| 1. |
- Chemtob, Raphaelle A, et al.
(author)
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Stroke in acute type A aortic dissection: the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD).
- 2020
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In: European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. - 1873-734X. ; 58:5, s. 1027-1034
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Journal article (peer-reviewed)abstract
- Stroke is a serious complication in patients with acute type A aortic dissection (ATAAD). Previous studies investigating stroke in ATAAD patients have been limited by small cohorts and have shown diverging results. We sought to identify risk factors for stroke and to evaluate the effect of stroke on outcomes in surgical ATAAD patients.The Nordic Consortium for Acute Type A Aortic Dissection database included patients operated for ATAAD at 8 Scandinavian Hospitals between 2005 and 2014.Stroke occurred in 177 (15.7%) out of 1128 patients. Patients with stroke presented more frequently with cerebral malperfusion (20.6% vs 6.3%, P<0.001), syncope (30.6% vs 17.6%, P<0.001), cardiogenic shock (33.1% vs 20.7%, P<0.001) and pericardial tamponade (25.9% vs 14.7%, P<0.001) and more often underwent total aortic arch replacement (10.7% vs 4.7%, P=0.016), compared to patients without stroke. In the 86 patients presenting with cerebral malperfusion, 38.4% developed stroke. Thirty-day and 5-year mortality in patients with and without stroke were 27.1% vs 13.6% and 42.9% vs 25.6%, respectively. Stroke was an independent predictor of early- [odds ratio 2.02, 95% confidence interval (CI) 1.34-3.05; P<0.001] and midterm mortality (hazard ratio 1.68, 95% CI 1.27-2.23; P<0.001).Stroke in ATAAD patients is associated with increased early- and midterm mortality. Preoperative cerebral malperfusion and impaired haemodynamics, as well as total aortic arch replacement, were more frequent among patients who developed stroke. Importantly, a large proportion of patients presenting with cerebral malperfusion did not develop a permanent stroke, indicating that signs of cerebral malperfusion should not be considered a contraindication for surgery.
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| 2. |
- Barbu, Mikael, et al.
(author)
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Cardiopulmonary bypass management and acute kidney injury in cardiac surgery patients.
- 2024
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In: Acta anaesthesiologica Scandinavica. - 1399-6576. ; 68:3, s. 328-336
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Journal article (peer-reviewed)abstract
- Cardiopulmonary bypass (CPB) ensures tissue oxygenation during cardiac surgery. New technology allows continuous registration of CPB variables during the operation. The aim of the present investigation was to study the association between CPB management and the risk of postoperative acute kidney injury (AKI).This observational study based on prospectively registered data included 2661 coronary artery bypass grafting and/or valve patients operated during 2016-2020. Individual patient characteristics and postoperative outcomes collected from the SWEDEHEART registry were merged with CPB variables automatically registered every 20s during CPB. Associations between CPB variables and AKI were analyzed with multivariable logistic regression models adjusted for patient characteristics.In total, 387 patients (14.5%) developed postoperative AKI. After adjustments, longer time on CPB and aortic cross-clamp, periods of compromised blood flow during aortic cross-clamp time, and lower nadir hematocrit were associated with the risk of AKI, while mean blood flow, bladder temperature, central venous pressure, and mixed venous oxygen saturation were not. Patient characteristics independently associated with AKI were advanced age, higher body mass index, hypertension, diabetes mellitus, atrial fibrillation, lower left ventricular ejection fraction, estimated glomerular filtration rate<60 or>90mL/min/m2 , and preoperative hemoglobin concentration below or above the normal sex-specific range.To reduce the risk of AKI after cardiac surgery, aortic clamp time and CPB time should be kept short, and low hematocrit and periods of compromised blood flow during aortic cross-clamp time should be avoided if possible.
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| 3. |
- Chemtob, Raphaelle A., et al.
