| 41. |
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| 42. |
- Flachskampf, Frank, 1957-, et al.
(author)
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The Role of Novel Cardiac Imaging for Contemporary Management of Heart Failure
- 2022
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In: Journal of Clinical Medicine. - : MDPI. - 2077-0383. ; 11:20
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Research review (peer-reviewed)abstract
- Heart failure is becoming the central problem in cardiology. Its recognition, differential diagnosis, and the monitoring of therapy are intimately coupled with cardiac imaging. Cardiac imaging has witnessed an explosive growth and differentiation, with echocardiography continuing as the first diagnostic step; the echocardiographic exam itself has become considerably more complex than in the last century, with the assessment of diastolic left ventricular function and strain imaging contributing important information, especially in heart failure. Very often, however, echocardiography can only describe the fact of functional impairment and morphologic remodeling, whereas further clarification of the underlying disease, such as cardiomyopathy, myocarditis, storage diseases, sarcoidosis, and others, remains elusive. Here, cardiovascular magnetic resonance and perfusion imaging should be used judiciously to arrive as often as possible at a clear diagnosis which ideally enables specific therapy.
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| 43. |
- Gard, Anton, et al.
(author)
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Diagnosing type 2 myocardial infarction in clinical routine. A validation study
- 2019
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In: Scandinavian Cardiovascular Journal. - : TAYLOR & FRANCIS LTD. - 1401-7431 .- 1651-2006. ; 53:5, s. 259-265
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Journal article (peer-reviewed)abstract
- Objective. Since 2010, myocardial infarction (MI) patients reported to the Swedish registry for MI (SWEDEHEART) are routinely classified into MI subtypes. The registry has been used to study the type 2 MI population but the MI-classification in the registry has not previously been validated. The aim of this study was to validate the type 2 MI classification in the registry. Design. A total of 772 patients diagnosed with MI in 2011 and reported to the SWEDEHEART registry were included in the study. All patients were retrospectively classified into MI type 1-5 or myocardial injury by independent reviewers strictly adhering to The Third Universal Definition of MI. This gold standard classification was compared with the classification in the registry. Results. Forty-eight (6.2%) patients were classified as type 2 MI in the registry compared with 93 (12.0%) according to the gold standard classification. A type 2 MI diagnosis was confirmed in 30 out of the 48 type 2 MI patients in the registry (PPV: 62.5%). There was a moderate rate of agreement (kappa: 0.43) between the gold standard classification and the classification in SWEDEHEART in deciding a type 2 MI diagnosis. Conclusion. The SWEDEHEART registry agreed moderately with the gold standard in classifying patients with type 2 MI diagnosis. Thus, studies on patients with type 2 MI in the registry should be interpreted with caution. Since the prevalence of type 2 MI is substantially underestimated in SWEDEHEART, the registry should not be used to study the prevalence of type 2 MI.
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| 44. |
- Gard, Anton, 1985-, et al.
(author)
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Effect on long term mortality of clinical myocardial infarction diagnosis in non-type 1 myocardial infarction
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Other publication (other academic/artistic)abstract
- ObjectiveType 2 myocardial infarction (MI) and myocardial injury are common conditions among patients with elevated cardiac troponins, both giving rise to therapeutic uncertainty among physicians since the effects of treating any of these conditions as MI are unknown. Therefore, the objective of this study was to compare treatment and prognosis in type 2 MI and myocardial injury, with and without a clinical MI diagnosis.DesignThis observational study included two cohorts; one with 964 consecutive patients with a clinical MI diagnosis and one with 281 consecutive patients without a clinical MI diagnosis in 2011. All were followed regarding all-cause death until February 2017 and all cases were retrospectively adjudicated into MI types or myocardial injury. Adjudicated type 2 MI and myocardial injury patients with a clinical MI diagnosis were compared to those without a clinical MI diagnosis.ResultsDiagnosis adjudication identified 138 and 37 type 2 MI and 86 and 185 myocardial injury with and without a clinical MI diagnosis respectively. In adjudicated type 2 MI, a clinical MI diagnosis was associated with more coronary angiography investigations (39.1% vs 5.4%, p <0.001) and an increased use of Aspirin, P2Y12 inhibitors, RAAS-blockers, beta blockers and statins (all with p <0.001). However, no difference was observed in adjusted five year all-cause mortality between patients with and without a clinical MI diagnosis (hazard ratio: 0.71 with 95% confidence interval 0.39-1.30). The results were similar for adjudicated myocardial injury.ConclusionIn both type 2 MI and myocardial injury, a clinical MI diagnosis was associated with more investigations and treatment targeting coronary artery disease. However, no prognostic effect of receiving a clinical MI diagnosis could be observed for either of these conditions.
