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1.
  • Hachinski, Vladimir, et al. (author)
  • Preventing dementia by preventing stroke : The Berlin Manifesto
  • 2019
  • In: Alzheimer's and Dementia. - : Wiley. - 1552-5260 .- 1552-5279. ; 15:7, s. 961-984
  • Research review (peer-reviewed)abstract
    • The incidence of stroke and dementia are diverging across the world, rising for those in low- and middle-income countries and falling in those in high-income countries. This suggests that whatever factors cause these trends are potentially modifiable. At the population level, neurological disorders as a group account for the largest proportion of disability-adjusted life years globally (10%). Among neurological disorders, stroke (42%) and dementia (10%) dominate. Stroke and dementia confer risks for each other and share some of the same, largely modifiable, risk and protective factors. In principle, 90% of strokes and 35% of dementias have been estimated to be preventable. Because a stroke doubles the chance of developing dementia and stroke is more common than dementia, more than a third of dementias could be prevented by preventing stroke. Developments at the pathological, pathophysiological, and clinical level also point to new directions. Growing understanding of brain pathophysiology has unveiled the reciprocal interaction of cerebrovascular disease and neurodegeneration identifying new therapeutic targets to include protection of the endothelium, the blood-brain barrier, and other components of the neurovascular unit. In addition, targeting amyloid angiopathy aspects of inflammation and genetic manipulation hold new testable promise. In the meantime, accumulating evidence suggests that whole populations experiencing improved education, and lower vascular risk factor profiles (e.g., reduced prevalence of smoking) and vascular disease, including stroke, have better cognitive function and lower dementia rates. At the individual levels, trials have demonstrated that anticoagulation of atrial fibrillation can reduce the risk of dementia by 48% and that systolic blood pressure lower than 140 mmHg may be better for the brain. Based on these considerations, the World Stroke Organization has issued a proclamation, endorsed by all the major international organizations focused on global brain and cardiovascular health, calling for the joint prevention of stroke and dementia. This article summarizes the evidence for translation into action.
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2.
  • Hachinski, Vladimir, et al. (author)
  • Preventing dementia by preventing stroke : The Berlin Manifesto
  • 2024
  • In: International Journal of Stroke. - : SAGE Publications. - 1747-4930 .- 1747-4949.
  • Research review (peer-reviewed)abstract
    • The incidence of stroke and dementia are diverging across the world, rising for those in low-and middle-income countries and falling in those in high-income countries. This suggests that whatever factors cause these trends are potentially modifiable. At the population level, neurological disorders as a group account for the largest proportion of disability-adjusted life years globally (10%). Among neurological disorders, stroke (42%) and dementia (10%) dominate. Stroke and dementia confer risks for each other and share some of the same, largely modifiable, risk and protective factors. In principle, 90% of strokes and 35% of dementias have been estimated to be preventable. Because a stroke doubles the chance of developing dementia and stroke is more common than dementia, more than a third of dementias could be prevented by preventing stroke. Developments at the pathological, pathophysiological, and clinical level also point to new directions. Growing understanding of brain pathophysiology has unveiled the reciprocal interaction of cerebrovascular disease and neurodegeneration identifying new therapeutic targets to include protection of the endothelium, the blood-brain barrier, and other components of the neurovascular unit. In addition, targeting amyloid angiopathy aspects of inflammation and genetic manipulation hold new testable promise. In the meantime, accumulating evidence suggests that whole populations experiencing improved education, and lower vascular risk factor profiles (e.g., reduced prevalence of smoking) and vascular disease, including stroke, have better cognitive function and lower dementia rates. At the individual levels, trials have demonstrated that anticoagulation of atrial fibrillation can reduce the risk of dementia by 48% and that systolic blood pressure lower than 140 mmHg may be better for the brain. Based on these considerations, the World Stroke Organization has issued a proclamation, endorsed by all the major international organizations focused on global brain and cardiovascular health, calling for the joint prevention of stroke and dementia. This article summarizes the evidence for translation into action.
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4.
  • Akerstrom, Finn, et al. (author)
  • Association between catheter ablation of atrial fibrillation and mortality or stroke
  • 2024
  • In: Heart. - : BMJ PUBLISHING GROUP. - 1355-6037 .- 1468-201X. ; 110, s. 163-169
  • Journal article (peer-reviewed)abstract
    • Objective Catheter ablation of atrial fibrillation effectively reduces symptomatic burden. However, its long-term effect on mortality and stroke is unclear. We investigated if patients with atrial fibrillation who undergo catheter ablation have lower risk for all-cause mortality or stroke than patients who are managed medically. Methods We retrospectively included 5628 consecutive patients who underwent first-time catheter ablation for atrial fibrillation between 2008 and 2018 at three major Swedish electrophysiology units. Control individuals with an atrial fibrillation diagnosis but without previous stroke were selected from the Swedish National Patient Register, resulting in a control group of 48 676 patients. Propensity score matching was performed to produce two cohorts of equal size (n=3955) with similar baseline characteristics. The primary endpoint was a composite of all-cause mortality or stroke. Results Patients who underwent catheter ablation were healthier (mean CHA(2)DS(2)-VASc score 1.4 +/- 1.4 vs 1.6 +/- 1.5, p<0.001), had a higher median income (288 vs 212 1000 Swedish krona [KSEK]/year, p<0.001) and had more frequently received university education (45.1% vs 28.9%, p<0.001). Mean follow-up was 4.5 +/- 2.8 years. After propensity score matching, catheter ablation was associated with lower risk for the combined primary endpoint (HR 0.58, 95% CI 0.48 to 0.69). The result was mainly driven by a decrease in all-cause mortality (HR 0.51, 95% CI 0.41 to 0.63), with stroke reduction showing a trend in favour of catheter ablation (HR 0.75, 95% CI 0.53 to 1.07). Conclusions Catheter ablation of atrial fibrillation was associated with a reduction in the primary endpoint of all-cause mortality or stroke. This result was driven by a marked reduction in all-cause mortality.
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5.
  • Alberto Garcia-Rodriguez, Luis, et al. (author)
  • Rationale and design of a European epidemiological post-authorization safety study (PASS) program : rivaroxaban use in routine clinical practice
  • 2020
  • In: Expert Opinion on Drug Safety. - : TAYLOR & FRANCIS LTD. - 1474-0338 .- 1744-764X. ; 19:11, s. 1513-1520
  • Journal article (peer-reviewed)abstract
    • Background Rivaroxaban is a highly selective factor Xa inhibitor approved for use in Europe for multiple indications. Study design and methods The European rivaroxaban epidemiological post-authorization safety study (PASS) program consists of seven complementary observational studies. For four of the studies, data are obtained from health-care databases in the UK, the Netherlands, Germany, and Sweden. These database studies describe patterns of rivaroxaban use and patient characteristics over time, and investigate safety and effectiveness outcomes in new users of rivaroxaban using a cohort analysis and nested case-control analysis. To put these results in context, safety outcomes are also analyzed in new users of standard of care. In addition, a modified prescription event monitoring study conducted in the early post-launch phase in primary care, and two specialist cohort event monitoring studies that investigated rivaroxaban use in the secondary care hospital setting, systematically collected drug utilization and safety data via questionnaires completed by health-care professionals in the UK. Discussion The European rivaroxaban epidemiological PASS is a comprehensive program of complementary studies generating evidence from patients treated in routine clinical practice that will expand our understanding of the risk-benefit profile of rivaroxaban.
