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Petursson P, Oštarijaš E, Redfors B, Råmunddal T, Angerås O, Völz S, Rawshani A, Hambraeus K, Koul S, Alfredsson J, Hagström H, Loghman H, Hofmann R, Fröbert O, Jernberg T, James S, Erlinge D, Omerovic E. Effects of pharmacological interventions on mortality in patients with Takotsubo syndrome: a report from the SWEDEHEART registry. ESC Heart Fail 2024; 11:1720-1729. [PMID: 38454651 PMCID: PMC11098647 DOI: 10.1002/ehf2.14713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/17/2023] [Accepted: 01/18/2024] [Indexed: 03/09/2024] Open
Abstract
AIMS Takotsubo syndrome (TS) is a heart condition mimicking acute myocardial infarction. TS is characterized by a sudden weakening of the heart muscle, usually triggered by physical or emotional stress. In this study, we aimed to investigate the effect of pharmacological interventions on short- and long-term mortality in patients with TS. METHODS AND RESULTS We analysed data from the SWEDEHEART (the Swedish Web System for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry, which included patients who underwent coronary angiography between 2009 and 2016. In total, we identified 1724 patients with TS among 228 263 individuals in the registry. The average age was 66 ± 14 years, and 77% were female. Nearly half of the TS patients (49.4%) presented with non-ST-elevation acute coronary syndrome, and a quarter (25.9%) presented with ST-elevation myocardial infarction. Most patients (79.1%) had non-obstructive coronary artery disease on angiography, while 11.7% had a single-vessel disease and 9.2% had a multivessel disease. All patients received at least one pharmacological intervention; most of them used beta-blockers (77.8% orally and 8.3% intravenously) or antiplatelet agents [aspirin (66.7%) and P2Y12 inhibitors (43.6%)]. According to the Kaplan-Meier estimator, the probability of all-cause mortality was 2.5% after 30 days and 16.6% after 6 years. The median follow-up time was 877 days. Intravenous use of inotropes and diuretics was associated with increased 30 day mortality in TS [hazard ratio (HR) = 9.92 (P < 0.001) and HR = 3.22 (P = 0.001), respectively], while angiotensin-converting enzyme inhibitors and statins were associated with decreased long-term mortality [HR = 0.60 (P = 0.025) and HR = 0.62 (P = 0.040), respectively]. Unfractionated and low-molecular-weight heparins were associated with reduced 30 day mortality [HR = 0.63 (P = 0.01)]. Angiotensin receptor blockers, oral anticoagulants, P2Y12 antagonists, aspirin, and beta-blockers did not statistically correlate with mortality. CONCLUSIONS Our findings suggest that some medications commonly used to treat TS are associated with higher mortality, while others have lower mortality. These results could inform clinical decision-making and improve patient outcomes in TS. Further research is warranted to validate these findings and to identify optimal pharmacological interventions for patients with TS.
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Affiliation(s)
- Petur Petursson
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
| | | | - Björn Redfors
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Department of Molecular and Clinical MedicineSahlgrenska Academy at University of GothenburgGothenburgSweden
| | - Truls Råmunddal
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Department of Molecular and Clinical MedicineSahlgrenska Academy at University of GothenburgGothenburgSweden
| | - Oskar Angerås
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Department of Molecular and Clinical MedicineSahlgrenska Academy at University of GothenburgGothenburgSweden
| | - Sebastian Völz
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Department of Molecular and Clinical MedicineSahlgrenska Academy at University of GothenburgGothenburgSweden
| | - Araz Rawshani
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Department of Molecular and Clinical MedicineSahlgrenska Academy at University of GothenburgGothenburgSweden
| | | | - Sasha Koul
- Department of CardiologySkåne University HospitalLundSweden
| | - Joakim Alfredsson
- Department of CardiologyLinköping University HospitalLinköpingSweden
| | | | - Henareh Loghman
- Department of CardiologyKarolinska University HospitalStockholmSweden
| | - Robin Hofmann
- Department of CardiologySödra HospitalStockholmSweden
| | - Ole Fröbert
- Department of CardiologyÖrebro University HospitalÖrebroSweden
| | - Tomas Jernberg
- Department of CardiologyDanderyd University HospitalStockholmSweden
| | - Stefan James
- Department of CardiologyUppsala University HospitalUppsalaSweden
| | - David Erlinge
- Department of CardiologySkåne University HospitalLundSweden
| | - Elmir Omerovic
- Department of CardiologySahlgrenska University HospitalGothenburgSweden
- Department of Molecular and Clinical MedicineSahlgrenska Academy at University of GothenburgGothenburgSweden
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2
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Sigurjonsson J, Grubb D, Grubb A, Christensson A, Öberg CM, Ederoth P, Koul S, Götberg M, Yndigegn T, Tödt T, Viterius B, Bjursten H. A study of size-selective renal elimination using a novel human model. Scand J Clin Lab Invest 2024; 84:115-120. [PMID: 38587086 DOI: 10.1080/00365513.2024.2338742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
The recently discovered selective glomerular hypofiltration syndromes have increased interest in the actual elimination of molecules in the human kidney. In the present study, a novel human model was introduced to directly measure the single-pass renal elimination of molecules of increasing size. Plasma concentrations of urea, creatinine, C-peptide, insulin, pro-BNP, β2-microglobulin, cystatin C, troponin-T, orosomucoid, albumin, and IgG were analysed in arterial and renal venous blood from 45 patients undergoing Transcatheter Aortic Valve Implantation (TAVI). The renal elimination ratio (RER) was calculated as the arteriovenous concentration difference divided by the arterial concentration. Estimated glomerular filtration rate (eGFR) was calculated by the CKD-EPI equations for both creatinine and cystatin C. Creatinine (0.11 kDa) showed the highest RER (21.0 ± 6.3%). With increasing molecular size, the RER gradually decreased, where the RER of cystatin C (13 kDa) was 14.4 ± 5.3% and troponin-T (36 kDa) was 11.3 ± 4.6%. The renal elimination threshold was found between 36 and 44 kDa as the RER of orosomucoid (44 kDa) was -0.2 ± 4.7%. The RER of creatinine and cystatin C showed a significant and moderate positive linear relationship with eGFR (r = 0.48 and 0.40). In conclusion, a novel human model was employed to demonstrate a decline in renal elimination with increasing molecular size. Moreover, RERs of creatinine and cystatin C were found to correlate with eGFR, suggesting the potential of this model to study selective glomerular hypofiltration syndromes.
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Affiliation(s)
- Johann Sigurjonsson
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
| | - David Grubb
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
| | - Anders Grubb
- Department of Clinical Chemistry, Skåne University Hospital, Lund University, Lund, Sweden
| | - Anders Christensson
- Department of Nephrology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Carl M Öberg
- Department of Nephrology, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Per Ederoth
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Matthias Götberg
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Troels Yndigegn
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Tim Tödt
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Benedicte Viterius
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Henrik Bjursten
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
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3
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Omerovic E, James S, Råmundal T, Fröbert O, Linder R, Danielewicz M, Hamid M, Pagonis C, Henareh L, Wagner H, Stewart J, Jensen J, Lindros P, Robertsson L, Wikström H, Ulvenstam A, Bhiladval P, Tödt T, Ioanes D, Kellerth T, Zagozdzon L, Götberg M, Andersson J, Angerås O, Östlund O, Held C, Koul S, Erlinge D. Bivalirudin versus heparin in ST and non-ST-segment elevation myocardial infarction-Outcomes at two years. Cardiovasc Revasc Med 2024:S1553-8389(24)00113-1. [PMID: 38575449 DOI: 10.1016/j.carrev.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 03/18/2024] [Accepted: 03/22/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND The registry-based randomized VALIDATE-SWEDEHEART trial (NCT02311231) compared bivalirudin vs. heparin in patients undergoing percutaneous coronary intervention (PCI) for myocardial infarction (MI). It showed no difference in the composite primary endpoint of death, MI, or major bleeding at 180 days. Here, we report outcomes at two years. METHODS Analysis of primary and secondary endpoints at two years of follow-up was prespecified in the study protocol. We report the study results for the extended follow-up time here. RESULTS In total, 6006 patients were enrolled, 3005 with ST-segment elevation MI (STEMI) and 3001 with Non-STEMI (NSTEMI), representing 70 % of all eligible patients with these diagnoses during the study. The primary endpoint occurred in 14.0 % (421 of 3004) in the bivalirudin group compared with 14.3 % (429 of 3002) in the heparin group (hazard ratio [HR] 0.97; 95 % confidence interval [CI], 0.85-1.11; P = 0.70) at one year and in 16.7 % (503 of 3004) compared with 17.1 % (514 of 3002), (HR 0.97; 95 % CI, 0.96-1.10; P = 0.66) at two years. The results were consistent in patients with STEMI and NSTEMI and across major subgroups. CONCLUSIONS Until the two-year follow-up, there were no differences in endpoints between patients with MI undergoing PCI and allocated to bivalirudin compared with those allocated to heparin. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02311231.
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Affiliation(s)
- Elmir Omerovic
- Dept of Cardiology, Sahlgrenska University, Gothenburg, Sweden.
| | - Stefan James
- Dept of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Truls Råmundal
- Dept of Cardiology, Sahlgrenska University, Gothenburg, Sweden
| | - Ole Fröbert
- Dept of Cardiology, Örebro University, Faculty of Health, Sweden
| | - Rikard Linder
- Dept of Cardiology, Danderyd, Karolinska University, Stockholm, Sweden
| | | | - Mehmet Hamid
- Dept of Cardiology, Mälarsjukhuset, Eskilstuna, Sweden
| | - Christos Pagonis
- Dept of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - Loghman Henareh
- Dept of Cardiology, Karolinska Hospital, Karolinska University, Stockholm, Sweden
| | - Henrik Wagner
- Dept of Cardiology, Helsingborg Lasarett, Helsingborg, Sweden
| | - Jason Stewart
- Dept of Cardiology, Skaraborgs Hospital, Skövde, Sweden
| | - Jens Jensen
- Dept of Clinical Science and Education, Södersjukhuset, Karolinska Institute, Unit of Cariology, Capio St Görans Sjukhus, Stockholm
| | | | | | - Helena Wikström
- Dept of Cardiology, Kristianstad Hospital, Kristianstad, Sweden
| | | | - Pallonji Bhiladval
- Dept of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tim Tödt
- Dept of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Dan Ioanes
- Dept of Cardiology, Sahlgrenska University, Gothenburg, Sweden
| | - Thomas Kellerth
- Dept of Cardiology, Örebro University, Faculty of Health, Sweden
| | - Leszek Zagozdzon
- Dept of Cardiology, Örebro University, Faculty of Health, Sweden
| | - Matthias Götberg
- Dept of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | | | - Oskar Angerås
- Dept of Cardiology, Sahlgrenska University, Gothenburg, Sweden
| | - Ollie Östlund
- Dept of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Claes Held
- Dept of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Sasha Koul
- Dept of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - David Erlinge
- Dept of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
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4
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Lindow T, Mokhtari A, Nyström A, Koul S, Smith SW, Ekelund U. Comparison of diagnostic accuracy of current left bundle branch block and ventricular pacing ECG criteria for detection of occlusion myocardial infarction. Int J Cardiol 2024; 395:131569. [PMID: 37931659 DOI: 10.1016/j.ijcard.2023.131569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/18/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Electrocardiographic detection of patients with occlusion myocardial infarction (OMI) can be difficult in patients with left bundle branch block (LBBB) or ventricular paced rhythm (VPR) and several ECG criteria for the detection of OMI in LBBB/VPR exist. Most recently, the Barcelona criteria, which includes concordant ST deviation and discordant ST deviation in leads with low R/S amplitudes, showed superior diagnostic accuracy but has not been validated externally. We aimed to describe the diagnostic accuracy of four available ECG criteria for OMI detection in patients with LBBB/VPR at the emergency department. METHODS The unweighted Sgarbossa criteria, the modified Sgarbossa criteria (MSC), the Barcelona criteria and the Selvester criteria were applied to chest pain patients with LBBB or VPR in a prospectively acquired database from five emergency departments. RESULTS In total, 623 patients were included, among which 441 (71%) had LBBB and 182 (29%) had VPR. Among these, 82 (13%) patients were diagnosed with AMI, and an OMI was identified in 15 (2.4%) cases. Sensitivity/specificity of the original unweighted Sgarbossa criteria were 26.7/86.2%, for MSC 60.0/86.0%, for Barcelona criteria 53.3/82.2%, and for Selvester criteria 46.7/88.3%. In this setting with low prevalence of OMI, positive predictive values were low (Sgarbossa: 4.6%; MSC: 9.4%; Barcelona criteria: 6.9%; Selvester criteria: 9.0%) and negative predictive values were high (all >98.0%). CONCLUSIONS Our results suggests that ECG criteria alone are insufficient in predicting presence of OMI in an ED setting with low prevalence of OMI, and the search for better rapid diagnostic instruments in this setting should continue.
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Affiliation(s)
- Thomas Lindow
- Clinical Physiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Clinical Physiology, Department of Research and Development, Region Kronoberg, Växjö Central Hospital, Växjö, Sweden.
| | - Arash Mokhtari
- Department of Cardiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Axel Nyström
- Occupational and Environmental Medicine, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Stephen W Smith
- Department of Medicine, Hennepin County Medical Center, Minneapolis, MN, USA; Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ulf Ekelund
- Emergency Medicine, Clinical Sciences Lund, Lund University, Lund, Sweden; Department of Emergency Medicine, Skåne University Hospital, Lund, Sweden
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Emilsson OL, Koul S. Reply: Pretreatment with unfractionated heparin in patients undergoing primary PCI: a standard of treatment together with DAPT? EUROINTERVENTION 2023; 18:1473-1474. [PMID: 37092267 PMCID: PMC10111130 DOI: 10.4244/eij-d-22-00867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 04/25/2023]
Affiliation(s)
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
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Berntorp K, Rylance R, Yndigegn T, Koul S, Fröbert O, Christiansen EH, Erlinge D, Götberg M. Clinical Outcome of Revascularization Deferral With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A 5-Year Follow-Up Substudy From the iFR-SWEDEHEART Trial. J Am Heart Assoc 2023; 12:e028423. [PMID: 36734349 PMCID: PMC9973641 DOI: 10.1161/jaha.122.028423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Although physiology-based assessment of coronary artery stenosis using instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) are established methods of guiding coronary revascularization, its clinical outcome in long-term deferral needs further evaluation, especially with acute coronary syndrome as a clinical presentation. The aim was to evaluate the long-term clinical outcome of deferral of revascularization based on iFR or FFR. Methods and Results This is a substudy of the iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trial, where patients deferred from revascularization from each study arm were selected. Nine hundred eight patients deferred from coronary revascularization with iFR (n=473) and FFR (n=435) were followed for 5 years. The national quality registry, SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies), was used for patient data collection and clinical follow-up. The end point was major adverse cardiac events and their individual components all-cause death, cardiovascular death, noncardiovascular death, nonfatal myocardial infarction, and unplanned revascularization. No significant difference was found in major adverse cardiac events (iFR 18.6% versus FFR 16.8%; adjusted hazard ratio, 1.08 [95% CI, 0.79-1.48]; P=0.63) or their individual components. Conclusions No differences in clinical outcomes after 5-year follow-up were noted when comparing iFR versus FFR as methods for deferral of coronary revascularization in patients presenting with stable angina pectoris and acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02166736.
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Affiliation(s)
- Karolina Berntorp
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Rebecca Rylance
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Troels Yndigegn
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Sasha Koul
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Ole Fröbert
- Faculty of Health, Department of CardiologyÖrebro University HospitalÖrebroSweden
| | | | - David Erlinge
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
| | - Matthias Götberg
- Department of CardiologySkåne University Hospital, Clinical Sciences, Lund UniversityLundSweden
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Sabbah M, Veien K, Niemela M, Freeman P, Linder R, Ioanes D, Terkelsen CJ, Kajander OA, Koul S, Savontaus M, Karjalainen P, Erglis A, Minkkinen M, Jørgensen T, Sondergaard L, De Backer O, Engstrøm T, Lønborg J. Routine revascularization with percutaneous coronary intervention in patients with coronary artery disease undergoing transcatheter aortic valve implantation - the third nordic aortic valve intervention trial - NOTION-3. Am Heart J 2023; 255:39-51. [PMID: 36220354 DOI: 10.1016/j.ahj.2022.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/24/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) frequently coexists with severe aortic valve stenosis (AS) in patients planned for transcatheter aortic valve implantation (TAVI). How to manage CAD in this patient population is still an unresolved question. In particular, it is still not known whether fractional flow reserve (FFR) guided revascularization with percutaneous coronary intervention (PCI) is superior to medical treatment for CAD in terms of clinical outcomes. STUDY DESIGN The third Nordic Aortic Valve Intervention (NOTION-3) Trial is an open-label investigator-initiated, multicenter multinational trial planned to randomize 452 patients with severe AS and significant CAD to either FFR-guided PCI or medical treatment, in addition to TAVI. Patients are eligible for the study in the presence of at least 1 significant PCI-eligible coronary stenosis. A significant stenosis is defined as either FFR ≤0.80 and/or diameter stenosis >90%. The primary end point is a composite of first occurring all-cause mortality, myocardial infarction, or urgent revascularization (PCI or coronary artery bypass graft performed during unplanned hospital admission) until the last included patient have been followed for 1 year after the TAVI. SUMMARY NOTION-3 is a multicenter, multinational randomized trial aiming at comparing FFR-guided revascularization vs medical treatment of CAD in patients with severe AS planned for TAVI.
