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Bäck M, Banach M, Braunschweig F, De Rosa S, Flachskampf FA, Kahan T, Ketelhuth DFJ, Lancellotti P, Larsson SC, Mellbin L, Nagy E, Savarese G, Szummer K, Wahl D. Editors' highlight picks from 2023 in EHJ Open. Eur Heart J Open 2024; 4:oeae008. [PMID: 38390349 PMCID: PMC10882979 DOI: 10.1093/ehjopen/oeae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Magnus Bäck
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17176 Stockholm, Sweden
- Nancy University Hospital, University of Lorraine and INSERM U1116, 54505 Vandoeuvre les Nancy Cedex, France
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz and Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Frieder Braunschweig
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
| | - Frank A Flachskampf
- Divisions of Clinical Physiology and Cardiology, Uppsala University Clinic, and the Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Thomas Kahan
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Daniel F J Ketelhuth
- Department of Medicine Solna, Karolinska Institutet, 17176 Stockholm, Sweden
- Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Centre Hospitalier Universitaire Sart Tilman, Liège, Belgium
| | - Susanna C Larsson
- Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Linda Mellbin
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Edit Nagy
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Gianluigi Savarese
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17176 Stockholm, Sweden
| | - Karolina Szummer
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Denis Wahl
- Nancy University Hospital, University of Lorraine and INSERM U1116, 54505 Vandoeuvre les Nancy Cedex, France
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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
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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.
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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
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Pundi K, Perino AC, Fan J, Din N, Szummer K, Heidenreich P, Turakhia MP. Association of CHA 2DS 2-VASc and HAS-BLED to frailty and frail outcomes: From the TREAT-AF study. Am Heart J 2023; 261:85-94. [PMID: 37024025 DOI: 10.1016/j.ahj.2023.03.015] [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] [Received: 11/15/2022] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Morbidity and mortality associated with high CHA2DS2-VASc and HAS-BLED scores is not specific to atrial fibrillation (AF). Frailty could be an important contributor to this morbidity and mortality while being mechanistically independent from AF. We sought to evaluate the association of stroke and bleeding risk to noncardiovascular frail events and the association of stroke prevention therapy to outcomes in frail patients with AF. METHODS Using the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the Veterans Health Administration, we identified patients with newly diagnosed AF from 2004 to 2014. Baseline frailty was identified using a previously validated claims-based index requiring ≥2 of 12 ICD-9 diagnoses. Logistic regressions modeled the association between CHA2DS2-VASc and modified HAS-BLED and frailty. Cox proportional hazard regressions were used to evaluate the association between CHA2DS2-VASc and modified HAS-BLED and a composite of noncardiovascular frail events (fractures, urinary tract infections, bacterial pneumonia, or dehydration). We also evaluated the association of oral anticoagulant (OAC) use with stroke, bleeding, and 1-year mortality in frail patients and non-frail patients. RESULTS In 213,435 patients (age 70 ± 11; 98% male; CHA2DS2-VASc 2.4 ± 1.7) with AF, 8,498 (4%) were frail. CHA2DS2-VASc > 0 and HAS-BLED > 0 were strongly associated with frailty (odds ratio [OR] 13.3 (95% CI: 11.6-15.2) for CHA2DS2-VASc 4+ and OR 13.4 (10.2-17.5) for HAS-BLED 3+). After adjusting for covariates, CHA2DS2-VASc, and HAS-BLED > 0 were associated with higher risk of non-cardiovascular frail events (hazard ratio [HR] 2.1 (95% CI: 2.0-2.2) for CHA2DS2-VASc 4+ and HR 1.4 (95% CI: 1.3-1.5) for HAS-BLED 3+). In frail patients, OAC use was associated with significantly lower risk of 1-year mortality (HR 0.82; 95% CI 0.72-0.94, P = .0031) but did not reach significance for risk of stroke (HR 0.80; 95% CI 0.55-1.18, P = .26) or major bleeding (HR 1.08; 95% CI 0.93-1.25, P = .34). CONCLUSIONS High CHA2DS2-VASc and HAS-BLED scores are strongly associated with frailty. However, in frail patients, OAC use was associated with reduction in 1-year mortality. For this challenging clinical population with competing risks of frailty and frail events, focused prospective studies are needed to support clinical decision-making. Until then, careful evaluation of frailty should inform shared decision-making.
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Affiliation(s)
- Krishna Pundi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Center for Digital Health, Stanford University School of Medicine, Stanford, CA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Natasha Din
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Karolina Szummer
- Karolinska University Hospital, Theme Heart and Vessel; Karolinska Institutet, Stockholm, Sweden
| | - Paul Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, CA; Center for Digital Health, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
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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.
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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
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Bäck M, Banach M, Braunschweig F, De Rosa S, Gimelli A, Kahan T, Ketelhuth DFJ, Lancellotti P, Larsson SC, Mellbin L, Nagy E, Savarese G, Szummer K, Wahl D. Highlights from 2022 in EHJ Open. Eur Heart J Open 2022; 2:oeac084. [PMID: 36600883 PMCID: PMC9801405 DOI: 10.1093/ehjopen/oeac084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Magnus Bäck
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17177 Stockholm, Sweden
- Nancy University Hospital, University of Lorraine and INSERM U1116, 54511 Nancy, France
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz and Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Frieder Braunschweig
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Alessia Gimelli
- Cardiovascular and Imaging Departments, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Thomas Kahan
- Department of Cardiology, Danderyd University Hospital, Stockohlm, Sweden
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Daniel F J Ketelhuth
- Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, University of Liège Hospital, Centre Hospitalier Universitaire Sart Tilman, Liège, Belgium
| | - Susanna C Larsson
- Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Linda Mellbin
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Edit Nagy
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Gianluigi Savarese
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine Solna, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Karolina Szummer
- Department of Cardiology, Heart and Vascular Center, Karolinska University Hospital, 17177 Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Denis Wahl
- Nancy University Hospital, University of Lorraine and INSERM U1116, 54511 Nancy, France
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Vavilis G, Back M, Barany P, Ruck A, Szummer K. Prognosis after aortic valve replacement in dialysis patients: results from the Swedish Renal Registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1563] [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 choice of aortic valve prosthesis in aortic stenosis patients is based on patient preference, preoperative age, life expectancy, need for anticoagulant therapy and valve durability. Major uncertainties remain regarding optimal prosthetic valve choice in dialysis patients.
Objectives
The aim of the study was to compare the clinical outcomes after aortic valve replacement with mechanical (MAV) or bioprosthetic valves (BAV) in dialysis patients.
Methods
We used the observational, prospective, multicenter cohort from the Swedish Renal Registry, which includes all dialysis patients in Sweden. The study included 294 dialysis patients with aortic stenosis who underwent aortic valve replacement with MAV or BAV (obtained from surgical procedure codes) between 2005 and 2018, either before (n=155) or after dialysis start (n=139). Comorbidities and net adverse clinical events (bleeding events, stroke and reoperation) were obtained from national registries and defined by International Classification of Diseases codes (ICD-10). The incidence rate (IR) of primary endpoint comprised of all-cause death, bleeding events, stroke and aortic valve reoperation, as well as only all-cause death rates between recipients of MAV or BAV were estimated with Kaplan – Meier curves.
Results
The median age was 72 years (interquartile range [IQR]: 63.9, 77.3), 77% were males and 60% received mechanical valves. During a median follow-up of 1.49 years (IQR: 0.66–2.83), the primary endpoint occurred in 202 patients. Compared to BAV-recipients, those who received MAV had comparable IR of the primary end-point (40.1/100 person-years; [95% Confidence Interval (CI): 33.7–47.7], vs 36.2/100 person-years; [95% CI: 28.9–45.4], P=0.322) (Figure 1).
Mortality rate at 1-year of follow-up was 28.9% without difference between recipients of MAV or BAV (68.8% in MAV-group and 57.6% with BAV; mortality rate MAV 33.3/100 person-year; (95% CI: 27.9–39.8) vs BAV 27.3/100 person-year; (95% CI: 21.5–34.6), P=0. 183)), (Figure 2). Additional statistical analysis of the secondary endpoint based on the occurrence of aortic valve intervention before or after dialysis start, was consistent with the main results.
Conclusion
There is no difference in mortality and complication rates in dialysis patients who underwent aortic valve replacement with MAV or BAV.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- G Vavilis
- Department of Medicine, Huddinge, Karolinska Institutet, Theme Heart and Vessels, Division of Coronary and Valvular Diseases; Karolinska University Hospital , Stockholm , Sweden
| | - M Back
- Karolinska University Hospital, Theme Heart and Vessels, Division of Coronary and Valvular Heart Disease, , Stockholm , Sweden
| | - P Barany
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet , Stockholm , Sweden
| | - A Ruck
- Karolinska University Hospital, Theme Heart and Vessels, Division of Coronary and Valvular Heart Disease, , Stockholm , Sweden
| | - K Szummer
- Department of Medicine, Huddinge, Karolinska Institutet, Theme Heart and Vessels, Division of Coronary and Valvular Diseases; Karolinska University Hospital , Stockholm , Sweden
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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
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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
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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
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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
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10
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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.
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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
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11
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Chesnaye NC, Al-Sodany E, Szummer K, Barany P, Heimbürger O, Almquist T, Melander S, Uhlin F, Dekker F, Wanner C, Jager KJ, Evans M. Association of Longitudinal High-Sensitivity Troponin T With Mortality in Patients With Chronic Kidney Disease. J Am Coll Cardiol 2022; 79:327-336. [DOI: 10.1016/j.jacc.2021.11.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 11/28/2022]
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12
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Yndigegn T, Gilje P, Dankiewicz J, Mokhtari A, Isma N, Holmqvist J, Schiopu A, Ravn-Fischer A, Hofmann R, Szummer K, Jernberg T, James SK, Gale CP, Fröbert O, Mohammad MA. Safety of early hospital discharge following admission with ST-elevation myocardial infarction treated with percutaneous coronary intervention: a nationwide cohort study. EUROINTERVENTION 2022; 17:1091-1099. [PMID: 34338642 PMCID: PMC9725020 DOI: 10.4244/eij-d-21-00501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Second Primary Angioplasty in Myocardial Infarction (PAMI-II) risk score is recommended by guidelines to identify low-risk patients with ST-elevation myocardial infarction (STEMI) for an early discharge strategy. AIMS We aimed to assess the safety of early discharge (≤2 days) for low-risk STEMI patients treated with primary percutaneous coronary intervention (PCI). METHODS Using nationwide data from the SWEDEHEART registry, we identified patients with STEMI treated with primary PCI during the period 2009-2017, of whom 8,092 (26.4%) were identified as low risk with the PAMI-II score. Low-risk patients were stratified according to their length of hospital stay (≤2 days vs >2 days). The primary endpoint was major adverse cardiovascular events (MACE, including death, reinfarction treated with PCI, stroke or heart failure hospitalisation) at one year, assessed using a Cox proportional hazards model with propensity score as well as an inverse probability weighting propensity score of average treatment effect to adjust for confounders. RESULTS A total of 1,449 (17.9%) patients were discharged ≤2 days from admission. After adjustment, the one-year MACE rate was not higher for patients discharged at >2 days from admission than for patients discharged ≤2 days (4.3% vs 3.2%; adjusted HR 1.31, 95% confidence interval [CI]: 0.92-1.87, p=0.14), and no difference was observed regarding any of the individual components of the main outcome. Results were consistent across all subgroups with no difference in MACE between early and late discharge patients. CONCLUSIONS Nationwide observational data suggest that early discharge of low-risk patients with STEMI treated with PCI is not associated with an increase in one-year MACE.
