| 1. |
- Batra, Gorav, et al.
(author)
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Biomarker-Based Prediction of Recurrent Ischemic Events in Patients With Acute Coronary Syndromes
- 2022
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In: Journal of the American College of Cardiology. - : Elsevier. - 0735-1097 .- 1558-3597. ; 80:18, s. 1735-1747
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Journal article (peer-reviewed)abstract
- BACKGROUND: In patients with acute coronary syndrome (ACS), there is residual and variable risk of recurrent ischemic events.OBJECTIVES: This study aimed to develop biomarker-based prediction models for 1-year risk of cardiovascular (CV) death and myocardial infarction (MI) in patients with ACS undergoing percutaneous coronary intervention.METHODS: We included 10,713 patients from the PLATO (A Comparison of Ticagrelor [AZD6140] and Clopidogrel in Patients With Acute Coronary Syndrome) trial in the development cohort and externally validated in 3,508 patients from the TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) trial. Variables contributing to risk of CV death/MI were assessed using Cox regression models, and a score was derived using subsets of variables approximating the full model.RESULTS: There were 632 and 190 episodes of CV death/MI in the development and validation cohorts. The most important predictors of CV death/MI were the biomarkers, growth differentiation factor 15, and N-terminal pro-B-type natriuretic peptide, which had greater prognostic value than all candidate variables. The final model included 8 items: age (A), biomarkers (B) (growth differentiation factor 15 and N-terminal pro-B-type natriuretic peptide), and clinical variables (C) (extent of coronary artery disease, previous vascular disease, Killip class, ACS type, P2Y12 inhibitor). The model, named ABC-ACS ischemia, was well calibrated and showed good discriminatory ability for 1-year risk of CV death/MI with C-indices of 0.71 and 0.72 in the development and validation cohorts, respectively. For CV death, the score performed better, with C-indices of 0.80 and 0.84 in the development and validation cohorts, respectively.CONCLUSIONS: An 8-item score for the prediction of CV death/MI was developed and validated for patients with ACS undergoing percutaneous coronary intervention. The ABC-ACS ischemia score showed good calibration and discrimination and might be useful for risk prediction and decision support in patients with ACS. (A Comparison of Ticagrelor [AZD6140] and Clopidogrel in Patients With Acute Coronary Syndrome [PLATO]; NCT00391872; Trial to Assess the Effects of Vorapaxar [SCH 530348; MK-5348] in Preventing Heart Attack and Stroke in Participants With Acute Coronary Syndrome [TRACER]; NCT00527943)
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| 2. |
- Ghatnekar, Ola, et al.
(author)
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Medical Resource Utilization and Cost of HIV-Related Care in the Highly Active Antiretroviral Therapy Era at a University Clinic in Sweden.
- 2010
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In: PharmacoEconomics. - : Springer Science and Business Media LLC. - 1179-2027 .- 1170-7690. ; 28:S1, s. 49-57
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Journal article (peer-reviewed)abstract
- Introduction: Little is known regarding healthcare costs for HIV/AIDS patients in the era of highly active antiretroviral therapy (HAART) and subgroups of patients according to the severity and progression of HIV infection in Sweden. The objective of this study is therefore to describe the direct medical resource use and cost of healthcare for HIV patients at a university clinic in Sweden. Methods: A patient registry database for HIV treatment at the Department of Infectious Diseases, Sahlgrenska University Hospital, between 2000 and 2005 provided information on patient characteristics, antiretroviral drugs and dosages, tests and diagnostic procedures, outpatient visits and inpatient stays. The review used publicly available unit costs with a county council perspective, expressed in 2006 Euros. Results: Two hundred and eighty-five patients with a mean age of 38 years in 2000 (64% men) were followed for 1368 patient-years. They had a mean (median) of 6.3 (0) inpatient days, 4.1 (3.7) physician visits, 4.2 (3.8) nurse visits, 2.6 (0.7) counsellor visits and 11.5 (7.7) tests and diagnostic procedures per patient-year. Only 12 deaths were recorded during the study period, and the proportion of treated patients with successful treatment (HIV-RNA <50copies/mL) increased from 74% to 92% during the period. The mean cost per patient-month amounted to &U20AC;1069. The main cost driver was HIV drugs (51%), followed by inpatient stays (including hospitalizations for opportunistic infections; 22%), outpatient physician, nurse or therapist visits (19%) and diagnostics and tests (7%). All non-drug costs increased with a decreasing CD4 cell count. Conclusions: Overall, approximately half of the direct costs of HIV treatment were not related to antiretroviral treatment. The non-antiretroviral costs were inversely correlated with HIV-induced immune deficiency.
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| 3. |
- Gisslén, Magnus, 1962, et al.
(author)
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Antiretroviral treatment of HIV infection: Swedish recommendations 2005.
- 2006
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In: Scandinavian journal of infectious diseases. - : Informa UK Limited. - 0036-5548 .- 1651-1980. ; 38:2, s. 86-103
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Journal article (peer-reviewed)abstract
- On 2 earlier occasions, in 2002 and 2003, the Swedish Medical Products Agency (MPA) and the Swedish Reference Group for Antiviral Therapy (RAV) have jointly publicized recommendations for the treatment of HIV infection. A working group from the same expert team that produced the 2002 report has now revised the text again. Since the publication of the last treatment recommendations, 4 new medicines have become available: emtricitabine, atazanavir, fosamprenavir, and enfuvirtid. The last-mentioned belongs to a new class of HIV medications called fusion inhibitors (Box 1). It is likely that tipranavir will also be on the market soon. Simultaneously, the drug zalcitabin has been deregistered. The following updated recommendations parallel the earlier ones, but increased knowledge allows us to be more specific in our recommendations. Thus, it is now suggested that the initial treatment for HIV infection consist of 2 nucleoside reverse transcriptase inhibitors (NRTIs) and 1 non-nucleoside reverse transcriptase inhibitor (NNRTI); or 2 NRTIs and 1 protease inhibitor (PI). In the group of the NRTIs, stavudine is no longer recommended for this purpose. In the NNRTI group, efavirenz should be preferred to nevirapine, except under special circumstances. Finally, PIs ought to be boosted with ritonavir (PI/r). Also new are recommendations regarding treatment choices for patients co-infected with hepatitis B virus (HBV) or tuberculosis (TB). As in the case of the previous publication, recommendations are evidence-graded in accordance with the Oxford Centre for Evidence Based Medicine, 2001 (see http://www.cebm.net/levels_of_evidence.asp#levels), and have been supplemented with references to newly-added sections and data not referred to in earlier background documentation.
