| 1. |
- Buccheri, Sergio, et al.
(author)
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Assessing the Nationwide Impact of a Registry-Based Randomized Clinical Trial on Cardiovascular Practice The TASTE Trial in Perspective
- 2019
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In: Circulation. Cardiovascular Interventions. - : Lippincott Williams & Wilkins. - 1941-7640 .- 1941-7632. ; 12:3
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Journal article (peer-reviewed)abstract
- BACKGROUND: Registry-based randomized clinical trials have emerged as useful tools to provide evidence on the comparative efficacy and safety of different therapeutic strategies. However, it remains unknown whether the results of registry-based randomized clinical trials have a sizable impact on daily clinical practice. We sought, therefore, to describe the temporal trends in thrombus aspiration (TA) use in Sweden before, during, and after dissemination of the TASTE trial (Thrombus Aspiration in ST-Elevation Myocardial Infarction in Scandinavia) results.METHODS AND RESULTS: From January 1, 2006, to December 31, 2017, we included all consecutive patients with ST-segment-elevation myocardial infarction undergoing percutaneous revascularization in Sweden. All patients were registered in the Swedish Coronary Angiography and Angioplasty Registry. A total of 55 809 ST-segment-elevation myocardial infarction patients were included. TA use in Sweden substantially decreased after dissemination of TASTE results (from 39.8% to 11.8% during and after TASTE, respectively). Substantial variability in TA use across treating centers was observed before TASTE (TA use ranging from 0% to 70%), but after TASTE both the interhospital variability and the frequency of TA use were markedly reduced. A constant shift in medical practice was seen about 4 months after dissemination of the TASTE trial results. Time trends for all-cause mortality and definite stent thrombosis at 30 days were not associated with variations in TA use (P values >0.05 using the Granger test).CONCLUSIONS: In Sweden, the results of the TASTE trial were impactful in daily clinical practice and led to a relevant decrease in TA use in ST-segment-elevation myocardial infarction patients undergoing percutaneous revascularization.
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| 2. |
- Hrafnkelsdottir, Thordis, 1965, et al.
(author)
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Regulation of local availability of active tissue-type plasminogen activator in vivo in man
- 2004
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In: J Thromb Haemost. - 1538-7933. ; 2:11, s. 1960-8
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Journal article (peer-reviewed)abstract
- Free, biologically active tissue-type plasminogen activator (tPA) is the main initiator of intravascular fibrinolysis, but little is known about the regulation of active tPA on the organ level. The aim was to investigate if the local availability of active tPA on the organ level depends on the local release rate of tPA or the arterial input of tPA and plasminogen activator inhibitor type 1 (PAI-1). Also, we wanted to evaluate if plasma levels predict capacity for endothelial release of fibrinolytic proteins. Invasive perfused-forearm studies were performed in 96 healthy subjects. Local release rates of fibrinolytic proteins were assessed at baseline and during endothelial stimulation. Stimulation by methacholine and desmopressin induced a 6- and 12-fold increase in total tPA release rates, respectively. With increasing local release rates of tPA a gradually closer correlation emerged between the total tPA secretion and the forearm output of active tPA (from r = 0.102, ns to r = 0.85, P < 0.0001). Forearm availability of active tPA was not related to arterial input of either tPA or PAI-1. Release rates and plasma levels of tPA were not correlated. Baseline release rates of active tPA increased to noon. The major determinant for the local availability of active tPA is the capacity of the endothelium to release tPA rather than the arterial input of PAI-1 or tPA. Despite a molar excess of PAI-1, the majority of tPA released during stimulation does not undergo local inactivation. The capacity to release tPA locally cannot be predicted from its plasma concentration.
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| 3. |
- Gudnadottir, Gudny Stella, et al.
