| 1. |
- Alfredsson, Joakim, 1962-, et al.
(författare)
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Bleeding complications with clopidogrel or ticagrelor in ST-elevation myocardial infarction patients : A real life cohort study of two treatment strategies
- 2020
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Ingår i: IJC Heart & Vasculature. - : Elsevier. - 2352-9067. ; 27
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Tidskriftsartikel (refereegranskat)abstract
- IntroductionDual antiplatelet therapy (DAPT), including potent P2Y12 inhibition after ST-elevation myocardial infarction (STEMI) is recommended in clinical guidelines. However, bleeding complications are common, and associated with worse outcomes. The aim of this study was to assess incidence of bleeding events with a clopidogrel-based compared to a ticagrelor-based DAPT strategy, in a real world population. Secondary aims were to assess ischemic complications and mortality.Methods and ResultsWe identified 330 consecutive STEMI patients with a clopidogrel-based and 330 with a ticagrelor-based DAPT strategy. Patientś medical records were searched for bleeding and ischemic complications, over 6 months follow-up.The two groups were well balanced in baseline characteristics, age (69 years inboth groups), sex (31% vs 32% females), history of diabetes (19% vs 21%), hypertension (43% in both) and MI (17% vs 15%). There was no difference in CRUSADE bleeding score (28 vs 29). After discharge, there were more than twice as many bleeding events with a ticagrelor-based compared with a clopidogrel-based strategy (13.3% vs. 6.5%, p = 0.005). Bleeding events included significantly more severe bleeding complications (TIMI major/minor [5.8 vs 1.0, p = 0.001]) during the ticagrelor-based period. There was no significant difference in the composite of death, MI or stroke (7.8% vs 7.1%, p = 0.76).ConclusionsIn this observational study, a ticagrelor-based DAPT strategy was associated with significantly more bleeding complications, without any significant change in death, MI or stroke. Larger studies are needed to determine whether bleeding complications off-sets benefits with a more potent DAPT strategy in older and more comorbid real-life patients.
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| 2. |
- Alfredsson, Joakim, et al.
(författare)
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Individual long-term variation of platelet reactivity in patients with dual antiplatelet therapy after myocardial infarction.
- 2019
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Ingår i: Platelets. - : Informa UK Limited. - 0953-7104 .- 1369-1635. ; 30:5, s. 572-578
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Tidskriftsartikel (refereegranskat)abstract
- There is a large inter-individual variation in response to clopidogrel treatment, and previous studies have indicated higher risk of thrombotic events in those with high residual platelet reactivity (HPR). Less is known about individual variation over time. The aim of this prospective cohort study was to investigate intra-individual variation in platelet reactivity. Platelet aggregation in whole blood was assessed in 77 patients, at 3 days, 8 days and 6 months after admission for acute myocardial infarction and loading dose of clopidogrel. All patients were treated with aspirin and clopidogrel through 6-month follow-up. We found a significant increase in median ADP-stimulated aggregation from third to eighth day (195 vs. 250 AU*min, p-value = 0.001) but not from day 8 to 6 months (250 vs. 223 AU*min, p-value = 0.666). There was no significant change in the overall rate of HPR (15.6% vs 20.8%, p-value 0.503) or low platelet reactivity (LPR) (37.7% vs 33.8%, p-value = 0.609) from day 8 to 6-month follow-up. In contrast, more than one in four changed HPR status, 15.6% from non-HPR to HPR and 10.4% HPR to non-HPR. A shift in LPR status appeared even more frequent, occurring in about one of three patients. In spite of similar median aggregation and rate of HPR during 6-month follow-up, about one in four of the patients changed HPR status and one in three changed LPR status. This may be important information for a concept of risk stratification based on a single aggregation value early after an acute coronary syndromes.
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| 3. |
- Alfredsson, Joakim, et al.
(författare)
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Large early variation of residual platelet reactivity in Acute Coronary Syndrome patients treated with clopidogrel : Results from Assessing Platelet Activity in Coronary Heart Disease (APACHE).
- 2015
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Ingår i: Thrombosis Research. - : Pergamon Press. - 0049-3848 .- 1879-2472. ; 136:2, s. 335-340
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: There is a large inter-individual variation in response to clopidogrel treatment and previous studies have indicated higher risk of thrombotic events in patients with high residual platelet reactivity (HRPR), but the optimal time-point for testing is not established. The aim of this study was to investigate the optimal time-point for aggregometry testing and the risk of major adverse cardiac events associated with HRPR.METHOD AND RESULTS: We included 125 patients with ACS (73 with STEMI, and 71 received abciximab). The prevalence of HRPR varied substantially over time. The rate of HRPR in patients treated and not treated with abciximab were 43% vs 67% (p=0.01) before, 2% vs 23% (p=0.001) 6-8h after, 8% vs 9% (p=0.749) 3days after, and 23% vs 12% (p=0.138) 7-9 days after loading dose of clopidogrel. We found HRPR in 18% of the patients but only four ischemic events during 6months follow-up, with no significant difference between HRPR patients compared to the rest of the population. There were 3 TIMI major bleedings, all of which occurred in the low residual platelet reactivity (LRPR) group.CONCLUSION: There is a large variation in platelet reactivity over time, also depending on adjunctive therapy, which has a large impact on optimal time-point for assessment. We found HRPR in almost 1 in 5 patients, but very few MACE, and not significantly higher in HRPR patients. In a contemporary ACS population, with low risk for stent thrombosis, the predictive value of HRPR for ischemic events will probably be low.