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| 4. |
- Gregersen, Ida, et al.
(author)
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Legumain in Acute Coronary Syndromes : A Substudy of the PLATO (Platelet Inhibition and Patient Outcomes) Trial
- 2020
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In: Journal of the American Heart Association. - : WILEY. - 2047-9980. ; 9:17
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Journal article (peer-reviewed)abstract
- BACKGROUND: The cysteine protease legumain is increased in patients with atherosclerosis, but its causal role in atherogenesis and cardiovascular disease is still unclear. The aim of the study was to investigate the association of legumain with clinical outcome in a large cohort of patients with acute coronary syndrome. METHODS AND RESULTS : Serum levels of legumain were analyzed in 4883 patients with acute coronary syndrome from a substudy of the PLATO (Platelet Inhibition and Patient Outcomes) trial. Levels were analyzed at admission and after 1 month follow-up. Associations between legumain and a composite of cardiovascular death, spontaneous myocardial infarction or stroke, and its individual components were assessed by multivariable Cox regression analyses. At baseline, a 50% increase in legumain level was associated with a hazard ratio (HR) of 1.13 (95% CI, 1.04-1.21),P=0.0018, for the primary composite end point, adjusted for randomized treatment. The association remained significant after adjustment for important clinical and demographic variables (HR, 1.10; 95% CI, 1.02-1.19;P=0.013) but not in the fully adjusted model. Legumain levels at 1 month were not associated with the composite end point but were negatively associated with stroke (HR, 0.62; 95% CI, 0.44-0.88;P=0.0069), including in the fully adjusted model (HR, 0.57; 95% CI, 0.37-0.88;P=0.0114). CONCLUSIONS: Baseline legumain was associated with the primary outcome in patients with acute coronary syndrome, but not in the fully adjusted model. The association between high levels of legumain at 1 month and decreased occurrence of stroke could be of interest from a mechanistic point of view, illustrating the potential dual role of legumain during atherogenesis and acute coronary syndrome. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00391872.
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| 5. |
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| 6. |
- Hijazi, Ziad, et al.
(author)
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Association of Different Estimates of Renal Function With Cardiovascular Mortality and Bleeding in Atrial Fibrillation
- 2020
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In: Journal of the American Heart Association. - : WILEY. - 2047-9980. ; 9:18
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Journal article (peer-reviewed)abstract
- Background We compared different methods of estimated glomerular filtration rate (eGFR) and their association with cardiovascular death and major bleeding in 14 980 patients with atrial fibrillation in the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial. Methods and Results eGFR was calculated using equations based on creatinine (Cockcroft-Gault, Modification of Diet in Renal Disease, and Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]) and/or cystatin C (CKD-EPI(CysC)and CKD-EPICysC+Creatinine). These 5 eGFR equations, as well as the individual variables that are used in these equations, were assessed for correlation and discriminatory ability for cardiovascular death and major bleeding. The median age was 70.0 years, and 35.6% were women. The median eGFR was highest with Cockcroft-Gault (74.1 mL/min) and CKD-EPICysC(74.2 mL/min), and lowest with Modification of Diet in Renal Disease (66.5 mL/min). Correlation between methods ranged from 0.49 (Cockroft-Gault and CKD-EPICysC) to 0.99 (Modification of Diet in Renal Disease and CKD-EPI). Among the eGFR equations, those based on cystatin C yielded the highest C indices for cardiovascular death and major bleeding: 0.628 (CKD-EPICysC) and 0.612 (CKD-EPICysC+Creatinine), respectively. A model based on the variables within the different eGFR equations (age, sex, weight, creatinine, and cystatin C) yielded the highest discriminatory value for both outcomes, with a C index of 0.673 and 0.656, respectively. Conclusions In patients with atrial fibrillation on anticoagulation, correlation between eGFR calculated using different methods varied substantially. Cystatin C-based eGFRs seem to provide the most robust information for predicting death and bleeding. A model based on the individual variables within the eGFR equations, however, provided the highest discriminatory value. Our findings may help refine risk stratification in patients with atrial fibrillation and define how renal function should be determined in future atrial fibrillation studies.
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| 7. |
- Hållmarker, Ulf, 1946-, et al.
(author)
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Risk of recurrent ischaemic events after myocardial infarction in long-distance ski race participants
- 2016
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In: European Journal of Preventive Cardiology. - : Oxford University Press (OUP). - 2047-4873 .- 2047-4881. ; 23:3, s. 282-290
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Journal article (peer-reviewed)abstract
- Aims: To study whether a high level of physical activity prior to myocardial infarction (MI) also protects against recurrent MI (re-MI) or death.Methods and Results: A longitudinal study of a primary cohort consisting of 204,038 skiers with a proved substantially high level of physical activity in the world's largest long-distance ski race, Vasaloppet, and 499,543 non-skiers selected from the Swedish population. Individuals with severe diseases at baseline were excluded. In the nationwide clinical register, Swedeheart, we identified 7092 individuals with a first MI incident between 1989 and 2010. Of these, 1039 (0.5%) were skiers and 6053 (1.2%) were non-skiers. One hundred and sixty-three (15.7%) skiers and 1352 (22.3%) non-skiers suffered a re-MI or died during follow-up (median 4.44 years), corresponding to an incidence rate of 38.9 (95% confidence interval (CI) 33.2-45.4)/1000 person-years and 55.6 (95% CI 52.7-58.7)/1000 person-years, respectively. Severity of MI in both groups was the same. For skiers compared to non-skiers the unadjusted hazard ratio (HR) for re-MI was 0.66 (95% CI 0.52-0.82). For death or re-MI, HR was 0.70 (95% CI 0.59-0.82) with consistent results in subgroups based on race year, age, gender, education level, marital status. After adjustment for also smoking, diabetes, hypertension and cardiovascular medication, HR was 0.80 (95% CI 0.67-0.97).Conclusions: This large cohort study supports the hypothesis that patients with MI and with prior physical activity and healthy lifestyle, as evidenced by their participation in a long-distance ski race, have a lower risk of subsequent re-MI or death.