(author)
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Effects of Sex on Early Outcome following Repair of Acute Type A Aortic Dissection : Results from the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD)
- 2019
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In: AORTA. - : Georg Thieme Verlag KG. - 2325-4637. ; 7:1, s. 7-14
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Journal article (peer-reviewed)abstract
- Background Female sex is known to have increased perioperative mortality in cardiac surgery. Studies reporting effects of sex on outcome following surgical repair for acute Type A aortic dissection (ATAAD) have been limited by small cohorts of heterogeneous patient populations and have shown diverging results. This study aimed to compare perioperative characteristics, operative management, and postoperative outcome between sexes in a large and well-defined cohort of patients operated for ATAAD. Methods The Nordic Consortium for Acute Type A Aortic Dissection study included patients with surgical repair of ATAAD at eight Nordic centers between January 2005 and December 2014. Independent predictors of 30-day mortality were identified using multivariable logistic regression. Results Females represented 373 (32%) out of 1,154 patients and were significantly older (65 ± 11 vs. 60 ± 12 years, p < 0.001), had lower body mass index (25.8 ± 5.4 vs. 27.2 ± 4.3 kg/m 2, p < 0.001), and had more often a history of hypertension (59% vs. 48%, p = 0.001) and chronic obstructive pulmonary disease (8% vs. 4%, p = 0.033) compared with males. More females presented with DeBakey class II as compared with males with dissection of the ascending aorta alone (33.4% vs. 23.1%, p = 0.003). Hypothermic cardiac arrest time (28 ± 16 vs. 31 ± 19 minutes, p = 0.026) and operation time (345 ± 133 vs. 374 ± 135 minutes, p < 0.001) were shorter among females. There was no difference between the sexes in unadjusted intraoperative death (9.1% vs. 6.7%, p = 0.17) or 30-day mortality (17.7% vs. 17.4%, p = 0.99). In a multivariable analysis including perioperative factors influencing mortality, no difference was found between females and males in 30-day mortality (odds ratio: 0.92, 95% confidence interval: 0.62-1.38, p = 0.69). Conclusions This study found no association between sex and early mortality following surgery for ATAAD, despite females being older and having more comorbidities, yet also presenting with a less widespread dissection than males.
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| 4. |
- Hansson, Emma C., 1985, et al.
(author)
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Preoperative dual antiplatelet therapy increases bleeding and transfusions but not mortality in acute aortic dissection type A repair.
- 2019
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In: European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. - : Oxford University Press (OUP). - 1873-734X .- 1010-7940. ; 56:1, s. 182-188
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Journal article (peer-reviewed)abstract
- Acute aortic dissection type A is a life-threatening condition, warranting immediate surgery. Presentation with sudden chest pain confers a risk of misdiagnosis as acute coronary syndrome resulting in subsequent potent antiplatelet treatment. We investigated the impact of dual antiplatelet therapy (DAPT) on bleeding and mortality using the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database.The NORCAAD database is a retrospective multicentre database where 119 of 1141 patients (10.4%) had DAPT with ASA+clopidogrel (n=108) or ASA+ticagrelor (n=11) before surgery. The incidence of major bleeding and 30-day mortality was compared between DAPT and non-DAPT patients with logistic regression models before and after propensity score matching.Before matching, 51.3% of DAPT patients had major bleeding when compared to 37.7% of non-DAPT patients (P=0.0049). DAPT patients received more transfusions of red blood cells [median 8U (Q1-Q3 4-15) vs 5.5U (2-11), P<0.0001] and platelets [4U (2-8) vs 2U (1-4), P=0.0001]. Crude 30-day mortality was 19.3% vs 17.0% (P=0.60). After matching, major bleeding remained significantly more common in DAPT patients, 51.3% vs 39.3% [odds ratio (OR) 1.63, 95% confidence interval (CI) 1.05-2.51; P=0.028], but mortality did not significantly differ (OR 0.88, 95% CI 0.51-1.50; P=0.63). Major bleeding was associated with increased 30-day mortality (adjusted OR 2.44, 95% CI 1.72-3.46; P<0.0001).DAPT prior to acute aortic dissection repair was associated with increased bleeding and transfusions but not with mortality. Major bleeding per se was associated with a significantly increased mortality. Correct diagnosis is important to avoid DAPT and thereby reduce bleeding risk, but ongoing DAPT should not delay surgery.
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| 5. |
- Taha, Amar, 1978, et al.
(author)
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Cardiopulmonary bypass management and risk of new-onset atrial fibrillation after cardiac surgery.