(author)
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Gender differences in coronary angiography, subsequent interventions, and outcomes among patients with acute coronary syndromes
- 2017
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In: American Heart Journal. - : MOSBY-ELSEVIER. - 0002-8703 .- 1097-6744. ; 191, s. 65-74
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Journal article (peer-reviewed)abstract
- Background The objective was to investigate whether gender disparities are found in referrals of patients with acute coronary syndromes to percutaneous coronary interventions (PCIs) or coronary artery bypass grafting (CABG) and, furthermore, to study gender differences in complications and mortality. Methods All consecutive coronary angiographies (CAs) and PCIs performed in Sweden and Iceland are prospectively registered in the Swedish Coronary Angiography and Angioplasty Registry. For the present analysis, data of patients with acute coronary syndromes, enrolled in 2007-2011, were used to analyze gender differences in revascularization, in-hospital complications, and 30-day mortality. Results A total of 106,881 CAs were performed during the study period. In patients with significant coronary artery disease, the adjusted odds ratio (OR) for women to undergo PCI compared with men was 0.95 (95% CI 0.92-0.99) and 0.81 (0.76-0.87) for referrals to CABG. In patients with 1-vessel disease, women were less likely to undergo PCI than men, but women with 2- or 3-vessel or left main stem disease were more likely to undergo PCI. All in-hospital complications after CA followed by PCI were more frequent among women (adjusted OR 1.58 [1.47-1.70]). There was no gender difference in adjusted 30-day mortality after PCI (1.02 [0.92-1.12]) and after CABG (0.97 [0.72-1.31]). Conclusions After CA showing 1-vessel disease, women as compared with men were less likely to undergo PCI. In the group with 2- or 3-vessel disease or left main stem stenosis, women were more likely to undergo PCI but less likely to undergo CABG. However, there was no gender difference in 30-day mortality.
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| 4. |
- Gudnadottir, Gudny Stella, 1979, et al.
(author)
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Multimorbidity and Readmissions in Older People with Acute Coronary Syndromes.
- 2022
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In: Cardiology. - : S. Karger AG. - 1421-9751 .- 0008-6312. ; 147:2, s. 121-132
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Journal article (peer-reviewed)abstract
- This study aimed to examine the multimorbidity as well as the 30-day and 1-year readmission rates in a large, unselected cohort of elderly patients with acute coronary syndrome (ACS).All patients ≥70 years hospitalized due to ACS during January 1, 2006, to December 31, 2013, and registered in the SWEDEHEART registry were included. In-hospital multimorbidity and disease burden were determined. Outcomes included 30-day and 1-year all-cause mortality, any readmission, and readmissions due to ACS, heart failure, ischaemic stroke or transient ischaemic attack (TIA), and bleeding events. Out of 80,176 patients, 25.6% had ST-elevation myocardial infarction (STEMI) and 74.4% non-ST-segment elevation ACS (NSTE-ACS). The mean age was 79.8 (±6.4 standard deviation) and 43.4% were women. Multimorbidity, or two chronic diseases, was present in 67.7%, thereof in 53.0% of STEMI patients and 72.7% of NSTE-ACS patients. In-hospital mortality was 7.0%. Of the 74,577 patients who survived to discharge, 24.6% were readmitted within 30 days and 59.5% were readmitted during the following year. Multimorbid patients had a higher risk of readmissions than those without multimorbidity. Multimorbid STEMI patients were admitted the following year in 56.2% of cases compared to 44.5% of STEMI patients without multimorbidity, adjusted odds ratio (OR) 1.35 (95% confidence interval: 1.26-1.45). Multimorbid patients with NSTE-ACS were readmitted in 63.4% of cases the following year compared with 49.1% of those without multimorbidity, adjusted OR 1.42 (1.35-1.50). More than half of the readmissions were due to cardiovascular causes (ACS, stroke, TIA, or heart failure) or bleeding events.Older people with ACS have a high multimorbidity burden and a high readmission rate both within 30 days and 1 year. Half of the readmissions were due to a cardiovascular event or a bleeding event. The presence of multimorbidity increases the risk of readmissions for patients with ACS. As hospital admissions are costly for the health care system and can include risks, especially for older patients, there may be opportunities in better risk stratifying this group at discharge for subsequent decrease in readmission rates.