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Affiliation(s)
- Muhammad Sabbah
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Denmark
| | - Karsten Veien
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Matti Niemela
- Department of Cardiology, Oulu University Hospital, University of Oulu, Finland
| | - Phillip Freeman
- Department of Cardiology, Aalborg University Hospital, Denmark
| | - Rickard Linder
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Christian Juhl Terkelsen
- The Danish Heart Foundation; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Olli A Kajander
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | | | - Pasi Karjalainen
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | | | - Mikko Minkkinen
- Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Troels Jørgensen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Denmark
| | - Lars Sondergaard
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Ole De Backer
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Jacob Lønborg
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Denmark.
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8
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Emilsson OL, Bergman S, Mohammad MA, Olivecrona GK, Götberg M, Erlinge D, Koul S. Pretreatment with heparin in patients with ST-segment elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). EUROINTERVENTION 2022; 18:709-718. [PMID: 36036797 PMCID: PMC10241276 DOI: 10.4244/eij-d-22-00432] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/03/2022] [Indexed: 09/20/2023]
Abstract
BACKGROUND Unfractionated heparin (UFH) is frequently administered before percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). AIMS The aim of the study was to investigate if pretreatment with UFH prior to arrival at the catheterisation laboratory affects coronary artery occlusion, mortality, and in-hospital major bleeding in patients with STEMI undergoing PCI. METHODS Patients with a first STEMI event undergoing PCI between 2008 and 2016 were extracted from the Swedish Coronary Angiography and Angioplasty Registry. Risk ratios for UFH pretreatment versus no pretreatment regarding coronary artery occlusion at presentation in the catheterisation laboratory, 30-day mortality, and bleeding were obtained using adjusted Poisson regression models with robust standard errors. Analyses of propensity score (PS)-matched groups were performed to obtain absolute risk differences. RESULTS In all, 41,631 patients were included, 16,026 (38%) with and 25,605 (62%) without UFH pretreatment. Adjusted risk ratios were 0.89 (95% confidence interval [CI]: 0.87 to 0.90) for coronary artery occlusion, 0.87 (0.77 to 0.99) for mortality, and 1.01 (0.86 to 1.18) for bleeding. In the PS-matched analyses, the absolute risk differences were -0.087 (-0.074 to -0.099) for coronary artery occlusion, -0.011 (-0.017 to -0.0041) for mortality, and 0 (-0.0052 to 0.0052) for bleeding. CONCLUSIONS Pretreatment with UFH was associated with a reduction in coronary artery occlusion among patients with STEMI, with a number needed to treat (NNT) of 12, without increasing the risk of major in-hospital bleeding. Regarding mortality, a reduction was found with UFH pretreatment, with an NNT of 94, but this effect was not robust over all sensitivity analyses and residual confounding cannot be excluded.
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Affiliation(s)
| | - Sofia Bergman
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Moman A Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Göran K Olivecrona
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
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9
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Emilsson OL, Bergman S, Mohammad M, Rylance R, Olivecrona G, Gotberg M, Erlinge D, Koul S. Heparin pre-treatment in patients with ST elevation myocardial infarction: a cohort study investigating the effects on coronary artery occlusion, mortality, and bleeding. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2038] [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
Unfractionated heparin (UFH) is often administered before arrival at the cath lab in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). However, large studies regarding the clinical impacts of UFH pre-treatment are scarce.
Purpose
To investigate if pre-treatment with heparin affects total coronary artery occlusion at angiography, mortality at 30 days, and major bleeding during hospitalization in patients with STEMI undergoing primary PCI.
Methods
The study population was extracted from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) and consisted of unique patients with a first STEMI event undergoing PCI during the study period 2008 to 2016. Patients receiving UFH pre-treatment were compared with patients not receiving UFH pre-treatment. To obtain relative risks of the outcomes adjusted Poisson regression models with robust standard errors were used. In the adjusted models, we included age, sex, smoking status, year, comorbidities (as specified under tables 1 and 2), and anti-thrombotic treatment (as specified under tables 1 and 2). To obtain absolute risk differences, analyses of propensity score (PS) matched groups were performed. PS was based on the same variables as in the adjusted Poisson regression, and a caliper of 0.02 was used.
Results
A total of 41,631 patients were included in the study population (median age: 67 years; 71% male), with 16,026 receiving pre-treatment with UFH and 25,605 not receiving UFH pre-treatment. The adjusted Poisson model revealed that UFH pre-treatment was associated with an 11% relative risk reduction of coronary artery occlusion (95% confidence interval (CI): 9%; 12%), and an 13% (95% CI: 2%; 23%) reduced relative risk of mortality. For bleeding, no statistically significant difference was found. In the PS-matched analysis (median age: 67 years, 71% male), the absolute risk differences were for coronary artery occlusion 8.3% (95% CI: 7.1%; 9.5%) in favour of UFH pre-treatment, and for mortality 0.5% (−0.1%; 1.2%), with a modest trend in favour of UFH pre-treatment. For bleeding, no statistically significant difference was found.
Conclusion
UFH pre-treatment was associated with a reduction in coronary artery occlusion at presentation at the cath lab in patients with STEMI, the number needed to treat being 13, without increasing the risk of bleeding. Regarding mortality, a reduced relative risk was found in the adjusted regression analysis, but the absolute risk difference was small and not statistically significant in the PS-matched analysis. Due to the retrospective study design, residual confounding cannot be excluded.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- O L Emilsson
- Lund University, Department of Cardiology, Clinical Sciences , Lund , Sweden
| | - S Bergman
- Lund University, Department of Cardiology, Skåne University Hospital , Lund , Sweden
| | - M Mohammad
- Lund University, Department of Cardiology, Skåne University Hospital , Lund , Sweden
| | - R Rylance
- Lund University, Department of Cardiology, Clinical Sciences , Lund , Sweden
| | - G Olivecrona
- Lund University, Department of Cardiology, Skåne University Hospital , Lund , Sweden
| | - M Gotberg
- Lund University, Department of Cardiology, Skåne University Hospital , Lund , Sweden
| | - D Erlinge
- Lund University, Department of Cardiology, Skåne University Hospital , Lund , Sweden
| | - S Koul
- Lund University, Department of Cardiology, Skåne University Hospital , Lund , Sweden
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Omerovic E, Erlinge D, Koul S, Frobert O, Andersson J, Ponten J, Björklund F, Kastberg R, Petzold M, Ljungman C, Bolin K, Redfors B. Rationale and design of switch Swedeheart: A registry-based, stepped-wedge, cluster-randomized, open-label multicenter trial to compare prasugrel and ticagrelor for treatment of patients with acute coronary syndrome. Am Heart J 2022; 251:70-77. [PMID: 35644221 DOI: 10.1016/j.ahj.2022.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND European treatment guidelines recommend prasugrel over ticagrelor for treating patients with non-ST-elevation acute coronary syndrome (ACS), prompting several Swedish administrative regions to transition from ticagrelor to prasugrel as the preferred treatment for patients with ACS. We aim to systematically evaluate this transition to determine the relative efficacy of prasugrel versus ticagrelor in a real-world cohort of patients with ACS. STUDY DESIGN AND OBJECTIVES The SWITCH SWEDEHEART trial is a prospective, multicenter, open-label, cross-sectional, stepped-wedge cluster-randomized clinical trial, in which administrative regions in Sweden will constitute the clusters. At the start of the study, all clusters will use ticagrelor as the P2Y12 inhibitor drug of choice for ACS. The order in which the clusters will implement the transition from ticagrelor to prasugrel will be randomly assigned. Every 9 months, 1 cluster will switch from ticagrelor to prasugrel as the P2Y12 inhibitor of choice for patients with ACS. The primary endpoint is the composite 1-year rate of the death, stroke, or myocardial infarction. CONCLUSIONS The SWITCH SWEDEHEART study will provide an extensive randomized comparison between ticagrelor and prasugrel. Novel therapies are frequently costly and supported by evidence from few or small studies, and systematic evaluation after the introduction is rare. This study will establish an important standard for introducing and evaluating the effects of health care changes within our societies.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Ole Frobert
- Department of Cardiology, Faculty of Health, Örebro University Hospital, Örebro, Sweden; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Jonas Andersson
- Department of Cardiology, Umeå University Hospital, Umeå, Sweden
| | - Johan Ponten
- Department of Cardiology, Hallands hospital Halmstad, Halmstad, Sweden
| | | | - Robert Kastberg
- Department of Cardiology, Östersund Hospital, Östersund, Sweden
| | - Max Petzold
- School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Sweden
| | - Charlotta Ljungman
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian Bolin
- Department of Economics, Centre for Health Economics, University of Gothenburg, Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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11
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Bjursten H, Koul S, Duvernoy O, Fagman E, Samano N, Nilsson J, Nielsen NE, Rück A, Johansson J, James S, Settergren M, Götberg M, Pistea A. Calcium Load in the Aortic Valve, Aortic Root, and Left Ventricular Outflow Tract and the Risk for a Periprocedural Stroke. Struct Heart 2022; 6:100070. [PMID: 37288334 PMCID: PMC10242559 DOI: 10.1016/j.shj.2022.100070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/07/2022] [Accepted: 06/17/2022] [Indexed: 06/09/2023]
Abstract
Background Periprocedural stroke during transcatheter aortic valve implantation is a rare but devastating complication. The calcified aortic valve is the most likely source of the emboli in a periprocedural stroke. The total load and distribution of calcium in the leaflets, aortic root, and left ventricular outflow tract varies from patient to patient. Consequently, there could be patterns of calcification that are associated with a higher risk of stroke. This study aimed to explore whether the pattern of calcification in the left ventricular outflow tract, annulus, aortic valve, and ascending aorta can be used to predict a periprocedural stroke. Methods Among the 3282 consecutive patients who received a transcatheter aortic valve implantation in the native valve in Sweden from 2014 to 2018, we identified 52 who had a periprocedural stroke. From the same cohort, a control group of 52 patients was constructed by propensity score matching. Both groups had one missing cardiac computed tomography, and 51 stroke and 51 control patients were blindly reviewed by an experienced radiologist. Results The groups were well balanced in terms of demographics and procedural data. Of the 39 metrics created to describe calcium pattern, only one differed between the groups. The length of calcium protruding above the annulus was 10.6 mm (interquartile range 7-13.6) for patients without stroke and 8 mm (interquartile range 3-10) for stroke patients. Conclusions This study could not find any pattern of calcification that predisposes for a periprocedural stroke.
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Affiliation(s)
- Henrik Bjursten
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Olov Duvernoy
- Section of Radiology, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Erika Fagman
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Sahlgrenska Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ninos Samano
- Faculty of Medicine and Health, University Health Care Research Centre, Örebro University, Örebro, Sweden
| | - Johan Nilsson
- Institution of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Niels Erik Nielsen
- Department of Cardiology, Heart Centre, University Hospital, Linköping, Sweden
| | - Andreas Rück
- Department of Cardiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Jan Johansson
- Department of Cardiology, Blekinge Hospital, Karlskrona, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Magnus Settergren
- Department of Cardiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Matthias Götberg
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Adrian Pistea
- Department of Radiology, Skåne University Hospital, Lund University, Lund, Sweden
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Mohammad MA, Olesen KKW, Koul S, Gale CP, Rylance R, Jernberg T, Baron T, Spaak J, James S, Lindahl B, Maeng M, Erlinge D. Development and validation of an artificial neural network algorithm to predict mortality and admission to hospital for heart failure after myocardial infarction: a nationwide population-based study. Lancet Digit Health 2021; 4:e37-e45. [PMID: 34952674 DOI: 10.1016/s2589-7500(21)00228-4] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/28/2021] [Accepted: 09/10/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients have an estimated mortality of 15-20% within the first year following myocardial infarction and one in four patients who survive myocardial infarction will develop heart failure, severely reducing quality of life and increasing the risk of long-term mortality. We aimed to establish the accuracy of an artificial neural network (ANN) algorithm in predicting 1-year mortality and admission to hospital for heart failure after myocardial infarction. METHODS In this nationwide population-based study, we used data for all patients admitted to hospital for myocardial infarction and discharged alive from a coronary care unit in Sweden (n=139 288) between Jan 1, 2008, and April 1, 2017, from the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) nationwide registry; these patients were randomly divided into training (80%) and testing (20%) datasets. We developed an ANN using 21 variables (including age, sex, medical history, previous medications, in-hospital characteristics, and discharge medications) associated with the outcomes of interest with a back-propagation algorithm in the training dataset and tested it in the testing dataset. The ANN algorithm was then validated in patients with incident myocardial infarction enrolled in the Western Denmark Heart Registry (external validation cohort) between Jan 1, 2008, and Dec 31, 2016. The predictive ability of the model was evaluated using area under the receiver operating characteristic curve (AUROC) and Youden's index was established as a means of identifying an empirical dichotomous cutoff, allowing further evaluation of model performance. FINDINGS 139 288 patients who were admitted to hospital for myocardial infarction in the SWEDEHEART registry were randomly divided into a training dataset of 111 558 (80%) patients and a testing dataset of 27 730 (20%) patients. 30 971 patients with myocardial infarction who were enrolled in the Western Denmark Heart Registry were included in the external validation cohort. A first event, either all-cause mortality or admission to hospital for heart failure 1 year after myocardial infarction, occurred in 32 308 (23·2%) patients in the testing and training cohorts only. For 1-year all-cause mortality, the ANN had an AUROC of 0·85 (95% CI 0·84-0·85) in the testing dataset and 0·84 (0·83-0·84) in the external validation cohort. The AUROC for admission to hospital for heart failure within 1 year was 0·82 (0·81-0·82) in the testing dataset and 0·78 (0·77-0·79) in the external validation dataset. With an empirical cutoff the ANN algorithm correctly classified 73·6% of patients with regard to all-cause mortality and 61·5% of patients with regard to admission to hospital for heart failure in the external validation cohort, ruling out adverse outcomes with 97·1-98·7% probability in the external validation cohort. INTERPRETATION Identifying patients at a high risk of developing heart failure or death after myocardial infarction could result in tailored therapies and monitoring by the allocation of resources to those at greatest risk. FUNDING The Swedish Heart and Lung Foundation, Swedish Scientific Research Council, Swedish Foundation for Strategic Research, Knut and Alice Wallenberg Foundation, ALF Agreement on Medical Education and Research, Skane University Hospital, The Bundy Academy, the Märta Winkler Foundation, the Anna-Lisa and Sven-Eric Lundgren Foundation for Medical Research.
