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1.	Aengerud, Karin Hellstroem, et al. (författare) Symptoms of Acute Myocardial Infarction as Described in Calls to Tele-Nurses and in Questionnaires A Mixed-Methods Study 2023 Ingår i: Journal of Cardiovascular Nursing. - : LIPPINCOTT WILLIAMS & WILKINS. - 0889-4655 .- 1550-5049. ; 38:2, s. 150-157 Tidskriftsartikel (refereegranskat)abstract BackgroundPatient-reported symptoms of acute myocardial infarction (MI) may be affected by recall bias depending on when and where symptoms are assessed.AimThe aim of this study was to gain an understanding of patients symptom description in more detail before and within 24 hours after a confirmed MI diagnosis.MethodsA convergent parallel mixed-methods design was used to examine symptoms described in calls between the tele-nurse and the patient compared with symptoms selected by the patient from a questionnaire less than 24 hours after hospital admission. Quantitative and qualitative data were analyzed separately and then merged into a final interpretation.ResultsThirty patients (median age, 67.5 years; 20 men) were included. Chest pain was the most commonly reported symptom in questionnaires (24/30). Likewise, in 19 of 30 calls, chest pain was the first complaint mentioned, usually described together with the symptom onset. Expressions used to describe symptom quality were pain, pressure, discomfort, ache, cramp, tension, and soreness. Associated symptoms commonly described were pain or numbness in the arms, cold sweat, dyspnea, weakness, and nausea. Bodily sensations, such as feeling unwell or weak, were also described. Fear and tiredness were described in calls significantly less often than reported in questionnaires (P = .01 and P = .02), whereas "other" symptoms were more often mentioned in calls compared with answers given in the questionnaire (P = .02). Some symptoms expressed in the calls were not listed in the questionnaire, which expands the understanding of acute MI symptoms. The results showed no major inconsistencies between datasets.ConclusionPatients MI symptom descriptions in tele-calls and those reported in questionnaires after diagnosis are comparable and convergent.
2.	Alabas, Oras A., et al. (författare) Sex Differences in Treatments, Relative Survival, and Excess Mortality Following Acute Myocardial Infarction : National Cohort Study Using the SWEDEHEART Registry 2017 Ingår i: Journal of the American Heart Association. - : WILEY. - 2047-9980. ; 6:12 Tidskriftsartikel (refereegranskat)abstract Background - This study assessed sex differences in treatments, all-cause mortality, relative survival, and excess mortality following acute myocardial infarction.Methods and Results - A population-based cohort of all hospitals providing acute myocardial infarction care in Sweden (SWEDEHEART [Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies]) from 2003 to 2013 was included in the analysis. Excess mortality rate ratios (EMRRs), adjusted for clinical characteristics and guideline-indicated treatments after matching by age, sex, and year to background mortality data, were estimated. Although there were no sex differences in all-cause mortality adjusted for age, year of hospitalization, and comorbidities for ST-segment-elevation myocardial infarction (STEMI) and non-STEMI at 1 year (mortality rate ratio: 1.01 [95% confidence interval (CI), 0.96-1.05] and 0.97 [95% CI, 0.95-.99], respectively) and 5 years (mortality rate ratio: 1.03 [95% CI, 0.99-1.07] and 0.97 [95% CI, 0.95-.99], respectively), excess mortality was higher among women compared with men for STEMI and non-STEMI at 1 year (EMRR: 1.89 [95% CI, 1.66-2.16] and 1.20 [95% CI, 1.16-1.24], respectively) and 5 years (EMRR: 1.60 [95% CI, 1.48-1.72] and 1.26 [95% CI, 1.21-1.32], respectively). After further adjustment for the use of guideline-indicated treatments, excess mortality among women with non-STEMI was not significant at 1 year (EMRR: 1.01 [95% CI, 0.97-1.04]) and slightly higher at 5 years (EMRR: 1.07 [95% CI, 1.02-1.12]). For STEMI, adjustment for treatments attenuated the excess mortality for women at 1 year (EMRR: 1.43 [95% CI, 1.26-1.62]) and 5 years (EMRR: 1.31 [95% CI, 1.19-1.43]).Conclusions - Women with acute myocardial infarction did not have statistically different all-cause mortality, but had higher excess mortality compared with men that was attenuated after adjustment for the use of guideline-indicated treatments. This suggests that improved adherence to guideline recommendations for the treatment of acute myocardial infarction may reduce premature cardiovascular death among women.
3.	Alfredsson, Joakim, et al. (författare) Although women are less likely to be admitted to coronary care units, they are treated equally to men and have better outcome : A prospective cohort study in patients with non ST-elevation acute coronary syndromes 2009 Ingår i: Acute cardiac care. - : Informa Healthcare. - 1748-295X .- 1748-2941. ; 11:3, s. 173-180 Tidskriftsartikel (refereegranskat)abstract Background: The aim of this study was to assess gender differences in admission level of care, management and outcome in patients with non ST-elevation acute coronary syndromes (NSTE-ACS), initially admitted to either coronary care units (CCU) or general wards. Method: Patients admitted to CCUs were routinely registered in the RIKS-HIA registry. In addition, patients admitted to general wards with suspected ACS were also identified and registered. Multivariable regression analysis was used to adjust for baseline differences between the genders. Results: We included 570 consecutive patients with a discharge diagnosis of NSTE-ACS. Women were less likely to be admitted to coronary care units (56% versus 69%, P=0.002), even after adjustment (odds ratio (OR), 0.65; 95% confidence interval (CI): 0.43-0.98). After adjustment for differences in baseline characteristics, women were treated similarly to men. We found no significant differences in crude short-, or long-term mortality between the genders. However, adjustment for background characteristics revealed lower one-year mortality in women (OR: 0.58; 95% CI: 0.34-0.99). Conclusion: In this study on patients with NSTE-ACS, women were less likely to be admitted to coronary care units. However, the overall treatment was as intensive for women as for men. Moreover, after adjustment, one-year mortality was lower in women.
4.	Alfredsson, Joakim, 1962-, et al. (författare) Gender influence tretment and outcome of patients with unstable coronary artery disease. 2003 Ingår i: European Heart Journal,2003. ; , s. 72-72 Konferensbidrag (refereegranskat)
5.	Alfredsson, Joakim, 1962-, et al. (författare) Randomized comparison of early supplemental oxygen versus ambient air in patients with confirmed myocardial infarction : Sex-related outcomes from DETO2X-AMI 2021 Ingår i: American Heart Journal. - : Mosby Inc.. - 0002-8703 .- 1097-6744. ; 237, s. 13-24 Tidskriftsartikel (refereegranskat)abstract Background: The purpose of this study is to investigate the impact of oxygen therapy on cardiovascular outcomes in relation to sex in patients with confirmed myocardial infarction (MI).Methods: The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction trial randomized 6,629 patients to oxygen at 6 L/min for 6-12 hours or ambient air. In the present subgroup analysis including 5,010 patients (1,388 women and 3,622 men) with confirmed MI, we report the effect of supplemental oxygen on the composite of all-cause death, rehospitalization with MI, or heart failure at long-term follow-up, stratified according to sex.Results: Event rate for the composite endpoint was 18.1% in women allocated to oxygen, compared to 21.4% in women allocated to ambient air (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.65-1.05). In men, the incidence was 13.6% in patients allocated to oxygen compared to 13.3% in patients allocated to ambient air (HR 1.03, 95% CI 0.86-1.23). No significant interaction in relation to sex was found (P=.16). Irrespective of allocated treatment, the composite endpoint occurred more often in women compared to men (19.7 vs 13.4%, HR 1.51; 95% CI, 1.30-1.75). After adjustment for age alone, there was no difference between the sexes (HR 1.06, 95% CI 0.91-1.24), which remained consistent after multivariate adjustment.Conclusion: Oxygen therapy in normoxemic MI patients did not significantly affect all-cause mortality or rehospitalization for MI or heart failure in women or men. The observed worse outcome in women was explained by differences in baseline characteristics, especially age
6.	Alfredsson, Joakim, 1962-, et al. (författare) Unstable coronary artery disease - a missed diagnosis. 2003 Ingår i: European Heart Journal,2003. ; , s. 74-74 Konferensbidrag (refereegranskat)
7.	Andersson, Per, et al. (författare) Characteristics of patients with acute myocardial infarction contacting primary healthcare before hospitalisation: a cross-sectional study 2018 Ingår i: BMC Family Practice. - : BMC. - 1471-2296. ; 19 Tidskriftsartikel (refereegranskat)abstract Background: The characteristics of patients with on-going myocardial infarction (MI) contacting the primary healthcare (PHC) centre before hospitalisation are not well known. Prompt diagnosis is crucial in patients with MI, but many patients delay seeking medical care. The aims of this study was to 1) describe background characteristics, symptoms, actions and delay times in patients contacting the PHC before hospitalisation when falling ill with an acute MI, 2) compare those patients with acute MI patients not contacting the PHC, and 3) explore factors associated with a PHC contact in acute MI patients. Methods: This was a cross-sectional multicentre study, enrolling consecutive patients with MI within 24 hours of admission to hospital from Nov 2012 until Feb 2014. Results: A total of 688 patients with MI, 519 men and 169 women, were included; the mean age was 66 +/- 11 years. One in five people contacted PHC instead of the recommended emergency medical services (EMS), and 94% of these patients experienced cardinal symptoms of an acute MI; i.e., chest pain, and/or radiating pain in the arms, and/or cold sweat. Median delay time from symptom-onset-to-decision-to-seek-care was 2:15 hours in PHC patients and 0:40 hours in non-PHC patients (pamp;lt;0.01). The probability of utilising the PHC before hospitalisation was associated with fluctuating symptoms (OR 1.74), pain intensity (OR 0.90) symptoms during off-hours (OR 0.42), study hospital (OR 3.49 and 2.52, respectively, for two of the county hospitals) and a final STEMI diagnosis (OR 0.58). Conclusions: Ambulance services are still underutilized in acute MI patients. A substantial part of the patients contacts their primary healthcare centre before they are diagnosed with MI, although experiencing cardinal symptoms such as chest pain. There is need for better knowledge in the population about symptoms of MI and adequate pathways to qualified care. Knowledge and awareness amongst primary healthcare professionals on the occurrence of MI patients is imperative.
8.	Björkman, Stina, et al. (författare) Microvascular dysfunction in women with a history of hypertensive disorders of pregnancy: A population-based retrospective cohort study 2024 Ingår i: British Journal of Obstetrics and Gynecology. - : WILEY. - 1470-0328 .- 1471-0528. ; 131:4, s. 433-443 Tidskriftsartikel (refereegranskat)abstract ObjectiveTo evaluate microvascular function in women with previous hypertensive disorders of pregnancy (HDP).DesignRetrospective population-based cohort study.SettingLinkoping, Sweden.PopulationWomen aged 50-65 years, participating in the Swedish CArdioPulmonary bioImage Study (SCAPIS) at one site (Linkoping) 2016-18, who underwent microcirculatory assessment (N = 1222).MethodsForearm skin comprehensive microcirculatory assessment was performed with a PeriFlux PF6000 EPOS (Enhanced Perfusion and Oxygen Saturation) system measuring oxygen saturation and total speed resolved perfusion. Obstetric records were reviewed to identify women with previous HDP. Data on cardiovascular risk factors, comorbidities, medication, lifestyle, anthropometric data, and biochemical analyses were obtained from SCAPIS. The microcirculatory data were compared between women with and without previous HDP.Main outcome measuresSkin microcirculatory oxygen saturation and total speed resolved perfusion at baseline and post-ischaemic peak.ResultsWomen with previous pre-eclampsia displayed impaired post-ischaemic peak oxygen saturation compared with women with normotensive pregnancies (88%, interquartile range [IQR] 84-89% vs 91%, IQR 87-94%, p = 0.001) 6-30 years after pregnancy. The difference remained after multivariable adjustment (& beta; -2.69, 95% CI -4.93 to -0.45).ConclusionsThe findings reveal microvascular dysfunction at long-term follow up in women with previous pre-eclampsia and strengthen the possible role of endothelial dysfunction as a link to the increased risk of cardiovascular disease in women with HDP.
