Validation of myocardial infarction diagnosis in patients with congenital heart disease in Sweden

Ischemic Stroke in Patients With Congenital Heart Disease and Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia in patients with congenital heart disease (CHD), but little is known about the risk for ischemic stroke among younger patients with CHD (aged <65 years) with AF.

METHODS AND RESULTS

Using data from the National Swedish Patient Register and Cause of Death Register, we identified all patients with both CHD and AF born in Sweden between 1970 and 2017. The Swedish total population register was used to identify age- and sex-matched patients without CHD; those with AF were used as controls. Bottos hierarchical classification was used to define CHD as either complex or noncomplex. Controls were followed from the onset of AF until the index ischemic stroke, death, or end of study (December 31, 2017). We identified 951 patients with CHD with AF and 606 controls with AF. Among patients with both CHD and AF, 2.9% of patients (n=28) developed ischemic stroke, compared with 0.5% (n=3) in controls. When adjusted for age, sex, hypertension, and heart failure, a hazard ratio (HR) of 5.16 (95% CI, 1.52-17.46) was acquired. The HR in noncomplex CHD was 3.84 (95% CI, 1.07-13.84), and the HR in complex CHD was 8.34 (95% CI, 2.27-30.57). For patients born in 1970 to 1989, the HR in ischemic stroke was 7.35 (95% CI, 1.70-31.75). No adjusted HR for patients with CHD born in 1990 to 2017 could be acquired due to few events.

CONCLUSIONS

The risk for ischemic stroke may be 5 times higher in patients with both CHD and AF compared with patients without CHD with AF. However, larger studies may be needed to confirm/refute these results.

Impact of Down Syndrome on Survival Among Patients With Congenital Heart Disease

BACKGROUND

Increasing survival among patients with congenital heart disease (CHD) has recently been reported. However, the impact of Down syndrome (DS) in patients with CHD is still debated. We aimed to estimate survival in patients with CHD with versus without DS compared with matched controls from the general population without CHD or DS.

METHODS AND RESULTS

We linked data from Swedish health registries to identify patients with CHD born between 1970 and 2017. Data from the Total Population Register were used to match each patient with CHD by sex and birth year with 8 controls without CHD or DS. A Cox proportional regression model was used to estimate mortality risk, and Kaplan-Meier curves were analyzed for the survival analysis. We identified 3285 patients with CHD-DS, 64 529 patients with CHD without DS, and 26 128 matched controls. The mortality risk was 25.1 times higher (95% CI, 21.3-29.5) in patients with CHD-DS versus controls. The mortality rate was 2 times higher (95% CI, 1.94-2.31) for patients with CHD with versus without DS. Lower mortality was found during the second versus first birth periods in patients with CHD-DS compared with controls; hazard ratio: 46.8 (95% CI, 29.5-74.0) and 17.7 (95% CI, 12.8-24.42) in those born between 1970 and 1989 versus 1990 and 2017, respectively.

CONCLUSIONS

In this retrospective cohort study, the mortality risk among patients with CHD-DS was 25 times higher compared with matched controls and 2 times higher compared with patients with CHD without DS. Survival was higher in patients with CHD-DS born after versus before 1990, coinciding with the modern era of congenital heart care.

No Increased Risk of Cardiac Birth Defects in Infants of Mothers With Celiac Disease: A Population and Sibling Comparison

INTRODUCTION

Several earlier studies have indicated an increased risk of cardiac birth defects among infants born to mothers with celiac disease (CeD). Through linking nationwide Swedish health care registries, we aimed to investigate maternal CeD and risk of any or cardiac birth defects in their offspring.

METHODS

We performed a retrospective cohort study of infants born between 2002 and 2016 to women with biopsy-proven CeD (villous atrophy, Marsh III) matched to infants born to nonceliac women from the general population. Conditional logistic regression with odds ratios (OR) and their 95% confidence intervals (CI) was used to determine the association between maternal CeD and birth defects. To minimize the impact of intrafamilial confounding, we also compared infants born to mothers with CeD with infants born to their nonaffected sisters.