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Affiliation(s)
- Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Patrik Gilje
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Josef Dankiewicz
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Arash Mokhtari
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Nazim Isma
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Jasminka Holmqvist
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Alexandru Schiopu
- Department of Internal Medicine, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Annika Ravn-Fischer
- Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, Department of Cardiology, University of Gothenburg, Gothenburg, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Karolina Szummer
- Department of Medicine (Huddinge), Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Stefan K. James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Medicine, University of Leeds, Leeds, United Kingdom,Leeds Institute for Data Analytics, University of Leeds, Leeds, United Kingdom,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Moman A. Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, 221 85 Lund, Sweden
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13
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Vavilis G, Bäck M, Bárány P, Szummer K. Epidemiology of Aortic Stenosis/Aortic Valve Replacement (from the Nationwide Swedish Renal Registry). Am J Cardiol 2022; 163:58-64. [PMID: 34799087 DOI: 10.1016/j.amjcard.2021.09.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022]
Abstract
Contemporary data on the prevalence and incidence of aortic stenosis (AS) and aortic valve replacement (AVR) in patients initiating dialysis are scarce. This observational cohort study aimed to estimate (1) the point prevalence of AS and AVR at dialysis start and (2) the AS incidence and associated factors prospective to dialysis initiation. The study included 14,550 patients initiating dialysis registered in the Swedish Renal Registry between 2005 and 2018. AS was defined by the International Statistical Classification of Diseases, Tenth Revision codes, and AVR by the surgical procedure codes. Associations between covariates and outcomes were assessed in Cox regression models. The median age was 68 (57 to 77), 66% were males, and the point prevalence of AS and AVR was 3.4% and 1.1%, respectively. In those without known AS/AVR at dialysis initiation (n = 14,050), AS was diagnosed in 595 patients (incidence 16.3/1000 person-years, 95% confidence interval [CI] 15.1 to 17.7/1,000 person-years) during a median follow-up of 2.7 years (interquartile range 1.1 to 5.7). In adjusted Cox regression models, higher age (hazard ratio [HR] 1.03, 95% CI 1.02 to 1.04), male gender (HR 1.51, 95% CI 1.25 to 1.83), atrial fibrillation (HR 1.32, 95% CI 1.06 to 1.64), and hypertension (HR 1.65, 95% CI 1.03 to 2.65) were associated with incident AS. Peritoneal dialysis patients had a nonsignificant trend toward higher AS risk compared with hemodialysis (HR 1.18, 95% CI 0.99 to 1.40). About 20% of patients (n = 113) diagnosed with incident AS underwent AVR (incidence 3.1/1000 person-years, 95% CI 2.6 to 3.7/1,000). Only the male gender was associated with AVR (HR 2.07, 95% CI 1.30 to 3.30). In conclusion, the prevalence and incidence of AS and AVR in patients initiating dialysis are high. A fifth of newly diagnosed AS underwent AVR after dialysis onset.
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Affiliation(s)
- Georgios Vavilis
- Department of Medicine, Huddinge; Heart and Vascular Theme, Division of Coronary and Valvular Heart Disease, Karolinska University Hospital, Stockholm, Sweden.
| | - Magnus Bäck
- Heart and Vascular Theme, Division of Coronary and Valvular Heart Disease, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Solna
| | - Peter Bárány
- Division of Renal Medicine, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Karolina Szummer
- Department of Medicine, Huddinge; Heart and Vascular Theme, Division of Coronary and Valvular Heart Disease, Karolinska University Hospital, Stockholm, Sweden
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14
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Pundi KN, Perino AC, Fan J, Schmitt S, Kothari M, Szummer K, Askari M, Heidenreich PA, Turakhia MP. Direct Oral Anticoagulant Adherence of Patients With Atrial Fibrillation Transitioned from Warfarin. J Am Heart Assoc 2021; 10:e020904. [PMID: 34779243 PMCID: PMC9075386 DOI: 10.1161/jaha.121.020904] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Reduced time in international normalized ratio therapeutic range (TTR) limits warfarin safety and effectiveness. In patients switched from warfarin to direct oral anticoagulants (DOACs), patient factors associated with low TTR could also increase risk of DOAC nonadherence. We investigated the relationship between warfarin TTR and DOAC adherence in warfarin‐treated patients with atrial fibrillation switched to DOAC. Methods and Results Using data from the Veterans Health Administration, we identified patients with atrial fibrillation switched from warfarin to DOAC (switchers) or treated with warfarin alone (non‐switchers). Logistic regression was used to evaluate association between warfarin TTR and DOAC adherence. We analyzed 128 605 patients (age, 71±9; 1.6% women; CHA2DS2‐VASc 3.5±1.6); 32 377 switchers and 96 228 non‐switchers. In 8016 switchers with international normalized ratio data to calculate 180‐day TTR before switch, TTR was low (median 0.45; IQR, 0.26–0.64). Patients with TTR <0.5 were more likely to be switched to DOAC (odds ratio [OR],1.68 [95% CI,1.62–1.74], P<0.0001), as were those with TTR <0.6 or TTR <0.7. Proportion of days covered ≥0.8 was achieved by 76% of switchers at 365 days. In low‐TTR individuals, proportion of days covered ≥0.8 was achieved by 70%, 72%, and 73% of switchers with TTR <0.5, 0.6, and 0.7, respectively. After multivariable adjustment, TTR <0.5 decreased odds of achieving 365‐day proportion of days covered ≥0.8 (OR, 0.49; 0.43–0.57, P<0.0001), with similar relationships for TTR <0.6 and TTR <0.7. In non‐switchers with TTR <0.5, long‐term TTR remained low. Conclusions In patients with atrial fibrillation switched from warfarin to DOAC, most achieved adequate DOAC adherence despite low pre‐switch TTRs. However, TTR trajectories remained low in non‐switchers. Patients with low warfarin TTR more consistently achieved treatment targets after switching to DOACs, although adherence‐oriented interventions may be beneficial.
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Affiliation(s)
- Krishna N Pundi
- Department of Medicine Stanford University School of Medicine Stanford CA
| | - Alexander C Perino
- Department of Medicine Stanford University School of Medicine Stanford CA.,Center for Digital Health Stanford University School of Medicine Stanford CA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Susan Schmitt
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Mitra Kothari
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Karolina Szummer
- Department of Medicine Stanford University School of Medicine Stanford CA.,Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Paul A Heidenreich
- Department of Medicine Stanford University School of Medicine Stanford CA.,Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Mintu P Turakhia
- Department of Medicine Stanford University School of Medicine Stanford CA.,Center for Digital Health Stanford University School of Medicine Stanford CA.,Veterans Affairs Palo Alto Health Care System Palo Alto CA
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15
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Ekberg S, Harrysson S, Jernberg T, Szummer K, Andersson PO, Jerkeman M, Smedby KE, Eloranta S. Myocardial infarction in diffuse large B-cell lymphoma patients - a population-based matched cohort study. J Intern Med 2021; 290:1048-1060. [PMID: 34003533 DOI: 10.1111/joim.13303] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/27/2021] [Accepted: 03/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The outcome for diffuse large B-cell lymphoma (DLBCL) patients has improved with the immunochemotherapy combination R-CHOP. An increased rate of heart failure is well documented following this treatment, whereas incidence and outcome of other cardiac complications, for example myocardial infarction, are less well known. METHOD We identified 3548 curatively treated DLBCL patients in Sweden diagnosed between 2007 and 2014, and 35474 matched lymphoma-free general population comparators. The incidence, characteristics and outcome of acute myocardial infarctions (AMIs) were assessed using population-based registers up to 11 years after diagnosis. The rate of AMI was estimated using flexible parametric models. RESULTS Overall, a 33% excess rate of AMI was observed among DLBCL patients compared with the general population (HR: 1.33, 95% CI: 1.14-1.55). The excess rate was highest during the first year after diagnosis and diminished after 2 years. High age, male sex and comorbidity were the strongest risk factors for AMI. Older patients (>70 years) with mild comorbidities (i.e. hypertension or diabetes) had a 61% higher AMI rate than comparators (HR: 1.61, 95% CI: 1.10-2.35), whereas the corresponding excess rate was 28% for patients with severe comorbidities (HR: 1.28, 95% CI: 1.01-1.64). Among younger patients (≤70), a short-term excess rate of AMI was limited to those with severe comorbidities. There was no difference in AMI characteristics, pharmacological treatment or 30-day survival among patients and comparators. CONCLUSION DLBCL patients have an increased risk of AMI, especially during the first 2 years, which calls for improved cardiac monitoring guided by age and comorbidities. Importantly, DLBCL was not associated with differential AMI management or survival.
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Affiliation(s)
- S Ekberg
- From the, Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - S Harrysson
- From the, Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Hematology, Karolinska University Hospital, Solna, Sweden
| | - T Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - K Szummer
- Section of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - P-O Andersson
- Department of Hematology, South Älvsborg Hospital, Borås, Sweden.,Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - M Jerkeman
- Division of Oncology, Lund University and Skane University Hospital, Lund, Sweden
| | - K E Smedby
- From the, Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Department of Hematology, Karolinska University Hospital, Solna, Sweden
| | - S Eloranta
- From the, Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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16
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Szummer K, Pundi K, Perino AC, Fan J, Kothari M, Turakhia MP. Association of kidney function and atrial fibrillation progression to clinical outcomes in patients with cardiac implantable electronic devices. Am Heart J 2021; 241:6-13. [PMID: 34118202 DOI: 10.1016/j.ahj.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Kidney function may promote progression of AF. OBJECTIVE We evaluated the association of kidney function to AF progression and resultant clinical outcomes in patients with cardiac implantable electronic devices (CIED). METHODS We performed a retrospective cohort study using national clinical data from the Veterans Health Administration linked to CIED data from the Carelink® remote monitoring data warehouse (Medtronic Inc, Mounds View, MN). All devices had atrial leads and at least 75% of remote monitoring transmission coverage. Patients were included at the date of the first AF episode lasting ≥6 minutes, and followed until the occurrence of persistent AF in the first year, defined as ≥7 consecutive days with continuous AF. We used Cox regression analyses with persistent AF as a time-varying covariate to examine the association to stroke, myocardial infarction, heart failure and death. RESULTS Of, 10,323 eligible patients, 1,771 had a first CIED-detected AF (mean age 69 ± 10 years, 1.2% female). In the first year 355 (20%) developed persistent AF. Kidney function was not associated with persistent AF after multivariable adjustment including CHA2DS2-VASc variables and prior medications. Only higher age increased the risk (HR: 1.37 per 10 years; 95% CI:1.22-1.54). Persistent AF was associated to higher risk of heart failure (HR: 2.27; 95% CI: 1.88-2.74) and death (HR: 1.60; 95% CI: 1.30-1.96), but not stroke (HR: 1.28; 95% CI: 0.62-2.62) or myocardial infarction (HR: 1.43; 95% CI: 0.91-2.25). CONCLUSION Kidney function was not associated to AF progression, whereas higher age was. Preventing AF progression could reduce the risk of heart failure and death.