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| 8. |
- Hållmarker, Ulf, 1946-, et al.
(author)
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Risk of recurrent stroke and death after first stroke in long-distance ski race participants
- 2015
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In: Journal of the American Heart Association. - : Wiley-Blackwell. - 2047-9980. ; 4:10
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Journal article (peer-reviewed)abstract
- Background: Physical activity is of benefit for primary prevention of cardiovascular diseases, but it appears to increase the risk for atrial fibrillation. We aimed to study a cohort of patients following a first stroke in individuals with previous high physical activity, compare them to the general population with respect to recurrent stroke and death, and relate these to atrial fibrillation.Methods and results: From the participants of the Vasaloppet, the world's largest ski-race, and matched individuals from the general population (n=708 604), we identified 5964 patients hospitalized with a first-time stroke between 1994 and 2010. Individuals with severe diseases were excluded. One half percent of skiers and 1% of nonskiers were hospitalized due to stroke. The incidence rate was 8.3 per 100 person-years among skiers and 11.1 among nonskiers. The hazard ratio (HR) for recurrent stroke or death between the 2 groups was 0.76 (95% CI 0.67 to 0.86). The result was consistent in subgroups. The HR for death was 0.66 (95% CI 0.56 to 0.78) and for recurrent stroke 0.82 (95% CI 0.70 to 0.96). After adjustment for smoking and socioeconomic factors, the HR for death was consistent at 0.70 (95% CI 0.56 to 0.87) while the HR for recurrent stroke was not statistically significant. Outcomes for skiers with atrial fibrillation tended to show a lower risk than for nonskiers.Conclusions: This large cohort study supports the hypothesis that patients with a stroke and with prior regular physical activity have a lower risk of death, while their risk for recurrent stroke is similar to that of nonskiers. The skiers had a higher incidence of atrial fibrillation, but still no increased risk of recurring stroke.
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| 9. |
- Hållmarker, Ulf, 1946-, et al.
(author)
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Survival and incidence of cardiovascular diseases in participants in a long-distance ski race (Vasaloppet, Sweden) compared to the background population
- 2018
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In: European Heart Journal - Quality of Care and Clinical Outcomes. - : Oxford University Press (OUP). - 2058-5225 .- 2058-1742. ; 4:2, s. 91-97
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Journal article (peer-reviewed)abstract
- AimsWe studied the relationship between taking part in a long-distance ski race and incidence of cardiovascular diseases (CVDs) to address the hypothesis that lifestyle lowers the incidence.Methods and resultsA cohort of 399 630 subjects in Sweden, half were skiers in the world’s largest ski race, and half were non-skiers. Non-skiers were frequency matched for sex, age, and year of race. Individuals with severe diseases were excluded. The endpoints were death, myocardial infarction, or stroke. The subjects were followed up for a maximum of 21.8 years and median of 9.8 years. We identified 9399 death, myocardial infarction, or stroke events among non-skiers and 4784 among the Vasaloppet skiers. The adjusted hazard ratios (HRs) comparing skiers and non-skiers were 0.52 [95% confidence interval (CI) 0.49–0.54] for all-cause mortality, 0.56 (95% CI 0.52–0.60) for myocardial infarction and 0.63 (95% CI 0.58–0.67) for stroke and for all three outcomes 0.56 (95% CI 0.54–0.58). The results were consistent across subgroups: age, sex, family status, education, and race year. For skiers, a doubling of race time was associated with a higher age-adjusted risk of 19%, and male skiers had a doubled risk than female skiers, with a HR 2.06 (95% CI 1.89–2.41). The outcome analyses revealed no differences in risk of atrial fibrillation between skiers and non-skiers.ConclusionThis large cohort study provides additional support for the hypothesis that individuals with high level of physical activity representing a healthy lifestyle, as evident by their participation in a long-distance ski race, have a lower risk of CVD or death.
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| 10. |
- James, Stefan K, et al.
(author)
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An acute inflammatory reaction induced by myocardial damage is superimposed on a chronic inflammation in unstable coronary artery disease
- 2005
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In: American Heart Journal. - : Elsevier BV. - 0002-8703 .- 1097-6744. ; 149:4, s. 619-626
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Journal article (peer-reviewed)abstract
- BACKGROUND:Inflammation plays an important role in unstable coronary artery disease (CAD). We assessed the kinetics of inflammatory markers from symptom onset in patients with unstable CAD and their relation to myocardial damage.METHODS:Serial measurements of inflammatory mediators were performed in consecutive patients with unstable CAD enrolled at selected sites in the FRISC II (n = 558) and the GUSTO IV (n = 404) trials. The time from symptom onset was calculated for every serum sample (total 4400 samples).RESULTS:Median levels of interleukin 6 and C-reactive protein reached their peaks at 36 to 42 hours and at 48 to 54 hours, respectively, from symptom onset and returned to early postsymptom levels within 6 weeks. The early increase occurred almost exclusively in patients with baseline troponin T elevation (>0.01 microg/L). In contrast, median levels of fibrinogen increased continuously up to 120 hours after symptom onset, independently of myocardial damage. At 6 months, fibrinogen levels were still higher than in the early phase after symptom onset. The median levels of interleukin 6, C-reactive protein, and fibrinogen were still higher at 6 months than in healthy controls matched for age and sex to a population with unstable CAD.CONCLUSIONS:An early acute inflammatory reaction induced by myocardial damage seems to be superimposed on a chronic inflammatory condition, both of which might influence long-term outcome in unstable CAD.
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| 11. |
- James, Stefan K., 1964-, et al.