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| 5. |
- Gudnadottir, Gudny Stella, et al.
(author)
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Outcomes after STEMI in old multimorbid patients with complex health needs and the effect of invasive management
- 2019
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In: American Heart Journal. - : MOSBY-ELSEVIER. - 0002-8703 .- 1097-6744. ; 211, s. 11-21
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Journal article (peer-reviewed)abstract
- Background: The aim of this study was to assess one-year outcomes of invasive and non-invasive strategies in ST-elevation myocardial infarction (STEMI) among multimorbid older people with complex health needs.Methods: We included patients, registered between 2006 and 2013 in the SWEDEHEART registry, who were 70 years old or older with STEMI, had multimorbidily and complex health needs and were discharged alive. The one-year outcomes of patients who underwent invasive strategy (examined with coronary angiography <= 14 days) were compared to those who did not. The primary event was a composite of all-cause death, admission due to new acute coronary syndrome, stroke or transient ischemic attack.Results: We identified patients, and 1089 were managed invasively and 570 non-invasively. The mean age was 79 years and 83 years in the 2 groups, respectively. After multivariable adjustment for baseline differences between the groups, including propensity scores, the primary event occurred in 31% of patients in the invasive group and 55% in the non-invasive group, adjusted hazard ratio (95% confidence intervals): 0.67 (0.54-0.83). One-year mortality was 18% in the invasive group and 45% in the non-invasive group, adjusted hazard ratio 0.51 (0.39-0.65).Conclusions: Multimorbid older people with complex health needs and STEMI had high rates of new ischemic events and death. In this cohort of older, high risk STEMI patients, an invasive strategy was associated with lower event rates. Randomized studies are needed to clarify whether these high risk patients who might benefit from invasive care are being managed too conservatively.
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| 6. |
- Gudnason, Thorarinn, 1964
(author)
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Endogenous tissue-type plasminogen activator andendothelial function in vivo. A clinical perspective
- 2004
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Doctoral thesis (other academic/artistic)abstract
- Endogenous fibrinolysis is initiated by the glycoprotein tissue-type plasminogen activator (tPA), which is released from the vascular endothelium. Plasminogen activator inhibitor type 1 (PAI-1) is the main inhibitor of tPA. There is limited knowledge available on the local kinetics of active tPA in vivo, and no non-invasive method available for estimation of the endothelial tPA-release capacity in man. Many cardiovascular risk factors impair endothelial function and/or the capacity for tPA release, which may reduce the defense against formation of arterial clots. However, knowledge about the impact of age, coronary artery disease (CAD) and chronic heart failure (CHF) on tPA release is limited. The impact of these factors on stimulated tPA release was studied using the perfused-forearm model and different stimuli. The tPA response to exercise and its relationship with invasively determined endothelial tPA release was also investigated. The majority of tPA acutely released from the endothelium was found to remain free and active during its transit through the forearm tissue, in spite of great molar excess of PAI-1 over tPA. With increasing endothelial release rates, the relative increase in active tPA was proportionally greater than the increase in tPA protein. Neither plasma tPA nor PAI-1 levels at rest determined the capacity for endothelial tPA release. In healthy individuals, tPA release was up-regulated with age, while age had no impact on endothelium-dependent vasodilation. Optimally treated patients with CAD complicated by CHF had preserved capacity for tPA release and vasodilation. The exercise-induced tPA response could be used to predict the capacity for local desmopressin-stimulated release of tPA. This model may serve as a non-invasive method to investigate endothelial tPA release.In conclusion, the local availability of active tPA on the organ level is mainly determined by the release of tPA from the endothelium rather than the inflow of tPA or its inhibitors. The capacity for stimulated endogenous tPA release increases with age. Optimally treated patients with CAD and CHF have preserved vasomotor and fibrinolytic endothelial functions. Exercise-induced rise in venous plasma tPA is reproducible and may be used to non-invasively determine the capacity for endothelial tPA release in humans.