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Affiliation(s)
- Moman A Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden.
| | - Kevin K W Olesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Rebecca Rylance
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Tomasz Baron
- Department of Medical Sciences and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Jonas Spaak
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
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13
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James S, Koul S, Andersson J, Angerås O, Bhiladvala P, Calais F, Danielewicz M, Fröbert O, Grimfjärd P, Götberg M, Henareh L, Ioanes D, Jensen J, Linder R, Lindroos P, Omerovic E, Panayi G, Råmunddal T, Sarno G, Ulvenstam A, Völtz S, Wagner H, Wikström H, Östlund O, Erlinge D. Bivalirudin Versus Heparin Monotherapy in ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2021; 14:e008969. [PMID: 34903034 DOI: 10.1161/circinterventions.120.008969] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bivalirudin was not superior to unfractionated heparin in patients with myocardial infarction (MI) treated with percutaneous coronary intervention and no planned use of GPI (glycoprotein IIb/IIIa inhibitors) in contemporary clinical practice of radial access and potent P2Y12-inhibitors in the VALIDATE-SWEDEHEART randomized clinical trial (Bivalirudin Versus Heparin in STEMI and NSTEMI Patients on Modern Antiplatelet Therapy-Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies Registry). METHODS In this prespecified separately powered subgroup analysis, we included patients with ST-segment-elevation MI undergoing primary percutaneous coronary intervention with the primary composite end point of all-cause death, MI, or major bleeding event within 180 days. RESULTS Among the 6006 patients enrolled in the trial, 3005 patients with ST-segment-elevation MI were randomized to receive bivalirudin or heparin. The mean age was 66.8 years. According to protocol recommendations, 87% were treated with potent oral P2Y12-inhibitors before start of angiography and radial access was used in 90%. GPI was used in 51 (3.4%) and 74 (4.9%) of patients randomized to receive bivalirudin and heparin, respectively. The primary end point occurred in 12.5% (187 of 1501) and 13.0% (196 of 1504; hazard ratio [HR], 0.95 [95% CI, 0.78-1.17], P=0.64) with consistent results in all major subgroups. All-cause death occurred in 3.9% versus 3.9% (HR, 1.00 [0.70-1.45], P=0.98), MI in 1.7% versus 2.2% (HR, 0.76 [0.45-1.28], P=0.30), major bleeding in 8.3% versus 8.0% (HR, 1.04 [0.81-1.33], P=0.78), and definite stent thrombosis in 0.5% versus 1.3% (HR, 0.42 [0.18-0.96], P=0.04). CONCLUSIONS In patients with ST-segment-elevation MI undergoing primary percutaneous coronary intervention with radial access and receiving current recommended treatments with potent P2Y12-inhibitors rate of the composite of all-cause death, MI, or major bleeding was not lower in those randomized to receive bivalirudin as compared with heparin. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02311231.
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Affiliation(s)
- Stefan James
- Department of Medical Sciences (S.J., G.S.), Uppsala University, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Sweden (S.K., P.B., M.G., D.E.)
| | | | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Pallonji Bhiladvala
- Department of Cardiology, Clinical Sciences, Lund University, Sweden (S.K., P.B., M.G., D.E.)
| | - Fredrik Calais
- Department of Cardiology, Faculty of Health, Örebro University, Sweden (F.C., O.F.)
| | | | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Sweden (F.C., O.F.)
| | - Per Grimfjärd
- Department of Internal Medicine, Västmanlands Sjukhus, Västerås, Sweden (P.G.)
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Sweden (S.K., P.B., M.G., D.E.)
| | - Loghman Henareh
- Department of Cardiology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden (L.H.)
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Jens Jensen
- Department of Cardiology, Capio St Görans Hospital AB, Stockholm, Sweden (J.J., P.L.)
| | - Rikard Linder
- Department of Cardiology, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (R.L.)
| | - Pontus Lindroos
- Department of Cardiology, Capio St Görans Hospital AB, Stockholm, Sweden (J.J., P.L.)
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Georgios Panayi
- Department of Cardiology, Linköping University, Sweden (G.P.)
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Giovanna Sarno
- Department of Medical Sciences (S.J., G.S.), Uppsala University, Sweden
| | | | - Sebastian Völtz
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (O.A., D.I., E.O., T.R., S.V.)
| | - Henrik Wagner
- Department of Cardiology, Helsingborg Lasarett, Sweden (H. Wagner)
| | - Helena Wikström
- Department of Cardiology, Kristianstad Hospital, Sweden (H. Wikström)
| | - Ollie Östlund
- Uppsala Clinical Research Center (O.Ö.), Uppsala University, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Sweden (S.K., P.B., M.G., D.E.)
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14
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Abstract
Background The Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE‐DAPT) score has been shown to predict out‐of‐hospital major bleeding after myocardial infarction treated with percutaneous coronary intervention and dual antiplatelet therapy (DAPT). However, large validation studies have been scarce and the discriminative ability for patients with a preexisting bleeding risk factor (elderly, underweight, women, anemia, kidney dysfunction, or cancer) in a real‐world setting is unknown. Methods and Results Patients undergoing percutaneous coronary intervention for myocardial infarction between 2008 and 2017 were included from the SWEDEHEART (Swedish Web System for Enhancement of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) registry (n=66 295). The predictive value of the PRECISE‐DAPT score for rehospitalization with major bleeding during dual antiplatelet therapy was evaluated using receiver operating characteristic analyses. A high PRECISE‐DAPT score (≥25; n=13 894) was associated with increased risk of major bleeding (3.9% versus 1.8%; hazard ratio [HR], 2.2; 95% CI, 2.0–2.5; P<0.001) compared with a non‐high score (<25; n=52 401). The score demonstrated a c‐statistic of 0.64 (95% CI, 0.63–0.66). The discriminative ability of the score to further stratify bleeding risk in patients with preexisting bleeding risk factors was poor, especially in patients who are elderly (c‐statistic=0.57; 95% CI, 0.55–0.60) or underweight (c‐statistic=0.56; 95% CI, 0.51–0.61), for whom a non‐high PRECISE‐DAPT score was associated with similar bleeding risk as a high PRECISE‐DAPT score in the general myocardial infarction population. Conclusions In this nationwide population‐based study, the PRECISE‐DAPT score performed moderately in the general myocardial infarction population and poorly in patients with preexisting bleeding risk factors, where its usefulness seems limited.
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Affiliation(s)
- Axel Wester
- Department of Cardiology Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Moman A Mohammad
- Department of Cardiology Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Göran Olivecrona
- Department of Cardiology Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Jasminka Holmqvist
- Department of Cardiology Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Troels Yndigegn
- Department of Cardiology Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Sasha Koul
- Department of Cardiology Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
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Demidova MM, Rylance R, Koul S, Dworeck C, James S, Aasa M, Erlinge D, Platonov PG. The incidence, time distribution and prognostic value of monomorphic ventricular tachycardia in ST-elevation myocardial infarction: the prespecified analysis of VALIDATE SWEADHEART trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1464] [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 assessment of prognostic impact of ventricular arrhythmias in ST-elevation myocardial infarction (STEMI) is currently based mainly on their timing with regard to the symptom onset and does not distinguish between monomorphic ventricular tachycardia (VT) and polymorphic VT/ventricular fibrillation (VF). However, recent data indicate long-term hazard of monomorphic VT occurring early in the course of STEMI.
Purpose
To evaluate the incidence, time distribution and prognostic value of early monomorphic VT compared to polymorphic VT/VF in STEMI patients treated by primary percutaneous coronary interventions (PCI).
Methods
A prespecified analysis of the multicentre prospective registry-based randomised VALIDATE-SWEDEHEART trial included STEMI patients enrolled at 16 sites in Sweden between June 2014 and September 2016. Source data verification regarding the type and timing of arrhythmia from all patients with VT/VF during STEMI was performed. Survival status was obtained from the Swedish national population registry. Endpoint was total mortality at 180 days.
Results
In total, 2886 patients were identified. Among them, 97 (3.4%) had VF or polymorphic VT, 16 (0.5%) monomorphic VT, 6 (0.2%) had other undefined shockable rhythm. Total mortality (10.9% vs 2.8%, p≤0.001) was higher among patients with VT/VF. VT/VF was associated with total mortality (HR 3.18 95% CI 1.74–5.8; p≤0.001) after adjustment on age, gender and myocardial infarction localisation. In patients discharged from hospital, VT/VF did not influence the long-term prognosis.
Patients with monomorphic VT had similar clinical characteristics as compared to those with polymorphic VT/VF. The time distribution of VT/VF differed with regard to the type of arrhythmia: 63% of monomorphic VT/VF episodes occurred after PCI (n=10) compared to 24% (n=23) of all documented polymorphic VT/VF, p=0.003. Total mortality (12.5% vs 10.3%, p=0.678) did not differ between patients with monomorphic VT and polymorphic VT/VF. In Cox model, total mortality was not associated with the type of arrhythmia (Figure).
Conclusion
Early VT/VF is a marker of poor short-term outcome in patients with STEMI, which does not affect long-term prognosis in those who are successfully resuscitated and discharged from hospital.
The incidence of monomorphic VT in STEMI treated by primary PCI is low, and it occurs mainly after PCI. Though no significant difference in mortality was found between patients with monomorphic VT and polymorphic VT/VF, the observed low incidence hampers drawing conclusions with regard to the prognostic hazard impact of monomorphic VT.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The Swedish Heart Lung Foundation
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Affiliation(s)
- M M Demidova
- Lund University, Lund, Sweden and National Medical Research Centre, Saint Petersburg, Russian Federation
| | | | - S Koul
- Lund University, Lund, Sweden
| | - C Dworeck
- Sahlgrenska University Hospital, Göteborg, Sweden
| | - S James
- Uppsala University, Uppsala, Sweden
| | - M Aasa
- South General Hospital, Stockholm, Sweden
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Bergman S, Mohammad MA, James SK, Angerås O, Wagner H, Jensen J, Scherstén F, Fröbert O, Koul S, Erlinge D. Clinical Impact of Intraprocedural Stent Thrombosis During Percutaneous Coronary Intervention in Patients Treated With Potent P2Y12 inhibitors - a VALIDATE-SWEDEHEART Substudy. J Am Heart Assoc 2021; 10:e022984. [PMID: 34514849 PMCID: PMC8649533 DOI: 10.1161/jaha.121.022984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background The clinical importance of intraprocedural stent thrombosis (IPST) during percutaneous coronary intervention in the contemporary era of potent oral P2Y12 inhibitors is not established. The aim of this study was to assess IPST and its association with clinical outcome in patients with myocardial infarction undergoing percutaneous coronary intervention with contemporary antithrombotic medications. Methods and Results The VALIDATE‐SWEDEHEART study (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) included 6006 patients with myocardial infarction, treated with potent P2Y12 inhibitors during percutaneous coronary intervention. IPST, defined as a new or worsening thrombus related to a stent deployed during the procedure, was reported by the interventional cardiologist in 55 patients (0.9%) and was significantly associated with ST‐segment elevation myocardial infarction presentation, longer stents, bailout glycoprotein IIb/IIIa inhibitors, and final Thrombolysis in Myocardial Infarction flow <3. The primary composite end point included cardiovascular death, myocardial infarction, out‐of‐laboratory definite stent thrombosis and target vessel revascularization within 30 days. Secondary end points were major bleeding and the individual components of the primary composite end point. Patients with versus without IPST had significantly higher rates of the primary composite end point (20.0% versus 4.4%), including higher rates of cardiovascular death, target vessel revascularization, and definite stent thrombosis, but not myocardial infarction or major bleeding. By multivariable analysis, IPST was independently associated with the primary composite end point (hazard ratio, 3.82; 95% CI, 2.05–7.12; P<0.001). Conclusions IPST is a rare but dangerous complication during percutaneous coronary intervention, independently associated with poor prognosis, even in the current era of potent antiplatelet agents. Future treatment studies are needed to reduce the rate of IPST and to improve the poor outcome among these patients. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02311231.
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Affiliation(s)
- Sofia Bergman
- Department of Cardiology, Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Moman A Mohammad
- Department of Cardiology, Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Oskar Angerås
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Henrik Wagner
- Department of Cardiology Helsingborg Lasarett Helsingborg Sweden
| | - Jens Jensen
- Department of Clinical Science and Education SödersjukhusetKarolinska Institutet Stockholm Sweden.,Department of Cardiology Capio S:t Görans Hospital AB Stockholm Sweden
| | - Fredrik Scherstén
- Department of Cardiology, Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health Örebro University Örebro Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences Lund UniversitySkåne University Hospital Lund Sweden
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17
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Völz S, Redfors B, Angerås O, Ioanes D, Odenstedt J, Koul S, Valeljung I, Dworeck C, Hofmann R, Hansson E, Venetsanos D, Ulvenstam A, Jernberg T, Råmunddal T, Pétursson P, Fröbert O, Erlinge D, Jeppsson A, Omerovic E. Long-term mortality in patients with ischaemic heart failure revascularized with coronary artery bypass grafting or percutaneous coronary intervention: insights from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Eur Heart J 2021; 42:2657-2664. [PMID: 34023903 PMCID: PMC8282315 DOI: 10.1093/eurheartj/ehab273] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 09/15/2020] [Accepted: 04/23/2021] [Indexed: 01/17/2023] Open
Abstract
Aims To compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for treatment of patients with heart failure due to ischaemic heart disease. Methods and results We analysed all-cause mortality following CABG or PCI in patients with heart failure with reduced ejection fraction and multivessel disease (coronary artery stenosis >50% in ≥2 vessels or left main) who underwent coronary angiography between 2000 and 2018 in Sweden. We used a propensity score-adjusted logistic and Cox proportional-hazards regressions and instrumental variable model to adjust for known and unknown confounders. Multilevel modelling was used to adjust for the clustering of observations in a hierarchical database. In total, 2509 patients (82.9% men) were included; 35.8% had diabetes and 34.7% had a previous myocardial infarction. The mean age was 68.1 ± 9.4 years (47.8% were >70 years old), and 64.9% had three-vessel or left main disease. Primary designated therapy was PCI in 56.2% and CABG in 43.8%. Median follow-up time was 3.9 years (range 1 day to 10 years). There were 1010 deaths. Risk of death was lower after CABG than after PCI [odds ratio (OR) 0.62; 95% confidence interval (CI) 0.41–0.96; P = 0.031]. The risk of death increased linearly with quintiles of hospitals in which PCI was the preferred method for revascularization (OR 1.27, 95% CI 1.17–1.38, P
trend < 0.001). Conclusion In patients with ischaemic heart failure, long-term survival was greater after CABG than after PCI.
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Affiliation(s)
- Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
| | - Sasha Koul
- Department of Cardiology, Skåne University Hospital, 22242 Lund, Sweden
| | - Inger Valeljung
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
| | - Christian Dworeck
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
| | - Robin Hofmann
- Division of Cardiology, Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, 11861 Stockholm, Sweden
| | - Emma Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Cardiothoracic Surgery, Sahlgrenska University Hospital and Institute of Medicine, University of Gothenburg, 413 45 Gothenburg, Sweden
| | - Dimitrios Venetsanos
- Division of Cardiology, Department of Medicine, Karolinska Institute and Karolinska University Hospital, Karolinska Solna, 171 76 Stockholm, Sweden
| | - Anders Ulvenstam
- Department of Cardiology, Östersund Hospital, 831 83 Östersund, Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, 182 88 Stockholm, Sweden
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
| | - Pétur Pétursson
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
| | - Ole Fröbert
- Department of Cardiology, Örebro University, Faculty of Health, 781 85 Örebro, Sweden
| | - David Erlinge
- Department of Cardiology, Skåne University Hospital, 22242 Lund, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Cardiothoracic Surgery, Sahlgrenska University Hospital and Institute of Medicine, University of Gothenburg, 413 45 Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Bruna straket 16, 413 45 Gothenburg, Sweden
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18
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Vasamsetti SB, Coppin E, Zhang X, Florentin J, Koul S, Götberg M, Clugston AS, Thoma F, Sembrat J, Bullock GC, Kostka D, St Croix CM, Chattopadhyay A, Rojas M, Mulukutla SR, Dutta P. Apoptosis of hematopoietic progenitor-derived adipose tissue-resident macrophages contributes to insulin resistance after myocardial infarction. Sci Transl Med 2021; 12:12/553/eaaw0638. [PMID: 32718989 DOI: 10.1126/scitranslmed.aaw0638] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 11/27/2019] [Accepted: 07/01/2020] [Indexed: 12/13/2022]
Abstract
Patients with insulin resistance have high risk of cardiovascular disease such as myocardial infarction (MI). However, it is not known whether MI can initiate or aggravate insulin resistance. We observed that patients with ST-elevation MI and mice with MI had de novo hyperglycemia and features of insulin resistance, respectively. In mouse models of both myocardial and skeletal muscle injury, we observed that the number of visceral adipose tissue (VAT)-resident macrophages decreased because of apoptosis after these distant organ injuries. Patients displayed a similar decrease in VAT-resident macrophage numbers and developed systemic insulin resistance after ST-elevation MI. Loss of VAT-resident macrophages after MI injury led to systemic insulin resistance in non-diabetic mice. Danger signaling-associated protein high mobility group box 1 was released by the dead myocardium after MI in rodents and triggered macrophage apoptosis via Toll-like receptor 4. The VAT-resident macrophage population in the steady state in mice was transcriptomically distinct from macrophages in the brain, skin, kidney, bone marrow, lungs, and liver and was derived from hematopoietic progenitor cells just after birth. Mechanistically, VAT-resident macrophage apoptosis and de novo insulin resistance in mouse models of MI were linked to diminished concentrations of macrophage colony-stimulating factor and adiponectin. Collectively, these findings demonstrate a previously unappreciated role of adipose tissue-resident macrophages in sensing remote organ injury and promoting MI pathogenesis.