(author)
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Long-term safety and efficacy of drug-eluting versus bare-metal stents in Sweden
- 2009
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In: New England Journal of Medicine. - 0028-4793 .- 1533-4406. ; 360:19, s. 1933-1945
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Journal article (peer-reviewed)abstract
- BACKGROUND: The long-term safety and efficacy of drug-eluting coronary stents have been questioned. METHODS: We evaluated 47,967 patients in Sweden who received a coronary stent and were entered into the Swedish Coronary Angiography and Angioplasty Registry between 2003 and 2006 and for whom complete follow-up data were available for 1 to 5 years (mean, 2.7). In the primary analysis, we compared patients who received one drug-eluting coronary stent (10,294 patients) with those who received one bare-metal stent (18,659), after adjustment for differences in clinical characteristics of the patients and characteristics of the vessels and lesions. RESULTS: Analyses of outcome were based on 2380 deaths and 3198 myocardial infarctions. There was no overall difference between the group that received drug-eluting stents and the group that received bare-metal stents in the combined end point of death or myocardial infarction (relative risk with drug-eluting stents, 0.96; 95% confidence interval [CI], 0.89 to 1.03) or the individual end points of death (relative risk, 0.94; 95% CI, 0.85 to 1.05) and myocardial infarction (relative risk, 0.97; 95% CI, 0.88 to 1.06), and there was no significant difference in outcome among subgroups stratified according to the indication for stent implantation. Patients who received drug-eluting stents in 2003 had a significantly higher rate of late events than patients who received bare-metal stents in the same year, but we did not observe any difference in outcome among patients treated in later years. The average rate of restenosis during the first year was 3.0 events per 100 patient-years with drug-eluting stents versus 4.7 with bare-metal stents (adjusted relative risk, 0.43; 95% CI, 0.36 to 0.52); 39 patients would need to be treated with drug-eluting stents to prevent one case of restenosis. Among high-risk patients, the adjusted risk of restenosis was 74% lower with drug-eluting stents than with bare-metal stents, and only 10 lesions would need to be treated to prevent one case of restenosis. CONCLUSIONS: As compared with bare-metal stents, drug-eluting stents are associated with a similar long-term incidence of death or myocardial infarction and provide a clinically important decrease in the rate of restenosis among high-risk patients.
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| 12. |
- James, Stefan K., 1964-, et al.
(author)
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Troponin-T and N-terminal pro-B-type natriuretic peptide predict mortality benefit from coronary revascularization in acute coronary syndromes : a GUSTO-IV substudy
- 2006
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In: Journal of the American College of Cardiology. - : Elsevier BV. - 0735-1097 .- 1558-3597. ; 48:6, s. 1146-1154
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Journal article (peer-reviewed)abstract
- OBJECTIVES: This study was designed to evaluate biomarkers for selection of patients with non-ST-segment elevation acute coronary syndromes (ACS) that derive mortality benefit from revascularization. BACKGROUND: Biomarkers are essential for identification of patients at increased risk, which may be reduced by revascularization. METHODS: During the initial 30 days, 2,340 patients of 7,800 (30%) with non-ST-segment elevation ACS in the GUSTO (Global Utilization of Strategies To open Occluded arteries)-IV trial underwent coronary revascularization. The 1-year mortality was calculated in 30-day survivors stratified by status of revascularization and levels of biomarkers. A propensity score for receiving revascularization was constructed and included in a survival analysis that also included the time point of revascularization as a time-dependent covariate. RESULTS: Elevation of troponin-T or N-terminal pro-B-type natriuretic peptide (NT-proBNP) was associated with a high mortality. In patients with either or both of these markers elevated, a lower mortality following revascularization was observed. In contrast, patients without elevation of these markers had low 1-year mortality without any reduction in mortality following revascularization. In fact, in patients with normal levels of both troponin-T and NT-proBNP, a significant increase in 1-year mortality after revascularization was observed. Elevation of C-reactive protein, interleukin-6, creatinine clearance, and ST-segment depression was also related to a higher mortality. However, independent of these markers, mortality was lower after revascularization. CONCLUSIONS: Markers of troponin-T and NT-proBNP not only assist in risk stratification of patients with non-ST-segment elevation ACS but also appear to identify patients who have a reduced mortality associated with early coronary revascularization.
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| 13. |
- Lagerqvist, Bo, 1952-, et al.
(author)
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Long-term outcomes with drug-eluting stents versus bare-metal stents in Sweden
- 2007
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In: New England Journal of Medicine. - : Massachusetts Medical Society. - 0028-4793 .- 1533-4406. ; 356:10, s. 1009-1019
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Journal article (peer-reviewed)abstract
- BACKGROUND: Recent reports have indicated that there may be an increased risk of late stent thrombosis with the use of drug-eluting stents, as compared with bare-metal stents. METHODS: We evaluated 6033 patients treated with drug-eluting stents and 13,738 patients treated with bare-metal stents in 2003 and 2004, using data from the Swedish Coronary Angiography and Angioplasty Registry. The outcome analysis covering a period of up to 3 years was based on 1424 deaths and 2463 myocardial infarctions and was adjusted for differences in baseline characteristics. RESULTS: The two study groups did not differ significantly in the composite of death and myocardial infarction during 3 years of follow-up. At 6 months, there was a trend toward a lower unadjusted event rate in patients with drug-eluting stents than in those with bare-metal stents, with 13.4 fewer such events per 1000 patients. However, after 6 months, patients with drug-eluting stents had a significantly higher event rate, with 12.7 more events per 1000 patients per year (adjusted relative risk, 1.20; 95% confidence interval [CI], 1.05 to 1.37). At 3 years, mortality was significantly higher in patients with drug-eluting stents (adjusted relative risk, 1.18; 95% CI, 1.04 to 1.35), and from 6 months to 3 years, the adjusted relative risk for death in this group was 1.32 (95% CI, 1.11 to 1.57). CONCLUSIONS: Drug-eluting stents were associated with an increased rate of death, as compared with bare-metal stents. This trend appeared after 6 months, when the risk of death was 0.5 percentage point higher and a composite of death or myocardial infarction was 0.5 to 1.0 percentage point higher per year. The long-term safety of drug-eluting stents needs to be ascertained in large, randomized trials.
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| 14. |
- Lagerqvist, Bo, 1952-, et al.
