost-effective compared to no screening at a willingness-to-pay threshold of EUR 20,000 per QALY. CONCLUSION Screening for AF among 70-74-year olds in primary care using intermittent ECG appears to be cost-effective at 3-year follow-up with high anticoagulants adherence and no increased mortality.
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Affiliation(s)
- Faris Ghazal
- Department of Clinical Science, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Aronsson
- Department of Health Care Analysis and Department of Medical and Health Sciences, Linkopings Universitet, Linkoping, Sweden.,AstraZeneca, Sodertalje, Sweden
| | - Faris Al-Khalili
- Department of Clinical Science, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Science, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lars-Åke Levin
- Department of Health Care Analysis and Department of Medical and Health Sciences, Linkopings Universitet, Linkoping, Sweden
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12
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Rivard L, Friberg L, Conen D, Healey JS, Berge T, Boriani G, Brandes A, Calkins H, Camm AJ, Yee Chen L, Lluis Clua Espuny J, Collins R, Connolly S, Dagres N, Elkind MSV, Engdahl J, Field TS, Gersh BJ, Glotzer TV, Hankey GJ, Harbison JA, Haeusler KG, Hills MT, Johnson LSB, Joung B, Khairy P, Kirchhof P, Krieger D, Lip GYH, Løchen ML, Madhavan M, Mairesse GH, Montaner J, Ntaios G, Quinn TJ, Rienstra M, Rosenqvist M, Sandhu RK, Smyth B, Schnabel RB, Stavrakis S, Themistoclakis S, Van Gelder IC, Wang JG, Freedman B. Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration. Circulation 2022; 145:392-409. [PMID: 35100023 DOI: 10.1161/circulationaha.121.055018] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.
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Affiliation(s)
- Léna Rivard
- Montreal Heart Institute, Université de Montréal, Canada (L.R., P. Khairy)
| | - Leif Friberg
- Karolinska Institute, Stockholm, Sweden (L.F., M.R.)
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (D.C., J.S.H., S.C.)
| | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (D.C., J.S.H., S.C.)
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy (G.B.)
| | | | | | - A John Camm
- Cardiovascular Clinical Academic Group, St Georges Hospital, London, UK (A.J.C.)
| | | | | | | | - Stuart Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (D.C., J.S.H., S.C.)
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Germany (N.D.)
| | | | - Johan Engdahl
- Karolinska Institutet, Department of Clinical Sciences, Danderyds Hospital, Stockholm, Sweden (J.E.)
| | - Thalia S Field
- University of British Columbia, Vancouver Stroke Program, Canada (T.S.F.)
| | | | | | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia (G.J.H.)
| | | | - Karl G Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Germany (K.G.H.)
| | | | | | - Boyoung Joung
- Yonsei University College of Medicine, Seoul, South Korea (B.J.)
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Canada (L.R., P. Khairy)
| | - Paulus Kirchhof
- University Heart and Vascular Center UKE Hamburg, Germany (P. Kirchhof)
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Germany (P. Kirchhof)
- Institute of Cardiovascular Sciences, University of Birmingham, UK, and AFNET, Münster, Germany (P. Kirchhof)
| | - Derk Krieger
- University Hospital of Zurich, Switzerland (D.K.)
| | | | - Maja-Lisa Løchen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø (M.L.L.)
| | - Malini Madhavan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (M.M.)
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain (J.M.)
- Stroke Research Program, Institute of Biomedicine of Seville, Spain (J.M.)
- IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville, Spain (J.M.)
- Department of Neurology, Hospital Universitario Virgen Macarena, Seville, Spain (J.M.)
| | | | | | - Michiel Rienstra
- Karolinska Institute, Stockholm, Sweden (L.F., M.R.)
- University of Groningen, University Medical Center Groningen, the Netherlands (M.R., I.C.V.G.)
| | | | | | - Breda Smyth
- Department of Public Health, Health Service Executive West, Galway, Ireland (B.S.)
| | | | | | | | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, the Netherlands (M.R., I.C.V.G.)
| | - Ji-Guang Wang
- Jiaotong University School of Medicine, China (J.G.W.)
| | - Ben Freedman
- Charles Perkins Centre and Concord Hospital Cardiology, University of Sydney, Australia (B.F.)
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13
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Pennlert J, Rosenqvist M, Kesek M. Detection of paroxysmal atrial fibrillation in 994 patients with a cerebrovascular event by intermittent 21-day ECG-monitoring and 7-day continuous Holter-recording. Ups J Med Sci 2022; 127:8318. [PMID: 35722185 PMCID: PMC9169544 DOI: 10.48101/ujms.v127.8318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 04/02/2022] [Accepted: 04/02/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The detection of paroxysmal atrial fibrillation (AF) is of importance in stroke care. The method used is continuous electrocardiogram (ECG)-monitoring or multiple short ECG-recordings during an extended period. Their relative efficiency is a matter of discussion. In a retrospective cohort study on 994 patients with an ischemic stroke or transient ischemic attack (TIA), we have compared continuous 7-day monitoring to intermittent recording 60 sec three times daily with a handheld device during 3 weeks. We related the result to subsequent occurrence of AF as detected in 12-lead ECG recordings. METHODS The patients were identified in the local database of cardiovascular investigations. Their clinical profile and vital status during the follow-up were obtained from the Swedish Stroke Register and the Swedish general population registry. For comparison, we used an age- and sex-matched population with no known cerebrovascular event and a population with a cerebrovascular event that was not screened. RESULTS AF was detected in 7.1% by continuous screening and in 5.1% by intermittent screening (P = 0.3). During follow-up of 32 months, AF in 12-lead ECG was found in 7.0%. In the subgroup with positive screening, 46.3% had AF compared with 6.7% in the subgroup with negative screening (P < 0.0001). CONCLUSIONS The two screening approaches had a similar yield of arrhythmia, in spite of the group with intermittent monitoring having a more favorable clinical profile. A positive screening was highly predictive of AF in ECG during the follow-up.
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Affiliation(s)
- Johanna Pennlert
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Mårten Rosenqvist
- Danderyd University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Milos Kesek
- Department of Public Health and Clinical Medicine and Heart Center, Umeå University, Umeå, Sweden
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14
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Svennberg E, Friberg L, Frykman V, Al-Khalili F, Engdahl J, Rosenqvist M. Clinical outcomes in systematic screening for atrial fibrillation (STROKESTOP): a multicentre, parallel group, unmasked, randomised controlled trial. Lancet 2021; 398:1498-1506. [PMID: 34469764 DOI: 10.1016/s0140-6736(21)01637-8] [Citation(s) in RCA: 143] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/03/2021] [Accepted: 07/08/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation is a leading cause of ischaemic stroke. Early detection of atrial fibrillation can enable anticoagulant therapy to reduce ischaemic stroke and mortality. In this randomised study in an older population, we aimed to assess whether systematic screening for atrial fibrillation could reduce mortality and morbidity compared with no screening. METHODS STROKESTOP was a multicentre, parallel group, unmasked, randomised controlled trial done in Halland and Stockholm in Sweden. All 75-76-year-olds residing in these two regions were randomly assigned (1:1) to be invited to screening for atrial fibrillation or to a control group. Participants attended local screening centres and those without a history of atrial fibrillation were asked to register intermittent electrocardiograms (ECGs) for 14 days. Treatment with oral anticoagulants was offered if atrial fibrillation was detected or untreated. All randomly assigned individuals were followed up in the intention-to-treat analysis for a minimum of 5 years for the primary combined endpoint of ischaemic or haemorrhagic stroke, systemic embolism, bleeding leading to hospitalisation, and all-cause death. This trial is registered with ClinicalTrials.gov, NCT01593553. FINDINGS From March 1, 2012, to May 28, 2014, 28 768 individuals were assessed for eligibility and randomly assigned to be invited to screening (n=14 387) or the control group (n=14 381). 408 individuals were excluded from the intervention group and 385 were excluded from the control group due to death or migration before invitation. There was no loss to follow-up. Of those invited to screening, 7165 (51·3%) of 13 979 participated. After a median follow-up of 6·9 years (IQR 6·5-7·2), significantly fewer primary endpoint events occurred in the intervention group (4456 [31·9%] of 13 979; 5·45 events per 100 years [95% CI 5·52-5·61]) than in the control group (4616 [33·0%] of 13 996; 5·68 events per 100 years [5·52-5·85]; hazard ratio 0·96 [95% CI 0·92-1·00]; p=0·045). INTERPRETATION Screening for atrial fibrillation showed a small net benefit compared with standard of care, indicating that screening is safe and beneficial in older populations. FUNDING Stockholm County Council, the Swedish Heart & Lung Foundation, King Gustav V and Queen Victoria's Freemasons' Foundation, the Klebergska Foundation, the Tornspiran Foundation, the Scientific Council of Halland Region, the Southern Regional Healthcare Committee, the Swedish Stroke Fund, Carl Bennet AB, Boehringer Ingelheim, Bayer, and Bristol Myers Squibb-Pfizer.