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17
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Bäck M, Banach M, Braunschweig F, De Rosa S, Gimelli A, Kahan T, Ketelhuth DFJ, Lancellotti P, Larsson SC, Mellbin L, Nagy E, Savarese G, Szummer K, Wahl D. Open Up your Science in EHJ Open. European Heart Journal Open 2021; 1:oeab021. [PMID: 35923168 PMCID: PMC9242074 DOI: 10.1093/ehjopen/oeab021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Magnus Bäck
- Department of Cardiology, Karolinska University Hospital , Solna, Sweden
- Department of Medicine Solna, Karolinska Institutet , Stockholm, Sweden
- Nancy University Hospital, University of Lorraine and INSERM U1116 , Nancy, France
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz and Polish Mother's Memorial Hospital Research Institute , Lodz, Poland
| | - Frieder Braunschweig
- Department of Cardiology, Karolinska University Hospital , Solna, Sweden
- Department of Medicine Solna, Karolinska Institutet , Stockholm, Sweden
| | | | | | - Thomas Kahan
- Department of Cardiology, Danderyd University Hospital , Danderyd, Sweden
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet , Stockholm, Sweden
| | - Daniel F J Ketelhuth
- Department of Medicine Solna, Karolinska Institutet , Stockholm, Sweden
- Department of Molecular Medicine, University of Southern Denmark , Odense, Denmark
| | - Patrizio Lancellotti
- GIGA Cardiovascular Sciences, Centre Hospitalier Universitaire Sart Tilman, University of Liège Hospital , Liège, Belgium
| | - Susanna C Larsson
- Unit of Cardiovascular and Nutritional Epidemiology, Institute of Environmental Medicine, Karolinska Institutet , Stockholm, Sweden
- Department of Surgical Sciences, Uppsala University , Uppsala, Sweden
| | - Linda Mellbin
- Department of Cardiology, Karolinska University Hospital , Solna, Sweden
- Department of Medicine Solna, Karolinska Institutet , Stockholm, Sweden
| | - Edit Nagy
- Department of Cardiology, Karolinska University Hospital , Solna, Sweden
- Department of Medicine Solna, Karolinska Institutet , Stockholm, Sweden
| | - Gianluigi Savarese
- Department of Cardiology, Karolinska University Hospital , Solna, Sweden
- Department of Medicine Solna, Karolinska Institutet , Stockholm, Sweden
| | - Karolina Szummer
- Department of Cardiology, Karolinska University Hospital , Solna, Sweden
- Department of Medicine Huddinge, Karolinska Institutet , Stockholm, Sweden
| | - Denis Wahl
- Nancy University Hospital, University of Lorraine and INSERM U1116 , Nancy, France
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18
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de Jong Y, Fu EL, van Diepen M, Trevisan M, Szummer K, Dekker FW, Carrero JJ, Ocak G. Validation of risk scores for ischaemic stroke in atrial fibrillation across the spectrum of kidney function. Eur Heart J 2021; 42:1476-1485. [PMID: 33769473 PMCID: PMC8046502 DOI: 10.1093/eurheartj/ehab059] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/18/2020] [Accepted: 01/22/2021] [Indexed: 12/14/2022] Open
Abstract
Aims The increasing prevalence of ischaemic stroke (IS) can partly be explained by the likewise growing number of patients with chronic kidney disease (CKD). Risk scores have been developed to identify high-risk patients, allowing for personalized anticoagulation therapy. However, predictive performance in CKD is unclear. The aim of this study is to validate six commonly used risk scores for IS in atrial fibrillation (AF) patients across the spectrum of kidney function. Methods and results Overall, 36 004 subjects with newly diagnosed AF from SCREAM (Stockholm CREAtinine Measurements), a healthcare utilization cohort of Stockholm residents, were included. Predictive performance of the AFI, CHADS2, Modified CHADS2, CHA2DS2-VASc, ATRIA, and GARFIELD-AF risk scores was evaluated across three strata of kidney function: normal kidney function [estimated glomerular filtration rate (eGFR) >60 mL/min/1.73 m2], mild CKD (eGFR 30–60 mL/min/1.73 m2), and advanced CKD (eGFR <30 mL/min/1.73 m2). Predictive performance was assessed by discrimination and calibration. During 1.9 years, 3069 (8.5%) patients suffered an IS. Discrimination was dependent on eGFR: the median c-statistic in normal eGFR was 0.75 (range 0.68–0.78), but decreased to 0.68 (0.58–0.73) and 0.68 (0.55–0.74) for mild and advanced CKD, respectively. Calibration was reasonable and largely independent of eGFR. The Modified CHADS2 score showed good performance across kidney function strata, both for discrimination [c-statistic: 0.78 (95% confidence interval 0.77–0.79), 0.73 (0.71–0.74) and 0.74 (0.69–0.79), respectively] and calibration. Conclusion In the most clinically relevant stages of CKD, predictive performance of the majority of risk scores was poor, increasing the risk of misclassification and thus of over- or undertreatment. The Modified CHADS2 score performed good and consistently across all kidney function strata, and should therefore be preferred for risk estimation in AF patients.
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Affiliation(s)
- Ype de Jong
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands.,Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Karolina Szummer
- Department of Cardiology, Karolinska University Hospital, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Gurbey Ocak
- Department of Clinical Epidemiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands.,Department of Internal Medicine, Sint Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
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19
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Matthews AA, Szummer K, Dahabreh IJ, Lindahl B, Erlinge D, Feychting M, Jernberg T, Berglund A, Hernán MA. Comparing Effect Estimates in Randomized Trials and Observational Studies From the Same Population: An Application to Percutaneous Coronary Intervention. J Am Heart Assoc 2021; 10:e020357. [PMID: 33998290 PMCID: PMC8483524 DOI: 10.1161/jaha.120.020357] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background To understand when results from observational studies and randomized trials are comparable, we performed an observational emulation of a target trial designed to ask similar questions as the VALIDATE (Bivalirudin Versus Heparin in ST‐Segment and Non–ST‐Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy) randomized trial. The VALIDATE trial compared the effect of bivalirudin and heparin during percutaneous coronary intervention on the risk of death, myocardial infarction, and bleeding across Sweden. Methods and Results We specified the protocol of a target trial similar to the VALIDATE trial, then emulated the target trial in the period before the VALIDATE trial took place using data from the SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) registry—the same registry in which the trial was undertaken. The target trial emulation and the VALIDATE trial both estimated little or no effect of bivalirudin versus heparin on the risk of death or myocardial infarction by 180 days (target trial emulation risk ratio for death, 1.21 [95% CI, 0.88 – 1.54]; VALIDATE trial hazard ratio for death, 1.05 [95% CI, 0.78 – 1.41]). The observational data, however, could not capture less severe cases of bleeding, resulting in an inability to define a bleeding outcome like the trial, and could not accurately estimate the comparative risk of death by 14 days, which may be the result of intractable confounding early in follow‐up or the inability to precisely emulate the trial’s eligibility criteria. Conclusions Using real‐world data to emulate a target trial can deliver accurate effect estimates. Yet, even with rich observational data, it is not always possible to estimate the short‐term effect of interventions or the effect on outcomes for which data are not routinely collected.
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Affiliation(s)
- Anthony A Matthews
- Unit of Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Karolina Szummer
- Department of Cardiology Karolinska University Hospital Stockholm Sweden.,Department of Medicine Karolinska Institutet Huddinge Sweden
| | - Issa J Dahabreh
- Department of Biostatistics Harvard T.H. Chan School of Public Health Boston MA.,Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - David Erlinge
- Department of Cardiology Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Maria Feychting
- Unit of Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences Danderyd University Hospital-Karolinska Institute Danderyd Sweden
| | - Anita Berglund
- Unit of Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden
| | - Miguel A Hernán
- Unit of Epidemiology Institute of Environmental Medicine Karolinska Institutet Stockholm Sweden.,Department of Biostatistics Harvard T.H. Chan School of Public Health Boston MA.,Department of Epidemiology Harvard T.H. Chan School of Public Health Boston MA.,Harvard-MIT Division of Health Sciences and Technology Boston MA
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20
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Snaedal S, Bárány P, Lund SH, Qureshi AR, Heimbürger O, Stenvinkel P, Löwbeer C, Szummer K. High-sensitivity troponins in dialysis patients: variation and prognostic value. Clin Kidney J 2020; 14:1789-1797. [PMID: 34221386 PMCID: PMC8243265 DOI: 10.1093/ckj/sfaa215] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 09/08/2020] [Indexed: 11/23/2022] Open
Abstract
Background Dialysis patients have a high prevalence of cardiovascular mortality but also elevated cardiac troponins (cTns) even without signs of cardiac ischaemia. The study aims to assess variation and prognostic value of high-sensitivity cTnI and cTnT in prevalent dialysis patients. Methods In 198 prevalent haemodialysis (HD) and 78 peritoneal dialysis (PD) patients, 4-monthly serum troponin I and T measurements were obtained. Reference change values (RCVs) were used for variability assessment and competing-risk regression models for survival analyses; maximal follow-up was 50 months. Results HD and PD patients had similar troponin levels [median (interquartile range) troponin I: 25 ng/L (14–43) versus 21 ng/L (11–37), troponin T: 70 ng/L (44–129) versus 67 ng/L (43–123)]. Of troponin I and T levels, 42% versus 98% were above the decision level of myocardial infarction. RCVs were +68/−41% (troponin I) and +29/−23% (troponin T). Increased variability of troponins related to higher age, male sex, protein-energy wasting and congestive heart failure, but not ischaemic heart disease or dialysis form. Elevated troponin T, but not troponin I, predicted death after adjusting for confounders. Conclusions A large proportion of prevalent dialysis patients without current established or ongoing cardiac events have elevated levels of high-sensitivity cTns. Mortality risk was doubled in patients with persistently high troponin T levels. The large intraindividual variation of cTns suggests that serial measurements and reference change levels may be used to improve diagnostic utility. However, evidence-based recommendations require more data from large studies of dialysis patients with cardiac events.
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Affiliation(s)
- Sunna Snaedal
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Landspitali University Hospital, Reykjavik, Iceland
| | - Peter Bárány
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Sigrún H Lund
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Abdul R Qureshi
- Department of Baxter Novum, Karolinska Institutet, Stockholm, Sweden
| | - Olof Heimbürger
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Stenvinkel
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Löwbeer
- Department of Laboratory Medicine, Division of Clinical Chemistry, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Chemistry, SYNLAB Medilab, Täby, Sweden
| | - Karolina Szummer
- Department of Medicine (Huddinge), Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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21
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Faxén J, Jernberg T, Hollenberg J, Gadler F, Herlitz J, Szummer K. Incidence and Predictors of Out-of-Hospital Cardiac Arrest Within 90 Days After Myocardial Infarction. J Am Coll Cardiol 2020; 76:2926-2936. [DOI: 10.1016/j.jacc.2020.10.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/17/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022]
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22
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Szummer K, Montez-Rath ME, Alfredsson J, Erlinge D, Lindahl B, Hofmann R, Ravn-Fischer A, Svensson P, Jernberg T. Comparison Between Ticagrelor and Clopidogrel in Elderly Patients With an Acute Coronary Syndrome. Circulation 2020; 142:1700-1708. [DOI: 10.1161/circulationaha.120.050645] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [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: 11/16/2022]
Abstract
Background:
The comparative efficacy and safety of ticagrelor versus clopidogrel in older patients with myocardial infarction (MI) has received limited study.
Methods:
We performed an observational analysis of all patients ≥80 years (n=14 005) who were discharged alive with aspirin combined with either clopidogrel (60.2%) or ticagrelor (39.8%) after a MI between 2010 and 2017 registered in the national registry SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies). Inverse probability treatment weighting was used in Cox regression models to adjust for differences in demographics, in-hospital therapies, and medications. The primary ischemic outcome (death, MI, or stroke), and bleeding were obtained from national registries at 1 year. A sensitivity analysis in <80-year-old patients was performed.
Results:
In patients ≥80 years, the incidence of the primary ischemic outcome (hazard ratio [HR], 0.97 [95% CI, 0.88–1.06]) was similar for ticagrelor- and clopidogrel-treated patients. Ticagrelor was associated with a 17% and 48% higher risk of death (HR, 1.17 [95% CI, 1.03–1.32]) and bleeding (HR, 1.48 [95% CI, 1.25–1.76]), but a lower risk of MI (HR, 0.80 [95% CI, 0.70–0.92]) and stroke (HR, 0.72 [95% CI, 0.56–0.93]). In <80-year-old patients, the incidence of the primary ischemic outcome was 17% (HR, 0.83 [95% CI, 0.77–0.89]) lower with ticagrelor. Ticagrelor was associated with 15% (HR, 0.85 [95% CI, 0.76–0.96]) lower risk of death, 32% higher risk of bleeding (HR, 1.32 [95% CI, 1.18–1.47]), but lower risk of MI (HR, 0.82 [95% CI, 0.75–0.91]) and stroke (HR, 0.82 [95% CI, 0.69–0.98]).
Conclusions:
Ticagrelor use among elderly patients with MI was associated with higher risk of bleeding and death compared with clopidogrel. A randomized study of ticagrelor versus clopidogrel in the elderly is needed.
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Affiliation(s)
- Karolina Szummer
- Department of Medicine (Huddinge), Karolinska Institutet; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (K.S.)
| | - Maria E. Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA (M.E.M.-R.)
| | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Sweden (J.A.)
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Sweden (D.E.)
