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  • Khunti, Kamlesh, et al. (författare)
  • Statin Use in Primary Prevention : A Simple Trial-Based Approach Compared With Guideline-Recommended Risk Algorithms for Selection of Eligible Patients
  • 2019
  • Ingår i: Canadian Journal of Cardiology. - : ELSEVIER SCIENCE INC. - 0828-282X .- 1916-7075. ; 35:5, s. 644-652
  • Tidskriftsartikel (refereegranskat)abstract
    • Background: Cardiovascular disease risk assessment tools help identify individuals likely to benefit from preventative therapies. In this study we compared outcomes using the American College of Cardiology/American Heart Association (ACC/AHA) risk algorithm and the Framingham Risk Score (FRS) tool in the Heart Outcomes Prevention Evaluation (HOPE)-3 study.Methods: We compared outcomes using the ACC/AHA algorithm and the FRS with those seen in HOPE-3, which randomized participants to 10 mg rosuvastatin or placebo. The first coprimary outcome was the composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke; second coprimary outcome additionally included heart failure, cardiac arrest, and revascularization.Results: Relative risks using risk scores were similar to those observed in the HOPE-3. Hazards ratios for the first coprimary outcome according to risk categories of <= 10%, 10%-20%, and <= 20% using the ACC/AHA algorithm were 0.82 (95% confidence interval [CI], 0.53-1.28), 0.72 (95% CI, 0.53-0.96), and 0.72 (95% CI, 0.55-0.93), and absolute risk reduction (ARR) of 0.18%, 1.33%, and 1.85%, respectively, over a median of 5.6 years. Corresponding results using the FRS were 0.69 (95% CI, 0.36-1.35), 0.73 (95% CI, 0.52-1.01), and 0.75 (95% CI, 0.60-0.94); and ARR of 1.32%, 0.61%, and 1.43%. Hazard ratios for the second coprimary outcome were 0.77 (95% CI, 0.51-1.14), 0.73 (95% CI, 0.56-0.95), and 0.74 (95% CI, 0.58-0.94); and ARR of 0.36%, 1.49%, and 1.85%, using the ACC/AHA algorithm and 0.76 (95% CI, 0.41-1.41), 0.70 (95% CI, 0.52-0.95), and 0.76 (95% CI, 0.62-0.94); and ARR of 1.08%, 0.83%, and 1.56% using the FRS.Conclusions: The pragmatic HOPE-3 trial approach identifies in an ethnically diverse primary prevention population individuals at intermediate risk who benefit from statin therapy using simple clinical characteristics without the need for complex, currently used risk assessment tools.
  • Liljeroos, Thea, et al. (författare)
  • Self-perceived cognitive status and cognitive challenges associated with cardiac rehabilitation management : experiences of elderly myocardial infarction patients.
  • 2021
  • Ingår i: Disability and Rehabilitation. - 0963-8288 .- 1464-5165. ; , s. 1-9
  • Tidskriftsartikel (refereegranskat)abstract
    • PURPOSE: The study aimed to explore the self-perceived cognitive status and cognitive challenges associated with lifestyle changes in cardiac rehabilitation among elderly myocardial infarction (MI) patients (≥65 years). Further, the study explored coping strategies developed to manage these challenges in the everyday life.METHODS: Nine patients were included in the study. Data were collected by telephone or in person, between 6 and 12 weeks post MI, using semi-structured interviews. Data were analysed inductively, using thematic analysis.RESULTS: Four major themes were identified, highlighting elderly MI patients' experiences of their cognitive status and cardiac rehabilitation management: (1) A change in cognition over time, (2) Situating the MI within a challenging and changing life context, (3) Navigating the hurdles of cardiac rehabilitation, and (4) Being seen within the healthcare system.CONCLUSION: Elderly MI patients are situated in a complex life context, dealing with a transition to retirement, multiple health issues and age-related cognitive decline. In this context, the MI experience is marginalised, and cognitive decline normalized. By adopting individually tailored interventions and improving healthcare provider continuity and accessibility, cognitive challenges associated with cardiac rehabilitation could be easier to overcome.IMPLICATIONS FOR REHABILITATIONSelf-perceived cognitive impairment, in particular regarding memory, seems fairly common among elderly MI patients and should likely be identified prior to hospital discharge in order to optimize the prospects of self-care.There seems to exist an unmet need to implement the practice of individually adapted education and information further, in accordance with current recommendations for elderly cardiac patients.The overall health and cognitive status, social network and the objective living conditions (e.g., distance from service and housing) should be taken into account when planning the patient's cardiac rehabilitation management.Healthcare providers likely need to strengthen the continuity of care and increase its accessibility for elderly MI patients, in particular following the transfer from hospital care to local health centres.