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Affiliation(s)
- Emma Svennberg
- Karolinska Institutet, Department of Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden.
| | - Leif Friberg
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
| | - Viveka Frykman
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
| | - Faris Al-Khalili
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
| | - Johan Engdahl
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Karolinska Institutet, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd University Hospital, Stockholm, Sweden
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15
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Scorza R, Jansson A, Sörensson P, Rosenqvist M, Frykman V. Magnetic Resonance Detects Structural Heart Disease in Patients with Frequent Ventricular Ectopy and Normal Echocardiographic Findings. Diagnostics (Basel) 2021; 11:1505. [PMID: 34441439 PMCID: PMC8392672 DOI: 10.3390/diagnostics11081505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/16/2021] [Accepted: 08/19/2021] [Indexed: 02/02/2023] Open
Abstract
The prognosis of patients with ventricular ectopy and a normal heart, as evaluated by echocardiography, is virtually unknown. Cardiac magnetic resonance (CMR) can detect focal ventricular anomalies that could act as a possible site of origin for premature ventricular contractions (PVCs). The aim of this study was to investigate the presence of cardiac anomalies in patients with normal findings at echocardiogram. METHODS Fifty-one consecutive patients (23 women, 28 men, mean age 59 years) with very high PVC burden (>10,000 PVC/day) and normal findings at standard echocardiography and exercise test were examined with CMR. The outcome was pathologic findings, defined as impaired ejection fraction, regional wall motion abnormalities, abnormal ventricular volume, myocardial edema and fibrosis. RESULTS Sixteen out of 51 patients (32%) had structural ventricular abnormalities at CMR. In five patients CMR showed impairment of the left ventricular and/or right ventricular systolic function, and six patients had a dilated left and/or right ventricle. Regional wall motion abnormalities were seen in six patients and fibrosis in four. No patient had CMR signs of edema or met CMR criteria for arrhythmogenic right ventricular cardiomyopathy. Five patients had extra-ventricular findings (enlarged atria in three cases, enlarged thoracic aorta in one case and pericardial effusion in one case). CONCLUSIONS In this study 16 out of 51 patients with a high PVC burden and normal findings at echocardiography showed signs of pathology in the ventricles with CMR. These findings indicate that CMR should be considered in evaluating patients with a high PVC burden and a normal standard investigation.
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Affiliation(s)
- Raffaele Scorza
- Cardiovascular Unit, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, 18288 Stockholm, Sweden; (A.J.); (M.R.); (V.F.)
| | - Anders Jansson
- Cardiovascular Unit, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, 18288 Stockholm, Sweden; (A.J.); (M.R.); (V.F.)
| | - Peder Sörensson
- Department of Medicine, Solna, Karolinska University Hospital, Karolinska Institutet, 17177 Stockholm, Sweden;
| | - Mårten Rosenqvist
- Cardiovascular Unit, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, 18288 Stockholm, Sweden; (A.J.); (M.R.); (V.F.)
| | - Viveka Frykman
- Cardiovascular Unit, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, 18288 Stockholm, Sweden; (A.J.); (M.R.); (V.F.)
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Gibbs H, Freedman B, Rosenqvist M, Virdone S, Mahmeed WA, Ambrosio G, Camm AJ, Jacobson B, Jerjes-Sanchez C, Kayani G, Oto A, Panchenko E, Ragy H, Kakkar AK. Clinical Outcomes in Asymptomatic and Symptomatic Atrial Fibrillation Presentations in GARFIELD-AF: Implications for AF Screening. Am J Med 2021; 134:893-901.e11. [PMID: 33607088 DOI: 10.1016/j.amjmed.2021.01.017] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asymptomatic atrial fibrillation is often detected incidentally. Prognosis and optimal therapy for asymptomatic compared with symptomatic atrial fibrillation is uncertain. This study compares clinical characteristics, treatment, and 2-year outcomes of asymptomatic and symptomatic atrial fibrillation presentations. METHODS Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) is a global, prospective, observational study of newly diagnosed atrial fibrillation with ≥1 stroke risk factors (http://www.clinicaltrials.gov, unique identifier: NCT01090362). Patients were characterized by atrial fibrillation-related symptoms at presentation and the CHA2DS2-VASc score. Two-year follow-up recorded anticoagulation patterns (vitamin K antagonist, direct oral anticoagulants, parenteral therapy) and outcomes (stroke/systemic embolism, all-cause mortality, and bleeding). RESULTS At presentation, of 52,032 eligible patients, 25.4% were asymptomatic and 74.6% symptomatic. Asymptomatic patients were slightly older (72 vs 70 years), more often male (64.2% vs 52.9%), and more frequently initiated on anticoagulation ± antiplatelets (69.4% vs 66.0%). No difference in events (adjusted hazard ratios, 95% confidence interval) for nonhemorrhagic stroke/systemic embolism (1.19, 0.97-1.45), all-cause mortality (1.06, 0.94-1.20), or bleeding (1.02, 0.87-1.19) was observed. Anticoagulation was associated with comparable reduction in nonhemorrhagic stroke/systemic embolism (0.59, 0.43-0.82 vs 0.78, 0.65-0.93) and all-cause mortality (0.69, 0.59-0.81 vs 0.77, 0.71-0.85) in asymptomatic versus symptomatic, respectively. CONCLUSIONS Major outcomes do not differ between asymptomatic and symptomatic atrial fibrillation presentations and are comparably reduced by anticoagulation. Opportunistic screening-detected asymptomatic atrial fibrillation likely has the same prognosis as asymptomatic atrial fibrillation at presentation and likely responds similarly to anticoagulation thromboprophylaxis.
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Affiliation(s)
- Harry Gibbs
- The Alfred Hospital, Melbourne, VIC, Australia
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, and Sydney School of Medicine, University of Sydney, Sydney, NSW, Australia.
| | - Mårten Rosenqvist
- Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | | | - Wael Al Mahmeed
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - A John Camm
- St George's University of London, London, UK
| | - Barry Jacobson
- Johannesburg Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Carlos Jerjes-Sanchez
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Instituto de Cardiologia y Medicina Vascular, TEC Salud, Monterrey, Mexico
| | | | - Ali Oto
- Hacettepe University, Ankara, Turkey
| | | | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, UK; University College London, London, UK
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Kemp Gudmundsdottir K, Fredriksson T, Svennberg E, Al-Khalili F, Friberg L, Frykman V, Hijazi Z, Rosenqvist M, Engdahl J. Stepwise mass screening for atrial fibrillation using N-terminal B-type natriuretic peptide: the STROKESTOP II study. Europace 2021; 22:24-32. [PMID: 31790147 PMCID: PMC6945054 DOI: 10.1093/europace/euz255] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 08/18/2019] [Indexed: 12/28/2022] Open
Abstract
Aims To study the prevalence of unknown atrial fibrillation (AF) in a high-risk, 75/76-year-old, population using N-terminal B-type natriuretic peptide (NT-proBNP) and handheld electrocardiogram (ECG) recordings in a stepwise screening procedure. Methods and results The STROKESTOP II study is a population-based cohort study in which all 75/76-year-old in the Stockholm region (n = 28 712) were randomized 1:1 to be invited to an AF screening programme or to serve as the control group. Participants without known AF had NT-proBNP analysed and were stratified into low-risk (NT-proBNP <125 ng/L) and high-risk (NT-proBNP ≥125 ng/L) groups. The high-risk group was offered extended ECG-screening, whereas the low-risk group performed only one single-lead ECG recording. In total, 6868 individuals accepted the screening invitation of which 6315 (91.9%) did not have previously known AF. New AF was detected in 2.6% [95% confidence interval (CI) 2.2–3.0] of all participants without previous AF. In the high-risk group (n = 3766/6315, 59.6%), AF was diagnosed in 4.4% (95% CI 3.7–5.1) of the participants. Out of these, 18% had AF on their index-ECG. In the low-risk group, one participant was diagnosed with AF on index-ECG. The screening procedure resulted in an increase in known prevalence from 8.1% to 10.5% among participants. Oral anticoagulant treatment was initiated in 94.5% of the participants with newly diagnosed AF. Conclusion N-terminal B-type natriuretic peptide-stratified systematic screening for AF identified 4.4% of the high-risk participants with new AF. Oral anticoagulant treatment initiation was well accepted in the group diagnosed with new AF.
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Affiliation(s)
- Katrin Kemp Gudmundsdottir
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, SE-182 88 Stockholm, Sweden
| | - Tove Fredriksson
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, SE-182 88 Stockholm, Sweden
| | - Emma Svennberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, SE-182 88 Stockholm, Sweden
| | - Faris Al-Khalili
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, SE-182 88 Stockholm, Sweden
| | - Leif Friberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, SE-182 88 Stockholm, Sweden
| | - Viveka Frykman
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, SE-182 88 Stockholm, Sweden
| | - Ziad Hijazi
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Mårten Rosenqvist
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, SE-182 88 Stockholm, Sweden
| | - Johan Engdahl
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, SE-182 88 Stockholm, Sweden
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Lund I, Engdahl J, Rosenqvist M, Puererfellner H, Sieghartsleitner S, Hendrikx T, Lillqvist J, Pervez Sheikh A, Bech Jensen J, Dixen U. Prevalence of silent atrial fibrillation in high-risk patients - preliminary results from a European three-country handheld ECG-screening study. Europace 2021. [DOI: 10.1093/europace/euab116.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Helsefonden Lilly and Herbert Hansens Foundation
Introduction
Patients with atrial fibrillation (AF) should in most cases be offered prophylactic anticoagulation treatment to prevent a stroke. However, the arrhythmia can appear without symptoms, so-called silent AF. Even without symptoms AF constitutes a risk for stroke.
Purpose
To screen high-risk patients with diabetes type 2 (DMII) or heart failure (CHF) for silent AF.
Methods
We included patients > 64 years with either DMII or CHF from out-patient clinics and local health centers. Exclusion criteria were known AF, anticoagulation treatment, recent stroke, or an implanted pacemaker or ICD. Patients were recruited from a total of eleven study centers in three countries. All underwent 14-days of intermittent ECG screening with a handheld ECG recording four times each day; the recordings were digitally stored. AF was diagnosed in cases of irregular heart rhythm and absence of P waves on at least one recording (thirty seconds) or on at least two recordings for a minimum of ten seconds.