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology (B.L.), Uppsala University, Sweden
- Uppsala Clinical Research Center (B.L.), Uppsala University, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden (R.H., P.S.)
| | - Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (A.R.-F.)
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.-F.)
| | - Per Svensson
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden (R.H., P.S.)
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital (T.J.), Karolinska Institutet, Stockholm, Sweden
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23
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Von Renteln F, Hassan S, Szummer K, Edfors R, Venetsanos D, Kober L, Braunschweig F, Lewinter C. Immediate versus staged revascularisation in multivessel coronary disease: an updated meta-analysis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1487] [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
Percutaneous coronary interventions (PCIs) are often aimed at the culprit vessel in acute coronary syndromes (ACSs) followed by revascularisation of other stenoses later in the index hospitalisation or shortly after discharge. PCI delay of non-culprit coronary vessels stenoses is supported by lower contrast fluid use and thrombocyte aggregation. Distinct coronary interventions increase the risk of both non- and coronary artery complications, e.g. acute abdominal and periphery artery bleeding, suggesting undertaking all PCIs at the same time.
Purpose
To assess the effect on mortality and re-myocardial infarction (MI) of immediate versus staged revascularisation in multivessel coronary disease, with the latter constrained to initial PCI of the culprit coronary vessel.
Methods
The syntax of “randomised controlled trial (RCT) & acute coronary syndrome & complete revascularisation” was undertaken in PubMed.
Clinical characteristics were gathered at the index hospitalisation. The intervention scenario was acute coronary syndrome or not.
Meta-analyses calculated relative risk (RR) reductions on outcomes of 1) mortality and 2) re-MI. Meta-regression assessed linear difference between interventional treatment benefits and baseline characteristics.
Results
A total of 148 studies was found. Of those, 8 was found eligible for further analyses and their baseline characteristics are shown in Table 1.
Comparison of immediate versus staged revascularisation on mortality was nonsignificant (RR, 1.19; 95% CI: 0.78–1.81, p=0.43) (Figure 1). The impact of Immediate vs staged revascularisation on re-MI was also nonsignificant (RR, 0.83; 95% CI: 0.44–1.55, p=0.56). Meta-regression found no associations between the outcomes and study characteristics (not shown).
Conclusion
The intervention of immediate compared to staged revascularisation assessed on outcomes of all-cause mortality and re-MI were nonsignificant.
Figure 1
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
| | - S Hassan
- Karolinska University Hospital, Stockholm, Sweden
| | - K Szummer
- Karolinska University Hospital, Stockholm, Sweden
| | - R Edfors
- Karolinska University Hospital, Stockholm, Sweden
| | - D Venetsanos
- Karolinska University Hospital, Stockholm, Sweden
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital, Heart Centre, Copenhagen, Denmark
| | | | - C Lewinter
- Karolinska University Hospital, Stockholm, Sweden
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24
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Edfors R, Lindhagen L, Spaak J, Evans M, Andell P, Baron T, Mörtberg J, Rezeli M, Salzinger B, Lundman P, Szummer K, Tornvall P, Wallén HN, Jacobson SH, Kahan T, Marko-Varga G, Erlinge D, James S, Lindahl B, Jernberg T. Use of proteomics to identify biomarkers associated with chronic kidney disease and long-term outcomes in patients with myocardial infarction. J Intern Med 2020; 288:581-592. [PMID: 32638487 DOI: 10.1111/joim.13116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 04/30/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have poor outcomes following myocardial infarction (MI). We performed an untargeted examination of 175 biomarkers to identify those with the strongest association with CKD and to examine the association of those biomarkers with long-term outcomes. METHODS A total of 175 different biomarkers from MI patients enrolled in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry were analysed either by a multiple reaction monitoring mass spectrometry assay or by a multiplex assay (proximity extension assay). Random forests statistical models were used to assess the predictor importance of biomarkers, CKD and outcomes. RESULTS A total of 1098 MI patients with a median estimated glomerular filtration rate of 85 mL min-1 /1.73 m2 were followed for a median of 3.2 years. The random forests analyses, without and with adjustment for differences in demography, comorbidities and severity of disease, identified six biomarkers (adrenomedullin, TNF receptor-1, adipocyte fatty acid-binding protein-4, TNF-related apoptosis-inducing ligand receptor 2, growth differentiation factor-15 and TNF receptor-2) to be strongly associated with CKD. All six biomarkers were also amongst the 15 strongest predictors for death, and four of them were amongst the strongest predictors of subsequent MI and heart failure hospitalization. CONCLUSION In patients with MI, a proteomic approach could identify six biomarkers that best predicted CKD. These biomarkers were also amongst the most important predictors of long-term outcomes. Thus, these biomarkers indicate underlying mechanisms that may contribute to the poor prognosis seen in patients with MI and CKD.
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Affiliation(s)
- R Edfors
- From the, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Bayer AB, Solna, Sweden
| | - L Lindhagen
- Uppsala Clinical Research Center, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - J Spaak
- From the, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - M Evans
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - P Andell
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden
| | - T Baron
- Uppsala Clinical Research Center, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - J Mörtberg
- Department of Clinical Sciences, Division of Renal Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - M Rezeli
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - B Salzinger
- Department of Clinical Sciences, Division of Renal Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - P Lundman
- From the, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - K Szummer
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden
| | - P Tornvall
- Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - H N Wallén
- From the, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - S H Jacobson
- Department of Clinical Sciences, Division of Renal Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - T Kahan
- From the, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - G Marko-Varga
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - D Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - S James
- Uppsala Clinical Research Center, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - B Lindahl
- Uppsala Clinical Research Center, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - T Jernberg
- From the, Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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25
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Näslund E, Stenberg E, Hofmann R, Ottosson J, Sundbom M, Marsk R, Svensson P, Szummer K, Jernberg T. Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Previous Myocardial Infarction and Severe Obesity: A Nationwide Cohort Study. Circulation 2020; 143:1458-1467. [PMID: 33103469 DOI: 10.1161/circulationaha.120.048585] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [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: 12/16/2022]
Abstract
BACKGROUND The number of patients with myocardial infarction and severe obesity is increasing and there is a lack of evidence how these patients should be treated. The aim of this study was to investigate the association between metabolic surgery (Roux-en-Y gastric bypass and sleeve gastrectomy) and major adverse cardiovascular events in patients with previous myocardial infarction (MI) and severe obesity. METHODS Of 566 patients with previous MI registered in the SWEDEHEART registry (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) undergoing metabolic surgery and registered in the nationwide Scandinavian Obesity Surgery Registry, 509 patients (Roux-en-Y gastric bypass n=465; sleeve gastrectomy n=44) could be matched 1:1 to a control with MI from SWEDEHEART, but no subsequent metabolic surgery regarding sex, age (±3 years), year of MI (±3 years), and body mass index (±3). The 2 groups were well matched, except for a lower proportion of reduced ejection fraction after MI (7% versus 12%), previous heart failure (10% versus 19%), atrial fibrillation (6% versus 10%), and chronic obstructive pulmonary disease (4% versus 7%) in patients undergoing metabolic surgery. RESULTS The median (interquartile range) follow-up time was 4.6 (2.7-7.1) years. The 8-year cumulative probability of major adverse cardiovascular events was lower in patients undergoing metabolic surgery (18.7% [95% CI, 15.9-21.5%] versus 36.2% [33.2-39.3%], adjusted hazard ratio, 0.44 [95% CI, 0.32-0.61]). Patients undergoing metabolic surgery had also a lower risk of death (adjusted HR, 0.45 [95% CI, 0.29-0.70]; MI, 0.24 [0.14-0.41]) and new onset heart failure, but there were no significant differences regarding stroke (0.91 [0.38-2.20]) and new onset atrial fibrillation (0.56 [0.31-1.01]). CONCLUSIONS In severely obese patients with previous MI, metabolic surgery is associated with a low risk for serious complications, lower risk of major adverse cardiovascular events, death, new MI, and new onset heart failure. These findings need to be confirmed in a randomized, controlled trial.
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Affiliation(s)
- Erik Näslund
- Division of Surgery (E.N., R.M.), Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Sweden (E.S., J.O.)
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology (R.H., P.S.), Karolinska Institutet, Stockholm, Sweden
| | - Johan Ottosson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Sweden (E.S., J.O.)
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Sweden (M.S.)
| | - Richard Marsk
- Division of Surgery (E.N., R.M.), Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - Per Svensson
- Department of Clinical Science and Education, Division of Cardiology (R.H., P.S.), Karolinska Institutet, Stockholm, Sweden
| | - Karolina Szummer
- Department of Medicine, Huddinge, Section of Cardiology (K.S.), Karolinska Institutet, Stockholm, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine (T.J.), Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
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26
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Szummer K, Pundi K, Perino A, Fan J, Kothari M, Turakhia M. DETERMINANTS OF ATRIAL FIBRILLATION PROGRESSION IN CHRONIC KIDNEY DISEASE PATIENTS WITH CARDIAC IMPLANTABLE ELECTRONIC DEVICES (DATA FROM THE MEDTRONIC CARELINK DATABASE). J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31115-3] [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: 10/24/2022]
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27
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Littmann K, Szummer K, Hagström H, Dolapcsiev K, Brinck J, Eriksson M. Lomitapide treatment in a female with homozygous familial hypercholesterolaemia: a case report. Eur Heart J Case Rep 2020; 4:1-6. [PMID: 32128483 PMCID: PMC7047050 DOI: 10.1093/ehjcr/ytaa020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/20/2019] [Accepted: 01/20/2020] [Indexed: 12/17/2022]
Abstract
Background Homozygous familial hypercholesterolaemia (FH) is an autosomal-dominant inherited disease presenting with highly elevated low-density lipoprotein cholesterol (LDL-C) levels. Untreated, the patient can develop atherosclerosis and cardiovascular disease already in adolescence. Treatment with statins and ezetimibe is usually not sufficient and LDL apheresis is often required. Lomitapide, an inhibitor of the microsomal triglyceride transfer protein, reduces LDL-C and triglyceride levels and can be used alone or in combination with other therapies in homozygous FH. However, experience with this agent is still limited. Case summary We present a young female who was diagnosed with homozygous FH at 6 years of age. She shows a complete lack of normal LDL receptor activity and no cholesterol-lowering effect from statins. The patient was treated with LDL apheresis from 7 years of age. When LDL apheresis treatment extended to twice a week, she began to experience adverse effects, including catheter-related complications, infections, and hospital admissions. When lomitapide treatment was initiated, the frequency of apheresis reduced, the LDL-C levels improved and she has not had any further hospital admissions since. Initially, she suffered from gastrointestinal disturbances. However, after 3 years of treatment with lomitapide 20 mg/day, the patient has not experienced any adverse effects. Discussion In this female with homozygous FH adding lomitapide treatment to LDL apheresis has contributed to improved LDL-C levels, a reduction in LDL apheresis sessions and enhanced quality of life. No adverse effects have been reported. These findings suggest that lomitapide can be a drug of choice in patients with homozygous FH.