- 2023
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In: Interdisciplinary cardiovascular and thoracic surgery. - 2753-670X. ; 37:3
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Journal article (peer-reviewed)abstract
- Cardiopulmonary bypass management may potentially play a role in the development of new-onset atrial fibrillation after cardiac surgery. The aim of this study was to explore this potential association.Patients who underwent coronary artery bypass grafting and/or valvular surgery during 2016-2020 were included in an observational single-centre study. Data collected from the SWEDEHEART Registry, and a local Cardiopulmonary bypass database were merged. Associations between individual cardiopulmonary bypass variables (Cardiopulmonary bypass and aortic clamp times, arterial and central venous pressure, mixed venous oxygen saturation, blood flow index, bladder temperature, and haematocrit) and new-onset atrial fibrillation were analysed using multivariable logistic regression models adjusted for patient characteristics, comorbidities, and surgical procedure.Out of 1,999 patients, 758 (37.9%) developed new-onset atrial fibrillation. Patients with new-onset postoperative atrial fibrillation were older, had a higher incidence of previous stroke, worse renal function and higher EuroSCORE II and CHA2DS2-VASc scores, and more often underwent valve surgery. Longer cardiopulmonary bypass time (adjusted odds ratio (aOR) 1.05 per 10min (95% confidence interval (CI) 1.01-1.08); p=0.008) and higher flow index (aOR 1.21 per 0.2L/m2 (95% CI 1.02-1.42); p=0.026) were associated with an increased risk for new-onset atrial fibrillation, while the other variables were not. A sensitivity analysis only including patients with isolated coronary artery bypass grafting supported the primary analyses.Cardiopulmonary bypass management following current guideline recommendations appears to have minor or no influence on the risk of developing new-onset atrial fibrillation after cardiac surgery.
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| 6. |
- Björklund, Erik, et al.
(author)
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Comparison of Midterm Outcomes Associated With Aspirin and Ticagrelor vs Aspirin Monotherapy After Coronary Artery Bypass Grafting for Acute Coronary Syndrome.
- 2021
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In: JAMA network open. - : American Medical Association (AMA). - 2574-3805. ; 4:8
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Journal article (peer-reviewed)abstract
- Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak.To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy.This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020.Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only.Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up.A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P=.34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P=.29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P=.011). Sensitivity analyses confirmed the results.In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.
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| 7. |
- Björklund, Erik, et al.
(author)
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Secondary prevention medications after coronary artery bypass grafting and long-term survival : a population-based longitudinal study from the SWEDEHEART registry.
- 2019
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In: European Heart Journal. - : Oxford University Press. - 0195-668X .- 1522-9645. ; 41:17, s. 1653-1661
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Journal article (peer-reviewed)abstract
- AIMS: To evaluate the long-term use of secondary prevention medications [statins, β-blockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and platelet inhibitors] after coronary artery bypass grafting (CABG) and the association between medication use and mortality.METHODS AND RESULTS: All patients who underwent isolated CABG in Sweden from 2006 to 2015 and survived at least 6 months after discharge were included (n = 28 812). Individual patient data from SWEDEHEART and other mandatory nationwide registries were merged. Multivariable Cox regression models using time-updated data on dispensed prescriptions were used to assess associations between medication use and long-term mortality. Statins were dispensed to 93.9% of the patients 6 months after discharge and to 77.3% 8 years later. Corresponding figures for β-blockers were 91.0% and 76.4%, for RAAS inhibitors 72.9% and 65.9%, and for platelet inhibitors 93.0% and 79.8%. All medications were dispensed less often to patients ≥75 years. Treatment with statins [hazard ratio (HR) 0.56, 95% confidence interval (95% CI) 0.52-0.60], RAAS inhibitors (HR 0.78, 95% CI 0.73-0.84), and platelet inhibitors (HR 0.74, 95% CI 0.69-0.81) were individually associated with lower mortality risk after adjustment for age, gender, comorbidities, and use of other secondary preventive drugs (all P < 0.001). There was no association between β-blockers and mortality risk (HR 0.97, 95% CI 0.90-1.06; P = 0.54).CONCLUSION: The use of secondary prevention medications after CABG was high early after surgery but decreased significantly over time. The results of this observational study, with inherent risk of selection bias, suggest that treatment with statins, RAAS inhibitors, and platelet inhibitors is essential after CABG whereas the routine use of β-blockers may be questioned.
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| 8. |
- Giang, Kok Wai, 1984, et al.
(author)
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The risk of dementia after coronary artery bypass grafting in relation to age and sex
- 2021
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In: Alzheimers & Dementia. - : Wiley. - 1552-5260 .- 1552-5279. ; 17:6, s. 1042-1050
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Journal article (peer-reviewed)abstract
- Introduction We examined the long-term risk of dementia after coronary artery bypass grafting (CABG) in relation to age and sex. Methods All CABG patients in Sweden 1992-2015 (n = 111,335), and matched controls (n = 222,396) were included in a population-based study. Adjusted hazard ratios (aHR) for all-cause dementia, vascular dementia, and Alzheimer's disease were calculated. Results There was no difference in the risk for all-cause dementia between CABG patients and control subjects (aHR 0.98 [95% confidence interval 0.95 to 1.02]). CABG patients <65 years and 65 to 74 years had higher risk (aHR 1.29 [1.17-1.42] and 1.08 [1.02-1.13], respectively), and patients >= 75 years had lower risk (aHR 0.76 [0.71-0.81]). The highest risk was observed in women <65 years (aHR 1.64 [1.31-2.05]). Discussion Overall, the long-term risk for all-cause dementia does not differ between CABG patients and the general population. Younger patients have a higher risk, while older patients have a lower risk, compared to controls.