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| 7. |
- Hrafnkelsdottir, Thordis, 1965, et al.
(author)
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Impaired endothelial release of tissue-type plasminogen activator in patients with chronic kidney disease and hypertension
- 2004
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In: Hypertension. - 1524-4563. ; 44:3, s. 300-4
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Journal article (peer-reviewed)abstract
- We have shown that the capacity for local release of tissue-type plasminogen activator (tPA) from the vascular endothelium is impaired in patients with primary hypertension. Because this response is an important protective mechanism against intravascular clotting, we investigated whether this system is also defective in patients with advanced chronic kidney disease and hypertension. Nine nondiabetic nonsmoking men with chronic kidney disease (glomerular filtration rate 11 to 28 mL/min x 1.73 m2; aged 33 to 75 years) were compared with age-matched healthy controls. Intraarterial infusions of desmopressin, methacholine, and sodium nitroprusside were given locally in the brachial artery. Forearm blood flow was measured by venous occlusion plethysmography and blood collected repeatedly during the desmopressin infusion for determination of stimulated net and total cumulated release of tPA. The maximal release rate of active tPA (P<0.05) and the capacity for acute tPA release were markedly impaired in the renal patients as compared with healthy subjects (ANOVA, P=0.013). Accordingly, the accumulated release of tPA was 1905 (SEM 366) and 3387 (718) ng/L tissue, respectively (P<0.05). However, there were no significant differences in vasodilator responses between the groups. Thus, patients with advanced chronic kidney disease and hypertension have a markedly impaired capacity for acute release of tissue plasminogen activator, despite preserved endothelium-dependent vasodilation. This defect may contribute to a defective local defense against arterial thrombosis.
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| 8. |
- Lagerqvist, Bo, et al.
(author)
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Outcomes 1 year after thrombus aspiration for myocardial infarction.
- 2014
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In: New England Journal of Medicine. - : Massachusetts Medical Society. - 0028-4793 .- 1533-4406. ; 371:12, s. 1111-1120
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Journal article (peer-reviewed)abstract
- Routine intracoronary thrombus aspiration before primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) has not been proved to reduce short-term mortality. We evaluated clinical outcomes at 1 year after thrombus aspiration.
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| 9. |
- Odell, Annika, 1960, et al.
(author)
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One-year outcome after percutaneous coronary intervention for stable and unstable angina pectoris with or without application of general usage of stents in unselected European patient groups.
- 2002
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In: The American journal of cardiology. - 0002-9149. ; 90:2, s. 112-8
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Journal article (peer-reviewed)abstract
- The outcome after percutaneous coronary intervention (PCI) of all patients treated for stable and unstable angina pectoris from July 1992 to June 1993 (group A [n = 590], of whom 3.7% received stents) was compared with the outcome in patients treated from July 1996 to June 1997 (group B [n = 768], of whom 64.7% received stents). All patients were followed up for at least 1 year. PCI was performed due to unstable angina in 34.1% and 33.5% of patients in groups A and B, respectively. More patients in group B than in group A had systemic hypertension, previous coronary artery bypass grafting, and PCI. Within 1 year, 42.2% of patients in group A versus 27.2% in group B (p <0.001) either died, had a nonfatal acute myocardial infarction (AMI), or underwent a new revascularization procedure. The difference between the groups persisted after correction for differences in baseline characteristics. No difference was seen in the subgroup that had previously undergone PCI. Mortality (2.0% vs 1.4%, p = NS) and the composite of death plus AMI (6.6% vs 6.1%, p = NS) was similar in groups A and B. The diagnoses of unstable angina and systemic hypertension at the time of the procedure were also predictors of adverse outcome. Thus, in a cohort of patients treated after the general acceptance of stenting, the composite of death, AMI, and/or revascularization procedures was significantly less than that in the cohort treated before this increase in stenting. However, this did not result in a reduced frequency of death or AMI.
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