1
|
Eriksson C, Sun J, Bryder M, Bröms G, Everhov ÅH, Forss A, Jernberg T, Ludvigsson JF, Olén O. Impact of inflammatory bowel disease on the risk of acute coronary syndrome: A Swedish Nationwide Cohort Study. Aliment Pharmacol Ther 2024; 59:1122-1133. [PMID: 38425022 DOI: 10.1111/apt.17932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/21/2023] [Accepted: 02/20/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND There are conflicting data on the risk of acute coronary syndrome (ACS) in patients with inflammatory bowel disease (IBD). Only a few previous reports include patients diagnosed during the last decade. AIM To assess and compare the risk of ACS between patients with IBD and the general population. METHODS In this cohort study, we used nationwide registers to identify patients diagnosed with IBD in Sweden 2003-2021. Every patient was matched by birth year, sex, calendar year and area of residence with up to 10 general population comparators. The primary outcome was incident ACS. We used semi-parametric Cox proportional hazard models to estimate hazard ratios (HRs). RESULTS We identified 76,517 patients with IBD (Crohn's disease [CD], N = 22,732; ulcerative colitis [UC], N = 42,194 and IBD-unclassified, N = 11,591) and 757,141 comparators. During a median follow-up of 8 years, 2546 patients with IBD (37.5/10,000 person-years) were diagnosed with ACS compared with 19,598 (28.0/10,000 person-years) among comparators (HR 1.30; 95% confidence interval 1.24-1.35) after adjustments for confounding factors, and approximately one extra case of ACS in 100 IBD patients followed for 10 years. The highest HRs for ACS were in patients with elderly onset IBD (≥60 years) and among patients with CD or UC with extra-intestinal manifestations. No increased HRs were observed in patients diagnosed with IBD before the age of 40. CONCLUSION In this contemporary cohort of patients with IBD, exposed to modern IBD care, there was an increased risk for ACS compared with individuals from the general population.
Collapse
Affiliation(s)
- Carl Eriksson
- Department of Gastroenterology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Jiangwei Sun
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Matti Bryder
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Gabriella Bröms
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Division of Gastroenterology, Department of Specialist Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Åsa H Everhov
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anders Forss
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Gastroenterology Unit, Department of Gastroenterology, Dermatovenereology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatrics, Örebro University Hospital, Örebro, Sweden
- Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Ola Olén
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden
| |
Collapse
|
2
|
Yndigegn T, Lindahl B, Mars K, Alfredsson J, Benatar J, Brandin L, Erlinge D, Hallen O, Held C, Hjalmarsson P, Johansson P, Karlström P, Kellerth T, Marandi T, Ravn-Fischer A, Sundström J, Östlund O, Hofmann R, Jernberg T. Beta-Blockers after Myocardial Infarction and Preserved Ejection Fraction. N Engl J Med 2024; 390:1372-1381. [PMID: 38587241 DOI: 10.1056/nejmoa2401479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Most trials that have shown a benefit of beta-blocker treatment after myocardial infarction included patients with large myocardial infarctions and were conducted in an era before modern biomarker-based diagnosis of myocardial infarction and treatment with percutaneous coronary intervention, antithrombotic agents, high-intensity statins, and renin-angiotensin-aldosterone system antagonists. METHODS In a parallel-group, open-label trial performed at 45 centers in Sweden, Estonia, and New Zealand, we randomly assigned patients with an acute myocardial infarction who had undergone coronary angiography and had a left ventricular ejection fraction of at least 50% to receive either long-term treatment with a beta-blocker (metoprolol or bisoprolol) or no beta-blocker treatment. The primary end point was a composite of death from any cause or new myocardial infarction. RESULTS From September 2017 through May 2023, a total of 5020 patients were enrolled (95.4% of whom were from Sweden). The median follow-up was 3.5 years (interquartile range, 2.2 to 4.7). A primary end-point event occurred in 199 of 2508 patients (7.9%) in the beta-blocker group and in 208 of 2512 patients (8.3%) in the no-beta-blocker group (hazard ratio, 0.96; 95% confidence interval, 0.79 to 1.16; P = 0.64). Beta-blocker treatment did not appear to lead to a lower cumulative incidence of the secondary end points (death from any cause, 3.9% in the beta-blocker group and 4.1% in the no-beta-blocker group; death from cardiovascular causes, 1.5% and 1.3%, respectively; myocardial infarction, 4.5% and 4.7%; hospitalization for atrial fibrillation, 1.1% and 1.4%; and hospitalization for heart failure, 0.8% and 0.9%). With regard to safety end points, hospitalization for bradycardia, second- or third-degree atrioventricular block, hypotension, syncope, or implantation of a pacemaker occurred in 3.4% of the patients in the beta-blocker group and in 3.2% of those in the no-beta-blocker group; hospitalization for asthma or chronic obstructive pulmonary disease in 0.6% and 0.6%, respectively; and hospitalization for stroke in 1.4% and 1.8%. CONCLUSIONS Among patients with acute myocardial infarction who underwent early coronary angiography and had a preserved left ventricular ejection fraction (≥50%), long-term beta-blocker treatment did not lead to a lower risk of the composite primary end point of death from any cause or new myocardial infarction than no beta-blocker use. (Funded by the Swedish Research Council and others; REDUCE-AMI ClinicalTrials.gov number, NCT03278509.).
Collapse
Affiliation(s)
- Troels Yndigegn
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Bertil Lindahl
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Katarina Mars
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Joakim Alfredsson
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Jocelyne Benatar
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Lisa Brandin
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - David Erlinge
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Ola Hallen
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Claes Held
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Patrik Hjalmarsson
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Pelle Johansson
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Patric Karlström
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Thomas Kellerth
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Toomas Marandi
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Annica Ravn-Fischer
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Johan Sundström
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Ollie Östlund
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Robin Hofmann
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| | - Tomas Jernberg
- From the Department of Cardiology, Clinical Sciences, Lund University, and Skåne University Hospital, Lund (T.Y., D.E.), the Department of Medical Sciences, Uppsala University (B.L., C.H., J.S.), and Uppsala Clinical Research Center (B.L., C.H., O.Ö.), Uppsala, the Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset (K.M., R.H.), the Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet (P.H., T.J.), and the Heart and Lung Patients Association (P.J.), Stockholm, the Departments of Cardiology (J.A.) and Health, Medicine, and Caring Sciences (J.A., P.K.), Linköping University, Linköping, the Division of Cardiology, Skaraborgs Sjukhus, Skövde (L.B.), the Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, Karlstad (O.H., T.K.), the Department of Internal Medicine, Ryhov County Hospital, Jönköping (P.K.), and the Department of Cardiology, Sahlgrenska University Hospital, and the Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg (A.R.-F.) - all in Sweden; Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (J.B.); the Department of Cardiology, Institute of Clinical Medicine, University of Tartu, Tartu, and the Center of Cardiology, North Estonia Medical Center, Tallinn - both in Estonia (T.M.); and the George Institute for Global Health, University of New South Wales, Sydney (J.S.)
| |
Collapse
|
3
|
Lenell J, Lindahl B, Erlinge D, Jernberg T, Spaak J, Baron T. Global longitudinal strain in long-term risk prediction after acute coronary syndrome: an investigation of added prognostic value to ejection fraction. Clin Res Cardiol 2024:10.1007/s00392-024-02439-w. [PMID: 38526603 DOI: 10.1007/s00392-024-02439-w] [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] [Received: 02/11/2024] [Accepted: 03/18/2024] [Indexed: 03/26/2024]
Abstract
AIMS This study aimed to investigate the additional value of global longitudinal strain (GLS) on top of left ventricular ejection fraction (LVEF) in long-term risk prediction of combined death and heart failure (HF) re-hospitalization after acute coronary syndrome (ACS). METHOD AND RESULTS This retrospective study included patients admitted with ACS between 2008 and 2014 from the three participating university hospitals. LVEF and GLS were assessed at a core lab from images acquired during the index hospital stay. Their prognostic value was studied with the Cox proportional hazards model (median follow-up 6.2 years). A nested model comparison was performed with C-statistics. A total of 941 patients qualified for multivariable analysis after multiple imputation of missing baseline covariables. The combined outcome was reached in 17.7% of the cases. Both GLS and LVEF were independent predictors of the combined outcome, hazard ratio (HR) 1.068 (95% CI 1.017-1.121) and HR 0.980 (95% CI 0.962-0.998), respectively. The C-statistic increased from 0.742 (95% CI 0.702-0.783) to 0.749 (95% CI 0.709-0.789) (P = 0.693) when GLS entered the model with clinical data and LVEF. CONCLUSION GLS emerged as an independent long-term risk predictor of all-cause death and HF re-hospitalization. However, there was no significant incremental predictive value of GLS when LVEF was already known.
Collapse
Affiliation(s)
- Joel Lenell
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- Department of Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Dept. of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Spaak
- Division of Cardiovascular Medicine, Dept. of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Tomasz Baron
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| |
Collapse
|
4
|
Ekström M, Sundh J, Andersson A, Angerås O, Blomberg A, Börjesson M, Caidahl K, Emilsson ÖI, Engvall J, Frykholm E, Grote L, Hedman K, Jernberg T, Lindberg E, Malinovschi A, Nyberg A, Rullman E, Sandberg J, Sköld M, Stenfors N, Sundström J, Tanash H, Zaigham S, Carlhäll CJ. Exertional breathlessness related to medical conditions in middle-aged people: the population-based SCAPIS study of more than 25,000 men and women. Respir Res 2024; 25:127. [PMID: 38493081 PMCID: PMC10944596 DOI: 10.1186/s12931-024-02766-6] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/12/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Breathlessness is common in the population and can be related to a range of medical conditions. We aimed to evaluate the burden of breathlessness related to different medical conditions in a middle-aged population. METHODS Cross-sectional analysis of the population-based Swedish CArdioPulmonary bioImage Study of adults aged 50-64 years. Breathlessness (modified Medical Research Council [mMRC] ≥ 2) was evaluated in relation to self-reported symptoms, stress, depression; physician-diagnosed conditions; measured body mass index (BMI), spirometry, venous haemoglobin concentration, coronary artery calcification and stenosis [computer tomography (CT) angiography], and pulmonary emphysema (high-resolution CT). For each condition, the prevalence and breathlessness population attributable fraction (PAF) were calculated, overall and by sex, smoking history, and presence/absence of self-reported cardiorespiratory disease. RESULTS We included 25,948 people aged 57.5 ± [SD] 4.4; 51% women; 37% former and 12% current smokers; 43% overweight (BMI 25.0-29.9), 21% obese (BMI ≥ 30); 25% with respiratory disease, 14% depression, 9% cardiac disease, and 3% anemia. Breathlessness was present in 3.7%. Medical conditions most strongly related to the breathlessness prevalence were (PAF 95%CI): overweight and obesity (59.6-66.0%), stress (31.6-76.8%), respiratory disease (20.1-37.1%), depression (17.1-26.6%), cardiac disease (6.3-12.7%), anemia (0.8-3.3%), and peripheral arterial disease (0.3-0.8%). Stress was the main factor in women and current smokers. CONCLUSION Breathlessness mainly relates to overweight/obesity and stress and to a lesser extent to comorbidities like respiratory, depressive, and cardiac disorders among middle-aged people in a high-income setting-supporting the importance of lifestyle interventions to reduce the burden of breathlessness in the population.
Collapse
Affiliation(s)
- Magnus Ekström
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Faculty of Medicine, Lund University, 221 84, Lund, Sweden.
| | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anders Andersson
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
- COPD Center, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Blomberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Mats Börjesson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg, Sweden
- Center for Lifestyle Intervention, Department MGAÖ, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kenneth Caidahl
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Sahlgrenska University Hospital, and Sahlgrenska Academy, Gothenburg, Sweden
| | - Össur Ingi Emilsson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Jan Engvall
- CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Erik Frykholm
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Ludger Grote
- Center for Sleep and Vigilance Disorders, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Sleep Disorders Centre, Department of Respiratory Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristofer Hedman
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Eva Lindberg
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - André Nyberg
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden
| | - Eric Rullman
- Department of Laboratory Medicine, Section of Clinical Physiology, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jacob Sandberg
- Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Faculty of Medicine, Lund University, 221 84, Lund, Sweden
| | - Magnus Sköld
- Respiratory Medicine Unit, Department of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Nikolai Stenfors
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hanan Tanash
- Department of Respiratory Medicine, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Suneela Zaigham
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Carl-Johan Carlhäll
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
| |
Collapse
|
5
|
Petursson P, Oštarijaš E, Redfors B, Råmunddal T, Angerås O, Völz S, Rawshani A, Hambraeus K, Koul S, Alfredsson J, Hagström H, Loghman H, Hofmann R, Fröbert O, Jernberg T, James S, Erlinge D, Omerovic E. Effects of pharmacological interventions on mortality in patients with Takotsubo syndrome: a report from the SWEDEHEART registry. ESC Heart Fail 2024. [PMID: 38454651 DOI: 10.1002/ehf2.14713] [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] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/17/2023] [Accepted: 01/18/2024] [Indexed: 03/09/2024] Open
Abstract
AIMS Takotsubo syndrome (TS) is a heart condition mimicking acute myocardial infarction. TS is characterized by a sudden weakening of the heart muscle, usually triggered by physical or emotional stress. In this study, we aimed to investigate the effect of pharmacological interventions on short- and long-term mortality in patients with TS. METHODS AND RESULTS We analysed data from the SWEDEHEART (the Swedish Web System for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry, which included patients who underwent coronary angiography between 2009 and 2016. In total, we identified 1724 patients with TS among 228 263 individuals in the registry. The average age was 66 ± 14 years, and 77% were female. Nearly half of the TS patients (49.4%) presented with non-ST-elevation acute coronary syndrome, and a quarter (25.9%) presented with ST-elevation myocardial infarction. Most patients (79.1%) had non-obstructive coronary artery disease on angiography, while 11.7% had a single-vessel disease and 9.2% had a multivessel disease. All patients received at least one pharmacological intervention; most of them used beta-blockers (77.8% orally and 8.3% intravenously) or antiplatelet agents [aspirin (66.7%) and P2Y12 inhibitors (43.6%)]. According to the Kaplan-Meier estimator, the probability of all-cause mortality was 2.5% after 30 days and 16.6% after 6 years. The median follow-up time was 877 days. Intravenous use of inotropes and diuretics was associated with increased 30 day mortality in TS [hazard ratio (HR) = 9.92 (P < 0.001) and HR = 3.22 (P = 0.001), respectively], while angiotensin-converting enzyme inhibitors and statins were associated with decreased long-term mortality [HR = 0.60 (P = 0.025) and HR = 0.62 (P = 0.040), respectively]. Unfractionated and low-molecular-weight heparins were associated with reduced 30 day mortality [HR = 0.63 (P = 0.01)]. Angiotensin receptor blockers, oral anticoagulants, P2Y12 antagonists, aspirin, and beta-blockers did not statistically correlate with mortality. CONCLUSIONS Our findings suggest that some medications commonly used to treat TS are associated with higher mortality, while others have lower mortality. These results could inform clinical decision-making and improve patient outcomes in TS. Further research is warranted to validate these findings and to identify optimal pharmacological interventions for patients with TS.
Collapse
Affiliation(s)
- Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Araz Rawshani
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | | | - Sasha Koul
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - Henrik Hagström
- Department of Cardiology, Umeå University Hospital, Umeå, Sweden
| | - Henareh Loghman
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Robin Hofmann
- Department of Cardiology, Södra Hospital, Stockholm, Sweden
| | - Ole Fröbert
- Department of Cardiology, Örebro University Hospital, Örebro, Sweden
| | - Tomas Jernberg
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Stefan James
- Department of Cardiology, Uppsala University Hospital, Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
6
|
Zwackman S, Häggström J, Hagström E, Jernberg T, Karlsson JE, Lawesson SS, Leosdottir M, Ravn-Fischer A, Eriksson M, Alfredsson J. Management and outcome in foreign-born vs native-born patients with myocardial infarction in Sweden. Eur Heart J Qual Care Clin Outcomes 2024:qcae020. [PMID: 38453451 DOI: 10.1093/ehjqcco/qcae020] [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] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Previous studies on disparities in healthcare and outcome have shown conflicting results. The aim of this study was to assess differences in baseline characteristics, management, and outcome in myocardial infarction (MI) patients, by country of birth. METHODS In total, 194 259 MI patients (64% male, 15% foreign-born) from the nationwide SWEDEHEART registry were included and compared by geographic region of birth. The primary outcome was one-year major adverse cardiovascular events (MACE) including all-cause death, MI, and stroke. Secondary outcomes were long-term MACE (up to 12 years), the individual components of MACE, 30-day mortality, management, and risk factors. Logistic regression, Cox proportional hazard models and propensity score matching (PSM), accounting for baseline differences, were used. RESULTS Foreign-born patients were younger, often male, and had a higher cardiovascular (CV) risk factor burden, including smoking, diabetes, and hypertension. In PSM analyses, Asia-born patients had higher likelihood of revascularisation (OR 1.16, 95% CI 1.04-1.30), statins and betablocker prescription at discharge and a 34% lower risk of 30-day mortality. Furthermore, no statistically significant differences were found in the primary outcomes except for Asia-born patients having lower risk of one-year MACE (HR 0.85, 95% CI 0.73-0.98), driven by lower mortality (HR 0.72, 95% CI 0.57-0.91). The results persisted over long-term follow-up. CONCLUSIONS This study shows that in a system with universal healthcare coverage in which acute and secondary preventive treatments do not differ by country of birth, foreign-born patients, despite higher CV risk factor burden, will do at least as well as native-born patients.
Collapse
Affiliation(s)
- Sammy Zwackman
- Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Jenny Häggström
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Sweden
- Uppsala Clinical Research Centre, Uppsala University, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm Sweden
| | - Jan-Erik Karlsson
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Department of Internal Medicine, County Hospital Ryhov, Jönköping, Sweden
| | - Sofia Sederholm Lawesson
- Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Margret Leosdottir
- Department of Cardiology, Skane University Hospital and Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Annica Ravn-Fischer
- Institution of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Gothenburg University. Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marie Eriksson
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
7
|
Mazhar F, Hjemdahl P, Sjölander A, Kahan T, Jernberg T, Carrero JJ. Intensity of and adherence to lipid-lowering therapy as predictors of goal attainment and major adverse cardiovascular events in primary prevention. Am Heart J 2024; 269:118-130. [PMID: 38109988 DOI: 10.1016/j.ahj.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 10/01/2023] [Revised: 11/25/2023] [Accepted: 12/10/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND The effectiveness of lipid-lowering therapy (LLT) for primary prevention of atherosclerotic cardiovascular disease (ASCVD) in routine care may depend on treatment intensity and adherence. METHODS Observational study of adults with newly initiated LLT for primary prevention of ASCVD in Stockholm, Sweden, during 2017-2021. Study exposures were LLT adherence [proportion of days covered (PDC)], LLT intensity (expected reduction of LDL cholesterol), and the combined measure of adherence and intensity. At each LLT fill, adherence and intensity were calculated during the previous 12 months, and the patients estimated ASCVD risk was categorized. Study outcomes were major adverse cardiovascular events (MACE) and LDL-C goal attainment. RESULTS Thirty-six thousand two hundred eighty-three individuals (mean age 63 years, 47% women, median follow-up 2 years), with a baseline low-moderate (40%), high (49%), and very-high (11%) ASCVD risk started LLT. Increases in LLT adherence, intensity, or adherence-adjusted intensity of 10% over 1 year were associated with lower risks of MACE (with hazard ratios of 0.95 [95% CI, 0.93-0.98]; 0.93 [0.86-1.00]; and 0.90 [0.85-0.95], respectively) and higher odds of attaining LDL goals. Patients with good adherence (≥80%) had similar risks of MACE and similar odds ratios for LDL-C goal attainment with low-moderate and high-intensity LLT. Treatment discontinuation was associated with increased MACE risk. The relative and absolute benefits of good adherence were greatest in patients with very high ASCVD risk. CONCLUSION In routine-care primary prevention, better adherence to LLT was associated with a lower risk of MACE across all treatment intensities. Improving adherence is especially important among patients with very high ASCVD risk.