Results
In total, 813 patients were included, 541 of these with DMII. The mean age was 73,4 years ± 5,8 SD, 40,7% of the patients were female.
In the DMII group thirteen patients (2.4%) were diagnosed with silent AF and offered anticoagulation. In the CHF group six (2.2%) patients had diagnosed silent AF on the handheld ECG. The prevalence of AF increased with increasing age, see Table 1. Thus, in the youngest group AF was diagnosed in 1.3% of the patients compared to 3.9 % in the age group 75 years or older.
Conclusions
Screening for silent AF in high-risk patients with DMII or CHF seems worthwhile, especially in patients 75 years or older. Abstract Figure. ECG with atrial fibrillation
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Affiliation(s)
- I Lund
- Hvidovre Hospital - Copenhagen University Hospital, Hvidovre, Denmark
| | - J Engdahl
- Karolinska Institutet, Department of Clinical Science, Stockholm, Sweden
| | - M Rosenqvist
- Karolinska Institutet, Department of Clinical Science, Stockholm, Sweden
| | - H Puererfellner
- Ordensklinikum Linz Elisabethinen, Department of Cardiology, Linz, Austria
| | - S Sieghartsleitner
- Ordensklinikum Linz Elisabethinen, Department of Cardiology, Linz, Austria
| | - T Hendrikx
- Umea University Hospital, Family Medicine, Department of Public Health and Medicine, Umea, Sweden
| | - J Lillqvist
- Umea University Hospital, Family Medicine, Department of Public Health and Medicine, Umea, Sweden
| | - A Pervez Sheikh
- Hvidovre Hospital - Copenhagen University Hospital, Hvidovre, Denmark
| | - J Bech Jensen
- Hvidovre Hospital - Copenhagen University Hospital, Hvidovre, Denmark
| | - U Dixen
- Hvidovre Hospital - Copenhagen University Hospital, Hvidovre, Denmark
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Engdahl J, Rosenqvist M. Large-scale screening studies for atrial fibrillation - is it worth the effort? J Intern Med 2021; 289:474-492. [PMID: 33411987 PMCID: PMC8048511 DOI: 10.1111/joim.13217] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/13/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) is a common disease with increasing prevalence, approximately 3.2% in the adult population. In addition, about one third of AF cases are considered asymptomatic. Due to increased longevity, increased detection and increased prevalence of risk factors, the prevalence of AF is expected to at least double by the year 2060. Patients with AF have an increased risk for ischaemic stroke, heart failure, death and cognitive decline. Treatment with oral anticoagulation reduces the risk of ischaemic stroke and mortality, and the effect on cognitive decline is being studied. Based on the increasing prevalence of AF, its often asymptomatic and paroxysmal presentation and the efficacy of oral anticoagulation treatment, screening for AF has been proposed. AF seems to fulfil most of the Wilson-Jungner criteria for screening issued by the World Health Organization, but some knowledge gaps remain, gaps that will be addressed by several ongoing studies. The knowledge gaps in AF screening consist of the magnitude of the net benefit or net harm inflicted by AF screening because the oral anticoagulation treatment will also increase the risk of bleeding, and the psychological effects of AF screening are not very well studied. So far, the AF screening recommendations issued by the European Society of Cardiology have had limited impact on national and regional AF screening activities. Several large-scale AF screening studies will report results on hard endpoints within the next few years, and these results will hopefully manifest AF as a cardiovascular disease which we need to pay more attention to.
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Affiliation(s)
- J Engdahl
- From the, Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyds University Hospital, Stockholm, Sweden
| | - M Rosenqvist
- From the, Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyds University Hospital, Stockholm, Sweden
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20
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Friberg L, Andersson T, Rosenqvist M. Less dementia and stroke in low-risk patients with atrial fibrillation taking oral anticoagulation. Eur Heart J 2020; 40:2327-2335. [PMID: 31095295 PMCID: PMC6642728 DOI: 10.1093/eurheartj/ehz304] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/30/2019] [Accepted: 05/03/2019] [Indexed: 12/04/2022] Open
Affiliation(s)
- Leif Friberg
- Department of Clinical Sciences, Karolinska Institutet at Danderyd University Hospital, Storskogsvägen 5, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Sciences, Karolinska Institutet at Danderyd University Hospital, Storskogsvägen 5, Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Karolinska Institutet at Danderyd University Hospital, Storskogsvägen 5, Stockholm, Sweden
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21
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Al-Khalili F, Kemp-Gudmundsdottir K, Svennberg E, Fredriksson T, Frykman V, Friberg L, Rosenqvist M, Engdahl J. Clinical and echocardiographic characteristics of individuals aged 75/76 years old with screening-detected elevated NT-proBNP levels. Open Heart 2020; 7:e001200. [PMID: 32153793 PMCID: PMC7046938 DOI: 10.1136/openhrt-2019-001200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/15/2019] [Accepted: 01/05/2020] [Indexed: 12/23/2022] Open
Abstract
Background High plasma levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) indicate increased probability of congestive heart failure (CHF) and atrial fibrillation (AF) and are associated with poor prognosis. Objective We aimed to describe the clinical and echocardiographic characteristics of a population of individuals aged 75/76 years old with NT-proBNP ≥900 ng/L without previously known CHF or AF. Methods All individuals aged 75/76 years in the Stockholm region were randomised to a screening study for AF. Half of them were invited to screening. Of those invited, 49.5% agreed to participate. Individuals with NT-proBNP ≥900 ng/L without known CHF were invited for further clinical evaluation. Results Among 6315 participants without AF who had NT-proBNP sampled, 102 without previously known CHF had ≥900 ng/L. Of these, 93 completed further clinical investigations. In the population that was clinically investigated, 53% were female, and the median NT-proBNP was 1200 ng/L. New AF was found in 28 (30%). The NT-proBNP value in this group was not significantly different from those where AF was not detected (median 1285 vs 1178 ng/L). Patients with newly detected AF had larger left atrial volume and higher pulmonary artery pressure than those without AF. Preserved left ventricular ejection fraction (≥50%) was found in 86% of the participants, mid-range ejection fraction (40%–49%) in 3.2% and reduced ejection fraction (<40%) in 10.8%. Thirteen patients (14%) had other serious cardiac disorders that required medical attention. Conclusion Elderly individuals with NT-proBNP levels ≥900 ng/L constitute a population at high cardiovascular risk even in the absence of diagnosed CHF or AF, and therefore merit further investigation.
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Affiliation(s)
- Faris Al-Khalili
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden.,Heart, Lung and Allergy Clinic, Sophiahemmet Hospital, Stockholm, Sweden
| | | | - Emma Svennberg
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Tove Fredriksson
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Viveka Frykman
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Johan Engdahl
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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22
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Ghazal F, Theobald H, Rosenqvist M, Al-Khalili F. Validity of daily self-pulse palpation for atrial fibrillation screening in patients 65 years and older: A cross-sectional study. PLoS Med 2020; 17:e1003063. [PMID: 32231369 PMCID: PMC7108684 DOI: 10.1371/journal.pmed.1003063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 02/21/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The European Society of Cardiology guidelines recommend (Class IA) single-time-point screening for atrial fibrillation (AF) using pulse palpation. The role of pulse palpation for AF detection has not been validated against electrocardiogram (ECG) recordings. We aimed to study the validity of AF screening using self-pulse palpation compared with an ECG recording conducted at the same time using a handheld ECG 3 times a day for 2 weeks. METHODS AND FINDINGS In this cross-sectional screening study, patients 65 years of age and older attending 4 primary care centers (PCCs) outside Stockholm County were invited to take part in AF screening from July 2017 to December 2018. Patients were included irrespective of their reason for visiting the PCC. Handheld intermittent ECGs 3 times per day were offered to patients without AF for a period of 2 weeks, and patients were instructed in how to take their own pulse at the same time. A total of 1,010 patients (mean age 73 years, 61% female, with an average CHA2DS2-VASc score 2.9) participated in the study, and 27 (2.7%, 95% CI 1.8%-3.9%) new cases of AF were detected. Anticoagulants (ACs) could be initiated in 26 (96%, 95% CI 81%-100%) of these cases. A total of 53,782 simultaneous ECG recordings and pulse measurements were registered. AF was verified in 311 ECG recordings, of which the pulse was palpated as irregular in 77 recordings (25%, 95% CI 20%-30% sensitivity per measurement occasion). Of the 27 AF cases, 15 cases felt an irregular pulse on at least one occasion (56%, 95% CI 35%-75% sensitivity per individual). 187 individuals without AF felt an irregular pulse on at least one occasion. The specificity per measurement occasion and per individual was (98%, 95% CI 98%-98%) and (81%, 95% CI 78%-83%), respectively. CONCLUSIONS AF screening using self-pulse palpation 3 times daily for 2 weeks has lower sensitivity compared with simultaneous intermittent ECG. Thus, it may be better to screen for AF using intermittent ECG without stepwise screening using pulse palpation. A limitation of this model could be the reduced availability of handheld ECG recorders in primary care centers.
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Affiliation(s)
- Faris Ghazal
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Holger Theobald
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Faris Al-Khalili
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
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23
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Schnabel RB, Haeusler KG, Healey JS, Freedman B, Boriani G, Brachmann J, Brandes A, Bustamante A, Casadei B, Crijns HJGM, Doehner W, Engström G, Fauchier L, Friberg L, Gladstone DJ, Glotzer TV, Goto S, Hankey GJ, Harbison JA, Hobbs FDR, Johnson LSB, Kamel H, Kirchhof P, Korompoki E, Krieger DW, Lip GYH, Løchen ML, Mairesse GH, Montaner J, Neubeck L, Ntaios G, Piccini JP, Potpara TS, Quinn TJ, Reiffel JA, Ribeiro ALP, Rienstra M, Rosenqvist M, Themistoclakis S, Sinner MF, Svendsen JH, Van Gelder IC, Wachter R, Wijeratne T, Yan B. Searching for Atrial Fibrillation Poststroke: A White Paper of the AF-SCREEN International Collaboration. Circulation 2019; 140:1834-1850. [PMID: 31765261 DOI: 10.1161/circulationaha.119.040267] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.
