| 51. |
- Lind, Marcus, 1975-
(författare)
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Determinants of adverse events during oral anticoagulant treatment
- 2012
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Treament with oral anticoagulation is highly effective in reducing the burden of thromboembolic complications in several clinical conditions. The number of patients receiving oral anticoagulation is growing steadily. InSwedenabout 1.5 percent of the population receives treatment. Although the treatment is highly effective in preventing thromboembolic complications, it is also associated with a substantial increase in the risk of bleeding. In clinical practice every physician has to balance the potential benefit of treatment against the risk of bleeding complications in the individual patient. To aid in this decision making, risk scores addressing the likelihood of thromboembolic events, as well as the risk of bleeding complications, have been developed. These scores are imperfect and, to some degree limited by the fact that the risk factors predictive of thromboembolic events are also often associated with bleeding complications. The addition of biomarkers has the potential to increase the predictive ability of risk scores and further enhance the net benefit of oral anticoagulant treatment in the individual patient. In this thesis several potential biomarkers for thromoboembolic and haemorrhagic complications of anticoagulant therapy have been investigated in a longitudinal cohort study of 719 patients with a median follow-up time of 4.2 years. Thrombomodulin is a key component in the generation of activated protein C and hence, a coagulation inhibitor. Conversely, it is also a key component in the inhibition of fibrinolysis by activation of trombin-activated fibrinolysis inhibitor. In warfarin-treated patients we demonstrate that thrombomodulin predicts an increased risk of bleeding complications, but not cardiovascular events. Thus, thrombomodulin has potential as a biomarker specifically for bleeding complications. Von Willebrand factor plays a central and intricate role in the aggregation of platelets and low levels of VWF have been associated with bleeding as a manifestation of von Willebrand’s disease. In our study we noted that high levels of von Willebrand factor predict an increased risk of cardiovascular as well as all-cause mortality, possibly as an expression of endothelial dysfunction. We also noted that high levels of WVF seem to be associated with serious bleeding complications. Decreased renal function is usually measured by an increase in the levels of creatinine and cystatin C, or a decrease in the calculated glomerular filtration rate. A decrease in kidney function is regarded as a marker of an increased risk of bleeding complications. We investigated all the mentioned markers of kidney function and no association with bleeding complications became apparent. However, a clear association between a decrease in kidney function and mortality was noted. Our findings indicate that the emphasis on impaired kidney function as a risk marker needs to be shifted from bleeding complications toward thromboembolic events. Fibrinolysis is important in containing coagulation and several constituents of the fibrinolytic pathway have been shown to predict cardiovascular events and mortality. We found that fibrinolytic factors seem to predict cardiovascular events in patients with oral anticoagulation and that D-dimer also predicts bleeding complications. In conclusion, we have found several biomarkers which exhibit different predictive abilities in patients with oral anticoagulation. It is likely that biomarkers, either alone, in combination, or as ancillary components of risk scores, can contribute to improved risk stratification in patients with oral anticoagulation.
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| 52. |
- Lind, Marcus, et al.
(författare)
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Von Willebrand factor predicts major bleeding and mortality during oral anticoagulant treatment
- 2012
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Ingår i: Journal of Internal Medicine. - : Wiley. - 0954-6820 .- 1365-2796. ; 271:3, s. 239-246
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Tidskriftsartikel (refereegranskat)abstract
- Aims. Oral anticoagulation (OAC), predominantly with warfarin, is an effective treatment to prevent thromboembolic events. Serious bleeding is a frequent and feared treatment complication. In this longitudinal cohort study of OAC-treated patients, we aimed to evaluate the relationship between von Willebrand factor (VWF) levels and risk of bleeding complications, cardiovascular mortality and all-cause mortality.Methods and results. A total of 719 patients receiving warfarin treatment were observed for a mean duration of 4.2 years. All bleeding complications causing hospitalization were registered and classified into clinically relevant bleeding (CRB) and major bleeding. Ischaemic stroke, peripheral arterial embolism, myocardial infarction, and death were also recorded. We identified 113 cases of CRB and 73 of major bleeding. In total, 161 deaths occurred during follow-up with cardiovascular disease identified as the cause of death in 110 patients. Patients in the highest tertile of VWF had a significantly increased risk of bleeding complications: hazard ratio (HR) 2.53 (95% CI 1.41-4.56) for major bleeding and HR 2.19 (95% CI 1.38-3.48) for CRB. VWF, expressed either in tertiles or as a continuous variable, showed a significant association with cardiovascular mortality (HR 1.68, 95% CI 1.40-2.01) and all-cause mortality (HR 1.77, 95% CI 1.52-2.05). In multivariate Cox regression analysis, the findings remained significant after adjusting for age, high-sensitivity C-reactive protein and creatinine.Conclusions. Patients with high levels of VWF had an increased risk of bleeding complications, cardiovascular mortality and all-cause mortality during OAC treatment. Our findings imply that the use of VWF as a risk marker for thromboembolic events is complicated by the association of VWF with bleeding complications.