9.	Chan, Nathan, et al. (författare) Pregnancy and Spontaneous Coronary Artery Dissection : Lessons From Survivors and Nonsurvivors 2022 Ingår i: Circulation. - : Lippincott, Williams & Wilkins. - 0009-7322 .- 1524-4539. ; 146:1, s. 69-72 Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract n/a
10.	El-Saadi, Walid, 1984-, et al. (författare) A head-to-head comparison of myocardial strain by fast-strain encoding and feature tracking imaging in acute myocardial infarction 2022 Ingår i: Frontiers in Cardiovascular Medicine. - : Frontiers Media SA. - 2297-055X. ; 9 Tidskriftsartikel (refereegranskat)abstract BackgroundMyocardial infarction (MI) is a major cause of heart failure. Left ventricular adverse remodeling is common post-MI. Several studies have demonstrated a correlation between reduced myocardial strain and the development of adverse remodeling. Cardiac magnetic resonance (CMR) with fast-strain encoding (fast-SENC) or feature tracking (FT) enables rapid assessment of myocardial deformation. The aim of this study was to establish a head-to-head comparison of fast-SENC and FT in post-ST-elevated myocardial infarction (STEMI) patients, with clinical 2D speckle tracking echocardiography (2DEcho) as a reference. MethodsThirty patients treated with primary percutaneous coronary intervention for STEMI were investigated. All participants underwent CMR examination with late gadolinium enhancement, cine-loop steady-state free precession, and fast-SENC imaging using a 1.5T scanner as well as a 2DEcho. Global longitudinal strain (GLS), segmental longitudinal strain (SLS), global circumferential strain (GCS), and segmental circumferential strain (SCS) were assessed along with the MI scar extent. ResultsThe GCS measurements from fast-SENC and FT were nearly identical: the mean difference was 0.01 (2.5)% (95% CI - 0.92 to 0.95). For GLS, fast-SENC values were higher than FT, with a mean difference of 1.8 (1.4)% (95% CI 1.31-2.35). Tests of significance for GLS did not show any differences between the MR methods and 2DEcho. Average strain in the infarct-related artery (IRA) segments compared to the remote myocardium was significantly lower for the left anterior descending artery and right coronary artery culprits but not for the left circumflex artery culprits. Fast-SENC displayed a higher area under the curve for detecting infarcted segments than FT for both SCS and SLS. ConclusionGLS and GCS did not significantly differ between fast-SENC and FT. Both showed acceptable agreement with 2DEcho for longitudinal strain. Segments perfused by the IRA showed significantly reduced strain values compared to the remote myocardium. Fast-SENC presented a higher sensitivity and specificity for detecting infarcted segments than FT.
11.	El-Saadi, Walid, et al. (författare) Correction: A head-to-head comparison of myocardial strain by fast-strain encoding and feature tracking imaging in acute myocardial infarction (vol 9, 949440, 2022) 2023 Ingår i: Frontiers in Cardiovascular Medicine. - : FRONTIERS MEDIA SA. - 2297-055X. ; 10 Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
12.	Ericsson, Maria, 1970-, et al. (författare) Factors associated with patient decision time in ST-segment elevation myocardial infarction, in early and late responders : an observational cross-sectional survey study 2022 Ingår i: European Journal of Cardiovascular Nursing. - : Oxford University Press. - 1474-5151 .- 1873-1953. ; 21:7, s. 694-701 Tidskriftsartikel (refereegranskat)abstract AIMS: A short time span from symptom onset to reperfusion is imperative in ST-segment elevation myocardial infarction (STEMI). The aim of this study was to determine factors associated with patient decision time for seeking care in STEMI, particularly how symptoms were experienced and affected patient response.METHODS AND RESULTS: A multicentre cross-sectional self-report survey study was completed at five Swedish hospitals representing geographic diversity. The 521 patients were divided into three groups based on their time to respond to symptoms: early (<20 min), intermediate (20-90 min), and late responders (>90 min). Only one out of five patients both responded early and called an ambulance within 20 min. Believing symptoms were cardiac in origin [odds ratio (OR) 2.60], male sex (OR 2.40), left anterior descending artery as culprit artery (OR 1.77), and bystanders calling an ambulance (OR 4.32) were factors associated with early response and correct action. Associated symptoms such as dyspnoea (OR 1.67) and weakness (OR 1.65) were associated with an early action (<20 min), while chest pain was not independently associated with response time. Cold sweat (OR 0.61) prevented late care-seeking behaviour as did a high symptom burden (OR 0.86).CONCLUSION: Misinterpretation of symptoms delays correct care-seeking behaviour because patient expectations may not be aligned with the experience when stricken by Myocardial infarction. Therefore, it is imperative to continuously enhance public awareness in correct symptom recognition and appropriate care-seeking behaviour and to make efforts to educate individuals at risk for STEMI as well as their next of kin.
13.	Ericsson, Maria, et al. (författare) Interaction between tele-nurses and callers with an evolving myocardial infarction : consequences for level of directed care 2019 Ingår i: European Journal of Cardiovascular Nursing. - : Sage Publications. - 1474-5151 .- 1873-1953. ; 18:7, s. 545-553 Tidskriftsartikel (refereegranskat)abstract Background: Rapid contact with emergency medical services is imperative to save the lives of acute myocardial infarction patients. However, many patients turn to a telehealth advisory nurse instead, where the delivery of urgent and safe care largely depends on how the interaction in the call is established.Purpose: The purpose of this study was to explore the interaction between tele-nurses and callers with an evolving myocardial infarction after contacting a national telehealth advisory service number as their first medical contact.Method: Twenty men and 10 women (aged 46–89 years) were included. Authentic calls were analysed using inductive content analysis.Findings: One overall category, Movement towards directed level of care, labelled the whole interaction between the tele-nurse and the caller. Four categories conceptualised the different interactions: a distinct, reasoning, indecisive or irrational interaction. The interactions described how tele-nurses and callers assessed and elaborated on symptoms, context and actions. The interaction was pivotal for progress in the dialogue and affected the achievement of mutual understanding in the communicative process. An indecisive or irrational interaction could increase the risk of failing to recommend or call for acute care.Conclusion: The interaction in the communication could either lead or mislead the level of care directed in the call. This study adds new perspectives to the communicative process in the acute setting in order to identify a myocardial infarction and the level of urgency from both individuals experiencing myocardial infarction and professionals in the health system.
14.	Ericsson, Maria, 1970- (författare) No time to waste : Pre-hospital actions and time delays in patients with ST elevation myocardial infarction – temporal trends and prognostic impact on short- and long-term survival 2022 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Background: In ST-elevation myocardial infarction (STEMI) patients, a rapid diagnosis is imperative to reduce total ischaemic time minimizing risk for heart failure, serious arrhythmias, or death. Prehospital context is complex, and the patient delay constitute major part of the pre-hospital phase. Patient delay has been prone hard to impact but the system delay has had major transformation during the years. Aim: The overall aim was to explore pre-hospital actions and time delays in STEMI patients, investigating temporal trends and estimate prognostic impact on short- and long-term survival. Methods: Study I, was a multicentre survey study, exploring decisions, and actions in relation to the choice of first medical contact (FMC). Study II was a sub-study to the multicentre survey, exploring the interaction between tele nurses and callers in authentic calls when the caller with an evolving myocardial infarction (MI) chose to call Swedish health care direct (SHD) as FMC. Study III, was based on the same database as study I, exploring early (< 20 minutes) and late (> 90 minutes) response from symptom onset in STEMI patients. Study IV, was based on SWEDEHEART-registry, investigating temporal trends in pre-specified risk groups for pro-longed pre-hospital delay times (PHDT), estimating cumulative survival in short and long term stratified in six different PHDT groups. Results: Study I, only half of the patients’ contacted emergency medical services (EMS) as their FMC. Choice of FMC prolonged time to diagnosis in relation of calling EMS. Choosing SHD pro-longed delay to diagnosis with 38 minutes. Study II, four interactions were found between tele-nurses and callers, reasoning, distinct, irrational, and indecisive, and type of interaction could lead or mislead the call moving progressively forward or not. Study III, bystanders calling EMS, men, intensive and alarming symptoms such as dyspnoea and weakness and to interpret symptoms attributed from the heart was associated with a rapid action calling an ambulance within 20 minutes, which was performed by one of five patients. Study IV, trend curves for median PHDT was hump shaped for the 20 years studied. Women, older age, and patients with diabetes had consistent pro-longed PHDT, except for the oldest patients (> 80 years). PHDT was an independent risk for short- and long-term survival. Patients with the shortest PHDT 0-1 hour had the highest mortality up to five days. In five-year follow up this group accompanied with the group within 1-2 hours had highest estimated survival. Conclusion: Pre-hospital delay is an independent predictor of short- and long-term survival. To interpret symptom correctly and knowledge in how to act, calling an ambulance rapidly, impact time to diagnosis and diminish time delays. Pre-hospital delay merits further attention regarding future interventions.
15.	Hellström Ängerud, Karin, et al. (författare) Differences in symptoms, first medical contact and pre-hospital delay times between patients with ST- and non-ST-elevation myocardial infarction 2019 Ingår i: European Heart Journal. - : Sage Publications. - 2048-8726 .- 2048-8734. ; 8:3, s. 201-207 Tidskriftsartikel (refereegranskat)abstract Aim: In ST-elevation myocardial infarction, time to reperfusion is crucial for the prognosis. Symptom presentation in myocardial infarction influences pre-hospital delay times but studies about differences in symptoms between patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction are sparse and inconclusive. The aim was to compare symptoms, first medical contact and pre-hospital delay times in patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction.Methods and results: This multicentre, observational study included 694 myocardial infarction patients from five hospitals. The patients filled in a questionnaire about their pre-hospital experiences within 24 h of hospital admittance. Chest pain was the most common symptom in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction (88.7 vs 87.0%, p=0.56). Patients with cold sweat (odds ratio 3.61, 95% confidence interval 2.29–5.70), jaw pain (odds ratio 2.41, 95% confidence interval 1.04–5.58), and nausea (odds ratio 1.70, 95% confidence interval 1.01–2.87) were more likely to present with ST-elevation myocardial infarction, whereas the opposite was true for symptoms that come and go (odds ratio 0.58, 95% confidence interval 0.38-0.90) or anxiety (odds ratio 0.52, 95% confidence interval 0.29–0.92). Use of emergency medical services was higher among patients admitted with ST-elevation myocardial infarction. The pre-hospital delay time from symptom onset to first medical contact was significantly longer in non-ST-elevation myocardial infarction (2:05 h vs 1:10 h, p=0.001).Conclusion: Patients with ST-elevation myocardial infarction differed from those with non-ST-elevation myocardial infarction regarding symptom presentation, ambulance utilisation and pre-hospital delay times. This knowledge is important to be aware of for all healthcare personnel and the general public especially in order to recognise symptoms suggestive of ST-elevation myocardial infarction and when to decide if there is a need for an ambulance.
16.	Hellström Ängerud, Karin, et al. (författare) Differences in symptoms in relation to myocardial infarction. 2016 Konferensbidrag (övrigt vetenskapligt/konstnärligt)abstract Background: In myocardial infarction (MI) rapid diagnosis and treatment is crucial for the prognosis. Previous research has found that symptom presentation influence pre hospital delay times but studies about differences in MI symptoms between patients with ST-elevation myocardial infarction (STEMI) and non ST-elevation myocardial infarction (NSTEMI) are sparse and inconclusive. To enhance the understanding of symptom presentation in regard to MI type, we aimed to describe symptoms in relation to MI type and to find predictors of STEMI versus NSTEMI in patients with MI.Methods: Patients with MI (n=694) from the SymTime study were included. SymTime was a multicentre cross-sectional study of symptoms and actions in the prehospital phase of MI and data were collected using a previously validated questionnaire administered to MI patients within 24 h of admission to hospital.Results: Patients with STEMI were younger, more often men and smokers. Patients with NSTEMI were more likely to have a history of hypertension, MI and stroke. Chest pain was the most common symptom in both groups. Pain, discomfort, or pressure located in the jaw or teeth, vertigo/pre-syncope, cold sweat and nausea/vomiting were significantly more frequent in patients with STEMI (Table 1). In a multivariate logistic regression model patients with STEMI were more likely to present with cold sweat (OR 4.13, 95% CI 2.71–6.29) jaw pain (OR 2.14, 95% CI 1.02–4.50), and nausea (OR 2.01, 95% CI 1.20–3.33), and less likely to have a history of stroke (OR 0.35, 95% CI 0.15–0.84), fluctuating symptoms (OR 0.54, 95% CI 0.36–0.83) and anxiety (OR 0.54, 95% CI 0.32–0.92) compared to patients with NSTEMI.Conclusion: Patients with STEMI differed significantly from those with NSTEMI regarding symptom presentation. This knowledge is important for health care personnel to recognize symptoms alarming for STEMI when evaluating patients with MI symptoms.