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Affiliation(s)
- Renate B Schnabel
- University Heart Centre, Hamburg, Germany; German Cardiovascular Research Center (DZHK), Partner Site Hamburg/Kiel/Lübeck (R.B.-S.)
| | | | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.S.H.)
- Division of Cardiology, McMaster University; Arrhythmia Services, Hamilton Health Sciences; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J. Healey)
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, and Concord Hospital Cardiology, University of Sydney, Australia (B.F.)
| | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Italy (G.B.)
| | | | - Axel Brandes
- Odense University Hospital, Denmark (A. Brandes)
| | - Alejandro Bustamante
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebron (VHIR), Barcelona, Spain (A. Bustamante, J.M.)
| | - Barbara Casadei
- Division of Cardiovascular Medicine, British Heart Foundation Centre for Research Excellence, NIHR Oxford Biomedical Research Centre (B.C.), University of Oxford, United Kingdom
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center, the Netherlands (H.J.G.M.C.)
| | - Wolfram Doehner
- Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), partner site Berlin, and BIH Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Germany (W.D.)
| | - Gunnar Engström
- Department of Clinical Sciences, Lund University, Malmö, Sweden (G.E., L.J.)
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France (L.F.)
| | - Leif Friberg
- Karolinska Institute, Stockholm, Sweden (L.F., M. Rosenqvist)
| | - David J Gladstone
- Department of Medicine, University of Toronto; and Hurvitz Brain Sciences Program and Regional Stroke Centre, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Canada (D.J.G.)
| | | | - Shinya Goto
- Tokai University School of Medicine, Metabolic Disease Research Center, Kanagawa, Japan (S.G.)
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth; and Department of Neurology, Sir Charles Gairdner Hospital, Perth, Australia (G.J.H.)
| | | | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Harris Manchester College (F.D.R.H.), University of Oxford, United Kingdom
| | - Linda S B Johnson
- Department of Clinical Sciences, Lund University, Malmö, Sweden (G.E., L.J.)
| | - Hooman Kamel
- Weill Cornell Medical College, New York, NY (H.K.)
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom; Sandwell and West Birmingham Hospitals and University Hospitals Birmingham NHS trusts, United Kingdom; AFNET, Muenster, Germany (P.K.)
| | - Eleni Korompoki
- Division of Brain Science, Imperial College London, United Kingdom (E.K.)
| | - Derk W Krieger
- Mohammed Bin Rashid University, Dubai, United Arab Emirates; and Neurosciences, Mediclinic City Hospital, Dubai, United Arab Emirates (D.W.K.)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, United Kingdom (G.Y.H.L.)
| | - Maja-Lisa Løchen
- University Hospital of North Norway, Department of Cardiology, Tromsø (M.-L.L.)
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Institut de Recerca, Hospital Universitari Vall d'Hebron (VHIR), Barcelona, Spain (A. Bustamante, J.M.)
| | - Lis Neubeck
- Edinburgh Napier University, United Kingdom (L.N.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N.)
| | - Jonathan P Piccini
- Duke University Medical Center; and Duke Clinical Research Institute, Durham, NC (J.P.P.)
| | - Tatjana S Potpara
- Internal Medicine/Cardiology, School of Medicine, University of Belgrade, Serbia (T.S.P.)
| | - Terence J Quinn
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, United Kingdom (T.Q.)
| | - James A Reiffel
- Department of Medicine, Division of Cardiology, Columbia University, New York, NY (J.A.R.)
| | - Antonio Luiz Pinho Ribeiro
- Internal Medicine Department, School of Medicine, Federal University of Minas Gerais (UFMG); Hospital das Clínicas, UFMG, Belo Horizonte, Brazil (A.L.P.R.)
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M. Rienstra)
| | | | - Sakis Themistoclakis
- Unit of Electrophysiology and Cardiac Pacing, Ospedale dell'Angelo Venice-Mestre, Italy (T.S.)
| | - Moritz F Sinner
- Department of Medicine I, University Hospital Munich, Ludwig-Maximilian's University, Munich, Germany (M.F.S.)
- German Centre for Cardiovascular Research, partner site: Munich Heart Alliance, Munich, Germany (M.F.S.)
| | - Jesper Hastrup Svendsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark (J.H.S.)
- Department of Clinical Medicine, University of Copenhagen, Denmark (J.H.S.)
| | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, the Netherlands (I.v.G.)
| | - Rolf Wachter
- University Hospital Leipzig, Germany (R.W.)
- University Medicine Göttingen, Germany (R.W.)
- German Cardiovascular Research Center (DZHK), partner site: Göttingen (R.W.)
| | - Tissa Wijeratne
- Department of Neurology and Stroke Medicine, The University of Melbourne and Western Health, Australian Institute for Musculoskeletal Science (AIMSS), Sunshine Hospital St Albans, Australia (T.W.)
| | - Bernard Yan
- Royal Melbourne Hospital, Comprehensive Stroke Centre, Australia (B.Y.)
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Ghazal F, Al-Khalili F, Rosenqvist M. P6538Validity of two weeks daily self pulse-palpation for opportunistic screening for atrial fibrillation among patients 65 years and older. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.1128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Pulse-palpation is recommended (ESC IA) for single time-point screening for atrial fibrillation (AF). AF may, however, be paroxysmal which can make AF detection difficult to detect on single time-point measurement. Intermittent ECG recording is a sensitive method to detect AF. However, the role of pulse-palpation for AF detection has not been validated against simultaneous ECG recordings.
Purpose
To study the validity of AF detection using self pulse-palpation simultaneously with hand-hold ECG recording 3 times daily for two weeks for AF.
Method
Patients 65 years and older visiting four primary health care centers, four any reason, were invited to AF screening from July 2017 to December 2018. Hand-held intermittent ECG recordings, 30 seconds three times a day, was offered to participants without AF for a period of 2 weeks. Patients were instructed how to take their own pulse, simultaneously with intermittent ECG measurement and in written to note whether it was irregular or not.
Results
A total of 1010 patients (mean age 73 years, 61% women) participated in the study, 27 new cases of AF (mostly paroxysmal) were detected. Totally 53 782 simultaneous ECG-recordings and pulse-measurements were registered. AF was verified in 311 ECG-recordings but the pulse was palpated as irregular only in 77 of these recordings (25% sensitivity per measurement-occasion). Of those 27 detected AF cases, 15 cases felt their pulse as irregular at least at once occasion (56% sensitivity per individuals). 187 individuals without AF felt their pulse as irregular in at least one occasion. The specificity per measurement-occasion and per individuals were 98% and 81% respectively. Diagnostic odds ratio was 5.3.
AF 27 patients No AF 983 patients Irregular pulse 202 individuals 15 187 Regular pulse 808 individuals 12 796 Sensitivity 56% Specificity 81% Positive Predictive Value 7% Negative Predictive Value 99% AF 311 measurements No AF 53471 measurements Irregular pulse 1046 measurements 77 969 Regular pulse 52,736 measurements 234 52,502 Sensitivity 25% Specificity 98% Positive Predictive Value 7% Negative Predictive Value 99%
Conclusion
AF screening using own pulse-palpation 3 times daily for two weeks is feasible but has a low sensitivity for AF detection.
Acknowledgement/Funding
This study was supported by the Swedish Heart and Lung Foundation, Pfizer, Boehringer-Ingelheim and Bayer
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Affiliation(s)
- F Ghazal
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - F Al-Khalili
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - M Rosenqvist
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
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25
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Wahlström M, Rosenqvist M, Medin J, Walfridsson U, Rydell-Karlsson M. MediYoga as a part of a self-management programme among patients with paroxysmal atrial fibrillation - a randomised study. Eur J Cardiovasc Nurs 2019; 19:74-82. [PMID: 31526039 DOI: 10.1177/1474515119871796] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Paroxysmal atrial fibrillation is associated with impaired health-related quality of life. Yoga has been suggested to improve health-related quality of life among patients with heart failure and hypertension. AIM The aim of the study was to evaluate the effects of MediYoga, in respect of health-related quality of life, blood pressure, heart rate, as well as N-terminal pro b-type natriuretic peptide, among patients with symptomatic paroxysmal atrial fibrillation, compared with standard therapy or relaxation. METHODS Patients with symptomatic paroxysmal atrial fibrillation, n=132, were stratified for gender and randomised to MediYoga, a relaxation group or a control group, 44 patients per group with a 12-week follow-up. Health-related quality of life, blood pressure, heart rate and N-terminal pro b-type natriuretic peptide were assessed. RESULTS After 12 weeks, there were no differences in health-related quality of life between the groups. There were improvements in Short-Form Health Survey bodily pain, general health, social function, mental health and mental component summary scores within the MediYoga group (p=0.014, p=0.037, p=0.029, p=0.030, p=0.019, respectively). No change was seen in the relaxation and control groups. Systolic blood pressure decreased in the MediYoga group (134±18 to 127±13) compared with the control group (126±17 to 127±15, p=0.041); no difference compared with the relaxation group (131±17 to 125±12). Diastolic blood pressure decreased in the MediYoga group (79±9 to 74 ±9) compared with the control group (76±9 to 79±8, p=0.005); no difference compared with the relaxation group (76±9 to 77±8). There were no differences in heart rate and N-terminal pro b-type natriuretic peptide between the groups after 12 weeks. CONCLUSIONS MediYoga improves health-related quality of life and decreases blood pressure in patients with paroxysmal atrial fibrillation. MediYoga may be used as a part of a self-management programme among patients with paroxysmal atrial fibrillation.