Collapse
Affiliation(s)
- Faizan Mazhar
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology Unit/Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Kahan
- Department of Clinical Sciences, Karolinska Institutet, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Karolinska Institutet, Division of Cardiovascular Medicine, Danderyd Hospital, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Campus Solna, Karolinska Institutet, Stockholm, Sweden; Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Danderyd, Sweden
| |
Collapse
|
8
|
Salzinger B, Lundwall K, Evans M, Mörtberg J, Wallén H, Jernberg T, Kahan T, Lundman P, Tornvall P, Erlinge D, Lindahl B, Baron T, Rezeli M, Spaak J, Jacobson SH. Associations between inflammatory and angiogenic proteomic biomarkers, and cardiovascular events and mortality in relation to kidney function. Clin Kidney J 2024; 17:sfae050. [PMID: 38524235 PMCID: PMC10959071 DOI: 10.1093/ckj/sfae050] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Indexed: 03/26/2024] Open
Abstract
Background The links between chronic kidney disease (CKD) and the high burden of cardiovascular disease remain unclear. We aimed to explore the association between selected inflammatory and angiogenic biomarkers, kidney function and long-term outcome in patients with an acute coronary syndrome (ACS) and to test the hypothesis that CKD status modifies this association. Methods A total of 1293 ACS patients hospitalized between 2008 and 2015 were followed until 31 December 2017. Plasma was collected on days 1-3 after admission. A total of 13 biomarkers were a priori identified and analysed with two proteomic methods, proximity extension assay or multiple reaction monitoring mass spectrometry. Boxplots and multiple linear regression models were used to study associations between biomarkers and kidney function and adjusted standardized Cox regression with an interaction term for CKD was used to assess whether CKD modified the association between biomarkers and major adverse cardiovascular events and death (MACE+). Results The concentrations of nine biomarkers-endothelial cell-specific molecule-1 (ESM-1), fibroblast growth factor 23 (FGF-23), fractalkine (CX3CL1), interleukin-1 receptor antagonist (IL-1RA), interleukin-18 (IL-18), monocyte chemotactic protein-1 (MCP-1), placenta growth factor (PlGF), transmembrane immunoglobulin 1 (TIM-1) and vascular endothelial growth factor A (VEGFA)-were inversely associated with kidney function. ESM-1, FGF-23 and TIM-1 showed associations with MACE+. Only FGF23 remained independently associated after adjustment for the other biomarkers (hazard ratio per standard deviation increase 1.34; 95% Bonferroni corrected confidence interval 1.19-1.50). None of the biomarkers showed an interaction with CKD. Conclusions The concentrations of 9 of the 13 prespecified inflammatory and angiogenic proteomic biomarkers increased when kidney function declined. Only FGF-23 demonstrated an independent association with MACE+, and this association was not modified by CKD status. These findings further support FGF-23 as an independent prognostic marker in ACS patients with and without CKD.
Collapse
Affiliation(s)
- Barbara Salzinger
- Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Kristina Lundwall
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Marie Evans
- ME Renal Medicine, Department of Clinical Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Josefin Mörtberg
- Division of Nephrology, Department of Internal Medicine, Centre for Clinical Research, County of Vastmanland and Uppsala University, Uppsala, Sweden
| | - Håkan Wallén
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Pia Lundman
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Per Tornvall
- Department of Clinical Science and Education, Sodersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Tomasz Baron
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Melinda Rezeli
- Clinical Protein Science & Imaging, Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Jonas Spaak
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| |
Collapse
|
9
|
Ludzki AC, Hansen M, Zareifi D, Jalkanen J, Huang Z, Omar-Hmeadi M, Renzi G, Klingelhuber F, Boland S, Ambaw YA, Wang N, Damdimopoulos A, Liu J, Jernberg T, Petrus P, Arner P, Krahmer N, Fan R, Treuter E, Gao H, Rydén M, Mejhert N. Transcriptional determinants of lipid mobilization in human adipocytes. Sci Adv 2024; 10:eadi2689. [PMID: 38170777 PMCID: PMC10776019 DOI: 10.1126/sciadv.adi2689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024]
Abstract
Defects in adipocyte lipolysis drive multiple aspects of cardiometabolic disease, but the transcriptional framework controlling this process has not been established. To address this, we performed a targeted perturbation screen in primary human adipocytes. Our analyses identified 37 transcriptional regulators of lipid mobilization, which we classified as (i) transcription factors, (ii) histone chaperones, and (iii) mRNA processing proteins. On the basis of its strong relationship with multiple readouts of lipolysis in patient samples, we performed mechanistic studies on one hit, ZNF189, which encodes the zinc finger protein 189. Using mass spectrometry and chromatin profiling techniques, we show that ZNF189 interacts with the tripartite motif family member TRIM28 and represses the transcription of an adipocyte-specific isoform of phosphodiesterase 1B (PDE1B2). The regulation of lipid mobilization by ZNF189 requires PDE1B2, and the overexpression of PDE1B2 is sufficient to attenuate hormone-stimulated lipolysis. Thus, our work identifies the ZNF189-PDE1B2 axis as a determinant of human adipocyte lipolysis and highlights a link between chromatin architecture and lipid mobilization.
Collapse
Affiliation(s)
- Alison C. Ludzki
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Mattias Hansen
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Danae Zareifi
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Jutta Jalkanen
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Zhiqiang Huang
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, SE-141 83 Stockholm, Sweden
| | - Muhmmad Omar-Hmeadi
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Gianluca Renzi
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Felix Klingelhuber
- Institute for Diabetes and Obesity, Helmholtz Center Munich, Neuherberg, Germany
- Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Sebastian Boland
- Department of Molecular Metabolism, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Yohannes A. Ambaw
- Department of Molecular Metabolism, Harvard T. H. Chan School of Public Health, Boston, MA, USA
- Department of Cell Biology, Memorial Sloan Kettering Cancer Center (MSKCC), New York, NY, USA
| | - Na Wang
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Anastasios Damdimopoulos
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, SE-141 83 Stockholm, Sweden
| | - Jianping Liu
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, SE-182 88 Stockholm, Sweden
| | - Paul Petrus
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Peter Arner
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Natalie Krahmer
- Institute for Diabetes and Obesity, Helmholtz Center Munich, Neuherberg, Germany
- Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Rongrong Fan
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, SE-141 83 Stockholm, Sweden
| | - Eckardt Treuter
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, SE-141 83 Stockholm, Sweden
| | - Hui Gao
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, SE-141 83 Stockholm, Sweden
| | - Mikael Rydén
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| | - Niklas Mejhert
- Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden
| |
Collapse
|
10
|
Engström G, Lampa E, Dekkers K, Lin YT, Ahlm K, Ahlström H, Alfredsson J, Bergström G, Blomberg A, Brandberg J, Caidahl K, Cederlund K, Duvernoy O, Engvall JE, Eriksson MJ, Fall T, Gigante B, Gummesson A, Hagström E, Hamrefors V, Hedner J, Janzon M, Jernberg T, Johnson L, Lind L, Lindberg E, Mannila M, Nilsson U, Persson A, Persson HL, Persson M, Ramnemark A, Rosengren A, Schmidt C, Skoglund Larsson L, Sköld CM, Swahn E, Söderberg S, Torén K, Waldenström A, Wollmer P, Zaigham S, Östgren CJ, Sundström J. Pulmonary function and atherosclerosis in the general population: causal associations and clinical implications. Eur J Epidemiol 2024; 39:35-49. [PMID: 38165527 PMCID: PMC10811042 DOI: 10.1007/s10654-023-01088-z] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024]
Abstract
Reduced lung function is associated with cardiovascular mortality, but the relationships with atherosclerosis are unclear. The population-based Swedish CArdioPulmonary BioImage study measured lung function, emphysema, coronary CT angiography, coronary calcium, carotid plaques and ankle-brachial index in 29,593 men and women aged 50-64 years. The results were confirmed using 2-sample Mendelian randomization. Lower lung function and emphysema were associated with more atherosclerosis, but these relationships were attenuated after adjustment for cardiovascular risk factors. Lung function was not associated with coronary atherosclerosis in 14,524 never-smokers. No potentially causal effect of lung function on atherosclerosis, or vice versa, was found in the 2-sample Mendelian randomization analysis. Here we show that reduced lung function and atherosclerosis are correlated in the population, but probably not causally related. Assessing lung function in addition to conventional cardiovascular risk factors to gauge risk of subclinical atherosclerosis is probably not meaningful, but low lung function found by chance should alert for atherosclerosis.
Collapse
Affiliation(s)
- Gunnar Engström
- Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden.
| | - Erik Lampa
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Koen Dekkers
- Department of Medical Sciences, Molecular Epidemiology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Yi-Ting Lin
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Huddinge, Sweden
- Department of Family Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Kristin Ahlm
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Håkan Ahlström
- Department of Surgical Sciences, Section of Radiology, Uppsala University, Uppsala, Sweden
- BFC, Uppsala University Hospital, Uppsala, Sweden
- Antaros Medical AB, Mölndal, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Blomberg
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - John Brandberg
- Department of Radiology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kenneth Caidahl
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Physiology, Sahlgrenska University Hospital, Sahlgrenska Academy, Gothenburg, Sweden
| | - Kerstin Cederlund
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Olov Duvernoy
- Department of Surgical Sciences, Section of Radiology, Uppsala University, Uppsala, Sweden
| | - Jan E Engvall
- CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden
- Department of Clinical Physiology; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Maria J Eriksson
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Tove Fall
- Department of Medical Sciences, Molecular Epidemiology and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Bruna Gigante
- Division of Cardiovascular Medicine Unit, Department of Medicine Solna, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Science, Danderyd University Hospital, Stockholm, Sweden
| | - Anders Gummesson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Genetics and Genomics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Viktor Hamrefors
- Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Jan Hedner
- Pulmonary Department, Sleep Disorders Center, Sahlgrenska University Hospital, Gothenburg, Sweden
- Center of Sleep and Wake Disorders, Sahlgrenska Academy, Gothenburg University, Göteborg, Sweden
| | - Magnus Janzon
- Department of Cardiology, Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Linda Johnson
- Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden
| | - Lars Lind
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
| | - Eva Lindberg
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Maria Mannila
- Heart and Vascular Theme, Department of Cardiology, and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Nilsson
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Anders Persson
- CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden
- Department of Radiology, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Sciences, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Hans Lennart Persson
- Respiratory Medicine, Department of Medical and Health Sciences (IMH), Linköping University, Linköping, Sweden
| | - Margaretha Persson
- Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Anna Ramnemark
- Department of Community Medicine and Rehabilitation, Geriatric Medicine, Umeå University, Umeå, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine Geriatrics and Emergency Medicine, Sahlgrenska University Hospital Östra Hospital, Gothenburg, Sweden
| | - Caroline Schmidt
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - C Magnus Sköld
- Department of Respiratory Medicine and Allergy, Karolinska University Hospital Solna, Stockholm, Sweden
- Respiratory Medicine Unit, Department of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Eva Swahn
- Department of Cardiology, Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Kjell Torén
- Section of Occupational and Environmental Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Waldenström
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Per Wollmer
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Suneela Zaigham
- Department of Clinical Sciences in Malmö, Lund University, Lund, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Carl Johan Östgren
- CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| |
Collapse
|
11
|
Tjerkaski J, Jernberg T, Szummer K. Balancing the risks of bleeding and ischaemia in myocardial infarction patients at high bleeding risk. Eur Heart J Cardiovasc Pharmacother 2023; 9:770-771. [PMID: 37740444 PMCID: PMC10719447 DOI: 10.1093/ehjcvp/pvad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/24/2023]
Affiliation(s)
- J Tjerkaski
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm 182 88, Sweden
| | - T Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm 182 88, Sweden
| | - K Szummer
- Section of Cardiology, Department of Medicine, Karolinska Institutet, Huddinge, Stockholm 171 77, Sweden
| |
Collapse
|
12
|
Bonaca MP, Lesén E, Giannitsis E, Hedberg J, Jernberg T, Lambrelli D, Duong M, Maggioni AP, Ariza-Solé A, ten Berg J, Storey RF. Characteristics and outcomes in patients with a prior myocardial infarction treated with extended dual antiplatelet therapy with ticagrelor 60 mg: findings from ALETHEIA, a multi-country observational study. Eur Heart J Cardiovasc Pharmacother 2023; 9:701-708. [PMID: 37653447 PMCID: PMC10719500 DOI: 10.1093/ehjcvp/pvad062] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/17/2023] [Accepted: 08/29/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Guidelines recommend extended dual antiplatelet therapy, including ticagrelor 60 mg twice daily, in high-risk post-myocardial infarction (MI) patients who have tolerated 12 months and are not at high bleeding risk. The real-world utilization and bleeding and ischaemic outcomes associated with long-term ticagrelor 60 mg in routine clinical practice have not been well described. METHODS Register and claims data from the USA (Optum Clinformatics, IBM MarketScan, and Medicare) and Europe (Sweden, Italy, UK, and Germany) were extracted. Patients initiating ticagrelor 60 mg ≥12 months after MI, meeting eligibility criteria for the PEGASUS-TIMI (Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin - Thrombolysis in Myocardial Infarction 45) 54 trial, were included. The cumulative incidence of the composite of MI, stroke, or all-cause mortality and that of bleeding requiring hospitalization were calculated. Meta-analyses were performed to combine estimates from each source. RESULTS A total of 7035 patients treated with ticagrelor 60 mg met eligibility criteria. Median age was 67 years and 29% were females; 12% had a history of multiple MIs. The majority (95%) had been treated with ticagrelor 90 mg prior to initiating ticagrelor 60 mg. At 12 months from initiation of ticagrelor 60 mg, the cumulative incidence [95% confidence interval (CI)] of MI, stroke, or mortality was 3.33% (2.73-4.04) and was approximately three-fold the risk of bleeding (0.96%; 0.69-1.33). CONCLUSIONS This study provides insights into the use of ticagrelor 60 mg in patients with prior MI in clinical practice. Observed event rates for ischaemic events and bleeding generally align with those in the pivotal trials, support the established safety profile of ticagrelor, and highlight the significant residual ischaemic risk in this population.Clinical Trials.gov Registration NCT04568083.
Collapse
Affiliation(s)
- M P Bonaca
- Department of Medicine, Cardiovascular Division, University of Colorado School of Medicine, Aurora, CO, USA
| | - E Lesén
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | | | - J Hedberg
- BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - T Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - D Lambrelli
- Real-World Evidence, Evidera Inc., London, UK
| | - M Duong
- Real-World Evidence, Evidera Inc., London, UK
| | - A P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
- Ricerca e Salute (ReS) Foundation, Rome, Italy
| | - A Ariza-Solé
- Bellvitge University Hospital, Bioheart, Grup de Malalties Cardiovasculars, Institut d'Investigació Biomèdica de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - J ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- University Medical School Maastricht, Maastricht, The Netherlands
| | - R F Storey
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK and NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
13
|
Löfmark H, Muhrbeck J, Eggers KM, Linder R, Ljung L, Martinsson A, Melki D, Sarkar N, Svensson P, Lindahl B, Jernberg T. HEART-score can be simplified without loss of discriminatory power in patients with chest pain - Introducing the HET-score. Am J Emerg Med 2023; 74:104-111. [PMID: 37804822 DOI: 10.1016/j.ajem.2023.09.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/02/2023] [Revised: 09/04/2023] [Accepted: 09/19/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND The History, Electrocardiogram (ECG), Age, Risk factors and Troponin, (HEART) score is useful for early risk stratification in chest pain patients. The aim was to validate previous findings that a simplified score using history, ECG and troponin (HET-score) has similar ability to stratify risk. METHODS Patients presenting with chest pain with duration of ≥10 min and an onset of last episode ≤12 h but without ST-segment elevation on ECG at 6 emergency departments were eligible for inclusion. The HEART-score and the simplified HET-score were calculated. The endpoint was a composite of myocardial infarction (MI) as index diagnosis, readmission due to new MI or death within 30 days. RESULTS HEART-score identified 32% as low risk (0-2p), 47% as intermediate risk (3-5p), and 20% as high risk (6-10p) patients. The endpoint occurred in 0.5%, 7.3% and 35.7%, respectively. HET-score identified 39%, 42% and 19% as low- (0p), intermediate- (1-2p) and high-risk (3-6p) patients, with the endpoint occurring in 0.6%, 6.2% and 43.2%, respectively. When all variables included in the HEART-score were included in a multivariable logistic regression analysis, only History (OR, CI [95%]): 2.97(2.16-4.09), ECG (1.61[1.14-2.28]) and troponin level (5.21[3.91-6.95]) were significantly associated with cardiovascular events. When HEART- and HET-score were compared in a ROC-analysis, HET-score had a significantly larger AUC (0.887 vs 0.853, p < 0.001). CONCLUSIONS Compared with HEART-score, HET-score is simpler and appears to have similar ability to discriminate between chest pain patients with and without cardiovascular event.
Collapse
Affiliation(s)
- Henrik Löfmark
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Josephine Muhrbeck
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Kai M Eggers
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Rickard Linder
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Lina Ljung
- Department of Clinical Sciences, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | | | - Dina Melki
- Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Nondita Sarkar
- Department of Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Per Svensson
- Department of Clinical Sciences, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
14
|
Ekblom-Bak E, Börjesson M, Ekblom Ö, Angerås O, Bergman F, Berntsson C, Carlhäll CJ, Engström G, Engvall J, Fagman E, Flinck A, Johansson P, Jujic A, Kero T, Lind L, Mannila M, Ostenfeld E, Persson A, Persson J, Persson M, Redfors B, Sandberg C, Wennberg P, Öhlin J, Östgren CJ, Jernberg T. Accelerometer derived physical activity and subclinical coronary and carotid atherosclerosis: cross-sectional analyses in 22 703 middle-aged men and women in the SCAPIS study. BMJ Open 2023; 13:e073380. [PMID: 37996228 PMCID: PMC10668326 DOI: 10.1136/bmjopen-2023-073380] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES The aim included investigation of the associations between sedentary (SED), low-intensity physical activity (LIPA), moderate-to-vigorous intensity PA (MVPA) and the prevalence of subclinical atherosclerosis in both coronaries and carotids and the estimated difference in prevalence by theoretical reallocation of time in different PA behaviours. DESIGN Cross-sectional. SETTING Multisite study at university hospitals. PARTICIPANTS A total of 22 670 participants without cardiovascular disease (51% women, 57.4 years, SD 4.3) from the population-based Swedish CArdioPulmonary bioImage study were included. SED, LIPA and MVPA were assessed by hip-worn accelerometer. PRIMARY AND SECONDARY OUTCOMES Any and significant subclinical coronary atherosclerosis (CA), Coronary Artery Calcium Score (CACS) and carotid atherosclerosis (CarA) were derived from imaging data from coronary CT angiography and carotid ultrasound. RESULTS High daily SED (>70% ≈10.5 hours/day) associated with a higher OR 1.44 (95% CI 1.09 to 1.91), for significant CA, and with lower OR 0.77 (95% CI 0.63 to 0.95), for significant CarA. High LIPA (>55% ≈8 hours/day) associated with lower OR for significant CA 0.70 (95% CI 0.51 to 0.96), and CACS, 0.71 (95% CI 0.51 to 0.97), but with higher OR for CarA 1.41 (95% CI 1.12 to 1.76). MVPA above reference level, >2% ≈20 min/day, associated with lower OR for significant CA (OR range 0.61-0.67), CACS (OR range 0.71-0.75) and CarA (OR range 0.72-0.79). Theoretical replacement of 30 min of SED into an equal amount of MVPA associated with lower OR for significant CA, especially in participants with high SED 0.84 (95% CI 0.76 to 0.96) or low MVPA 0.51 (0.36 to 0.73). CONCLUSIONS MVPA was associated with a lower risk for significant atherosclerosis in both coronaries and carotids, while the association varied in strength and direction for SED and LIPA, respectively. If causal, clinical implications include avoiding high levels of daily SED and low levels of MVPA to reduce the risk of developing significant subclinical atherosclerosis.