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| 5. |
- De Geer, Jakob, et al.
(författare)
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Software-based on-site estimation of fractional flow reserve using standard coronary CT angiography data.
- 2016
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Ingår i: Acta Radiologica. - : Sage Publications. - 0284-1851 .- 1600-0455. ; 57:10, s. 1186-1192
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The significance of a coronary stenosis can be determined by measuring the fractional flow reserve (FFR) during invasive coronary angiography. Recently, methods have been developed which claim to be able to estimate FFR using image data from standard coronary computed tomography angiography (CCTA) exams.PURPOSE: To evaluate the accuracy of non-invasively computed fractional flow reserve (cFFR) from CCTA.MATERIAL AND METHODS: A total of 23 vessels in 21 patients who had undergone both CCTA and invasive angiography with FFR measurement were evaluated using a cFFR software prototype. The cFFR results were compared to the invasively obtained FFR values. Correlation was calculated using Spearman's rank correlation, and agreement using intraclass correlation coefficient (ICC). Sensitivity, specificity, accuracy, negative predictive value, and positive predictive value for significant stenosis (defined as both FFR ≤0.80 and FFR ≤0.75) were calculated.RESULTS: The mean cFFR value for the whole group was 0.81 and the corresponding mean invFFR value was 0.84. The cFFR sensitivity for significant stenosis (FFR ≤0.80/0.75) on a per-lesion basis was 0.83/0.80, specificity was 0.76/0.89, and accuracy 0.78/0.87. The positive predictive value was 0.56/0.67 and the negative predictive value was 0.93/0.94. The Spearman rank correlation coefficient was ρ = 0.77 (P < 0.001) and ICC = 0.73 (P < 0.001).CONCLUSION: This particular CCTA-based cFFR software prototype allows for a rapid, non-invasive on-site evaluation of cFFR. The results are encouraging and cFFR may in the future be of help in the triage to invasive coronary angiography.
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| 6. |
- Ekerstad, Niklas, et al.
(författare)
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Clinical frailty scale – skörhet är ett sätt att skatta biologisk ålder
- 2022
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Ingår i: Lakartidningen. - 0023-7205. ; 119, s. 1-5
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Forskningsöversikt (refereegranskat)abstract
- The term frailty denotes a multi-dimensional syndrome characterised by reduced physiological reserves and increased vulnerability. Frailty may be used as a marker of biological age, distinct from chronological age. There are several instruments for frailty assessment. The Clinical Frailty Scale (CFS) is probably the most commonly used in the acute care context. It is a 9-level scale, derived from the accumulated deficit model of frailty, which combines comorbidity, disability, and cognitive impairment. The CFS assessment is fast and easy to implement in daily clinical practice. The CFS is relevant for risk stratification, and may also be used as a screening instrument to identify frail patients suitable for further geriatric evaluation, i.e. a comprehensive geriatric assessment (CGA). By providing information on long-term prognosis, it may improve informed decision-making on an individual basis.
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| 7. |
- Ekerstad, Niklas, 1969-, et al.
(författare)
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Clinical frailty scale – skörhet ärett sätt att skatta biologisk ålder : [Clinical Frailty Scale - a proxy estimate of biological age]
- 2022
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Ingår i: Läkartidningen. - : Sveriges Läkarforbund. - 0023-7205 .- 1652-7518. ; 119
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Forskningsöversikt (refereegranskat)abstract
- The term frailty denotes a multi-dimensional syndrome characterised by reduced physiological reserves and increased vulnerability. Frailty may be used as a marker of biological age, distinct from chronological age. There are several instruments for frailty assessment. The Clinical Frailty Scale (CFS) is probably the most commonly used in the acute care context. It is a 9-level scale, derived from the accumulated deficit model of frailty, which combines comorbidity, disability, and cognitive impairment. The CFS assessment is fast and easy to implement in daily clinical practice. The CFS is relevant for risk stratification, and may also be used as a screening instrument to identify frail patients suitable for further geriatric evaluation, i.e. a comprehensive geriatric assessment (CGA). By providing information on long-term prognosis, it may improve informed decision-making on an individual basis.
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| 8. |
- Ekerstad, Niklas, 1969-, et al.