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Affiliation(s)
| | | | | | - Ulla Walfridsson
- Department of Cardiology, Linköping University Hospital, Sweden.,Department of Medical and Health Sciences, Linköping University, Sweden
| | - Monica Rydell-Karlsson
- Department of Clinical Sciences, Karolinska Institutet, Sweden.,Ersta Sköndal Bräcke University College, Sweden
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Riva G, Ringh M, Jonsson M, Svensson L, Herlitz J, Claesson A, Djärv T, Nordberg P, Forsberg S, Rubertsson S, Nord A, Rosenqvist M, Hollenberg J. Survival in Out-of-Hospital Cardiac Arrest After Standard Cardiopulmonary Resuscitation or Chest Compressions Only Before Arrival of Emergency Medical Services: Nationwide Study During Three Guideline Periods. Circulation 2019; 139:2600-2609. [PMID: 30929457 DOI: 10.1161/circulationaha.118.038179] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In out-of-hospital cardiac arrest, chest compression-only cardiopulmonary resuscitation (CO-CPR) has emerged as an alternative to standard CPR (S-CPR), using both chest compressions and rescue breaths. Since 2010, CPR guidelines recommend CO-CPR for both untrained bystanders and trained bystanders unwilling to perform rescue breaths. The aim of this study was to describe changes in the rate and type of CPR performed before the arrival of emergency medical services (EMS) during 3 consecutive guideline periods in correlation to 30-day survival. METHODS All bystander-witnessed out-of-hospital cardiac arrests reported to the Swedish register for cardiopulmonary resuscitation in 2000 to 2017 were included. Nonwitnessed, EMS-witnessed, and rescue breath-only CPR cases were excluded. Patients were categorized as receivers of no CPR (NO-CPR), S-CPR, or CO-CPR before EMS arrival. Guideline periods 2000 to 2005, 2006 to 2010, and 2011 to 2017 were used for comparisons over time. The primary outcome was 30-day survival. RESULTS A total of 30 445 patients were included. The proportions of patients receiving CPR before EMS arrival changed from 40.8% in the first time period to 58.8% in the second period, and to 68.2% in the last period. S-CPR changed from 35.4% to 44.8% to 38.1%, and CO-CPR changed from 5.4% to 14.0% to 30.1%, respectively. Thirty-day survival changed from 3.9% to 6.0% to 7.1% in the NO-CPR group, from 9.4% to 12.5% to 16.2% in the S-CPR group, and from 8.0% to 11.5% to 14.3% in the CO-CPR group. For all time periods combined, the adjusted odds ratio for 30-day survival was 2.6 (95% CI, 2.4-2.9) for S-CPR and 2.0 (95% CI, 1.8-2.3) for CO-CPR, in comparison with NO-CPR. S-CPR was superior to CO-CPR (adjusted odds ratio, 1.2; 95% CI, 1.1-1.4). CONCLUSIONS In this nationwide study of out-of-hospital cardiac arrest during 3 periods of different CPR guidelines, there was an almost a 2-fold higher rate of CPR before EMS arrival and a concomitant 6-fold higher rate of CO-CPR over time. Any type of CPR was associated with doubled survival rates in comparison with NO-CPR. These findings support continuous endorsement of CO-CPR as an option in future CPR guidelines because it is associated with higher CPR rates and overall survival in out-of-hospital cardiac arrest.
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Affiliation(s)
- Gabriel Riva
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
| | - Mattias Ringh
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
| | - Martin Jonsson
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
| | - Leif Svensson
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
| | - Johan Herlitz
- The Centre for Pre-hospital Research in Western Sweden, University of Borås, and Sahlgrenska University Hospital, Gothenburg (J. Herlitz)
| | - Andreas Claesson
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
| | - Therese Djärv
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
| | - Per Nordberg
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
| | - Sune Forsberg
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
- Department of Anesthesiology and Intensive Care, Norrtälje Hospital, Sweden (S.F.)
| | - Sten Rubertsson
- Department of Surgical Sciences, Anesthesiology and Intensive Care Medicine, Uppsala University, Sweden (S.R.)
| | - Anette Nord
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
| | - Mårten Rosenqvist
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Section of Cardiology, Stockholm, Sweden (M. Rosenqvist)
| | - Jacob Hollenberg
- Center for Resuscitation Science, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (G.R., M. Ringh, M.J., L.S., A.C., T.D., P.N., S.F., A.N., J. Hollenberg)
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Ghazal F, Theobald H, Rosenqvist M, Al-Khalili F. Assessment of N-terminal pro-B-type natriuretic peptide level in screening for atrial fibrillation in primary health care. PLoS One 2019; 14:e0212974. [PMID: 30807614 PMCID: PMC6391046 DOI: 10.1371/journal.pone.0212974] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/12/2019] [Indexed: 11/18/2022] Open
Abstract
Background Atrial fibrillation (AF), an important cause of thromboembolic events, is often silent and intermittent, thus presenting a diagnostic challenge. The aim of this study was to assess whether the plasma level of N-terminal pro-brain natriuretic peptide (NT-proBNP) is related to the presence of AF and thereby might be used to facilitate screening programs for AF in primary care. Methods This was a cross sectional screening study. A population of 70–74-year-old individuals registered at a single primary care center in Stockholm were invited to AF screening. Intermittent ECG recording, 30 seconds twice a day using a hand-held device over 2 weeks, was offered to participants without previously known AF. Of the 324 participating persons, 34 patients had already known AF and 16 new cases of AF were detected by screening. Plasma NT-proBNP was measured in patients with previously known AF, newly detected AF, and 53 control participants without AF. Findings The median NT-proBNP was 697 ng/L in patients with previously known AF, 335 ng/L in new cases of AF, and 146 ng/L in patients without AF. After adjustment for several clinical variables and morbidities, the differences of median NT-proBNP levels were statistically significant between cases of previously known AF and new cases of AF as well as between new cases of AF and those without AF. The area under receiver operating characteristic curve of detection of new AF was 0.68 (95% CI 0.56 to 0.79) yielding a cut-off point of 124 ng/L with 75% sensitivity, 45% specificity, and 86% negative predictive value. Conclusions The NT-proBNP plasma levels among patients with known AF are higher than those with newly detected AF, and the latter have higher levels than those without AF. Therefore NT-proBNP might be a useful screening marker for the detection of AF and its persistence.
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Affiliation(s)
- Faris Ghazal
- Karolinska Institute, Department of Clinical Sciences, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden
- * E-mail:
| | - Holger Theobald
- Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Stockholm, Sweden
| | - Mårten Rosenqvist
- Karolinska Institute, Department of Clinical Sciences, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden
| | - Faris Al-Khalili
- Karolinska Institute, Department of Clinical Sciences, Cardiology Unit, Danderyd University Hospital, Stockholm, Sweden
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Olbers J, Jacobson E, Viberg F, Witt N, Ljungman P, Rosenqvist M, Östergren J. Systolic blood pressure increases in patients with atrial fibrillation regaining sinus rhythm after electrical cardioversion. J Clin Hypertens (Greenwich) 2019; 21:363-368. [DOI: 10.1111/jch.13496] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/03/2018] [Accepted: 12/14/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Joakim Olbers
- Department of Clinical Science and Education, Cardiology Unit Södersjukhuset, Karolinska Institutet Stockholm Sweden
| | - Ellen Jacobson
- Department of Medicine, Clinical Medicine Unit, Functional Area of Emergency Medicine at Karolinska University Hospital Karolinska Institutet Solna Sweden
| | - Fredrik Viberg
- Department of Medicine, Clinical Medicine Unit, Functional Area of Emergency Medicine at Karolinska University Hospital Karolinska Institutet Solna Sweden
| | - Nils Witt
- Department of Clinical Science and Education, Cardiology Unit Södersjukhuset, Karolinska Institutet Stockholm Sweden
| | - Petter Ljungman
- Department of Clinical Sciences, Danderyd University Hospital Karolinska Institutet StockholmSweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Danderyd University Hospital Karolinska Institutet StockholmSweden
| | - Jan Östergren
- Department of Medicine, Clinical Medicine Unit, Functional Area of Emergency Medicine at Karolinska University Hospital Karolinska Institutet Solna Sweden
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Engdahl J, Svennberg E, Rosenqvist M. Electrocardiography Screening for Atrial Fibrillation. JAMA 2018; 320:2598. [PMID: 30575869 DOI: 10.1001/jama.2018.17764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Johan Engdahl
- Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Emma Svennberg
- Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
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Kemp Gudmundsdottir K, Svennberg E, Al-Khalili F, Fredriksson T, Frykman V, Friberg L, Rosenqvist M, Engdahl J. 1359Mass screening for atrial fibrillation using n-terminal pro b-type natriuretic peptide - preliminary results from the strokestop 2 study. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.1359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - E Svennberg
- Danderyd University Hospital, Stockholm, Sweden
| | | | | | - V Frykman
- Danderyd University Hospital, Stockholm, Sweden
| | - L Friberg
- Karolinska Institute, Stockholm, Sweden
| | | | - J Engdahl
- Danderyd University Hospital, Stockholm, Sweden
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Fredriksson T, Kemp Gudmundsdottir K, Al-Khalili F, Frykman V, Friberg L, Rosenqvist M, Engdahl J, Svennberg E. P1932A comparison of intermittent and continuous event recording in population screening for atrial fibrillation. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- T Fredriksson
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - K Kemp Gudmundsdottir
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - F Al-Khalili
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - V Frykman
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - L Friberg
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - M Rosenqvist
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - J Engdahl
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - E Svennberg
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
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Al-Khalili F, Gudmundsdottir K, Svennberg E, Fredriksson T, Frykman V, Friberg L, Rosenqvist M, Engdahl J. P2797Clinical characteristics of an elderly population with screening-detected elevated NT-proBNP levels without previous diagnosis of heart failure or atrial fibrillation. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- F Al-Khalili