(author)
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Stent thrombosis in Sweden : a report from the Swedish Coronary Angiography and Angioplasty Registry
- 2009
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In: Circulation: Cardiovascular Interventions. - 1941-7640 .- 1941-7632. ; 2:5, s. 401-408
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Journal article (peer-reviewed)abstract
- BACKGROUND: The objective was to evaluate the role of risk factors and stent type for stent thrombosis (ST) using a large real world registry. METHODS AND RESULTS: We evaluated all consecutive coronary stent implantations in Sweden from May 1, 2005, to June 30, 2007. All cases of ST, documented in the Swedish coronary angiography and angioplasty registry until September 21, 2008, were analyzed. ST was registered in 882 of 73 798 stents. Acute coronary syndromes, insulin-treated diabetes mellitus, smoking, previous coronary intervention, warfarin treatment, small stent diameter, and stenting in restenotic, complex, or bypass graft lesions had the strongest association with ST in the multivariable statistical model. There were considerable differences in the frequency of ST between different stent brands. The overall risk of ST was lower in drug-eluting stents compared with bare metal stents (adjusted risk ratio, 0.79; 99% CI, 0.63 to 0.99). However, from 6 months after stent implantation and onward, the risk for ST was higher in drug-eluting stents compared with bare metal stents (adjusted risk ratio, 2.02; 99% CI, 1.30 to 3.14). CONCLUSIONS: ST is a multifactor disease, and the incidence varies considerably between patients based on clinical, vessel, and stent characteristics. For drug-eluting stents compared with bare metal stents, the risk pattern was biphasic; initially, bare metal stents demonstrated a higher risk of ST; whereas after the first months, ST risk was higher with drug-eluting stents. Our findings highlight the need for prospective randomized studies with head-to-head comparisons between different stents.
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| 15. |
- Lindbäck, Stefan
(author)
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Primary HIV-1 infection : diagnostic, prognostic, and therapeutic aspects
- 1999
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Doctoral thesis (other academic/artistic)abstract
- Primary HIV-1 infection (PHI) is usually defined as a mononucleosis-like illness associated with seroconversion to HIV. In earlier studies using 1st generation antibody tests, the duration of the 'window period' from infection to detection of specific HIV-antibodies, could be 2 to 3 months, or longer. We evaluated currently available tests for HIV-antibody, using sequential sera obtained from PHI patients and found that seroconversion was detected in all patients within 2 weeks after onset of illness by 24 of 27 screening-tests, and that reactivity to all HIV antigens, by Western blot, had appeared within 4 weeks. Thus, the combination of a HIV-antigen-test and a Western blot test provides a convenient strategy by which a PHI diagnosis usually can be confirmed or excluded the same day the patient seeks medical attention. We were able to detect four phases of viremia during primary HIV infection by determination of HIV-RNA in plasma samples from 8 PHI patients not receiving antiviral treatment: (1) increasing viral density: HIV appears in the blood during the week preceding onset of PHI illness, and levels are rapidly increasing reaching a peak at about I week following onset of illness; (2) rapid decay: HIV density rapidly decline over a period of about 2 weeks, associated with lymph gland enlargement, CD8+ lymphocytosis, and appearance of IgG-antibodies; (3) slow decay: the clearance of HIV continue but at a rate of only 1/10 or less of the rate during the rapid decline; (4) steady-state: HIV-Ievels reach a steady-state between production and clearance at an average of 3-4 months following infection. We found a significant correlation between PHI peak HIV-RNA plasma levels and steady-state levels, and steady-state levels have, by others, been shown to correlate with disease outcome. We recorded time from seroconversion to development of AIDS; and the "final endpoint"; time to death from AIDS; in about 200 HIV-infected homo-/bisexual men (HS) and injection drug users (IDU) followed for a median time of about 7 years. A more rapid progression of HIV disease was detected in homosexual men than in IDUs; in particular in those who had developed a glandular-fever-like illness at PHI. In summary, a prognostic significance was established for three different variables present even before seroconversion to HIV: mode of transmission, severity of PHI illness, and level of peak viremia at PHI; thus, providing support for initiation of antiretroviral treatment in primary HIV infection. Other investigators had reported a benefit of zidovudine monotherapy in PHI, using surrogate markers in short-term studies. We studied the long-term outcome of 21 zidovudine treated PHI patients vs. 64 non-treated controls and found no significant difference between the two groups. We evaluated a three-drug combination with two nucleoside analogues and one protease inhibitor, in 9 PHI patients. HIV-RNA declined rapidly to below the detection limit (50 copies/mL), in particular in the 6 patients with treatment started within 10 days from onset of PHI illness: all samples drawn day 69 or later from these were HIV-RNA negative.
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| 16. |
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| 17. |
- Lindholm, Daniel, et al.
(author)
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Prediction Of Major Bleeding In Revascularized Patients With Acute Coronary Syndromes : Development Of A Novel Biomarker-Based Clinical Prediction Model
- 2016
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In: Journal of the American College of Cardiology. - Uppsala Univ, Dept Med Sci, Cardiol, Uppsala, Sweden. Uppsala Univ, Uppsala Clin Res Ctr, Uppsala, Sweden.. - 0735-1097 .- 1558-3597. ; 67:13, s. 493-493
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Journal article (other academic/artistic)
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| 18. |
- Milonas, Christos, et al.
(author)
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Effect of Angiotensin-Converting Enzyme Inhibition on One-Year Mortality and Frequency of Repeat Acute Myocardial Infarction in Patients With Acute Myocardial Infarction
- 2010
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In: AMERICAN JOURNAL OF CARDIOLOGY. - : Elsevier Science B. V., Amsterdam. - 0002-9149 .- 1879-1913. ; 105:9, s. 1229-1234
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Journal article (peer-reviewed)abstract
- Controversy exists regarding whether all patients with acute myocardial infarction (AM!) benefit from angiotensin-converting enzyme inhibitors (ACEIs). We examined the association between ACEI treatment and mortality in a large, unselected population of patients with AMI. The present study included 105,224 patients with AMI who were not treated with ACEIs on admission. A logistic regression analysis, including 33 variables, calculated a propensity score for each patient to estimate the probability of receiving ACEIs at discharge, given the background. The association between ACEI treatment at discharge and the 1-year outcome was evaluated in prespecified subgroups using the Cox regression analyses, adjusting for the propensity score and medications at discharge. A total of 38,395 patients (36.5%) received ACEIs at discharge. After adjustment, ACEI treatment was associated with a 24% reduction in mortality (relative risk 0.76, 95% confidence interval 0.73 to 0.80). The benefit was largest in patients with a history or present signs of heart failure. In patients without heart failure, a significant benefit of ACEI treatment was seen only in patients with renal dysfunction (relative risk 0.69, 95% confidence interval 0.54 to 0.88). In the whole group, the risk of AMI decreased by 7% (relative risk 0.93, 95% confidence interval 0.90 to 0.96), with a larger effect seen in patients with ST-segment elevation AMI or systolic left ventricular dysfunction. In conclusion, in unselected patients with AMI, ACEI treatment was associated with a reduction in 1-year mortality, mainly in patients with heart failure or renal dysfunction, and a small reduction in the risk of reinfarction, mainly in patients with ST-segment elevation AMI or systolic left ventricular dysfunction.