Collapse
Affiliation(s)
- Elin Ekblom-Bak
- Department of Physical Activity and Health, Swedish School of Sport and Health Sciences GIH, Stockholm, Sweden
| | - Mats Börjesson
- Center for Health and Performance, University of Gothenburg, Goteborg, Sweden
- Institute of Medicine, University of Gothenburg, Goteborg, Sweden
| | - Örjan Ekblom
- Department of Physical Activity and Health, Swedish School of Sport and Health Sciences GIH, Stockholm, Sweden
| | - Oskar Angerås
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Cardiology, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
| | - Frida Bergman
- Department of Public Health and Clinical Medicine, Umeå Universitet, Umeå, Sweden
| | - Caroline Berntsson
- Department of Radiology, Sahlgrenska University Hospital, Goteborg, Sweden
- Department of Radiology, Institute of Clinical Sciences, University of Gothenburg, Goteborg, Sweden
| | - Carl-Johan Carlhäll
- Department of Health, Medicine and Caring Sciences and Department of Clinical Physiology, Linköping University, Linkoping, Sweden
- Center for Medical Image Science and Visualization, Linköping University, Linkoping, Sweden
| | - Gunnar Engström
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Jan Engvall
- Department of Health, Medicine and Caring Sciences and Department of Clinical Physiology, Linköping University, Linkoping, Sweden
- Center for Medical Image Science and Visualization, Linköping University, Linkoping, Sweden
| | - Erika Fagman
- Department of Radiology, Sahlgrenska University Hospital, Goteborg, Sweden
- Department of Radiology, Institute of Clinical Sciences, University of Gothenburg, Goteborg, Sweden
| | - Agneta Flinck
- Department of Radiology, Sahlgrenska University Hospital, Goteborg, Sweden
- Department of Radiology, Institute of Clinical Sciences, University of Gothenburg, Goteborg, Sweden
| | - Peter Johansson
- Occupational and Environmental Medicine, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Amra Jujic
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Cardiology, Skåne University Hospital Malmö, Malmo, Sweden
| | - Tanja Kero
- Medical Image Centre, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences and Radiology, Uppsala University, Uppsala, Sweden
| | - Lars Lind
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
| | - Maria Mannila
- Department of Cardiology and Clinical Genetics, Karolinska University Hospital, Stockholm, Sweden
| | - Ellen Ostenfeld
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Clinical Physiology, Skåne University Hospital, Lund, Sweden
| | - Anders Persson
- Center for Medical Image Science and Visualization, Linköping University, Linkoping, Sweden
- Department of Radiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
- Department of Clinical Sciences, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Jonas Persson
- Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Margaretha Persson
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Department of Internal Medicine, University Hospital, Malmö, Sweden
| | - Björn Redfors
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Cardiology, Gothenburg, Sweden
| | - Camilla Sandberg
- Department of Public Health and Clinical Medicine, Umeå Universitet, Umeå, Sweden
- Department of Community Medicine and Rehabilitation, Physiotherapy, Umeå University, Umea, Sweden
| | - Patrik Wennberg
- Public Health and Clinical Medicine, Family Medicine, Umeå University, Umea, Sweden
| | - Jerry Öhlin
- Department of Public Health and Clinical Medicine, Sustainable Health, Umeå University, Umeå, Sweden
| | - Carl Johan Östgren
- Center for Medical Image Science and Visualization, Linköping University, Linkoping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| |
Collapse
|
15
|
Tjerkaski J, Jernberg T, Alfredsson J, Erlinge D, James S, Lindahl B, Mohammad MA, Omerovic E, Venetsanos D, Szummer K. Comparison between ticagrelor and clopidogrel in myocardial infarction patients with high bleeding risk. Eur Heart J Cardiovasc Pharmacother 2023; 9:627-635. [PMID: 37263787 PMCID: PMC10627816 DOI: 10.1093/ehjcvp/pvad041] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/19/2023] [Accepted: 05/31/2023] [Indexed: 06/03/2023]
Abstract
AIMS Ticagrelor is associated with a lower risk of ischemic events than clopidogrel. However, it is uncertain whether the benefits of more intensive anti-ischemic therapy outweigh the risks of major bleeding in patients who have a high bleeding risk (HBR). Therefore, this study compared ticagrelor and clopidogrel in myocardial infarction (MI) patients with HBR. METHODS AND RESULTS This study included all patients enrolled in the SWEDEHEART registry who were discharged with dual antiplatelet therapy using ticagrelor or clopidogrel following MI between 2010 and 2017. High bleeding risk was defined as a PRECISE-DAPT score ≥25. Information on ischemic events, major bleeding, and mortality was obtained from national registries, with 365 days of follow-up. Additional outcomes include major adverse cardiovascular events (MACE), a composite of MI, stroke and all-cause mortality, and net adverse clinical events (NACE), a composite of MACE and bleeding. This study included 25 042 HBR patients, of whom 11 848 were treated with ticagrelor. Ticagrelor was associated with a lower risk of MI, stroke, and MACE, but a higher risk of bleeding compared to clopidogrel. There were no significant differences in mortality and NACE. Additionally, when examining the relationship between antiplatelet therapy and bleeding risk in 69 040 MI patients, we found no statistically significant interactions between the PRECISE-DAPT score and treatment effect. CONCLUSIONS We observed no difference in NACE when comparing ticagrelor and clopidogrel in HBR patients. Moreover, we found no statistically significant interactions between bleeding risk and the comparative effectiveness of clopidogrel and ticagrelor in a larger population of MI patients.
Collapse
Affiliation(s)
- Jonathan Tjerkaski
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, 18257 Danderyd, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, 18257 Danderyd, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, 581 83 Linköping, Sweden
| | - David Erlinge
- Department of Clinical Sciences, Cardiology, Lund University, 221 85 Lund, Sweden
| | - Stefan James
- Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, 751 85 Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, 751 85 Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, 751 85 Uppsala, Sweden
| | | | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, 41345 Gothenburg, Sweden
| | - Dimitrios Venetsanos
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, 581 83 Linköping, Sweden
| | - Karolina Szummer
- Section of Cardiology, Department of Medicine, Karolinska Institutet, Huddinge, 171 77 Stockholm, Sweden
| |
Collapse
|
16
|
Schubert J, Lindahl B, Melhus H, Renlund H, Leosdottir M, Yari A, Ueda P, Jernberg T, Hagström E. Elevated low-density lipoprotein cholesterol: An inverse marker of morbidity and mortality in patients with myocardial infarction. J Intern Med 2023; 294:616-627. [PMID: 37254886 DOI: 10.1111/joim.13656] [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] [Indexed: 06/01/2023]
Abstract
BACKGROUND The incidence of atherosclerotic cardiovascular disease increases with levels of low-density lipoprotein cholesterol (LDL-C). Yet, a paradox may exist where lower LDL-C levels at myocardial infarction (MI) are associated with poorer prognoses. OBJECTIVE To assess the association between LDL-C levels at MI with risk factor burden and cause-specific outcomes. METHODS Statin-naive patients hospitalized for a first MI and registered in SWEDEHEART were included. Data were linked to Swedish registers. Primary outcomes were all-cause mortality and nonfatal MI. Associations between LDL-C and outcomes were assessed using adjusted proportional hazards models. RESULTS Among 63,168 patients (median age, 66 years), the median LDL-C level was 3.0 mmol/L (interquartile range 2.4-3.6). Patient age and comorbidities increased as LDL-C decreased. During a median follow-up of 4.5 years, 10,236 patients died, and 4973 had nonfatal MI. Patients with the highest LDL-C had a lower risk of mortality (hazard ratio [HR] 0.75; 95% confidence interval [CI] 0.71-0.80). The risk of hospitalization for pneumonia, hip fracture, chronic obstructive pulmonary disease, and new cancer diagnosis was lower with higher LDL-C (HR range, 0.40-0.81). Patients with the highest LDL-C had a greater risk of recurrent MI (HR 1.16; 95% CI 1.07-1.26). CONCLUSIONS Patients with the highest LDL-C levels at MI had the lowest incidence of mortality and morbidity. This seems to reflect lower age at MI, less underlying morbidities, paired with the modifiability of LDL-C. However, supporting the causal association between LDL-C and ischemic heart disease, elevated LDL-C was simultaneously associated with an increased risk of nonfatal MI.
Collapse
Affiliation(s)
- Jessica Schubert
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala, Sweden
| | - Håkan Melhus
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Margrét Leosdottir
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Ali Yari
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Peter Ueda
- Department of Medicine, Clinical Epidemiology Division, Karolinska Institutet, Solna, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala, Sweden
| |
Collapse
|
17
|
Ritsinger V, Hagström E, Hambraeus K, James S, Jernberg T, Lagerqvist B, Leosdottir M, Lundman P, Pernow J, Östlund O, Norhammar A. Design and rationale of the myocardial infarction and new treatment with metformin study (MIMET) - Study protocol for a registry-based randomised clinical trial. J Diabetes Complications 2023; 37:108599. [PMID: 37683518 DOI: 10.1016/j.jdiacomp.2023.108599] [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: 05/23/2023] [Revised: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023]
Abstract
AIMS To investigate if addition of metformin to standard care (life-style advice) reduces the occurrence of cardiovascular events and death after myocardial infarction (MI) in patients with newly detected prediabetes. METHODS The Myocardial Infarction and new treatment with Metformin study (MIMET) is a large multicentre registry-based randomised clinical trial (R-RCT) within the SWEDEHEART registry platform expected to include 5160 patients with MI and newly detected prediabetes (identified with fasting blood glucose, HbA1c or 2-h glucose on oral glucose tolerance test) at ∼20 study sites in Sweden. Patients 18-80 years, without known diabetes and naïve to glucose lowering therapy, will be randomised 1:1 to open-label metformin therapy plus standard care or standard care alone. OUTCOMES Patients will be followed for 2 years for the primary outcome new cardiovascular event (first of death, non-fatal MI, hospitalisation for heart failure or non-fatal stroke). Secondary endpoints include individual components of the primary endpoint, diabetes diagnosis, initiation of any glucose lowering therapy, cancer, and treatment safety. Events will be collected from national healthcare registries. CONCLUSIONS The MIMET study will investigate if metformin is superior to standard care after myocardial infarction in preventing cardiovascular events in patients with prediabetes (Clinicaltrials.gov identifier: NCT05182970; EudraCT No: 2019-001487-30).
Collapse
Affiliation(s)
- Viveca Ritsinger
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Research and Development, Region Kronoberg, Växjö, Sweden.
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Margrét Leosdottir
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Pia Lundman
- Department of Clinical Sciences, Cardiology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - John Pernow
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ollie Östlund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Anna Norhammar
- Cardiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Capio S:t Görans Hospital, Stockholm, Sweden
| |
Collapse
|
18
|
Östgren CJ, Otten J, Festin K, Angerås O, Bergström G, Cederlund K, Engström G, Eriksson MJ, Eriksson M, Fall T, Gummesson A, Hagström E, Hellman U, James SK, Jernberg T, Kihlberg J, Kylhammar D, Markstad H, Nilsson P, Persson A, Persson M, Pirazzi C, Renklint R, Rosengren A, Söderberg S, Sundström J. Prevalence of atherosclerosis in individuals with prediabetes and diabetes compared to normoglycaemic individuals-a Swedish population-based study. Cardiovasc Diabetol 2023; 22:261. [PMID: 37759237 PMCID: PMC10537533 DOI: 10.1186/s12933-023-01982-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 03/03/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Patients with type 2 diabetes have an increased risk of death and cardiovascular events and people with diabetes or prediabetes have been found to have increased atherosclerotic burden in the coronary and carotid arteries. This study will estimate the cross-sectional prevalence of atherosclerosis in the coronary and carotid arteries in individuals with prediabetes and diabetes, compared with normoglycaemic individuals in a large population-based cohort. METHODS The 30,154 study participants, 50-64 years, were categorized according to their fasting glycaemic status or self-reported data as normoglycaemic, prediabetes, and previously undetected or known diabetes. Prevalence of affected coronary artery segments, severity of stenosis and coronary artery calcium score (CACS) were determined by coronary computed tomography angiography. Total atherosclerotic burden was assessed in the 11 clinically most relevant segments using the Segment Involvement Score and as the presence of any coronary atherosclerosis. The presence of atherosclerotic plaque in the carotid arteries was determined by ultrasound examination. RESULTS Study participants with prediabetes (n = 4804, 16.0%) or diabetes (n = 2282, 7.6%) had greater coronary artery plaque burden, more coronary stenosis and higher CACS than normoglycaemic participants (all, p < 0.01). Among male participants with diabetes 35.3% had CACS ≥ 100 compared to 16.1% among normoglycaemic participants. For women, the corresponding figures were 8.9% vs 6.1%. The prevalence of atherosclerosis in the coronary arteries was higher in participants with previously undetected diabetes than prediabetes, but lower than in patients with known diabetes. The prevalence of any plaque in the carotid arteries was higher in participants with prediabetes or diabetes than in normoglycaemic participants. CONCLUSIONS In this large population-based cohort of currently asymptomatic people, the atherosclerotic burden in the coronary and carotid arteries increased with increasing degree of dysglycaemia. The finding that the atherosclerotic burden in the coronary arteries in the undetected diabetes category was midway between the prediabetes category and patients with known diabetes may have implications for screening strategies and tailored prevention interventions for people with dysglycaemia in the future.
Collapse
Affiliation(s)
- Carl Johan Östgren
- Department of Health, Medicine and Caring Sciences, Centre of Medical Image Science and Visualization (CMIV), Linköping University, 581 83, Linköping, SE, Sweden.
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| | - Julia Otten
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Karin Festin
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kerstin Cederlund
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Gunnar Engström
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Maria J Eriksson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Eriksson
- Medicine Unit Endocrinology, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden
- Unit of Endocrinology, Department of Medicine, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Tove Fall
- Department of Medical Sciences, Molecular Epidemiology, Uppsala University, Uppsala, Sweden
| | - Anders Gummesson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Genetics and Genomics, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Urban Hellman
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Johan Kihlberg
- Department of Health, Medicine and Caring Sciences, Centre of Medical Image Science and Visualization (CMIV), Linköping University, 581 83, Linköping, SE, Sweden
- Department of Radiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - David Kylhammar
- Division of Diagnostics and Specialist Medicine, Department of Health, Medicine and Caring Sciences and Department of Clinical Physiology, Linköping University, Linköping, Sweden
| | - Hanna Markstad
- Center for Medical Imaging and Physiology, Skåne University Hospital and Lund University, Lund, Sweden
- Experimental Cardiovascular Research, Clinical Research Center, Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Peter Nilsson
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Anders Persson
- Department of Health, Medicine and Caring Sciences, Centre of Medical Image Science and Visualization (CMIV), Linköping University, 581 83, Linköping, SE, Sweden
- Department of Radiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Clinical Sciences, Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Margaretha Persson
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Carlo Pirazzi
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rebecka Renklint
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital Östra Hospital, Gothenburg, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| |
Collapse
|
19
|
Welén Schef K, Tornvall P, Alfredsson J, Hagström E, Ravn-Fischer A, Soderberg S, Yndigegn T, Jernberg T. Prevalence of angina pectoris and association with coronary atherosclerosis in a general population. Heart 2023; 109:1450-1459. [PMID: 37225242 PMCID: PMC10511980 DOI: 10.1136/heartjnl-2023-322345] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 01/03/2023] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
OBJECTIVE To assess the contemporary prevalence of, and factors associated with angina pectoris symptoms, and to examine the relationship to coronary atherosclerosis in a middle-aged, general population. METHODS Data were based on the Swedish CArdioPulmonary bioImage Study (SCAPIS), in which 30 154 individuals were randomly recruited from the general population between 2013 and 2018. Participants that completed the Rose Angina Questionnaire were included and categorised as angina or no angina. Subjects with a valid coronary CT angiography (CCTA) were categorised by degree of coronary atherosclerosis; ≥50% obstruction (obstructive coronary atherosclerosis), <50% obstruction or any atheromatosis (non-obstructive coronary atherosclerosis) or none (no coronary atherosclerosis). RESULTS The study population consisted of 28 974 questionnaire responders (median age 57.4 years, female 51.6%, hypertension 19.9%, hyperlipidaemia 7.9%, diabetes mellitus 3.7%), of which 1025 (3.5%) fulfilled the criteria of angina. Coronary atherosclerosis was more common in individuals having angina compared with those with no angina (n=24 602, obstructive coronary atherosclerosis 11.8% vs 5.4%, non-obstructive coronary atherosclerosis 38.9% vs 37.0%, no coronary atherosclerosis 49.4% vs 57.7%, all p<0.001). Factors independently associated with angina were birthplace outside of Sweden (OR 2.58 (95% CI 2.10 to 2.92)), low educational level (OR 1.41 (1.10 to 1.79)), unemployment (OR 1.51 (1.27 to 1.81)), poor economic status (OR 1.85 (1.38 to 2.47)), symptoms of depression (OR 1.63 (1.38 to 1.92)) and high degree of stress (OR 2.92 (1.80 to 4.73)). CONCLUSION Angina pectoris symptoms are common (3.5%) among middle-aged individuals of the general population of Sweden, though with low association to obstructive coronary atherosclerosis. Sociodemographic and psychological factors are highly associated with angina symptoms, irrespective of degree of coronary atherosclerosis.