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| 53. |
- Lindmark, Krister, et al.
(författare)
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Natriuretic Peptides
- 2010
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Ingår i: Heart Failure in Clinical Practice. - London : Springer London. - 9781849961523 - 9781849961530 ; , s. 309-318
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Bokkapitel (övrigt vetenskapligt/konstnärligt)abstract
- Natriuretic peptides are clinically used as biomarkers of heart failure and have in recent years become more and more valuable in the diagnosis of heart failure. B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-pro-BNP) have become commercially available, their accurate assays have been made, and their most widespread use has been achieved, although other natriuretic peptides can be of interest as well. The body of data supporting the use of BNP and NT-pro-BNP is steadily increasing. Low levels of BNP and NT-pro-BNP can, because of their high negative predictive values, be used to rule out heart failure, and high levels of these peptides predict a poor prognosis. There are, however, several pitfalls in the use of natriuretic peptides that one has to be aware of when using them in routine clinical practice. Many unanswered questions also remain to be resolved
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| 54. |
- Lonnebakken, Mai T., et al.
(författare)
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In-treatment stroke volume predicts cardiovascular risk in hypertension
- 2011
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Ingår i: Journal of Hypertension. - 0263-6352 .- 1473-5598. ; 29:8, s. 1508-1514
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Tidskriftsartikel (refereegranskat)abstract
- Objective To evaluate whether lower stroke volume during antihypertensive treatment is a predictor of cardiovascular events independent of left ventricular geometric pattern. Methods The association between left ventricular stroke volume and combined cardiovascular death, stroke and myocardial infarction, the prespecified primary study endpoint, was assessed in Cox regression analysis using data from baseline and annual follow-up visits in 855 patients during 4.8 years of randomized losartan-based or atenolol-based treatment in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) echocardiography substudy. Results During follow-up, a total of 91 primary endpoints occurred. At baseline, lower left ventricular stroke volume was associated with smaller body size, female sex, lower left ventricular mass and stress-corrected midwall shortening, higher relative wall thickness and total peripheral resistance, more concentric left ventricular geometry and impaired diastolic relaxation (all P<0.01). Baseline stroke volume did not predict outcome. However, in time-varying multivariable Cox regression analysis, lower in-treatment left ventricular stroke volume indexed for height(2.04) was associated with higher risk of cardiovascular events {hazard ratio 1.69 per 1 SD (6 ml/m(2.04)) lower stroke volume [95% confidence interval (CI) 1.35-2.11], P<0.001} independent of in-treatment left ventricular mass and concentric geometry and in a secondary model also independent of stress-corrected midwall shortening, impaired diastolic relaxation, heart rate, new-onset atrial fibrillation and study treatment [hazard ratio 1.46 per 1 SD (6 ml/m(2.04)) lower stroke volume (95% CI 1.13-1.88)]. Conclusion Assessment of in-treatment left ventricular stroke volume may reflect cardiac and vascular remodeling and impairment and, hence, adds information on cardiovascular risk in treated hypertensive patients beyond assessment of left ventricular structure alone.