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| 45. |
- Gard, Anton, 1985-, et al.
(author)
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Impact of clinical diagnosis of myocardial infarction in patients with elevated cardiac troponin
- 2023
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In: Heart. - : BMJ Publishing Group Ltd. - 1355-6037 .- 1468-201X. ; 109:20, s. 1533-1541
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Journal article (peer-reviewed)abstract
- Objective Type 2 myocardial infarction (MI) and myocardial injury are common conditions associated with an adverse prognosis. Physicians experience uncertainty how to distinguish these conditions, as well as how to manage and treat them. Therefore, the objective of this study was to compare treatment and prognosis in patients with an adjudicated diagnosis of type 2 MI and myocardial injury, who were discharged with and without a clinical diagnosis of MI.Design The study consisted of two cohorts, 964 and 281 consecutive patients with elevated cardiac troponin, discharged with and without a clinical diagnosis of MI, respectively. All cases were adjudicated into MI type 1–5 or myocardial injury and followed regarding all-cause death.Results The adjudication identified 138 and 37 cases of type 2 MI, and 86 and 185 of myocardial injury, with and without a clinical MI diagnosis, respectively. In patients with type 2 MI, a clinical MI diagnosis was associated with more coronary angiography investigations (39.1% vs 5.4%, p<0.001) and an increased use of secondary prevention medications (all p<0.001). However, no difference was observed in adjusted 5-year mortality between patients with and without a clinical MI diagnosis (HR: 0.77 with 95% CI 0.43 to 1.38). The results were similar for adjudicated myocardial injury.Conclusion In both type 2 MI and myocardial injury, a clinical diagnosis of MI at discharge was associated with more investigations and treatments. However, no prognostic effect of receiving a clinical MI diagnosis was observed.
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| 46. |
- Gard, Anton, et al.
(author)
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Interphysician agreement on subclassification of myocardial infarction.
- 2018
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In: Heart. - : BMJ. - 1355-6037 .- 1468-201X. ; 104:15, s. 1284-1291
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Journal article (peer-reviewed)abstract
- OBJECTIVE: The universal definition of myocardial infarction (MI) differentiates MI due to oxygen supply/demand mismatch (type 2) from MI due to plaque rupture (type 1) as well as from myocardial injuries of non-ischaemic or multifactorial nature. The purpose of this study was to investigate how often physicians agree in this classification and what factors lead to agreement or disagreement.METHODS: A total of 1328 patients diagnosed with MI at eight different Swedish hospitals 2011 were included. All patients were retrospectively reclassified into different MI or myocardial injury subtypes by two independent specially trained physicians, strictly adhering to the third universal definition of MI.RESULTS: Overall, there was a moderate interobserver agreement with a kappa coefficient (κ) of 0.55 in this classification. There was substantial agreement when distinguishing type 1 MI (κ: 0.61), compared with moderate agreement when distinguishing type 2 MI (κ: 0.54). In multivariate logistic regression analyses, ST elevation MI (P<0.001), performed coronary angiography (P<0.001) and larger changes in troponin levels (P=0.023) independently made the physicians agree significantly more often, while they disagreed more often with symptoms of dyspnoea (P<0.001), higher systolic blood pressure (P=0.001) and higher C reactive protein levels on admission (P=0.016).CONCLUSION: Distinguishing MI types is challenging also for trained adjudicators. Although strictly adhering to the third universal definition of MI, differentiation between type 1 MI, type 2 MI and myocardial injury only gave a moderate rate of interobserver agreement. More precise and clinically applicable criteria for the current classification, particularly for type 2 MI diagnosis, are urgently needed.
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| 47. |
- Gard, Anton, 1985-, et al.
(author)
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Treatment and Prognosis of Myocardial Infarction Outside Cardiology Departments.