  • Lindholm, Daniel, 1982-, et al. (författare)
  • Biomarker-Based Risk Model to Predict Cardiovascular Mortality in Patients With Stable Coronary Disease
  • 2017
  • Ingår i: Journal of the American College of Cardiology. - : Elsevier. - 0735-1097 .- 1558-3597. ; 70:7, s. 813-826
  • Tidskriftsartikel (refereegranskat)abstract
    • Background Currently, there is no generally accepted model to predict outcomes in stable coronary heart disease (CHD).Objectives This study evaluated and compared the prognostic value of biomarkers and clinical variables to develop a biomarker-based prediction model in patients with stable CHD.Methods In a prospective, randomized trial cohort of 13,164 patients with stable CHD, we analyzed several candidate biomarkers and clinical variables and used multivariable Cox regression to develop a clinical prediction model based on the most important markers. The primary outcome was cardiovascular (CV) death, but model performance was also explored for other key outcomes. It was internally bootstrap validated, and externally validated in 1,547 patients in another study.Results During a median follow-up of 3.7 years, there were 591 cases of CV death. The 3 most important biomarkers were N-terminal pro–B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), and low-density lipoprotein cholesterol, where NT-proBNP and hs-cTnT had greater prognostic value than any other biomarker or clinical variable. The final prediction model included age (A), biomarkers (B) (NT-proBNP, hs-cTnT, and low-density lipoprotein cholesterol), and clinical variables (C) (smoking, diabetes mellitus, and peripheral arterial disease). This “ABC-CHD” model had high discriminatory ability for CV death (c-index 0.81 in derivation cohort, 0.78 in validation cohort), with adequate calibration in both cohorts.Conclusions This model provided a robust tool for the prediction of CV death in patients with stable CHD. As it is based on a small number of readily available biomarkers and clinical factors, it can be widely employed to complement clinical assessment and guide management based on CV risk. (The Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy Trial [STABILITY]; NCT00799903)
  • Lissåker, Claudia, et al. (författare)
  • Persistent emotional distress after a first-time myocardial infarction and its assocation to late cardiovascular and non-cardiovascular mortality
  • 2019
  • Ingår i: European Journal of Preventive Cardiology. - 2047-4873 .- 2047-4881. ; 26:14, s. 1510-1518
  • Tidskriftsartikel (refereegranskat)abstract
    • BACKGROUND:Patients with symptoms of depression and/or anxiety - emotional distress - after a myocardial infarction (MI) have been shown to have worse prognosis and increased healthcare costs. However, whether specific subgroups of patients with emotional distress are more vulnerable is less well established. The purpose of this study was to identify the association between different patterns of emotional distress over time with late cardiovascular and non-cardiovascular mortality among first-MI patients aged <75 years in Sweden.METHODS:We utilized data on 57,602 consecutive patients with a first-time MI from the national SWEDEHEART registers. Emotional distress was assessed using the anxiety/depression dimension of the European Quality of Life Five Dimensions questionnaire two and 12 months after the MI, combined into persistent (emotional distress at both time-points), remittent (emotional distress at the first follow-up only), new (emotional distress at the second-follow up only) or no distress. Data on cardiovascular and non-cardiovascular mortality were obtained until the study end-time. We used multiple imputation to create complete datasets and adjusted Cox proportional hazards models to estimate hazard ratios.RESULTS:Patients with persistent emotional distress were more likely to die from cardiovascular (hazard ratio: 1.46, 95% confidence interval: 1.16, 1.84) and non-cardiovascular causes (hazard ratio: 1.54, 95% confidence interval: 1.30, 1.82) than those with no distress. Those with remittent emotional distress were not statistically significantly more likely to die from any cause than those without emotional distress.DISCUSSION:Among patients who survive 12 months, persistent, but not remittent, emotional distress was associated with increased cardiovascular and non-cardiovascular mortality. This indicates a need to identify subgroups of individuals with emotional distress who may benefit from further assessment and specific treatment.