17.	Hellström Ängerud, Karin, et al. (författare) Symptoms of Acute Myocardial Infarction as Described in Calls to Tele-Nurses and in Questionnaires 2023 Ingår i: Journal of Cardiovascular Nursing. - : Wolters Kluwer. - 0889-4655 .- 1550-5049. ; 38:2, s. 150-157 Tidskriftsartikel (refereegranskat)abstract Background: Patient-reported symptoms of acute myocardial infarction (MI) may be affected by recall bias depending on when and where symptoms are assessed.Aim: The aim of this study was to gain an understanding of patients' symptom description in more detail before and within 24 hours after a confirmed MI diagnosis.Methods: A convergent parallel mixed-methods design was used to examine symptoms described in calls between the tele-nurse and the patient compared with symptoms selected by the patient from a questionnaire less than 24 hours after hospital admission. Quantitative and qualitative data were analyzed separately and then merged into a final interpretation.Results: Thirty patients (median age, 67.5 years; 20 men) were included. Chest pain was the most commonly reported symptom in questionnaires (24/30). Likewise, in 19 of 30 calls, chest pain was the first complaint mentioned, usually described together with the symptom onset. Expressions used to describe symptom quality were pain, pressure, discomfort, ache, cramp, tension, and soreness. Associated symptoms commonly described were pain or numbness in the arms, cold sweat, dyspnea, weakness, and nausea. Bodily sensations, such as feeling unwell or weak, were also described. Fear and tiredness were described in calls significantly less often than reported in questionnaires (P = .01 and P = .02), whereas “other” symptoms were more often mentioned in calls compared with answers given in the questionnaire (P = .02). Some symptoms expressed in the calls were not listed in the questionnaire, which expands the understanding of acute MI symptoms. The results showed no major inconsistencies between datasets.Conclusion: Patients' MI symptom descriptions in tele-calls and those reported in questionnaires after diagnosis are comparable and convergent.
18.	Hellström Ängerud, Karin, 1967-, et al. (författare) Symptoms, response to symptoms, and delay times during myocardial infarction in 694 patients with and without diabetes Annan publikation (övrigt vetenskapligt/konstnärligt)
19.	Holm, Anna, 1973- (författare) Acute coronary syndrome : bleeding, platelets and gender 2019 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract BACKGROUNDBleeding complications increase mortality in patients with acute coronary syndrome (ACS). Potential gender difference in bleeding regarding prevalence, location, severity and prognostic impact is still controversial and not well investigated. In regard to this aspect the relevance of triple antithrombotic therapy (TAT) is questioned. There is an ongoing debate on the clinical implications of TAT and furthermore assumed that bleeding complications, except impact on outcome, also are associated with great influence on health economy.The main focus of this thesis was to further investigate the incidence and impact of bleeding complications in patients treated for ACS, with special reference to gender disparities, TAT and health economics. The thesis will highlight the importance of improved bleeding prevention strategies for both men and women.METHODPaper I, II and IIIObservational studies from the SWEDEHEART register.In paper I we investigated patients hospitalised with myocardial infarction (MI) during 2006–2008. Outcomes were in-hospital bleedings, in-hospital mortality and one-year mortality in hospital survivors.In paper II, all patients with MI, in the County of Östergötland, Sweden during 2010 were included and followed for one year. The patients' medical records were evaluated, in relation to short and long-term bleeding complications, bleeding location, withdrawal of platelet inhibiting drugs and nonfatal MI and death.Paper III included all patients discharged with (TAT) in the County of Östergötland 2009-2015. Information about bleeds and ischemic complications during one-year follow-up were retrieved from the medical records. Estimation of the health care costs associated with bleeding episodes were added to the evaluation.Paper IVPatients with MI, scheduled for coronary angiography were recruited. All patients received clopidogrel and aspirin. A subgroup of patients received GP IIb/IIIa-inhibitor. Outcomes were platelet aggregation assessed at several time points, using a Multiplate impedance aggregometer, measurement of P-selectin in plasma, evaluation of high residual platelet reactivity (HRPR) and low residual platelet reactivity (LRPR) respectively and incidence of bleeding complications. A comparison between women and men was performed.RESULTSPaper IA total number of 50.399 patients were included, 36.6% women. In-hospital bleedings were more common in women (1.9% vs. 3.1%, p<0.001) even after multivariable adjustment (OR 1.17, 95%, CI 1.01–1.37). The increased risk for women was found in STEMI (OR 1.46, 95% CI 1.10–1.94) and in those who underwent PCI (OR 1.80, 95% CI 1.45–2.24).In contrast the risk was lower in medically treated women (OR 0.79, 95% CI 0.62–1.00). After adjustment, in-hospital bleeding was associated with higher risk of oneyear mortality in men (OR 1.35, 95% CI 1.04–1.74), whereas this was not the case in women (OR 0.97, 95% CI 0.72–1.31).Paper IIIn total 850 consecutive patients were included. The total incidence of bleeding events was 24.4% (81 women and 126 men, p=ns). The incidence of all in hospital bleeding events was 13.2%, with no gender difference. Women had significantly more minor nonsurgery related bleeding events than men (5% vs 2.2%, p=0.02). During follow-up, 13.5% had a bleeding, with more non-surgery related bleeding events among women, 14.7% vs 9.7% (p=0.03). The most common bleeding localisation was the gastrointestinal tract, more in women than men (12.1% vs 7.6%, p=0.03). Women also had more access site bleeding complications (4% vs 1.7%, p=0.04), while men had more surgery related bleeding complications (6.4% vs 0.9%, p≤0.001). Increased mortality was found only in men with non-surgery related bleeding events (p=0.008).Paper IIIAmong 272 identified patients, 156 bleeds occurred post-discharge, of which 28.8% were of gastrointestinal origin. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post-discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p=0.01) and bled more (48.6 vs. 37.1%, p=0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively.Paper IVWe recruited 125 patients (37 women and 88 men). We observed significantly more inhospital bleeding events in women as compared to men (18.9% vs 6.8%, p=0.04). There were no differences in platelet aggregation using three different agonists, reflecting treatment of GPIIb/IIIa inhibitors, clopidogrel and aspirin, at four different time-points nor were there any differences in p-selectin in plasma 3 days after admission.CONCLUSIONThere is a remarkably high bleeding incidence among patients treated with DAPT and even more so if treated with TAT. Female gender is an independent risk factor of inhospital bleeding after myocardial infarction, this higher bleeding risk in women appears to be restricted to invasively treated patients and STEMI patients. Even if women had higher short- and long-term mortality, there was no difference between the genders among those who bled. After multivariable adjustment the prognostic impact of bleeding complications was higher in menWomen seem to experience more minor/minimal bleeding complications than men, predominantly GI bleeding events and access site bleeding events, with no apparent impact on outcome.In contrast men with non-surgery related bleeding complications had higher mortality. There is a lack of differences between the genders concerning platelet aggregation. Our results do not support gender disparities in platelet reactivity and excess dosing as a major explanation for increased bleeding risk in women. Improved bleeding prevention strategies are warranted for both men and women.
20.	Holm, Anna, et al. (författare) Bleeding complications after myocardial infarction in a real world population - An observational retrospective study with a sex perspective 2018 Ingår i: Thrombosis Research. - : PERGAMON-ELSEVIER SCIENCE LTD. - 0049-3848 .- 1879-2472. ; 167, s. 156-163 Tidskriftsartikel (refereegranskat)abstract Introduction: The aim of the current study was to assess bleeding events, including severity, localisation and prognostic impact, in a real world population of men and women with myocardial infarction (MI). Methods and results: In total 850 consecutive patients were included during 2010 and followed for one year. Bleeding complications were identified by searching of each patients medical records and characterised according to the TIMI criteria. For this analysis, only the first event was calculated. The total incidence of bleeding events was 24.4% (81 women and 126 men, p=ns). The incidence of all inhospital bleeding events was 13.2%, with no sex difference. Women had significantly more minor non-surgery related bleeding events than men (5% vs 2.2%, p=0.02). During follow-up, 13.5% had a bleeding, with more non-surgery related bleeding events among women, 14.7% vs 9.7% (p=0.03). The most common bleeding localisation was the gastrointestinal tract, more in women than men (12.1% vs 7.6%, p=0.03). Women had also more access site bleeding complications (4% vs 1.7%, p=0.04), while men had more surgery related bleeding complications (6.4% vs 0.9%, p=0.001). Increased mortality was found only in men with non-surgery related bleeding events (p=0.008). Conclusions: Almost one in four patients experienced a bleeding complication through 12 months follow-up after a myocardial infarction. Women experienced more non-surgery related minor/minimal bleeding complications than men, predominantly GI bleeding events and access site bleeding events, with no apparent impact on outcome. In contrast men with non-surgery related bleeding complications had higher mortality. Improved bleeding prevention strategies are warranted for both men and women.
21.	Holm, Anna, et al. (författare) Gender difference in prognostic impact of in-hospital bleeding after myocardial infarction - data from the SWEDEHEART registry. 2016 Ingår i: European Heart Journal. - : Sage Publications. - 2048-8726 .- 2048-8734. ; 6, s. 463-472 Tidskriftsartikel (refereegranskat)abstract BACKGROUND: Bleeding complications increase mortality in myocardial infarction patients. Potential gender difference in bleeding regarding prevalence and prognostic impact is still controversial.OBJECTIVES: Gender comparison regarding incidence and prognostic impact of bleeding in patients hospitalised with myocardial infarction during 2006-2008.METHODS: Observational study from the SWEDEHEART register. Outcomes were in-hospital bleedings, in-hospital mortality and one-year mortality in hospital survivors.RESULTS: A total number of 50,399 myocardial infarction patients were included, 36.6% women. In-hospital bleedings were more common in women (1.9% vs. 3.1%, p<0.001) even after multivariable adjustment (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.01-1.37). The increased risk for women was found in ST-elevation myocardial infarction (OR 1.46, 95% CI 1.10-1.94) and in those who underwent percutaneous coronary intervention (OR 1.80, 95% CI 1.45-2.24). In contrast the risk was lower in medically treated women (OR 0.79, 95% CI 0.62-1.00). After adjustment, in-hospital bleeding was associated with higher risk of one-year mortality in men (OR 1.35, 95% CI 1.04-1.74), whereas this was not the case in women (OR 0.97, 95% CI 0.72-1.31).CONCLUSIONS: Female gender is an independent risk factor of in-hospital bleeding after myocardial infarction. A higher bleeding risk in women appeared to be restricted to invasively treated patients and ST-elevation myocardial infarction patients. Even though women have higher short- and long-term mortality, there was no difference between the genders among bleeders. After multivariable adjustment the prognostic impact of bleeding complications was higher in men.
22.	Holm, Anna, 1973-, et al. (författare) Long term risk and costs of bleeding in men and women treated with triple antithrombotic therapy : An observational study 2021 Ingår i: PLOS ONE. - : Public Library of Science. - 1932-6203. ; 16:3 Tidskriftsartikel (refereegranskat)abstract Objectives Bleeding is the most common non-ischemic complication in patients with coronary revascularisation procedures, associated with prolonged hospitalisation and increased mortality. Many factors predispose for bleeds in these patients, among those sex. Anyhow, few studies have characterised the population receiving triple antithrombotic therapy (TAT) as well as long term bleeds from a sex perspective. We investigated the one year rate of bleeds in patients receiving TAT, potential sex disparities and premature discontinuation of TAT. We also assessed health care costs in bleeders vs non-bleeders. Setting Three hospitals in the County of ostergotland, Sweden during 2009-2015. Participants All patients discharged with TAT registered in the SWEDEHEART registry. Primary and secondary outcome measures All bleeds receiving medical attention during one-year follow-up were collected by retrieving relevant information about each patient from medical records. Resource use associated with bleeds was assigned unit cost to estimate the health care costs associated with bleeding episodes. Results Among 272 patients, 156 bleeds occurred post-discharge, of which 28.8% were gastrointestinal. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p = 0.01) and bled more (48.6 vs. 37.1%, p = 0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively. Conclusion The high bleeding incidence in patients with TAT, especially in women, is a cause of concern. There is a need for an adequately sized randomised, controlled trial to determine a safe but still effective treatment for these patients.