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6.
  • Almroth, Henrik, et al. (author)
  • Safety of flecainide for atrial fibrillation : the Swedish atrial fibrillation cohort study
  • Other publication (other academic/artistic)abstract
    • Background Little is known about the safety of flecainide in atrial fibrillation (AF). Whether current flecainide treatment practice in Sweden is associated with increased mortality compared to treatment with beta-blockers alone was investigated in patients with atrial fibrillation (AF).Methods and Results A total of 182,678 patients diagnosed with AF between 1 July 2005 and 31 December 2008 were identified through the Swedish National Hospital Discharge Register. These data were matched to data from the Prescribed Drug Register and information about death from the Total Population Register. The primary outcome was all cause mortality at the end of the study period, 1 Feb 2010. Flecainide was prescribed to 5381 patients (2.9%), and 64,918 patients (45.7%) received beta-blockers only. During follow-up, 2.8% and 30.8% of these patients died, respectively. After coarsened and exact matching, 2,178 patients (1.2% of total) on flecainide and beta-blockers had more similar baseline characteristics to 27,313 patients (15.3% of total) on beta-blockers only. In the main analysis, flecainide exposure was not associated with increased mortality (OR 0.27, 95% CI 0.21-0.36,P<0.001). In the matched flecainide population, 205 (9.4%) patients had underlying structural heart disease. Sixteen (28.6%) of the flecainide-exposed patients who died had structural heart disease. The patients who only received flecainide (n=264) had higher mortality rate than the patients who received flecainide and beta-blockers (6.8 versus 2.6%,P<0.001).Conclusions Flecainide is not associated with increased mortality in patients with AF compared to beta-blockers alone. Patients who die after receiving flecainide often have structural heart disease.
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7.
  • Almroth, Henrik, 1970-, et al. (author)
  • The safety of flecainide treatment of atrial fibrillation : long-term incidence of sudden cardiac death and proarrhythmic events
  • 2011
  • In: Journal of Internal Medicine. - : John Wiley & Sons. - 0954-6820 .- 1365-2796. ; 270:3, s. 281-290
  • Journal article (peer-reviewed)abstract
    • Objective:To assess the safety of long-term treatment with flecainide in patients with atrial fibrillation (AF), particularly with regard to sudden cardiac death (SCD) andproarrhythmic events.Design: Retrospective,observational cohort study.Setting.Single-centre study at Örebro University Hospital, Sweden.Setting: Single-centre study at Orebro University Hospital, Sweden.Subjects: A total of 112 patients with paroxysmal (51%) or persistent (49%) AF (mean age 60 ± 11 years) were included after identifying all patients with AF who initiated oral flecainide treatment (mean dose 203 ± 43 mg per day) between 1998 and 2006. Standard exclusion⁄inclusion criteria for flecainide were used,andflecainidetreatmentwasusually combined withanatrioventricular-blocking agent (89%).Main outcome measure: Death was classified as sudden or nonsudden according to standard definitions. Proarrhythmia was defined as cardiac syncope or lifethreatening arrhythmia.Results: Eight deaths were reported during a mean follow- up of 3.4 ± .4 years. Compared to the general population, the standardized mortality ratios were 1.57 (95% confidence interval (CI) 0.68–3.09) for allcause mortality and 4.16 (95% CI 1.53–9.06) for death from cardiovascular disease. Three deaths were classified as SCDs. Proarrhythmic events occurred in six patients (two each with wide QRS tachycardia, 1 : 1 conducted atrial flutter and syncope during exercise).Conclusion: We found an increased incidence of SCD or proarrhythmic events in this real-world study of flecainide used for the treatment of AF. The findings suggest that further investigation into the safety of flecainide for the treatment of patients with AF is warranted.
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  • Aronsson, Mattias, et al. (author)
  • Cost-effectiveness of mass screening for untreated atrial fibrillation using intermittent ECG recording
  • 2015
  • In: Europace. - : Oxford University Press (OUP): Policy B - Oxford Open Option B - CC-BY. - 1099-5129 .- 1532-2092. ; 17:7, s. 1023-1029
  • Journal article (peer-reviewed)abstract
    • Aims The aim of this study was to estimate the cost-effectiveness of 2 weeks of intermittent screening for asymptomatic atrial fibrillation (AF) in 75/76-year-old individuals. Methods and results The cost-effectiveness analysis of screening in 75-year-old individuals was based on a lifelong decision analytic Markov model. In this model, 1000 hypothetical individuals, who matched the population of the STROKESTOP study, were simulated. The population was analysed for different parameters such as prevalence, AF status, treatment with oral anticoagulation, stroke risk, utility, and costs. In the base-case scenario, screening of 1000 individuals resulted in 263 fewer patient-years with undetected AF. This implies eight fewer strokes, 11 more life-years, and 12 more quality-adjusted life years (QALYs) per 1000 screened individuals. The screening implies an incremental cost of (sic)50 012, resulting in a cost of (sic)4313 per gained QALY and (sic)6583 per avoided stroke. Conclusions With the use of a decision analytic simulation model, it has been shown that screening for asymptomatic AF in 75/76-year-old individuals is cost-effective.
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10.
  • Aronsson, Mattias, 1989-, et al. (author)
  • Designing an optimal screening program for unknown atrial fibrillation : a cost-effectiveness analysis.
  • 2017
  • In: Europace. - Oxford : Oxford University Press. - 1099-5129 .- 1532-2092. ; 19:10, s. 1650-1656
  • Journal article (peer-reviewed)abstract
    • Aims: The primary objective of this study was to use computer simulations to suggest an optimal age for initiation of screening for unknown atrial fibrillation and to evaluate if repeated screening will add value.Methods and results: In the absence of relevant clinical studies, this analysis was based on a simulation model. More than two billion different designs of screening programs for unknown atrial fibrillation were simulated and analysed. Data from the published scientific literature and registries were used to construct the model and estimate lifelong effects and costs. Costs and effects generated by 2 147 483 648 different screening designs were calculated and compared. Program designs that implied worse clinical outcome and were less cost-effective compared to other programs were excluded from the analysis. Seven program designs were identified, and considered to be cost effective depending on what the health-care decision makers are ready to pay for gaining a quality-adjusted life-year (QALY). Screening at the age of 75 implied the lowest cost per gained QALY (€4 800/QALY).Conclusion: In conclusion, examining the results of more than two billion simulated screening program designs for unknown atrial fibrillation, seven designs were deemed cost-effective depending on how much we are prepared to pay for gaining QALYs. Our results showed that repeated screening for atrial fibrillation implied additional health benefits to a reasonable cost compared to one-off screening.