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Affiliation(s)
- Sathish Babu Vasamsetti
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Emilie Coppin
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA.,Regeneration in Hematopoiesis, Leibniz Institute on Aging- Fritz Lipmann Institute, Jena 07745, Germany
| | - Xinyi Zhang
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA.,The Third Xiangya Hospital, Central South University, Changsha, Hunan 410013, China
| | - Jonathan Florentin
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Sasha Koul
- Department of Cardiology, Lund University, Skane University Hospital, Lund, 22184, Sweden
| | - Matthias Götberg
- Department of Cardiology, Lund University, Skane University Hospital, Lund, 22184, Sweden
| | - Andrew S Clugston
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Floyd Thoma
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - John Sembrat
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA.,Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Grant C Bullock
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Dennis Kostka
- Department of Developmental Biology, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | | | | | - Mauricio Rojas
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA.,Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Suresh R Mulukutla
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Partha Dutta
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA. .,Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA.,Department of Immunology, University of Pittsburgh, Pittsburgh, PA 15213, USA
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19
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Rylance RT, Wagner P, Omerovic E, Held C, James S, Koul S, Erlinge D. Assessing the external validity of the VALIDATE-SWEDEHEART trial. Clin Trials 2021; 18:427-435. [PMID: 34011198 PMCID: PMC8290983 DOI: 10.1177/17407745211012438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims: The VALIDATE-SWEDEHEART trial was a registry-based randomized trial comparing bivalirudin and heparin in patients with acute myocardial infarction undergoing percutaneous coronary intervention. It showed no differences in mortality at 30 or 180 days. This study examines how well the trial population results may generalize to the population of all screened patients with fulfilled inclusion criteria in regard to mortality at 30 and 180 days. Methods: The standardized difference in the mean propensity score for trial inclusion between trial population and the screened not-enrolled with fulfilled inclusion criteria was calculated as a metric of similarity. Propensity scores were then used in an inverse-probability weighted Cox regression analysis using the trial population only to estimate the difference in mortality as it would have been had the trial included all screened patients with fulfilled inclusion criteria. Patients who were very likely to be included were weighted down and those who had a very low probability of being in the trial were weighted up. Results: The propensity score difference was 0.61. There were no significant differences in mortality between bivalirudin and heparin in the inverse-probability weighted analysis (hazard ratio 1.11, 95% confidence interval (0.73, 1.68)) at 30 days or 180 days (hazard ratio 0.98, 95% confidence interval (0.70, 1.36)). Conclusion: The propensity score difference demonstrated that the screened not-enrolled with fulfilled inclusion criteria and trial population were not similar. The inverse-probability weighted analysis showed no significant differences in mortality. From this, we conclude that the VALIDATE results may be generalized to the screened not-enrolled with fulfilled inclusion criteria.
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Affiliation(s)
- Rebecca T Rylance
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Philippe Wagner
- Center for Clinical Research, Uppsala University, Västerås, Sweden
| | - Elmir Omerovic
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Claes Held
- Department of Medical Sciences and Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan James
- Department of Medical Sciences and Cardiology, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden.,Swedish Society of Cardiology, Uppsala, Sweden
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20
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Dworeck C, Redfors B, Völz S, Haraldsson I, Angerås O, Råmunddal T, Ioanes D, Myredal A, Odenstedt J, Hirlekar G, Koul S, Fröbert O, Linder R, Venetsanos D, Hofmann R, Ulvenstam A, Petursson P, Sarno G, James S, Erlinge D, Omerovic E. Radial artery access is associated with lower mortality in patients undergoing primary PCI: a report from the SWEDEHEART registry. Eur Heart J Acute Cardiovasc Care 2021; 9:323-332. [PMID: 33025815 PMCID: PMC7756052 DOI: 10.1177/2048872620908032] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The purpose of this observational study was to evaluate the effects of radial artery access versus femoral artery access on the risk of 30-day mortality, inhospital bleeding and cardiogenic shock in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. METHODS We used data from the SWEDEHEART registry and included all patients who were treated with primary percutaneous coronary intervention in Sweden between 2005 and 2016. We compared patients who had percutaneous coronary intervention by radial access versus femoral access with regard to the primary endpoint of all-cause death within 30 days, using a multilevel propensity score adjusted logistic regression which included hospital as a random effect. RESULTS During the study period, 44,804 patients underwent primary percutaneous coronary intervention of whom 24,299 (54.2%) had radial access and 20,505 (45.8%) femoral access. There were 2487 (5.5%) deaths within 30 days, of which 920 (3.8%) occurred in the radial access and 1567 (7.6%) in the femoral access group. After propensity score adjustment, radial access was associated with a lower risk of death (adjusted odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55-0.88, P = 0.025). We found no interaction between access site and age, gender and cardiogenic shock regarding 30-day mortality. Radial access was also associated with a lower adjusted risk of bleeding (adjusted OR 0.45, 95% CI 0.25-0.79, P = 0.006) and cardiogenic shock (adjusted OR 0.41, 95% CI 0.24-0.73, P = 0.002). CONCLUSIONS In patients with ST-elevation myocardial infarction, primary percutaneous coronary intervention by radial access rather than femoral access was associated with an adjusted lower risk of death, bleeding and cardiogenic shock. Our findings are consistent with, and add external validity to, recent randomised trials.
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Affiliation(s)
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Inger Haraldsson
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Anna Myredal
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Geir Hirlekar
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Sweden
| | - Ole Fröbert
- Department of Cardiology, Örebro University, Sweden
| | - Rickard Linder
- Department of Cardiology, Karolinska University Hospital, Sweden
| | | | - Robin Hofmann
- Department of Clinical Science and Education, Karolinska Institutet, Sweden
| | | | - Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Giovanna Sarno
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
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21
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Nilsson K, Buccheri S, Christersson C, Koul S, Nilsson J, Pétursson P, Renlund H, Rück A, James S. Causes, Pattern, Predictors and Prognostic Implications of New Hospitalizations after TAVI: A Long-Term Nationwide Observational Study. Eur Heart J Qual Care Clin Outcomes 2021; 8:150-160. [PMID: 33831187 PMCID: PMC8888128 DOI: 10.1093/ehjqcco/qcab026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/31/2021] [Accepted: 04/07/2021] [Indexed: 11/12/2022]
Abstract
Aims The aim of this study was to investigate the pattern, causes, and predictors of all new hospitalizations in patients who underwent transcatheter aortic valve implantation (TAVI). Methods and results The nationwide Swedish TAVI registry was merged with other mandatory healthcare registries, which enabled the analysis of all TAVI procedures, new hospital admissions, and death between the years 2008 and 2017. A total of 2821 patients underwent TAVI with a mean of 2.5 hospitalizations during a mean follow-up of 2.2 years. Hospitalizations were associated with worse prognosis. Heart failure (HF) was the most common cause of hospitalization with 19% having at least one hospitalization due to HF causing, 16% of all-cause admissions, and 50% of cardiovascular admissions. Male gender, age >90 years, high Charlson Comorbidity Index, atrial fibrillation, present neurologic disease, severe renal impairment, peripheral vascular disease, New York Heart Association class IV, mild or moderate mean aortic valve gradients, and pulmonary hypertension were associated with an increased risk for all-cause hospitalizations or death. For cardiovascular hospitalization or death, the pattern was similar, with the addition of impaired systolic left ventricular function as a predictor. Conclusion Multiple hospitalizations after TAVI are common and are often caused by HF. Reducing the rate of HF hospitalizations is important to mitigate the burden on the healthcare system due to new hospitalizations after TAVI.
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Affiliation(s)
- Konrad Nilsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Department of Medicine, Visby Hospital, Visby, Sweden
| | - Sergio Buccheri
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Christina Christersson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala, Sweden
| | - Sasha Koul
- Department of Cardiology, Lund University, Lund, Sweden
| | - Johan Nilsson
- Dep of Public Health and Clinical Medicine, Umea University, Umea, Sweden
| | - Pétur Pétursson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Henrik Renlund
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Andreas Rück
- Department of Cardiology, Karolinska Institute, Stockholm, Sweden
| | - Stefan James
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala, Sweden
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22
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Mohammad MA, Koul S, Gale CP, Alfredsson J, James S, Fröbert O, Omerovic E, Erlinge D. The association of mode of location activity and mobility with acute coronary syndrome: a nationwide ecological study. J Intern Med 2021; 289:247-254. [PMID: 33259680 PMCID: PMC7898898 DOI: 10.1111/joim.13206] [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: 12/24/2022]
Abstract
BACKGROUND We aimed to study the effect of social containment mandates on ACS presentation during COVID-19 pandemic using location activity and mobility data from mobile phone map services. METHODS We conducted a cross-sectional study using data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) including all ACS presentations during the pandemic until 7 May 2020. Using a count regression model, we adjusted for day of the week, daily weather and incidence of COVID-19. RESULTS A 10% increase in activity around areas of residence was associated with 38% lower rates of ACS hospitalizations, whereas increased activity relating to retail and recreation, grocery stores and pharmacies, workplaces and mode of mobility was associated with 10-20% higher rates of ACS hospitalizations. CONCLUSION Government policy regarding social containment mandates has important public health implications for medical emergencies such as ACS and may explain the decline in ACS presentations observed during COVID-19 pandemic.
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Affiliation(s)
- M A Mohammad
- From the, Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - S Koul
- From the, Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - C P Gale
- Leeds Institute of Cardiovascular and Medicine, University of Leeds, Leeds, UK
| | - J Alfredsson
- Department of Cardiology, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - S James
- Department of Medical Sciences and Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden
| | - O Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - E Omerovic
- Department of Cardiology, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - D Erlinge
- From the, Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
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23
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Farooq S, Alharthi FA, Alsalme A, Hussain A, Dar BA, Hamid A, Koul S. Dihydropyrimidinones: efficient one-pot green synthesis using Montmorillonite-KSF and evaluation of their cytotoxic activity. RSC Adv 2020; 10:42221-42234. [PMID: 35516739 PMCID: PMC9057999 DOI: 10.1039/d0ra09072g] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 11/13/2020] [Indexed: 01/31/2023] Open
Abstract
A simple, efficient, cost-effective, recyclable and green approach has been developed for the synthesis of new dihydropyrimidinone analogs via the Biginelli reaction. The methodology involves a multicomponent reaction catalyzed by “HPA-Montmorillonite-KSF” as a reusable and heterogeneous catalyst. This method gives an efficient and much improved modification of the original Biginelli reaction, in terms of yield and short reaction times under solvent free conditions. All the derivatives were subjected to cytotoxicity screening against a panel of four different human cancer cell lines viz. colon (Colo-205), prostate (PC-3), leukemia (THP-1) and lung (A549) to check their effect on percentage growth. MTT [3-(4,5-dimethylthiazol-yl)-diphenyl tetrazoliumbromide] cytotoxicity assay was employed to check IC50 values. Of the synthesized analogs, 16a showed the best activity with IC50 of 7.1 ± 0.8, 13.1 ± 1.4, 13.8 ± 0.9 and 14.7 ± 1.1 μM against lung (A549), leukemia (THP-1), prostate (PC-3) and colon (Colo-205) cancer lines, respectively. The 16a analog was further checked for its effect on cancer cell properties through clonogenic (colony formation) and scratch motility (wound healing) assays and thereby was found that it reduced both the colony formation and migratory properties of the lung cancer cell line (A549). Further, molecular docking studies were performed with 16a to show its binding mode. The general method for the preparation of DHPM analogs; cytotoxic activity and binding mode of the most active derivative against PI3Kγ and CDK2 targets.![]()
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Affiliation(s)
- Saleem Farooq
- Department of Higher Education, Department of Chemistry, Government Degree College for Boys Baramulla 193101 J&K India +91-1952-234214 +91-1952-234214.,Bioorganic Chemistry Division, CSIR-Indian Institute of Integrative Medicine Canal Road Jammu 180001 J&K India
| | - Fahad A Alharthi
- Department of Chemistry, College of Science, King Saud University P.O. Box 2455 Riyadh 11451 Saudi Arabia
| | - Ali Alsalme
- Department of Chemistry, College of Science, King Saud University P.O. Box 2455 Riyadh 11451 Saudi Arabia
| | - Aashiq Hussain
- Cancer Pharmacology Division, CSIR-Indian Institute of Integrative Medicine Canal Road Jammu 180001 J&K India
| | - Bashir A Dar
- Department of Higher Education, Department of Chemistry, Govt. Degree College Sopore Baramulla 193201 J&K India
| | - Abid Hamid
- Cancer Pharmacology Division, CSIR-Indian Institute of Integrative Medicine Canal Road Jammu 180001 J&K India.,Department of Biotechnology, Central University of Kashmir Ganderbal 191201 J&K India
| | - S Koul
- Bioorganic Chemistry Division, CSIR-Indian Institute of Integrative Medicine Canal Road Jammu 180001 J&K India
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Mohammad MA, Koul S, Lønborg JT, Nepper-Christensen L, Høfsten DE, Ahtarovski KA, Bang LE, Helqvist S, Kyhl K, Køber L, Kelbæk H, Vejlstrup N, Holmvang L, Schoos MM, Göransson C, Engstrøm T, Erlinge D. Usefulness of High Sensitivity Troponin T to Predict Long-Term Left Ventricular Dysfunction After ST-Elevation Myocardial Infarction. Am J Cardiol 2020; 134:8-13. [PMID: 32933755 DOI: 10.1016/j.amjcard.2020.07.060] [Citation(s) in RCA: 7] [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: 04/20/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 01/02/2023]
Abstract
Guidelines recommend the use of transthoracic echocardiography (TTE) and clinical scores to risk stratify patients after ST-elevation myocardial infarction (STEMI). High sensitivity troponin T (hs-cTnT) is predictive of outcome after STEMI but the predictive value of hs-cTnT relative to other risk assessment tools has not been established. We aimed to compare the predictive value of hs-cTnT to other risk assessment tools in patients with STEMI. A subset of 578 patients with STEMI were included in this post-hoc study from the Third DANish Study of Optimal Acute Treatment of Patients with ST-segment Elevation Myocardial Infarction trial. Patients underwent cardiac magnetic resonance imaging (CMR) during index hospitalization as well as TTE at 1 year after their STEMI. The predictive value of hs-cTnT was compared with CKMB, infarct size (IS)/left ventricular ejection fraction (LVEF) assessed with CMR, LVEF assessed at discharge with TTE and the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) risk-scores. The primary outcome was LV systolic dysfunction defined as LVEF ≤40% after 1 year on TTE. The area under the receiver operating characteristic curve analyses showed no significant difference between hs-cTnT and early CMR-assessed IS or LVEF in predicting subsequent LVEF ≤40%. Area under the curve for hs-cTnT was 0.82, 0.85 for IS (p = 0.22), and 0.87 for LVEF (p = 0.23). For predischarge TTE-assessed LVEF, the value was 0.85 (p = 0.45), 0.63 for creatine kinase-MB (p <0.001), 0.61 for the GRACE score (p <0.001), and 0.70 for the TIMI score (p = 0.02). A peak hs-cTnT value <3,500 ng/L ruled out LVEF ≤40% with probability of 98%. In conclusion, in patients presenting with STEMI undergoing PCI, hs-cTnT level strongly predicted long-term LV dysfunction and could be used as a clinical risk stratification tool to identify patients at high risk of progressing to LV dysfunction due to its general availability and high-predictive accuracy.
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Wester A, Mohammad M, Erlinge D, Koul S. External validation of the PRECISE-DAPT score in a large nationwide population of myocardial infarction patients: a SWEDEHEART study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1435] [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
Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with stent placement in myocardial infarction (MI) patients has improved ischemic outcomes but increased the risk of bleeding. The PRECISE-DAPT (Predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy) score has been implemented in recent guidelines to tailor the duration of DAPT based on each patient's individual risk profile. However, to date it has only been externally validated on small data samples or exclusively for subgroups of PCI treated MI patients.
Purpose
To assess the performance of the PRECISE-DAPT score in a nationwide cohort of MI patients undergoing PCI with subsequent DAPT. This will be the world's largest validation of the PRECISE-DAPT score in approximately 20.000 unique real-world MI patients.
Methods
Data from the Swedish Websystem for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry on MI patients treated with DAPT after PCI between 2008 and 2016 in Sweden were obtained and merged with the Swedish Patient Registry as well as the Prescribed Drugs Registry that holds data from all Swedish pharmacies. The ability of PRECISE-DAPT to predict bleeding and ischemic outcomes in relation to DAPT duration was determined.
Results
Results are to be announced.
Conclusions
Whether the PRECISE-DAPT score can be validated or not in a large nationwide cohort of MI patients in relation to DAPT duration, has the potential to impact current DAPT guidelines and clinical decision making in everyday practice. Further results and conclusions are to be announced.