- Karolinska Institute, Dept. of Clinical Sciences, Danderyd Hospital., Stockholm, Sweden
| | - K Gudmundsdottir
- Karolinska Institute, Dept. of Clinical Sciences, Danderyd Hospital., Stockholm, Sweden
| | - E Svennberg
- Karolinska Institute, Dept. of Clinical Sciences, Danderyd Hospital., Stockholm, Sweden
| | - T Fredriksson
- Karolinska Institute, Dept. of Clinical Sciences, Danderyd Hospital., Stockholm, Sweden
| | - V Frykman
- Karolinska Institute, Dept. of Clinical Sciences, Danderyd Hospital., Stockholm, Sweden
| | - L Friberg
- Karolinska Institute, Dept. of Clinical Sciences, Danderyd Hospital., Stockholm, Sweden
| | - M Rosenqvist
- Karolinska Institute, Dept. of Clinical Sciences, Danderyd Hospital., Stockholm, Sweden
| | - J Engdahl
- Karolinska Institute, Dept. of Clinical Sciences, Danderyd Hospital., Stockholm, Sweden
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Kemp Gudmundsdottir K, Svennberg E, Al-Khalili F, Fredriksson T, Frykman V, Friberg L, Rosenqvist M, Engdahl J. P6625Pulse palpation and history of palpitations in atrial fibrillation screening - preliminary results from the strokestop 2 study. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - E Svennberg
- Danderyd University Hospital, Stockholm, Sweden
| | | | | | - V Frykman
- Danderyd University Hospital, Stockholm, Sweden
| | - L Friberg
- Karolinska Institute, Stockholm, Sweden
| | | | - J Engdahl
- Danderyd University Hospital, Stockholm, Sweden
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Scorza R, Rosenqvist M, Frykman V. P603The role of magnetic resonance in patients with premature ventricular contractions and normal findings at echocardiography. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.p603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- R Scorza
- Danderyd University Hospital, Cardiology, Stockholm, Sweden
| | - M Rosenqvist
- Danderyd University Hospital, Cardiology, Stockholm, Sweden
| | - V Frykman
- Danderyd University Hospital, Cardiology, Stockholm, Sweden
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Ghazal F, Theobald H, Rosenqvist M, Al-Khalili F. P1933Assessment of N-terminal pro-brain natriuretic peptide level in the screening for atrial fibrillation in the primary health care. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- F Ghazal
- Karolinska Institute, Section for Gerneral Praction, Stockholm, Sweden
| | - H Theobald
- Karolinska Institute, Section for Gerneral Praction, Stockholm, Sweden
| | - M Rosenqvist
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - F Al-Khalili
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
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Zijlstra JA, Koster RW, Blom MT, Lippert FK, Svensson L, Herlitz J, Kramer-Johansen J, Ringh M, Rosenqvist M, Palsgaard Møller T, Tan HL, Beesems SG, Hulleman M, Claesson A, Folke F, Olasveengen TM, Wissenberg M, Hansen CM, Viereck S, Hollenberg J. Different defibrillation strategies in survivors after out-of-hospital cardiac arrest. Heart 2018; 104:1929-1936. [PMID: 29903805 DOI: 10.1136/heartjnl-2017-312622] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 03/31/2018] [Accepted: 04/17/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In the last decade, there has been a rapid increase in the dissemination of automated external defibrillators (AEDs) for prehospital defibrillation of out-of-hospital cardiac arrest patients. The aim of this study was to study the association between different defibrillation strategies on survival rates over time in Copenhagen, Stockholm, Western Sweden and Amsterdam, and the hypothesis was that non-EMS defibrillation increased over time and was associated with increased survival. METHODS We performed a retrospective analysis of four prospectively collected cohorts of out-of-hospital cardiac arrest patients between 2008 and 2013. Emergency medical service (EMS)-witnessed arrests were excluded. RESULTS A total of 22 453 out-of-hospital cardiac arrest patients with known survival status were identified, of whom 2957 (13%) survived at least 30 days postresuscitation. Of all survivors with a known defibrillation status, 2289 (81%) were defibrillated, 1349 (59%) were defibrillated by EMS, 454 (20%) were defibrillated by a first responder AED and 429 (19%) were defibrillated by an onsite AED and 57 (2%) were unknown. The percentage of survivors defibrillated by first responder AEDs (from 13% in 2008 to 26% in 2013, p<0.001 for trend) and onsite AEDs (from 14% in 2008 to 30% in 2013, p<0.001 for trend) increased. The increased use of these non-EMS AEDs was associated with the increase in survival rate of patients with a shockable initial rhythm. CONCLUSION Survivors of out-of-hospital cardiac arrest are increasingly defibrillated by non-EMS AEDs. This increase is primarily due to a large increase in the use of onsite AEDs as well as an increase in first-responder defibrillation over time. Non-EMS defibrillation accounted for at least part of the increase in survival rate of patients with a shockable initial rhythm.
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Affiliation(s)
- Jolande A Zijlstra
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marieke T Blom
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Freddy K Lippert
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Leif Svensson
- Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Johan Herlitz
- Department of Metabolism and Cardiovascular Research, Institute of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jo Kramer-Johansen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) and Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
| | - Mattias Ringh
- Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Thea Palsgaard Møller
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Hanno L Tan
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Stefanie G Beesems
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Michiel Hulleman
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Andreas Claesson
- Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Folke
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Theresa Mariero Olasveengen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) and Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
| | - Mads Wissenberg
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Carolina Malta Hansen
- Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - Soren Viereck
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Hollenberg
- Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
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Svennberg E, Stridh M, Engdahl J, Al-Khalili F, Friberg L, Frykman V, Rosenqvist M. Safe automatic one-lead electrocardiogram analysis in screening for atrial fibrillation. Europace 2018; 19:1449-1453. [PMID: 28339578 DOI: 10.1093/europace/euw286] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/13/2016] [Indexed: 11/14/2022] Open
Abstract
Aims Screening for atrial fibrillation (AF) using intermittent electrocardiogram (ECG) recordings can identify individuals at risk of AF-related morbidity in particular stroke. We aimed to validate the performance of an AF screening algorithm compared with manual ECG analysis by specially trained nurses and physicians (gold standard) in 30 s intermittent one-lead ECG recordings. Methods and results The STROKESTOP study is a mass-screening study for AF using intermittent ECG recordings. All individuals in the study without known AF registered a 30-s ECG recording in Lead I two times daily for 2 weeks, and all ECGs were manually interpreted. A computerized algorithm was used to analyse 80 149 ECG recordings in 3209 individuals. The computerized algorithm annotated 87.1% (n = 69 789) of the recordings as sinus rhythm/minor rhythm disturbances. The manual interpretation (gold standard) was that 69 758 ECGs were normal, making the negative predictive value of the algorithm 99.9%. The number of ECGs requiring manual interpretation in order to find one pathological ECG was reduced from 288 to 35. Atrial fibrillation was diagnosed in 84 patients by manual interpretation, in all of whom the algorithm indicated pathology. On an ECG level, 278 ECGs were manually interpreted as AF, and of these the algorithm annotated 272 ECGs as pathological (sensitivity 97.8%). Conclusion Automatic ECG screening using a computerized algorithm safely identifies normal ECGs in Lead I and reduces the need for manual evaluation of individual ECGs with >85% with 100% sensitivity on an individual basis.
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Affiliation(s)
- Emma Svennberg
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
| | - Martin Stridh
- Department of Biomedical Engineering, Lund University, Lund and Cardiolund Research AB, Lund, Sweden
| | - Johan Engdahl
- Department of Medicine, Halland Hospital, Halmstad, Sweden
| | - Faris Al-Khalili
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
| | - Viveka Frykman
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Cardiology Unit, Karolinska Institutet, Danderyd University Hospital, Stockholm SE-182 88, Sweden
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Ghazal F, Theobald H, Rosenqvist M, Al-Khalili F. Feasibility and outcomes of atrial fibrillation screening using intermittent electrocardiography in a primary healthcare setting: A cross-sectional study. PLoS One 2018; 13:e0198069. [PMID: 29795689 PMCID: PMC5993113 DOI: 10.1371/journal.pone.0198069] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/14/2018] [Indexed: 12/03/2022] Open
Abstract
Background Atrial fibrillation (AF) is a major risk factor for ischemic stroke unless treated with an anticoagulant. Detecting AF can be difficult because AF is often paroxysmal and asymptomatic. The aims of this study were to develop a screening model to detect AF in a primary healthcare setting and to initiate oral anticoagulant therapy in high-risk patients to prevent stroke. Methods This was a cross-sectional study. All 70- to 74-year-old individuals registered at a single primary healthcare center in Stockholm were invited to participate in AF screening upon visiting the center during a ten-month period. Those who did not have contact with the center during this period were invited to participate by letter. Thirty-second intermittent ECG recordings were made twice a day using a handheld Zenicor device over a 2-week period in participants without AF. Oral anticoagulant therapy was offered to patients with newly detected AF. Findings Of the 415 eligible individuals, a total of 324 (78.1%) patients participated in the study. The mean age of the participants was 72 years, 52.2% were female, and the median CHA2DS2-VASc score of the participants was 3. In the target population, 34 (8.2%) individuals had previously diagnosed AF. Among participants without previously known AF, 16 (5.5%) cases of AF were detected. The final AF prevalence in the target population was 12%. Oral anticoagulant therapy was successfully initiated in 88% of these patients with newly detected AF. Conclusions The AF screening project exhibited a high participation rate and resulted in a high rate of newly discovered AF; of these newly diagnosed patients, 88% could be treated with an oral anticoagulant.