- 2020
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In: Journal of Clinical Medicine. - BASEL SWITZERLAND : MDPI AG. - 2077-0383. ; 10:1
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Journal article (peer-reviewed)abstract
- AIM: Our aim was to investigate the characteristics, treatment and prognosis of patients with myocardial infarction (MI) treated outside a cardiology department (CD), compared with MI patients treated at a CD.METHODS: A cohort of 1310 patients diagnosed with MI at eight Swedish hospitals in 2011 were included in this observational study. Patients were followed regarding all-cause mortality until 2018.RESULTS: A total of 235 patients, exclusively treated outside CDs, were identified. These patients had more non-cardiac comorbidities, were older (mean age 83.7 vs. 73.1 years) and had less often type 1 MIs (33.2% vs. 74.2%), in comparison with the CD patients. Advanced age and an absence of chest pain were the strongest predictors of non-CD care. Only 3.8% of non-CD patients were investigated with coronary angiography and they were also prescribed secondary preventive pharmacological treatments to a lesser degree, with only 32.3% having statin therapy at discharge. The all-cause mortality was higher in non-CD patients, also after adjustment for baseline parameters, both at 30 days (hazard ratio (HR) 2.28; 95% confidence interval (CI) 1.62-3.22), one year (HR 1.82; 95% CI 1.39-2.36) and five years (HR 1.62; 95% CI 1.32-1.98).CONCLUSIONS: MI treatment outside CDs is associated with an adverse short- and long-term prognosis. An improved use of percutaneous coronary intervention (PCI) and secondary preventive pharmacological treatment might improve the long-term prognosis in these patients.
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| 48. |
- Gard, Anton, 1985-
(author)
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Type 2 myocardial infarction : Aspects of diagnosis, prognosis and treatment
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Unlike the coronary thromboembolic type 1 myocardial infarction (MI), a type 2 MI occurs secondary to other conditions causing an imbalance in myocardial oxygen supply and demand. Type 2 MI is associated with high mortality and evidence based treatment is lacking. It may also be difficult to differentiate type 2 MI from type 1 MI and myocardial injury, which causes uncertainty among physicians. Therefore, the aim of this thesis was to evaluate the current classification of MI types and myocardial injury with special emphasis on evaluating the therapeutic and prognostic importance of distinguishing and diagnosing type 2 MI. The validity of type 2 MI reports in the Swedish national register for MI (SWEDEHEART) was also investigated.The study populations consisted of 1328 patients with a clinical MI diagnosis from eight sites, whereof 792 had been reported to SWEDEHEART, as well as 281 patients with elevated cardiac troponins but without a clinical MI diagnosis from one site. The diagnosis of each patient was retrospectively adjudicated in accordance with the Third Universal Definition of Myocardial Infarction.Overall, the adjudicators agreed moderately when deciding the diagnosis and it was particularly difficult to distinguish type 2 MI and non-ischemic myocardial injury. Patients with type 2 MI were often treated outside cardiology departments which led to a significant underreporting to SWEDEHEART. Using the adjudicated diagnosis as a gold standard, type 2 MI registry reports had a positive predictive value of 62.5%. Receiving care outside cardiology departments was found to be associated with a lesser use of MI specific therapies and an adverse short and long term prognosis in MI patients overall. However, although clinically unrecognized type 2 MI patients received the least cardiology care in all aspects, this was still not observed to significantly affect the long term prognosis.In conclusion; the current MI classification defines type 2 MI as a very heterogeneous condition that is difficult to distinguish. This makes clinically defined type 2 MI populations, such as the one in SWEDEHEART, unreliable and it also makes it difficult to find and apply specific, prognostically relevant recommendations and therapeutic strategies for this serious condition.
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| 49. |
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| 50. |
- Gosciniak, Piotr, et al.
(author)
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Updates for the diagnosis and management of cardiac amyloidosis
- 2022
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In: Advances in Clinical and Experimental Medicine. - : Wroclaw Medical University. - 1899-5276 .- 2451-2680. ; 31:2, s. 175-185
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Research review (peer-reviewed)abstract
- A substantial increase in the interest in transthyretin cardiac amyloidosis (ATTR-CA) is a result of the constantly growing number of patients, the use of clear diagnostic protocols and the availability of the first selective drug for these patients. This has also raised the awareness of the disease among physicians of all specialties. The topic is particularly relevant to cardiologists, who use non-invasive multimodal imaging in their daily practice.The differential diagnosis of the causes of myocardial hypertrophy includes arterial hypertension, hypertrophic cardiomyopathy, aortic stenosis (AS), athletic heart syndrome, Fabry disease, and cardiac amyloidosis (CA). It turns out that in patients with myocardial hypertrophy >15 mm, amyloidosis is the most common cause of left ventricular (LV) hypertrophy. In parallel, CA is one of the most common infiltrative diseases leading to a clinical picture that may mimic heart failure with preserved ejection fraction (HFpEF).The accumulation of amyloid in the extracellular space impairs the diastolic function of the myocardium, which is observed as the restrictive cardiomyopathy phenotype. In advanced cases, the LV systolic function is also impaired. Moreover, protein deposits contribute to the disturbances of calcium metabolism and cell metabolism as well as to cardiotoxicity, leading to edema and damage to cardiomyocytes.
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