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  • Atterman, Adriano, et al. (author)
  • Net benefit of oral anticoagulants in patients with atrial fibrillation and active cancer : a nationwide cohort study
  • 2020
  • In: Europace. - : Oxford University Press. - 1099-5129 .- 1532-2092. ; 22:1, s. 58-65
  • Journal article (peer-reviewed)abstract
    • Aims: To estimate the net cerebrovascular benefit of prophylactic treatment with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and active cancer.Methods and results: We included all Swedish patients who had been diagnosed with AF in a hospital or in a hospital-associated outpatient unit between 1 July 2005 and 1 October 2017. Patients with active cancer (n = 22 596) and without cancer (n = 440 848) were propensity score matched for the likelihood of receiving OACs at baseline. At baseline, 38.3% of cancer patients with AF and high stroke risk according to CHA2DS2-VASc score received OACs. There was a net benefit of OACs, assessed by the composite outcome of ischaemic stroke, extracranial arterial thromboembolism, all major bleedings, and death, both among patients with active cancer [hazard ratio (HR): 0.81, confidence interval (CI): 0.78-0.85] and among patients without cancer (HR: 0.81, CI: 0.80-0.82). When limiting follow-up to 1 year to minimize the effects of possible treatment cross-over and additionally accounting for death as a competing risk in cancer patients, a net cerebrovascular benefit regarding ischaemic stroke or intracranial bleeding was observed for OACs [subhazard ratio (sHR): 0.67, CI: 0.55-0.83]. A net cerebrovascular benefit was also seen for non-vitamin K antagonist OACs over warfarin after competing risk analyses in cancer patients (sHR: 0.65, CI: 0.48-0.88).Conclusion: Patients with AF and active cancer benefit from OAC treatment.
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  • Batra, Gorav, et al. (author)
  • Antithrombotic therapy after myocardial infarction in patients with atrial fibrillation undergoing percutaneous coronary intervention
  • 2018
  • In: European Heart Journal - Cardiovascular Pharmacotherapy. - : Oxford University Press (OUP). - 2055-6837 .- 2055-6845. ; 4:1, s. 36-45
  • Journal article (peer-reviewed)abstract
    • Aims Optimal antithrombotic therapy after percutaneous coronary intervention (PCI) in patients with myocardial infarction (MI) and atrial fibrillation is uncertain. In this study, we compared antithrombotic regimes with regard to a composite cardiovascular outcome of all-cause mortality, MI or ischaemic stroke, and major bleeds. Methods and results Patients between October 2005 and December 2012 were identified in Swedish registries, n = 7116. Landmark 0-90 and 91-365 days of outcome were evaluated with Cox-regressions, with dual antiplatelet therapy as reference. At discharge, 16.2% received triple therapy (aspirin, clopidogrel, and warfarin), 1.9% aspirin plus warfarin, 7.3% clopidogrel plus warfarin, and 60.8% dual antiplatelets. For cardiovascular outcome, adjusted hazard ratio with 95% confidence interval (HR) for triple therapy was 0.86 (0.70-1.07) for 0-90 days and 0.78 (0.58-1.05) for 91-365 days. A HR of 2.16 (1.48-3.13) and 1.61 (0.98-2.66) during 0-90 and 91-365 days, respectively, was observed for major bleeds. For aspirin plus warfarin, HR 0.82 (0.54-1.26) and 0.62 (0.48-0.79) was observed for cardiovascular outcome and 1.30 (0.60-2.85) and 1.01 (0.63-1.62) for major bleeds during 0-90 and 91-365 days, respectively. For clopidogrel plus warfarin, HR of 0.90 (0.68-1.19) and 0.68 (0.49-0.95) was observed for cardiovascular outcome and 1.28 (0.71-2.32) and 1.08 (0.57-2.04) for major bleeds during 0-90 and 91-365 days, respectively. Conclusion Compared to dual antiplatelets, aspirin or clopidogrel plus warfarin therapy was associated with similar 0-90 days and lower 91-365 days of risk of the cardiovascular outcome, without higher risk of major bleeds. Triple therapy was associated with non-significant lower risk of cardiovascular outcome and higher risk of major bleeds.
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  • Björck, Staffan, et al. (author)
  • Atrial Fibrillation, Stroke Risk, and Warfarin Therapy Revisited: A Population-Based Study.
  • 2013
  • In: Stroke; a journal of cerebral circulation. - 1524-4628. ; 44, s. 3103-3108
  • Journal article (peer-reviewed)abstract
    • Background and Purpose—Atrial fibrillation (AF) is a major risk factor for ischemic stroke. This study aims to update the knowledge about AF and associated stroke risk and benefits of anticoagulation. Methods—We extracted data from the hospital, specialized outpatient, and primary healthcare and drug registries in a Swedish region with 1.56 million residents. We identified all individuals who had received an AF diagnosis during the previous 5 years; all stroke events during 2010; and patients with AF aged ≥50 years who had received warfarin during 2009. Results—AF had been diagnosed in 38 446 subjects who were alive at the beginning of 2010 (prevalence of 3.2% in the adult [≥20 years] population); ≈46% received warfarin therapy. In 2010, there were 4565 ischemic stroke events and 861 intracranial hemorrhages. AF had been diagnosed in 38% of ischemic events (≥50% among those aged ≥80 years) and in 23% of intracranial hemorrhages. An AF diagnosis was often lacking in hospital discharge records after stroke events. Warfarin therapy was associated with an odds ratio of 0.50 (confidence interval, 0.43–0.57) for ischemic stroke and, despite an increased risk of intracranial hemorrhage, an odds ratio of 0.57 (confidence interval, 0.50–0.64) for the overall risk for stroke. Conclusions—AF is more common than present guidelines suggest. The attributable risk of AF for ischemic stroke increases with age and is close to that of hypertension in individuals aged ≥80 years. Because a majority of patients with AF with increased risk for stroke had not received anticoagulation therapy, there is a large potential for improvement.
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  • Elfwen, Ludvig, et al. (author)
  • Direct or subacute coronary angiography in out-of-hospital cardiac arrest (DISCO)-An initial pilot-study of a randomized clinical trial
  • 2019
  • In: Resuscitation. - : ELSEVIER IRELAND LTD. - 0300-9572 .- 1873-1570. ; 139, s. 253-261
  • Journal article (peer-reviewed)abstract
    • Background: The clinical importance of immediate coronary angiography, with potentially subsequent percutaneous coronary intervention (PCI), in out-of-hospital cardiac arrest (OHCA) patients without ST-elevation on the ECG is unclear. In this study, we assessed feasibility and safety aspects of performing immediate coronary angiography in a pre-specified pilot phase of the 'DIrect or Subacute Coronary angiography in Out-of-hospital cardiac arrest' (DISCO) randomized controlled trial (ClinicalTrials.gov ID: NCT02309151). Methods: Resuscitated bystander witnessed OHCA patients > 18 years without ST-elevation on the ECG were randomized to immediate coronary angiography versus standard of care. Event times, procedure related adverse events and safety variables within 7 days were recorded. Results: In total, 79 patients were randomized to immediate angiography (n = 39) or standard of care (n = 40). No major differences in baseline characteristics between the groups were found. There were no differences in the proportion of bleedings and renal failure. Three patients randomized to immediate angiography and six patients randomized to standard care died within 24 h. The median time from EMS arrival to coronary angiography was 135 min in the immediate angiography group. In patients randomized to immediate angiography a culprit lesion was found in 14/38 (36.8%) and PCI was performed in all these patients. In 6/40 (15%) patients randomized to standard of care, coronary angiography was performed before the stipulated 3 days. Conclusion: In this out-of-hospital cardiac arrest population without ST-elevation, randomization to a strategy to perform immediate coronary angiography was feasible although the time window of 120 min from EMS arrival at the scene of the arrest to start of coronary angiography was not achieved. No significant safety issues were reported.