Collapse
Affiliation(s)
- Kerstin Welén Schef
- Department of Clinical Sciences, Danderyd Hospital division of Cardiology, Karolinska Institutet, Stockholm, Sweden
| | - Per Tornvall
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala Universitet, Uppsala, Sweden
| | - Annica Ravn-Fischer
- Department of Cardiology, Sahlgrenska University Hospital Institute of Medicine, Göteborg, Sweden
- Department of Molecular and Clinical Medicine Sahlgrenska, Sahlgrenska Academy at University of Gothenburg, Göteborg, Sweden
| | - Stefan Soderberg
- Department of Public Health and Clinical Medicine, Heart Centre, Umeå University, Umeå, Sweden
| | - Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Skane University Hospital, Lunds Universitet, Lund, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital division of Cardiology, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
20
|
Neumann JT, Twerenbold R, Ojeda F, Aldous SJ, Allen BR, Apple FS, Babel H, Christenson RH, Cullen L, Di Carluccio E, Doudesis D, Ekelund U, Giannitsis E, Greenslade J, Inoue K, Jernberg T, Kavsak P, Keller T, Lee KK, Lindahl B, Lorenz T, Mahler SA, Mills NL, Mokhtari A, Parsonage W, Pickering JW, Pemberton CJ, Reich C, Richards AM, Sandoval Y, Than MP, Toprak B, Troughton RW, Worster A, Zeller T, Ziegler A, Blankenberg S. Personalized diagnosis in suspected myocardial infarction. Clin Res Cardiol 2023; 112:1288-1301. [PMID: 37131096 PMCID: PMC10449973 DOI: 10.1007/s00392-023-02206-3] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/11/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND In suspected myocardial infarction (MI), guidelines recommend using high-sensitivity cardiac troponin (hs-cTn)-based approaches. These require fixed assay-specific thresholds and timepoints, without directly integrating clinical information. Using machine-learning techniques including hs-cTn and clinical routine variables, we aimed to build a digital tool to directly estimate the individual probability of MI, allowing for numerous hs-cTn assays. METHODS In 2,575 patients presenting to the emergency department with suspected MI, two ensembles of machine-learning models using single or serial concentrations of six different hs-cTn assays were derived to estimate the individual MI probability (ARTEMIS model). Discriminative performance of the models was assessed using area under the receiver operating characteristic curve (AUC) and logLoss. Model performance was validated in an external cohort with 1688 patients and tested for global generalizability in 13 international cohorts with 23,411 patients. RESULTS Eleven routinely available variables including age, sex, cardiovascular risk factors, electrocardiography, and hs-cTn were included in the ARTEMIS models. In the validation and generalization cohorts, excellent discriminative performance was confirmed, superior to hs-cTn only. For the serial hs-cTn measurement model, AUC ranged from 0.92 to 0.98. Good calibration was observed. Using a single hs-cTn measurement, the ARTEMIS model allowed direct rule-out of MI with very high and similar safety but up to tripled efficiency compared to the guideline-recommended strategy. CONCLUSION We developed and validated diagnostic models to accurately estimate the individual probability of MI, which allow for variable hs-cTn use and flexible timing of resampling. Their digital application may provide rapid, safe and efficient personalized patient care. TRIAL REGISTRATION NUMBERS Data of following cohorts were used for this project: BACC ( www. CLINICALTRIALS gov ; NCT02355457), stenoCardia ( www. CLINICALTRIALS gov ; NCT03227159), ADAPT-BSN ( www.australianclinicaltrials.gov.au ; ACTRN12611001069943), IMPACT ( www.australianclinicaltrials.gov.au , ACTRN12611000206921), ADAPT-RCT ( www.anzctr.org.au ; ANZCTR12610000766011), EDACS-RCT ( www.anzctr.org.au ; ANZCTR12613000745741); DROP-ACS ( https://www.umin.ac.jp , UMIN000030668); High-STEACS ( www. CLINICALTRIALS gov ; NCT01852123), LUND ( www. CLINICALTRIALS gov ; NCT05484544), RAPID-CPU ( www. CLINICALTRIALS gov ; NCT03111862), ROMI ( www. CLINICALTRIALS gov ; NCT01994577), SAMIE ( https://anzctr.org.au ; ACTRN12621000053820), SEIGE and SAFETY ( www. CLINICALTRIALS gov ; NCT04772157), STOP-CP ( www. CLINICALTRIALS gov ; NCT02984436), UTROPIA ( www. CLINICALTRIALS gov ; NCT02060760).
Collapse
Affiliation(s)
- Johannes Tobias Neumann
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Raphael Twerenbold
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Francisco Ojeda
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sally J Aldous
- Department of Cardiology, Christchurch Hospital, Christchurch, New Zealand
| | - Brandon R Allen
- Department of Emergency Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Fred S Apple
- Departments of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC and University of Minnesota, Minneapolis, MN, USA
| | - Hugo Babel
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Louise Cullen
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | | | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Ulf Ekelund
- Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Jaimi Greenslade
- Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Kenji Inoue
- Juntendo University Nerima Hospital, Tokyo, Japan
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Thiess Lorenz
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon A Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Arash Mokhtari
- Department of Internal Medicine and Emergency Medicine and Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - William Parsonage
- Australian Centre for Health Service Innovation, Queensland University of Technology, Kelvin Grove, Australia
| | - John W Pickering
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Christopher J Pemberton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Christoph Reich
- Department of Cardiology, Heidelberg University Hospital, Heidelberg, Germany
| | - A Mark Richards
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Yader Sandoval
- Minneapolis Heart Institute, Abbott Northwestern Hospital, and Minneapolis Heart Institute Foundation, Minneapolis, MN, USA
| | - Martin P Than
- Department of Medicine, Christchurch and Emergency Department, University of Otago, Christchurch Hospital, Christchurch, New Zealand
| | - Betül Toprak
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Richard W Troughton
- Department of Medicine, Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Andrew Worster
- Division of Emergency Medicine, McMaster University, Hamilton, ON, Canada
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- University Center of Cardiovascular Science, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Ziegler
- Cardio-CARE, Medizincampus Davos, Davos, Switzerland
- School of Mathematics, Statistics and Computer Science, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
- German Center for Cardiovascular Research (DZHK), Partner SiteHamburg/Kiel/Lübeck, Hamburg, Germany.
- Population Health Research Department, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
21
|
Lörstad S, Shekarestan S, Jernberg T, Tehrani S, Åstrand P, Gille-Johnson P, Persson J. First Sampled High-Sensitive Cardiac Troponin T is Associated With One-Year Mortality in Sepsis Patients and 30- to 365-Day Mortality in Sepsis Survivors. Am J Med 2023; 136:814-823.e8. [PMID: 37156347 DOI: 10.1016/j.amjmed.2023.04.029] [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: 03/30/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Previous studies using cardiac troponin levels to investigate the relationship between myocardial injury and mortality in sepsis patients have been conflicting. Our aim was to investigate the relationship between plasma high-sensitive cardiac troponin T (hs-cTnT) level and 30-day and 1-year mortality in sepsis patients and 30- to 365-day mortality in sepsis survivors. METHODS Sepsis patients requiring vasopressor support and admitted to our institution between 2012 and 2021 (n = 586) were included in this retrospective cohort study. Elevated hs-cTnT values (≥15 ng/L) were divided into quartiles (Q): Q1 15-35 ng/L; Q2 36-61 ng/L; Q3 62-125 ng/L; Q4 126-8630 ng/L. Stratified Kaplan-Meier curves and multivariable Cox regression were used for survival analyses. RESULTS First sampled hs-cTnT was elevated in 529 (90%) patients. One-year mortality was 45% (n = 264). Increasing level of hs-cTnT was independently associated with higher adjusted hazard ratios (HR) for 1-year mortality compared with normal levels: Q1 HR 2.9 (95% confidence interval [CI], 1.03-8.1); Q2 HR 3.5 (95% CI, 1.2-9.8); Q3 HR 4.8 (95% CI, 1.7-13.4); Q4 HR 5.7 (95% CI, 2.1-16). In acute phase survivors, first sampled hs-cTnT was an independent predictor of 30- to 365-day mortality (HR 1.3; 95% CI, 1.1-1.6 per loge hs-cTnT). CONCLUSIONS First sampled plasma hs-cTnT in critically ill sepsis patients was independently associated with 30-day and 1-year mortality. Importantly, first sampled hs-cTnT was associated with mortality during the convalescence phase (30- to 365-day) and could be a feasible marker to identify acute phase survivors at high risk of death.
Collapse
Affiliation(s)
- Samantha Lörstad
- Division of Internal Medicine and Infectious Diseases, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden.
| | - Shajan Shekarestan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Sara Tehrani
- Division of Internal Medicine and Infectious Diseases, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Per Åstrand
- Internal Medicine and Infectious Diseases Clinic, Danderyd University Hospital, Stockholm, Sweden
| | - Patrik Gille-Johnson
- Internal Medicine and Infectious Diseases Clinic, Danderyd University Hospital, Stockholm, Sweden
| | - Jonas Persson
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| |
Collapse
|
22
|
Cederström S, Lundman P, Alfredsson J, Hagström E, Ravn-Fischer A, Söderberg S, Yndigegn T, Tornvall P, Jernberg T. Association between high-sensitivity C-reactive protein and coronary atherosclerosis in a general middle-aged population. Sci Rep 2023; 13:12171. [PMID: 37500663 PMCID: PMC10374905 DOI: 10.1038/s41598-023-39051-3] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/19/2023] [Indexed: 07/29/2023] Open
Abstract
Despite abundant knowledge about the relationship between inflammation and coronary atherosclerosis, it is still unknown whether systemic inflammation measured as high-sensitivity C-reactive protein (hsCRP) is associated with coronary atherosclerosis in a general population. This study aimed to examine the association between hsCRP and coronary computed tomography angiography (CCTA)-detected coronary atherosclerosis in a population-based cohort. Out of 30,154 randomly invited men and women aged 50 to 64 years in the Swedish Cardiopulmonary Bioimage Study (SCAPIS), 25,408 had a technically acceptable CCTA and analysed hsCRP. Coronary atherosclerosis was defined as presence of plaque of any degree in any of 18 coronary segments. HsCRP values were categorised in four groups. Compared with hsCRP below the detection limit, elevated hsCRP (≥ 2.3 mg/L) was weakly associated with any coronary atherosclerosis (OR 1.15, 95% CI 1.07-1.24), coronary diameter stenosis ≥ 50% (OR 1.27, 95% CI 1.09-1.47), ≥ 4 segments involved (OR 1.13, 95% CI 1.01-1.26 ) and severe atherosclerosis (OR 1.33, 95% CI 1.05-1.69) after adjustment for age, sex and traditional risk factors. The associations were attenuated after further adjustment for body mass index (BMI), although elevated hsCRP still associated with noncalcified plaques (OR 1.16, 95% CI 1.02-1.32), proposed to be more vulnerable. In conclusion, the additional value of hsCRP to traditional risk factors in detection of coronary atherosclerosis is low. The association to high-risk noncalcified plaques, although unlikely through a causal pathway, could explain the relationship between hsCRP and clinical coronary events in numerous studies.
Collapse
Affiliation(s)
- Sofia Cederström
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Pia Lundman
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Annica Ravn-Fischer
- Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Heart Centre, Umeå University, Umeå, Sweden
| | - Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | - Per Tornvall
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
23
|
Ohm J, Kuja-Halkola R, Warnqvist A, Häbel H, Skoglund PH, Sundström J, Hambraeus K, Jernberg T, Svensson P. Socioeconomic Disparities and Mediators for Recurrent Atherosclerotic Cardiovascular Disease Events After a First Myocardial Infarction. Circulation 2023; 148:256-267. [PMID: 37459408 PMCID: PMC10348618 DOI: 10.1161/circulationaha.123.064440] [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: 02/17/2023] [Accepted: 06/13/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Low socioeconomic status is associated with worse secondary prevention use and prognosis after myocardial infarction (MI). Actions for health equity improvements warrant identification of risk mediators. Therefore, we assessed mediators of the association between socioeconomic status and first recurrent atherosclerotic cardiovascular disease event (rASCVD) after MI. METHODS In this cohort study on 1-year survivors of first-ever MI with Swedish universal health coverage ages 18 to 76 years, individual-level data from SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) and linked national registries was collected from 2006 through 2020. Exposure was socioeconomic status by disposable income quintile (principal proxy), educational level, and marital status. The primary outcome was rASCVD and secondary outcomes were cardiovascular and all-cause mortality. We initially assessed the incremental attenuation of hazard ratios with 95% CIs in sequential multivariable models adding groups of potential mediators (ie, previous risk factors, acute presentation and infarct severity, initial therapies, and secondary prevention). Thereafter, the proportion of excess rASCVD associated with a low income mediated through nonparticipation in cardiac rehabilitation, suboptimal statin management, a cardiometabolic risk profile, persistent smoking, and blood pressure above target after MI were calculated using causal mediation analysis. RESULTS Among 68 775 participants (73.8% men), 7064 rASCVD occurred during a mean 5.7-year follow-up. Income, adjusted for age, sex, and calendar year, was associated with rASCVD (hazard ratio, 1.63 [95% CI, 1.51-1.76] in the lowest versus highest income quintile). Risk attenuated most by adjustment for previous risk factors and by adding secondary prevention variables for a final model (hazard ratio, 1.38 [95% CI, 1.26-1.51]) in the lowest versus highest income quintile. The proportions of the excess 15-year rASCVD risk in the lowest income quintile mediated through nonparticipation in cardiac rehabilitation, cardiometabolic risk profile, persistent smoking, and poor blood pressure control were 3.3% (95% CI 2.1-4.8), 3.9% (95% CI, 2.9-5.5), 15.2% (95% 9.1-25.7), and 1.0% (95% CI 0.6-1.5), respectively. Risk mediation through optimal statin management was negligible. CONCLUSIONS Nonparticipation in cardiac rehabilitation, a cardiometabolic risk profile, and persistent smoking mediate income-dependent prognosis after MI. In the absence of randomized trials, this causal inference approach may guide decisions to improve health equity.
Collapse
Affiliation(s)
- Joel Ohm
- Department of Emergency Medicine Solna (J.O.), Karolinska University Hospital, Stockholm, Sweden
- Coagulation Unit, Department of Hematology (J.O.), Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Solna (J.O., P.H.S.), Karolinska Institutet, Stockholm, Sweden
| | - Ralf Kuja-Halkola
- Department of Medical Epidemiology and Biostatistics (R.K.-H.), Karolinska Institutet, Stockholm, Sweden
| | - Anna Warnqvist
- Institute of Environmental Medicine, Division of Biostatistics (A.W., H.H.), Karolinska Institutet, Stockholm, Sweden
| | - Henrike Häbel
- Institute of Environmental Medicine, Division of Biostatistics (A.W., H.H.), Karolinska Institutet, Stockholm, Sweden
| | - Per H. Skoglund
- Department of Medicine Solna (J.O., P.H.S.), Karolinska Institutet, Stockholm, Sweden
- Center for Palliative Care, Stiftelsen Stockholms Sjukhem, Stockholm, Sweden (P.H.S.)
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Sweden (J.S.)
| | | | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital (T.J.), Karolinska Institutet, Stockholm, Sweden
| | - Per Svensson
- Department of Clinical Science and Education, Södersjukhuset (P.S.), Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden (P.S.)
| |
Collapse
|
24
|
Ishak D, Aktaa S, Lindhagen L, Alfredsson J, Dondo TB, Held C, Jernberg T, Yndigegn T, Gale CP, Batra G. Association of beta-blockers beyond 1 year after myocardial infarction and cardiovascular outcomes. Heart 2023; 109:1159-1165. [PMID: 37130746 PMCID: PMC10359586 DOI: 10.1136/heartjnl-2022-322115] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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] [Received: 11/08/2022] [Accepted: 02/14/2023] [Indexed: 05/04/2023] Open
Abstract
OBJECTIVE Beta-blockers (BB) are an established treatment following myocardial infarction (MI). However, there is uncertainty as to whether BB beyond the first year of MI have a role in patients without heart failure or left ventricular systolic dysfunction (LVSD). METHODS A nationwide cohort study was conducted including 43 618 patients with MI between 2005 and 2016 in the Swedish register for coronary heart disease. Follow-up started 1 year after hospitalisation (index date). Patients with heart failure or LVSD up until the index date were excluded. Patients were allocated into two groups according to BB treatment. Primary outcome was a composite of all-cause mortality, MI, unscheduled revascularisation and hospitalisation for heart failure. Outcomes were analysed using Cox and Fine-Grey regression models after inverse propensity score weighting. RESULTS Overall, 34 253 (78.5%) patients received BB and 9365 (21.5%) did not at the index date 1 year following MI. The median age was 64 years and 25.5% were female. In the intention-to-treat analysis, the unadjusted rate of primary outcome was lower among patients who received versus not received BB (3.8 vs 4.9 events/100 person-years) (HR 0.76; 95% CI 0.73 to 1.04). Following inverse propensity score weighting and multivariable adjustment, the risk of the primary outcome was not different according to BB treatment (HR 0.99; 95% CI 0.93 to 1.04). Similar findings were observed when censoring for BB discontinuation or treatment switch during follow-up. CONCLUSION Evidence from this nationwide cohort study suggests that BB treatment beyond 1 year of MI for patients without heart failure or LVSD was not associated with improved cardiovascular outcomes.
Collapse
Affiliation(s)
- Divan Ishak
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Suleman Aktaa
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Division of Epidemiology and Biostatistics, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Cardiology, Linköping University, Linköping, Sweden
| | - Tatendashe Bernadette Dondo
- Division of Epidemiology and Biostatistics, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | | | - Chris P Gale
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Division of Epidemiology and Biostatistics, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Gorav Batra
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala, Sweden
| |
Collapse
|
25
|
Khedri M, Szummer K, Lundman P, Jernberg T, Desta L, Lindahl B, Erlinge D, Jacobson SH, Spaak J. Statin Treatment Intensity, Discontinuation, and Long-Term Outcome in Patients With Acute Myocardial Infarction and Impaired Kidney Function. J Cardiovasc Pharmacol 2023; 81:400-410. [PMID: 36735336 DOI: 10.1097/fjc.0000000000001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 10/14/2022] [Accepted: 01/07/2023] [Indexed: 02/04/2023]
Abstract
ABSTRACT Statin dosage in patients with acute myocardial infarction (AMI) and concomitant kidney dysfunction is a clinical dilemma. We studied discontinuation during the first year after an AMI and long-term outcome in patients receiving high versus low-moderate intensity statin treatment, in relation to kidney function. For the intention-to-treat analysis (ITT-A), we included all patients admitted to Swedish coronary care units for a first AMI between 2005 and 2016 that survived in-hospital, had known creatinine, and initiated statin therapy (N = 112,727). High intensity was initiated in 38.7% and low-moderate in 61.3%. In patients with estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m 2 , 25% discontinued treatment the first year; however, the discontinuation rate was similar regardless of the statin intensity. After excluding patients who died, changed therapy, or were nonadherent during the first year, 84,705 remained for the on-treatment analysis (OT-A). Patients were followed for 12.6 (median 5.6) years. In patients with eGFR 30-59 mL/min, high-intensity statin was associated with lower risk for the composite death, reinfarction, or stroke both in ITT-A (hazard ratio [HR] 0.93; 95% confidence interval, 0.87-0.99) and OT-A (HR 0.90; 0.83-0.99); the interaction test for OT-A indicated no heterogeneity for the eGFR < 60 mL/min group ( P = 0.46). Similar associations were seen for all-cause mortality. We confirm that high-intensity statin treatment is associated with improved long-term outcome after AMI in patients with reduced kidney function. Most patients with reduced kidney function initiated on high-intensity statins are persistent after 1 year and equally persistent as patients initiated on low-moderate intensity.
Collapse
Affiliation(s)
- Masih Khedri
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Karolina Szummer
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Pia Lundman
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Liyew Desta
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; and
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Stefan H Jacobson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Spaak
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
26
|
Leosdottir M, Hagstrom E, Hadziosmanovic N, Norhammar A, Lindahl B, Hambraeus K, Jernberg T, Bäck M. Temporal trends in cardiovascular risk factors, lifestyle and secondary preventive medication for patients with myocardial infarction attending cardiac rehabilitation in Sweden 2006-2019: a registry-based cohort study. BMJ Open 2023; 13:e069770. [PMID: 37173109 DOI: 10.1136/bmjopen-2022-069770] [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: 05/15/2023] Open
Abstract
OBJECTIVES Registries have been highlighted as means to improve quality of care. Here, we describe temporal trends in risk factors, lifestyle and preventive medication for patients after myocardial infarction (MI) registered in the quality registry Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART). DESIGN A registry-based cohort study. SETTING All coronary care units and cardiac rehabilitation (CR) centres in Sweden. PARTICIPANTS Patients attending a CR visit at 1-year post-MI 2006-2019 were included (n=81 363, 18-74 years, 74.7% men). OUTCOME MEASURES Outcome measures at 1-year follow-up included blood pressure (BP) <140/90 mm Hg, low-density lipoprotein-cholesterol (LDL-C)<1.8 mmol/L, persistent smoking, overweight/obesity, central obesity, diabetes prevalence, inadequate physical activity, and prescription of secondary preventive medication. Descriptive statistics and testing for trends were applied. RESULTS The proportion of patients attaining the targets for BP<140/90 mmHg increased from 65.2% (2006) to 86.0% (2019), and LDL-C<1.8 mmol/L from 29.8% (2006) to 66.9% (2019, p<0.0001 both). While smoking at the time of MI decreased (32.0% to 26.5%, p<0.0001), persistent smoking at 1 year was unchanged (42.8% to 43.2%, p=0.672) as was the prevalence of overweight/obesity (71.9% to 72.9%, p=0.559). Central obesity (50.5% to 57.0%), diabetes (18.2% to 27.2%) and patients reporting inadequate levels of physical activity (57.0% to 61.5%) increased (p<0.0001 for all). From 2007, >90.0% of patients were prescribed statins and approximately 98% antiplatelet and/or anticoagulant therapy. Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription increased from 68.7% (2006) to 80.2% (2019, p<0.0001). CONCLUSIONS While little change was observed for persistent smoking and overweight/obesity, large improvements were observed for LDL-C and BP target achievements and prescription of preventive medication for Swedish patients after MI 2006-2019. Compared with published results from patients with coronary artery disease in Europe during the same period, these improvements were considerably larger. Continuous auditing and open comparisons of CR outcomes might possibly explain some of the observed improvements and differences.