23.	Holm, Anna, 1973-, et al. (författare) Sex differences in platelet reactivity in patients with myocardial infarction treated with triple antiplatelet therapy-results from assessing platelet activity in coronary heart disease (APACHE) 2021 Ingår i: Platelets. - : Taylor & Francis. - 0953-7104 .- 1369-1635. ; 32:1, s. 524-532 Tidskriftsartikel (refereegranskat)abstract )Several earlier studies have reported increased risk of bleeding in women with myocardial infarction, (MI) compared to men. The reasons for the observed difference are incompletely understood, but one suggested explanation has been excess dosing of antithrombotic drugs in women. The aim of this prospective observational study was to assess sex differences in platelet activity in patients treated with three different platelet inhibitors. We recruited 125 patients (37 women and 88 men) with MI, scheduled for coronary angiography. All patients received clopidogrel and aspirin. A subgroup of patients received glycoprotein (GP) IIb/IIIa-inhibitor. Platelet aggregation in whole blood was assessed at several time points, using impedance aggregometry. SolubleP-selectin was measured 3 days after admission. There were no significant differences between women and men in baseline features or comorbidities except higher frequency of diabetes, lower hemoglobin value, and lower estimated glomerular filtration rate, in women on admission. We observed significantly more in-hospital bleeding events in women compared to men (18.9% vs. 6.8%,p= .04). There were no differences in platelet aggregation using three different agonists, reflecting treatment effect of GPIIb/IIIa-inhibitors, clopidogrel, and aspirin, 6-8 hours, 3 days, 7-9 days, or 6 months after loading dose. Moreover, there was no significant difference in solubleP-selectin. The main finding of this study was a consistent lack of difference between the sexes in platelet aggregation, using three different agonists at several time-points. Our results do not support excess dosing of anti-platelet drugs as a major explanation for increased bleeding risk in women.
24.	Isaksson, Rose-Marie, 1964-, et al. (författare) Geographical Diversities in Symptoms, Actions and Prehospital Delay Times in Swedish ST-Elevation Myocardial Infarction(STEMI) Patients : A Descriptive Multicenter Cross-Sectional Survey Study 2019 Ingår i: Insights of Cardiology Open Access. - : GRF Publishers. Tidskriftsartikel (refereegranskat)abstract Background: Geographical variations in cardiovascular mortality have been reported in Sweden as well as in other countries. Little attention has been given to possible variations in symptoms, actions and pre-hospital delay times in ST-elevation myocardial infarction (STEMI) patients, as a reason for this diversity. We aimed to study whether STEMI patients from the northern and southern parts of Sweden differ in symptoms and actions that may affect the pre-hospital delay times.Methods: SymTime was a multicentre cross-sectional survey study where STEMI patients admitted to the coronary care unit completed a validated questionnaire within 24 hours after admission. In total, 531 patients were included, 357 in the southern and 174 in the northern part of Sweden.Results: There were no significant differences in age. However, patients in the north had more often hypertension (52 vs 42%, p=0.02) or other concomitant comorbidities (24 vs 14%, p=0.01). Patients in the south experienced more anxiety (14 vs. 7%, p=0.01) and fear (23 vs. 14%, p=0.02) and more often contacted the emergency medical services (EMS) as first medical contact (FMC) (54 vs 44%, p=0.05). There were no differences in other main or associated symptoms or in pre-hospital delay times. Conclusions: Patients with STEMI in the southern vs. the northern part of Sweden had more anxiety and fear, despite that they were less often alone at onset of symptoms. There were no differences in pre-hospital delay times. Although patients from the southern region contacted EMS as their FMC more frequently, it is still worrying that too few patients utilize the EMS.
25.	Miao Jonasson, Junmei, 1972, et al. (författare) Social Support, Social Network Size, Social Strain, Stressful Life Events, and Coronary Heart Disease in Women With Type 2 Diabetes: A Cohort Study Based on the Women's Health Initiative 2020 Ingår i: Diabetes care. - : American Diabetes Association. - 0149-5992 .- 1935-5548. ; 43:8, s. 1759-1766 Tidskriftsartikel (refereegranskat)abstract OBJECTIVE We studied associations between social support, social network size, social strain, or stressful life events and risk of coronary heart disease (CHD) in postmenopausal women with type 2 diabetes. RESEARCH DESIGN AND METHODS From the Women's Health Initiative, 5,262 postmenopausal women with type 2 diabetes at baseline were included. Cox proportional hazards regression models adjusted for demographics, depressive symptoms, anthropometric variables, and lifestyle factors were used to examine associations between social factors and CHD. RESULTS A total of 672 case subjects with CHD were observed during an average 12.79 (SD 6.29) years of follow-up. There was a significant linear trend toward higher risk of CHD as the number of stressful life events increased (Pfor trend = 0.01; hazard ratio [HR] [95% CI] for the third and fourth quartiles compared with first quartile: 1.27 [1.03-1.56] and 1.30 [1.04-1.64]). Being married or in an intimate relationship was related to decreased risk of CHD (HR 0.82 [95% CI 0.69-0.97]). CONCLUSIONS Among postmenopausal women with type 2 diabetes, higher levels of stressful life events were associated with higher risk of CHD. Experience of stressful life events might be considered as a risk factor for CHD among women with type 2 diabetes.
26.	Nilsson, Sigrid, 1997- (författare) Vasomotor Symptoms, Cardiovascular Risk and the Role of Physical Activity in Midlife Women 2023 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Background: The menopausal transition is, for most women, accompanied by hot flushes and night sweats (i.e., vasomotor symptoms, VMS). VMS has been associated with a worsened cardiovascular risk profile, but whether VMS constitutes an independent risk marker for developing subclinical atherosclerotic cardiovascular disease (ASCVD) is still uncertain. Visceral adipose tissue (VAT) contributes more to systemic low-grade inflammation than abdominal subcutaneous adipose tissue (ASAT), enhancing atherosclerosis development. Physical activity is an effective behavioral strategy to maintain and improve cardiovascular health. Whether a resistance training intervention (RTI) could reduce low-grade inflammation and VAT volume in postmenopausal women with VMS remains unclear, and whether the RTI-associated effects could be maintained over time requires further investigation.Material and Methods: This thesis is based on three studies. Study 1 was conducted on a subset of participants from the cross-sectional population-based Swedish CArdioPulmonary BioImage Study (SCAPIS), including women 50-64 years of age. The women underwent comprehensive cardiovascular assessments and completed an extensive female-specific questionnaire. VMS was assessed on a 4-point scale. Subclinical ASCVD was detected via coronary computed tomography angiography (CCTA), computed tomography (CT), and carotid ultrasound. Study 2 is a sub-study of 65 postmenopausal women with VMS and low physical activity, randomized to either three days/week of an RTI or unchanged physical activity for 15 weeks. Women underwent anthropometric measurements, magnetic resonance imaging (MRI), and blood sampling at baseline and after 15 weeks. During the last followup contact in Study 2 after two years, 35 women agreed to attend an additional clinic visit to reevaluate cardiovascular risk markers, marking the inception of Study 3.Results: Of 2995 women included in Study 1, 14.2% reported severe VMS (n = 425), 18.1% moderate VMS (n = 543), and 67.7% no or mild VMS (n = 2027). Current or previous severe VMS, but not moderate VMS, was significantly associated with CCTA-detected coronary atherosclerosis, with odds ratio (OR) before and after multivariable adjustment 1.36, 95% confidence interval (CI) 1.08 – 1.72 and 1.33, 95% CI 1.02 – 1.72, respectively. This association was only present for >5 years durations of severe VMS or when the onset of severe VMS occurred before menopause. Adjustment for menopausal hormone therapy strengthened the association for women with severe VMS >5 years (OR 1.67, 95% CI 1.16 – 2.40). Women compliant with an RTI had compared to a control group (CG), decreased adiponectin (p < 0.01), ASAT (p < 0.01), VAT (p < 0.01), total abdominal adipose tissue (TAAT) (p < 0.01) and fat ratio (p <0.001). Furthermore, an RTI reduced moderate to severe VMS frequency to six months post-intervention compared to a CG, but did neither contribute to preserved cardiovascular health markers nor improved health-related quality of life (HRQoL) after two years compared to a CG.Conclusions: There is a need for extra vigilance regarding cardiovascular risk factors in the group of women suffering from severe VMS. Implementing a 15-week RTI in these women could counteract the VAT redistribution and alter the frequency of moderate to severe VMS with maintained effects up to six months.
27.	Papageorgiou, Joanna-Maria, et al. (författare) Fulminant myocarditis in a COVID-19 positive patient treated with mechanical circulatory support : - a case report 2021 Ingår i: European Heart Journal. Case Reports. - : Oxford University Press. - 2514-2119. ; 5:2 Tidskriftsartikel (refereegranskat)abstract Background Coronavirus disease 2019 (COVID-19) spreading from Wuhan, Hubei province in China, is an expanding global pandemic with significant morbidity and mortality. Even though respiratory failure is the cardinal form of severe COVID-19, concomitant cardiac involvement is common. Myocarditis is a challenging diagnosis due to heterogeneity of clinical presentation, ranging from mild symptoms to fatal arrhythmia and cardiogenic shock (CS). The aetiology is often viral and endomyocardial biopsy (EMB) is the gold standard for definite myocarditis. However, the diagnosis is often made on medical history, clinical presentation, magnetic resonance imaging, and blood tests. Case summary We present a 43-year-old man with mixed connective tissue disease treated with hydroxychloroquine who rapidly developed CS 4 days from symptom onset with fever and cough, showing positive polymerase chain reaction nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA. While computed tomography of the thorax was normal, high-sensitivity troponin T was elevated and electrocardiogram showed diffuse ST elevation and low voltage as signs of myocardial oedema. Echocardiography showed severe depression of left ventricular function. The myocardium recovered completely after a week with mechanical circulatory support (MCS). EMB was performed but could neither identify the virus in the cardiomyocytes, nor signs of inflammation. Still the most probable aetiology of CS in this case is myocarditis as a sole symptom of COVID-19. Discussion COVID-19 patients in need of hospitalization present commonly with respiratory manifestations. We present the first case of fulminant myocarditis rapidly progressing to CS in a COVID-19 patient without respiratory failure, successfully treated with inotropes and MCS.
28.	Prytz, Erik, et al. (författare) Pilot evaluation of a persuasive mobile application to change individuals behavior during recurrent myocardial infarction 2019 Ingår i: PROCEEDINGS OF THE 31ST EUROPEAN CONFERENCE ON COGNITIVE ERGONOMICS: DESIGN FOR COGNITION (ECCE 2019). - New York, NY, USA : ASSOC COMPUTING MACHINERY. - 9781450371667 ; , s. 192-195 Konferensbidrag (refereegranskat)abstract Objective: The objective of the current study was to develop and evaluate a persuasive decision-support aiming at reducing pre hospital delay and increasing ambulance service use for patients who suffer from a recurrent myocardial infarction. Materials and methods: The system was developed as a prototype mobile application for smartphones. The system was evaluated by four end-users with previous experience of myocardial infarction. The user tests were complemented with cognitive walkthroughs and heuristic evaluation. Results: A total of 14 persuasive design principles were used to guide the design of the system. The usability was regarded as high with an average score of 82 on the System Usability Scale. The users reported that they found the system highly persuasive. Conclusions: User-centered design together with persuasive design principles through iterative testing and development has resulted in a prototype app with potential to improve patients care seeking behavior. The content in the prototype will be further evaluated before it is integrated in educational interventions.