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  • Engdahl, Johan, 1968, et al. (author)
  • Geographic and socio-demographic differences in uptake of population-based screening for atrial fibrillation: The STROKESTOP I study
  • 2016
  • In: International Journal of Cardiology. - : Elsevier BV. - 0167-5273 .- 1874-1754. ; 222, s. 430-435
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: The rationale behind screening for atrial fibrillation (AF) is to prevent ischemic stroke. Socio-demographic differences are expected to affect screening uptake. Geographic differences may provide further insights leading to targeted interventions for improved uptake. The objective of this study was to evaluate geographic and socio-demographic differences in uptake of AF screening in the population-based study STROKESTOP I. METHODS: STROKESTOP was carried out in two Swedish counties with a total population of 2.3 million inhabitants. Half of the residents aged 75-76years were randomized to the screening arm: invitation to clinical examination followed by ambulant ECG recording. Information on each invited person's residential parish (n=157) was used. On parish-level, aggregated data for the participants and non-participants, respectively, were obtained with respect to socioeconomic variables: educational level, disposable income, immigrant and marital status. Geo-maps displaying participation ratios were estimated by hierarchical Bayes methods. RESULTS: The overall participation rate was similar in men and women but lower in Stockholm, 47.6% (5665/11,903) than in Halland, 61.2% (1495/2443). Participation was clearly associated with the socioeconomic variables. Participation not taking into account socioeconomy varied more markedly across the parishes in the Stockholm county (range: 0.65-1.26) than in the Halland county (0.94-1.27). After adjustment for socioeconomic variables, a geographic variation remained in Stockholm, but not in Halland. CONCLUSION: Participation in AF screening varied according to socioeconomic conditions. Geographic variation in participation was marked in the Stockholm county, with only one screening clinic. Geo-mapping of participation yielded useful information needed to intervene for improved screening uptake.
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  • Freedman, Ben, et al. (author)
  • Screening for Atrial Fibrillation A Report of the AF-SCREEN International Collaboration
  • 2017
  • In: Circulation. - : LIPPINCOTT WILLIAMS & WILKINS. - 0009-7322 .- 1524-4539. ; 135:19, s. 1851-
  • Journal article (peer-reviewed)abstract
    • Approximately 10% of ischemic strokes are associated with atrial fibrillation (AF) first diagnosed at the time of stroke. Detecting asymptomatic AF would provide an opportunity to prevent these strokes by instituting appropriate anticoagulation. The AF-SCREEN international collaboration was formed in September 2015 to promote discussion and research about AF screening as a strategy to reduce stroke and death and to provide advocacy for implementation of country-specific AF screening programs. During 2016, 60 expert members of AF-SCREEN, including physicians, nurses, allied health professionals, health economists, and patient advocates, were invited to prepare sections of a draft document. In August 2016, 51 members met in Rome to discuss the draft document and consider the key points arising from it using a Delphi process. These key points emphasize that screen-detected AF found at a single timepoint or by intermittent ECG recordings over 2 weeks is not a benign condition and, with additional stroke factors, carries sufficient risk of stroke to justify consideration of anticoagulation. With regard to the methods of mass screening, handheld ECG devices have the advantage of providing a verifiable ECG trace that guidelines require for AF diagnosis and would therefore be preferred as screening tools. Certain patient groups, such as those with recent embolic stroke of uncertain source (ESUS), require more intensive monitoring for AF. Settings for screening include various venues in both the community and the clinic, but they must be linked to a pathway for appropriate diagnosis and management for screening to be effective. It is recognized that health resources vary widely between countries and health systems, so the setting for AF screening should be both country-and health system-specific. Based on current knowledge, this white paper provides a strong case for AF screening now while recognizing that large randomized outcomes studies would be helpful to strengthen the evidence base.
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19.
  • Friberg, Leif, et al. (author)
  • Atrial Fibrillation Prevalence Revisited.
  • 2013
  • In: Journal of internal medicine. - : Wiley. - 1365-2796 .- 0954-6820. ; 274:5, s. 461-468
  • Journal article (peer-reviewed)abstract
    • The estimate of 0.4-1.0% prevalence of atrial fibrillation in the most recent American guidelines is based mainly on studies including patients with permanent AF; although recent evidence shows that the stroke risk is similar with paroxysmal and persistent AF. Our objective was to determine the prevalence of AF in Sweden, irrespective of type, and to what extent AF patients receive adequate stroke prophylaxis.
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20.
  • Friberg, Leif, et al. (author)
  • Benefit of Anticoagulation Unlikely in Patients With Atrial Fibrillation and a CHA(2)DS(2)-VASc Score of 1
  • 2015
  • In: Journal of the American College of Cardiology. - : Elsevier BV. - 0735-1097 .- 1558-3597. ; 65:3, s. 225-232
  • Journal article (peer-reviewed)abstract
    • BACKGROUND Patients with atrial fibrillation (AF) and >= 1 point on the stroke risk scheme CHA(2)DS(2)-VASc (congestive heart failure, hypertension, age >= 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category) are considered at increased risk for future stroke, but the risk associated with a score of 1 differs markedly between studies. OBJECTIVES The goal of this study was to assess AF-related stroke risk among patients with a score of 1 on the CHA(2)DS(2)-VASc. METHODS We conducted this retrospective study of 140,420 patients with AF in Swedish nationwide health registries on the basis of varying definitions of "stroke events." RESULTS Using a wide "stroke" diagnosis (including hospital discharge diagnoses of ischemic stroke as well as unspecified stroke, transient ischemic attack, and pulmonary embolism) yielded a 44% higher annual risk than if only ischemic strokes were counted. Including stroke events in conjunction with the index hospitalization for AF doubled the long-term risk beyond the first 4 weeks. For women, annual stroke rates varied between 0.1% and 0.2% depending on which event definition was used; for men, the corresponding rates were 0.5% and 0.7%. CONCLUSIONS The risk of ischemic stroke in patients with AF and a CHA(2)DS(2)-VASc score of 1 seems to be lower than previously reported. (C) 2015 by the American College of Cardiology Foundation.