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| 19. |
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| 20. |
- Nilsson, Konrad, et al.
(author)
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Fully independent external validation of the Transcatheter Aortic Valve Replacement 30-day (TAVR-30) hospital readmission model
- 2023
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In: Cardiovascular Revascularization Medicine. - : Elsevier. - 1553-8389 .- 1878-0938. ; 56, s. 9-15
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Journal article (peer-reviewed)abstract
- Background: Early and late readmissions after Transcatheter Aortic Valve Replacement (TAVR) are common and associated with worse outcome. A risk prediction model (TAVR-30) was recently developed using readily available clinical variables to identify patients at risk for hospital readmission within 30 days after TAVR. We performed an independent external validation of the TAVR-30 model.Methods: The Swedish TAVR-registry, linked together with other mandatory national registries was used to identify all TAVR procedures, variables from the original model, hospitalizations and deaths between the years 2008 to 2021.Results: A total of 8459 patients underwent TAVR, 7693 patients had complete data and were included in the analysis. Out of these, 928 patients experienced a readmission within 30 days. Using the estimates from the original model, a concordance (c)-index of 0.51, a calibration slope of 0.07 and intercept of −0.62 were obtained respectively, overall implying poor model performance.Conclusions: This independent external validation indicates poor performance of the TAVR-30 model in a Swedish setting. Further research is needed to develop more reliable tools for predicting the risk of early hospital readmission after TAVR, as well as, for providing a deeper understanding of how to develop risk models that performs well in patients with multiple underlying comorbidities.
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| 21. |
- Nilsson, Konrad, et al.
(author)
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Regional assessment of availability for transcatheter aortic valve implantation in Sweden : a long-term observational study
- 2023
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In: European Heart Journal - Quality of Care and Clinical Outcomes. - : Oxford University Press. - 2058-5225 .- 2058-1742.
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Journal article (peer-reviewed)abstract
- BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an increasingly important treatment option for patients with severe aortic stenosis. Its best implementation is debated, as few centres with high volumes are associated with better outcomes, while centralisation might lead to an inferior availability of treatment for patients living far away. The aim of this study was to investigate the implementation of TAVI in Sweden with a focus on regional differences in terms of availability, short-term mortality and waiting times.METHODS: All patients undergoing TAVI between 2008 and 2020 from the Swedish Transcatheter Cardiac Intervention Registry (SWENTRY) were included. SWENTRY was linked to the National Cause of Death Registry and to publicly available geospatial data from Statistics Sweden.RESULTS: A total of 7280 patients were included. Over time, TAVI interventions increased markedly, while surgical aortic valve replacement (SAVR) remained constant. There were no statistically significant regional differences in incidence between counties with or without a local TAVI centre (p = 0.7) and no clustering tendencies around regions with a local TAVI centre (p = 0.99). Thirty-day mortality improved over time without evidence of regional differences. No regional differences in waiting time from decision to intervention were found for TAVI centre regions and non-TAVI centre regions (p = 0.7).CONCLUSION: This nationwide study indicated no regional differences in terms of availability, short-term mortality or waiting times. An organisation with a few specialised centres was found to be sufficient to provide national coverage of TAVI interventions.
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| 22. |
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| 23. |
- Olofsson, Thomas, et al.
(author)
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Produktmodeller i ett flexibelt industriellt byggande
- 2004
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Reports (other academic/artistic)abstract
- PROFLEX projektet har studerat hur moderna produktorienterade IT - system kan stödja ett flexibelt industriellt byggande. Två informationssystem har studerats. Ett produktmodellorienterat system där informationen samlas på ett ställe och är tillgänglig för alla parter i projekteringsskedet. Ett MPS system för styrning av materialflödet och produktion i företaget Nödvändiga tekniska förutsättningar är:(1) Informationsmodellen (produktstrukturen) skall anpassas till företagets projekterings och produktionsprocess eller vice versa. Produktstrukturen måste också kunna kommuniceras mellan produktmodellen och MPS systemet.(2) Informell information om leveransprocess, produktionssystem etc. måste kunna formaliseras i artikel- och leverantörsregister, ställtider, produktionstider och ledtider för olika produktionsenheter för att kunna hanteras av systemen. Organisationen bör vara processorienterad och de industriella arbetsmetoderna utvecklade för att företaget skall kunna utnyttja systemens fördelar till fullo. Det är en klar fördel om företaget "äger" stora delar av affärsprocessen eftersom förändringar i arbetsflöde och metoder kan vara nödvändiga när systemen införs i organisationen. En IT strategi bör också formuleras och tas av ledningen. Införande bör göras i små steg för att minimera störningar i produktionen och medge tid för anpassning, integration och utbildning. Det är viktigt att utbildningen inte bara handlar om hur utan också talar om varför för att få acceptans i organisationen. Projektet har också visat att problematiken med kundanpassningar som val och tillval i produktion av bostadsrätter kan hanteras med tilläggsfunktioner som integreras i den föreslagna systemlösningen. De ekonomiska effekterna är svåra att uppskatta eftersom systemen påverkar kärnprocesserna i företaget. Utfallet styrs av hur väl systemen kan integreras, nyttjas och utvecklas i takt med att produkten och produktionsmetoderna utvecklas. Kvalitetsförbättringar fås genom att teknologin stödjer, spårbarhet, versionshantering på komponentnivå samt en säker informationshantering av val och tillval Processerna kan förbättras genom att systemen stödjer en samtidig projekteringsprocess, återanvändning av