29.	Sederholm Lawesson, Sofia, et al. (författare) A gender perspective on short- and long term mortality in ST-elevation myocardial infarction : a report from the SWEDEHEART register 2013 Ingår i: International Journal of Cardiology. - : Elsevier Ireland Ltd. - 0167-5273 .- 1874-1754. ; 18:2, s. 1041-1047 Tidskriftsartikel (refereegranskat)abstract Background: Previous studies of patients admitted for ST-elevation myocardial infarction [STEMI] have indicated that women have a higher risk of early mortality than do men. These studies have presented limited information on gender related differences in the short term and almost no information on the long term. Methods and results: We analysed a prospective, consecutively included STEMI population consisting of 54,146 patients (35% women). This population consists of almost all patients hospitalised in Sweden between January 1, 1995 and December 31, 2006 as recorded in the SWEDEHEART register (formerly RIKS-HIA). Follow-up time ranged from one to 13 years (mean 4.6). Women had a lower probability of being given reperfusion therapy, odds ratio [OR] 0.83 (95% confidence interval [CI] 0.79-0.88). During the time these STEMI patients were in the hospital, 13% of the women and 7% of men died, multivariable adjusted OR 1.21 (95% CI 1.11-1.32). During the follow up period, 46% of the women died as compared with 32% of the men. There was, however, no gender difference in age-adjusted risk of long term mortality (hazard ratio [HR] 0.98, 95% CI 0.95-1.01) whereas the multivariable adjusted risk was lower in women (HR 0.92, 95% CI 0.89-0.96). The long term risk of re-infarction was the same in men and women (HR 0.98, 95% CI 0.93-1.03) whereas men in the youngest group had a higher risk than women in that age group (HR 0.82, 95% CI 0.72-0.94). Conclusion: In STEMI, women had a higher risk of in-hospital mortality but the long-term risk of death was higher in men. More studies are needed in the primary percutaneous coronary intervention (pPCI) era that are designed to determine why women fare worse than men after STEMI during the first phase when they are in hospital
30.	Sederholm Lawesson, Sofia, 1973-, et al. (författare) Adherence to Study Drugs A Matter of Sex? 2021 Ingår i: Circulation. - : LIPPINCOTT WILLIAMS & WILKINS. - 0009-7322 .- 1524-4539. ; 143:7, s. 696-698 Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract n/a
31.	Sederholm Lawesson, Sofia, 1973-, et al. (författare) Association Between History of Adverse Pregnancy Outcomes and Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography. 2023 Ingår i: JAMA. - : American Medical Association (AMA). - 1538-3598 .- 0098-7484. ; 329:5, s. 393-404 Tidskriftsartikel (refereegranskat)abstract Adverse pregnancy outcomes are recognized risk enhancers for cardiovascular disease, but the prevalence of subclinical coronary atherosclerosis after these conditions is unknown.To assess associations between history of adverse pregnancy outcomes and coronary artery disease assessed by coronary computed tomography angiography screening.Cross-sectional study of a population-based cohort of women in Sweden (n=10528) with 1 or more deliveries in 1973 or later, ascertained via the Swedish National Medical Birth Register, who subsequently participated in the Swedish Cardiopulmonary Bioimage Study at age 50 to 65 (median, 57.3) years in 2013-2018. Delivery data were prospectively collected.Adverse pregnancy outcomes, including preeclampsia, gestational hypertension, preterm delivery, small-for-gestational-age infant, and gestational diabetes. The reference category included women with no history of these exposures.Coronary computed tomography angiography indexes, including any coronary atherosclerosis, significant stenosis, noncalcified plaque, segment involvement score of 4 or greater, and coronary artery calcium score greater than 100.A median 29.6 (IQR, 25.0-34.9) years after first registered delivery, 18.9% of women had a history of adverse pregnancy outcomes, with specific pregnancy histories ranging from 1.4% (gestational diabetes) to 9.5% (preterm delivery). The prevalence of any coronary atherosclerosis in women with a history of any adverse pregnancy outcome was 32.1% (95% CI, 30.0%-34.2%), which was significantly higher (prevalence difference, 3.8% [95% CI, 1.6%-6.1%]; prevalence ratio, 1.14 [95% CI, 1.06-1.22]) compared with reference women. History of gestational hypertension and preeclampsia were both significantly associated with higher and similar prevalence of all outcome indexes. For preeclampsia, the highest prevalence difference was observed for any coronary atherosclerosis (prevalence difference, 8.0% [95% CI, 3.7%-12.3%]; prevalence ratio, 1.28 [95% CI, 1.14-1.45]), and the highest prevalence ratio was observed for significant stenosis (prevalence difference, 3.1% [95% CI, 1.1%-5.1%]; prevalence ratio, 2.46 [95% CI, 1.65-3.67]). In adjusted models, odds ratios for preeclampsia ranged from 1.31 (95% CI, 1.07-1.61) for any coronary atherosclerosis to 2.21 (95% CI, 1.42-3.44) for significant stenosis. Similar associations were observed for history of preeclampsia or gestational hypertension among women with low predicted cardiovascular risk.Among Swedish women undergoing coronary computed tomography angiography screening, there was a statistically significant association between history of adverse pregnancy outcomes and image-identified coronary artery disease, including among women estimated to be at low cardiovascular disease risk. Further research is needed to understand the clinical importance of these associations.
32.	Sederholm Lawesson, Sofia, et al. (författare) Gender differences in first medical contact and pre-hospital delay times in ST-elevation myocardial infarction - a prospective multicenter report from the SymTime study group. 2016 Konferensbidrag (övrigt vetenskapligt/konstnärligt)
33.	Sederholm Lawesson, Sofia, 1973-, et al. (författare) Gender differences in symptom presentation of ST-elevation myocardial infarction : an observational multicenter survey study 2018 Ingår i: International Journal of Cardiology. - : Elsevier. - 0167-5273 .- 1874-1754. ; 264, s. 7-11 Tidskriftsartikel (refereegranskat)abstract BACKGROUND: Symptom presentation has been sparsely studied from a gender perspective restricting the inclusion to ST elevation myocardial infarction (STEMI) patients. Correct symptom recognition is vital in order to promptly seek care in STEMI where fast reperfusion therapy is of utmost importance. Female gender has been found associated with atypical presentation in studies on mixed MI populations but it is unclear whether this is valid also in STEMI.OBJECTIVES: We assessed whether there are gender differences in symptoms and interpretation of these in STEMI, and if this is attributable to sociodemographic and clinical factors.METHODS: SymTime was a multicenter observational study including a validated questionnaire and data from medical records. Eligible STEMI patients (n = 532) were enrolled within 24 h after admittance at five Swedish hospitals.RESULTS: Women were older, more often single and had lower educational level. Chest pain was less prevalent in women (74 vs 93%, p < 0.001), whereas shoulder (33 vs 15%, p < 0.001), throat/neck (34 vs 18%, p < 0.001), back pain (29 versus 12%, p < 0.001) and nausea (49 vs 29%, p < 0.001) were more prevalent. Women less often interpreted their symptoms as of cardiac origin (60 vs 69%, p = 0.04). Female gender was the strongest independent predictor of non-chest pain presentation, odds ratio 5.29, 95% confidence interval 2.85-9.80.CONCLUSIONS: A striking gender difference in STEMI symptoms was found. As women significantly misinterpreted their symptoms more often, it is vital when informing about MI to the society or to high risk individuals, to highlight also other symptoms than just chest pain.
34.	Sederholm Lawesson, Sofia, 1973-, et al. (författare) Gender disparities in first medical contact and delay in ST-elevation myocardial infarction : a prospective multicentre Swedish survey study 2018 Ingår i: BMJ Open. - : BMJ. - 2044-6055. ; 8:5 Tidskriftsartikel (refereegranskat)abstract OBJECTIVES: Compare gender disparities in ST-elevation myocardial infarction (STEMI) regarding first medical contact (FMC) and prehospital delay times and explore factors associated with prehospital delay in men and women separately.DESIGN: Cross-sectional study based on medical records and a validated questionnaire. Eligible patients were enrolled within 24 hours after admittance to hospital.SETTING: Patients were included from November 2012 to January 2014 from five Swedish hospitals with catheterisation facilities 24/7.PARTICIPANTS: 340 men and 109 women aged between 31 and 95 years completed the survey.MAIN OUTCOME MEASURES: FMC were divided into five possible contacts: primary healthcare centre by phone or directly, national advisory nurse by phone, emergency medical services (EMS) and emergency room directly. Two parts of prehospital delay times were studied: time from symptom onset to FMC and time from symptom onset to diagnostic ECG.RESULTS: Women more often called an advisory nurse as FMC (28% vs 18%, p=0.02). They had a longer delay until FMC, 90 (IQR 39-221) vs 66 (28-161) min, p=0.04 and until ECG, 146 (68-316) vs 103 (61-221) min, p=0.03. Men went to hospital because of believing they were stricken by an MI to a higher extent than women did (25% vs 15%, p=0.04) and were more often recommended to call EMS by bystanders (38% vs 22%, p<0.01). Hesitating about going to hospital and experiencing pain in the stomach/back/shoulders were factors associated with longer delays in women. Believing the symptoms would disappear or interpreting them as nothing serious were corresponding factors in men. In both genders bystanders acting by contacting EMS explained shorter prehospital delays.CONCLUSIONS: In STEMI, women differed from men in FMC and they had longer delays. This was partly due to atypical symptoms and a longer decision time. Bystanders acted more promptly when men than when women fell ill. Public knowledge of MI symptoms, and how to act properly, still seems insufficient.