Collapse
Affiliation(s)
- Margret Leosdottir
- Department of Cardiology, Skane University Hospital, Malmo, Sweden
- Department of Clinical Sciences Malmo, Lund University, Malmo, Sweden
| | - Emil Hagstrom
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Anna Norhammar
- Department of Medicine Solna, Cardiology Unit, Karolinska Institutet, Stockholm, Sweden
- Capio Sankt Gorans Sjukhus, Stockholm, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Maria Bäck
- Department of Medical and Health Sciences, Division of Physiotherapy, Linkoping University, Linkoping, Sweden
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
27
|
Mörtberg J, Salzinger B, Lundwall K, Edfors R, Jacobson SH, Wallén HN, Jernberg T, Baron T, Erlinge D, Andell P, James S, Eggers KM, Hjort M, Kahan T, Lundman P, Tornvall P, Rezeli M, Marko-Varga G, Lindahl B, Spaak J. Prognostic importance of biomarkers associated with haemostatic, vascular and endothelial disturbances in acute coronary syndrome patients in relation to kidney function. Int J Cardiol 2023; 373:64-71. [PMID: 36476672 DOI: 10.1016/j.ijcard.2022.12.005] [Citation(s) in RCA: 2] [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] [Received: 09/27/2022] [Revised: 11/15/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with kidney failure have a high risk for cardiovascular events. We aimed to evaluate the prognostic importance of selected biomarkers related to haemostasis, endothelial function, and vascular regulation in patients with acute coronary syndrome (ACS), and to study whether this association differed in patients with renal dysfunction. METHODS Plasma was collected in 1370 ACS patients included between 2008 and 2015. Biomarkers were analysed using a Proximity Extension Assay and a Multiple Reaction Monitoring mass spectrometry assay. To reduce multiplicity, biomarkers correlating with eGFR were selected a priori among 36 plasma biomarkers reflecting endothelial and vascular function, and haemostasis. Adjusted Cox regression were used to study their association with the composite outcome of myocardial infarction, ischemic stroke, heart failure or death. Interaction with eGFR strata above or below 60 ml/min/1.73 m2 was tested. RESULTS Tissue factor, proteinase-activated receptor, soluble urokinase plasminogen activator surface receptor (suPAR), thrombomodulin, adrenomedullin, renin, and angiotensinogen correlated inversely with eGFR and were selected for the Cox regression. Mean follow-up was 5.2 years during which 428 events occurred. Adrenomedullin, suPAR, and renin were independently associated with the composite outcome. Adrenomedullin showed interaction with eGFR strata (p = 0.010) and was associated with increased risk (HR 1.88; CI 1.44-2.45) only in patients with eGFR ≥60 ml/min/ 1.73 m2. CONCLUSIONS Adrenomedullin, suPAR, and renin were associated with the composite outcome in all. Adrenomedullin, involved in endothelial protection, showed a significant interaction with renal function and outcome, and was associated with the composite outcome only in patients with preserved kidney function.
Collapse
Affiliation(s)
- Josefin Mörtberg
- Centre for Clinical Research, Vastmanland Hospital Vasteras, Region Vastmanland - Uppsala University, Sweden; Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Barbara Salzinger
- Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Lundwall
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Robert Edfors
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Stefan H Jacobson
- Division of Nephrology, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Håkan N Wallén
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Tomasz Baron
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Pontus Andell
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Heart and Vascular Division, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Kai M Eggers
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Marcus Hjort
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Thomas Kahan
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Pia Lundman
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Per Tornvall
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Melinda Rezeli
- Clinical Protein Science & Imaging, Department of Biomedical Engineering, Lund University, BMC D13, Lund SE-221 84, Sweden
| | - György Marko-Varga
- Clinical Protein Science & Imaging, Department of Biomedical Engineering, Lund University, BMC D13, Lund SE-221 84, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Jonas Spaak
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
28
|
Sederholm Lawesson S, Swahn E, Pihlsgård M, Andersson T, Angerås O, Bacsovics Brolin E, Bergdahl E, Blomberg M, Christersson C, Gonçalves I, Gunnarsson OS, Jernberg T, Johnston N, Leander K, Lilliecreutz C, Pehrson M, Rosengren A, Sandström A, Sandström A, Sarno G, Själander S, Svanvik T, Thunström E, Wikström AK, Timpka S. Association Between History of Adverse Pregnancy Outcomes and Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography. JAMA 2023; 329:393-404. [PMID: 36749333 PMCID: PMC10408276 DOI: 10.1001/jama.2022.24093] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [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: 08/29/2022] [Accepted: 12/13/2022] [Indexed: 02/08/2023]
Abstract
IMPORTANCE Adverse pregnancy outcomes are recognized risk enhancers for cardiovascular disease, but the prevalence of subclinical coronary atherosclerosis after these conditions is unknown. OBJECTIVE To assess associations between history of adverse pregnancy outcomes and coronary artery disease assessed by coronary computed tomography angiography screening. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of a population-based cohort of women in Sweden (n = 10 528) with 1 or more deliveries in 1973 or later, ascertained via the Swedish National Medical Birth Register, who subsequently participated in the Swedish Cardiopulmonary Bioimage Study at age 50 to 65 (median, 57.3) years in 2013-2018. Delivery data were prospectively collected. EXPOSURES Adverse pregnancy outcomes, including preeclampsia, gestational hypertension, preterm delivery, small-for-gestational-age infant, and gestational diabetes. The reference category included women with no history of these exposures. MAIN OUTCOMES AND MEASURES Coronary computed tomography angiography indexes, including any coronary atherosclerosis, significant stenosis, noncalcified plaque, segment involvement score of 4 or greater, and coronary artery calcium score greater than 100. RESULTS A median 29.6 (IQR, 25.0-34.9) years after first registered delivery, 18.9% of women had a history of adverse pregnancy outcomes, with specific pregnancy histories ranging from 1.4% (gestational diabetes) to 9.5% (preterm delivery). The prevalence of any coronary atherosclerosis in women with a history of any adverse pregnancy outcome was 32.1% (95% CI, 30.0%-34.2%), which was significantly higher (prevalence difference, 3.8% [95% CI, 1.6%-6.1%]; prevalence ratio, 1.14 [95% CI, 1.06-1.22]) compared with reference women. History of gestational hypertension and preeclampsia were both significantly associated with higher and similar prevalence of all outcome indexes. For preeclampsia, the highest prevalence difference was observed for any coronary atherosclerosis (prevalence difference, 8.0% [95% CI, 3.7%-12.3%]; prevalence ratio, 1.28 [95% CI, 1.14-1.45]), and the highest prevalence ratio was observed for significant stenosis (prevalence difference, 3.1% [95% CI, 1.1%-5.1%]; prevalence ratio, 2.46 [95% CI, 1.65-3.67]). In adjusted models, odds ratios for preeclampsia ranged from 1.31 (95% CI, 1.07-1.61) for any coronary atherosclerosis to 2.21 (95% CI, 1.42-3.44) for significant stenosis. Similar associations were observed for history of preeclampsia or gestational hypertension among women with low predicted cardiovascular risk. CONCLUSIONS AND RELEVANCE Among Swedish women undergoing coronary computed tomography angiography screening, there was a statistically significant association between history of adverse pregnancy outcomes and image-identified coronary artery disease, including among women estimated to be at low cardiovascular disease risk. Further research is needed to understand the clinical importance of these associations.
Collapse
Affiliation(s)
- Sofia Sederholm Lawesson
- Department of Cardiology, Linköping University Hospital, and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Eva Swahn
- Department of Cardiology, Linköping University Hospital, and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Mats Pihlsgård
- Perinatal and Cardiovascular Epidemiology, Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Therese Andersson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elin Bacsovics Brolin
- Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Capio St Görans Hospital, Stockholm, Sweden
| | - Ellinor Bergdahl
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Marie Blomberg
- Department of Obstetrics and Gynecology, Linköping University Hospital, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Isabel Gonçalves
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
- Cardiovascular Research Translational Studies, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Omar Sigurvin Gunnarsson
- Perinatal and Cardiovascular Epidemiology, Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund and Malmö, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Nina Johnston
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Karin Leander
- Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Caroline Lilliecreutz
- Department of Obstetrics and Gynecology, Linköping University Hospital, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Moa Pehrson
- Perinatal and Cardiovascular Epidemiology, Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics, and Emergency Medicine, Sahlgrenska University Hospital, Östra Hospital, Gothenburg, Sweden
| | - Anette Sandström
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Anna Sandström
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Giovanna Sarno
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Sara Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Teresia Svanvik
- Department of Obstetrics and Gynecology, University of Gothenburg, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | - Erik Thunström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics, and Emergency Medicine, Sahlgrenska University Hospital, Östra Hospital, Gothenburg, Sweden
| | - Anna Karin Wikström
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Simon Timpka
- Perinatal and Cardiovascular Epidemiology, Lund University Diabetes Centre, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Obstetrics and Gynecology, Skåne University Hospital, Lund and Malmö, Sweden
| |
Collapse
|
29
|
Bergström G, Rosengren A, Bacsovics Brolin E, Brandberg J, Cederlund K, Engström G, Engvall JE, Eriksson MJ, Gonçalves I, Hagström E, James SK, Jernberg T, Lilja M, Magnusson M, Persson A, Persson M, Sandström A, Schmidt C, Skoglund Larsson L, Sundström J, Swahn E, Söderberg S, Torén K, Östgren CJ, Lampa E, Lind L. Body weight at age 20 and in midlife is more important than weight gain for coronary atherosclerosis: Results from SCAPIS. Atherosclerosis 2023; 373:46-54. [PMID: 36813601 DOI: 10.1016/j.atherosclerosis.2023.01.024] [Citation(s) in RCA: 2] [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] [Received: 11/21/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Elevated body weight in adolescence is associated with early cardiovascular disease, but whether this association is traceable to weight in early adulthood, weight in midlife or to weight gain is not known. The aim of this study is to assess the risk of midlife coronary atherosclerosis being associated with body weight at age 20, body weight in midlife and body weight change. METHODS We used data from 25,181 participants with no previous myocardial infarction or cardiac procedure in the Swedish CArdioPulmonary bioImage Study (SCAPIS, mean age 57 years, 51% women). Data on coronary atherosclerosis, self-reported body weight at age 20 and measured midlife weight were recorded together with potential confounders and mediators. Coronary atherosclerosis was assessed using coronary computed tomography angiography (CCTA) and expressed as segment involvement score (SIS). RESULTS The probability of having coronary atherosclerosis was markedly higher with increasing weight at age 20 and with mid-life weight (p < 0.001 for both sexes). However, weight increase from age 20 until mid-life was only modestly associated with coronary atherosclerosis. The association between weight gain and coronary atherosclerosis was mainly seen in men. However, no significant sex difference could be detected when adjusting for the 10-year delay in disease development in women. CONCLUSIONS Similar in men and women, weight at age 20 and weight in midlife are strongly related to coronary atherosclerosis while weight increase from age 20 until midlife is only modestly related to coronary atherosclerosis.
Collapse
Affiliation(s)
- Göran Bergström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medicine Geriatrics and Emergency Medicine, Sahlgrenska University Hospital Östra Hospital, Gothenburg, Sweden
| | - Elin Bacsovics Brolin
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden; Department of Radiology, Capio S:t Göran Hospital, Stockholm, Sweden
| | - John Brandberg
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kerstin Cederlund
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - Gunnar Engström
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden
| | - Jan E Engvall
- CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Maria J Eriksson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Isabel Gonçalves
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Cardiovascular Research Translational Studies, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Emil Hagström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Lilja
- Department of Public Health and Clinical Medicine, Unit of Research, Education, and Development, Östersund Hospital, Umeå University, Umeå, Sweden
| | - Martin Magnusson
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden; Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden; Hypertension in Africa Research Team HART, North-West University, Potchefstroom, South Africa
| | - Anders Persson
- CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Radiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Clinical Sciences, Huddinge University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Margaretha Persson
- Department of Clinical Sciences in Malmö, Lund University, Malmö, Sweden; Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | - Anette Sandström
- Heart Centre and Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Caroline Schmidt
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden; The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Eva Swahn
- Department of Cardiology and Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Kjell Torén
- Section of Occupational and Environmental Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carl Johan Östgren
- CMIV, Centre of Medical Image Science and Visualization, Linköping University, Linköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Erik Lampa
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lars Lind
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
| |
Collapse
|
30
|
Hamilton E, Desta L, Lundberg A, Alfredsson J, Christersson C, Erlinge D, Kellerth T, Lindmark K, Omerovic E, Reitan C, Jernberg T. Prevalence and prognostic impact of left ventricular systolic dysfunction or pulmonary congestion after acute myocardial infarction. ESC Heart Fail 2023; 10:1347-1357. [PMID: 36732932 PMCID: PMC10053177 DOI: 10.1002/ehf2.14301] [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] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 10/23/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023] Open
Abstract
AIMS The aim was to describe the prevalence, characteristics, and outcome of patients with acute myocardial infarction (MI) developing left ventricular (LV) systolic dysfunction or pulmonary congestion by applying different criteria to define the population. METHODS AND RESULTS In patients with MI included in the Swedish web-system for enhancement and development of evidence-based care in heart disease (SWEDEHEART) registry, four different sets of criteria were applied, creating four not mutually exclusive subsets of patients: patients with MI and ejection fraction (EF) < 50% and/or pulmonary congestion (subset 1); EF < 40% and/or pulmonary congestion (subset 2); EF < 40% and/or pulmonary congestion and at least one high-risk feature (subset 3, PARADISE-MI like); and EF < 50% and no diabetes mellitus (subset 4, DAPA-MI like). Subsets 1, 2, 3, and 4 constituted 31.6%, 15.0%, 12.8%, and 22.8% of all patients with MI (n = 87 177), respectively. The age and prevalence of different co-morbidities varied between subsets. For median age, 70 to 77, for diabetes mellitus, 22 to 33%; for chronic kidney disease, 22 to 38%, for prior MI, 17 to 21%, for atrial fibrillation, 7 to 14%, and for ST-elevations, 38 to 50%. The cumulative incidence of death or heart failure hospitalization at 3 years was 17.4% (95% CI: 17.1-17.7%) in all MIs; 26.9% (26.3-27.4%) in subset 1; 37.6% (36.7-38.5%) in subset 2; 41.8% (40.7-42.8%) in subset 3; and 22.6% (22.0-23.2%) in subset 4. CONCLUSIONS Depending on the definition, LV systolic dysfunction or pulmonary congestion is present in 13-32% of all patients with MI and is associated with a two to three times higher risk of subsequent death or HF admission. There is a need to optimize management and improve outcomes for this high-risk population.
Collapse
Affiliation(s)
- Eleonora Hamilton
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Liyew Desta
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Joakim Alfredsson
- Department of Cardiology, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Christina Christersson
- Department of Medical Sciences, Department of Cardiology, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | | | - Krister Lindmark
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Heart Centre, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital Institute of Medicine, Department of Molecular and Clinical Medicine, Academy at University of Gothenburg, Gothenburg, Sweden
| | - Christian Reitan
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
31
|
Lenell J, Lindahl B, Karlsson P, Batra G, Erlinge D, Jernberg T, Spaak J, Baron T. Reliability of estimating left ventricular ejection fraction in clinical routine: a validation study of the SWEDEHEART registry. Clin Res Cardiol 2023; 112:68-74. [PMID: 35581481 PMCID: PMC9849182 DOI: 10.1007/s00392-022-02031-0] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 04/28/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Patients hospitalized with acute coronary syndrome (ACS) in Sweden routinely undergo an echocardiographic examination with assessment of left ventricular ejection fraction (LVEF). LVEF is a measurement widely used for outcome prediction and treatment guidance. The obtained LVEF is categorized as normal (> 50%) or mildly, moderately, or severely impaired (40-49, 30-39, and < 30%, respectively) and reported to the nationwide registry for ACS (SWEDEHEART). The purpose of this study was to determine the reliability of the reported LVEF values by validating them against an independent re-evaluation of LVEF. METHODS A random sample of 130 patients from three hospitals were included. LVEF re-evaluation was performed by two independent reviewers using the modified biplane Simpson method and their mean LVEF was compared to the LVEF reported to SWEDEHEART. Agreement between reported and re-evaluated LVEF was assessed using Gwet's AC2 statistics. RESULTS Analysis showed good agreement between reported and re-evaluated LVEF (AC2: 0.76 [95% CI 0.69-0.84]). The LVEF re-evaluations were in agreement with the registry reported LVEF categorization in 86 (66.0%) of the cases. In 33 (25.4%) of the cases the SWEDEHEART-reported LVEF was lower than re-evaluated LVEF. The opposite relation was found in 11 (8.5%) of the cases (p < 0.005). CONCLUSION Independent validation of SWEDEHEART-reported LVEF shows an overall good agreement with the re-evaluated LVEF. However, a tendency towards underestimation of LVEF was observed, with the largest discrepancy between re-evaluated LVEF and registry LVEF in subjects with subnormal LV-function in whom the reported assessment of LVEF should be interpreted more cautiously.
Collapse
Affiliation(s)
- Joel Lenell
- grid.8993.b0000 0004 1936 9457Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- grid.8993.b0000 0004 1936 9457Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Per Karlsson
- grid.412354.50000 0001 2351 3333Department of Cardiology and Clinical Physiology, Uppsala University Hospital, Uppsala, Sweden
| | - Gorav Batra
- grid.8993.b0000 0004 1936 9457Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Tomas Jernberg
- grid.4714.60000 0004 1937 0626Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - Jonas Spaak
- grid.4714.60000 0004 1937 0626Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - Tomasz Baron
- grid.8993.b0000 0004 1936 9457Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| |
Collapse
|
32
|
Yndigegn T, Lindahl B, Alfredsson J, Benatar J, Brandin L, Erlinge D, Haaga U, Held C, Johansson P, Karlström P, Kellerth T, Marandi T, Mars K, Ravn-Fischer A, Sundström J, Östlund O, Hofmann R, Jernberg T. Design and rationale of randomized evaluation of decreased usage of beta-blockers after acute myocardial infarction (REDUCE-AMI). Eur Heart J Cardiovasc Pharmacother 2022; 9:192-197. [PMID: 36513329 PMCID: PMC9892870 DOI: 10.1093/ehjcvp/pvac070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/23/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
AIMS Most trials showing benefit of beta-blocker treatment after myocardial infarction (MI) included patients with large MIs and are from an era before modern biomarker-based MI diagnosis and reperfusion treatment. The aim of the randomized evaluation of decreased usage of beta-blockers after acute myocardial infarction (REDUCE-AMI) trial is to determine whether long-term oral beta-blockade in patients with an acute MI and preserved left ventricular ejection fraction (EF) reduces the composite endpoint of death of any cause or recurrent MI. METHODS AND RESULTS It is a registry-based, randomized, parallel, open-label, multicentre trial performed at 38 centres in Sweden, 1 centre in Estonia, and 6 centres in New Zealand. About 5000 patients with an acute MI who have undergone coronary angiography and with EF ≥ 50% will be randomized to long-term treatment with beta-blockade or not. The primary endpoint is the composite endpoint of death of any cause or new non-fatal MI. There are several secondary endpoints, including all-cause death, cardiovascular death, new MI, readmission because of heart failure and atrial fibrillation, symptoms, functional status, and health-related quality of life after 6-10 weeks and after 1 year of treatment. Safety endpoints are bradycardia, AV-block II-III, hypotension, syncope or need for pacemaker, asthma or chronic obstructive pulmonary disease, and stroke. CONCLUSION The results from REDUCE-AMI will add important evidence regarding the effect of beta-blockers in patients with MI and preserved EF and may change guidelines and clinical practice.