RESULTS

A total of 6,990 infants were born to mothers with diagnosed CeD compared with 34,643 infants born to reference mothers. Any birth defect was seen in 234 (33 per 1,000 infants) and 1,244 (36/1,000) reference infants corresponding to an OR of 0.93 (95% CI 0.81-1.08). Cardiac birth defects were seen in 113 (16/1,000) vs 569 (16/1,000) infants (OR 0.98, 95% CI 0.80-1.20). Similar OR for any and cardiac birth defects were also seen in sibling comparisons.

DISCUSSION

We found no statistically significant risk of any or cardiac birth defects in infants born to mothers with diagnosed CeD compared with the general population and to their nonaffected sisters.

Percutaneous atrial shunt closure and the risk of recurrent ischemic stroke: A register-based, nationwide cohort study

OBJECTIVES

We aimed to investigate the risk of recurrent stroke in patients with transcatheter closure of an atrial shunt (ASCIos), compared to patients with an atrial shunt and cerebrovascular event (CVE) but only medical treated (ASMed), and to age- and sex-matched control individuals without a previous CVE.

METHODS

In total, 663 ASCIos patients were identified in the Swedish National Patient Register from 1997 to 2016 and matched by using propensity score with 663 ASMed patients. Nine age- and sex-matched controls to ASCIos patients (n = 6,302) without a diagnosis of atrial shunt or history of CVE were randomly selected from the general population.

RESULTS

At a mean follow-up of 6.5 years, the incidence rate of recurrent stroke in the ASCIos group vs ASMed group was 0.9 vs 0.7 per 100 patient-years. The hazard ratio of recurrent stroke in the ASCIos group compared with index stroke in the control group was 9.9 (95% confidence interval, 5.5-17.9). The incidence of atrial fibrillation was similar in the ASCIos and the ASMed group, however four times higher in the ASCIos than in the control group.

CONCLUSIONS

Our large nationwide, register-based cohort study showed that, unexpectedly, the risk of recurrent stroke in the ASCos group was as high as in the ASMed group and almost ten times higher than the risk of an index stroke in matched controls without previous stroke.

Cardiovascular disease risk in paediatric and young adult non-alcoholic fatty liver disease

OBJECTIVE

Longitudinal evidence is lacking regarding the long-term risk of major adverse cardiovascular events (MACE) in children and young adults with non-alcoholic fatty liver disease (NAFLD).

DESIGN

This nationwide cohort study included all Swedish children and young adults ≤25 years old with histologically confirmed NAFLD and without underlying cardiovascular disease (CVD) at baseline (1966-2016; n=699). NAFLD was defined from prospectively recorded histopathology, and further categorised as simple steatosis or non-alcoholic steatohepatitis (NASH). NAFLD patients were matched to ≤5 population controls without NAFLD or CVD (n=3353). Using Cox proportional hazards modelling, we calculated multivariable-adjusted HRs (aHRs) and 95% CIs for incident MACE (ie, ischaemic heart disease, stroke, congestive heart failure or cardiovascular mortality). In secondary analyses, we also explored rates of incident cardiac arrhythmias.

RESULTS

Over a median follow-up of 16.6 years, incident MACE was confirmed in 33 NAFLD patients and 52 controls. NAFLD patients had significantly higher rates of MACE than controls (3.1 vs 0.9/1000 person-years (PY); difference=2.1/1000 PY; aHR=2.33, 95% CI=1.43 to 3.78), including higher rates of ischaemic heart disease (difference=1.4/1000 PY; aHR=3.07, 95% CI 1.62 to 5.83) and congestive heart failure (difference=0.5/1000 PY; aHR=3.89, 95% CI=1.20 to 12.64). Rates of incident MACE outcomes appeared to be further augmented with NASH (aHR=5.27, 95% CI=1.96 to 14.19). In secondary analyses, NAFLD patients also had significantly higher rates of cardiac arrythmias (aHR=3.16, 95% CI=1.49 to 6.68).

CONCLUSION

Compared with matched population controls, children and young adults with biopsy-proven NAFLD had significantly higher rates of incident MACE, including ischaemic heart disease and congestive heart failure. Research to better characterise cardiovascular risk in children and young adults with NAFLD should be prioritised.