35.	Sederholm Lawesson, Sofia (författare) Management and Outcome in ST-Elevation Myocardial Infarction from a Gender Perspective 2012 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract The aim of this thesis was to evaluate baseline characteristics, management and outcome in real life ST-elevation myocardial infarction [STEMI] cohorts from a gender perspective. We aimed to evaluate the total STEMI population as well as certain subgroups, such as the youngest. Moreover we aimed to analyse gender differences in renal function, and the prognostic impact of reduced renal function in men and women with STEMI.In Paper I all STEMI patients registered in RIKS-HIA between 1st Jan 1995 and 31st Dec 2006 were included, in total 54 146 patients, 35% women. Women were 7 years older than men, with 30 min longer median symptomto-door time. They had higher prevalence of co-morbidities such as diabetes, hypertension and heart failure whereas men were more often smokers, had a previous myocardial infarction [MI] or were previously revascularised. During hospital care, fewer women than men, 63% vs. 72%, p<0.001, received acute reperfusion therapy, odds ratio [OR] 0.83 (95% confidence interval [CI] 0.79 – 0.88) after multivariable adjustment. Inhospital mortality was 13% vs. 7%, women vs. men, p<0.001. After multivariable adjustments women had 22% higher risk of in-hospital death, OR 1.22 (95% CI 1.11 – 1.33). Adding reperfusion therapy to the adjustment model did not change the odds of death, OR 1.21 (1.11 – 1.32). Stratifying the cohort into four age-groups revealed increased mortality with increasing age as well as higher mortality in women than in men in all groups. The multivariable adjusted risk in women relative to men was highest amongst the youngest, OR 1.45 (95% CI 0.98 – 2.14). The long term prognosis was assessed in women vs. men with Cox proportional regression analyses, follow-up time 1 to 13 years. Women had 8% lower risk of long term mortality after multivariable adjustments, and after age-stratifying, women had better long term survival in all age-groups, except the youngest.Previous studies based on mixed MI cohorts had found a gender-age interaction with higher risk of death women relative to men in the youngest group. In Paper II we included all STEMI patients <46 years old registered in RIKS-HIA between 1st Jan 1995 and 31st Dec 2006, 1748 men and 384 women. Cardiovascular risk factors were common, and women had more often clustering of risk factors compared to men. The most prevalent risk factor was smoking, 64% of the women compared to 58% of the men were current smokers. There was no gender difference in delay times or in rate of reperfusion. Almost 60% of both women and men underwent coronary angiography within one week. There was no gender difference in prevalence of non-obstructive disease, (p=0.64), but men had had multi-vessel/left main disease much more often than women (33.6% vs. 19.2%; p<0.001). In-hospital mortality was low, 3% in women vs. 1% in men, crude OR women vs. men 2.83 (95% CI 1.32 – 6.03). Female gender appeared as an independent predictor in the multivariable model of in-hospital mortality, OR 2.85 (95% CI 1.31– 6.19). When the cohort was followed up to 10 years (mean 5.4 years) the risk of mortality was not higher in women (hazard ratio [HR] 0.93, 95% CI 0.60 – 1.45; p=0.75), and men had significantly higher risk of a second new MI during the following 10 years, HR 1.82 (95% CI 1.25 – 2.65; p=0.002).In the beginning of the 21st century there was a shift in reperfusion strategy with a decline in use of fibrinolytic therapy and an increase in use of primary PCI. We hypothesised that the gender differences noticed during the fibrinolytic era with lower chance of receiving reperfusion therapy and higher risk of early mortality in women, would have diminished during the new primary PCI era, as this is a better reperfusion strategy, especially for women. In Paper III we included STEMI patients from two time periods with different dominating reperfusion strategies in order to compare management and outcome between genders in both periods. Patients in the early period (n=15 697, 35% women) were registered in RIKS-HIA between 1st Jan 1998 and 31st Dec 2000 and those in the late period (n=14 380, 35% women) between 1st Jan 2004 and 31st Dec 2006. Among patients treated with reperfusion therapy 9% in the early compared to 68% in the late period were treated with primary PCI. The use of reperfusion therapy increased between the two periods, in men from 70.9% to 75.3%, in women from 63.1% to 63.6%. After multivariable adjustment, women were 14% and 20% less likely than men to receive reperfusion therapy, early and late periods, respectively. Heart failure, cardiogenic chock and major bleedings were more common in women compared to men. Evidence-based secondary preventive therapies were prescribed more often in the late compared to the early period in both genders, but more seldom to women in both periods. After multivariable adjustments women still had less chance of receiving ACE-inhibitors/ARBs but higher chance of receiving statins in the early period. In the late period women had 14 – 25% less chance of receiving any of the evidence-based secondary preventive therapies.In Paper IV all consecutive patients who fulfilled the criteria for ST-elevation or bundle branch block on admission ECG and who were planned to undergo immediate coronary angiography with the intention to perform primary PCI at the Department of Cardiology in Linköping were included, 98 women and 176 men. Estimated glomerular filtration rate [eGFR] according to Modification of Diet in Renal Disease study [MDRD] was calculated for all patients and they were staged into CKD stages 1-5. Estimated GFR was lower in women than in men, mean eGFR 54 vs. 68 mL/min/1.73m2, p<0.001. Ten men but no woman were classified belonging to the best CKD stage 1(eGFR >90 mL/min/1.73m2). In total 67% of women compared to 27% of men were classified as having renal insufficiency [RI] (eGFR <60 mL/min/1.73m2) and female sex was a strong independent factor associated with RI, OR 5.06 (95% CI 2.66 – 9.59). Reduced eGFR per 10 mL/min decline was independently associated to higher risk of death and MACE (death, new MI or stroke) within one year in women whereas we found no such associations in men. There was a borderline significant interaction between gender and eGFR regarding one year mortality (p=0.08) but not regarding MACE (p=0.11).As we found a remarkable gender difference in RI prevalence in Paper IV, we analysed an updated SWEDEHEART database including the years since S-creatinine became a mandatory variable to register. In Paper V all STEMI patients registered between 1st of Jan 2003 and 31st of Dec 2009 were included, in total 37 991 patients (36% women). RI was present in 38% in women vs. 19% in men according to MDRD and in 50% of men vs. 22% of men according to Cockcroft Gault [CG] (p<0.001 for both comparisons). Female gender was independently associated with RI regardless of used formula. In both genders, RI patients were older, had higher co-morbidity, suffered from more complications and had lower chance of receiving reperfusion therapy and evidence-based therapy at discharge compared to non RI patients. Among both RI and non RI patients, men had significantly higher chance than women of getting these therapies. In-hospital mortality was four to five times higher in RI vs. non RI patients. RI compared to non RI patients had approximately doubled risk of inhospital mortality in women and 2.5 times higher risk in men after multivariable adjustment. Regardless of used formula, the risk of dying at hospital increased with approximately 30% and the risk of long term mortality with approximately 10% in both genders per 10 mL/min decline of eGFR. There was no significant interaction between gender and eGFR regarding short- or long term outcome according to any of the formulas. Women had twice as high in-hospital and also higher cumulative long term mortality than men. After multivariable adjustments including all confounders except kidney function women had 7% lower risk of long term mortality but still 11% higher risk of in-hospital mortality. If eGFR according to any of the formulas was also included, there was no longer a gender difference regarding in-hospital mortality and women had lower risk of long term mortality. This was also the case if only adjusting for eGFR according to CG.Conclusion: In the real life STEMI setting, women were older with higher co-morbidity, longer delay, more complications and twice as high in-hospital mortality. They had significantly less chance of receiving acute reperfusion therapy, also after adjusting for possible confounders. During the fibrinolytic era women had higher risk of severe bleedings. We hypothesised that the gap in management would have decreased during the new primary PCI era, with a less time-dependent regime with less risk of fatal complications. Our hypothesis failed, and future studies ought to further scrutinise this gender difference in management. The less chance of reperfusion therapy did anyhow not explain the higher in-hospital mortality in women, which was 10-20% higher after multivariable adjustments, consistent with previous findings. Moderate to severe chronic kidney disease was very common in women with STEMI, 50% according to the Cockcroft Gault formula. Estimated GFR has seldom been taken into account in studies evaluating gender differences in outcome. If adjustment for eGFR was done, alone or added to the all other co-variates, women had no longer higher risk of in-hospital mortality. Adjusted long term outcome was better in women than in men, which was also the case in the youngest cohort when studied separately.
36.	Sederholm Lawesson, Sofia, et al. (författare) Prevalence and prognostic impact of chronic kidney disease in STEMI from a gender perspective : data from the SWEDEHEART register, a large Swedish prospective cohort. 2015 Ingår i: BMJ Open. - : BMJ. - 2044-6055. ; 5:6, s. e008188- Tidskriftsartikel (refereegranskat)abstract OBJECTIVES: Gender differences in prevalence and prognostic impact of chronic kidney disease (CKD) in ST segment elevation myocardial infarction (STEMI) have been poorly evaluated. In STEMI, female gender has been independently associated with an increased risk of mortality. CKD has been found to be an important prognostic marker in myocardial infarction. The aim of this study was to evaluate gender differences in prevalence and prognostic impact of CKD on short-term and long-term mortality.DESIGN: Prospective observational cohort study.SETTING: The national quality register SWEDEHEART was used. In the beginning of the study period, 94% of the Swedish coronary care units contributed data to the register, which subsequently increased to 100%. The glomerular filtration rate was estimated (eGFR) according to Modification of Diet in Renal Disease Study (MDRD) and Cockcroft-Gault (CG).PARTICIPANTS: All patients with STEMI registered in SWEDEHEART from the years 2003-2009 were included (37,991 patients, 66% men).MAIN RESULTS: Women had 1.6 (MDRD) to 2.2 (CG) times higher multivariable adjusted risk of CKD. Half of the women had CKD according to CG. CKD was associated with 2-2.5 times higher risk of in-hospital mortality and approximately 1.5 times higher risk of long-term mortality in both genders. Each 10 mL/min decline of eGFR was associated with an increased risk of in-hospital and long-term mortality (22-33% and 9-16%, respectively) and this did not vary significantly by gender. Both in-hospital and long-term mortality were doubled in women. After multivariable adjustment including eGFR, there was no longer any gender difference in early outcome and the long-term outcome was better in women.CONCLUSIONS: Among patients with STEMI, female gender was independently associated with CKD. Reduced eGFR was a strong independent risk factor for short-term and long-term mortality without a significant gender difference in prognostic impact and seems to be an important reason why women have higher mortality than men with STEMI.
37.	Sederholm Lawesson, Sofia, et al. (författare) Prevalence and prognostic impact of renal insufficiency in STEMI from a gender perspective : data from a large prospective cohort Annan publikation (övrigt vetenskapligt/konstnärligt)abstract Background: Data indicate that female gender may be associated with increased risk of RI in MI but also that presence of RI has higher prognostic impact in women. In case of ST-elevation MI [STEMI], women have higher adjusted mortality compared to men but RI has seldom been taken into account. Methods and Results: All STEMI patients registered in the Swedish national quality register SWEDEHEART between 2003 and 2009 were included (37991 patients, 66% men). Based on s-creatinine on admission, glomerular filtration rate [GFR] was estimated according to MDRD and Cockcroft-Gault [CG]. RI was defined as eGFR below 60 mL/min. Women had 1.6-2.2 times higher multivariable adjusted risk of RI and half of all women had RI according to CG. RI was associated with 2-2.5 times higher risk of in-hospital and approximately 1.5 times higher risk of long-term mortality in both genders. Each 10 mL/min decline of eGFR was associated with 22-33% and 9-16% increased risk of in-hospital and. long-term mortality, respectively. There was no significant interaction between gender and eGFR regarding outcome. Both in-hospital and long-term mortality was twice as high in women but after adjusting for eGFR according to CG, there was no longer any gender difference in early outcome and long term outcome was better in women. Conclusions: Among STEMI patients 1) Female sex was independently associated with RI 2) Reduced eGFR regardless of used formula was a strong independent risk factor for mortality without a significant gender difference in prognostic impact. 3) Reduced eGFR (according to CG) appeared to be a main explanatory variable to the higher mortality in women.
38.	Sederholm Lawesson, Sofia, et al. (författare) Symptoms and pre-hospital delay times in relation to infarct related artery in ST-elevation myocardial infarction patients - a survey report from the SymTime study group. 2016 Konferensbidrag (övrigt vetenskapligt/konstnärligt)
39.	Sederholm Lawesson, Sofia, et al. (författare) Time trends in STEMI—improved treatment and outcome but still a gender gap : a prospective observational cohort study from the SWEDEHEART register 2012 Ingår i: BMJ Open. - : BMJ. - 2044-6055. ; 2:2 Tidskriftsartikel (refereegranskat)abstract Objective In ST elevation myocardial infarction women received less evidence-based medicine and had worse outcome during the fibrinolytic era. With the shift to primary percutaneous coronary intervention (pPCI) as preferred reperfusion strategy, the authors aimed to investigate whether these gender differences has diminished.Design, setting and participants Cohort study including consecutive ST elevation myocardial infarction patients registered 1998–2000 (n=15 697) and 2004–2006 (n=14 380) in the Register of Information and Knowledge about Swedish Heart Intensive care Admissions.Outcome measures 1. Use of evidence-based medicine such as reperfusion therapy (pPCI or fibrinolysis) and evidence-based drugs at discharge. 2. Inhospital and 1-year mortality.Results Of those who got reperfusion therapy, pPCI was the choice in 9% in the early period compared with 68% in the late period. In the early period, reperfusion therapy was given to 63% of women versus 71% of men, p<0.001. Corresponding figures in the late period were 64% vs 75%, p<0.001. After multivariable adjustments, the ORs (women vs men) were 0.86 (95% CI 0.78 to 0.94) in the early and 0.80 (95% CI 0.73 to 0.89) in the late period. As regards evidence-based secondary preventive drugs at discharge in hospital survivors (platelet inhibitors, statins, ACE inhibitors/angiotensin receptor blockers and β-blockers), there were small gender differences in the early period. In the late period, women had 14%–25% less chance of receiving these drugs, OR 0.75 (95% CI 0.68 to 0.81) through 0.86 (95% CI 0.73 to 1.00). In both periods, multivariable-adjusted inhospital mortality was higher in women, OR 1.18 (95% CI 1.02 to 1.36) and 1.21 (1.00 to 1.46). One-year mortality was gender equal, HR 0.95 (95% CI 0.87 to 1.05) and 0.96 (0.86 to 1.08), after adding evidence-based medicine to the multivariable adjustments.Conclusion In spite of an intense gender debate, focus on guideline adherence and the change in reperfusion strategy, the last decade gender differences in use of reperfusion therapy and evidence-based therapy at discharge did not decline during the study period, rather the opposite. Moreover, higher mortality in women persisted.