Funding Acknowledgement
Type of funding source: Foundation. Main funding source(s): Märta Winkler's research foundation and Thorsten Westerström's research foundation
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Affiliation(s)
| | | | | | - S Koul
- Lund University, Lund, Sweden
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Mohammad MA, Koul S, Olivecrona GK, Gӧtberg M, Tydén P, Rydberg E, Scherstén F, Alfredsson J, Vasko P, Omerovic E, Angerås O, Fröbert O, Calais F, Völz S, Ulvenstam A, Venetsanos D, Yndigegn T, Oldgren J, Sarno G, Grimfjärd P, Persson J, Witt N, Ostenfeld E, Lindahl B, James SK, Erlinge D. Incidence and outcome of myocardial infarction treated with percutaneous coronary intervention during COVID-19 pandemic. Heart 2020; 106:1812-1818. [PMID: 33023905 PMCID: PMC7677488 DOI: 10.1136/heartjnl-2020-317685] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 09/03/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022] Open
Abstract
Objective Most reports on the declining incidence of myocardial infarction (MI) during the COVID-19 have either been anecdotal, survey results or geographically limited to areas with lockdowns. We examined the incidence of MI during the COVID-19 pandemic in Sweden, which has remained an open society with a different public health approach fighting COVID-19. Methods We assessed the incidence rate (IR) as well as the incidence rate ratios (IRRs) of all MI referred for coronary angiography in Sweden using the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR), during the COVID-19 pandemic in Sweden (1 March 2020–7 May 2020) in relation to the same days 2015–2019. Results A total of 2443 MIs were referred for coronary angiography during the COVID-19 pandemic resulting in an IR 36 MIs/day (204 MIs/100 000 per year) compared with 15 213 MIs during the reference period with an IR of 45 MIs/day (254 MIs/100 000 per year) resulting in IRR of 0.80, 95% CI (0.74 to 0.86), p<0.001. Results were consistent in all investigated patient subgroups, indicating no change in patient category seeking cardiac care. Kaplan-Meier event rates for 7-day case fatality were 439 (2.3%) compared with 37 (2.9%) (HR: 0.81, 95% CI (0.58 to 1.13), p=0.21). Time to percutaneous coronary intervention (PCI) was shorter during the pandemic and PCI was equally performed, indicating no change in quality of care during the pandemic. Conclusion The COVID-19 pandemic has significantly reduced the incidence of MI referred for invasive treatment strategy. No differences in overall short-term case fatality or quality of care indicators were observed.
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Affiliation(s)
- Moman A Mohammad
- 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
| | - Göran K Olivecrona
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Matthias Gӧtberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Patrik Tydén
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Erik Rydberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Fredrik Scherstén
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Peter Vasko
- Department of Medicine, Växjö Hospital, Växjö, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Department of Molecular and Clinical Medicine, Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine,Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Department of Molecular and Clinical Medicine, Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine,Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Fredrik Calais
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Sebastian Völz
- Department of Cardiology, Department of Molecular and Clinical Medicine, Department of Cardiology, Sahlgrenska University Hospital, Institute of Medicine, Department of Molecular and Clinical Medicine,Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | | | | | - Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Jonas Oldgren
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Giovanna Sarno
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Per Grimfjärd
- Department of Internal Medicine, Västmanlands Sjuk, Lund, Sweden
| | - Jonas Persson
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockolm, Sweden
| | - Nils Witt
- Dvision of Cardiology, Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, Stockholm, Sweden
| | - Ellen Ostenfeld
- Department of Clinical Physiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
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Dworeck C, Redfors B, Angerås O, Haraldsson I, Odenstedt J, Ioanes D, Petursson P, Völz S, Persson J, Koul S, Venetsanos D, Ulvenstam A, Hofmann R, Jensen J, Albertsson P, Råmunddal T, Jeppsson A, Erlinge D, Omerovic E. Association of Pretreatment With P2Y12 Receptor Antagonists Preceding Percutaneous Coronary Intervention in Non-ST-Segment Elevation Acute Coronary Syndromes With Outcomes. JAMA Netw Open 2020; 3:e2018735. [PMID: 33001202 PMCID: PMC7530628 DOI: 10.1001/jamanetworkopen.2020.18735] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [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: 01/12/2023] Open
Abstract
IMPORTANCE Pretreatment of patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) with P2Y12 receptor antagonists is a common practice despite the lack of definite evidence for its benefit. OBJECTIVE To investigate the association of P2Y12 receptor antagonist pretreatment vs no pretreatment with mortality, stent thrombosis, and in-hospital bleeding in patients with NSTE-ACS undergoing percutaneous coronary intervention (PCI). DESIGN, SETTING, AND PARTICIPANTS This cohort study used prospective data from the Swedish Coronary Angiography and Angioplasty Registry of 64 857 patients who underwent procedures between 2010 and 2018. All patients who underwent PCI owing to NSTE-ACS in Sweden were stratified by whether they were pretreated with P2Y12 receptor antagonists. Associations of pretreatment with P2Y12 receptor antagonists with the risks of adverse outcomes were investigated using instrumental variable analysis and propensity score matching. Data were analyzed from March to June 2019. EXPOSURES Pretreatment with P2Y12 receptor antagonists. MAIN OUTCOMES AND MEASURES The primary end point was all-cause mortality within 30 days. Secondary end points were 1-year mortality, stent thrombosis within 30 days, and in-hospital bleeding. RESULTS In total, 64 857 patients (mean [SD] age, 64.7 [10.9] years; 46 809 [72.2%] men) were included. A total of 59 894 patients (92.4%) were pretreated with a P2Y12 receptor antagonist, including 27 867 (43.7%) pretreated with clopidogrel, 34 785 (54.5%) pretreated with ticagrelor, and 1148 (1.8%) pretreated with prasugrel. At 30 days, there were 971 deaths (1.5%) and 101 definite stent thromboses (0.2%) in the full cohort. Pretreatment was not associated with better survival at 30 days (odds ratio [OR], 1.17; 95% CI, 0.66-2.11; P = .58), survival at 1 year (OR, 1.34; 95% CI, 0.77-2.34; P = .30), or decreased stent thrombosis (OR, 0.81; 95% CI, 0.42-1.55; P = .52). However, pretreatment was associated with increased risk of in-hospital bleeding (OR, 1.49; 95% CI, 1.06-2.12; P = .02). CONCLUSIONS AND RELEVANCE This cohort study found that pretreatment of patients with NSTE-ACS with P2Y12 receptor antagonists was not associated with improved clinical outcomes but was associated with increased risk of bleeding. These findings support the argument that pretreatment with P2Y12 receptor antagonists should not be routinely used in patients with NSTE-ACS.
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Affiliation(s)
- Christian Dworeck
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Inger Haraldsson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonas Persson
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Sasha Koul
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | | | | | - Robin Hofmann
- Division of Cardiology, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Jens Jensen
- Department of Clinical Science and Education, Karolinska Institutet, Cardiology Capio Sankt Goran Hospital, Stockholm, Sweden
| | - Per Albertsson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Erlinge
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Attar R, Wester A, Koul S, Eggert S, Polcwiartek C, Jernberg T, Erlinge D, Andell P. Higher risk of major adverse cardiac events after acute myocardial infarction in patients with schizophrenia. Open Heart 2020; 7:openhrt-2020-001286. [PMID: 32994353 PMCID: PMC7526274 DOI: 10.1136/openhrt-2020-001286] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/29/2020] [Accepted: 08/03/2020] [Indexed: 11/22/2022] Open
Abstract
Background Patients with schizophrenia are a high-risk population due to higher prevalences of cardiovascular risk factors and comorbidities that contribute to shorter life expectancy. Purpose To investigate patients with and without schizophrenia experiencing an acute myocardial infarction (AMI) in relation to guideline recommended in-hospital management, discharge medications and 5-year major adverse cardiac events (MACE: composite of all-cause mortality, rehospitalisation for reinfarction, stroke or heart failure). Methods All patients with schizophrenia who experienced AMI during 2000–2018 were identified (n=1008) from the nationwide Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry and compared with AMI patients without schizophrenia (n=2 85 325). Kaplan-Meier survival curves and multivariable Cox regression models were used to compare the populations. Results Patients with schizophrenia presented with AMI approximately 10 years earlier (median age 64 vs 73 years), and had higher prevalences of diabetes, heart failure and chronic obstructive pulmonary disease. They were less likely to be invasively investigated or discharged with aspirin, P2Y12 inhibitors, ACE inhibitors/angiotensin II receptor blockers, beta-blockers and statins (all p<0.005). AMI patients with schizophrenia had higher adjusted risk of MACE (aHR=2.05, 95% CI 1.63 to 2.58), mortality (aHR=2.38, 95% CI 1.84 to 3.09) and hospitalisation for heart failure (aHR=1.39, 95% CI 1.04 to 1.86) compared with AMI patients without schizophrenia. Conclusion Patients with schizophrenia experienced an AMI almost 10 years earlier than patients without schizophrenia. They less often underwent invasive procedures and were less likely to be treated with guideline recommended medications at discharge, and had more than doubled risk of MACE and all-cause mortality. Improved primary and secondary preventive measures, including adherence to guideline recommendations, are warranted and may improve outcome.
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Affiliation(s)
- Rubina Attar
- Cardiology and Clinical Sciences, Lund University, Lund, Sweden .,Cardiology and Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Axel Wester
- Cardiology and Clinical Sciences, Lund University, Lund, Sweden
| | - Sasha Koul
- Cardiology, Lund University, Lund, Sweden
| | - Svend Eggert
- Cardiology and Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | | | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - David Erlinge
- Cardiology and Clinical Sciences, Lund University, Lund, Sweden
| | - Pontus Andell
- Cardiology and Clinical Sciences, Lund University, Lund, Sweden.,Unit of Cardiology, Department of medicine and Heart and Vascular Division, Karolinska Institute, Stockholm, Sweden
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Thim T, Götberg M, Fröbert O, Nijveldt R, van Royen N, Baptista SB, Koul S, Kellerth T, Bøtker HE, Terkelsen CJ, Christiansen EH, Jakobsen L, Kristensen SD, Maeng M. Agreement between nonculprit stenosis follow-up iFR and FFR after STEMI (iSTEMI substudy). BMC Res Notes 2020; 13:410. [PMID: 32873327 PMCID: PMC7466494 DOI: 10.1186/s13104-020-05252-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/21/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate agreement between instantaneous wave free ratio (iFR) and fractional flow reserve (FFR) for the functional assessment of nonculprit coronary stenoses at staged follow-up after ST-segment elevation myocardial infarction (STEMI). Results We measured iFR and FFR at staged follow-up in 112 STEMI patients with 146 nonculprit stenoses. Median interval between STEMI and follow-up was 16 (interquartile range 5–32) days. Agreement between iFR and FFR was 77% < 5 days after STEMI and 86% after ≥ 5 days (p = 0.19). Among cases with disagreement, the proportion of cases with hemodynamically significant iFR and non-significant FFR were different when assessed < 5 days (5 in 8, 63%) versus ≥ 5 days (3 in 15, 20%) after STEMI (p = 0.04). Overall classification agreement between iFR and FFR was comparable to that observed in stable patients. Time interval between STEMI and follow-up evaluation may impact agreement between iFR and FFR.
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Affiliation(s)
- Troels Thim
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Matthias Götberg
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Ole Fröbert
- Department of Cardiology, Örebro University, Örebro, Sweden
| | - Robin Nijveldt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Sasha Koul
- Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Evald Høj Christiansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Lars Jakobsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Mohammad MA, Tham J, Koul S, Rylance R, Bergh C, Erlinge D, Fröbert O. Association of acute myocardial infarction with influenza: A nationwide observational study. PLoS One 2020; 15:e0236866. [PMID: 32760080 PMCID: PMC7410234 DOI: 10.1371/journal.pone.0236866] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/15/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Influenza may precipitate cardiovascular disease, but influenza typically peaks in winter, coinciding with other triggers of myocardial infarction (MI) such as low air temperature, high wind velocity, low atmospheric pressure, and short sunshine duration. Objective We aimed to determine the relationship of week-to-week variation in influenza cases and acute MI, controlling for meteorological factors in a nationwide population. Methods Weekly laboratory-confirmed influenza case reports were obtained from the Public Health Agency of Sweden from 2009 to 2016 and merged with the nationwide SWEDEHEART MI registry. Weekly incidence of MI was studied with regard to number of influenza cases stratified into tertiles of 0–16, 17–164, and >164 cases/week. Incidence rate ratios (IRR) were calculated using a count regression model for each category and compared to a non-influenza period as reference, controlling for air temperature, atmospheric pressure, wind velocity, and sunshine duration. Results A total of 133562 MI events was reported to the registry during the study period. Weeks with influenza cases were associated with higher incidence of MI than those without in unadjusted analysis for overall MI, ST-elevation MI and non ST-elevation MI independently. During the influenza season, weeks with 0–16 reported cases/week were not associated with MI incidence after adjusting for weather parameters, adjusted IRR for MI was 1.03 (95% CI 1.00–1.06, P = 0.09). However, weeks with more cases reported were associated with MI incidence: 17–163 reported cases/week, adjusted IRR = 1.05 (95% CI 1.02–1.08, P = 0.003); and for ≥164 cases/week, the IRR = 1.06 (95% CI 1.02–1.09, P = 0.002). Results were consistent across a large range of subgroups. Conclusions In this nationwide observational study, we found an association of incidence of MI with incidence of influenza cases beyond what could be explained by meteorological factors.
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Affiliation(s)
- Moman A. Mohammad
- Department of Cardiology, Clinical Sciences Lund University, Lund, Sweden
- * E-mail:
| | - Johan Tham
- Infectious Diseases Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences Lund University, Lund, Sweden
| | - Rebecca Rylance
- Department of Cardiology, Clinical Sciences Lund University, Lund, Sweden
| | - Cecilia Bergh
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences Lund University, Lund, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Medicine and Health; Örebro University, Örebro, Sweden
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Killander F, Wieslander E, Karlsson P, Holmberg E, Lundstedt D, Holmberg L, Werner L, Koul S, Haghanegi M, Kjellen E, Nilsson P, Malmström P. No Increased Cardiac Mortality or Morbidity of Radiation Therapy in Breast Cancer Patients After Breast-Conserving Surgery: 20-Year Follow-up of the Randomized SweBCGRT Trial. Int J Radiat Oncol Biol Phys 2020; 107:701-709. [PMID: 32302682 DOI: 10.1016/j.ijrobp.2020.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Radiation therapy (RT) after breast-conserving surgery reduces locoregional recurrences and improves survival but may cause late side effects. The main purpose of this paper was to investigate long-term side effects after whole breast RT in a randomized clinical trial initiated in 1991 and to report dose-volume data based on individual 3-dimensional treatment plans for organs at risk. METHODS AND MATERIALS The trial included 1187 patients with T1-2 N0 breast cancer randomized to postoperative tangential whole breast RT or no further treatment. The prescription dose to the clinical target volume was 48 to 54 Gy. We present 20-year follow-up on survival, cause of death, morbidity, and later malignancies. For a cohort of patients (n = 157) with accessible computed tomography-based 3-dimensional treatment plans in Dicom-RT format, dose-volume descriptors for organs at risk were derived. In addition, these were compared with dose-volume data for a cohort of patients treated with contemporary RT techniques. RESULTS The cumulative incidence of cardiac mortality was 12.4% in the control group and 13.0% in the RT group (P = .8). There was an increase in stroke mortality: 3.4% in the control group versus 6.7% in the RT group (P = .018). Incidences of contralateral breast cancer and lung cancer were similar between groups. The median Dmean (range) heart dose for left-sided treatments was 3.0 Gy (1.1-8.1), and the corresponding value for patients treated in 2017 was 1.5 Gy (0.4-6.0). CONCLUSIONS In this trial, serious late side effects of whole breast RT were limited and less than previously reported in large meta-analyses. We observed no increase in cardiac mortality in irradiated patients. Doses to the heart were a median Dmean of 3.0 Gy for left-sided RT. The observed increase in stroke mortality may partly be secondary to cardiac side effects, complications to anticoagulant treatment, or to chance, rather than a direct side effect of tangential whole breast irradiation.