Congenital heart disease: changes in recorded birth prevalence and cardiac interventions over the past half-century in Sweden

AIMS

Our objective was to assess changes in the birth prevalence of CHD over a half-century in a high-resource, nationwide setting, as well as changes in the prevalence of cardiac interventions in this population.

METHODS AND RESULTS

The Swedish National Patient and Cause of Death registers were linked to estimate the annual rates of CHD and cardiac interventions among live-born infants from 1970 to 2017. Additionally, separate estimates were obtained by lesion complexity, from mild to the most complex forms of CHD. Overall, the numbers of live-born infants with a CHD identified varied from 624 to 2459 annual cases, with rates increasing steadily from 5.7 to an average of 20 per 1000 live births at the end of the study period, and with a more pronounced increase from 1996 to 2005. The largest increase over time was observed for mild CHD lesions. Overall, the proportion of cardiac interventions among patients with CHD declined from 40.7% in 1970 to below 15.0% after 2014. However, in the most complex CHD lesion groups, overall cardiac interventions increased from 57.1 to 76.8% in patients with conotruncal defects and from 32.8 to 39.5% in those with severe non-conotruncal defects.

CONCLUSION

The live-birth prevalence of CHD in Sweden more than tripled during the past half-century, most likely resulting from more accurate diagnostic capabilities. The largest increase over time was observed among patients with simple defects. During the same period, overall cardiac interventions decreased whereas interventions for the most complex CHD groups increased.

Risk of cancer in young and older patients with congenital heart disease and the excess risk of cancer by syndromes, organ transplantation and cardiac surgery: Swedish health registry study (1930-2017)

Background

Increasing survival of patients with congenital heart disease (CHD) will result in an increased risk of age-dependent acquired diseases later in life. We aimed to investigate the risk of cancer in young and older patients with CHD and to evaluate the excess risk of cancer by syndromes, organ transplantation and cardiac surgery.

Methods

Patients with CHD born between 1930 and 2017 were identified using Swedish Health Registers. Each patient with CHD (n = 89,542) was matched by sex and birth year with ten controls without CHD (n = 890,472) from the Swedish Total Population Register.

Findings

4012 patients with CHD (4·5%) and 35,218 controls (4·0%) developed cancer. The median follow-up time was 58·8 (IQR 42·4-69·0) years. The overall cancer risk was 1·23 times higher (95% confidence interval (CI) 1·19-1·27) in patients with CHD compared with matched controls, and remained significant when patients with syndromes and organ transplant recipients were excluded. The risk of cancer was higher in all CHD age groups, and in patients that underwent cardiac surgery during the first year after birth (Hazard Ratio 1·83; 95% CI 1·32-2·54). The highest risk was found in children (0-17 years), HR 3·21 (95% CI 2·90-3·56).

Interpretation

The cancer risk in patients with CHD was 23% higher than in matched controls without CHD. The highest risk was found in children and in the latest birth cohort (1990-2017).

Funding

Funding by the Swedish state (Grant Number: 236611), the Swedish Research Council (Grant Number: 2019-00193), the Swedish Childhood Cancer Fund (Grant Number: SP2017-0012) and the Swedish Heart-Lung Foundation (Grant Number: 20190724).

Mortality in patients with myocardial infarction and potential risk factors: A five-year data analysis

BACKGROUND

Coronary artery disease (CAD) is among the most common causes of death in almost all countries across the world. Awareness of risk factors for the management and prevention of the disease can reduce complications and mortality rates. This study was conducted with the aim to investigate the mortality and potential risk factors of myocardial infarction (MI) as well as their relationships in patients who were admitted to one university hospital in the North of Iran from 2014 to 2018.

METHODS

This study had retrospective descriptive design. Using a checklist, all necessary information was extracted from 5-year medical records data of MI patients in the university hospital from 2014 to 2018 (n = 564). The data analysis was performed in SPSS software using descriptive statistics and two binary logistic regression analyses.