40.	Skibniewski, Mikolaj, et al. (författare) Long-term antithrombotic therapy after coronary artery bypass grafting in patients with preoperative atrial fibrillation. A nationwide observational study from the SWEDEHEART registry 2023 Ingår i: American Heart Journal. - : Elsevier BV. - 0002-8703 .- 1097-6744. ; 257, s. 69-77 Tidskriftsartikel (refereegranskat)abstract Aims To provide data guiding long-term antithrombotic therapy after coronar y arter y by-pass grafting (CABG) in patients with preoperative atrial fibrillation (AF). Methods and results From the SWEDEHEART registry, we included all patients, between January 2006 and September 2016, with preoperative AF and CHA2DS2-VASC score >2, undergoing CABG. Based on dispensed prescriptions 12 to 18 months after CABG, patients were divided in 3 groups: use of platelet inhibitors (PI) only, oral anticoagulant (OAC) only or a combination of OAC + PI. Outcomes were: Major adverse cardiac and cerebrovascular events (MACCE, [all-cause death, myocardial infarction, or stroke]), net adverse clinical events (NACE, [MACCE or bleeding]) and the individual components of NACE. Inverse probability of treatment weighting was used to adjust for the non-randomized study design. Among 2,564 patients, 1,040 (41%) were treated with PI alone, 1,064 (41%) with OAC alone, and 460 (18%) with PI + OAC. Treatment with PI alone was associated with higher risk for MACCE (adjusted HR 1.43, 95% CI 1.09-1.88), driven by higher risk for stroke and MI, compared with OAC alone. Treatment with PI + OAC, was associated with higher risk for NACE (adjusted HR 1.40, 95% CI 1.06-1.85), driven by higher risk for bleeds, compared with OAC alone. Conclusion In this real-world observational study, a high proportion of patients with AF, undergoing CABG, did not receive a long-term OAC therapy. Treatment with OAC alone was associated with a net clinical benefit, compared with PI alone or PI + OAC. (Am Heart J 2023;257:69-77.)
41.	Träff, Erik, et al. (författare) Real-world data on potent P2Y12-inhibition in patients with suspected chronic coronary syndrome, referred for coronary angiography 2022 Ingår i: Cardiology. - : Karger. - 0008-6312 .- 1421-9751. ; 147:5-6, s. 486-496 Tidskriftsartikel (refereegranskat)abstract IntroductionPotential benefit with potent platelet inhibition in patients with chronic coronary syndrome (CCS), undergoing percutaneous coronary intervention (PCI) has been discussed. The aim of this study was to compare a potent P2Y12 inhibition strategy using ticagrelor with clopidogrel, in CCS patients referred for coronary angiography (CA) and PCI if feasible. MethodsIn this retrospective real-world study, patients referred for outpatient CA due to suspected CCS were included. To adjust for group differences, a propensity score reflecting the probability of being treated with ticagrelor was calculated and added to the logistic regression outcome model.Results In total 1 003 patients were included in the primary analysis (577 treated with clopidogrel and 426 with ticagrelor). Among clopidogrel treated patients 132 (22.9%) experienced a bleeding complication compared with 93 (21.8%) among ticagrelor treated patients, with no significant difference between the groups (p=0.70). There was no difference in bleeding severity. Furthermore, we observed no statistically significant difference in major adverse cardiovascular event (MACE [death, stent thrombosis, myocardial infarction or stroke]), (1.2% vs 2.3%, p=0.17). A subgroup analysis restricted to patients undergoing PCI ad hoc displayed a similar pattern. Also patients undergoing CA without PCI ad hoc frequently experienced a bleeding complication, with no difference between the two treatments (21.0 % vs 17.3%, p=0.27). Propensity score adjusted analyses confirmed the results. Discussion/ConclusionIn patients with CCS referred for CA and PCI if feasible, a more potent P2Y12 inhibition strategy with ticagrelor was not associated with bleeding complications or MACE compared with clopidogrel.
42.	Tödt, Tim, et al. (författare) Early treatment with abciximab in patients with ST elevation myocardial infarction results in a high rate of normal or near normal blood flow in the infarct related artery 2010 Ingår i: Acute cardiac care. - : Informa UK Limited. - 1748-295X .- 1748-2941. ; 12:1, s. 10-17 Tidskriftsartikel (refereegranskat)abstract There is debate whether early treatment with GpIIb/IIIa inhibitors is of clinical benefit in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). This study explored the effects of early given abciximab on coronary blood flow and major adverse cardiac events (MACE) in patients with STEMI treated with primary PCI and adjunctive abciximab. We studied all consecutive patients from our catchment area with STEMI undergoing acute angiography with the intention of primary PCI during 2005. Abciximab was given as early pre-treatment before, (n = 133) or at the cath. lab. after a diagnostic angiography (n = 109). Pre-procedural TIMI 2-3 flow was observed in 45.9 % of patients in the early group versus 20.2 % in the cath. lab. group, P = 0.0001. Mortality rates were 3.8 % versus 3.7% inhospital and 8.3 % versus 7.3% at one year in the early respectively the cath. lab. group, both P = NS. The MACE rate (death, non fatal myocardial infarction, unplanned revascularization) at one year was 19.5 % (early group) and 26.6 % (cath. lab. group), P = 0.19. CONCLUSION: In this single centre registry study of unselected patients with STEMI early given abciximab was associated with a significantly higher rate of TIMI 2-3 flow compared to abciximab given after the acute angiography.
43.	Venetsanos, Dimitrios, et al. (författare) Association between gender and short-term outcome in patients with ST elevation myocardial infraction participating in the international, prospective, randomised Administration of Ticagrelor in the catheterisation Laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery (ATLANTIC) trial: a prespecified analysis 2017 Ingår i: BMJ Open. - : BMJ PUBLISHING GROUP. - 2044-6055. ; 7:9 Tidskriftsartikel (refereegranskat)abstract Objectives To evaluate gender differences in outcomes in patents with ST-segment elevation myocardial infarction (STEMI) planned for primary percutaneous coronary intervention (PPCI). Settings A prespecified gender analysis of the multicentre, randomised, double-blind Administration of Ticagrelor in the catheterisation Laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery. Participants Between September 2011 and October 2013, 1862 patients with STEMI and symptom duration amp;lt;6 hours were included. Interventions Patients were assigned to prehospital versus in-hospital administration of 180 mg ticagrelor. Outcomes The main objective was to study the association between gender and primary and secondary outcomes of the main study with a focus on the clinical efficacy and safety outcomes. Primary outcome: the proportion of patients who did not have 70% resolution of ST-segment elevation and did not meet the criteria for Thrombolysis In Myocardial Infarction (TIMI) flow 3 at initial angiography. Secondary outcome: the composite of death, MI, stent thrombosis, stroke or urgent revascularisation and major or minor bleeding at 30 days. Results Women were older, had higher TIMI risk score, longer prehospital delays and better TIMI flow in the infarct-related artery. Women had a threefold higher risk for all-cause mortality compared with men (5.7% vs 1.9%, HR 3.13, 95% CI 1.78 to 5.51). After adjustment, the difference was attenuated but remained statistically significant (HR 2.08, 95% CI 1.03 to 4.20). The incidence of major bleeding events was twofold to threefold higher in women compared with men. In the multivariable model, female gender was not an independent predictor of bleeding (Platelet Inhibition and Patient Outcomes major HR 1.45, 95% CI 0.73 to 2.86, TIMI major HR 1.28, 95% CI 0.47 to 3.48, Bleeding Academic Research Consortium type 3-5 HR 1.45, 95% CI 0.72 to 2.91). There was no interaction between gender and efficacy or safety of randomised treatment. Conclusion In patients with STEMI planned for PPCI and treated with modern antiplatelet therapy, female gender was an independent predictor of short-term mortality. In contrast, the higher incidence of bleeding complications in women could mainly be explained by older age and clustering of comorbidities.
44.	Venetsanos, Dimitrios, et al. (författare) Bivalirudin versus heparin with primary percutaneous coronary intervention 2018 Ingår i: American Heart Journal. - Philadelphia, United States : Mosby, Inc.. - 0002-8703 .- 1097-6744. ; 201, s. 9-16 Tidskriftsartikel (refereegranskat)abstract Background: Optimal adjunctive therapy in ST-segment elevation myocardial infarction (STEMI) patients treated with primary PCI (PPCI) remains a matter of debate. Our aim was to compare the efficacy and safety of bivalirudin to unfractionated heparin (UFH), with or without glycoprotein IIb/IIIa inhibitors (GPI) in a large real-world population, using data from the Swedish national registry, SWEDEHEART. Method: From 2008 to 2014 we identified 23,800 STEMI patients presenting within 12 hours from symptom onset treated with PPCI and UFH +/- GPI or bivalirudin +/- GPI. Primary outcomes included 30-day all-cause mortality and major in-hospital bleeding. Multivariable regression models and propensity score modelling were utilized to study adjusted association between treatment and outcome. Results: Treatment with UFH +/- GPI was associated with similar risk of 30-day mortality compared to bivalirudin +/- GPI (5.3% vs 5.5%, adjusted HR 0.94; 95% CI 0.82-1.07). The adjusted risk for 1-year mortality, 30-day and 1-year stent thrombosis and re-infarction did not differ significantly between UFH +/- GPI and bivalirudin +/- GPI. In contrast, treatment with UFH +/- GPI was associated with a significant higher risk of major in-hospital bleeding (adjusted OR 1.62; 95% CI 1.30-2.03). When including GPI use in the multivariable analysis, the difference was attenuated and no longer significant (adjusted OR 1.25; 95% CI 0.92-1.70). Conclusion: Bivalirudin +/- GPI was associated with significantly lower risk for major in hospital bleeding but no significant difference in 30-day or one year mortality, stent thrombosis or re-infarction compared with UFH +/- GPI. The bleeding reduction associated with bivalirudin could be explained by the greater GPI use with UFH. (C) 2018 Elsevier Inc. All rights reserved.
45.	Venetsanos, Dimitrios, et al. (författare) Chewed ticagrelor tablets provide faster platelet inhibition compared to integral tablets : The inhibition of platelet aggregation after administration of three different ticagrelor formulations (IPAAD-Tica) study, a randomised controlled trial. 2017 Ingår i: Thrombosis Research. - : Elsevier BV. - 0049-3848 .- 1879-2472. ; 149, s. 88-94 Tidskriftsartikel (refereegranskat)abstract AIMS: To provide pharmacodynamic data of crushed and chewed ticagrelor tablets, in comparison with standard integral tablets.METHODS: Ninety nine patients with stable angina were randomly assigned, in a 3:1:1 fashion, to one of the following 180mg ticagrelor loading dose (LD) formulations: A) Integral B) Crushed or C) Chewed tablets. Platelet reactivity (PR) was assessed with VerifyNow before, 20 and 60min after LD. High residual platelet reactivity (HRPR) was defined as >208 P2Y12 reaction units (PRU).RESULTS: There was no significant difference in PRU values at baseline. PRU 20min after LD were 237 (182-295), 112 (53-238) and 84 (29-129) and 60min after LD, 56 (15-150), 51 (18-85) and 9 (7-34) in integral, crushed and chewed ticagrelor LD, respectively (p<0.01 for both). Chewed ticagrelor tablets resulted in significantly lower PRU values compared to crushed or integral tablets at 20 and 60min. Crushed ticagrelor LD resulted in significantly lower PRU values compared to integral tablets at 20min whereas no difference was observed at 60min. At 20min, no patients had HRPR with chewed ticagrelor compared to 68% with integral and 30% with crushed ticagrelor LD (p<0.01).CONCLUSION: With crushed or chewed ticagrelor tablets a more rapid platelet inhibition may be achieved, compared to standard integral tablets. We also show that administration of chewed tablets is feasible and provides faster inhibition than either crushed or integral tablets.CLINICAL TRIAL REGISTRATION: European Clinical Trial Database (EudraCT number 2014-002227-96).