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| 55. |
- Mancusi, C., et al.
(författare)
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Impact of isolated systolic hypertension on normalization of left ventricular structure during antihypertensive treatment in patients with electrocardiographic left ventricular hypertrophy (LIFE)
- 2013
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Ingår i: European Heart Journal. - : Oxford University Press. - 0195-668X .- 1522-9645. ; 34:Supplement: 1, s. 597-597
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Objective: Hypertension is associated with changes in left ventricular(LV) mass and geometry. We tested the impact of isolated systolichypertension (ISH) on normalization of LV structure during antihypertensive treatment.Methods: Baseline and annual echocardiograms were recorded in 875 hypertensive patients with electrocardiographic signs of LV hypertrophy during 4.8 years randomized losartan or atenolol-based antihypertensive treatment in the Losartan Intervention For Endpoint (LIFE) reduction inhypertension study.Results: Patients with ISH at baseline (n=128) were older, included more women, patients with diabetes or previous myocardial infarctioncompared to non-ISH patients (n=747) (all p<0.05). Baseline systolicblood pressure (BP), LV mass and ejection fraction (EF) did not differ between groups, while pulse pressure/stroke volume index (PP/SVi, an index of arterial stiffness) was higher in the ISH group (p<0.01). At the final study visit, systolic BP, LV mass, relative wall thickness (RWT) and PP/SVi were higher in the ISH group (all p<0.05). In particular, ISH patients had less reduction in LV mass and more residual LV hypertrophy compared to non-ISH patients (p<0.05). In multivariate analysis, ISH at baseline predicted higher LV mass at study end (β=0.53) independent ofhigher baseline LV mass (β=0.54) body mass index (β=0.10), atenolol-based treatment (β=0.09), and higher systolic BP (β=0.07), RWT (β=0.23) and lower LV EF (β=-0.24) at the final visit (all p<0.05), while age, historyof diabetes and PP/SVi were not significant covariates in the model.Conclusions: Antihypertensive treatment is associated with impairednormalization of LV mass and LV geometry in ISH patients with ECG LV hypertrophy. The findings may help explain the higher cardiovascular event-rate previously reported in LIFE ISH-patients.
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| 56. |
- Mancusi, Costantino, et al.
(författare)
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Impact of isolated systolic hypertension on normalization of left ventricular structure during antihypertensive treatment (the LIFE study)
- 2014
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Ingår i: Blood Pressure. - : Informa UK Limited. - 0803-7051 .- 1651-1999. ; 23:4, s. 206-212
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: We tested the impact of isolated systolic hypertension (ISH) on normalization of left ventricular (LV) structure during antihypertensive treatment.METHODS: Baseline and annual echocardiograms were recorded in 873 hypertensive patients with electrocardiographic signs of LV hypertrophy during 4.8 years randomized losartan- or atenolol-based antihypertensive treatment in the Losartan Intervention For Endpoint (LIFE) reduction in hypertension study and classified as having ISH (n = 128) if systolic BP ≥ 160 mmHg and diastolic BP < 90 mmHg, or non-ISH divided into two groups by systolic BP ≥ 160 mmHg (non-ISH ≥ 160 mmHg) (n = 645) and systolic BP < 160 mm Hg (n = 100) (non-ISH < 160 mmHg), respectively.RESULTS: Patients with ISH were older, with higher prevalence of diabetes than non-ISH groups and higher pulse pressure/stroke volume index (all p < 0.05). Baseline systolic blood pressure (BP) differed between groups and was highest in the non-ISH ≥ 160 mmHg group (p < 0.05). Systolic BP reduction was less in the ISH group (p < 0.05). LV geometry did not differ between ISH and non-ISH ≥ 160 mmHg groups at baseline, but ISH had more residual LV hypertrophy of concentric type at the last study visit (p < 0.05). In multivariate analysis, less reduction of LV mass was predicted by ISH (β = - 0.07) independent of significant associations with baseline LVMi (β = 0.52) and atenolol-based treatment (β = - 0.08) and clinical confounders (all p < 0.05).CONCLUSIONS: ISH is associated with impaired normalization of LV mass during systematic antihypertensive treatment. The findings may help explain the higher cardiovascular event rate previously reported in ISH patients.