modellinformation på komponentnivå, en tätare integration med underleverantörer, bättre produktionsstyrning och uppföljning samt hantering av flera parallella projekt i produktionen. Nackdelar och risker är att systemen kan upplevas som krångliga eller onödiga. Nödvändig information läggs inte in i systemen. Processerna i företaget är inte kompatibla med valda lösning eller att systemen inte nyttjas i den grad som är möjligt. Misslyckade implemente- ringar kan ofta härledas till brister i upphandling, införandet och utbildning. Den kanske mest avgörande faktorn (viktigare än val av system) är att alla strävar mot ett gemensamt, tydligt och realistiskt mål och vet varför systemen används. För att nyttan och rationaliseringsvinsterna skall kunna tas tillvara i byggprojekt i allmänhet krävs framförallt nya organisationsformer och arbetsmetoder. Idag saknas drivkraft för att det skall ske spontant. Det finns ingen efterfrågan av 3D - orienterade produktmodeller i projekteringsskedet därför att entreprenören saknar system som kan hantera och vidareförädla den projekterade produktstrukturen i inköps och produktionsledet. Den nytta som produktmodeller kan ha i förvaltningsskedet är idag alltför liten för att beställarna skall ställa sig på barrikaderna och driva utvecklingen. Eftersom den omedelbara nyttan och dom största vinsterna kan göras i en effektivare inköpsprocess, materialflöde och produktionsprocess så tror utredarna att utveckling mot en produktmodellorienterad process först kommer att implementeras i specialiserade företag som producerar nischade produkter som byggelement, volymer, stommar och hallar o. dyl. Om teknologin skall tillämpas i normala byggprojekt över organisationsgränser måste flera aktörer samverka och dela risken (och vinsten). Långsiktiga nätverk i form av strategisk partnering är en möjlig plattform. Andra former kan vara samägda bolag, bestående av specialister, konsulter och entreprenörer som utvecklar och implementerar arbetsmetoder, produktstrukturer i olika byggprojekt. Det är viktigt att vara uthållig eftersom den fulla nyttan fås först när system och arbetsmetoder har trimmats in. Effekten på sikt blir antagligen en ökad industrialisering och bättre leverantörssamverkan eftersom teknologin i sig bygger på produktstrukturer där återanvändning av komponenter, korta leveranstider och effektiva produktionsformer premieras.
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| 24. |
- Sandström, Eric, et al.
(author)
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Antiretroviral treatment of human immunodeficiency virus infection: Swedish recommendations
- 2003
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In: Scand J Infect Dis. - : Informa UK Limited. ; 35:3, s. 155-67
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Research review (peer-reviewed)abstract
- The Swedish guidelines (SwG) for treatment of human immunodeficiency virus (HIV) infection have several important roles. A major task involves the promotion of a uniformly high standard of care in all HIV treatment clinics in Sweden and the identification of strengths, weaknesses and relevance of recent research findings. CD4+ T-cell counts < 200 cells/microl are clear indications for the initiation of treatment, whereas high viral loads serve as an indication for increased vigilance rather than a criterion for therapy. It is recommended that the first regimen consists of 2 nucleoside reverse transcriptase inhibitors in combination with 1 protease inhibitor or 1 non-nucleoside reverse transcriptase inhibitor. The definition of treatment failure is rigorous. Treatment change should be considered if the viral load has not fallen by at least 1.5 log in 4 weeks or is undetectable within 3-4 months. Resistance testing is endorsed at primary infection, in the event of treatment failure and in pregnant women. Interaction with experts in HIV resistance testing is emphasized. Therapeutic drug monitoring is advocated. Patients with treatment failure should be handled individually and the decision on therapeutic strategy should be based on treatment history, resistance testing and other clinical facts. The SwG do not give recommendations for some important issues such as prolonged drug holidays and preferences in initial treatment regimens. More scientific data are likely to be available soon and the SwG will be refined accordingly. The present guidelines are translated from Swedish; they are published on the Medical Products Agency (MPA) and Swedish Reference Group for Antiviral Therapy (RAV) websites (www.mpa.se and www.rav.nu.se), including 7 separate papers based on a thorough literature search. A complete reference list is available on request from the MPA.
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| 25. |
- Sjölin, Karl, et al.
(author)
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Plasma neurofilament light chain is elevated after transcatheter aortic valve implantation
- 2023
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In: Cardiology. - : S. Karger. - 0008-6312 .- 1421-9751. ; 148:5, s. 478-483
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Journal article (peer-reviewed)abstract
- Introduction: Transcatheter aortic valve implantation (TAVI) is associated with a high incidence of new silent brain infarcts (SBIs) on postprocedural neuroimaging. A venous blood sample reflecting neuronal damage following TAVI could help identify patients with potential SBIs. We aimed to investigate if a biochemical marker of neuronal injury, neurofilament light chain (NFL), is elevated after TAVI.Methods: In this observational study, NFL was measured in plasma from 31 patients before and after TAVI. Multivariable regression analysis was performed to investigate any effect of clinical- and procedure-related factors on differences in NFL levels before and after TAVI. Results: Samples were collected 41 (14–81) days before and 44 (35–59) days after TAVI, median (interquartile range). Median age was 81 (77–84) years, and 35% were female. No patient had any overt procedure-related neurological complications. The geometric mean (95% confidence interval) of the NFL concentration was 30 (25–36) pg/mL before TAVI and 48 (39–61) pg/mL, after TAVI, p <0.001. None of the included variables in the multiple linear regression model were statistically significantly associated with the difference in levels before and after TAVI.Conclusions: NFL levels in plasma were higher after TAVI as compared with levels before, with a mean increase of 60% (18 pg/mL). Further studies including neuroimaging and cognitive outcomes are needed to understand the potential value of measuring NFL in relation to TAVI.
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| 26. |
- Stenestrand, Ulf, et al.