46.	Venetsanos, Dimitrios (författare) Improving management of STEMI patients treated with primary PCI : Pharmacotherapy, renal function estimation and gender perspective 2017 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract This thesis focused on the acute management of patients with ST-segment elevation myocardial infarction (STEMI) in an effort to provide information that may improve outcome. The aim was to evaluate the efficacy and safety of bivalirudin versus unfractionated heparin (UFH) in STEMI patients during primary PCI. Furthermore, to provide pharmacodynamic data of novel ways of ticagrelor administration compared to standard tivcagrelor. Additionally, to identify subgroups of patients, such as women who may derive greater benefit from specific antithrombotic strategies due to their risk/benefit profile. Finally, to evaluate current formulas for estimation of renal function in the acute phase of STEMI.In Paper I, all STEMI patients in Sweden between 2008 and 2014, treated with primary PCI and UFH or bivalirudin were included in our analysis. Of the total population of 23 800 patients, 8 783 (36.9%) were included in the UFH group and 15 017 (63.1%) in the bivalirudin group. Concomitant GPI administration was 68.5% in the UFH arm compared to 3.5% in the bivalirudin arm (p<0.01).The adjusted incidence of 30-day mortality was not significant different between the two groups (UFH vs bivalirudin, adjusted HR 0.94; 95% CI 0.82 -1.07). The adjusted risk for 1-year mortality, 30-day and 1-year stent thrombosis and re-infarction did not differ significantly between the two groups. In contrast, patients treated with UFH had a significantly higher incidence of major in-hospital bleeding (adjusted OR 1.62; 95%CI 1.30 -2.03).In Paper II pharmacodynamic data of chewed or crushed ticagrelor compared to standard ticagrelor loading dose (LD) was assessed in 99 patients with stable angina. Platelet reactivity (PR) was assessed with VerifyNow before, 20 and 60 minutes after LD. High Residual platelet reactivity (HRPR) was defined as > 208 P2Y12 reaction units (PRU). Chewed ticagrelor tablets resulted in significantly lower PRU values compared to crushed or integral tablets at 20 and 60 minutes. Crushed ticagrelor LD resulted in significantly lower PRU values compared to integral tablets at 20 minutes whereas no difference was observed at 60 minutes. At 20 minutes, no patients had HRPR with chewed ticagrelor compared to 68% with integral and 30% with crushed ticagrelor LD (p<0.01).In Paper III we presented a pre-specified gender analysis of the ATLANTIC trial including 1 862 STEMI patients that were randomly assigned to pre-hospital versus in-hospital administration of 180mg ticagrelor. Women were older and had higher TIMI risk score. Women had a 3-fold higher risk for all-cause mortality compared to men (5.7% vs 1.9%, HR 3.13, 95% CI 1.78 – 5.51). However, after adjustment for baseline characteristics, the difference was lesser and no longer significant (HR 1.98, 95% CI 0.97 – 4.04). Female gender was not an independent predictor of risk for bleeding after multivariable adjustments (BARC type 3-5 HR 1.52, 95% CI 0.74-3.09). There was no interaction between gender and efficacy or safety of randomised treatment.In Paper IV, forty patients with PCI- treated STEMI were included between November 2011 and February 2013. We validated the performance of the Cockcroft-Gault (CG), the Modification of Diet in Renal Disease (MDRD-IDMS), the Chronic Kidney Disease Epidemiology (CKD-EPI) and the Grubb relative cystatin C (rGCystC) equations for estimation of GFR against measured GFR (mGFR) during the index hospitalisation for STEMI.MDRD-IDMS and CKD-EPI demonstrated a good performance to estimate GFR with accuracy within 30% (P30) 82.5% vs 82.5%, respectively. CKD was best classified by CKD-EPI (Kappa 0.83). CG showed the worst performance with the lowest P30. The rG-CystC equation had a marked bias of -17.8% and significantly underestimated mGFR (p=0.03).Conclusions – In STEMI patients treated with primary PCI, bivalirudin should be preferred in patient at high risk for bleeding. With crushed or chewed ticagrelor tablets a more rapid platelet inhibition may be achieved, compared with standard integral tablets. In STEMI patients, fast and potent platelet inhibition with chewed ticagrelor may reduce the risk of early stent thrombosis and patients treated with a less aggressive antithrombotic strategy, such as UFH or bivalirudin monotherapy, may derive a greater benefit. Although gender differences in adverse outcomes could mainly be explained by older age and clustering of comorbidities in women, a bleedreduction strategy in women with high risk characteristics is warranted in order to improve their outcome. Regardless the choice of antithrombotic strategy, dose adjustment of drugs cleared by kidneys based on GFR estimation is of crucial importance. MDRD and CKD-EPI should be the formulas used for estimation of GFR in STEMI patients
47.	Venetsanos, Dimitrios, et al. (författare) Long-term efficacy of drug coated balloons compared with new generation drug-eluting stents for the treatment of de novo coronary artery lesions 2018 Ingår i: Catheterization and Cardiovascular Interventions. - : Wiley. - 1522-1946 .- 1522-726X. ; 92:5, s. 317-326 Tidskriftsartikel (refereegranskat)abstract © 2018 Wiley Periodicals, Inc. Background: Studies comparing drug coated balloons (DCB) with new generation drug-eluting stents (nDES) for the treatment of de novo coronary artery lesions are lacking. Methods: From 2009 to 2016, DCB or nDES used for treatment of de novo coronary lesions at our institution were included, in total 1,197 DEB and 6,458 nDES. We evaluated target lesions restenosis (TLR) and definite target lesion thrombosis (TLT). Propensity score modeling were utilized to study adjusted associations between treatment and outcomes. Results: Median follow-up was 901days. DCB patients were older, with higher cardiovascular risk profile. Bailout stenting after DCB was performed in 8% of lesions. The cumulative rate of TLR and TLT was 7.0 vs. 4.9% and 0.2 vs. 0.8% for DCB vs. nDES, respectively. Before adjustment, DCB was associated with a higher risk of TLR [hazard ratio (HR) 1.44; 95% confidence interval (CI) 1.07-1.94] and a non-significantly lower risk of TLT (HR 0.30; 95% CI 0.07-1.24), compared to nDES. In the propensity matched population consisted of 1,197 DCB and 1,197 nDES, treatment with DCB was associated with similar risk for TLR (adjusted HR 1.05; 95% CI 0.72-1.53) but significantly lower risk for TLT (adjusted HR 0.18; 95% CI 0.04-0.82) compared to nDES. Conclusions: Treatment with DCB was associated with a similar risk of TLR and a lower risk of definite TLT compared with nDES. In selected cases, DCB appears as a good alternative to nDES for the treatment of de novo coronary lesions.
48.	Venetsanos, Dimitrios, et al. (författare) Pretreatment with ticagrelor may offset additional inhibition of platelet and coagulation activation with bivalirudin compared to heparin during primary percutaneous coronary intervention 2018 Ingår i: Thrombosis Research. - : Elsevier BV. - 0049-3848 .- 1879-2472. ; 171, s. 38-44 Tidskriftsartikel (refereegranskat)abstract Background: It remains unknown if bivalirudin compared to heparin confers any additional inhibition of platelet and coagulation activation during primary percutaneous coronary intervention (PPCI) after pretreatment with ticagrelor. Methods: In this substudy of VALIDATE-SWEDEHEART trial, 103 patients pretreated with ticagrelor were randomized before PPCI to heparin or bivalirudin. Blood samples were collected before and 1 and 12 h after PPCI. We measured platelet reactivity (PR) using Multiplate, soluble P-selectin, thrombin-antithrombin complexes (TAT) and prothrombin fragments 1 + 2 (F1 + 2) as markers of platelet and coagulation activation. Results: The median (IQR) time from ticagrelor administration to randomization was 63 (29) vs 60 (24) minutes, p = 0.28. ADP-induced PR did not significantly differ between groups over time (heparin vs bivalirudin, AUC 73 (62) vs 74 (68), p = 0.74, 32 (42) vs 43 (51), p = 0.38, 15 (15) vs 19 (15), p = 0.29, before, 1 and 12 h after PPCI). Soluble P-selectin did not significantly differ between groups. At 1 h TAT significantly increased with bivalirudin (3.0 (1.3) to 4.3 (4.2) ug/L; p < 0.01), but not with UFH (3.1 (2.1) to 3.5 (1.6) ug/L, p = 0.24). F1 + 2 increased in both groups but the rise was numerically higher with bivalirudin (170 (85) to 213 (126) pmol/L vs 168 (118) to 191 (103) pmol/L). At 12 h, a comparable significant increase in thrombin generation was observed in both groups. Conclusion: In patients treated with ticagrelor, we found no major differences between bivalirudin and heparin in platelet aggregation or coagulation markers, which is in agreement with the neutral clinical results of the VALIDATE-SWEDEHEART study.
49.	Venetsanos, Dimitrios, et al. (författare) Sex-related response to bivalirudin and unfractionated heparin in patients with acute myocardial infarction undergoing percutaneous coronary intervention : A subgroup analysis of the VALIDATE-SWEDEHEART trial 2019 Ingår i: European Heart Journal. - : Sage Publications. - 2048-8726 .- 2048-8734. ; 8:6, s. 502-509 Tidskriftsartikel (refereegranskat)abstract AIMS: Our aim was to study the impact of sex on anticoagulant treatment outcomes during percutaneous coronary intervention in acute myocardial infarction patients.METHODS: This study was a prespecified analysis of 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) trial, in which patients with myocardial infarction were randomised to bivalirudin or unfractionated heparin during percutaneous coronary intervention. The primary outcome was the composite of death, myocardial infarction or major bleeding at 180 days.RESULTS: There was a lower risk of the primary outcome in women assigned to bivalirudin than to unfractionated heparin (13.6% vs 17.1%, hazard ratio 0.78, 95% confidence interval (0.60-1.00)) with no significant difference in men (11.8% vs 11.2%, hazard ratio 1.06 (0.89-1.26), p for interaction 0.05). The observed difference was primarily due to lower risk of major bleeding (Bleeding Academic Research Consortium definition 2, 3 or 5) associated with bivalirudin in women (8.9% vs 11.8%, hazard ratio 0.74 (0.54-1.01)) but not in men (8.5% vs 7.3%, hazard ratio 1.16 (0.94-1.43) in men, p for interaction 0.02). Conversely, no significant difference in the risk of Bleeding Academic Research Consortium 3 or 5 bleeding, associated with bivalirudin, was found in women 4.5% vs 5.4% (hazard ratio 0.84 (0.54-1.31)) or men 2.9% vs 2.1% (hazard ratio 1.36 (0.93-1.99)). Bleeding Academic Research Consortium 2 bleeding occurred significantly less often in women assigned to bivalirudin than to unfractionated heparin. The risk of death or myocardial infarction did not significantly differ between randomised treatments in men or women.CONCLUSION: In women, bivalirudin was associated with a lower risk of adverse outcomes, compared to unfractionated heparin, primarily due to a significant reduction in Bleeding Academic Research Consortium 2 bleeds.
50.	Venetsanos, Dimitrios, et al. (författare) Uninterrupted Oral Anticoagulant Therapy in Patients Undergoing Unplanned Percutaneous Coronary Intervention 2021 Ingår i: JACC. - : ELSEVIER SCIENCE INC. - 1936-8798 .- 1876-7605. ; 14:7, s. 754-763 Tidskriftsartikel (refereegranskat)abstract OBJECTIVES This study sought to compare interrupted and uninterrupted oral anticoagulant therapy (I-OAC vs. U-OAC) in patients on OAC undergoing percutaneous coronary intervention. BACKGROUND There is a paucity of data regarding the optimal peri-procedural management of OAC-treated patients. METHODS In the SWEDEHEART registry, all patients on OAC who were admitted acutely and underwent percutaneous coronary intervention or coronary angiography with a diagnostic procedure, from 2005 to 2017, were included. Outcomes were major adverse cardiac and cerebrovascular events (MACCE; death, myocardial infarction, or stroke) and bleeds at 120 days. Propensity score was used to adjust for the nonrandomized treatment selection. RESULTS The study included 6,485 patients: 3,322 in the I-OAC group and 3,163 in the U-OAC group. The cumulative incidence of MACCE was 8.2% (269 events) versus 8.2% (254 events) in the I-OAC and the U-OAC groups, respectively. The adjusted risk for MACCE did not differ between the groups (I-OAC vs. U-OAC hazard ratio: 0.89; 95% confidence interval: 0.71 to 1.12). Similarly, no difference was found in the risk for MACCE or bleeds (12.6% vs. 12.9%, adjusted hazard ratio: 0.87; 95% confidence interval: 0.70 to 1.07). The risk for major or minor in-hospital bleeds did not differ between the groups. However, U-OAC was associated with a significantly shorter duration of hospitalization: 4 (3 to 7) days versus 5 (3 to 8) days; p < 0.01. CONCLUSIONS I-OAC and U-OAC were associated with equivalent risk for MACCE and bleeding complications. An U-OAC strategy was associated with shorter length of hospitalization. These data support U-OAC as the preferable strategy in patients on OAC undergoing coronary intervention. (c) 2021 by the American College of Cardiology Foundation.

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