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| 9. |
- Lindgren, Martin, et al.
(author)
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Beta blockers and long-term outcome after coronary artery bypass grafting: a nationwide observational study.
- 2022
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In: European heart journal. Cardiovascular pharmacotherapy. - : Oxford University Press (OUP). - 2055-6837 .- 2055-6845. ; 8:5, s. 529-36
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Journal article (peer-reviewed)abstract
- Beta blockers are associated with improved outcomes for selected patients with cardiovascular disease. We assessed long-term utilization of beta blockers after coronary artery bypass grafting (CABG) and its association with outcome.All 35,184 patients in Sweden who underwent first-time isolated CABG between 1 January 2006 and 31 December 2017 and were followed for at least 6 months were included in a nationwide observational study. Multivariable Cox regression models using time-updated data on dispensed prescriptions were used to assess associations between different types of beta blockers and outcome. The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause mortality, stroke and myocardial infarction (MI). Subgroup analyses were performed in patients with and without previous MI, heart failure, and reduced left ventricular ejection fraction (LVEF). Median follow-up was 5.2 years (range 0-11).At baseline, 33,159 (94.2%) of the patients were dispensed beta blockers, 32,225 (91.6%) of which were cardioselective beta blockers. After 10 years, the dispense of cardioselective beta blockers had declined to 73.7% of all patients. Ongoing treatment with cardioselective beta blockers was associated with a slight reduction in MACE (hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.89-0.98, p = 0.0063). The reduction was largely driven by a reduced risk of MI (HR 0.83, 95% CI 0.75-0.92, p = 0.0003), while there was no significant reduction in all-cause mortality (HR 0.99, 95% CI 0.93-1.05) and stroke (HR 0.96, 95% CI 0.87-1.05). The reduced risk for MI was consistent in all investigated subgroups.Ongoing treatment with cardioselective beta blockers after CABG is associated with a reduction in MACE, mainly because of reduced long-term risk for MI. The association between cardioselective beta blockers and MI was consistent in patients with and patients without previous MI, heart failure, atrial fibrillation, or reduced LVEF.
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| 10. |
- Martinsson, Andreas, et al.
(author)
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Renin-angiotensin system inhibition and outcome after coronary artery bypass grafting: A population-based study from the SWEDEHEART registry
- 2021
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In: International Journal of Cardiology. - : Elsevier BV. - 0167-5273. ; 331, s. 40-45
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Journal article (peer-reviewed)abstract
- Background: Renin-angiotensin system (RAS) inhibitors are recommended postoperatively to coronary artery bypass grafting (CABG) patients with reduced left ventricular function, diabetes, hypertension or previous myocardial infarction, but not to remaining patients. The aim of the study was to assess the long-term utilization of RAS inhibitors after CABG in patients with and without indication for treatment, and its association with outcome. Methods: All patients (n = 28,782) not meeting exclusion criterion in Sweden who underwent isolated first time CABG from 2006 to 2015 were included using nationwide registries. The association between treatment and outcome was assessed using adjusted Cox regression models with time-updated data on medications. The primary outcome was major adverse cardiovascular events (MACE), defined as all-cause mortality, stroke and/or myocardial infarction. Results: At baseline 26,284 (91.3%) of the patients had at least one indication for RAS inhibition while 2498 (8.7%) had not. RAS inhibitors were dispensed to 77.0% and 29.7% of patients with and without indication respectively. Dispense declined over time. RAS inhibition was associated with a reduction in MACE in the whole study population (adjusted hazard ratio (aHR) 0.88, 95% confidence interval (95% CI) 0.83–0.93, p < 0.0001), and in patients with (aHR 0.87 95% CI: 0.82–0.93, p < 0.0001) and without indication (aHR 0.75, 95% CI: 0.58–0.98, p = 0.034). Conclusions: RAS inhibition is underutilized after CABG. The use of RAS inhibitors was associated with a reduction in MACE, both in patients with and without indication for treatment. The results suggest that RAS inhibition is beneficial for all CABG patients. Randomized controlled trials are necessary to confirm this hypothesis. © 2021 The Authors
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