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  • Friberg, Leif, et al. (author)
  • Efficacy and safety of non-vitamin K antagonist oral anticoagulants compared with warfarin in patients with atrial fibrillation
  • 2017
  • In: Open heart. - : BMJ. - 2053-3624. ; 4:2
  • Journal article (peer-reviewed)abstract
    • AIMS: Non-vitamin K antagonist oral anticoagulants (NOACs) were in pivotal randomised controlled trials at least non-inferior to warfarin for stroke prevention in atrial fibrillation, but time in therapeutic range (TTR) for warfarin was lower (mean 55%-65%) than in Swedish general care where TTR is >70%. We compared efficacy and safety of NOACs and warfarin treatment for stroke prevention in Sweden.METHODS: Retrospective cohort study of all non-selected oral anticoagulation naïve atrial fibrillation patients with first prescription for NOACs or warfarin between December 2011 and December 2014, excluding patients with mitral stenosis or mechanical valvular prosthesis. Data were obtained from cross-linked national registers, propensity scores were used as continuous covariates, and associations between treatment and outcomes were evaluated by multivariable Cox regressions.RESULTS: -VASc points (mean) 3.38 vs 3.24, p<0.001, in NOAC and warfarin groups, respectively. HRs (95% CI) for NOACs versus warfarin were 1.04 (0.91-1.19) for all-cause stroke or systemic embolism, 1.16 (1.00-1.35) for ischaemic stroke, 0.85 (0.76-0.96) for major bleeding, 1.22 (1.01-1.46) for gastrointestinal bleeding, 0.60 (0.47-0.76) for intracranial haemorrhage and 0.89 (0.81-0.96) for all-cause mortality.CONCLUSION: In this large non-selected anticoagulation naïve Swedish atrial fibrillation cohort, the risks for all-cause stroke or systemic embolism were similar with NOACs and warfarin, but NOACs were associated with significantly lower risks of all-cause mortality, major bleeding and intracranial haemorrhage but higher risk of gastrointestinal bleeding. Better safety suggests NOACs as preferred treatment for patients with atrial fibrillation starting oral anticoagulation.
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23.
  • Friberg, Leif, 1957- (author)
  • Från sonett till drömtext : Gunnar Björlings väg mot modernismen
  • 2004
  • Doctoral thesis (other academic/artistic)abstract
    • The subject of this dissertation is the Finland-Swedish author Gunnar Björling (1887-1960) and his journey towards Modernism. The principle thesis of this dissertation, the idea that Björling’s distinctive language cannot be understood without an underlying modernistic current, is outlined in Chapter I. It also discusses the idea that Modernism cannot be reduced to a matter of style, but encompasses particular values, ideological stances and practical matters, such as the forming of alliances, writing manifestos and publishing journals.Chapter II examines how and why Björling came to be regarded as a modernist. A strongly contributing factor was Björling’s language, which from the very first violated prevailing ideas on acceptable forms of expression. The fact that he published his first book through the modernist publishing firm Daimon, and contributed to its journal Ultra, further confirmed his modernistic placing.Chapter III focuses on Björling’s unpublished juvenilia from the 1910’s. The young Björling wrote traditional rhyming verse but was also influenced by writings of a more symbolistic and modern character. The chapter concludes with a study of bizarrerierna, Björling’s dream notes, originally written during the 1910’s but first published in 1928. With their bold enjambments and highly compressed form, these notes came to influence the continued development of his lyrical imagery.Chapter IV deals with his debut Vilande dag (Resting day) (1922) and its symbolistically coloured language problematic. Björling struggled to find a language that would convey his experience of the limitlessness of being, a language striving to transcend words, leaving space for silence.This struggle for the right words continues in the later Korset och löftet (The cross and the promise) (1925) and Chapter V demonstrates how this is connected with the quest for God. In the wake of German Expressionism and Dadaism, Björling adopts a more disjointed syntax and a bolder and more dissonant lyrical imagery. There also occurs a thematic expansion, giving greater prominence to the daily life of the metropolis, a life transformed by media. In accordance with modernistic patterns, Björling chose to end his book with a theoretical epilogue, which is a distinctive collation of life philosophy, anti-clericalism, passionate religiousness, moral-philosophical discussions and aesthetic expositions.
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24.
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25.
  • Friberg, Leif, et al. (author)
  • High prevalence of atrial fibrillation among patients with ischemic stroke
  • 2014
  • In: Stroke. - 0039-2499 .- 1524-4628. ; 45:9, s. 2599-
  • Journal article (peer-reviewed)abstract
    • Background and Purpose-Atrial fibrillation (AF) is a common cause of devastating but potentially preventable stroke. Estimates of the prevalence of AF among patients with stroke vary considerably because of difficulties in detection of intermittent, silent AF. Better recognition of AF in this patient group may help to identify and offer protection to individuals at risk. Our aim was to determine the nationwide prevalence of AF among patients with ischemic stroke, as well as their use of oral anticoagulation. Methods-Cross-sectional study of unselected patients in cross-linked nationwide Swedish health registers. All 94 083 patients with a diagnosis of ischemic stroke in the nationwide stroke register Riks-Stroke between 2005 and 2010 were studied. Information about previously diagnosed AF, and comorbidity, was obtained from the nationwide Patient Register and cross-referenced with the national Drug Register containing data on all dispensed pharmacological prescriptions in Sweden. Results-Combination of data from Riks-Stroke and from the Patient Register showed that 31 428 (33.4%) patients with ischemic stroke had previously known, or newly diagnosed, AF. Of those, only 16.2% had received warfarin in a pharmacy within 6 months before stroke onset. After hospital discharge, only 35.0% of the survivors received warfarin within the first 3 months after discharge. The likelihood for underlying AF was strongly correlated to the CHA(2)DS(2)-VASC score, which is a point based scheme for assessment of stroke risk in AF but which also predicts likelihood of AF. In this scheme points are given for age, previous stroke or transient ischemic attack, hypertension, heart failure, diabetes, vascular disease and female sex. Conclusions-Access to nationwide register data shows that AF is more common among patients with ischemic stroke than those previously reported. Few patients with stroke and AF had anticoagulant treatment before the event, and few got it after the event. CHA(2)DS(2)-VASc could be a useful monitoring tool to intensify efforts to diagnose AF among patients with cryptogenic stroke.
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26.