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Affiliation(s)
- Fredrika Killander
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - Elinore Wieslander
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Regional Oncologic Centre West, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Holmberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Translational Oncology & Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, Kingś College London, London, United Kingdom
| | - Linda Werner
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden
| | - Sasha Koul
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mahnaz Haghanegi
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Elisabeth Kjellen
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Nilsson
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Per Malmström
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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Wester A, Attar R, Mohammad MA, Isma N, James S, Omerovic E, Erlinge D, Koul S. Bivalirudin Versus Heparin Monotherapy in Elderly Patients With Myocardial Infarction: A Prespecified Subgroup Analysis of the VALIDATE-SWEDEHEART Trial. Circ Cardiovasc Interv 2020; 13:e008671. [PMID: 32216471 DOI: 10.1161/circinterventions.119.008671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/16/2022]
Abstract
BACKGROUND Elderly patients with acute myocardial infarction undergoing percutaneous coronary intervention are at increased risk of both ischemic and bleeding complications. The optimal anticoagulation strategy in these patients is uncertain. Therefore, we compared bivalirudin to heparin monotherapy in a contemporary cohort of such patients. METHODS A prespecified subgroup analysis of elderly patients with myocardial infarction (≥75 years) from the VALIDATE-SWEDEHEART trial (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) was performed. In the trial, patients were randomized to either bivalirudin or heparin monotherapy during percutaneous coronary intervention, with mandatory potent P2Y12 inhibition, routine radial artery access, and only bail-out glycoprotein IIb/IIIa inhibition. Kaplan-Meier event rates were assessed for the primary end point, consisting of a composite of all-cause death, myocardial reinfarction, or major bleeding, within 180 days. RESULTS The elderly (n=1592) had more than twice the risk of all events compared with younger patients (n=4406). Baseline and periprocedural characteristics were equal between bivalirudin (n=799) and heparin (n=793) treated patients ≥75 years. No differences were found in the elderly between bivalirudin and heparin monotherapy regarding the primary end point (180-day all-cause death, myocardial reinfarction, or major bleeding), the individual components of the primary end point, definite stent thrombosis, or stroke. CONCLUSIONS In this prespecified subgroup analysis of the VALIDATE-SWEDEHEART trial, elderly patients with myocardial infarction had a highly increased risk of all events. However, no difference in outcomes could be observed with an anticoagulation strategy with either bivalirudin or heparin as monotherapy in this patient group.
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Affiliation(s)
- Axel Wester
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
| | - Rubina Attar
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.).,Department of Cardiology, Clinical Medicine, Aalborg University, Denmark (R.A.)
| | - Moman A Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
| | - Nazim Isma
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden (S.J.)
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O.)
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (A.W., R.A., M.A.M., N.I., D.E., S.K.)
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James SK, Erlinge D, Herlitz J, Alfredsson J, Koul S, Fröbert O, Kellerth T, Ravn-Fischer A, Alström P, Östlund O, Jernberg T, Lindahl B, Hofmann R. Effect of Oxygen Therapy on Cardiovascular Outcomes in Relation to Baseline Oxygen Saturation. JACC Cardiovasc Interv 2019; 13:502-513. [PMID: 31838113 DOI: 10.1016/j.jcin.2019.09.016] [Citation(s) in RCA: 9] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/13/2019] [Accepted: 09/04/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the effect of supplemental oxygen in patients with myocardial infarction (MI) on the composite of all-cause death, rehospitalization with MI, or heart failure related to baseline oxygen saturation. A secondary objective was to investigate outcomes in patients developing hypoxemia. BACKGROUND In the DETO2X-AMI (Determination of the Role of Oxygen in Suspected Acute Myocardial Infarction) trial, 6,629 normoxemic patients with suspected MI were randomized to oxygen at 6 l/min for 6 to 12 h or ambient air. METHODS The study population of 5,010 patients with confirmed MI was divided by baseline oxygen saturation into a low-normal (90% to 94%) and a high-normal (95% to 100%) cohort. Outcomes are reported within 1 year. To increase power, all follow-up time (between 1 and 4 years) was included post hoc, and interaction analyses were performed with oxygen saturation as a continuous covariate. RESULTS The composite endpoint of all-cause death, rehospitalization with MI, or heart failure occurred significantly more often in patients in the low-normal cohort (17.3%) compared with those in the high-normal cohort (9.5%) (p < 0.001), and most often in patients developing hypoxemia (23.6%). Oxygen therapy compared with ambient air was not associated with improved outcomes regardless of baseline oxygen saturation (interaction p values: composite endpoint, p = 0.79; all-cause death, p = 0.33; rehospitalization with MI, p = 0.86; hospitalization for heart failure, p = 0.35). CONCLUSIONS Irrespective of oxygen saturation at baseline, we found no clinically relevant beneficial effect of routine oxygen therapy in normoxemic patients with MI regarding cardiovascular outcomes. Low-normal baseline oxygen saturation or development of hypoxemia was identified as an independent marker of poor prognosis. (An Efficacy and Outcome Study of Supplemental Oxygen Treatment in Patients With Suspected Myocardial Infarction; NCT01787110).
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Affiliation(s)
- Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Johan Herlitz
- Department of Health Sciences, University of Borås, Borås, Sweden
| | - Joakim Alfredsson
- Department of Medical and Health Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Sasha Koul
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Thomas Kellerth
- Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine and Sahlgrenska University Hospital, Department of Cardiology, University of Gothenburg, Gothenburg, Sweden
| | - Patrik Alström
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Ollie Östlund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
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Andell P, Berntorp K, Christiansen EH, Gudmundsdottir IJ, Sandhall L, Venetsanos D, Erlinge D, Fröbert O, Koul S, Reitan C, Götberg M. Reclassification of Treatment Strategy With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A Substudy From the iFR-SWEDEHEART Trial. JACC Cardiovasc Interv 2019; 11:2084-2094. [PMID: 30336812 DOI: 10.1016/j.jcin.2018.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 05/14/2018] [Revised: 07/16/2018] [Accepted: 07/24/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The authors sought to compare reclassification of treatment strategy following instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR). BACKGROUND iFR was noninferior to FFR in 2 large randomized controlled trials in guiding coronary revascularization. Reclassification of treatment strategy by FFR is well-studied, but similar reports on iFR are lacking. METHODS The iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome Trial) study randomized 2,037 participants with stable angina or acute coronary syndrome to treatment guided by iFR or FFR. Interventionalists entered the preferred treatment (optimal medical therapy [OMT], percutaneous coronary intervention [PCI], or coronary artery bypass grafting [CABG]) on the basis of coronary angiograms, and the final treatment decision was mandated by the iFR/FFR measurements. RESULTS In the iFR/FFR (n = 1,009/n = 1,004) populations, angiogram-based treatment approaches were similar (p = 0.50) with respect to OMT (38%/35%), PCI of 1 (37%/39%), 2 (15%/16%), and 3 vessels (2%/2%) and CABG (8%/8%). iFR and FFR reclassified 40% and 41% of patients, respectively (p = 0.78). The majority of reclassifications were conversion of PCI to OMT in both the iFR/FFR groups (31.4%/29.0%). Reclassification increased with increasing number of lesions evaluated (odds ratio per evaluated lesion for FFR: 1.46 [95% confidence interval: 1.22 to 1.76] vs. iFR 1.37 [95% confidence interval: 1.18 to 1.59]). Reclassification rates for patients with 1, 2, and 3 assessed vessels were 36%, 52%, and 53% (p < 0.01). CONCLUSIONS Reclassification of treatment strategy of intermediate lesions was common and occurred in 40% of patients with iFR or FFR. The most frequent reclassification was conversion from PCI to OMT regardless of physiology modality. Irrespective of the physiological index reclassification of angiogram-based treatment strategy increased with the number of lesions evaluated.
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Affiliation(s)
- Pontus Andell
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden.
| | - Karolina Berntorp
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | | | | | - Lennart Sandhall
- Departments of Cardiology and Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Dimitrios Venetsanos
- Departments of Cardiology and of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Christian Reitan
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
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Ahmad Y, Vendrik J, Eftekhari A, Howard JP, Cook C, Rajkumar C, Malik I, Mikhail G, Ruparelia N, Hadjiloizou N, Nijjer S, Al-Lamee R, Petraco R, Warisawa T, Wijntjens GWM, Koch KT, van de Hoef T, de Waard G, Echavarria-Pinto M, Frame A, Sutaria N, Kanaganayagam G, Ariff B, Anderson J, Chukwuemeka A, Fertleman M, Koul S, Iglesias JF, Francis D, Mayet J, Serruys P, Davies J, Escaned J, van Royen N, Götberg M, Juhl Terkelsen C, Høj Christiansen E, Piek JJ, Baan J, Sen S. Determining the Predominant Lesion in Patients With Severe Aortic Stenosis and Coronary Stenoses: A Multicenter Study Using Intracoronary Pressure and Flow. Circ Cardiovasc Interv 2019; 12:e008263. [PMID: 31752515 PMCID: PMC6924937 DOI: 10.1161/circinterventions.119.008263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients with severe aortic stenosis (AS) often have coronary artery disease. Both the aortic valve and the coronary disease influence the blood flow to the myocardium and its ability to respond to stress; leading to exertional symptoms. In this study, we aim to quantify the effect of severe AS on the coronary microcirculation and determine if this is influenced by any concomitant coronary disease. We then compare this to the effect of coronary stenoses on the coronary microcirculation.
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Affiliation(s)
- Yousif Ahmad
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Jeroen Vendrik
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Ashkan Eftekhari
- Aarhus University Hospital Skejby, Denmark (A.E., C.J.T., E.H.C.)
| | - James P Howard
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Christopher Cook
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Christopher Rajkumar
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Iqbal Malik
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Ghada Mikhail
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Neil Ruparelia
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Nearchos Hadjiloizou
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Sukhjinder Nijjer
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Ricardo Petraco
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Takayuki Warisawa
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | | | - Karel T Koch
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Tim van de Hoef
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Guus de Waard
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands (G.d.W., N.v.R.)
| | | | - Angela Frame
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Nilesh Sutaria
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Gajen Kanaganayagam
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Ben Ariff
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Jon Anderson
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Andrew Chukwuemeka
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Michael Fertleman
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (S.K., M.G.)
| | - Juan F Iglesias
- Cardiology Department, Lausanne University Hospital, Switzerland (J.F.I.)
| | - Darrel Francis
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Jamil Mayet
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Patrick Serruys
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
| | - Justin Davies
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom (I.M., G.M., N.R., N.H., S.N., A.F., N.S., G.K., B.A., J.A., A.C., M.F., J.D.)
| | - Javier Escaned
- Hospital Clínico San Carlos, Madrid, Spain (M.E.-P., J.E.)
| | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands (G.d.W., N.v.R.)
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Sweden (S.K., M.G.)
| | | | | | - Jan J Piek
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Jan Baan
- Amsterdam UMC, University of Amsterdam, Heart Center, Department of Clinical and Experimental Cardiology, the Netherlands (J.V., K.T.K., T.v.d.H., J.J.P., J.B.)
| | - Sayan Sen
- National Heart and Lung Institute, Hammersmith Hospital, Imperial College London, United Kingdom (Y.A., J.P.H., C.C., C.R., R.A.-L., R.P., T.W., D.F., J.M., P.S., S.S.)
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Escaned J, Ryan N, Mejía-Rentería H, Cook CM, Dehbi HM, Alegria-Barrero E, Alghamdi A, Al-Lamee R, Altman J, Ambrosia A, Baptista SB, Bertilsson M, Bhindi R, Birgander M, Bojara W, Brugaletta S, Buller C, Calais F, Silva PC, Carlsson J, Christiansen EH, Danielewicz M, Di Mario C, Doh JH, Erglis A, Erlinge D, Gerber RT, Going O, Gudmundsdottir I, Härle T, Hauer D, Hellig F, Indolfi C, Jakobsen L, Janssens L, Jensen J, Jeremias A, Kåregren A, Karlsson AC, Kharbanda RK, Khashaba A, Kikuta Y, Krackhardt F, Koo BK, Koul S, Laine M, Lehman SJ, Lindroos P, Malik IS, Maeng M, Matsuo H, Meuwissen M, Nam CW, Niccoli G, Nijjer SS, Olsson H, Olsson SE, Omerovic E, Panayi G, Petraco R, Piek JJ, Ribichini F, Samady H, Samuels B, Sandhall L, Sapontis J, Sen S, Seto AH, Sezer M, Sharp ASP, Shin ES, Singh J, Takashima H, Talwar S, Tanaka N, Tang K, Van Belle E, van Royen N, Varenhorst C, Vinhas H, Vrints CJ, Walters D, Yokoi H, Fröbert O, Patel MR, Serruys P, Davies JE, Götberg M. Safety of the Deferral of Coronary Revascularization on the Basis of Instantaneous Wave-Free Ratio and Fractional Flow Reserve Measurements in Stable Coronary Artery Disease and Acute Coronary Syndromes. JACC Cardiovasc Interv 2019; 11:1437-1449. [PMID: 30093050 DOI: 10.1016/j.jcin.2018.05.029] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the clinical outcomes of patients deferred from coronary revascularization on the basis of instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) measurements in stable angina pectoris (SAP) and acute coronary syndromes (ACS). BACKGROUND Assessment of coronary stenosis severity with pressure guidewires is recommended to determine the need for myocardial revascularization. METHODS The safety of deferral of coronary revascularization in the pooled per-protocol population (n = 4,486) of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) and iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trials was investigated. Patients were stratified according to revascularization decision making on the basis of iFR or FFR and to clinical presentation (SAP or ACS). The primary endpoint was major adverse cardiac events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization at 1 year. RESULTS Coronary revascularization was deferred in 2,130 patients. Deferral was performed in 1,117 patients (50%) in the iFR group and 1,013 patients (45%) in the FFR group (p < 0.01). At 1 year, the MACE rate in the deferred population was similar between the iFR and FFR groups (4.12% vs. 4.05%; fully adjusted hazard ratio: 1.13; 95% confidence interval: 0.72 to 1.79; p = 0.60). A clinical presentation with ACS was associated with a higher MACE rate compared with SAP in deferred patients (5.91% vs. 3.64% in ACS and SAP, respectively; fully adjusted hazard ratio: 0.61 in favor of SAP; 95% confidence interval: 0.38 to 0.99; p = 0.04). CONCLUSIONS Overall, deferral of revascularization is equally safe with both iFR and FFR, with a low MACE rate of about 4%. Lesions were more frequently deferred when iFR was used to assess physiological significance. In deferred patients presenting with ACS, the event rate was significantly increased compared with SAP at 1 year.
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Affiliation(s)
- Javier Escaned
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Nicola Ryan
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Hernán Mejía-Rentería
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | | | - Hakim-Moulay Dehbi
- CRUK & UCL Cancer Trials Centre, University College London, London, United Kingdom
| | | | - Ali Alghamdi
- King Abdulaziz Medical City Cardiac Center, Riyadh, Saudi Arabia
| | - Rasha Al-Lamee
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - John Altman
- Colorado Heart and Vascular, Lakewood, Colorado
| | | | | | - Maria Bertilsson
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Mats Birgander
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Waldemar Bojara
- Gemeinschaftsklinikum Mittelrhein, Kemperhof Koblenz, Koblenz, Germany
| | - Salvatore Brugaletta
- Cardiovascular Institute, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | | | - Fredrik Calais
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | | | - Jörg Carlsson
- Kalmar County Hospital, and Linnaeus University, Faculty of Health and Life Sciences, Kalmar, Sweden
| | | | | | - Carlo Di Mario
- Royal Brompton Hospital, Imperial College London, United Kingdom, and University of Florence, Florence, Italy
| | - Joon-Hyung Doh
- Inje University Ilsan Paik Hospital, Daehwa-Dong, South Korea
| | - Andrejs Erglis
- Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Olaf Going
- Sana Klinikum Lichtenberg, Lichtenberg, Germany
| | | | - Tobias Härle
- Klinikum Oldenburg, European Medical School, Carl von Ossietzky University, Oldenburg, Germany
| | - Dario Hauer
- Departments of Cardiology and Medical and Health Sciences, Linköping University, Linköping, Sweden
| | | | | | - Lars Jakobsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jens Jensen
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, and Unit of Cardiology, Capio S:t Görans Sjukhus, Stockholm, and Department of Medicine, Sundsvall Hospital, Sundsvall, Sweden
| | - Allen Jeremias
- Stony Brook University Medical Center, Stony Brook, New York
| | - Amra Kåregren
- Department of Internal Medicine, Västmanland Hospital Västerås, Västerås, Sweden
| | | | - Rajesh K Kharbanda
- John Radcliffe Hospital, Oxford University Hospitals Foundation Trust, Oxford, United Kingdom
| | | | | | | | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul, South Korea
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mika Laine
- Helsinki University Hospital, Helsinki, Finland
| | | | - Pontus Lindroos
- Department of Cardiology, St. Göran Hospital, Stockholm, Sweden
| | - Iqbal S Malik
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Chang-Wook Nam
- Keimyung University Dongsan Medical Center, Daegu, South Korea
| | | | | | - Hans Olsson
- Department of Cardiology, Karlstad Hospital, Karlstad, Sweden
| | - Sven-Erik Olsson
- Departments of Cardiology and Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Gothenburg, Sweden
| | - Georgios Panayi
- Departments of Cardiology and Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Ricardo Petraco
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Jan J Piek
- AMC Heart Center, Academic Medical Center, Amsterdam, the Netherlands
| | | | | | - Bruce Samuels
- Cedars-Sinai Heart Institute, Los Angeles, California
| | - Lennart Sandhall
- Departments of Cardiology and Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | | | - Sayan Sen
- Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Arnold H Seto
- Veterans Affairs Long Beach Healthcare System, Long Beach, California
| | - Murat Sezer
- Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Andrew S P Sharp
- Royal Devon and Exeter Hospital and University of Exeter, Exeter, United Kingdom
| | - Eun-Seok Shin
- Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Jasvindar Singh
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Suneel Talwar
- Royal Bournemouth General Hospital, Bournemouth, United Kingdom
| | | | - Kare Tang
- Essex Cardiothoracic Centre, Basildon and Anglia Ruskin University, Chelmsford, United Kingdom
| | - Eric Van Belle
- Institut Coeur Poumon, Lille University Hospital, and INSERM Unité 1011, Lille, France
| | | | | | | | | | | | | | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | | | - Patrick Serruys
- Department of Cardiology, Imperial College London, London, United Kingdom
| | - Justin E Davies
- Hammersmith Hospital, Imperial College London, London, United Kingdom.