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| 57. |
- Minners, Jan, et al.
(författare)
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Adjusting parameters of aortic valve stenosis severity by body size
- 2014
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Ingår i: Heart. - : BMJ. - 1355-6037 .- 1468-201X. ; 100:13, s. 1024-1030
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Tidskriftsartikel (refereegranskat)abstract
- Background Adjustment of cardiac dimensions by measures of body size appears intuitively convincing and in patients with aortic stenosis, aortic valve area (AVA) is commonly adjusted by body surface area (BSA). However, there is little evidence to support such an approach. Objective To identify the adequate measure of body size for the adjustment of aortic stenosis severity. Methods Parameters of aortic stenosis severity (jet velocity, mean pressure gradient (MPG) and AVA) and measures of body size (height, weight, BSA and body mass index (BMI)) were analysed in 2843 consecutive patients with aortic stenosis (jet velocity >= 2.5 m/s) and related to outcomes in a second cohort of 1525 patients from the Simvastatin/Ezetimibe in Aortic Stenosis (SEAS) study. Results Whereas jet velocity and MPG were independent of body size, AVA was significantly correlated with height, weight, BSA and BMI (Pearson correlation coefficient (r) 0.319, 0.281, 0.317 and 0.126, respectively, all p<0.001) to the effect that larger patients presented with larger AVA (less severe stenosis). Of the anthropometric measures used for linear adjustment, BSA was most effective in eliminating the correlation between AVA and body size (r=0.007), rivalled only by allometric (non-linear) models, findings that are confirmed in 1525 prospectively followed patients from the SEAS study. Predictive accuracy for aortic valve events and cardiovascular death during 46 months of follow-up was unchanged by adjusting AVA, regardless of measure of body size (area under the receiver operating curve for AVA 0.72 (CI 0.58 to 0.87) versus, for example, AVA/BSA 0.75 (CI 0.61 to 0.88), p=0.22). Conclusions In the assessment of aortic stenosis, linear adjustment of AVA by BSA improves comparability between patients with diverging body size without, however, increasing the predictive accuracy for clinical events in a population with mild to moderate stenosis.
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| 58. |
- Norberg, Eva-Britt, 1956-
(författare)
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Dagliga aktiviteter bland äldre personer med kronisk hjärtsvikt : begränsningar och möjligheter
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Chronic Heart Failure (CHF) is known to have a substantial impact on activities of daily living (ADL) and symptoms such as breathlessness and fatigue are characteristic. Despite this, research in occupational therapy concerning people with CHF is rare. The overall aim of this thesis was to increase the knowledge of ADL ability and fatigue among those with CHF, to describe experiences of limitations in occupational performance and the strategies that these elderly people use to manage their daily activities and also to describe a programme including energy conservation for clients with CHF in primary healthcare.Method Three groups of older people with a verified diagnosis of CHF and one group of occupational therapists (OTs), all recruited from primary healthcare, were analyzed. The ADL ability of 40 participants was described, with reference to dependence on others, perceived strain and quality of occupational performance. The association between ADL ability and the New York Heart Association Classification (NYHA), a functional classification for people with CHF, was analyzed. Fatigue and its association to ADL ability, use of assistive devices and community support were also analyzed. Ten respondents were then interviewed and asked to describe the strategies they used to manage ADL. The interview results were combined with the current body of research and CHF guidelines to form a base for the development of an intervention programme, including energy conservation, for people with CHF. The programme, based on the Occupational Therapy Intervention Process Model (OTIPM), was used by OTs in primary healthcare, and the clients’ ADL, goal achievements and use of energy conservation strategies were described, as well as the five clients’ and two OTs’ experiences of the program.Results Most participants were independent in personal ADL activities (PADL). A majority was dependent in one or more instrumental ADL activities (IADL) and perceived strain when performing the activities independently. The Assessment of Motor and Process Skills (AMPS) showed a reduced quality of occupational performance compared with healthy people of the same age. Age had a significant impact on ADL performance. Despite this, participants in NYHA III/IV showed significantly increased effort (under motor cutoff) when performing ADL tasks compared with those in NYHA I/II. Fatigue was common and greater fatigue was associated significant with increased dependence and decreased quality