  • Lissåker, Claudia T., et al. (författare)
  • Emotional Distress as a Predictor of Statin Non-adherence among Swedish First-Time Myocardial Infarction Patients, 2006–2013
  • 2017
  • Ingår i: Journal of Psychosomatic Research. - 0022-3999 .- 1879-1360. ; 97, s. 30-37
  • Tidskriftsartikel (refereegranskat)abstract
    • Background: Emotional distress (depression and anxiety) has been known to affect mortality after a myocardial infarction (MI). One possible mechanism is through medication non-adherence. Few studies have investigated the link between statin adherence and emotional distress, and results are not consistent. We aimed to explore whether emotional distress affects adherence among first-time MI patients younger than 75 years old receiving a prescription for the first time.Methods: We identified first-MI individuals younger than 75 years from the SWEDEHEART national quality registers discharged with a statin prescription. The main exposure was the anxiety/depression portion of the EQ-5D from Interview 1 (6-10 weeks post -MI) and Interview 2 (12-14 months post -MI). We calculated adherence from the Swedish Prescribed Drugs Register during three observation periods (OP): [1] Interview 1 to Interview 2, [2] one year post Interview 2, and [3] two years post Interview 1.Results: Emotional distress at Interview 1 was not associated with statin adherence for OP1 (RR: 0.99, 95% CI: 0.98, 1.01). Emotional distress at Interview 2 was associated with lower adherence one year later (RR: 0.95, 95% CI: 0.93, 0.98). Emotional distress at Interview 1 was associated with a small decrease in adherence in the complete OP for adherence (RR: 0.98, 95% CI: 0.96, 0.99).Conclusion: Emotional distress was marginally, but independently, associated with lower adherence to statin two years after the MI. Our study suggests that emotional distress may be an important factor for long-term statin adherence, and, thus, may play a clinically important role in long-term outcome.
  • Lopes, Renato D., et al. (författare)
  • Intracranial hemorrhage in patients with atrial fibrillation receiving anticoagulation therapy
  • 2017
  • Ingår i: Blood. - : AMER SOC HEMATOLOGY. - 0006-4971 .- 1528-0020. ; 129:22, s. 2980-2987
  • Tidskriftsartikel (refereegranskat)abstract
    • We investigated the frequency and characteristics of intracranial hemorrhage (ICH), the factors associated with the risk of ICH, and outcomes post-ICH overall and by randomized treatment. We identified patients with ICH from the overall trial population enrolled in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation trial who received >= 1 dose of the study drug (n = 18 140). ICH was adjudicated by a central committee. Cox regression models were used to identify factors associated with ICH. ICH occurred in 174 patients; most ICH events were spontaneous (71.7%) versus traumatic (28.3%). Apixaban resulted in significantly less ICH (0.33% per year), regardless of type and location, than warfarin (0.80% per year). Independent factors associated with increased risk of ICH were enrollment in Asia or Latin America, older age, prior stroke/transient ischemic attack, and aspirin use at baseline. Among warfarin-treated patients, the median (25th, 75th percentiles) time from most recent international normalized ratio (INR) to ICH was 13 days (6, 21 days). Median INR prior to ICH was 2.6 (2.1, 3.0); 78.5% of patients had a pre-ICH INR <3.0. After ICH, the modified Rankin scale score at discharge was >= 4 in 55.7% of patients, and the overall mortality rate at 30 days was 43.3% with no difference between apixaban- and warfarin-treated patients. ICH occurred at a rate of 0.80% per year with warfarin regardless of INR control and at a rate of 0.33% per year with apixaban and was associated with high short-termmorbidity and mortality. This highlights the clinical relevance of reducing ICH by using apixaban rather than warfarin and avoiding concomitant aspirin, especially in patients of older age. This trial was registered at www.clinicaltrials.gov as #NCT00412984.
  • Lundman, Pia, et al. (författare)
  • A high-fat meal is accompanied by increased plasma interleukin-6 concentrations
  • 2007
  • Ingår i: NMCD. Nutrition Metabolism and Cardiovascular Diseases. - 0939-4753 .- 1590-3729. ; 17:3, s. 195-202
  • Tidskriftsartikel (refereegranskat)abstract
    • BACKGROUND AND AIM: Enhanced and prolonged postprandial lipaemia is associated with coronary heart disease (CHD). However, the mechanisms linking postprandial lipaemia to the increased risk of atherosclerosis and CHD remain to be determined. The aim of the present study was to examine the effects of a high-fat meal on plasma levels of the pro-inflammatory cytokine interleukin-6 (IL-6) and cellular adhesion molecules in CHD patients and control subjects. METHODS AND RESULTS: Forty-one middle-aged men with premature CHD and 26 healthy male controls were investigated. The plasma triglyceride response to the high-fat meal was significantly greater among cases than controls. The oral fat load induced a twofold increase in plasma concentrations of IL-6, an increase that was similar in CHD patients and control subjects. No changes could be detected in plasma concentrations of cellular adhesion molecules in response to postprandial lipaemia in either CHD patients or control subjects. CONCLUSION: The results of the present study suggest that a high-fat meal affects mechanisms that induce increased inflammatory activity, which is recognised as a key modulator in the development of atherosclerosis and CHD. However, the increased levels of plasma IL-6 appear not to be determined by the magnitude of the postprandial triglyceridaemia.