Collapse
Affiliation(s)
- Troels Yndigegn
- Corresponding author. Tel: +46-732 02 00 45, , Twitter: @YndigegnY
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, 751 05 Uppsala, Sweden
| | - Joakim Alfredsson
- Department of Cardiology Department of Health, Medicine and Caring Sciences, Linköping University, 581 83 Linköping, Sweden
| | - Jocelyne Benatar
- Department of Cardiology, Green Lane Cardiovascular Service, Auckland City Hospital, 1051 Auckland, New Zealand
| | - Lisa Brandin
- Division of Cardiology, Skaraborgs sjukhus Skövde, 541 42 Skövde, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Skane University Hospital, Lund University, 222 42 Lund, Sweden
| | - Urban Haaga
- Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, 651 85 Karlstad, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, 751 05 Uppsala, Sweden
| | - Pelle Johansson
- Heart and Lung Patients Association, 111 27 Stockholm, Sweden
| | - Patric Karlström
- Division of Cardiology, Department of Internal Medicine, Ryhov Hospital, 553 05 Jönköping, Sweden
| | - Thomas Kellerth
- Division of Cardiology and Emergency Medicine, Centralsjukhuset Karlstad, 651 85 Karlstad, Sweden
| | - Toomas Marandi
- Department of Cardiology, University of Tartu, 50406 Tartu, Centre of Cardiology, North Estonia Medical Centre, Tallinn, Estonia
| | - Katarina Mars
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, 118 83 Stockholm, Sweden
| | - Annica Ravn-Fischer
- Department of Cardiology, Sahlgrenska University Hospital Institute of Medicine, Department of Molecular and Clinical Medicine Sahlgrenska, Academy at University of Gothenburg, 413 45 Gothenburg, Sweden
| | - Johan Sundström
- Department of Medical Sciences, Cardiology, Uppsala University, 751 05 Uppsala, Sweden,The George Institute for Global Health, University of New South Wales, 2052 Sydney, Australia
| | - Ollie Östlund
- Department of Medical Sciences, Cardiology, Uppsala University, 751 05 Uppsala, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, 118 83 Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical sciences, Danderyd Hospital, Karolinska Institutet, 182 52 Stockholm, Sweden
| |
Collapse
|
33
|
Rylance RT, Wagner P, Olesen KKW, Carlson J, Alfredsson J, Jernberg T, Leosdottir M, Johansson P, Vasko P, Maeng M, Mohammed MA, Erlinge D. Patient-oriented risk score for predicting death 1 year after myocardial infarction: the SweDen risk score. Open Heart 2022; 9:openhrt-2022-002143. [PMID: 36460308 PMCID: PMC9723953 DOI: 10.1136/openhrt-2022-002143] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/28/2022] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Our aim was to derive, based on the SWEDEHEART registry, and validate, using the Western Denmark Heart registry, a patient-oriented risk score, the SweDen score, which could calculate the risk of 1-year mortality following a myocardial infarction (MI). METHODS The factors included in the SweDen score were age, sex, smoking, diabetes, heart failure and statin use. These were chosen a priori by the SWEDEHEART steering group based on the premise that the factors were information known by the patients themselves. The score was evaluated using various statistical methods such as time-dependent receiver operating characteristics curves of the linear predictor, area under the curve metrics, Kaplan-Meier survivor curves and the calibration slope. RESULTS The area under the curve values were 0.81 in the derivation data and 0.76 in the validation data. The Kaplan-Meier curves showed similar patient profiles across datasets. The calibration slope was 1.03 (95% CI 0.99 to 1.08) in the validation data using the linear predictor from the derivation data. CONCLUSIONS The SweDen risk score is a novel tool created for patient use. The risk score calculator will be available online and presents mortality risk on a colour scale to simplify interpretation and to avoid exact life span expectancies. It provides a validated patient-oriented risk score predicting the risk of death within 1 year after suffering an MI, which visualises the benefit of statin use and smoking cessation in a simple way.
Collapse
Affiliation(s)
- Rebecca Tremain Rylance
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Philippe Wagner
- Center for Clinical Research, Uppsala University, Uppsala, Sweden
| | - Kevin K W Olesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jonas Carlson
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Karolinska University Hospital, Linkoping, Sweden
| | - Tomas Jernberg
- The Swedish Heart and Lung Association, Stockholm, Sweden
| | - Margret Leosdottir
- Department of Clinical Sciences, Skåne University Hospital Lund, Malmö, Sweden,Department of Clinical Sciences, Lund University, Malmo, Sweden
| | | | - Peter Vasko
- Department of Cardiology, Karolinska University Hospital, Linkoping, Sweden
| | - Michael Maeng
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Moman Aladdin Mohammed
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| |
Collapse
|
34
|
Dobrosavljevic M, Fazel S, Du Rietz E, Li L, Zhang L, Chang Z, Jernberg T, Faraone SV, Jendle J, Chen Q, Brikell I, Larsson H. Risk prediction model for cardiovascular diseases in adults initiating pharmacological treatment for attention-deficit/hyperactivity disorder. Evid Based Ment Health 2022; 25:185-190. [PMID: 36396339 PMCID: PMC9685689 DOI: 10.1136/ebmental-2022-300492] [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] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 08/22/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Available prediction models of cardiovascular diseases (CVDs) may not accurately predict outcomes among individuals initiating pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD). OBJECTIVE To improve the predictive accuracy of traditional CVD risk factors for adults initiating pharmacological treatment of ADHD, by considering novel CVD risk factors associated with ADHD (comorbid psychiatric disorders, sociodemographic factors and psychotropic medication). METHODS The cohort composed of 24 186 adults residing in Sweden without previous CVDs, born between 1932 and 1990, who started pharmacological treatment of ADHD between 2008 and 2011, and were followed for up to 2 years. CVDs were identified using diagnoses according to the International Classification of Diseases, and dispended medication prescriptions from Swedish national registers. Cox proportional hazards regression was employed to derive the prediction model. FINDINGS The developed model included eight traditional and four novel CVD risk factors. The model showed acceptable overall discrimination (C index=0.72, 95% CI 0.70 to 0.74) and calibration (Brier score=0.008). The Integrated Discrimination Improvement index showed a significant improvement after adding novel risk factors (0.003 (95% CI 0.001 to 0.007), p<0.001). CONCLUSIONS The inclusion of the novel CVD risk factors may provide a better prediction of CVDs in this population compared with traditional CVD predictors only, when the model is used with a continuous risk score. External validation studies and studies assessing clinical impact of the model are warranted. CLINICAL IMPLICATIONS Individuals initiating pharmacological treatment of ADHD at higher risk of developing CVDs should be more closely monitored.
Collapse
Affiliation(s)
| | - Seena Fazel
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Ebba Du Rietz
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lin Li
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Le Zhang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Stephen V Faraone
- Departments of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Johan Jendle
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Qi Chen
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Isabell Brikell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
35
|
Cederstrom S, Lundman P, Alfredsson J, Hagstrom E, Ravn-Fischer A, Soderberg S, Yndigegn T, Tornvall P, Jernberg T. Association between high sensitivity C-reactive protein and coronary atherosclerosis in a general middle-aged population. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1157] [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: 11/12/2022] Open
Abstract
Abstract
Background
Despite abundant knowledge about the relationship between inflammation and coronary artery disease (CAD), it is still unknown whether high sensitivity C-reactive protein (hsCRP) is associated with coronary atherosclerosis in the general population.
Objectives
The project aimed to study the association between systemic inflammation, measured as hsCRP, and coronary artery atherosclerosis in a large population based cohort.
Methods
30,154 randomly selected men and women aged between 50 and 64 years were included in the SCAPIS (Swedish Cardiopulmonary Bioimage Study). After excluding those not undergoing coronary computed tomography angiography (CCTA), those with proximal segments not technically assessable and those with missing values of hsCRP, 25,408 individuals were analysed. Coronary artery atherosclerosis was defined as presence of plaque of any degree (1–49% or ≥50% diameter stenosis) or segments not assessable due to calcification in any of the 18 coronary segments. Analysis of severe atherosclerosis included participants with ≥50% diameter stenosis in any of the left main coronary artery (LMCA), the proximal left anterior descending artery (LAD) or three vessel disease including ≥50% diameter stenosis in any of the segments in each of the LAD, right coronary artery (RCA) and circumflex artery (CX). Participants with hsCRP above the lowest detection limit (≥0.7mg/L) were divided into tertiles and compared with hsCRP<0.7 mg/L as a reference.
Results
The highest tertile of measurable hsCRP (≥2.3 mg/L) was associated with coronary atherosclerosis in a multivariate analysis adjusted for classical cardiovascular risk factors (Table 1). HsCRP was also related to atherosclerosis with significant coronary artery diameter stenosis ≥50%, ≥4 segments involved, severe atherosclerosis and atherosclerosis with noncalcified plaques. Also, moderately elevated hsCRP (1.2–2.2 mg/L) was significant associated with noncalcified plaques. In a stratified analysis, coronary atherosclerosis was associated with the two highest tertiles of hsCRP (≥1.2 mg/L) in women, but not in men.
Conclusion
Elevated hsCRP was associated with the prevalence of coronary atherosclerosis in a population based cohort of middle-aged men and women. The relationships were more pronounced for atherosclerosis with noncalcified plaques and in women compared to men. This suggests that more attention should be given to hsCRP in risk assessment in middle-aged individuals without known disease, especially in women.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The Swedish Heart Lung FoundationKnut and Alice Wallenberg Foundation
Collapse
Affiliation(s)
- S Cederstrom
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital (KI DS) , Stockholm , Sweden
| | - P Lundman
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital (KI DS) , Stockholm , Sweden
| | - J Alfredsson
- Linkoping University, Faculty of Health Sciences , Linkoping , Sweden
| | - E Hagstrom
- Uppsala University, Department of Medical Sciences, Cardiology , Uppsala , Sweden
| | - A Ravn-Fischer
- Sahlgrenska University Hospital, Department of Molecular and Clinical Medicine , Gothenburg , Sweden
| | - S Soderberg
- Umea University, Department of Public Health and Clinical Medicine , Umea , Sweden
| | - T Yndigegn
- Lund University, Department of Clinical Sciences , Lund , Sweden
| | - P Tornvall
- Karolinska Institute, Department of Clinical Science and Education, Södersjukhuset (KI SÖS) , Stockholm , Sweden
| | - T Jernberg
- Karolinska Institute, Department of Clinical Sciences, Danderyd Hospital (KI DS) , Stockholm , Sweden
| |
Collapse
|
36
|
Ishak D, Aktaa S, Lindhagen L, Alfredsson J, Dondo TB, Held C, Jernberg T, Yndigegn T, Gale CP, Batra G. Association of beta-blockers beyond 1 year after myocardial infarction for patients without heart failure or left ventricular systolic dysfunction and cardiovascular outcomes: nationwide cohort study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2724] [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
Beta-blockers (BB) is an established treatment following presentation with myocardial infarction (MI). However, there is uncertainty as to whether BB use beyond the first year of MI has a secondary preventive role in patients without heart failure and/or left ventricular systolic dysfunction (LVSD).
Purpose
To investigate the association between BB treatment beyond one year after MI for patients without heart failure or LVSD and cardiovascular (CV) outcomes.
Methods
We used data from SWEDEHEART, the national Swedish register for coronary heart disease, to identify patients with MI who were hospitalised between 2005 and 2016. Deterministic linkage of individual patient data was performed with the National Patient Register, the Swedish Prescribed Drug Register, and the National Cause of Death Register. Patients with heart failure or LVSD with left ventricular ejection fraction <50% were excluded. Follow-up started at 1 year after hospitalisation with first MI (index date), when patients were allocated into two groups according to BB treatment. Information about BB treatment at index date and during follow-up was obtained from the Swedish National Prescribed Drug Register. The primary outcome was a composite of all-cause mortality, recurrent MI, unscheduled revascularisation or hospitalisation for heart failure. Secondary outcomes comprised the individual components of the composite outcome, CV death and stroke. Comparison of outcomes between the study groups was performed using Cox and Fine-Gray regression models adjusting for relevant clinical factors after propensity-score weighting. In the main intention-to-treat analysis, patients were censored at end of follow-up (31st December 2017), death or at pre-specified outcome, whichever came first. In supplementary per-protocol analysis, patients were, in addition, censored at the time of first BB discontinuation or switch between treatment arms.
Results
A total of 43,618 patients with MI were hospitalised between 2005 and 2016. Of these, 34,253 (78.5%) were prescribed BB and 9,365 (21.5%) were not on BB treatment at index date 1 year following MI. The median age of the population was 64 years, 25.5% were female, and 36.2% had a STEMI. Median follow-up was 4.5 years. In the intention-to-treat analysis, and after multivariable adjustments and propensity score weighting, BB treatment was associated with a similar rate of the composite CV outcome (hazard ratio [HR] 0.99; 95% confidence interval [CI] 0.93–1.04) compared with no BB treatment. A similar finding was observed when censoring for BB discontinuation or treatment switch during follow-up in a per-protocol analysis (HR 0.98; 95% CI 0.98–1.06). Similar associations were observed for all secondary outcomes (Figure 1).
Conclusions
BB treatment beyond one year after MI for patients without heart failure or LVSD is not associated with a different risk of cardiovascular outcomes compared with patients who do not receive BB.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was financed by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement.
Collapse
Affiliation(s)
- D Ishak
- Uppsala University, Department of Medical Sciences, Cardiology , Uppsala , Sweden
| | - S Aktaa
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds Institute for Data Analytics , Leeds , United Kingdom
| | - L Lindhagen
- Uppsala University, Uppsala Clinical Research Center , Uppsala , Sweden
| | - J Alfredsson
- Linköping University, Department of Health, Medicine and Caring Sciences and Department of Cardiology , Linköping , Sweden
| | - T B Dondo
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds Institute for Data Analytics , Leeds , United Kingdom
| | - C Held
- Uppsala University, Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center , Uppsala , Sweden
| | - T Jernberg
- Danderyd University Hospital, Division of Cardiovascular Medicine, Department of Clinical Sciences , Stockholm , Sweden
| | - T Yndigegn
- Lund University, Department of Cardiology , Lund , Sweden
| | - C P Gale
- University of Leeds, Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds Institute for Data Analytics , Leeds , United Kingdom
| | - G Batra
- Uppsala University, Department of Medical Sciences, Cardiology, Uppsala Clinical Research Center , Uppsala , Sweden
| |
Collapse
|
37
|
Yari A, Ueda P, Hagstrom E, Lundman P, Ravn-Fischer A, Soderberg S, Yndigegn T, Jernberg T. Distribution of cardiovascular disease risk according to SCORE2 and potential need for cholesterol and blood pressure lowering therapy in apparently healthy middle-aged individuals. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2279] [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: 11/13/2022] Open
Abstract
Abstract
Background
The 2021 European Society of Cardiology (ESC) prevention guidelines recommend the Systemic Coronary Risk Estimation 2 algorithm (SCORE2) to estimate the 10-year risk of cardiovascular disease (CVD) events to guide pharmacological treatment for primary prevention in apparently healthy individuals aged 40–69 years.
Purpose
To assess the distribution of CVD risk according to SCORE2 and the proportion of individuals who could be eligible for pharmacological treatment of blood cholesterol and blood pressure in an apparently healthy middle-aged population in Sweden.
Methods
We used data from the Swedish Cardiopulmonary Bioimage Study (SCAPIS) which used population registers to randomly recruit individuals aged 50–64 years at six Swedish study sites. Information was collected from the study participants through clinical examinations, national registries, and questionnaires. We excluded individuals with previously known atherosclerotic CVD, diabetes mellitus, or chronic kidney disease with eGFR <60 mL/min/1.73 m2. The SCORE2 algorithm designed for countries with moderate baseline CVD risk was used to categorize study participants' 10-year CVD risk as low-moderate (<5% risk); high (5-<10% risk); and very-high (≥10% risk). The proportions of the population who could be eligible, according to the 2021 ESC prevention guidelines, for pharmacological treatment of LDL-cholesterol (LDL-C) were assessed. Treatment thresholds for LDL-C according to SCORE2 risk were ≥1.8 mmol/L (high risk) and ≥1.4 mmol/L (very-high risk). Treatment threshold for hypertension was defined as a blood pressure ≥140/90 mmHg regardless of CVD risk.
Results
SCAPIS included 30,082 individuals. After exclusion criteria were applied 26,877 individuals remained (median age 57.2 years; 52.8% women). The median 10-year risk of CVD according to SCORE2 was 5.0 (interquartile range 3.0, 7.0) %. In total, 47.5% were classified as low-moderate risk, 45.9% as high risk, and 6.6% as very-high risk, with men having higher risk than women (figure). Almost all of those with high and very-high risk had LDL-C levels above the treatment thresholds. As such, according to the guidelines, lipid-lowering treatment should be considered (high risk) or was generally recommended (very-high risk) in 51.7% of the total population (Figure 1). The proportion of individuals with blood pressure ≥140/90 mmHg was 21.9%. The self-reported use of lipid-lowering therapy among low-moderate, high risk, and very-high risk individuals was 3.1%, 6.9%, and 6.3%, respectively. The use of blood pressure lowering therapy was 13.1% for those with blood pressure <140/80 mmHg and 29.2% for those ≥140/90 mmHg.
Conclusions
In this population-based study of nearly 27,000 apparently healthy middle-aged individuals in Sweden, around half of the individuals could be eligible for LDL-C-lowering therapy and around one in five could be eligible for antihypertensive therapy according to the 2021 ESC prevention guidelines.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): SCAPIS funding: The Swedish Heart-Lung Foundation and Knut and Alice Wallenberg Foundation.