RESULTS

The results showed that the mean age of the patients was 62.78 ± 13.38 years, and most of them were men (66.3%). The patients' mortality was 18.6% in a 5-year analysis. However, the number of mortalities was higher in the women (P = 0.001). Descriptive analysis showed that the most common risk factors of the disease in both genders were hypertension (46.6%), diabetes mellitus (DM) (38.5%), hyperlipidemia (24.1%), smoking (20%), and family history of CVDs (18.8%), respectively. However, the results of the adjusted regression model showed that the odds ratio (OR) of the patients' mortality increased in diabetic MI patients (OR: 2.33; 95%CI: 1.42-3.81; P = 0.001), but this ratio decreased in MI patients with a history of hyperlipidemia (OR: 0.23; 95%CI: 0.11-0.44; P ˂ 0.001).

CONCLUSION

Based on the results, individual- and population-based prevention strategies by focusing on hypertension and diabetes are recommended in our health programs. Surprisingly, the mortality rate of MI patients was lower among those with a history of hyperlipidemia. There are different hypotheses for the cause of this. Therefore, laboratory studies with animal models and prospective cohorts are suggested for future studies.

Burden of Ischemic Stroke in Patients With Congenital Heart Disease: A Nationwide, Case-Control Study

Background

Patients with congenital heart disease (CHD) are at increased risk of developing ischemic stroke (IS) compared with controls without CHD. However, the long‐term outcomes after IS, including IS recurrence and mortality risk, remain unclear.

Methods and Results

We identified all patients with CHD in Sweden who were born between 1930 and 2017 using the Swedish National Patient Register and the Cause of Death Register. Ten controls without CHD were randomly selected from the general population and matched for birth year and sex for each patient with CHD. The follow‐up of the study population was performed between January 1970 and December 2017. In total, 88 700 patients with CHD (50.6% men) and 890 450 matched controls (51.0%) were included in this study. During a mean follow‐up of 25.1±22.0 years, patients with CHD had a 5‐fold higher risk of developing an index IS (hazard ratio [HR], 5.01; 95% CI, 4.81–5.22) compared with controls. However, the risk of developing a recurrent IS was lower in patients with CHD compared with controls (HR, 0.66; 95% CI, 0.56–0.78), an observation that persisted after adjustment for cardiovascular risk factors and comorbidities. Patients with CHD were also at a significantly lower risk of all‐cause mortality after index IS than controls (HR, 0.53; 95% CI, 0.49–0.58).

Conclusions

Patients with CHD had a 5‐fold higher risk of developing index IS compared with matched controls. However, the risk of recurrent IS stroke and all‐cause mortality were 34% and 47% lower, respectively, in patients with CHD compared with controls.

Cumulative incidence of infective endocarditis in patients with congenital heart disease: a nationwide, case-control study over nine decades

BACKGROUND

Congenital heart disease (CHD) is a lifelong predisposing condition for infective endocarditis (IE). As a consequence of advances in pediatric care, the number of adults with CHD is now exceeding the number of children. The goal of the present study was to determine the cumulative incidence of IE in patients with CHD and detect temporal changes compared with controls.

METHODS

Nationwide registry-based case-control study of patients with CHD born 1930-2017 matched with 10 random controls. Infective endocarditis episodes were linked using the Swedish 10-digit personal identification number.

RESULTS

In total, 89,541 patients with CHD and 890,470 matched controls were included. In patients with CHD, 1477 IE episodes were registered and 447 episodes in controls. Patients with CHD had 8.5% cumulative incidence of IE at age 87 years, compared with 0.7% in matched controls. Incidence rate of IE per 100,000 person-years was 65.5 (95% confidence interval [CI] 62.2-68.9) and 1.8 (95% CI 1.7-2.0) in CHD patients and controls, respectively. By age 18 years, patients with CHD had an IE incidence similar to that of 81-year-old controls. Incidence of IE differed by age but not by birth year. Bacterial etiology was registered from 1997 in half of the IE episodes; among CHD IE cases, 43.3% were caused by streptococci, 29.8% by Staphylococcus aureus.

CONCLUSIONS

Infective endocarditis remains an important complication in patients with CHD. Incidence correlate with age and the number of IE episodes are expected to increase as the CHD population grow older.