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Affiliation(s)
- Faris Ghazal
- Karolinska Institute, Department of Clinical Sciences, Cardiology Unit, Danderyd Hospital, Stockholm, Sweden
| | - Holger Theobald
- Karolinska Institute, Department of Neurobiology, Care Sciences and Society, Stockholm, Sweden
| | - Mårten Rosenqvist
- Karolinska Institute, Department of Clinical Sciences, Cardiology Unit, Danderyd Hospital, Stockholm, Sweden
| | - Faris Al-Khalili
- Karolinska Institute, Department of Clinical Sciences, Cardiology Unit, Danderyd Hospital, Stockholm, Sweden
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39
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Engdahl J, Holmén A, Rosenqvist M, Strömberg U. A prospective 5-year follow-up after population-based systematic screening for atrial fibrillation. Europace 2018; 20:f306-f311. [DOI: 10.1093/europace/euy045] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/20/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Johan Engdahl
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Mörbygårdsvägen 5, Stockholm, Sweden
| | - Anders Holmén
- Department of Research and Development, Halland Hospital, Halmstad, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Mörbygårdsvägen 5, Stockholm, Sweden
| | - Ulf Strömberg
- Health Metrics Unit, Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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40
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Nielsen-Kudsk JE, Johnsen SP, Wester P, Damgaard D, Airaksinen J, Lund J, De Backer O, Pakarinen S, Odenstedt J, Vikman S, Settergren M, Kongstad O, Rosenqvist M, Krieger DW. Left atrial appendage occlusion versus standard medical care in patients with atrial fibrillation and intracerebral haemorrhage: a propensity score-matched follow-up study. EUROINTERVENTION 2018; 13:371-378. [PMID: 28485276 DOI: 10.4244/eij-d-17-00201] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to investigate the prognosis in patients with atrial fibrillation (AF) and intracerebral haemorrhage (ICH) having a left atrial appendage occlusion (LAAO) versus patients receiving standard medical therapy. METHODS AND RESULTS A total of 151 patients from the Nordic countries with AF and previous ICH who underwent LAAO using the AMPLATZER Cardiac Plug or the AMPLATZER AMULET were compared to a propensity score-matched group of 151 patients receiving standard medical therapy. The two groups were matched so that their risks for stroke and bleeding were similar (CHA2DS2-VASc and HAS-BLED scores). The standard care patients were identified from the Danish Stroke Registry among 787 patients with AF and ICH. The primary endpoint was a composite of all-cause mortality, ischaemic stroke and major bleeding. Patients with AF and a prior ICH treated with LAAO had a lower risk of the composite outcome as compared to patients treated with standard medical care (events/1,000 years [95% confidence interval]: 53.3 [44.3-64.1] vs. 366.7 [298.2-450.9]; hazard ratio 0.16 [0.07-0.37]). CONCLUSIONS LAAO is suggested to be of major clinical benefit in AF patients having sustained an ICH. These results have to be confirmed in a randomised clinical trial.
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41
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Ringh M, Hollenberg J, Palsgaard-Moeller T, Svensson L, Rosenqvist M, Lippert FK, Wissenberg M, Malta Hansen C, Claesson A, Viereck S, Zijlstra JA, Koster RW, Herlitz J, Blom MT, Kramer-Johansen J, Tan HL, Beesems SG, Hulleman M, Olasveengen TM, Folke F. The challenges and possibilities of public access defibrillation. J Intern Med 2018; 283:238-256. [PMID: 29331055 DOI: 10.1111/joim.12730] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Out-of-hospital cardiac arrest (OHCA) is a major health problem that affects approximately four hundred and thousand patients annually in the United States alone. It is a major challenge for the emergency medical system as decreased survival rates are directly proportional to the time delay from collapse to defibrillation. Historically, defibrillation has only been performed by physicians and in-hospital. With the development of automated external defibrillators (AEDs), rapid defibrillation by nonmedical professionals and subsequently by trained or untrained lay bystanders has become possible. Much hope has been put to the concept of Public Access Defibrillation with a massive dissemination of public available AEDs throughout most Western countries. Accordingly, current guidelines recommend that AEDs should be deployed in places with a high likelihood of OHCA. Despite these efforts, AED use is in most settings anecdotal with little effect on overall OHCA survival. The major reasons for low use of public AEDs are that most OHCAs take place outside high incidence sites of cardiac arrest and that most OHCAs take place in residential settings, currently defined as not suitable for Public Access Defibrillation. However, the use of new technology for identification and recruitment of lay bystanders and nearby AEDs to the scene of the cardiac arrest as well as new methods for strategic AED placement redefines and challenges the current concept and definitions of Public Access Defibrillation. Existing evidence of Public Access Defibrillation and knowledge gaps and future directions to improve outcomes for OHCA are discussed. In addition, a new definition of the different levels of Public Access Defibrillation is offered as well as new strategies for increasing AED use in the society.
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Affiliation(s)
- M Ringh
- Department for Medicine, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - J Hollenberg
- Department for Medicine, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - T Palsgaard-Moeller
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - L Svensson
- Department for Medicine, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - M Rosenqvist
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - F K Lippert
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - M Wissenberg
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - C Malta Hansen
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
| | - A Claesson
- Department for Medicine, Center for Resuscitation Science, Karolinska Institutet, Stockholm, Sweden
| | - S Viereck
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - J A Zijlstra
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - R W Koster
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - J Herlitz
- Institute of Internal Medicine, Department of Metabolism and Cardiovascular Research, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - M T Blom
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - J Kramer-Johansen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Air Ambulance Department, Oslo, Norway.,Department of Anaesthesiology Oslo University Hospital and University of Oslo, Oslo, Norway
| | - H L Tan
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - S G Beesems
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - M Hulleman
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - T M Olasveengen
- Department of Anaesthesiology Oslo University Hospital and University of Oslo, Oslo, Norway
| | - F Folke
- Emergency Medical Services Copenhagen, University of Copenhagen, Copenhagen, Denmark.,Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark
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42
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Sobocinski-Doliwa P, Corander JM, Rosenqvist M, Spaak J. P867Yield of targeted AF screening in a high-risk cohort with chronic kidney disease, diabetes mellitus and cardiovascular disease. Europace 2018. [DOI: 10.1093/europace/euy015.470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- P Sobocinski-Doliwa
- Karolinska Institute, Danderyd Hospital, Department of Clinical Sciences, Stockholm, Sweden
| | - J M Corander
- Karolinska Institute, Danderyd Hospital, Department of Clinical Sciences, Stockholm, Sweden
| | - M Rosenqvist
- Karolinska Institute, Danderyd Hospital, Department of Clinical Sciences, Stockholm, Sweden
| | - J Spaak
- Karolinska Institute, Danderyd Hospital, Department of Clinical Sciences, Stockholm, Sweden
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43
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Engdahl J, Holmen A, Rosenqvist M, Stromberg U. P376A prospective five-year follow-up after population-based systematic screening for atrial fibrillation. Europace 2018. [DOI: 10.1093/europace/euy015.187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J Engdahl
- Danderyd University Hospital, Karolinska Institutet, Dept. of Clinical Sciences, Cardiology Unit, Stockholm, Sweden
| | - A Holmen
- Halmstad Central County Hospital, Research and Development, Region Halland, Halmstad, Sweden
| | - M Rosenqvist
- Danderyd University Hospital, Karolinska Institutet, Dept. of Clinical Sciences, Cardiology Unit, Stockholm, Sweden
| | - U Stromberg
- Sahlgrenska Academy, Health Metrics Unit, Department of Public Health and Community Medicine, Institute of Medicine, Gothenburg, Sweden
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44
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Olbers J, Gille A, Ljungman P, Rosenqvist M, Östergren J, Witt N. High beat-to-beat blood pressure variability in atrial fibrillation compared to sinus rhythm. Blood Press 2018; 27:249-255. [DOI: 10.1080/08037051.2018.1436400] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Joakim Olbers
- Unit of Cardiology, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Adam Gille
- Unit of Cardiology, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Petter Ljungman
- Department of Clinical Sciences, Department of Cardiology, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Department of Cardiology, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Jan Östergren
- Departments of Medicine and Emergency Medicine, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Nils Witt
- Unit of Cardiology, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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45
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Giesecke P, Frykman V, Wallin G, Lönn S, Discacciati A, Törring O, Rosenqvist M. All-cause and cardiovascular mortality risk after surgery versus radioiodine treatment for hyperthyroidism. Br J Surg 2017; 105:279-286. [DOI: 10.1002/bjs.10665] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/24/2017] [Accepted: 07/09/2017] [Indexed: 11/05/2022]
Abstract
Abstract
Background
Little is known about the long-term side-effects of different treatments for hyperthyroidism. The few studies previously published on the subject either included only women or focused mainly on cancer outcomes. This register study compared the impact of surgery versus radioiodine on all-cause and cause-specific mortality in a cohort of men and women.
Methods
Healthcare registers were used to find hyperthyroid patients over 35 years of age who were treated with radioiodine or surgery between 1976 and 2000. Comparisons between treatments were made to assess all-cause and cause-specific deaths to 2013. Three different statistical methods were applied: Cox regression, propensity score matching and inverse probability weighting.