Collapse
Affiliation(s)
- A Yari
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital , Stockholm , Sweden
| | - P Ueda
- Karolinska Institutet, Department of Medicine, Solna , Stockholm , Sweden
| | - E Hagstrom
- Uppsala University, Department of Medical Sciences, Cardiology , Uppsala , Sweden
| | - P Lundman
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital , Stockholm , Sweden
| | - A Ravn-Fischer
- University of Gothenburg, Department of Molecular and Clinical Medicine , Gothenburg , Sweden
| | - S Soderberg
- Umea University, Department of Public Health and Clinical Medicine, and Heart Centre , Umea , Sweden
| | - T Yndigegn
- Lund University, Department of Clinical Sciences , Lund , Sweden
| | - T Jernberg
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital , Stockholm , Sweden
| |
Collapse
|
38
|
Gudmundsson T, Redfors B, Ramunddal T, Rawshani A, Petursson P, Fischer AR, Erlinge D, Alfredsson J, Mohamman MA, Angeras O, Frobert O, James S, Jernberg T, Omerovic E. Does the quality index of adherence to the evidence-based guidelines predict mortality in patients with myocardial infarction? Eur Heart J 2022. [PMCID: PMC9619580 DOI: 10.1093/eurheartj/ehac544.2282] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background The SWEDEHEART quality index of hospitals' adherence to the evidence-based (EB) guidelines for myocardial infarction (MI) patients has been continuously used for several decades in Sweden. The grading protocol is based on the consensus among hospitals. The hospitals are awarded points (0, 0.5, 1) for each of the 11 indicators depending on the proportion of patients who received EB treatment and achieved treatment goals. The 11 indicators at present are reperfusion treatment in STEMI (yes/no), time to-reperfusion treatment in STEMI, time to revascularisation in NSTEMI, P2Y12 antagonists at discharge, ACE-inhibitor/ARB at discharge, the proportion of patients at follow-up, smoking cessation at one-year, participation in a physical exercise program, target LDL-cholesterol and target blood pressure at one year. Purpose To evaluate whether the SWEDEHEART quality index predicts mortality in patients with MI. Methods We used data for all MI patients reported to the SWEDEHEART registry from 72 hospitals in Sweden between 2015–2021. We calculated the difference in quality index between 2021 and 2015. The hospitals were divided into quintiles based on the difference in the score. Logistic regression with log-time offset was used to adjust for confounders (age, gender, diabetes, hypertension, hyperlipidemia, STEMI/NSTEMI, cardiac arrest before admission, occupation status, history of heart failure, prior MI, prior PCI, prior CABG, cardiogenic shock). Results We identified 98,635 patients with MI, 32,608 (33.1%) were women and 34,198 (34.7%) had STEMI. The average age was 70.8±12.2 years. The median follow-up time was 2.7 years (IQR 1.06–4.63). The crude all-cause mortality rate was 5.5% at 30-days and 22.3% after long-term follow-up. Most hospitals (72.1%) improved their quality index on average by 3.4% per year (P<0.001). The increase in the quality index continued during COVID-19 pandemic (2020–2021) with average increase of 8.6%, 95% CI, 0.97–1.02; P<0.001. The median change in SWEDEHEART quality index score among the quintiles were −1.5 (Q1), 0,5 (Q2), 2,5 (Q3), 3 (Q4), and 4 (Q5). We found no difference in mortality between the quintiles at 30-days (OR 0.99; 95% CI 0.97–1.02; p=1.02) and long-term (OR 1.01; 95% CI 0,99–1.02; p=0.850). Conclusion The SWEDEHEART quality index provides valuable descriptive information about hospitals' adherence to the guidelines. However, the index, in its current form, does not predict mortality in patients with MI. Funding Acknowledgement Type of funding sources: None.
Collapse
Affiliation(s)
- T Gudmundsson
- Sahlgrenska University Hospital , Gothenburg , Sweden
| | - B Redfors
- Sahlgrenska University Hospital , Gothenburg , Sweden
| | - T Ramunddal
- Sahlgrenska University Hospital , Gothenburg , Sweden
| | - A Rawshani
- Sahlgrenska University Hospital , Gothenburg , Sweden
| | - P Petursson
- Sahlgrenska University Hospital , Gothenburg , Sweden
| | - A R Fischer
- Sahlgrenska University Hospital , Gothenburg , Sweden
| | - D Erlinge
- Skane University Hospital , Lund , Sweden
| | - J Alfredsson
- Linkoping University Hospital , Linkoping , Sweden
| | | | - O Angeras
- Sahlgrenska University Hospital , Gothenburg , Sweden
| | - O Frobert
- Orebro University Hospital , Orebro , Sweden
| | - S James
- Uppsala University Hospital , Uppsala , Sweden
| | - T Jernberg
- Danderyd University Hospital , Stockholm , Sweden
| | - E Omerovic
- Sahlgrenska University Hospital , Gothenburg , Sweden
| |
Collapse
|
39
|
Loerstad S, Shekarestan S, Tehrani S, Jernberg T, Astrand P, Gille-Johnson P, Persson J. First sampled plasma troponin T is associated with one-year mortality in sepsis and septic shock, independent of age, gender, comorbidities, and clinically relevant biomarkers. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1486] [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: 11/12/2022] Open
Abstract
Abstract
Background
Patients with sepsis and septic shock often have elevated troponin T levels indicating acute myocardial injury. Studies investigating the relationship between troponin T levels as a predictor for mortality in sepsis have been contradictory.
Purpose
To investigate if the first in-hospital sampled plasma troponin T value is associated with one-year mortality in sepsis and septic shock independent of comorbidities, Sequential Organ Failure Assessment (SOFA)-score, Clinical Frailty Scale, Charlson Comorbidity Index (including age) and clinical biomarkers (e.g., serum lactate, creatinine, C-reactive protein).
Methods
Patients with sepsis and sepsis shock were included if they were admitted to the intermediate and intensive care units at our institution between 1st of March 2012 and 30th of September 2021, and if at least one troponin T value was recorded within the first two calendar days from symptom onset. Variables were collected from medical records. Normal troponin-T was defined as <15 ng/L. Elevated troponin T values were divided into quartiles (Q): Q1 15–35.9 ng/L, Q2 36–61.9 ng/L, Q3 62–125.9 ng/L and Q4 ≥126 ng/L. Kaplan-Meier stratified survival curves were plotted for normal levels and Qs of elevated troponin T. Multivariate Cox regression was used for multivariate analysis.
Results
586 patients were included and 529 (90%) had a first sampled troponin T ≥15 ng/L. 523 (89%) met the Sepsis-3 criteria for septic shock, the remainder met the criteria for sepsis. The mean age was 71 years and 220 (38%) were women. One-year mortality was 45% (n=264). Increasing levels of first sampled plasma troponin T were associated with higher hazard ratios (HR) for one-year mortality compared to normal levels (<15 ng/L): Q1 HR 5.29 (95% confidence interval [CI] 1.9–14.7); Q2 HR 7.47 (95% CI 2.71–20.6); Q3 HR 12.81 (95% CI 4.7–35.0); Q 4 HR 13.82 (95% CI 5.06–37.7) (Figure 1). Troponin T was independently associated with one-year mortality after adjustment for gender, plasma lactate, plasma CRP, prior atrial fibrillation, in-hospital onset atrial fibrillation, SOFA-score, CFS, and CCI (including age) (Table 1).
Conclusions
Elevated first sampled plasma troponin T in patients with sepsis and septic shock was associated with higher one-year mortality, independent of age, gender, comorbidities, and clinically relevant biomarkers. There was a risk gradient across the Qs of elevated troponin T with increasingly higher risk of death at one year per higher Q. Further studies are needed to ascertain whether elevated troponin T levels and clinical assessment scores can be used together in the clinical setting to identify patients for more aggressive treatment and cardiac work-up.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Region Stockholm
Collapse
Affiliation(s)
- S Loerstad
- Karolinska Institutet Danderyd Hospital , Stockholm , Sweden
| | | | - S Tehrani
- Karolinska Institutet Danderyd Hospital , Stockholm , Sweden
| | - T Jernberg
- Karolinska Institutet Danderyd Hospital , Stockholm , Sweden
| | - P Astrand
- Danderyd University Hospital , Stockholm , Sweden
| | | | - J Persson
- Karolinska Institutet Danderyd Hospital , Stockholm , Sweden
| |
Collapse
|
40
|
Welen Schef K, Hagstrom E, Ravn-Fischer A, Soderberg S, Yndigegn T, Tornvall P, Jernberg T. Prevalence and risk factors of angina pectoris and its association with coronary atherosclerosis in a general population, a cross-sectional study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1155] [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: 11/12/2022] Open
Abstract
Abstract
Background
Angina pectoris (AP) is a common clinical presentation with low association to significant coronary artery disease (CAD) in selected cohorts, though yet associated with an elevated risk of major cardiovascular adverse events. Current knowledge on AP prevalence is not up to date since contemporary cross-sectional population-based studies using symptom evaluation are sparse and epidemiological studies often use administrative data from routine health care. Also, there is a lack of studies in the general population examining the association between AP and presence of coronary atherosclerosis.
Purpose
To assess the prevalence of AP, the relationship to CAD, and risk factors associated to the conditions in a population-based, middle-aged Swedish cohort.
Methods
Data were based on the Swedish CArdioPulmonary bioImage Study (SCAPIS), in which 30,154 men and women aged 50–64 years were recruited from the general population between 2013 and 2018. Exposure variables included information from blood sampling, physiological examinations, coronary computed tomographic angiography (CCTA) and an extensive questionnaire, including WHO Rose questionnaire on AP. Participants that completed the Rose questionnaire were included and categorized as having Rose angina or No angina. Subjects with a valid CCTA were further assessed regarding correlation between having Rose angina and degree of CAD, categorized as obstructive (>50% occlusion, O-CAD), non-obstructive (<50% occlusion, NO-CAD) or normal coronary angiography (Normal CA). Associations between risk factor exposures and outcomes were analysed in both cohorts using bivariate logistic regression.
Results
The main cohort consisted of N=28,974 individuals, of which n=1025 fulfilled the criteria of Rose angina, giving a prevalence of 3.5%. Out of these, N=24,602 subjects constituted the CCTA-cohort. Coronary atherosclerosis was significantly more common in individuals having Rose angina compared with those with No angina, (p≤0.001; O-CAD 11.8% vs 5.4%, NO-CAD 38.9% vs 37.0%, Normal CA 49.4% vs 57.7%). Factors associated with Rose angina were birthplace outside of Sweden, low educational level, unemployment, poor economic status, symptoms of depression, and high degree of general stress (Table). Physical inactivity, and current or previous cardiopulmonary diseases only marginally attenuated the associations. These findings were consistent in the sub-population of Rose angina with NO-CAD or Normal CA.
Conclusion
Rose Questionnaire AP was common in a Swedish general population, with a greater association to coronary atherosclerosis at CCTA compared with asymptomatic individuals. O-CAD was though uncommon. Risk factors associated with AP were sociodemographic and psychological, irrespective of degree of CAD.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): SCAPIS has been funded mainly from the Swedish Heart- and Lung foundation and Knut och Alice Wallenberg foundation.
Collapse
Affiliation(s)
- K Welen Schef
- Danderyd University Hospital, Cardiology , Stockholm , Sweden
| | - E Hagstrom
- Uppsala University Hospital, Cardiology , Uppsala , Sweden
| | - A Ravn-Fischer
- Sahlgrenska University Hospital, Cardiology , Gothenburg , Sweden
| | - S Soderberg
- Umea University Hospital, Cardiology , Umea , Sweden
| | - T Yndigegn
- Skane University Hospital, Cardiology , Lund , Sweden
| | - P Tornvall
- South Hospital Stockholm, Cardiology , Stockholm , Sweden
| | - T Jernberg
- Danderyd University Hospital, Cardiology , Stockholm , Sweden
| |
Collapse
|
41
|
Simonsson M, Alfredsson J, Szummer K, Jernberg T, Ueda P. Association of ischemic and bleeding events with mortality in patients with a recent acute myocardial infarction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1298] [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: 11/13/2022] Open
Abstract
Abstract
Background/Introduction
Duration and intensity of antithrombotic treatment after myocardial infarction should be individualized based on a patient's ischemic and bleeding risk [1,2]. While such strategies are typically based on calculations that give equal weight to both types of events, uncertainty remains regarding their relative importance.
Purpose
To describe the incidence of ischemic and bleeding events in patients with a recent myocardial infarction, to compare the association of an ischemic vs bleeding event with mortality and to assess whether this association had changed over the past two decades.
Methods
Patients with acute myocardial infarction enrolled in the SWEDEHEART registry and discharged alive with antithrombotic treatment (aspirin, P2Y12 inhibitor, or oral anticoagulant) from January 2012 to December 2017 were followed from discharge until an ischemic event (recurrent myocardial infarction or ischemic stroke) or bleeding event. Cox regression adjusted for demographic factors, comedications and comorbidities, was used to estimate hazard ratios (HR) for time to death after an ischemic and bleeding event as compared with no event (in a model using time-varying exposure definition) and for an ischemic vs bleeding event in a direct comparison. We then assessed whether the adjusted HR for mortality of an ischemic vs bleeding event had changed across three time-periods (1997–2000, 2001–2011 and 2012–2017) by using an interaction term between time period and type of event.
Results
From January 2012 until December 2017 86, 736 patients were discharged alive with antithrombotic treatment after a myocardial infarction. Of these, 4,039 patients experienced a first ischemic event (incidence rate 5.7 events per 100 person-years), and 3,399 a first bleeding event (incidence rate 4.8 events per 100 person-years). As compared with no event, both ischemic events (adjusted HR 4.16, 95% CI 3.91 to 4.43) and bleeding events (adjusted HR 3.43, 95% CI 3.17 to 3.71) were associated with an increased risk of death. In the direct comparison, ischemic events were associated with a higher risk of death than bleeding events (adjusted HR 1.27, 95% CI 1.15 to 1.40). There was no evidence of a change in the aHR across the three time periods (aHR; 1.17, 95% CI 1.02 to 1.35 in 1997–2000 and 1.18, 95% CI, 1.11 to 1.27 in 2001–2011, p for interaction between time period and type of event ≥0.646).
Conclusion
In this nationwide study of patients with a recent MI, post-discharge ischemic events were more common and associated with higher mortality risk as compared with bleeding events.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Swedish Heart and Lung FoundationSwedish Diabetes Foundation
Collapse
Affiliation(s)
- M Simonsson
- Karolinska Institutet Danderyd Hospital, Department of Clinical Sciences, Cardiology , Stockholm , Sweden
| | - J Alfredsson
- Linkoping University Hospital, Department of Health, Medicine and Caring Sciences and Department of Cardiology , Linkoping , Sweden
| | - K Szummer
- Karolinska Institute, Department of Medicine, Huddinge , Stockholm , Sweden
| | - T Jernberg
- Karolinska Institutet Danderyd Hospital, Department of Clinical Sciences, Cardiology , Stockholm , Sweden
| | - P Ueda
- Karolinska Institutet, Department of Medicine, Solna , Stockholm , Sweden
| |
Collapse
|
42
|
Tjerkaski J, Jernberg T, Alfredsson J, Erlinge D, James S, Lindahl B, Mohammad MA, Omerovic E, Venetsanos D, Szummer K. Comparison between ticagrelor and clopidogrel in high bleeding risk patients with acute coronary syndrome. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1390] [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: 11/13/2022] Open
Abstract
Abstract
Background
Potent antiplatelet agents such as ticagrelor are associated with a lower risk of ischemic events than clopidogrel in patients with acute coronary syndrome (ACS). However, it is uncertain whether the benefits of more intensive anti-ischemic therapy outweigh the risks of major bleeding in individuals who have a high bleeding risk (HBR). This study aimed to assess treatment outcomes following dual antiplatelet therapy (DAPT) using either ticagrelor or clopidogrel in ACS patients with HBR.
Methods
All HBR patients enrolled in the SWEDEHEART registry who were discharged with DAPT using ticagrelor or clopidogrel following ACS between 2010 and 2017 were included in this study. Bleeding risk was assessed using the 4-item PRECISE-DAPT score, which consists of age, prior bleeding, haemoglobin concentration and creatinine clearance. HBR was defined as a PRECISE-DAPT score ≥25. Inverse-probability of treatment weighting was used to adjust for baseline differences between the treatment groups. The main analysis consisted of a doubly robust estimation of causal effect using Cox proportional hazards models. Data on major bleeding, recurrent myocardial infarction (MI), ischemic stroke and all-cause mortality was obtained from national registries, with 365 days of follow-up. Additional outcomes include major adverse cardiovascular events (MACE), a composite of MI, ischemic stroke and all-cause mortality, and net adverse clinical events (NACE), a composite of MACE and major bleeding.
Results
Of all ACS patients, 36% (n=25,042) had a PRECISE-DAPT score ≥25. Approximately half of the study participants were treated with ticagrelor (n=11,848). Ticagrelor reduced the risk of MI (hazard ratio [HR], 0.82 [95% CI 0.74–0.91]), ischemic stroke (HR, 0.73 [95% CI 0.60–0.88]) and MACE (HR, 0.90 [95% CI 0.84–0.97]), while also increasing the risk of major bleeding compared to clopidogrel (HR, 1.30 [95% CI 1.16–1.47]). We found no significant differences in all-cause mortality (HR 1.02 [95% CI 0.92–1.12]) and NACE (HR 0.98 [95% CI 0.92–1.05]).
Conclusions
Ticagrelor was associated with a lower risk of recurrent ischemic events, but a higher risk of major bleeding compared to clopidogrel. There were no significant differences in all-cause mortality and NACE between the treatment groups. These results suggest that more potent antiplatelet agents might not be superior to clopidogrel in ACS patients with HBR.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): Stockholm county council
Collapse
Affiliation(s)
| | - T Jernberg
- Karolinska Institutet Danderyd Hospital , Stockholm , Sweden
| | - J Alfredsson
- Department of Medical and Health Sciences Linkoping University , Linkoping , Sweden
| | - D Erlinge
- Lund University, Department of Clinical Sciences, Cardiology , Lund , Sweden
| | - S James
- Uppsala University Hospital and Uppsala Clinical Research Center , Uppsala , Sweden
| | - B Lindahl
- Uppsala University Hospital and Uppsala Clinical Research Center , Uppsala , Sweden
| | - M A Mohammad
- Lund University, Department of Clinical Sciences, Cardiology , Lund , Sweden
| | - E Omerovic
- Institute of Medicine - Sahlgrenska Academy - University of Gothenburg , Gothenburg , Sweden
| | - D Venetsanos
- Karolinska Institutet, Section of Cardiology, Department of Medicine, Solna, Stockholm, Sweden , Stockholm , Sweden
| | - K Szummer
- Karolinska Institutet, Section of Cardiology, Department of Medicine, Huddinge , Stockholm , Sweden
| |
Collapse
|
43
|
Ostgren CJ, Otten J, Festin K, Jernberg T, Bergstrom G, Engstrom G, Sundstrom J. Prevalence of coronary atherosclerosis in individuals with pre-diabetes and diabetes compared to normoglycemic individuals. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1151] [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: 11/12/2022] Open
Abstract
Abstract
Background
Patients with type 2 diabetes have a two- to four-fold higher risk of death and cardiovascular events than the general population. Understanding the characteristics of atherosclerosis in people with different stages of dysglycaemia compared to normoglycaemic individuals may be useful for tailored prevention strategies in the future.
Purpose
To characterise the prevalence of coronary artery atherosclerosis in individuals with prediabetes, previously undetected diabetes and previously known diabetes compared with normoglycaemic individuals in a large population-based cohort.
Methods
Data were obtained from the Swedish CArdiopulumonary bioImage Study (SCAPIS), a population-based cohort of participants aged 50–64 years. The 25,553 study participants were categorised according to their glycaemic status: normoglycaemic (glucose: <6.1 mmol/L and HbA1c <6.0% (<42 mmol/mol)), pre-diabetes (6.1–6.9 mmol/L and/or elevated HbA1c 6.0–6.5% (42–47mmol/mol)), previously undetected diabetes (glucose ≥7.0 mmol/L and/or HbA1c >6.5% (≥48 mmol/mol)) or known diabetes. Plaque burden (number of diseased coronary segments) was determined by coronary computed tomography angiography (CCTA) in all 18 coronary artery segments. Total coronary artery atherosclerotic burden was assessed by segment involvement score (SIS) ≥4 and any coronary atherosclerosis. Imaging and analyses were performed using a calcium scoring protocol. The calcium content in each coronary artery was measured and summed to obtain an overall coronary artery calcification score (CACS).