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Affiliation(s)
- Karin Littmann
- Division of Clinical Chemistry, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Chemistry, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Hannes Hagström
- Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden
| | - Karoly Dolapcsiev
- Department of Pathology, Karolinska University Laboratory, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Brinck
- Metabolism Unit, Department of Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden.,Patient Area Endocrinology and Nephrology, Inflammation and Infection Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Eriksson
- Metabolism Unit, Department of Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden.,Patient Area Endocrinology and Nephrology, Inflammation and Infection Theme, Karolinska University Hospital, Stockholm, Sweden
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28
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Trevisan M, Fu EL, Szummer K, Norhammar A, Lundman P, Wanner C, Sjölander A, Jernberg T, Carrero JJ. Glucagon-like peptide-1 receptor agonists and the risk of cardiovascular events in diabetes patients surviving an acute myocardial infarction. Eur Heart J Cardiovasc Pharmacother 2020; 7:104-111. [PMID: 31999317 PMCID: PMC7957901 DOI: 10.1093/ehjcvp/pvaa004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 10/25/2019] [Revised: 12/03/2019] [Accepted: 01/23/2020] [Indexed: 02/06/2023]
Abstract
AIMS Trial evidence indicates that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) may reduce the risk of cardiovascular (CV) events in patients with diabetes and myocardial infarction (MI). We aimed to expand this observation to routine care settings. METHODS AND RESULTS Prospective observational study including all patients with diabetes surviving an MI and registered in the nationwide SWEDEHEART registry during 2010-17. Multivariable Cox regression analyses were used to estimate the association between GLP-1 RAs use and the study outcome, which was a composite of stroke, heart failure, Re-infarction, or CV death. Covariates included demographics, comorbidities, presentation at admission, and use of secondary CV prevention therapies. In total, 17 868 patients with diabetes were discharged alive after a first event of MI. Their median age was 71 years, 36% were women and their median estimated glomerular filtration rate was 75 mL/min/1.73m2. Of those, 365 (2%) were using GLP-1 RAs. During median 3 years of follow-up, 7005 patients experienced the primary composite outcome. Compared with standard of diabetes care, use of GLP-1 RAs was associated with a lower event risk [adjusted hazard ratio (HR) 0.72; 95% confidence interval (CI): 0.56-0.92], mainly attributed to a lower rate of re-infarction and stroke. Results were similar after propensity score matching or when compared with users of sulfonylurea. There was no suggestion of heterogeneity across subgroups of age, sex, chronic kidney disease, and STEMI. CONCLUSION GLP-1 RAs use, compared with standard of diabetes care, was associated with lower risk for major CV events in healthcare-managed survivors of an MI.
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Affiliation(s)
- Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 171 77 Stockholm, Sweden
| | - Edouard L Fu
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Karolina Szummer
- Department of Cardiology, Karolinska University Hospital, Solna, Sweden.,Department of Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Anna Norhammar
- Department of Medicine, Karolinska Institutet, Solna, Sweden.,Capio Saint Görans hospital, Stockholm, Sweden
| | - Pia Lundman
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Christoph Wanner
- Department of Medicine, Würzburg University Clinic, Würzburg, Germany
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 171 77 Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels väg 12A, 171 77 Stockholm, Sweden
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Szummer K, Wallentin L, Lindhagen L, Alfredsson J, Erlinge D, Held C, James S, Kellerth T, Lindahl B, Ravn-Fischer A, Rydberg E, Yndigegn T, Jernberg T. Relations between implementation of new treatments and improved outcomes in patients with non-ST-elevation myocardial infarction during the last 20 years: experiences from SWEDEHEART registry 1995 to 2014. Eur Heart J 2019; 39:3766-3776. [PMID: 30239671 DOI: 10.1093/eurheartj/ehy554] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [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] [Received: 11/28/2017] [Accepted: 08/20/2018] [Indexed: 11/14/2022] Open
Abstract
Aims We assessed the changes in short- and long-term outcomes and their relation to implementation of new evidence-based treatments in all patients with non-ST-elevation myocardial infarction (NSTEMI) in Sweden over 20 years. Methods and results Cases with NSTEMI (n = 205 693) between 1995 and 2014 were included from the nationwide Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry. During 20 years in-hospital invasive procedures increased from 1.9% to 73.2%, percutaneous coronary intervention or coronary artery bypass grafting 6.5% to 58.1%, dual antiplatelet medication 0% to 72.7%, statins 13.3% to 85.6%, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blocker 36.8% to 75.5%. The standardized 1-year mortality ratio compared with a control population decreased from 5.53 [95% confidence interval (CI) 5.30-5.75] to 3.03 (95% CI 2.89-3.19). If patients admitted the first 2 years were modelled to receive the same invasive treatments as the last 2 years the expected mortality/myocardial infarction (MI) rate would be reduced from 33.0% to 25.0%. After adjusting for differences in baseline characteristics, the change of 1-year cardiovascular death/MI corresponded to a linearly decreasing odds ratio trend of 0.930 (95% CI 0.926-0.935) per 2-year period. This trend was substantially attenuated [0.970 (95% CI 0.964-0.975)] after adjusting for changes in coronary interventions, and almost eliminated [0.988 (95% CI 0.982-0.994)] after also adjusting for changes in discharge medications. Conclusion In NSTEMI patients during the last 20 years, there has been a substantial improvement in long-term survival and reduction in the risk of new cardiovascular events. These improvements seem mainly explained by the gradual uptake and widespread use of in-hospital coronary interventions and evidence-based long-term medications.
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Affiliation(s)
- Karolina Szummer
- Section of Cardiology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital Hälsovägen 4, Stockholm, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Dag Hammarskjölds Väg 38, Uppsala, Sweden
| | - Lars Lindhagen
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Dag Hammarskjölds Väg 38, Uppsala, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Linköping University, Linköping, Sweden.,Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Akutgatan 4, Lund, Sweden
| | - Claes Held
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Dag Hammarskjölds Väg 38, Uppsala, Sweden
| | - Stefan James
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Dag Hammarskjölds Väg 38, Uppsala, Sweden
| | - Thomas Kellerth
- Department of Cardiology, Örebro University Hospital, Södra Grev Rosengatan, Örebro, Sweden
| | - Bertil Lindahl
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Dag Hammarskjölds Väg 38, Uppsala, Sweden
| | - Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska University Hospital, Blå Stråket, Göteborg, Sweden
| | - Erik Rydberg
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Akutgatan 4, Lund, Sweden
| | - Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Akutgatan 4, Lund, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Mörbygårdsvägen 88, Danderyd, Sweden
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30
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Vavilis G, Bäck M, Occhino G, Trevisan M, Bellocco R, Evans M, Lindholm B, Szummer K, Carrero JJ. Kidney Dysfunction and the Risk of Developing Aortic Stenosis. J Am Coll Cardiol 2019; 73:305-314. [PMID: 30678761 DOI: 10.1016/j.jacc.2018.10.068] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [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: 06/26/2018] [Revised: 09/07/2018] [Accepted: 10/14/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) and aortic stenosis (AS) share many risk factors. OBJECTIVES This study sought to evaluate whether kidney dysfunction is associated with the development of AS in the community. METHODS The study included 1,121,875 Stockholm citizens without a prior diagnosis of AS from the SCREAM (Stockholm CREAtinine Measurements) project. Estimated glomerular filtration rate (eGFR) (ml/min/1.73 m2) was calculated from serum creatinine. AS incidence during follow-up was ascertained by clinical diagnostic codes. The association between eGFR and AS incidence was estimated with multivariable Cox proportional hazards models. Sensitivity analyses included analysis of possible reverse causation bias by excluding the first 6 months to 2 years after enrollment and excluding individuals with comorbid heart failure. RESULTS The median age was 50 years (interquartile range [IQR]: 36 to 64 years), and 54% of participants were women. Median eGFR was 96 ml/min/1.73 m2 (IQR: 82 to 109 ml/min/1.73 m2), and 66,949 (6.0%) participants had CKD (eGFR <60 ml/min/1.73 m2). During a median follow-up of 5.1 years (IQR: 3.3 to 6.1 years), 5,858 (0.5%) individuals developed AS (incidence rate [IR] 1.13/1,000 person-years). Compared with eGFR >90 (IR 0.34/1,000 person-years), lower eGFR strata were associated with higher hazards of AS: eGFR 60 to 90 ml/min/1.73 m2; IR: 1.88; hazard ratio (HR): 1.14; 95% confidence interval (CI): 1.05 to 1.25; eGFR 45 to 59 ml/min/1.73 m2; IR: 4.61; HR: 1.17; 95% CI: 1.05 to 1.30; eGFR 30 to 44 ml/min/1.73 m2; IR: 6.62; HR: 1.22; 95% CI: 1.07 to 1.39; and eGFR 30 ml/min/1.73 m2; IR: 8.27; HR: 1.56; 95% CI: 1.29 to 1.87. Sensitivity analysis attenuated only slightly the magnitude of the association; individuals with eGFR ≤44 ml/min/1.73 m2 remained at an approximate 20% risk of AS both when excluding events within the 2 years after baseline (HR: 1.22; 95% CI: 1.06 to 1.42) and when excluding participants with heart failure (HR: 1.20; 95% CI: 1.03 to 1.39). CONCLUSIONS CKD, even in moderate to severe stages, is associated with an increased risk of AS.
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Affiliation(s)
- Georgios Vavilis
- Department of Medicine, Karolinska Institute, Huddinge, Stockholm, Sweden; Theme of Heart and Vessels, Division of Coronary and Valvular Heart Disease, Karolinska University Hospital, Stockholm, Sweden; Functional Area of Emergency Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
| | - Magnus Bäck
- Theme of Heart and Vessels, Division of Coronary and Valvular Heart Disease, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine, Karolinska Institute, Solna, Stockholm, Sweden
| | - Giuseppe Occhino
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden; Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Rino Bellocco
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden; Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Marie Evans
- Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - Bengt Lindholm
- Department of Clinical Science, Intervention, and Technology, Karolinska Institute, Stockholm, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institute, Huddinge, Stockholm, Sweden; Theme of Heart and Vessels, Division of Coronary and Valvular Heart Disease, Karolinska University Hospital, Stockholm, Sweden. https://twitter.com/karolinskainst
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
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31
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Löfman I, Szummer K, Evans M, Carrero JJ, Lund LH, Jernberg T. Incidence of, Associations With and Prognostic Impact of Worsening Renal Function in Heart Failure With Different Ejection Fraction Categories. Am J Cardiol 2019; 124:1575-1583. [PMID: 31558270 DOI: 10.1016/j.amjcard.2019.07.065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/15/2022]
Abstract
There are no studies of long-term worsening renal function (WRF) in heart failure (HF) with different ejection fraction (EF) groups. The aim was to compare incidence of, associations with and prognostic impact of WRF in HF with preserved (HFpEF), mid-range (HFmrEF), and reduced EF (HFrEF). The Swedish Heart Failure Registry (SwedeHF) was merged with the Stockholm Creatinine Measurement (SCREAM) registry 2006 to 2010. The associations between EF and WRF (≥25% decrease in eGFR) and the associations between WRF25-49% and WRF≥50% within year one and subsequent all-cause mortality were all assessed with multiadjusted Cox regression. Of 7,154 patients, 41.6% of HFpEF versus 34.5% and 35.4% of HFmrEF and HFrEF patients developed WRF≥25% during year one. The WRF risk was higher in HFpEF (reference) than in HFmrEF, hazard ratio (95% confidence interval) 0.890 (0.794 to 0.997) and HFrEF 0.870 (0.784 to 0.965). WRF within year one was strongly associated with subsequent long-term mortality in all EF groups, yielding adjusted HRs with WRF25-49% and WRF≥50%: HFpEF, 1.101 (0.913 to 1.328) and 2.096 (1.652 to 2.659), in HFmrEF 1.654 (1.353 to 2.022) and 2.375 (1.807 to 3.122) and in HFrEF 1.212 (1.060 to 1.386) and 1.694 (1.412 to 2.033). In conclusion, the long-term WRF risk was high in HF and highest in HFpEF. WRF was strongly associated with mortality in all EF groups, although in HFpEF only with the most severe WRF.