(författare)
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Frailty as a Predictor of Short-Term Outcomes for Elderly Patients with non-ST-Elevation Myocardial Infarction (NSTEMI)
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Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
- Background – For the large and growing population of elderly patients with cardiovascular disease it is important to identify clinically relevant measures of biological age and their contribution to risk. Frailty is an emerging concept in medicine denoting increased vulnerability and decreased physiologic reserves. We analyzed how the variable frailty predicts short-term outcomes for elderly NSTEMI patients. Methods and Results – Patients, aged 75 years or older, with diagnosed NSTEMI were included at three centers, and clinical data including judgement of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (CFS). Of 307 patients, 150 (48.5%) were considered frail. Frail patients were slightly older and presented with a greater burden of comorbidity. By multiple logistic regression, frailty was found to be a strong independent risk factor for inhospital mortality, one-month mortality (OR 3.8, 95% CI 1.3 to 10.8) and the primary composite outcome (OR 2.2, 95% CI 1.3 to 3.7). Particularly frail patients with a high comorbidity burden manifested a markedly increased risk for the primary composite outcome. By multiple linear regression, frailty was identified as a strong independent predictor for prolonged hospital care (frail 13.4 bed days, non-frail 7.5 bed days; P<0.0001). Conclusions - Frailty is a strong independent predictor of in-hospital mortality, one-month mortality, prolonged hospital care and the primary composite outcome. The combined use of frailty and comorbidity may constitute an ultimate risk prediction concept regarding cardiovascular patients with complex needs.
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| 9. |
- Ekerstad, Niklas, et al.
(författare)
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Frailty as an instrument for evaluation of elderly patients with non-ST-segment elevation myocardial infarction: A follow-up after more than 5 years
- 2018
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Ingår i: European Journal of Preventive Cardiology. - : SAGE PUBLICATIONS LTD. - 2047-4873 .- 2047-4881. ; 25:17, s. 1813-1821
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Tidskriftsartikel (refereegranskat)abstract
- Background There is a growing body of evidence on the relevance of using frailty measures also in a cardiovascular context. The estimated time to death is crucial in clinical decision-making in cardiology. However, data on the importance of frailty in long-term mortality are very scarce. The aim of the study was to assess the prognostic value of frailty on mortality at long-term follow-up of more than 5 years in patients 75 years or older hospitalised for non-ST-segment elevation myocardial infarction. We hypothesised that frailty is independently associated with long-term mortality. Design This was a prospective, observational study conducted at three centres. Methods and results Frailty was assessed according to the Canadian Study of Health and Aging clinical frailty scale (CFS). Of 307 patients, 149 (48.5%) were considered frail according to the study instrument (degree 5-7 on the scale). The long-term all-cause mortality of more than 5 years (median 6.7 years) was significantly higher among frail patients (128, 85.9%) than non-frail patients (85, 53.8%), (P amp;lt; 0.001). In Cox regression analysis, frailty was independently associated with mortality from the index hospital admission to the end of follow-up (hazard ratio 2.06, 95% confidence interval 1.51-2.81; P amp;lt; 0.001) together with age (P amp;lt; 0.001), ejection fraction (P = 0.012) and Charlson comorbidity index (P = 0.018). Conclusions In elderly non-ST-segment elevation myocardial infarction patients, frailty was independently associated with all-cause mortality at long-term follow-up of more than 6 years. The combined use of frailty and comorbidity may be the ultimate risk prediction concept in the context of cardiovascular patients with complex needs.
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| 10. |
- Ekerstad, Niklas, et al.
(författare)
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Frailty is independently associated with 1-year mortality for elderly patients with non-ST-segment elevation myocardial infarction
- 2014
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Ingår i: European Journal of Preventive Cardiology. - : Sage Publications. - 2047-4873 .- 2047-4881. ; 21:10, s. 1216-1224
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: For the large population of elderly patients with cardiovascular disease, it is crucial to identify clinically relevant measures of biological age and their contribution to risk. Frailty is denoting decreased physiological reserves and increased vulnerability. We analysed the manner in which the variable frailty is associated with 1-year outcomes for elderly non-ST-segment elevation myocardial infarction (NSTEMI) patients. METHODS AND RESULTS: Patients aged 75 years or older, with diagnosed NSTEMI were included at three centres, and clinical data including judgment of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale. Of 307 patients, 149 (48.5%) were considered frail. By Cox regression analyses, frailty was found to be independently associated with 1-year mortality after adjusting for cardiovascular risk and comorbid conditions (hazard ratio 4.3, 95% CI 2.4-7.8). The time to the first event was significantly shorter for frail patients than for nonfrail (34 days, 95% CI 10-58, p = 0.005). CONCLUSIONS: Frailty is strongly and independently associated with 1-year mortality. The combined use of frailty and comorbidity may constitute an important risk prediction concept in regard to cardiovascular patients with complex needs.
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