Results
Study participants with dysclycaemia were defined as pre-diabetes (n=3,989, 16%), undetected diabetes (n=648, 2.5%) or known diabetes (n=1,033, 6.5%). The prevalence of CCTA-detected atherosclerosis among study participants, stratified by glycaemic status into four groups, is shown in Figure 1. The distribution of CACS categories by glycaemic status is shown in Figure 2. The association between CACS and glycaemic status, with normoglycemia as reference, was further explored in an adjusted (age, sex and site) ordinal regression: pre-diabetes 1.33 (95% CI 1.25–1.42), undetected diabetes 1.82 (95% CI 1.59–2.09), known diabetes 2.88 (95% CI 2.59–3.20). In a sensitivity analysis excluding people with previous myocardial infarction, coronary artery bypass grafting, percutaneous coronary intervention or with stent (n=693), the results were virtually unchanged, pre-diabetes 1.31 (95% CI 1.23–1.40), undetected diabetes 1.80 (95% CI 1.57–2.07), known diabetes 2.73 (95% CI 2.45–3.05).
Conclusions
The prevalence of coronary atherosclerosis increased substantially with increasing dysglycaemia. Our data suggest that more aggressive screening and/or treatment of individuals with prediabetes and diabetes to prevent cardiovascular disease should be discussed in the future.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The main funding body of The Swedish CArdioPulmonary bioImage Study (SCAPIS) is the Swedish Heart- and Lung Foundation.
Collapse
Affiliation(s)
- C J Ostgren
- Linkoping University, Department of Health, Medicine and Caring Sciences , Linkoping , Sweden
| | - J Otten
- Umea University, Department of Public Health and Clinical Medicine , Umea , Sweden
| | - K Festin
- Linkoping University, Department of Health, Medicine and Caring Sciences , Linkoping , Sweden
| | - T Jernberg
- Karolinska Institutet, Dept of clinical sciences, Danderyd Hospital , Stockholm , Sweden
| | - G Bergstrom
- University of Gothenburg, Department of Molecular and Clinical Medicine, Sahlgrenska Academy , Gothenburg , Sweden
| | - G Engstrom
- Lund University, Department of Clinical Science in Malmo , Malmo , Sweden
| | - J Sundstrom
- Uppsala University, Department of Medical Sciences, Clinical Epidemiology , Uppsala , Sweden
| |
Collapse
|
44
|
Lenell J, Lindahl B, Erlinge D, Spaak J, Jernberg T, Baron T. Incremental value of global longitudinal strain in long-term risk prediction after acute coronary syndrome. A SWEDEHEART registry based echo study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.053] [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
Global longitudinal strain (GLS) by 2D speckle tracking echocardiography has emerged as a new method for assessing left ventricular (LV) function, however its added value in long-term risk prediction after Acute Coronary Syndrome (ACS) has not been clearly established. This study aimed to investigate GLS as a predictor of death and heart failure re-hospitalization after ACS in relation to more established echocardiographic measures.
Method
1385 consecutive patients with acute coronary syndrome (47% STEMI, 45% NSTEMI, unstable angina 3.6% and unspecified ACS 4.5%), admitted between 2008 and 2014 to the three participating Swedish university hospitals were reported to the SWEDEHEART registry and underwent routine echocardiography during their hospital stay. The echo data was retrospectively collected from each study site and reviewed at a Core Lab. The prognostic value of systolic left ventricular function parameters (LVEF and GLS) regarding all-cause mortality and heart failure (HF) hospitalizations (median follow-up 6.8 years) was studied using the Cox proportional Hazards model. A nested model comparison was performed with C-statistics.
Results
In the 942 patients remaining after exclusion (median age 65 years, 77% men) median LVEF was 55% (inter quartile range (IQR) 47–60) and median GLS −14.8% (IQR −17.8–11.8). The combined endpoint of HF hospitalization and all-cause death was reached in 17.7% of the patients, 12.1% of the patients died and 8.7% were re-admitted due to HF. After adjustment for baseline characteristics, both LVEF and GLS were individual independent predictors of the combined endpoint, HR 0.964 (95% CI 0.949–0.980, p<0.001) and HR 1.042 (95% CI 1.002–1.084, p=0.042) respectively. The C-statistics increased from 0.752 (95% CI 0.712–0.792) to 0.755 (95% CI 0.706–0.785) when GLS entered the model with clinical data and LVEF.
Conclusion
In a large cohort of patients with ACS and normal or near-normal ejection fraction, GLS emerged as an independent long-term risk predictor of all-cause mortality and heart failure hospitalizations. The incremental predictive value of GLS on top of clinical background and LVEF was statistically significant, but of limited clinical significance.
Funding Acknowledgement
Type of funding sources: None.
Collapse
Affiliation(s)
- J Lenell
- Uppsala Clinical Research Center, Dept. of Medical Sciences, Cardiology, Uppsala University , Uppsala , Sweden
| | - B Lindahl
- Uppsala Clinical Research Center, Dept. of Medical Sciences, Cardiology, Uppsala University , Uppsala , Sweden
| | - D Erlinge
- Lund University, Dept. of Clinical Sciences, Cardiology , Lund , Sweden
| | - J Spaak
- Karolinska Institute, Dept. of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital , Stockholm , Sweden
| | - T Jernberg
- Karolinska Institute, Dept. of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital , Stockholm , Sweden
| | - T Baron
- Uppsala Clinical Research Center, Dept. of Medical Sciences, Cardiology, Uppsala University , Uppsala , Sweden
| |
Collapse
|
45
|
Li L, Chang Z, Sun J, Garcia‐Argibay M, Du Rietz E, Dobrosavljevic M, Brikell I, Jernberg T, Solmi M, Cortese S, Larsson H. Attention-deficit/hyperactivity disorder as a risk factor for cardiovascular diseases: a nationwide population-based cohort study. World Psychiatry 2022; 21:452-459. [PMID: 36073682 PMCID: PMC9453905 DOI: 10.1002/wps.21020] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [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: 11/08/2022] Open
Abstract
Accumulating evidence suggests a higher risk for cardiovascular diseases among individuals with mental disorders, but very little is known about the risk for overall and specific groups of cardiovascular diseases in people with attention-deficit/hyperactivity disorder (ADHD). To fill this knowledge gap, we investigated the prospective associations between ADHD and a wide range of cardiovascular diseases in adults. In a nationwide population-based cohort study, we identified 5,389,519 adults born between 1941 and 1983, without pre-existing cardiovascular diseases, from Swedish registers. The study period was from January 1, 2001 to December 31, 2013. Incident cardiovascular disease events were identified according to ICD codes. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using Cox proportional hazards regression model, with ADHD as a time-varying exposure. After an average 11.80 years of follow-up, 38.05% of individuals with ADHD versus 23.57% of those without ADHD had at least one diagnosis of cardiovascular disease (p<0.0001). ADHD was significantly associated with increased risk of any cardiovascular disease (HR=2.05, 95% CI: 1.98-2.13) after adjusting for sex and year of birth. Further adjustments for education level, birth country, type 2 diabetes mellitus, obesity, dyslipidemia, sleep problems and heavy smoking attenuated the association, which however remained significant (HR=1.84, 95% CI: 1.77-1.91). Further adjustment for psychiatric comorbidities attenuated but could not fully explain the association (HR=1.65, 95% CI: 1.59-1.71). The strongest associations were found for cardiac arrest (HR=2.28, 95% CI: 1.81-2.87), hemorrhagic stroke (HR=2.16, 95% CI: 1.68-2.77), and peripheral vascular disease/arteriosclerosis (HR=2.05, 95% CI: 1.76-2.38). Stronger associations were observed in males and younger adults, while comparable associations were found among individuals with or without psychotropic medications and family history of cardiovascular diseases. These data suggest that ADHD is an independent risk factor for a wide range of cardiovascular diseases. They highlight the importance of carefully monitoring cardiovascular health and developing age-appropriate and individualized strategies to reduce the cardiovascular risk in individuals with ADHD.
Collapse
Affiliation(s)
- Lin Li
- School of Medical SciencesÖrebro UniversityÖrebroSweden,Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Zheng Chang
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Jiangwei Sun
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden,Institute of Environmental MedicineKarolinska InstitutetStockholmSweden
| | | | - Ebba Du Rietz
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | | | - Isabell Brikell
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Tomas Jernberg
- Department of Clinical SciencesDanderyd University HospitalStockholmSweden
| | - Marco Solmi
- Department of PsychiatryUniversity of OttawaOttawaONCanada,Department of Mental HealthOttawa HospitalOttawaONCanada,Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology ProgramUniversity of OttawaOttawaONCanada,Centre for Innovation in Mental Health ‐ Developmental Lab, School of PsychologyUniversity of Southampton, and NHS TrustSouthamptonUK
| | - Samuele Cortese
- Centre for Innovation in Mental Health ‐ Developmental Lab, School of PsychologyUniversity of Southampton, and NHS TrustSouthamptonUK,Hassenfeld Children's Hospital at NYU LangoneNew York University Child Study CenterNew York CityNYUSA,Division of Psychiatry and Applied Psychology, School of MedicineUniversity of NottinghamNottinghamUK
| | - Henrik Larsson
- School of Medical SciencesÖrebro UniversityÖrebroSweden,Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| |
Collapse
|
46
|
Eggers KM, James SK, Jernberg T, Lindahl B. Timing of coronary angiography in patients with non-ST-elevation acute coronary syndrome: long-term clinical outcomes from the nationwide SWEDEHEART registry. EUROINTERVENTION 2022; 18:582-589. [PMID: 35352681 PMCID: PMC10241271 DOI: 10.4244/eij-d-21-00982] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 11/11/2021] [Accepted: 02/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Current guidelines stress the importance of early invasive assessment of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), in particular those at high risk. However, supporting scientific evidence is limited. AIMS We aimed to investigate the prognostic impact of the timing of coronary angiography in a large cohort of NSTE-ACS patients. METHODS We performed a retrospective analysis including 34,666 NSTE-ACS patients registered from 2013 to 2018 in the SWEDEHEART registry. The prognostic implications of the timing of coronary angiography on a continuous scale and within <24 vs 24-72 hours were assessed using Cox regression analyses. RESULTS The median time interval from admission to invasive assessment was 32.8 (25th, 75th percentiles 20.4-63.8) hours. There was no apparent time window within 96 hours from admission that provided prognostic benefit. Coronary angiography within 24-72 hours (vs <24 hours) was not associated with worse outcome overall (all-cause mortality: hazard ratio 1.01, 95% confidence interval [CI] 0.92-1.11; major adverse events: hazard ratio 1.04, 95% CI: 0.98-1.12). Interaction analyses indicated a greater relative benefit of coronary angiography <24 hours in some lower-risk groups (women, non-diabetics, patients with minor troponin elevation) but neutral effects in higher-risk groups (defined by age or the GRACE 2.0 score). CONCLUSIONS These Swedish data do not provide support for an early invasive strategy in NSTE-ACS, especially in high-risk patients. Our results suggest that the timing of invasive assessment should rather be based on individualised decisions integrating symptoms and risk panorama than on strictly defined time intervals.
Collapse
Affiliation(s)
- Kai M Eggers
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| |
Collapse
|
47
|
Mazhar F, Hjemdahl P, Clase CM, Johnell K, Jernberg T, Carrero JJ. Lipid-lowering treatment intensity, persistence, adherence and goal attainment in patients with coronary heart disease. Am Heart J 2022; 251:78-90. [PMID: 35654163 DOI: 10.1016/j.ahj.2022.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 03/02/2022] [Revised: 05/24/2022] [Accepted: 05/25/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND To examine patterns of lipid-lowering therapy (LLT) use, and persistence and adherence among patients with coronary heart disease and their associations with lipoprotein cholesterol (LDL-C) goal attainment. METHODS Observational study among 26,768 patients who had suffered a myocardial infarction or had been revascularized in Stockholm during 2012 to 2018, and followed up through 2019. Outcomes included initiation of LLT, discontinuation, re-initiation, adherence to treatment and LDL-C goal attainment according to the European dyslipidaemia guidelines from 2011 and 2016 (mainly LDL-C <1.8 mmol/L). RESULTS 82% of patients commenced or continued LLT within 90 days after discharge. Of those, 71% were dispensed an LLT prescription within 30 days (62% of them for high-intensity LLT). High-intensity LLT prescribing increased over time, from 12% in 2012 to 78% in 2018. During a median follow-up of 3 (IQR 2-5) years 73% continued to fill prescriptions for a statin, 26.3% temporarily or permanently discontinued, and 0.5% changed to non-statin LLT. Only 1.3% discontinued statin treatment permanently. Throughout observation, about 80% of patients showed good statin adherence (proportion of days covered ≥80%). LDL-C target attainment was 52% the first year and <50% during subsequent years. LDL-C goal attainment was highest among patients receiving high-intensity statin treatment and showing good treatment adherence. CONCLUSION In secondary prevention for patients with established coronary heart disease, the proportion of LDL-C target attainment was low throughout the time period of the study, despite increasing use of high-intensity LLT and good treatment persistence and adherence.
Collapse
Affiliation(s)
- Faizan Mazhar
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden.
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institute and Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Catherine M Clase
- Department of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Ontario, Canada
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital (T.J.), Karolinska Institute, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Clinical Sciences, Danderyd University Hospital (T.J.), Karolinska Institute, Stockholm, Sweden
| |
Collapse
|
48
|
Mazhar F, Hjemdahl P, Clase C, Johnel K, Jernberg T, Carrero J. Intensity of lipid-lowering therapy, adherence and LDL-cholesterol goal attainment in patients with coronary heart disease. Atherosclerosis 2022. [DOI: 10.1016/j.atherosclerosis.2022.06.861] [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: 11/02/2022]
|
49
|
Simonsson M, Alfredsson J, Szummer K, Jernberg T, Ueda P. Association of Ischemic and Bleeding Events With Mortality Among Patients in Sweden With Recent Acute Myocardial Infarction Receiving Antithrombotic Therapy. JAMA Netw Open 2022; 5:e2220030. [PMID: 36036452 PMCID: PMC9425148 DOI: 10.1001/jamanetworkopen.2022.20030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Antithrombotic treatment after myocardial infarction (MI) should be individualized based on the patient's risk of ischemic and bleeding events. Uncertainty remains regarding the relative prognostic importance of the 2 types of events, and further study would be useful. OBJECTIVES To compare the association of ischemic vs bleeding events with mortality in patients with a recent MI and assess whether the relative mortality risk for the 2 types of events has changed over the past 2 decades. DESIGN, SETTING, AND PARTICIPANTS A cohort study based on nationwide registers in Sweden, 2012-2017, was conducted. Data were analyzed between July 2021 and May 2022. Patients with MI who were discharged alive with antithrombotic therapy (antiplatelet therapy or oral anticoagulation) were included in the analysis. MAIN OUTCOMES AND MEASURES The incidence of a first ischemic event (hospitalization for MI or ischemic stroke) or bleeding event (hospitalization with bleeding) up to 1 year after discharge and the mortality risk up to 1 year after each type of event were assessed. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHRs) for 1-year mortality after an ischemic and bleeding event vs no event, and after an ischemic vs bleeding event. Adjusted HRs for mortality after ischemic vs bleeding events were compared among patients discharged in 1997-2000, 2001-2011, and 2012-2017. RESULTS Of 86 736 patients discharged after MI in 2012-2017 (median age, 71 [IQR, 62-80] years; 57 287 [66.0%] men), 4039 individuals experienced a first ischemic event (5.7 per 100 person-years) and 3399 experienced a first bleeding event (4.8 per 100 person-years). The mortality rate was 46.2 per 100 person-years after an ischemic event and 27.1 per 100 person-years after a bleeding event. The aHR for 1-year mortality vs no event was 4.16 (95% CI, 3.91-4.43) after an ischemic event and 3.43 (95% CI, 3.17-3.71) after a bleeding event. When the 2 types of events were compared, the aHR was 1.27 (95% CI, 1.15-1.40) for an ischemic vs bleeding event. There was no statistically significant difference in the aHR of an ischemic vs bleeding event in 1997-2000, 2001-2011, and 2012-2017. CONCLUSIONS AND RELEVANCE In this nationwide cohort study of patients with a recent MI, postdischarge ischemic events were more common and associated with higher mortality risk compared with bleeding events.
Collapse
Affiliation(s)
- Moa Simonsson
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet, Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
50
|
Mazhar F, Hjemdahl P, Clase CM, Johnell K, Jernberg T, Sjölander A, Carrero JJ. Intensity of and Adherence to Lipid-Lowering Therapy as Predictors of Major Adverse Cardiovascular Outcomes in Patients With Coronary Heart Disease. J Am Heart Assoc 2022; 11:e025813. [PMID: 35861825 PMCID: PMC9707817 DOI: 10.1161/jaha.122.025813] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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] [Received: 02/17/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022]
Abstract
Background The effectiveness of lipid-lowering therapy (LLT) is affected by both intensity and adherence. This study evaluated the associations of LLT intensity, adherence, and the combination of these 2 aspects of LLT management with the risk of major adverse cardiovascular events (MACE) in people with coronary heart disease. Methods and Results This is an observational study of all adults who suffered a myocardial infarction or had coronary revascularization during 2012 to 2018 and initiated LLT in Stockholm, Sweden. Study exposures were LLT adherence (proportion of days covered), LLT intensity (expected reduction of low-density lipoprotein cholesterol), and the combined measure of adherence and intensity. At each LLT fill, adherence and intensity during the previous 12 months were calculated. The primary outcomes were MACE (nonfatal myocardial infarction or stroke and death); secondary outcomes were low-density lipoprotein cholesterol goal attainment and individual components of MACE. We studied 20 490 patients aged 68±11 years, 75% men, mean follow-up 2.6±1.1 years. Every 10% increase in 1-year adherence, intensity, or adherence-adjusted intensity was associated with a lower risk of MACE (hazard ratio [HR], 0.94 [95% CI, 0.93-0.96]; HR, 0.92 [95% CI, 0.88-0.96]; and HR, 0.91 [95% CI, 0.89-0.94], respectively) and higher odds of attaining low-density lipoprotein cholesterol goals (odds ratio [OR],1.12 [95% CI, 1.10-1.15]; OR, 1.42 [95% CI, 1.34-1.51], and OR, 1.16 [95% CI, 1.19-1.24], respectively). Among patients with good adherence (≥80%), the risk of MACE was similar with low-moderate and high-intensity LLT despite differences in the low-density lipoprotein cholesterol goal attainment with the treatment intensities. Discontinuation ≥1 year increased the risk markedly (HR,1.66 [95% CI, 1.23-2.22]). Conclusions In routine care, good adherence to LLT was associated with the greatest benefit for patients with coronary heart disease. Strategies that improve adherence and use of intensive therapies could substantially reduce cardiovascular risk.
Collapse
Affiliation(s)
- Faizan Mazhar
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Paul Hjemdahl
- Department of Medicine Solna, Clinical Epidemiology Unit, Karolinska Institutet and Clinical PharmacologyKarolinska University HospitalStockholmSweden
| | - Catherine M. Clase
- Department of Medicine and Health Research Methods, Evidence and ImpactMcMaster UniversityOntario
| | - Kristina Johnell
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Tomas Jernberg
- Department of Clinical SciencesDanderyd University Hospital, Karolinska InstitutetStockholmSweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetStockholmSweden
- Division of NephrologyDepartment of Clinical Sciences, Karolinska Institutet, Danderyd HospitalStockholmSweden
| |
Collapse
|