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital, Lund, Sweden
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Ritsinger V, Jensen J, Ohm D, Omerovic E, Koul S, Fröbert O, Erlinge D, James S, Lagerqvist B, Norhammar A. Elevated admission glucose is common and associated with high short-term complication burden after acute myocardial infarction: Insights from the VALIDATE-SWEDEHEART study. Diab Vasc Dis Res 2019; 16:582-584. [PMID: 31476896 DOI: 10.1177/1479164119871540] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To investigate the association between admission plasma glucose and cardiovascular events in patients with acute myocardial infarction treated with modern therapies including early percutaneous coronary intervention and modern stents. METHODS Patients (n = 5309) with established diabetes and patients without previously known diabetes with a reported admission plasma glucose, included in the VALIDATE trial 2014-2016, were followed for cardiovascular events (first of mortality, myocardial infarction, stroke, heart failure) within 180 days. Event rates were analysed by four glucose categories according to the World Health Organization criteria for hyperglycaemia and definition of diabetes. Odds ratios were calculated in a multivariate logistic regression model. RESULTS Mean age was 67 ± 11 years. Previously known diabetes was present in 21.2% (n = 1124). Cardiovascular events occurred in 3.7%, 3.8%, 6.6% and 15.7% in the four glucose level groups and 9.9% in those with known diabetes (p < 0.001), while bleeding complications did not differ significantly (9.1%, 8.5%, 8.4%, 12.2% and 8.5%, respectively). After adjustment, odds ratio (95% confidence interval) was 1.00 (0.65-1.53) for group II, 1.62 (1.14-2.29) for group III and 3.59 (1.99-6.50) for group IV compared to the lowest admission plasma glucose group (group I). The corresponding number for known diabetes was 2.42 (1.71-3.42). CONCLUSION In a well-treated contemporary population of acute myocardial infarction patients, 42% of those without diabetes had elevated admission plasma glucose levels with a greater risk for clinical events already within 180 days. Event rate increased with increasing admission plasma glucose levels. These findings highlight the importance of searching for undetected diabetes in the setting of acute myocardial infarction and that new treatment options are needed to improve outcome.
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Affiliation(s)
- Viveca Ritsinger
- Cardiology Unit, Department of Medicine K2, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm, Sweden
- Department of Research and Development, Region Kronoberg, Växjö, Sweden
| | - Jens Jensen
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm, Sweden
- Capio S:t Görans Hospital, Stockholm, Sweden
| | - Daniel Ohm
- Capio S:t Görans Hospital, Stockholm, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sasha Koul
- Departments of Cardiology and Clinical Sciences, Lund University, Lund, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - David Erlinge
- Departments of Cardiology and Clinical Sciences, Lund University, Lund, Sweden
| | - Stefan 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
| | - Anna Norhammar
- Cardiology Unit, Department of Medicine K2, Karolinska Institutet, Karolinska University Hospital, Solna, Stockholm, Sweden
- Capio S:t Görans Hospital, Stockholm, Sweden
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Mohammad MA, Koul S, Rylance R, Fröbert O, Alfredsson J, Sahlén A, Witt N, Jernberg T, Muller J, Erlinge D. Association of Weather With Day-to-Day Incidence of Myocardial Infarction: A SWEDEHEART Nationwide Observational Study. JAMA Cardiol 2019; 3:1081-1089. [PMID: 30422202 DOI: 10.1001/jamacardio.2018.3466] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [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: 01/03/2023]
Abstract
Importance Whether certain weather conditions modulate the onset of myocardial infarction (MI) is of great interest to clinicians because it could be used to prevent MIs as well as guide allocation of health care resources. Objective To determine if weather is associated with day-to-day incidence of MI. Design, Setting, and Participants In this prospective, population-based and nationwide setting, daily weather data from the Swedish Meteorological and Hydrological Institute were extracted for all MIs reported to the Swedish nationwide coronary care unit registry, Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART), during 1998 to 2013 and then merged with each MI on date of symptom onset and coronary care unit. All patients admitted to any coronary care unit in Sweden owing to MI were included. A total of 280 873 patients were included, of whom 92 044 were diagnosed as having ST-elevation MI. Weather data were available for 274 029 patients (97.6%), which composed the final study population. Data were analyzed between February 2017 and April 2018. Exposures The nationwide daily mean air temperature, minimum air temperature, maximum air temperature, wind velocity, sunshine duration, atmospheric air pressure, air humidity, snow precipitation, rain precipitation, and change in air temperature. Main Outcomes and Measures The nationwide daily counts of MI as outcome. Results In 274 029 patients, mean (SD) age was 71.7 (12) years. Incidence of MI increased with lower air temperature, lower atmospheric air pressure, higher wind velocity, and shorter sunshine duration. The most pronounced association was observed for air temperature, where a 1-SD increase in air temperature (7.4°C) was associated with a 2.8% reduction in risk of MI (unadjusted incidence ratio, 0.972; 95% CI, 0.967-0.977; P <.001). Results were consistent for non-ST-elevation MI as well as ST-elevation MI and across a large range of subgroups and health care regions. Conclusions and Relevance In this large, nationwide study, low air temperature, low atmospheric air pressure, high wind velocity, and shorter sunshine duration were associated with risk of MI with the most evident association observed for air temperature.
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Affiliation(s)
- Moman A Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Rebecca Rylance
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Ole Fröbert
- Örebro University, Faculty of Health, Department of Cardiology, Örebro, Sweden
| | - Joakim Alfredsson
- Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - Anders Sahlén
- Karolinska Institutet, Department of Medicine Huddinge, Sweden.,National Heart Centre Singapore, 5 Hospital Drive, Singapore
| | - Nils Witt
- Department of Cardiology, Clinical Science and Education, Södersjukhuset, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyds University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - James Muller
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
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Bergh C, Mohammad MA, Tham J, Koul S, Rylance R, Erlinge D, Frobert O. P6392Under the weather: acute myocardial infarction and subsequent case fatality with influenza burden - a nationwide observational study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0988] [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
Influenza may precipitate cardiovascular disease but influenza typically peaks in winter coinciding with other triggers of myocardial infarction (MI) such as low air temperature, high wind velocity, low air pressure and short sunshine duration. We aimed to study week-to-week variation in influenza cases and acute MI after meteorological confounder adjustment in a nationwide setting.
Methods
Weekly laboratory-confirmed influenza case reports were obtained from the Public Health Agency of Sweden from 2009 to 2016 and merged with the nationwide SWEDEHEART MI registry. Weekly counts of MI were studied with regard to influenza cases stratified into tertiles, 0–16, 17–164 and >164 influenza cases/week. Incidence rate ratios were calculated for each category and compared to a reference period of the year with no influenza. A negative binomial regression model was applied to adjust for weather parameters.
Results
A total of 133 562 MIs were reported to the registry during the study period of which 44 055 were ST-elevation MIs. Weeks with influenza cases were associated with higher risk of MI. For 0–16 influenza cases/week the unadjusted incidence rate ratio (IRR) for MI was 1.04 (95% confidence interval [CI] 1.01–1.07, p=0.007); for 17–163 cases/week the IRR=1.07 (95% CI 1.04–1.10, p≤0.001) and for ≥164 cases/week the IRR=1.08 (95% CI 1.05–1.11, p≤0.001). Results were consistent across a large range of subgroups and after adjusting for confounders. In addition, all-cause mortality was higher in weeks with highest reported rates of influenza cases.
Conclusion
In this nationwide observational study, we found an association between occurrence of MI and number of influenza cases beyond what could be explained by meteorological factors.
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Affiliation(s)
- C Bergh
- Örebro University, Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro, Sweden
| | - M A Mohammad
- Lund University, Department of Cardiology, Clinical Sciences, Lund, Sweden
| | - J Tham
- Lund University, Infectious Diseases Unit, Department of Clinical Sciences, Lund, Sweden
| | - S Koul
- Lund University, Department of Cardiology, Clinical Sciences, Lund, Sweden
| | - R Rylance
- Lund University, Department of Cardiology, Clinical Sciences, Lund, Sweden
| | - D Erlinge
- Lund University, Department of Cardiology, Clinical Sciences, Lund, Sweden
| | - O Frobert
- Örebro University, Faculty of Health, Department of Cardiology, Örebro, Sweden
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Attar R, Koul S, Jensen SE, Erlinge D, Andell P. P3627Characteristics and outcomes following myocardial infarction in patients with schizophrenia. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0485] [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
Patients with schizophrenia are a high-risk population due to a high prevalence of cardiovascular risk factors that translates into increased cardiovascular morbidity and mortality.
Purpose
To describe the characteristics of patients with schizophrenia experiencing a myocardial infarction (MI) and to analyse the 1-year major adverse cardiac events (MACE: all-cause mortality, reinfarction, stroke and heart failure) and prescriptions of guideline-recommended secondary preventive treatments at hospital discharge.
Methods
All patients with schizophrenia who experienced a MI in the period between 2000–2017 were identified and included from the SWEDEHEART registry and compared to patients without schizophrenia. Uni- and multivariable Cox proportional hazards and Kaplan-Meier survival models were used to compare the populations.
Results
The main results are shown in Table 1. Compared to the general population (n=285,325), patients with schizophrenia (n=1,008) were younger (63 vs 71 years), had a higher smoking burden and prevalence's of diabetes, heart failure, chronic obstructive pulmonary disorder and major bleeding (all p-values <0.05). On the contrary, lower prevalence's of diagnosed hypertension, hyperlipideamia, previous myocardial infarction, renal disease and peripheral artery disease were seen in this population. Lastly, patients with schizophrenia were less likely to be discharged with aspirin, P2Y12 inhibitors, ACE-inhibitors/angiotensin receptor blockers, beta blockers and statins (all p-values <0.005).
Table 1. Clinical endpoints at 5-years for patients with schizophrenia following a MI compared to patients without schizophrenia End-points Unadjusted HR (95% CI) Adjusted HR (95% CI) Model 1 Model 2 Model 3 MACE 1.35 (1.23–1.47)* 2.44 (2.23–2.67)* 2.20 (1.79–2.72)* 2.05 (1.63–2.58)* Mortality 1.44 (1.31–1.59)* 2.99 (2.72–3.29)* 2.53 (2.00–3.21)* 2.38 (1.84–3.09)* Reinfarction 1.00 (0.82–1.24) 1.53 (1.25–1.89)* 1.41 (0.86–2.30) 1.29 (0.77–2.13) Stroke 1.03 (0.80–1.34) 1.67 (1.29–2.17)* 1.72 (1.00–2.97) 1.72 (1.00–2.98) Heart failure 1.25 (1.10–1.42)* 2.14 (1.88–2.42)* 1.49 (1.13–1.98)* 1.39 (1.04–1.86)* *p<0.005. Model 1: adjusted for age and sex; Model 2: adjusted for age and sex, smoking, comorbidities, previous CAG and previous PCI; Model 3: adjusted for age and sex, smoking, comorbidities, previous CAG and previous PCI, discharge medications and treatment with CAG and PCI.
Conclusion
Patients with schizophrenia remain a high-risk population who experience a MI almost 10 years earlier than patients without schizophrenia and have worse outcome. Improved primary and secondary preventive measures are urgently warranted.
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Affiliation(s)
- R Attar
- Lund University, Lund, Sweden
| | - S Koul
- Lund University, Lund, Sweden
| | - S E Jensen
- Aalborg University Hospital, Department of Cardiology, Aalborg, Denmark
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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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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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Völz S, Angerås O, Koul S, Haraldsson I, Sarno G, Venetsanos D, Grimfärd P, Ulvenstam A, Hofmann R, Hamid M, Henareh L, Wagner H, Jensen J, Danielewicz M, Östlund O, Eriksson P, Scherstén F, Linder R, Råmunddal T, Pétursson P, Fröbert O, James S, Erlinge D, Omerovic E. Radial versus femoral access in patients with acute coronary syndrome undergoing invasive management: A prespecified subgroup analysis from VALIDATE-SWEDEHEART. Eur Heart J Acute Cardiovasc Care 2019; 8:510-519. [PMID: 31237158 DOI: 10.1177/2048872618817217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS In the 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 (VALIDATE-SWEDEHEART), bivalirudin was not superior to unfractionated heparin in patients with acute coronary syndrome undergoing invasive management. We assessed whether the access site had an impact on the primary endpoint of death, myocardial infarction or major bleeding at 180 days and whether it interacted with bivalirudin/unfractionated heparin. METHODS AND RESULTS A total of 6006 patients with acute coronary syndrome planned for percutaneous coronary intervention were randomised to either bivalirudin or unfractionated heparin. Arterial access was left to the operator discretion. Overall, 90.5% of patients underwent transradial access and 9.5% transfemoral access. Baseline risk was higher in transfemoral access. The unadjusted hazard ratio for the primary outcome was lower with transradial access (hazard ratio 0.53, 95% confidence interval 0.43-0.67, p<0.001) and remained lower after multivariable adjustment (hazard ratio 0.56, 95% confidence interval 0.52-0.84, p<0.001). Transradial access was associated with lower risk of death (hazard ratio 0.41, 95% confidence interval 0.28-0.60, p<0.001) and major bleeding (hazard ratio 0.57, 95% confidence interval 0.44-0.75, p<0.001). There was no interaction between treatment with bivalirudin and access site for the primary endpoint (p=0.976) or major bleeding (p=0.801). CONCLUSIONS Transradial access was associated with lower risk of death, myocardial infarction or major bleeding at 180 days. Bivalirudin was not associated with less bleeding, irrespective of access site.
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Affiliation(s)
- Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Sasha Koul
- Department of Cardiology, Lund University, Sweden
| | - Inger Haraldsson
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Giovanna Sarno
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden
| | | | - Per Grimfärd
- Department of Internal Medicine, Västmanlands Sjukhus, Sweden
| | | | - Robin Hofmann
- Department of Clinical Science and Education, Karolinska Institutet, Sweden
| | - Mehmet Hamid
- Department of Cardiology, Mälarsjukhuset, Sweden
| | - Loghman Henareh
- Department of Cardiology, Karolinska University Hospital, Sweden
| | - Henrik Wagner
- Department of Cardiology, Helsingborg Lasarett, Sweden
| | - Jens Jensen
- Department of Clinical Science and Education, Karolinska Institutet, Sweden.,Unit of Cardiology, Capio S:t Görans Sjukhus, Sweden
| | | | - Ollie Östlund
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden
| | | | | | | | | | - Pétur Pétursson
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
| | - Ole Fröbert
- Department of Cardiology, Örebro University, Sweden
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden
| | | | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Sweden
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44
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Sharma T, Rylance R, Karlsson S, Koul S, Venetsanos D, Omerovic E, Fröbert O, Persson J, James S, Erlinge D. Relationship between degree of heparin anticoagulation and clinical outcome in patients receiving potent P2Y12-inhibitors with no planned glycoprotein IIb/IIIa inhibitor during percutaneous coronary intervention in acute myocardial infarction: a VALIDATE-SWEDEHEART substudy. European Heart Journal - Cardiovascular Pharmacotherapy 2019; 6:6-13. [DOI: 10.1093/ehjcvp/pvz015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/15/2019] [Accepted: 05/06/2019] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
Heparin is the preferred choice of anticoagulant in percutaneous coronary intervention (PCI) for acute myocardial infarction (MI). An established dosage of heparin has not yet been determined, but treatment may be optimized through monitoring of activated clotting time (ACT). The aim of this study was to determine the relationship between heparin dose or ACT with a composite outcome of death, MI, or bleeding using data from the registry-based, randomized, controlled, and open-label VALIDATE-SWEDEHEART trial, although patients were not randomized to heparin dose in this substudy.