  • Friberg, Leif (author)
  • Paroxysmal atrial fibrillation : prognostic implications
  • 2008
  • Doctoral thesis (other academic/artistic)abstract
    • This thesis is based on data from the Stockholm Cohort on Atrial Fibrillation (SCAF). This cohort consists of all 2912 patients with atrial fibrillation or flutter who were treated as in or outpatients at South Hospital in Stockholm or at Gustavsberg Primary Care Centre during 2002. The patients have been followed prospectively through medical records complemented by information from national registers of hospitalisations and mortality. In Study I we evaluated the incidence of ischaemic and haemorrhagic stroke in 855 patients with paroxysmal atrial fibrillation (PxAF). We found that the stroke incidence was approximately twice as high as in the general population and similar to that of permanent atrial fibrillation (PermAF). Warfarin prophylaxis appeared to be as efficient in Px AF as in PermAF. The incidence of cerebral bleedings was low and not higher in patients using warfarin than in patients using aspirin. In Study II we investigated the mortality among patients with PxAF and found it to be higher than expected from age and sex adjusted specific rates in the general population. The standardized mortality ratio (SMR) was 1.6. Patients with PxAF died more often than expected from myocardial infarction (SMR 2.4), heart failure (SMR 2.6) and cardiovascular disease in general (SMR 2.1). The increased mortality in PxAF appears to be present mainly in subjects with concomitant cardiovascular co-morbidity. Treatment with warfarin was found to be associated with improved survival in PxAF patients. In Study III we studied how current guideline recommendations are translated into clinical practice. We found that approximately half of the patients who ought to have warfarin also had received such treatment. Undertreatment was particularly common in patients with PxAF and in patients aged >80 years. Important risk factors for stroke did not increase the likelihood of warfarin treatment. In Study IV we investigated whether patients who remain in sinus rhythm after DCcardioversion obtain any prognostic benefit from having normal sinus rhythm restored. From the SCAF-cohort 361 patients who had been DC-cardioverted were studied. Patients without known relapse to atrial fibrillation within three months after cardioversion had a lower incidence of all-cause mortality (HR 0.5, 95% C.I. 0.3-1.0) as well as a lower incidence of the composite end point consisting of death, ischaemic stroke, myocardial infarction or hospitalization for heart failure (HR 0.5, 95% C.I. 0.3-0.8) after multivariable adjustment. Conclusions: PxAF is associated with increased morbidity and mortality which is similar to that of PermAF. Underlying cardiovascular disease seems to account for most of this. Therefore it is essential to diagnose and treat any underlying cardiovascular disease in PxAF-patients. Warfarin seems to be helpful, not only against stroke but also against premature cardiovascular death. Therefore it is essential to provide PxAF-patients with adequate anticoagulant treatment unless there are clear contraindications for such therapy. Our results suggest that restoration and maintenance of sinus rhythm may improve the prognosis in patients with atrial fibrillation. Therefore, we propose that eligible patients should be given an opportunity to be restored to sinus rhythm before atrial fibrillation is accepted as permanent.
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27.
  • Friberg, Leif, et al. (author)
  • Population screening of 75- and 76-year-old men and women for silent atrial fibrillation (STROKESTOP)
  • 2013
  • In: Europace. - : Oxford University Press (OUP): Policy B. - 1099-5129 .- 1532-2092. ; 15:1, s. 135-140
  • Journal article (peer-reviewed)abstract
    • Atrial fibrillation (AF) is important because it is common and is a major cause of stroke unless treated with oral anticoagulant. The prevalence of AF increases with age as does the risk of stroke. At 75 years the risk from age alone is so high that current guidelines recommend anticoagulation even in the absence of other risk factors. Atrial fibrillation is often asymptomatic and only discovered by chance or when a stroke already has occurred. less thanbrgreater than less thanbrgreater thanWe have launched a major screening study for silent AF in which 25 000 Swedes aged 75 and 76 years are randomized to either participate in a screening programme using ambulant intermittent electrocardiogram (ECG) recording to detect silent AF, or act as a control group. Patients in whom AF is detected are offered cardiological examination and anticoagulant treatment according to current guidelines. The cohort and the controls will be followed prospectively for 5 years after the inclusion of the first participant. An interim analysis will be made after 3 years. less thanbrgreater than less thanbrgreater thanOur hypothesis is that screening for AF will reduce stroke incidence in the screened population, and that this screening will prove to be cost effective. Secondary endpoints are: any thromboembolic event, intracranial bleeding, other major bleeding, first ever diagnosis of dementia, death from any cause, and a composite of these endpoints.
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28.
  • Giesecke, Peter, et al. (author)
  • Increased Cardiovascular Mortality and Morbidity in Patients Treated for Toxic Nodular Goiter Compared to Graves' Disease and Nontoxic Goiter
  • 2017
  • In: Thyroid. - : Mary Ann Liebert. - 1050-7256 .- 1557-9077. ; 27:7, s. 878-885
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: Previous research has suggested an increased risk of death and cardiovascular disease in patients treated for hyperthyroidism. However, studies on this subject are heterogeneous, often based on old data, or have not considered the impact that treatment for hyperthyroidism might have on cardiovascular risk. It is also unclear whether long-term prognosis differs between Graves' disease and toxic nodular goiter. The aim of this study was to use a very large cohort built on recent data to assess whether improvements in cardiovascular care might have changed the prognosis over time. The study also investigated the impact of different etiologies of hyperthyroidism.METHODS: This was an observational register study for the period 1976-2012, with subjects followed for a median period of 18.4 years. Study patients were Stockholm residents treated for Graves' disease or toxic nodular goiter with either radioactive iodine or surgery (N = 12,239). This group was compared to Stockholm residents treated for nontoxic goiter (N = 3685), with adjustments made for age, sex, comorbidities, and time of treatment. Comparisons were also made to the general population of Stockholm. Outcomes were assessed in terms of all-cause and cardiovascular mortality as well as cardiovascular morbidity.RESULTS: The hazard ratios (HR) for all-cause mortality and for cardiovascular mortality were 1.27 [confidence interval (CI) 1.20-1.35] and 1.29 [CI 1.17-1.42], respectively, for hyperthyroid patients compared to those with nontoxic goiter. For cardiovascular morbidity, the HR was 1.12 [CI 1.06-1.18]. Patients aged ≥45 years who were treated for toxic nodular goiter were generally at greater risk than others, and those included from the year 1990 and onwards were at greater risk than those included earlier. Increased all-cause mortality, as well as cardiovascular mortality and morbidity, were also seen in comparisons with the general population.CONCLUSIONS: This is the first large study to indicate that the long-term risk of death and cardiovascular disease in hyperthyroid subjects is due to the hyperthyroidism itself and not an effect of confounding introduced by its treatment. Much of the excess risk is confined to individuals treated for toxic nodular goiter. Despite advances in cardiovascular care during recent decades, hyperthyroidism is still a diagnosis associated with increased cardiovascular morbidity and mortality.
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29.
  • Gudmundsdottir, Katrin Kemp, et al. (author)
  • Stepwise mass screening for atrial fibrillation using N-terminal B-type natriuretic peptide : the STROKESTOP II study
  • 2020
  • In: Europace. - : OXFORD UNIV PRESS. - 1099-5129 .- 1532-2092. ; 22:1, s. 24-32
  • Journal article (peer-reviewed)abstract
    • Aims: To study the prevalence of unknown atrial fibrillation (AF) in a high-risk, 75/76-year-old, population using N-terminal B-type natriuretic peptide (NT-proBNP) and handheld electrocardiogram (ECG) recordings in a stepwise screening procedure.Methods and results: The STROKESTOP II study is a population-based cohort study in which all 75/76-year-old in the Stockholm region (n = 28 712) were randomized 1:1 to be invited to an AF screening programme or to serve as the control group. Participants without known AF had NT-proBNP analysed and were stratified into low-risk (NT-proBNP <125 ng/L) and high-risk (NT-proBNP >= 125 ng/L) groups. The high-risk group was offered extended ECG-screening, whereas the low-risk group performed only one single-lead ECG recording. In total, 6868 individuals accepted the screening invitation of which 6315 (91.9%) did not have previously known AF. New AF was detected in 2.6% [95% confidence interval (CI) 2.2-3.0] of all participants without previous AF. In the high-risk group (n = 3766/6315, 59.6%), AF was diagnosed in 4.4% (95% CI 3.7-5.1) of the participants. Out of these, 18% had AF on their index-ECG. In the low-risk group, one participant was diagnosed with AF on index-ECG. The screening procedure resulted in an increase in known prevalence from 8.1% to 10.5% among participants. Oral anticoagulant treatment was initiated in 94.5% of the participants with newly diagnosed AF.Conclusion: N-terminal B-type natriuretic peptide-stratified systematic screening for AF identified 4.4% of the high-risk participants with new AF. Oral anticoagulant treatment initiation was well accepted in the group diagnosed with new AF.