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32
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Chesnaye NC, Szummer K, Bárány P, Heimbürger O, Magin H, Almquist T, Uhlin F, Dekker FW, Wanner C, Jager KJ, Evans M. Association Between Renal Function and Troponin T Over Time in Stable Chronic Kidney Disease Patients. J Am Heart Assoc 2019; 8:e013091. [PMID: 31662068 PMCID: PMC6898818 DOI: 10.1161/jaha.119.013091] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background People with reduced glomerular filtration rate (GFR) often have elevated cardiac troponin T (cTnT) levels. It remains unclear how cTnT levels develop over time in those with chronic kidney disease (CKD). The aim of this study was to prospectively study the association between cTnT and GFR over time in older advanced‐stage CKD patients not on dialysis. Methods and Results The EQUAL (European Quality Study) study is an observational prospective cohort study in stage 4 to 5 CKD patients aged ≥65 years not on dialysis (incident estimated GFR, <20 mL/min/1.73 m²). The EQUAL cohort used for the purpose of this study includes 171 patients followed in Sweden between April 2012 and December 2018. We used linear mixed models, adjusted for important groups of confounders, to investigate the effect of both measured GFR and estimated GFR on high‐sensitivity cTnT (hs‐cTnT) trajectory over 4 years. Almost all patients had at least 1 hs‐cTnT measurement elevated above the 99th percentile of the general reference population (≤14 ng/L). On average, hs‐cTnT increased by 16%/year (95% CI, 13–19; P<0.0001). Each 15 mL/min/1.73 m2 lower mean estimated GFR was associated with a 23% (95% CI, 14–31; P<0.0001) higher baseline hs‐cTnT and 9% (95% CI, 5–13%; P<0.0001) steeper increase in hs‐cTnT. The effect of estimated GFR on hs‐cTnT trajectory was somewhat lower than a previous myocardial infarction (15%), but higher than presence of diabetes mellitus (4%) and male sex (5%). Conclusions In CKD patients, hs‐cTnT increases over time as renal function decreases. Lower CKD stage (each 15 mL/min/1.73 m2 lower) is independently associated with a steeper hs‐cTnT increase over time in the same range as other established cardiovascular risk factors.
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Affiliation(s)
- Nicholas C Chesnaye
- Department of Medical Informatics Academic Medical Center University of Amsterdam Amsterdam Public Health Research Institute Amsterdam The Netherlands
| | - Karolina Szummer
- Department of Medicine Karolinska Institutet Stockholm Sweden.,Department of Cardiology Huddinge Karolinska University Hospital Stockholm Sweden
| | - Peter Bárány
- Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
| | - Olof Heimbürger
- Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
| | - Hasan Magin
- Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
| | - Tora Almquist
- Division of Nephrology Department of Clinical Sciences, Karolinska Institutet Danderyd Hospital Stockholm Sweden
| | - Fredrik Uhlin
- Department of Nephrology Linköping University Linköping Sweden.,Department of Medical and Health Sciences Linköping University Linköping Sweden.,Centre of Biomedical Engineering Department of Health Technologies School of Informatics Tallinn University of Technology Tallinn Estonia
| | - Friedo W Dekker
- Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
| | | | - Kitty J Jager
- Department of Medical Informatics Academic Medical Center University of Amsterdam Amsterdam Public Health Research Institute Amsterdam The Netherlands
| | - Marie Evans
- Department of Clinical Science, Intervention and Technology Karolinska Institutet Stockholm Sweden
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33
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Szummer K, Jernberg T, Wallentin L. From Early Pharmacology to Recent Pharmacology Interventions in Acute Coronary Syndromes. J Am Coll Cardiol 2019; 74:1618-1636. [DOI: 10.1016/j.jacc.2019.03.531] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/27/2019] [Accepted: 03/31/2019] [Indexed: 10/26/2022]
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Szummer K, Lindhagen L, Evans M, Spaak J, Koul S, Åkerblom A, Carrero JJ, Jernberg T. Treatments and Mortality Trends in Cases With and Without Dialysis Who Have an Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 12:e005879. [DOI: 10.1161/circoutcomes.119.005879] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Patients on dialysis who have an acute myocardial infarction (AMI) have an exceedingly poor prognosis, but it is unknown to what extent guideline-recommended interventions and treatments are used and to which benefit. We aimed to assess temporal changes in the use of treatments and survival rates in dialysis patients with an AMI.
Methods and Results:
All consecutive AMI cases from 1996 to 2013 enrolled in the SWEDEHEART registry (Swedish Web–System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) were included. The Swedish Renal Registry identified all chronic dialysis cases. Multivariable adjusted standardized 1-year mortality was estimated. An age-sex-calendar year–matched dialysis background population from the Swedish Renal Registry was used to obtain a standardized incidence ratio. All analyses were performed in 2-year blocks, where each individual could be included several times but in different time blocks; hence the term AMI cases and not patients is used. Of 289 699 cases with AMI, 1398 (0.5%) were on dialysis (73.6% hemodialysis; 26.4% peritoneal dialysis). Among dialysis cases, 29.4% were women, and 21.0% had ST-segment–elevation myocardial infarction. Through 1996 to 2013, dialysis cases had similar age (median, 70 years [interquartile range, 62–77];
P
for trend, 0.14), but the proportion with diabetes mellitus increased (36.0%–55.3%;
P
for trend, 0.005). Dialysis cases admitted with AMI were treated more invasively and received more discharge medications in the later years. From 1995 to 2013, in-hospital and 1-year mortality decreased from 25.4% to 9.4% and from 59.6% to 41.2%, respectively. The standardized in-hospital and 1-year mortality decreased from 25.7% to 9.4% and from 54.6% to 41.2%. Yet, compared with the matched dialysis population, the odds of death remained as high in 2012/2013 as in 1996/1997 (odds ratio, 2.04; 95% CI, 1.62–2.58 and odds ratio, 1.99; 95% CI, 1.52–2.60, respectively;
P
for trend, 0.34).
Conclusions:
Over the last 18 years, more patients on dialysis with AMI have been treated with evidence-based therapies. Overall, dialysis cases with AMI have an improved in-hospital and 1-year survival in the more recent years compared with earlier years. However, this appears largely to be because of improved survival in the general dialysis population.
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Affiliation(s)
- Karolina Szummer
- Department of Cardiology (MedH), Karolinska Institutet, Stockholm, Sweden (K.S.)
- Department of Medicine (K.S.), Karolinska Institutet, Stockholm, Sweden
| | | | - Marie Evans
- Division of Renal Medicine, CLINTEC (Department of Clinical Science, Intervention and Technology), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden (M.E.)
| | - Jonas Spaak
- Department of Clinical Sciences, Danderyd University Hospital (J.S., T.J.), Karolinska Institutet, Stockholm, Sweden
| | - Sasha Koul
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden (S.K.)
| | - Axel Åkerblom
- Department of Medical Sciences, Division of Cardiology, Uppsala Clinical Research Center, Uppsala University, Sweden (A.Å.)
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics (J.J.C.), Karolinska Institutet, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital (J.S., T.J.), Karolinska Institutet, Stockholm, Sweden
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35
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Simonsson M, Wallentin L, Alfredsson J, Erlinge D, Hellström Ängerud K, Hofmann R, Kellerth T, Lindhagen L, Ravn-Fischer A, Szummer K, Ueda P, Yndigegn T, Jernberg T. Temporal trends in bleeding events in acute myocardial infarction: insights from the SWEDEHEART registry. Eur Heart J 2019; 41:833-843. [DOI: 10.1093/eurheartj/ehz593] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [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] [Received: 07/02/2019] [Revised: 07/15/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
Aims
To describe the time trends of in-hospital and out-of-hospital bleeding parallel to the development of new treatments and ischaemic outcomes over the last 20 years in a nationwide myocardial infarction (MI) population.
Methods and results
Patients with acute MI (n = 371 431) enrolled in the SWEDEHEART registry from 1995 until May 2018 were selected and evaluated for in-hospital bleeding and out-of-hospital bleeding events at 1 year. In-hospital bleeding increased from 0.5% to a peak at 2% 2005/2006 and thereafter slightly decreased to a new plateau around 1.3% by the end of the study period. Out-of-hospital bleeding increased in a stepwise fashion from 2.5% to 3.5 % in the middle of the study period and to 4.8% at the end of the study period. The increase in both in-hospital and out-of-hospital bleeding was parallel to increasing use of invasive strategy and adjunctive antithrombotic treatment, dual antiplatelet therapy (DAPT), and potent DAPT, while the decrease in in-hospital bleeding from 2007 to 2010 was parallel to implementation of bleeding avoidance strategies. In-hospital re-infarction decreased from 2.8% to 0.6% and out-of-hospital MI decreased from 12.6% to 7.1%. The composite out-of-hospital MI, cardiovascular death, and stroke decreased in a similar fashion from 18.4% to 9.1%.
Conclusion
During the last 20 years, the introduction of invasive and more intense antithrombotic treatment has been associated with an increase in bleeding events but concomitant there has been a substantial greater reduction of ischaemic events including improved survival.
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Affiliation(s)
- Moa Simonsson
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Linkoping University Hospital, Linkoping, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Karin Hellström Ängerud
- Department of Cardiology, Heart Centre, Umea University, Umea, Sweden
- Department of Nursing, Umea University, Umea, Sweden
| | - Robin Hofmann
- Division of Cardiology, Department of Clinical Science and Education, Karolinska Institutet, Sodersjukhuset, Stockholm, Sweden
| | - Thomas Kellerth
- Department of Cardiology, Orebro University Hospital, Orebro, Sweden
| | - Lars Lindhagen
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institute, Huddinge, Stockholm, Sweden
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
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Wester A, Attar R, Mohammad MA, Andell P, Hofmann R, Jensen J, Szummer K, Erlinge D, Koul S. Impact of Baseline Anemia in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: A Prespecified Analysis From the VALIDATE-SWEDEHEART Trial. J Am Heart Assoc 2019; 8:e012741. [PMID: 31387441 PMCID: PMC6759912 DOI: 10.1161/jaha.119.012741] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The impact of baseline anemia in a contemporary acute coronary syndrome (ACS) population undergoing percutaneous coronary intervention in the era of predominant radial artery access, potent P2Y12 inhibition, and rare use of glycoprotein IIb/IIIa inhibitors has not been adequately studied. Methods and Results ACS patients who underwent percutaneous coronary intervention between 2014 and 2016 in the VALIDATE‐SWEDEHEART (Bivalirudin Versus Heparin in ST‐Segment and Non–ST‐Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies Registry) trial without missing values for hemoglobin were included (n=5482). Mortality, myocardial reinfarction, and major bleeding at 180 days were assessed using Cox regression models and propensity score matching. All studied comorbidities were more common in ACS patients who had anemia (n=792). ACS patients with anemia had higher rates of 180‐day mortality (6.9% versus 2.1%; hazard ratio, 1.9; 95% CI, 1.3–2.7; P<0.001), myocardial reinfarction (4.3% versus 1.9%; hazard ratio, 1.7; 95% CI, 1.1–2.7; P=0.013), and major bleeding (13.4% versus 8.2%; hazard ratio, 1.3; 95% CI, 1.0–1.6; P=0.041). The results were most evident in patients with a hemoglobin value <100 g/L, who had a nearly 10 times higher mortality rate. Conclusions Baseline anemia in ACS patients undergoing percutaneous coronary intervention, treated according to current practice including routine radial artery access, constitutes a high‐risk feature for both ischemic events, bleeding events, and mortality. A multidisciplinary approach is warranted to maximize benefit and minimize patient risk. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02311231.