  • Mahaffey, Kenneth W., et al. (författare)
  • Ticagrelor Compared With Clopidogrel by Geographic Region in the Platelet Inhibition and Patient Outcomes (PLATO) Trial
  • 2011
  • Ingår i: Circulation. - 0009-7322 .- 1524-4539. ; 124:5, s. 544-554
  • Tidskriftsartikel (refereegranskat)abstract
    • Background-In the Platelet Inhibition and Patient Outcomes (PLATO) trial, a prespecified subgroup analysis showed a significant interaction between treatment and region (P = 0.045), with less effect of ticagrelor in North America than in the rest of the world. Methods and Results-Reasons for the interaction were explored independently by 2 statistical groups. Systematic errors in trial conduct were investigated. Statistical approaches evaluated the likelihood of play of chance. Cox regression analyses were performed to quantify how much of the regional interaction could be explained by patient characteristics and concomitant treatments, including aspirin maintenance therapy. Landmark Cox regressions at 8 time points evaluated the association of selected factors, including aspirin dose, with outcomes by treatment. Systematic errors in trial conduct were ruled out. Given the large number of subgroup analyses performed and that a result numerically favoring clopidogrel in at least 1 of the 4 prespecified regions could occur with 32% probability, chance alone cannot be ruled out. More patients in the United States (53.6%) than in the rest of the world (1.7%) took a median aspirin dose >= 300 mg/d. Of 37 baseline and postrandomization factors explored, only aspirin dose explained a substantial fraction of the regional interaction. In adjusted analyses, both Cox regression with median maintenance dose and landmark techniques showed that, in patients taking low-dose maintenance aspirin, ticagrelor was associated with better outcomes compared with clopidogrel, with statistical superiority in the rest of the world and similar outcomes in the US cohort. Conclusions-The regional interaction could arise from chance alone. Results of 2 independently performed analyses identified an underlying statistical interaction with aspirin maintenance dose as a possible explanation for the regional difference. The lowest risk of cardiovascular death, myocardial infarction, or stroke with ticagrelor compared with clopidogrel is associated with a low maintenance dose of concomitant aspirin.
  • Mahmoodi, Bakhtawar K., et al. (författare)
  • Association of Factor V Leiden With Subsequent Atherothrombotic Events A GENIUS-CHD Study of Individual Participant Data
  • 2020
  • Ingår i: Circulation. - : LIPPINCOTT WILLIAMS & WILKINS. - 0009-7322 .- 1524-4539. ; 142:6, s. 546-555
  • Tidskriftsartikel (refereegranskat)abstract
    • Background: Studies examining the role of factor V Leiden among patients at higher risk of atherothrombotic events, such as those with established coronary heart disease (CHD), are lacking. Given that coagulation is involved in the thrombus formation stage on atherosclerotic plaque rupture, we hypothesized that factor V Leiden may be a stronger risk factor for atherothrombotic events in patients with established CHD. Methods: We performed an individual-level meta-analysis including 25 prospective studies (18 cohorts, 3 case-cohorts, 4 randomized trials) from the GENIUS-CHD (Genetics of Subsequent Coronary Heart Disease) consortium involving patients with established CHD at baseline. Participating studies genotyped factor V Leiden status and shared risk estimates for the outcomes of interest using a centrally developed statistical code with harmonized definitions across studies. Cox proportional hazards regression models were used to obtain age- and sex-adjusted estimates. The obtained estimates were pooled using fixed-effect meta-analysis. The primary outcome was composite of myocardial infarction and CHD death. Secondary outcomes included any stroke, ischemic stroke, coronary revascularization, cardiovascular mortality, and all-cause mortality. Results: The studies included 69 681 individuals of whom 3190 (4.6%) were either heterozygous or homozygous (n=47) carriers of factor V Leiden. Median follow-up per study ranged from 1.0 to 10.6 years. A total of 20 studies with 61 147 participants and 6849 events contributed to analyses of the primary outcome. Factor V Leiden was not associated with the combined outcome of myocardial infarction and CHD death (hazard ratio, 1.03 [95% CI, 0.92-1.16];I-2=28%;P-heterogeneity=0.12). Subgroup analysis according to baseline characteristics or strata of traditional cardiovascular risk factors did not show relevant differences. Similarly, risk estimates for the secondary outcomes including stroke, coronary revascularization, cardiovascular mortality, and all-cause mortality were also close to identity. Conclusions: Factor V Leiden was not associated with increased risk of subsequent atherothrombotic events and mortality in high-risk participants with established and treated CHD. Routine assessment of factor V Leiden status is unlikely to improve atherothrombotic events risk stratification in this population.
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