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30.
  • Herlitz, Johan, et al. (author)
  • Svenska rådet för HLR ska öka överlevnaden vid hjärtstopp
  • 2007
  • In: Läkartidningen. - 0023-7205. ; 104:8, s. 588-590
  • Journal article (peer-reviewed)abstract
    • It is estimated that about 30 000 people a year are successfully resuscitated after having suffered an out-of-hospital cardiac arrest in Europe. The number of patients that are successfully resuscitated after an in-hospital cardiac arrest is not known, but it can be assumed that this figure is even higher than that after an out-of-hospital cardiac arrest. The aim of the Swedish Resuscitation Council is to gather together people with specific skills in the field of cardiac arrest in a single organisation. The council has five specific aims: 1) To develop guidelines for the treatment of cardiac arrest, 2) To develop specific educational programmes for the treatment of cardiac arrest, 3) To develop ethical guidelines for the treatment of cardiac arrest, 4) To spread knowledge in the community and in health care about the treatment of cardiac arrest and 5) To follow the effect of these efforts in terms of survival and cerebral function after cardiac arrest. In the present article, the Swedish Resuscitation Council is presented in greater detail.
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31.
  • Hygrell, Tove, et al. (author)
  • Prognostic Implications of Supraventricular Arrhythmias
  • 2021
  • In: American Journal of Cardiology. - : Elsevier BV. - 0002-9149 .- 1879-1913. ; 151, s. 57-63
  • Journal article (peer-reviewed)abstract
    • The aim of this study was to establish the prevalence and prognostic implication of progressive supraventricular arrhythmias from frequent supraventricular ectopic complexes, isolated, in bi- or trigeminy, to supraventricular tachycardias with different characteristics. In the STROKESTOP I mass-screening study for atrial fibrillation (AF) in 75- and 76-year olds in Sweden, participants registered 30-second intermittent ECG twice daily for two weeks. The ECG-recordings from STROKESTOP I were re-evaluated using an automated algorithm to detect individuals with frequent supraventricular ectopic complexes or runs. Detected episodes were manually re-examined to confirm the findings. The primary endpoint was AF as ascertained from the national Swedish Patient register. Exploratory secondary endpoints were stroke and death. Median follow-up was 4.2 (interquartile range [IQR] 3.8-4.4) years. Of the examined 6,100 participants, 85% were free of significant supraventricular arrhythmia. In the 894 participants that had arrhythmia, frequent supraventricular ectopic complexes were the most common arrhythmia, n = 709 (11.6%) and irregular supraventricular tachycardias were more common than regular. Individuals with the most AF similar supraventricular tachycardias, irregular and lacking p-waves (termed micro-AF), n = 97 (1.6%) had the highest risk of developing AF (hazard ratio 4.3; 95% confidence interval [CI] 2.7-6.8). They also had increased risk of death (hazard ratio 2.0; CI 1.1-3.8). In conclusion, progression of atrial arrhythmias from supraventricular ectopic complexes to more AF-like episodes is associated with development of AF. Extended screening for AF should be considered in individuals with frequent supraventricular activity, especially in those with supraventricular tachycardias with AF characteristics.
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32.
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33.
  • Kirchhof, Paulus, et al. (author)
  • Comprehensive risk reduction in patients with atrial fibrillation : emerging diagnostic and therapeutic options - a report from the 3rd Atrial Fibrillation Competence NETwork/European Heart Rhythm Association consensus conference
  • 2012
  • In: Europace. - : Oxford University Press (OUP). - 1099-5129 .- 1532-2092. ; 14:1, s. 8-27
  • Research review (peer-reviewed)abstract
    • While management of atrial fibrillation (AF) patients is improved by guideline-conform application of anticoagulant therapy, rate control, rhythm control, and therapy of accompanying heart disease, the morbidity and mortality associated with AF remain unacceptably high. This paper describes the proceedings of the 3rd Atrial Fibrillation NETwork (AFNET)/European Heart Rhythm Association (EHRA) consensus conference that convened over 60 scientists and representatives from industry to jointly discuss emerging therapeutic and diagnostic improvements to achieve better management of AF patients. The paper covers four chapters: (i) risk factors and risk markers for AF; (ii) pathophysiological classification of AF; (iii) relevance of monitored AF duration for AF-related outcomes; and (iv) perspectives and needs for implementing better antithrombotic therapy. Relevant published literature for each section is covered, and suggestions for the improvement of management in each area are put forward. Combined, the propositions formulate a perspective to implement comprehensive management in AF.
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34.
  • Kompassriktning: 2000-talet : Festskrift till Catarina Ericson-Roos
  • 2011
  • Editorial collection (pop. science, debate, etc.)abstract
    • Denna festskrift är tillägnad Stockholms universitetsbiblioteks överbibliotekarie Catarina Ericson-Roos och överlämnades vid hennes pensionering i juni 2011. Festskriften innehåller 18 bidrag. Ämnesområdena i dessa är både breda och specifika. Ett par ämnen återkommer i flera av bidragen men med olika infallsvinklar. Informationsteknik och bibliotek, minnesbilder från tidigare och nuvarande kollegor på Stockholms universitetsbibliotek, ett samtal kring ledarskap, en historisk beskrivning av de finländska universitetsbiblioteken, några djupdykningar i Stockholms universitetsbiblioteks raritetssamlingar som till exempel en genomgång av två unika Tereniusutgåvor samt Bengt Bergius tryckta tal om välsmakande läckerheter, en beskrivning av Bergianska biblioteket, Nellingearkivet och bokförläggare Adam Helms och svensk marknadsföringshistoria, en etnologisk betraktelse av bilden av bibliotekarien samt en beskrivning av författarparet Tora och Knut Dahls litterära samtal på Lidingö. Författarnas bakgrund är både varierande och lika, flertalet är framstående företrädare för Stockholms universitet samt för bibliotekssverige. Flera är bibliotekarier och forskare med en gemensam nämnare: alla har någon anknytning till Stockholms universitet och dess universitetsbibliotek.
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35.
  • Levin, Lars-Åke, et al. (author)
  • A cost-effectiveness analysis of screening for silent atrial fibrillation after ischaemic stroke.