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Affiliation(s)
- Axel Wester
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden
| | - Rubina Attar
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden.,Department of Cardiology Clinical Medicine Aalborg University Aalborg Denmark
| | - Moman Aladdin Mohammad
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden
| | - Pontus Andell
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden.,Unit of Cardiology Department of Medicine Karolinska Institute Stockholm Sweden.,Heart and Vascular Division Karolinska University Hospital Stockholm Sweden
| | - Robin Hofmann
- Division of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institute Stockholm Sweden
| | - Jens Jensen
- Department of Clinical Science and Education Södersjukhuset Karolinska Institute Stockholm Sweden.,Unit of Cardiology Capio S:t Göran Hospital Stockholm Sweden
| | - Karolina Szummer
- Unit of Cardiology Department of Medicine Karolinska Institute Stockholm Sweden.,Heart and Vascular Division Karolinska University Hospital Stockholm Sweden
| | - David Erlinge
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden
| | - Sasha Koul
- Department of Cardiology Clinical Sciences Lund University Skåne University Hospital Lund Sweden
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Affiliation(s)
- Anton Gard
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Gorav Batra
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Marcus Hjort
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Karolina Szummer
- Department of Medicine, Huddinge, Section of Cardiology, Karolinska Institute, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tomasz Baron
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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Chesnaye N, Szummer K, Barany P, Heimburger O, Magin H, Uhlin F, Dekker FW, Wanner C, Jager K, Evans M. FP411THE ASSOCIATION BETWEEN RENAL FUNCTION AND TROPONIN T OVER TIME IN STABLE CKD PATIENTS. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz106.fp411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Chesnaye N, Szummer K, Barany P, Heimburger O, Stenvinkel P, Melander S, Dekker FW, Wanner C, Jager K, Evans M. FP392DYNAMIC PREDICTION OF MORTALITY IN ADVANCED CKD USING TROPONIN T. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz106.fp392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Trevisan M, Szummer K, Jernberg T, Carrero JJ. SaO012GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS AND THE RISK OF CARDIO-RENAL OUTCOMES IN DIABETIC PATIENTS SURVIVING A MYOCARDIAL INFARCTION. Nephrol Dial Transplant 2019. [DOI: 10.1093/ndt/gfz101.sao012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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41
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Simonsson M, Winell H, Olsson H, Szummer K, Alfredsson J, Hall M, Dondo TB, Gale CP, Jernberg T. Development and Validation of a Novel Risk Score for In-Hospital Major Bleeding in Acute Myocardial Infarction:-The SWEDEHEART Score. J Am Heart Assoc 2019; 8:e012157. [PMID: 30803289 PMCID: PMC6474938 DOI: 10.1161/jaha.119.012157] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/30/2019] [Indexed: 02/07/2023]
Abstract
Background Bleeding risk stratification in acute coronary syndrome is of highest clinical interest but current risk scores have limitations. We sought to develop and validate a new in-hospital bleeding risk score for patients with acute myocardial infarction. Methods and Results From the nationwide SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) register, 97,597 patients with acute myocardial infarction enrolled from 2009 until 2014 were selected. A full model with 23 predictor variables and 8 interaction terms was fitted using logistic regression. The full model was approximated by a model with 5 predictors and 1 interaction term. Calibration, discrimination, and clinical utility was evaluated and compared with the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Ad verse Outcomes With Early Implementation of the ACC /AHA Guidelines) scores. Internal and temporal validity was assessed. In-hospital major bleeding, defined as fatal, intracranial, or requiring surgery or blood transfusion, occurred in 1356 patients (1.4%). The 5 predictors in the approximate model that constituted the SWEDEHEART score were hemoglobin, age, sex, creatinine, and C-reactive protein. The ACTION and CRUSADE scores were poorly calibrated in the derivation cohort and therefore were recalibrated. The SWEDEHEART score showed higher discriminative ability than both recalibrated scores, overall ( C-index 0.80 versus 0.73/0.72) and in all predefined subgroups. Decision curve analysis demonstrated consistently positive and higher net benefit for the SWEDEHEART score compared with both recalibrated scores across all clinically relevant decision thresholds. The original ACTION and CRUSADE scores showed negative net benefit. Conclusions The 5-item SWEDEHEART score discriminates in-hospital major bleeding in patients with acute myocardial infarction and has superior model performance compared with the recalibrated ACTION and CRUSADE scores.
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Affiliation(s)
- Moa Simonsson
- Department of Clinical SciencesKarolinska InstitutetDanderydSweden
- Department of CardiologyKarolinska University HospitalSolnaSweden
| | - Henric Winell
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
- Department of StatisticsUppsala UniversityUppsalaSweden
| | - Henrik Olsson
- Department of Medical Epidemiology and BiostatisticsKarolinska InstitutetSolnaSweden
| | - Karolina Szummer
- Department of CardiologyKarolinska University HospitalSolnaSweden
- Department of MedicineKarolinska InstitutetHuddingeSweden
| | - Joakim Alfredsson
- Department of CardiologyDepartment of Medical and Health SciencesLinköping UniversityLinköpingSweden
| | - Marlous Hall
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsUnited Kingdom
| | - Tatendashe B. Dondo
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsUnited Kingdom
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsUnited Kingdom
| | - Tomas Jernberg
- Department of Clinical SciencesKarolinska InstitutetDanderydSweden
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Benedek P, Eriksson M, Duvefelt K, Freyschuss A, Frick M, Lundman P, Nylund L, Szummer K. Genetic testing for familial hypercholesterolemia among survivors of acute coronary syndrome. J Intern Med 2018; 284:674-684. [PMID: 29974534 DOI: 10.1111/joim.12812] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Familial hypercholesterolemia could be prevalent among patients with acute coronary syndrome. OBJECTIVE To investigate both the frequency of causative mutations for familial hypercholesterolemia (FH) and the optimal selection of patients for genetic testing among patients with an acute coronary syndrome (ACS). METHODS One hundred and sixteen patients with an ACS during 2009-2015 were identified through the SWEDEHEART registry. Patients who had either a high total cholesterol level ≥7 mmol L-1 combined with a triglyceride level ≤2.6 mmol L-1 , or were treated with lipid-lowering medication and had a total cholesterol level >4.9 mmol L-1 and a triglyceride level ≤2.6 mmol L-1 were included. Genetic testing was performed first with a regionally designed FH mutation panel (118 mutations), followed by testing with a commercially available FH genetic analysis (Progenika Biopharma). RESULTS A total of 6.9% (8/116) patients had a FH-causative mutation, all in the LDL-receptor. Five patients were detected on the panel, and further testing of the remaining 111 patients detected an additional 3 FH-causative mutations. Baseline characteristics were similar in FH-positive and FH-negative patients with respect to age, gender, prior ACS and diabetes. Patients with a FH-causative mutation had higher Dutch Lipid Clinical Network (DLCN) score (5.5 (5.0-6.5) vs 3.0 (2.0-5.0), P < 0.001) and a higher low-density lipoprotein level (5.7 (4.7-6.5) vs 4.9 (3.5-5.4), P = 0.030). The Dutch Lipid Clinical Network (DLCN) score had a good discrimination with an area under the curve of 0.856 (95% CI 0.763-0.949). CONCLUSION Genetic testing for FH should be considered in patients with ACS and high DLCN score.
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Affiliation(s)
- P Benedek
- Department of Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - M Eriksson
- Department of Medicine, Karolinska Institutet, Huddinge, Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - K Duvefelt
- Mutation Analysis Facility, Clinical Research Center, Karolinska University Hospital, Stockholm, Sweden
| | - A Freyschuss
- Department of Medicine, Section of Cardiology, Karolinska Institutet, Huddinge, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - M Frick
- Department of Cardiology, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - P Lundman
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - L Nylund
- Department of Medicine, Section of Cardiology, Karolinska Institutet, Huddinge, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - K Szummer
- Department of Medicine, Section of Cardiology, Karolinska Institutet, Huddinge, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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Faxén J, Xu H, Evans M, Jernberg T, Szummer K, Carrero JJ. Potassium levels and risk of in-hospital arrhythmias and mortality in patients admitted with suspected acute coronary syndrome. Int J Cardiol 2018; 274:52-58. [PMID: 30282599 DOI: 10.1016/j.ijcard.2018.09.099] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 05/15/2018] [Accepted: 09/25/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND In acute coronary syndrome (ACS), potassium imbalance at admission has been associated with in-hospital arrhythmias, cardiac arrest, and mortality. However, several important presentation characteristics and subtype of ACS have not been considered. METHODS Consecutive patients (n = 32,955) admitted with suspected ACS between 2006 and 2011, registered in the Swedish Web-System for Enhancement and Development of Evidence-Based care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) and the Stockholm CREAtinine Measurements (SCREAM) project were included. Associations between admission plasma potassium categories (reference 3.5-<4.0 mmol/L) and in-hospital outcomes including mortality, cardiac arrest, new-onset atrial fibrillation, and second- or third-degree atrioventricular block were assessed with logistic regression models. Covariates included demographics, presentation characteristics, comorbidities, estimated glomerular filtration rate (eGFR), main diagnosis, and medication on admission. RESULTS U-shaped associations between admission potassium, mortality and cardiac arrest were observed. However, in fully adjusted models, only hyperkalemia (5.0-<5.5 [OR 1.83; 95% CI, 1.34-2.49] and ≥5.5 mmol/L [OR 2.27; 95% CI, 1.57-3.27]) was associated with mortality, while only hypokalemia (3.0-<3.5 [OR 1.63; 95% CI, 1.21-2.19] and <3.0 mmol/L [OR 2.72; 95% CI, 1.56-4.74]) was associated with cardiac arrest. Potassium <3.0 mmol/L (OR 1.93; 95% CI, 1.00-3.76) was associated with new-onset atrial fibrillation. After multivariable adjustment, no association was observed between potassium and second- or third-degree atrioventricular block. Results were not modified by main diagnosis (ACS subtype or non-ACS diagnosis) or eGFR. CONCLUSIONS Hyperkalemia at admission is associated with in-hospital mortality and hypokalemia with cardiac arrest and new-onset atrial fibrillation in patients admitted with suspected ACS.
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Affiliation(s)
- Jonas Faxén
- Department of Medicine, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
| | - Hong Xu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Marie Evans
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Carrero JJ, Trevisan M, Sood MM, Bárány P, Xu H, Evans M, Friberg L, Szummer K. Incident Atrial Fibrillation and the Risk of Stroke in Adults with Chronic Kidney Disease: The Stockholm CREAtinine Measurements (SCREAM) Project. Clin J Am Soc Nephrol 2018; 13:1314-1320. [PMID: 30030271 PMCID: PMC6140568 DOI: 10.2215/cjn.04060318] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [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: 03/30/2018] [Accepted: 06/21/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with CKD have a high risk of atrial fibrillation. Both CKD and atrial fibrillation are associated with higher risk of stroke and death. However, the effect of incident atrial fibrillation on stroke risk among patients with CKD is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our study included adults with CKD (eGFR<60 ml/min per 1.73 m2) without previously documented atrial fibrillation who had been in contact with health care in Stockholm, Sweden during 2006-2011. Incident atrial fibrillation was identified by administrative diagnostic codes in outpatient or inpatient care and treated as a time-updated exposure in the analysis of stroke and death risk. Stroke events and deaths were ascertained from regional and national registers with complete coverage. Covariates included demographics, comorbidities, therapeutic procedures, and medications. Multivariable Cox regression analysis and competing risk analysis (accounting for death) were used to estimate the association between incident atrial fibrillation and stroke. RESULTS Among 116,184 adults with CKD, 13,412 (12%) developed clinically recognized atrial fibrillation during a mean follow-up of 3.9 years (interquartile range, 2.3-5.7 years). Incidence of atrial fibrillation increased across lower eGFR strata: from 29.4 to 46.3 atrial fibrillations per 1000 person-years in subjects with eGFR=45-60 and <30 ml/min per 1.73 m2, respectively; 1388 (53.8 per 1000 person-years) cases of stroke and 5592 (205.1 per 1000 person-years) deaths occurred after incident atrial fibrillation compared with 6850 (16.6 per 1000 person-years) cases of stroke and 28,613 (67.5 per 1000 person-years) deaths during periods without atrial fibrillation. After adjustment, incident atrial fibrillation was associated with higher risk of stroke (hazard ratio, 2.00; 95% confidence interval, 1.88 to 2.14) and death (hazard ratio, 1.76; 95% confidence interval, 1.71 to 1.82). This was attributed to both ischemic stroke (hazard ratio, 2.11; 95% confidence interval, 1.96 to 2.28) and intracranial bleeds (hazard ratio, 1.64; 95% confidence interval, 1.42 to 1.90). Stroke risk was similar across all eGFR strata. In competing risk analyses accounting for death, the association between incident atrial fibrillation and stroke was attenuated but remained higher (subhazard ratio, 1.49; 95% confidence interval, 1.39 to 1.60). CONCLUSIONS Patients with CKD who develop atrial fibrillation are at higher risk of stroke and death.
