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- Koul, Sasha
(författare)
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Improving outcomes in patients with coronary heart disease using national registers and platelet function testing
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Ischemic heart disease is the leading cause of death worldwide. The aims of this thesis were to evaluate different contemporary approaches in coronary care with regard to mortality and myocardial infarction. Methods: The thesis consists of 6 papers with 4 papers evaluating different exposures and their outcomes (clopidogrel pre-treatment, 5 different anti-platelet protocols, ticagrelor pre-treatment and treatment delays to PCI). Two papers involved evaluation of interventions: platelet function testing in patients with clopidogrel and clinical evaluation of bivalirudin versus heparin in patients with acute coronary syndromes, respectively. Patients with ischemic heart disease were identified using national and local registers. All patients in the six included papers were treated with PCI. Results: Pre-treatment with clopidogrel prior to primary PCI was associated with improved cardiovascular outcomes compared to peri-procedural clopidogrel. The composite end point of one-year mortality and MI was improved as well as mortality alone. Pre-treatement with ticagrelor compared to peri-procedural ticagrelor did not affect 30-day mortality. In one of three statistical models, 30-day myocardial infarction was reduced with ticagrelor pre-treatment. Platelet function testing failed to identify a clinically applicable cut-off value to predict stent thrombosis or new onset MI in patients with dual anti-platelet therapy. Using platelet function testing, a loading dose of either prasugrel or ticagrelor on top of a previous loading dose of clopidogrel, did not cause a pharmacodynamic overshoot of platelet inhibition. Treatment delays from first medical contact to PCI exceeding one hour were associated with higher mortality in patients with STEMI undergoing primary PCI. Finally, we showed that a register based randomized clinical trial designed to evaluate bivalirudin versus heparin in patients with ACS and PCI is feasible, with a higher degree of enrollment of “real-life” patients than in in conventional randomized clinical trials. Conclusions: This thesis has potential implications for acute care of patients with myocardial infarction.
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- Thim, Troels, et al.
(författare)
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Agreement between iFR and FFR in staged follow-up evaluation of non-culprit stenoses after ST-segment elevation myocardial infarction (iSTEMI substudy)
- 2017
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Ingår i: Journal of the American College of Cardiology. - : Elsevier. - 0735-1097 .- 1558-3597. ; 70:18, s. B91-B91
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- BACKGROUND: Classification agreement between instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) is approximately 80% in stable patients. It was recently shown that FFR guidance, as compared to iFR guidance, was associated with a higher risk of subsequent revascularization among patients with non- ST-segment elevation myocardial infarction. The classification agreement, and the impact of time interval, between iFR and FFR in the assessment of non-culprit lesions after recent ST-segment elevation myocardial infarction (STEMI) has not been described.METHODS: The iSTEMI study assessed agreement between iFR across non-culprit stenoses at the index procedure in patients with STEMI versus iFR and FFR at a follow-up angiography. The interval between STEMI and follow-up evaluation was at the discretion of the treating physicians. In this substudy, classification agreement between follow-up iFR and follow-up FFR was evaluated within groups defined according to follow-up time point after STEMI, i.e., <5days, 5-15days, and16 days. iFR<0.90 and FFR0.80 were considered hemodynamically significant.RESULTS: Among 120 patients with 157 non-culprit stenoses, follow-up iFR and FFR was available in 112 patients with 146 non-culprit stenoses. Median follow-up interval was 16 days (IQR 5-32 days). The overall classification agreement was 84%. With follow-up<5days after STEMI, there was classification agreement between iFR and FFR was in 27 of 35 (77%) non-culprit stenoses. With follow-up 5-15 after STEMI, there was classification agreement in 33 of 38 (86%) non-culprit stenoses. With follow-up 16 days after STEMI, there was classification agreement in 63 of 73 (86%) non-culprit stenoses. The observed differences in these proportions over time after STEMI were not statistically significant (<5versus5days, p¼0.19).CONCLUSION: Overall, classification agreement between iFR and FFR in the assessment of non-culprit lesions after STEMI was comparable to that observed in stable patients. Time interval between STEMI and follow-up evaluation may impact agreement between follow-up iFR and follow-up FFR, although the observed differences were not statistically significant.
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- Varenhorst, Christoph, et al.
(författare)
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Timing Of Pci In Patients With Non-St-Elevation Myocardial Infarction : A Swedeheart Study
- 2016
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Ingår i: Journal of the American College of Cardiology. - Uppsala Univ, Dept Med Sci, Cardiol, Uppsala, Sweden. Uppsala Univ, Uppsala Clin Res Ctr, Uppsala, Sweden.. - 0735-1097 .- 1558-3597. ; 67:13, s. 44-44
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
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