of occupational performance, with the exception of shopping. Participants who used assistive devices and home care estimated higher physical fatigue, but no correlation was found with community mobility services. Comorbidities, which can affect occupational performance, were common in all the studies.The participants experiences of limitations in occupational performance and the strategies that they used to manage their daily activities were described as redefining an active life, aware of one’s impaired body and planning activities and balancing the degree of effort.During the interventions according to the programme the clients’ increased their participation and independence in daily activities, consciously gave up what were less meaningful activities for them and deteriorated because of the progression of the CHF. Most goals were achieved and many energy conservation strategies were used by the clients. The clients’ experiences were described as working in collaboration to manage daily activities and using professional support from OTs to enhance their activities. The OTs’ experiences of the programme were described as being supported with specific knowledge and a structured way of working and finding clinical benefits from working according to the program, but doubt the possibilitiy of using it, due to constraints in clinical practice.Discussion The participants' physical fatigue and breathlessness had a negative impact on their ADL-ability. Age affected ADL performance, but the impact of a more severe CHF remained adjusted for age. An ongoing process of occupational adaptation due to periodical physical decline and fluctuating day-to-day ability was described. Many of the strategies used by the participants to handle daily activities could be described as energy conservation strategies, an indication that occupational therapy interventions including energy conservation management would be beneficial for clients with CHF. Both the OTs and the clients described that the specialized programme provided structure for the OTs’ work, knowledge about CHF and about valuable energy conservation strategies. The programme seemed to support the OTs to work in a more comprehensive client-centered way.Conclusion The work with this thesis has increased the limited existing knowledge about elderly people with CHF and their ADL ability, fatigue and the adaptation of occupational performance that they use to manage their daily activities. The experiences indicated that a specialized programme including energy conservation for occupational therapy in primary healthcare seemed to support the OTs work in a more comprehensive client-centered way. The programme needs to be further evaluated.
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| 59. |
- Norberg, Eva-Britt, et al.
(författare)
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Impact of fatigue on everyday life among older people with chronic heart failure
- 2010
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Ingår i: Australian Occupational Therapy Journal. - : Wiley. - 0045-0766 .- 1440-1630. ; 57:1, s. 34-41
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Tidskriftsartikel (refereegranskat)abstract
- Fatigue had a negative impact on ADL mainly from physical rather than from mental causes. Improved energy conservation strategies to reduce the consequences of fatigue are needed.
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| 60. |
- Norberg, Eva-Britt, et al.
(författare)
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Occupational performance and strategies for managing daily life among the elderly with heart failure
- 2014
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Ingår i: Scandinavian Journal of Occupational Therapy. - : Informa UK Limited. - 1103-8128 .- 1651-2014. ; 21:5, s. 392-399
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Tidskriftsartikel (refereegranskat)abstract
- Aim:The aim of this study was to describe experiences of limitations in occupational performance and strategies for managing daily activities among the elderly with chronic heart failure (CHF).Methods:Ten participants from primary healthcare with a confirmed diagnosis of CHF were interviewed. The interviews were analysed using qualitative content analysis.Results: The first theme, "Redefining an active life, aware of one's impaired body", was based on four sub-themes: realizing one's limited activity ability; striving to preserve an active life; focusing on meaningful activities; and changing vs. not changing habits and roles. The second theme, "Planning activities and balancing the degree of effort", was based on three sub-themes: limiting, organizing, and rationalizing activities; adjusting activities to today's ability; and using technology and adapting the environment.Conclusions:Elderly people with CHF are struggling with an ongoing process of occupational adaptation due to periodical physical decline and fluctuating day-to-day ability. This highlights a need for information on strategies from a holistic perspective and client-centred occupational therapy interventions.
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