(author)
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Safety and efficacy of drug-eluting vs. bare metal stents in patients with diabetes mellitus : long-term follow-up in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)
- 2010
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In: European Heart Journal. - : Oxford University Press (OUP). - 0195-668X .- 1522-9645. ; 31:2, s. 177-186
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Journal article (peer-reviewed)abstract
- AIMS: Patients with diabetes mellitus have more extensive coronary artery disease, more disease progression, and restenosis. The use of drug-eluting stents (DES) in these patients is widespread, despite uncertain long-term safety and efficacy. METHODS AND RESULTS: All consecutive patients with diabetes mellitus in Sweden who underwent percutaneous coronary intervention were entered into the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) during 2003-06 with complete follow-up for 1-4 years (median 2.5). Patients who received at least one DES (n = 4754) were compared with those who received only bare metal stents (BMS) (n = 4956) at the index procedure. Combined outcome of death or myocardial infarction (MI) showed no difference for DES vs. BMS, relative risk (RR), 0.91 [95% confidence interval (CI), 0.77-1.06]. Myocardial infarction was significantly less common with DES in patients who received only one stent RR, 0.80 (95% CI, 0.66-0.96). The restenosis rate was 50% lower in DES-treated patients RR, 0.50 (95% CI, 0.35-0.70) and was associated with a higher adjusted RR of MI, RR, 5.03 (95% CI, 4.25-5.97). DES was associated with reduced restenosis rates in all subgroups of diabetic patients with the greatest benefit in stent diameters <3 mm or stent length >20 mm. The number of lesions treated with DES to prevent one restenosis ranged from 11 to 47 in various subgroups. CONCLUSION: This real-life registry study shows that restenosis was halved by DES in diabetic patients with stable or unstable coronary disease, with similar risk of death or MI up to 4 years compared with BMS.
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| 27. |
- Szummer, Karolina, et al.
(author)
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Cockcroft-Gault is better than the Modification of Diet in Renal Disease study formula at predicting outcome after a myocardial infarction : Data from the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART)
- 2010
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In: American Heart Journal. - : Elsevier BV. - 0002-8703 .- 1097-6744. ; 159:6, s. 979-986
-
Journal article (peer-reviewed)abstract
- Background The aim was to examine whether the Modification of Diet in Renal Disease (MDRD) or the Cockcroft-Gault (CG) formula is better at predicting prognosis in myocardial infarction (MI) patients. Methods All consecutive MI patients entered in a nationwide registry between 2003 and 2006 with glomerular filtration rate (eGFR) estimated by both the MDRD and CG formula (N = 36,137) were analyzed. Results Cockcroft-Gault classified a larger proportion of patients as having at least a moderate (39.8% vs 31.1%, P<.001) or at least a severe renal dysfunction (7.6% vs 4.4%, P<.001) compared with the MDRD. The largest difference between the estimations was seen when patients were divided according to gender, age, and weight, where CG estimated a lower eGFR in women, the elderly, and those with low body weight. In a receiver operating characteristic analysis, CG had a stronger association to 1-year mortality (area under the curve 0.78, 95% CI 0.77-0.79) than MDRD (area under the curve 0.73, 95% CI 0.72-0.74). Within each renal function stage classified with the MDRD, there were patients identified with the CG as having both a worse renal function and a higher mortality. After multivariable adjustment, CG predicted 1-year mortality better than the MDRD (renal failure vs normal renal function: hazard ratio 3.00, 95% CI 2.42-3.71 with the CG; hazard ratio 2.56, 95% CI 2.10-3.11 with the MDRD). Conclusion Cockcroft-Gault is better than the MDRD equation at predicting mortality after a MI. This is mainly explained by differences in the coefficients and variables included in the eGFR equations, and less to differences in various subgroups of patients.
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| 28. |
- Södergård, Björn, et al.
(author)
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Adherence to treatment in Swedish HIV infected patients
- 2006
-
In: Journal of Clinical Pharmacy and Therapeutics. - : Hindawi Limited. - 0269-4727 .- 1365-2710. ; 31:6, s. 605-616
-
Journal article (peer-reviewed)abstract
- Objectives: The objectives were to assess the prevalence of adherence to antiretroviral treatment in Swedish human immunodeficiency virus (HIV)-infected patients and to evaluate factors associated with adherence. Methods: All HIV-treated patients, who attended one of 30 (of a total of 32) Swedish infectious diseases clinics, during 7 months, were asked to complete an anonymous questionnaire containing the 9-item Morisky Medication Adherence Scale (MMAS) and questions about other factors potentially affecting adherence. The summary score of MMAS ranges from 1 to 13, where 13 indicates perfect adherence; patients scoring 11 or above (corresponding to 95% adherence level) were classified as 'adherent'. Results and discussion: In total 946 patients participated (response rate 97.5%). The proportion of patients who reported not missing a dose during the day prior to the completion of the questionnaire was 97% and the proportion classified as 'adherent' was 63%. 'Adherent' patients were more likely to have a good relationship with their health care professionals (P < 0.05) and not have problems with drugs or alcohol (P < 0.01). Being older (P < 0.01) and having a shorter time on current treatment (P < 0.01) and on treatment in total (P < 0.05) were factors also associated with good adherence. Conclusion: Factors modifiable for interventions by health care professionals are patient-provider relationship, drug or alcohol problems and patients with long treatment periods.
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| 29. |
- Södergård, Björn, et al.
(author)
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Differences in adherence and motivation to HIV therapy : Two independent assessments in 1998 and 2002
- 2006
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In: Pharmacy World & Science. - : Springer Science and Business Media LLC. - 0928-1231 .- 1573-739X. ; 28:4, s. 248-256
-
Journal article (peer-reviewed)abstract
- Objective: The aim of this study was to compare the level of adherence and motivation in two independent cross-sectional samples of HIV-infected patients conducted in 1998 and 2002, and to investigate the relationship between adherence and motivation. Method: Consecutive HIV-infected patients on treatment at a Swedish clinic were asked to complete an anonymous questionnaire. In 1998, 60 patients participated and in 2002, 53 participated. In 2002, the 9-item Morisky Medication Adherence Scale (MMAS) was added to the questionnaire set. Main outcome measure: Self-reported adherence and motivation. Results: In 1998, 28.1% of the respondents were considered adherent, while the corresponding proportion was 57.4% in 2002 (P = 0.002). The mean summary score for MMAS was 10.7 in 2002 (13 = perfect adherence). The proportion considered motivated were 22.4% in the 1998 survey and 41.3% in 2002 (P = 0.038). Of the respondents considered motivated in the 2002 survey, 46.7% scored the maximum summary score on the MMAS, while 8.7% of the non-motivated respondents did so (P = 0.016). Conclusion: The respondents in 2002 were more adherent and motivated than the respondents in 1998 and a relationship between motivation and adherence was found. The difference in adherence and motivation might be due to a new treatment model at the clinic.
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