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Affiliation(s)
| | - Marco Trevisan
- Departments of Medical Epidemiology and Biostatistics and
| | - Manish M. Sood
- Division of Nephrology, and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Peter Bárány
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Hong Xu
- Departments of Medical Epidemiology and Biostatistics and
| | - Marie Evans
- Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Leif Friberg
- Department of Clinical Sciences, Danderyds Hospital, Stockholm, Sweden; and
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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Faxén J, Jernberg T, Szummer K. Reply to:’ The SAFER score in predicting in-hospital cardiac arrest: A decision curve analysis’. Resuscitation 2018; 129:e9. [DOI: 10.1016/j.resuscitation.2018.06.012] [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] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 06/08/2018] [Indexed: 10/14/2022]
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Szummer K, Wallentin L, Lindhagen L, Alfredsson J, Erlinge D, Held C, James S, Kellerth T, Lindahl B, Ravn-Fischer A, Rydberg E, Yndigegn T, Jernberg T. Improved outcomes in patients with ST-elevation myocardial infarction during the last 20 years are related to implementation of evidence-based treatments: experiences from the SWEDEHEART registry 1995-2014. Eur Heart J 2018; 38:3056-3065. [PMID: 29020314 PMCID: PMC5837507 DOI: 10.1093/eurheartj/ehx515] [Citation(s) in RCA: 271] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/17/2017] [Indexed: 12/15/2022] Open
Abstract
Aims Impact of changes of treatments on outcomes in ST-elevation myocardial infarction (STEMI) patients in real-life health care has not been documented. Methods and results All STEMI cases (n = 105.674) registered in the nation-wide SWEDEHEART registry between 1995 and 2014 were included and followed for fatal and non-fatal outcomes for up to 20 years. Most changes in treatment and outcomes occurred from 1994 to 2008. Evidence-based treatments increased: reperfusion from 66.2 to 81.7%; primary percutaneous coronary intervention: 4.5 to 78.0%; dual antiplatelet therapy from 0 to 89.6%; statin: 14.1 to 93.6%; beta-blocker: 78.2 to 91.0%, and angiotensin-converting-enzyme/angiotensin-2-receptor inhibitors: 40.8 to 85.2% (P-value for-trend <0.001 for all). One-year mortality decreased from 22.1 to 14.1%. Standardized incidence ratio compared with the general population decreased from 5.54 to 3.74 (P < 0.001). Cardiovascular (CV) death decreased from 20.1 to 11.1%, myocardial infarction (MI) from 11.5 to 5.8%; stroke from 2.9 to 2.1%; heart failure from 7.1 to 6.2%. After standardization for differences in demography and baseline characteristics, the change of 1-year CV-death or MI corresponded to a linear trend of 0.915 (95% confidence interval: 0.906–0.923) per 2-year period which no longer was significant, 0.997 (0.984–1.009), after adjustment for changes in treatment. The changes in treatment and outcomes were most pronounced from 1994 to 2008. Conclusion Gradual implementation of new and established evidence-based treatments in STEMI patients during the last 20 years has been associated with prolonged survival and lower risk of recurrent ischaemic events, although a plateauing is seen since around 2008.
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Affiliation(s)
- Karolina Szummer
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lars Lindhagen
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Linköping University, Linköping, Sweden.,Department of Medicine and Health Sciences, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - David Erlinge
- Department of Cardiology, Lund University, Skane University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Claes Held
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Stefan James
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Thomas Kellerth
- Department of Cardiology, Örebro University Hospital, Örebro, Sweden
| | - Bertil Lindahl
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Erik Rydberg
- Department of Cardiology, Lund University, Skane University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Troels Yndigegn
- Department of Cardiology, Lund University, Skane University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
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Löfman I, Szummer K, Olsson H, Carrero JJ, Lund LH, Jernberg T. Association Between Mineralocorticoid Receptor Antagonist Use and Outcome in Myocardial Infarction Patients With Heart Failure. J Am Heart Assoc 2018; 7:JAHA.118.009359. [PMID: 29980521 PMCID: PMC6064826 DOI: 10.1161/jaha.118.009359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background There are no studies of mineralocorticoid receptor antagonist (MRA) treatment examining outcome in unselected real‐life patients with myocardial infarction (MI) and heart failure (HF). There is uncertainty regarding effects of MRA in relation to left ventricular ejection fraction (LVEF) and chronic kidney disease (CKD). The aim was to assess MRA use and compare outcomes in MI patients with HF in relation to LVEF and CKD. Methods and Results Patients with MI and HF registered in the Swedish myocardial infarction registry, SWEDEHEART, 2005–2014, were included. Associations between MRA use and all‐cause mortality up to 3 years were assessed with multivariable Cox regression, stratified by EF groups and presence of CKD (estimated glomerular filtration rate <60 mL/min per 1.73 m2). Of 45 071 patients with MI and HF, 4470 (9.9%) received MRA. Those with HF and LVEF <40% more often had MRA (19.6%) compared with those with LVEF 40% to 49% (9.1%) or LVEF ≥50% (4.7%). 8.6% of patients with CKD received MRA. After adjustment, MRA use was associated with lower mortality in those with LVEF <40% (hazard ratio [95% confidence interval] 0.81 [0.75–0.88]) and LVEF 40% to 49% (0.88 [0.75–1.03]) but not in those with LVEF ≥50% (1.29 [1.09–1.53]), with significant interaction between MRA and LVEF (P<0.0001). The association between MRA use and mortality was similar in those without (0.96 [0.88–1.05]) and with (0.92 [0.85–0.99]) CKD. Conclusions In patients with MI and HF, MRA use was associated with better long‐term survival in patients with LVEF <40% but not in those with LVEF ≥50%, while the mortality risk was similar in MRA‐treated patients with or without CKD.
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Affiliation(s)
- Ida Löfman
- Unit of Cardiology, Heart and Vascular Theme, Huddinge, Department of Medicine, Karolinska Institutet Karolinska University Hospital, Stockholm, Sweden
| | - Karolina Szummer
- Unit of Cardiology, Heart and Vascular Theme, Huddinge, Department of Medicine, Karolinska Institutet Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Olsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Lars H Lund
- Unit of Cardiology, Heart and Vascular Theme, Solna, Department of Medicine, Karolinska Institutet Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital Karolinska Institutet, Stockholm, Sweden
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Edfors R, Sahlén A, Szummer K, Renlund H, Evans M, Carrero JJ, Spaak J, James SK, Lagerqvist B, Varenhorst C, Jernberg T. Outcomes in patients treated with ticagrelor versus clopidogrel after acute myocardial infarction stratified by renal function. Heart 2018; 104:1575-1582. [PMID: 29574413 DOI: 10.1136/heartjnl-2017-312436] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 09/14/2017] [Revised: 01/15/2018] [Accepted: 02/03/2018] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES We aimed to analyse outcomes of ticagrelor and clopidogrel stratified by estimated glomerular filtration rate (eGFR) in a large unselected cohort of patients with acute myocardial infarction (MI). METHODS We used follow-up data in MI survivors discharged on ticagrelor or clopidogrel enrolled in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry. The association between ticagrelor versus clopidogrel and the primary composite outcome of death, MI or stroke and the secondary outcome rehospitalisation with bleeding diagnosis at 1 year, was studied using adjusted Cox proportional hazards models, stratifying after eGFR levels. RESULTS In total, 45 206 patients with MI discharged on clopidogrel (n=33 472) or ticagrelor (n=11 734) were included. The unadjusted 1-year event rate for the composite endpoint of death, MI or stroke was 7.0%, 18.0% and 48.0% for ticagrelor treatment and 11.0%, 33.0% and 64.0% for clopidogrel treatment in patients with eGFR>60 (n=33 668), eGFR30-60 (n=9803) and eGFR<30 (n=1735), respectively. After adjustment, ticagrelor as compared with clopidogrel was associated with a lower 1-year risk of the composite outcome (eGFR>60: HR 0.87, 95% CI 0.76 to 99, eGFR30-60: 0.82 (0.70 to 0.97), eGFR<30: 0.95 (0.69 to 1.29), P for interaction=0.55) and a higher risk of bleeding (eGFR>60: HR 1.10, 95% CI 0.90 to 1.35, eGFR30-60: 1.13 (0.84 to 1.51), eGFR<30: 1.79 (1.00 to 3.21), P for interaction=0.30) across the eGFR strata. CONCLUSIONS Treatment with ticagrelor as compared with clopidogrel in patients with MI was associated with lower risk for the composite of death, MI or stroke and a higher bleeding risk across all strata of eGFR. Of caution, bleeding events were more abundant in patients with eGFR<30.
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Affiliation(s)
- Robert Edfors
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Sahlén
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,National Heart Centre, Singapore, Singapore
| | - Karolina Szummer
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Renlund
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Marie Evans
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Spaak
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Stefan K James
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Christoph Varenhorst
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
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Alabas OA, Gale CP, Hall M, Rutherford MJ, Szummer K, Lawesson SS, Alfredsson J, Lindahl B, Jernberg T. Sex Differences in Treatments, Relative Survival, and Excess Mortality Following Acute Myocardial Infarction: National Cohort Study Using the SWEDEHEART Registry. J Am Heart Assoc 2017; 6:e007123. [PMID: 29242184 PMCID: PMC5779025 DOI: 10.1161/jaha.117.007123] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 11/06/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study assessed sex differences in treatments, all-cause mortality, relative survival, and excess mortality following acute myocardial infarction. METHODS AND RESULTS A population-based cohort of all hospitals providing acute myocardial infarction care in Sweden (SWEDEHEART [Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies]) from 2003 to 2013 was included in the analysis. Excess mortality rate ratios (EMRRs), adjusted for clinical characteristics and guideline-indicated treatments after matching by age, sex, and year to background mortality data, were estimated. Although there were no sex differences in all-cause mortality adjusted for age, year of hospitalization, and comorbidities for ST-segment-elevation myocardial infarction (STEMI) and non-STEMI at 1 year (mortality rate ratio: 1.01 [95% confidence interval (CI), 0.96-1.05] and 0.97 [95% CI, 0.95-0.99], respectively) and 5 years (mortality rate ratio: 1.03 [95% CI, 0.99-1.07] and 0.97 [95% CI, 0.95-0.99], respectively), excess mortality was higher among women compared with men for STEMI and non-STEMI at 1 year (EMRR: 1.89 [95% CI, 1.66-2.16] and 1.20 [95% CI, 1.16-1.24], respectively) and 5 years (EMRR: 1.60 [95% CI, 1.48-1.72] and 1.26 [95% CI, 1.21-1.32], respectively). After further adjustment for the use of guideline-indicated treatments, excess mortality among women with non-STEMI was not significant at 1 year (EMRR: 1.01 [95% CI, 0.97-1.04]) and slightly higher at 5 years (EMRR: 1.07 [95% CI, 1.02-1.12]). For STEMI, adjustment for treatments attenuated the excess mortality for women at 1 year (EMRR: 1.43 [95% CI, 1.26-1.62]) and 5 years (EMRR: 1.31 [95% CI, 1.19-1.43]). CONCLUSIONS Women with acute myocardial infarction did not have statistically different all-cause mortality, but had higher excess mortality compared with men that was attenuated after adjustment for the use of guideline-indicated treatments. This suggests that improved adherence to guideline recommendations for the treatment of acute myocardial infarction may reduce premature cardiovascular death among women. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT02952417.
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Affiliation(s)
- Oras A Alabas
- Medical Research Council Bioinformatics Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom
| | - Chris P Gale
- Medical Research Council Bioinformatics Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom
- Department of Cardiology, York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | - Marlous Hall
- Medical Research Council Bioinformatics Centre, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, United Kingdom
| | - Mark J Rutherford
- Department of Health Sciences, University of Leicester, United Kingdom
| | - Karolina Szummer
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Sofia Sederholm Lawesson
- Department of Cardiology, Linköping University, Linköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Linköping University, Linköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyds Hospital, Karolinska Institutet, Stockholm, Sweden
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Andell P, Sjögren J, Batra G, Szummer K, Koul S. Outcome of patients with chronic obstructive pulmonary disease and severe coronary artery disease who had a coronary artery bypass graft or a percutaneous coronary intervention. Eur J Cardiothorac Surg 2017; 52:930-936. [DOI: 10.1093/ejcts/ezx219] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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