Results
Of the 10 992 patients included, 10 250 had been treated with radioiodine (mean age 65·1 years; 8668 women, 84·6 per cent) and 742 had been treated surgically (mean age 44·1 years; 633 women, 85·3 per cent). Mean duration of follow-up varied between 16·3 and 22·3 years, depending on the statistical method used. All-cause mortality was significantly lower among surgically treated patients, with a hazard ratio of 0·82 in the regression analysis, 0·80 in propensity score matching and 0·85 in inverse probability weighting. This was due mainly to lower cardiovascular mortality in the surgical group. Men in particular seemed to benefit from surgery compared with radioiodine treatment.
Conclusion
Compared with treatment with radioiodine, surgery for hyperthyroidism is associated with a lower risk of all-cause and cardiovascular mortality in the long term. This finding was more evident among men.
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Affiliation(s)
- P Giesecke
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - V Frykman
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - G Wallin
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - S Lönn
- Department of Research and Development, Region Halland, Halmstad, Sweden
| | - A Discacciati
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - O Törring
- Department of Clinical Research and Education, Karolinska Institute, Stockholm, Sweden
| | - M Rosenqvist
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
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46
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Friberg L, Rosenqvist M. Less dementia with oral anticoagulation in atrial fibrillation. Eur Heart J 2017; 39:453-460. [DOI: 10.1093/eurheartj/ehx579] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 09/27/2017] [Indexed: 11/14/2022] Open
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47
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Engdahl J, Svennberg E, Friberg L, Al-Khalili F, Frykman V, Kemp Gudmundsdottir K, Fredriksson T, Rosenqvist M. Stepwise mass screening for atrial fibrillation using N-terminal pro b-type natriuretic peptide: the STROKESTOP II study design. Europace 2017; 19:297-302. [PMID: 28011798 DOI: 10.1093/europace/euw319] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 09/19/2016] [Indexed: 11/14/2022] Open
Abstract
Aim Atrial fibrillation (AF) is the most prevalent clinical arrhythmia and a major risk factor for ischaemic stroke. Treatment with oral anticoagulants (OACs) reduces the risk of stroke by two thirds in AF patients with risk factors. Due to its often paroxysmal and asymptomatic presentation, AF is sometimes challenging to diagnose. So far, AF screening studies have applied opportunistic or systematic screening, most often using a single 12-lead electrocardiogram (ECG) recording or ambulatory ECG. We hypothesise that the biomarker N-terminal pro b-type natriuretic peptide (NT-proBNP) is a valuable adjunct in population based AF screening. Methods We are conducting a randomized population-based study on AF screening using ambulatory ECG recording where the decision to use prolonged intermittent ECG recording is directed by NT-proBNP levels, the STROKESTOP II trial. The entire population of inhabitants 75 or 76 years of age (n = 28 712) in the capital region of Sweden will be randomized 1:1 to intervention or control group. In the intervention group NT-proBNP will be analysed in all without previously known AF. Those with NT-proBNP ≤ 125 pg/L will make a single one lead ECG recording, participants with NTproBNP ≥ 125 np/L will be instructed to record ECG for 30 s at least twice daily for 2 weeks with a handheld ambulatory ECG recorder. Participants with newly diagnosed or undertreated AF will be referred to a cardiologist and offered OAC treatment. Primary endpoint is incidence of stroke or systemic embolus, during a 5 year follow-up period in the control group vs the group invited to screening.
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Affiliation(s)
- Johan Engdahl
- Department of Clinical Sciences, Karolinska Institute, Cardiology Unit, Danderyd's University Hospital, SE-18288 Stockholm, Sweden.,Department of Medicine, Hallands Hospital Halmstad, SE-30185 Halmstad, Sweden
| | - Emma Svennberg
- Department of Clinical Sciences, Karolinska Institute, Cardiology Unit, Danderyd's University Hospital, SE-18288 Stockholm, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Karolinska Institute, Cardiology Unit, Danderyd's University Hospital, SE-18288 Stockholm, Sweden
| | - Faris Al-Khalili
- Department of Clinical Sciences, Karolinska Institute, Cardiology Unit, Danderyd's University Hospital, SE-18288 Stockholm, Sweden.,Stockholm Heart Center, Kungsgatan 34, SE-11135 Stockholm, Sweden
| | - Viveka Frykman
- Department of Clinical Sciences, Karolinska Institute, Cardiology Unit, Danderyd's University Hospital, SE-18288 Stockholm, Sweden
| | - Katrin Kemp Gudmundsdottir
- Department of Clinical Sciences, Karolinska Institute, Cardiology Unit, Danderyd's University Hospital, SE-18288 Stockholm, Sweden
| | - Tove Fredriksson
- Department of Clinical Sciences, Karolinska Institute, Cardiology Unit, Danderyd's University Hospital, SE-18288 Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Karolinska Institute, Cardiology Unit, Danderyd's University Hospital, SE-18288 Stockholm, Sweden
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48
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Hasselqvist-Ax I, Nordberg P, Herlitz J, Svensson L, Jonsson M, Lindqvist J, Ringh M, Claesson A, Björklund J, Andersson JO, Ericson C, Lindblad P, Engerström L, Rosenqvist M, Hollenberg J. Dispatch of Firefighters and Police Officers in Out-of-Hospital Cardiac Arrest: A Nationwide Prospective Cohort Trial Using Propensity Score Analysis. J Am Heart Assoc 2017; 6:JAHA.117.005873. [PMID: 28978527 PMCID: PMC5721830 DOI: 10.1161/jaha.117.005873] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Dispatch of basic life support–trained first responders equipped with automated external defibrillators in addition to advanced life support–trained emergency medical services personnel in out‐of‐hospital cardiac arrest (OHCA) has, in some minor cohort studies, been associated with improved survival. The aim of this study was to evaluate the association between basic life support plus advanced life support response and survival in OHCA at a national level. Methods and Results This prospective cohort study was conducted from January 1, 2012, to December 31, 2014. People who experienced OHCA in 9 Swedish counties covered by basic life support plus advanced life support response were compared with a propensity‐matched contemporary control group of people who experienced OHCA in 12 counties where only emergency medical services was dispatched, providing advanced life support. Primary outcome was survival to 30 days. The analytic sample consisted of 2786 pairs (n=5572) derived from the total cohort of 7308 complete cases. The median time from emergency call to arrival of emergency medical services or first responder was 9 minutes in the intervention group versus 10 minutes in the controls (P<0.001). The proportion of patients admitted alive to the hospital after resuscitation was 31.4% (875/2786) in the intervention group versus 24.9% (694/2786) in the controls (conditional odds ratio, 1.40; 95% confidence interval, 1.24–1.57). Thirty‐day survival was 9.5% (266/2786) in the intervention group versus 7.7% (214/2786) in the controls (conditional odds ratio, 1.27; 95% confidence interval, 1.05–1.54). Conclusions In this nationwide interventional trial, using propensity score matching, dispatch of first responders in addition to emergency medical services in OHCA was associated with a moderate, but significant, increase in 30‐day survival. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02184468.
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Affiliation(s)
- Ingela Hasselqvist-Ax
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Solna, Sweden.,Section of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Per Nordberg
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Solna, Sweden.,Section of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Johan Herlitz
- Centre for Pre-Hospital Research in Western Sweden, University of Borås, Borås, Sweden
| | - Leif Svensson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Solna, Sweden.,Section of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Martin Jonsson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Solna, Sweden.,Section of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Jonny Lindqvist
- Institute of Medicine, Center for Cardiovascular and Metabolic Research, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Mattias Ringh
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Solna, Sweden.,Section of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Andreas Claesson
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Solna, Sweden.,Section of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | | | | | - Caroline Ericson
- Emergency Medical Services, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Pär Lindblad
- Värnamo County Hospital, Jönköping County, Sweden
| | | | - Mårten Rosenqvist
- Department of Clinical Sciences, Karolinska Institutet, Solna, Sweden.,Section of Cardiology, Danderyd Hospital, Danderyd, Sweden
| | - Jacob Hollenberg
- Department of Medicine, Center for Resuscitation Science, Karolinska Institutet, Solna, Sweden.,Section of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
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49
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Gibbs H, Freedman B, Rosenqvist M, Al Mahmeed W, Ambrosio G, Camm A, Connolly S, Gao H, Jacobson B, Jerjes-Sanchez C, Kayani G, Oto A, Panchenko E, Ragy H, Kakkar A. P4602Similar clinical outcomes of asymptomatic and symptomatic patients with newly diagnosed atrial fibrillation: results from GARFIELD-AF. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p4602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- H. Gibbs
- The Alfred Hospital, Melbourne, Australia
| | - B. Freedman
- Heart Research Institute, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - M. Rosenqvist
- Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - W. Al Mahmeed
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - G. Ambrosio
- University of Perugia School of Medicine, Perugia, Italy
| | - A.J. Camm
- St George's University of London, London, United Kingdom
| | | | - H. Gao
- Thrombosis Research Institute, London, United Kingdom
| | - B. Jacobson
- Johannesburg Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - C. Jerjes-Sanchez
- Instituto de Cardiologia y Medicina Vascular, TEC Salud, Tecnolόgico de Monterrey, Monterrey, Mexico
| | - G. Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - A. Oto
- Hacettepe University, Ankara, Turkey
| | - E. Panchenko
- Cardiology Research and Production Center, Moscow, Russian Federation
| | - H. Ragy
- Hayat Hospital, Cairo, Egypt
| | - A.K. Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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50
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Savarese G, Friberg L, Rosenqvist M, Dahlstrom U, Lund L. 1014Impact of CHA2DS2-VASc and HAS-BLED SCORES on oral anticoagulant use and outcomes in patients with atrial fibrillation and concomitant heart failure: an analysis of 22,055 patients from the SwedeHF. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.1014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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