Methods and results
Patients with MI undergoing PCI and receiving treatment with a potent P2Y12-inhibitor and anticoagulation with heparin, without the planned use of glycoprotein IIb/IIIa inhibitor (GPI), were enrolled in this substudy. The primary endpoint was a composite endpoint of death, MI, and bleeding at 30 days. The individual components and stent thrombosis were analysed separately. We divided patients into groups according to the initial dose of unfractionated heparin during PCI (<70 U/kg, 70–100 U/kg, and >100 U/kg) or ACT (ACT <250 s, 250–350 s, and >350 s) as well as investigating them as continuous variables in Cox proportional hazards models using univariable and multivariable analyses. No major differences were noted between heparin stratified in groups (P = 0.22) or heparin as a continuous variable in relation to the primary composite endpoint hazard ratio (HR) 1.0 confidence interval (CI) (0.99–1.01) for heparin dose/kg. No differences were found between ACT stratified in groups (P = 0.453) or ACT in seconds HR 1.0 CI (0.99–1.00) regarding the primary endpoint. The individual components of death, MI, major bleeding, and stent thrombosis were not significantly different across heparin doses or ACT levels either.
Conclusion
We found no association between heparin dose or ACT levels and death, MI bleeding complications, or stent thrombosis. Therefore, there is no strong support for a specific heparin dose or mandatory ACT monitoring in patients treated with potent P2Y12-inhibitors with no planned GPI.
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Affiliation(s)
- Tania Sharma
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Rebecca Rylance
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Sofia Karlsson
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Dimitrios Venetsanos
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jonas Persson
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Stefan James
- Department of Medical Sciences Cardiology, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
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Attar R, Wester A, Koul S, Eggert S, Andell P. Peripheral artery disease and outcomes in patients with acute myocardial infarction. Open Heart 2019; 6:e001004. [PMID: 31245013 PMCID: PMC6560667 DOI: 10.1136/openhrt-2018-001004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [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: 01/03/2019] [Revised: 03/21/2019] [Accepted: 04/14/2019] [Indexed: 12/13/2022] Open
Abstract
Aim To describe the population of patients with previously diagnosed peripheral artery disease (PAD) experiencing a myocardial infarction (MI) and to investigate 1-year major adverse cardiac events (MACE: all-cause mortality, reinfarction, stroke and heart failure hospitalisation) following MI. Background MI patients with PAD constitute a high-risk population with adverse cardiac outcomes. Contemporary real-life data regarding the clinical characteristics of this patient population and clinical event rates following MI remain scarce. Methods This observational study included all MI patients presenting with ST-elevation MI or non-ST-elevation MI between 01 January 2005 and 31 December 2014 with (n=4213) and without (n=106 763) a concurrent PAD diagnosis, identified in the nationwide Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry and the National Patient Registry (PAD prevalence: 3.8%). Cox proportional hazard models were applied to compare the outcome between the two populations. Results MI patients with PAD were older and more often burdened with comorbidities, such as diabetes, hypertension and previous MI. After adjustments, PAD was significantly associated with higher rates of MACE (HR 1.35, 95% CI 1.27 to 1.44), mortality (HR 1.59, 95% CI 1.43 to 1.76), reinfarction (HR 1.48, 95% CI 1.32 to 1.66), stroke (HR 1.27, 95% CI 1.05 to 1.53), heart failure (HR 1.29, 95% CI 1.20 to 1.40) and bleeding (HR 1.26, 95% CI 1.09 to 1.47) at 1 year. Conclusion A concurrent PAD diagnosis was independently significantly associated with higher rates of adverse outcomes following MI in a nationwide real-life MI population. The low prevalence of PAD compared with previous studies suggests significant underdiagnosing. Future studies should investigate if PAD screening with ankle–brachial index may increase diagnosing and subsequently lead to improved treatment of polyvascular disease
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Affiliation(s)
- Rubina Attar
- Cardiology and Clinical Sciences, Lunds Universitet, Lund, Sweden.,Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Axel Wester
- Cardiology and Clinical Sciences, Lunds Universitet, Lund, Sweden
| | - Sasha Koul
- Cardiology and Clinical Sciences, Lunds Universitet, Lund, Sweden
| | - Svend Eggert
- Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Pontus Andell
- Cardiology, Karolinska Institutet, Stockholm, Sweden
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46
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Redfors B, Dworeck C, Haraldsson I, Angerås O, Odenstedt J, Ioanes D, Petursson P, Völz S, Albertsson P, Råmunddal T, Persson J, Koul S, Erlinge D, Omerovic E. Pretreatment with P2Y12 receptor antagonists in ST-elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry. Eur Heart J 2019; 40:1202-1210. [DOI: 10.1093/eurheartj/ehz069] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/27/2018] [Accepted: 01/31/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Christian Dworeck
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Inger Haraldsson
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Per Albertsson
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Jonas Persson
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Sasha Koul
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | | | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
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47
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Berntorp K, Koul S, Nozohoor S, Harnek J, Bjursten H, Götberg M. Single-center evaluation of a next generation fully repositionable and retrievable transcatheter aortic valve replacement. BMC Cardiovasc Disord 2019; 19:44. [PMID: 30808296 PMCID: PMC6390309 DOI: 10.1186/s12872-019-1021-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The mechanically expandable Lotus Valve System is a fully repositionable and retrievable valve with an adaptive seal to minimize paravalvular leak (PVL). The aim of this study was to evaluate the short- and long-term safety and efficacy of the new device with focus on a new implantation technique to reduce the need for a permanent pacemaker (PPM) post procedure. METHODS We performed a prospective single-center, non-randomized evaluation of the Lotus Valve System. The first 100 consecutive Lotus Valve implantations were included in the analysis. Outcome was assessed according to VARC2-criteria. Postoperative pacemaker rates were assessed using the national pacemaker registry and electronic medical records. Mortality at 30 days and 12 months were acquired from the national population registry. RESULTS Mean age was 82.7 ± 5.6 years, mean Euroscore I was 25.3 ± 14.5%, mean STS-score was 6.5 ± 4.1% and mean aortic valve area was 0.6 ± 0.1 cm2. There were no cases of valve embolization, ectopic valve deployment or additional valve implantation. Device success according to the VARC2-criteria was 97%. The 30-day mortality rate was 3%. Two deaths occurred due to stroke and one due to a ventricular rupture. Major stroke rate was 2% and major vascular complication rate was 2%. The 12-month mortality rate was 14%. At discharge 87% of patients had no/trace PVL, 12% had mild PVL and one patient had a moderate PVL. A total of 13% received a new PPM post valve implantation. Among patients who did not have a PPM before the procedure, the PPM rate was 15.3%. CONCLUSIONS This single-center evaluation of the Lotus Valve System demonstrated a good clinical outcome with a low mortality, in a high-risk population. Introduction of a new implantation technique resulted in lower PPM rates than previously reported without negatively affecting PVL. TRIAL REGISTRATION Current Controlled Trials ISRCTN14952278 , retrospectively registered 06/11/2017.
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Affiliation(s)
- Karolina Berntorp
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, 221-85, Lund, SE, Sweden.
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, 221-85, Lund, SE, Sweden
| | - Shahab Nozohoor
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, 221-85, Lund, SE, Sweden
| | - Jan Harnek
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, 221-85, Lund, SE, Sweden
| | - Henrik Bjursten
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, 221-85, Lund, SE, Sweden
| | - Matthias Götberg
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, 221-85, Lund, SE, Sweden
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48
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Azarov JE, Demidova MM, Koul S, van der Pals J, Erlinge D, Platonov PG. Progressive increase of the Tpeak-Tend interval is associated with ischaemia-induced ventricular fibrillation in a porcine myocardial infarction model. Europace 2019; 20:880-886. [PMID: 28541470 DOI: 10.1093/europace/eux104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 03/22/2017] [Indexed: 01/12/2023] Open
Abstract
Aims Repolarization indices of ECG have been widely assessed as predictors of ventricular arrhythmias. However, little is known of the dynamic changes of these parameters during continuous monitoring in acute ischaemic episodes. The objective of the study was to evaluate repolarization-related predictors of ventricular fibrillation (VF) during progression of experimental myocardial infarction. Methods and results Myocardial infarction was induced in 27 pigs by 40-min balloon inflation in the left anterior descending coronary artery, and 12-lead ECG was continuously recorded. Rate-corrected durations of the total Tpeak-Tend intervals measured from the earliest T-wave peak to the latest T-wave end in any lead were determined at baseline and at minute 1, 2, 5, and then every 5th minute of occlusion. There were 7 early (1-3 min) and 10 delayed (15-30 min) VFs in 16 pigs. Baseline Tpeak-Tend did not differ between animals with and without VF. Tpeak-Tend interval rapidly increased immediately after balloon inflation and was greater in VF-susceptible animals at 2-15 min compared with the animals that never developed VF (P < 0.05). Tpeak-Tend was tested as a predictor of delayed VFs. Median Tpeak-Tend at 10th min of occlusion was higher in delayed VF group (n = 10) than in animals without VF (n = 11): 138 [IQR 121-148] ms vs. 111 [IQR 106-127] ms, P = 0.02. Tpeak-Tend ≥123 ms (10th min) predicted delayed VF episodes with HR = 4.5 95% CI 1.1-17.8, P = 0.031. Conclusion Tpeak-Tend prolongation during ischaemia progression predicts VF in the experimental porcine myocardial infarction model and warrants further testing in clinical settings of acute coronary syndromes.
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Affiliation(s)
- Jan E Azarov
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden.,Department of Cardiac Physiology, Institute of Physiology, Komi Science Center, Ural Branch, Russian Academy of Sciences, 50, Pervomayskaya st., 167982, Syktyvkar, Russia.,Department of Physiology, Medical Institute of Syktyvkar State University, 11, Babushkin st., 167000, Syktyvkar, Russia
| | - Marina M Demidova
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden.,Federal Medical Research Center, 2, Akkuratov st., 197341, St. Petersburg, Russia
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, SE-221?85, Lund, Sweden
| | - Jesper van der Pals
- Department of Cardiology, Clinical Sciences, Lund University, SE-221?85, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, SE-221?85, Lund, Sweden
| | - Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, SE-221 85, Lund, Sweden.,Arrhythmia Clinic, Skåne University Hospital, SE-22185, Lund, Sweden
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Farooq S, Hussain A, Qurishi MA, Hamid A, Koul S. Synthesis and Biological Evaluation of Novel Triazoles Linked 7-hydroxycoumarin as Potent Cytotoxic Agents. Anticancer Agents Med Chem 2019; 18:1531-1539. [DOI: 10.2174/1871520618666171229222956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/15/2017] [Accepted: 12/19/2017] [Indexed: 11/22/2022]
Abstract
Background:
BacCancer is regarded as second leading cause of death worldwide. Therefore, there is
a high demand for the discovery, development and improvement of novel anti-cancer agents which could efficiently
prevent proliferative pathways and clonal expansion of cells.
Objective:
In view of this, a new series of bioactive scaffolds viz triazoles linked 7-hydroxycoumarin (1) were
synthesized using click chemistry approach.
Method:
All the synthesized compounds were screened for cytotoxicity against a panel of seven different human
cancer cell lines viz. Colon (Colo-205 and HCT-116), breast (MCF-7), lung (NCI-H322 and A549), prostate
(PC-3) and skin (A-431) using 3-(4,5-Dimethylthiazol-yl)-diphenyl tetrazoliumbromide (MTT) assay.
Results:
Among all tested analogs, compound 5, displayed better cytotoxic activity as compared to the parent 7-
hydroxycoumarin (1) with IC50 of 5.1, 22.7, 14.3 and 10.2 µM against breast (MCF-7), lung (NCI- H322), prostate
(PC-3) and skin (A-431) cancer cell lines, respectively; the compound 5 was 8-fold more sensitive against
MCF-7 than the parent 7-hydroxycoumarin. Moreover, Compound 5 induced both cytotoxic as well as cytostatic
effects via induction of apoptosis and G1 phase arrest, respectively in breast cancer cells (MCF-7). The apoptotic
cell population enhanced to 18.8% at 8 µM of 5 from 9.8% in case of negative control, while G1 phase arrest
increased to 54.4% at 8 µM compared to negative control of 48.1%. Moreover, Compound 5 also exhibited a
remarkable decrease in mitochondrial membrane potential (ΛΨm) leading to apoptosis of cancer cells used.
Conclusion:
The structure-activity relationship study revealed that the derivatives bearing electron-withdrawing
substituents were more effective. The present study resulted in identification of the compounds demonstrating
broad spectrum cytotoxic activity.
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Affiliation(s)
- Saleem Farooq
- Bioorganic Chemistry Division, CSIR-Indian Institute of Integrative Medicine, Canal road Jammu-180001, Jammu and Kashmir, India
| | - Aashiq Hussain
- Cancer Pharmacology Division, CSIR-Indian Institute of Integrative Medicine, Canal road Jammu-18000, Jammu and Kashmir, India
| | - Mushtaq A. Qurishi
- Islamic University of Science & Technology, Department of Chemistry, Awantipora, Jammu and Kashmir, India
| | - Abid Hamid
- Cancer Pharmacology Division, CSIR-Indian Institute of Integrative Medicine, Canal road Jammu-18000, Jammu and Kashmir, India
| | - S. Koul
- Bioorganic Chemistry Division, CSIR-Indian Institute of Integrative Medicine, Canal road Jammu-180001, Jammu and Kashmir, India
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50
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Mohammad MA, Karlsson S, Haddad J, Cederberg B, Jernberg T, Lindahl B, Fröbert O, Koul S, Erlinge D. Christmas, national holidays, sport events, and time factors as triggers of acute myocardial infarction: SWEDEHEART observational study 1998-2013. BMJ 2018; 363:k4811. [PMID: 30541902 PMCID: PMC6289164 DOI: 10.1136/bmj.k4811] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [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: 11/25/2022]
Abstract
OBJECTIVES To study circadian rhythm aspects, national holidays, and major sports events as triggers of myocardial infarction. DESIGN Retrospective observational study using the nationwide coronary care unit registry, SWEDEHEART. SETTING Sweden. PARTICIPANTS 283 014 cases of myocardial infarction reported to SWEDEHEART between 1998 and 2013. Symptom onset date was documented for all cases, and time to the nearest minute for 88%. INTERVENTIONS Myocardial infarctions with symptom onset on Christmas/New Year, Easter, and Midsummer holiday were identified. Similarly, myocardial infarctions that occurred during a FIFA World Cup, UEFA European Championship, and winter and summer Olympic Games were identified. The two weeks before and after a holiday were set as a control period, and for sports events the control period was set to the same time one year before and after the tournament. Circadian and circaseptan analyses were performed with Sunday and 24:00 as the reference day and hour with which all other days and hours were compared. Incidence rate ratios were calculated using a count regression model. MAIN OUTCOME MEASURES Daily count of myocardial infarction. RESULTS Christmas and Midsummer holidays were associated with a higher risk of myocardial infarction (incidence rate ratio 1.15, 95% confidence interval 1.12 to 1.19, P<0.001, and 1.12, 1.07 to 1.18, P<0.001, respectively). The highest associated risk was observed for Christmas Eve (1.37, 1.29 to 1.46, P<0.001). No increased risk was observed during Easter holiday or sports events. A circaseptan and circadian variation in the risk of myocardial infarction was observed, with higher risk during early mornings and on Mondays. Results were more pronounced in patients aged over 75 and those with diabetes and a history of coronary artery disease. CONCLUSIONS In this nationwide real world study covering 16 years of hospital admissions for myocardial infarction with symptom onset documented to the nearest minute, Christmas, and Midsummer holidays were associated with higher risk of myocardial infarction, particularly in older and sicker patients, suggesting a role of external triggers in vulnerable individuals.
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Affiliation(s)
- Moman A Mohammad
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Sofia Karlsson
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Jonathan Haddad
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Björn Cederberg
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Tomas Jernberg
- Department of clinical sciences, Danderyd's University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Ole Fröbert
- Örebro University, Faculty of Health, Department of Cardiology, Örebro, Sweden
| | - Sasha Koul
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
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