  • 2015
  • In: Europace. - : Oxford University Press. - 1099-5129 .- 1532-2092. ; 17:2, s. 207-14
  • Journal article (peer-reviewed)abstract
    • AIMS: The purpose of this study was to estimate the cost-effectiveness of two screening methods for detection of silent AF, intermittent electrocardiogram (ECG) recordings using a handheld recording device, at regular time intervals for 30 days, and short-term 24 h continuous Holter ECG, in comparison with a no-screening alternative in 75-year-old patients with a recent ischaemic stroke.METHODS AND RESULTS: The long-term (20-year) costs and effects of all alternatives were estimated with a decision analytic model combining the result of a clinical study and epidemiological data from Sweden. The structure of a cost-effectiveness analysis was used in this study. The short-term decision tree model analysed the screening procedure until the onset of anticoagulant treatment. The second part of the decision model followed a Markov design, simulating the patients' health states for 20 years. Continuous 24 h ECG recording was inferior to intermittent ECG in terms of cost-effectiveness, due to both lower sensitivity and higher costs. The base-case analysis compared intermittent ECG screening with no screening of patients with recent stroke. The implementation of the screening programme on 1000 patients resulted over a 20-year period in 11 avoided strokes and the gain of 29 life-years, or 23 quality-adjusted life years, and cost savings of €55 400.CONCLUSION: Screening of silent AF by intermittent ECG recordings in patients with a recent ischaemic stroke is a cost-effective use of health care resources saving costs and lives and improving the quality of life.
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36.
  • Lund, Lars H., et al. (author)
  • Association Between Use of beta-Blockers and Outcomes in Patients With Heart Failure and Preserved Ejection Fraction
  • 2014
  • In: Journal of the American Medical Association (JAMA). - : American Medical Association (AMA): JAMA. - 0098-7484 .- 1538-3598. ; 312:19, s. 2008-2018
  • Journal article (peer-reviewed)abstract
    • IMPORTANCE Heart failure with preserved ejection fraction (HFPEF) may be as common and may have similar mortality as heart failure with reduced ejection fraction (HFREF). beta-Blockers reduce mortality in HFREF but are inadequately studied in HFPEF. OBJECTIVE To test the hypothesis that beta-blockers are associated with reduced all-cause mortality in HFPEF. DESIGN Propensity score-matched cohort study using the Swedish Heart Failure Registry. Propensity scores for beta-blacker use were derived from 52 baseline clinical and socioeconomic variables. SETTING Nationwide registry of 67 hospitals with inpatient and outpatient units and 95 outpatient primary care clinics in Sweden with patients entered into the registry between July 1, 2005, and December 30, 2012, and followed up until December 31, 2012. PARTICIPANTS From a consecutive sample of 41 976 patients, 19 083 patients with HFPEF (mean [SD] age, 76 [12] years; 46% women). Of these, 8244 were matched 2:1 based on age and propensity score for beta-blocker use, yielding 5496 treated and 2748 untreated patients with HFPEF. Also we conducted a positive-control consistency analysis involving 22 893 patients with HFREF, of whom 6081 were matched yielding 4054 treated and 2027 untreated patients. EXPOSURES beta-Blockers prescribed at discharge from the hospital or during an outpatient visit, analyzed 2 ways: without consideration of crossover and per-protocol analysis with censoring at crossover, if applicable. MAIN OUTCOMES AND MEASURES The prespecified primary outcome was all-cause mortality and the secondary outcome was combined all-cause mortality or heart failure hospitalization. RESULTS Median follow-up in HFPEF was 755 days, overall; 709 days in the matched cohort; no patients were lost to follow-up. In the matched HFPEF cohort, 1-year survival was 80% vs 79% for treated vs untreated patients, and 5-year survival was 45% vs 42%, with 2279(41%) vs 1244(45%) total deaths and 177 vs 191 deaths per 1000 patient-years (hazard ratio [HR], 0.93; 95% Cl, 0.86-0.996; P =.04). beta-Blockers were not associated with reduced combined mortality or heart failure hospitalizations: 3368(61%) vs 1753(64%) total for first events, with 371 vs 378 first events per 1000 patient-years (HR, 0.98; 95% Cl, 0.92-1.04; P = .46). In the matched HFREF cohort, beta-blockers were associated with reduced mortality (HR, 0.89; 95% Cl, 0.82-0.97, P=.005) and also with reduced combined mortality or heart failure hospitalization (HR, 0.89; 95% Cl, 0.84-0.95; P =.001). CONCLUSIONS AND RELEVANCE In patients with HFPEF, use of beta-blockers was associated with lower all-cause mortality but not with combined all-cause mortality or heart failure hospitalization. beta-Blockers in HFPEF should be examined in a large randomized clinical trial.
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37.
  • Lyth, Johan, 1980-, et al. (author)
  • Cost-effectiveness of population screening for atrial fibrillation : the STROKESTOP study
  • 2023
  • In: European Heart Journal. - : Oxford University Press. - 0195-668X .- 1522-9645. ; 3:3, s. 196-204
  • Journal article (peer-reviewed)abstract
    • Aims Previous studies on the cost-effectiveness of screening for atrial fibrillation (AF) are based on assumptions of long-term clinical effects. The STROKESTOP study, which randomised 27 975 persons aged 75/76 years into a screening invitation group and a control group, has a median follow-up time of 6.9 years. The aim of this study was to estimate the cost-effectiveness of population-based screening for AF using clinical outcomes. Methods and results The analysis is based on a Markov cohort model. The prevalence of AF, the use of oral anticoagulation, clinical event data, and all-cause mortality were taken from the STROKESTOP study. The cost for clinical events, age-specific utilities, utility decrement due to stroke, and stroke death was taken from the literature. Uncertainty in the model was considered in a probabilistic sensitivity analysis. Per 1000 individuals invited to the screening, there were 77 gained life years and 65 gained quality-adjusted life years. The incremental cost was euro1.77 million lower in the screening invitation group. Gained quality-adjusted life years to a lower cost means that the screening strategy was dominant. The result from 10 000 Monte Carlo simulations showed that the AF screening strategy was cost-effective in 99.2% and cost-saving in 92.7% of the simulations. In the base-case scenario, screening of 1000 individuals resulted in 10.6 [95% confidence interval (CI): -22.5 to 1.4] fewer strokes (8.4 ischaemic and 2.2 haemorrhagic strokes), 1.0 (95% CI: -1.9 to 4.1) more cases of systemic embolism, and 2.9 (95% CI: -18.2 to 13.1) fewer bleedings associated with hospitalization. Conclusion Based on the STROKESTOP study, this analysis shows that a broad AF screening strategy in an elderly population is cost-effective. Efforts should be made to increase screening participation.
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38.
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39.
  • Rivard, Léna, et al. (author)
  • Atrial Fibrillation and Dementia : A Report From the AF-SCREEN International Collaboration
  • 2022
  • In: Circulation. - 1524-4539. ; 145:5, s. 392-409
  • Research review (peer-reviewed)abstract
    • Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia.
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40.
  • Savarese, Gianluigi, et al. (author)
  • Reasons for and consequences of oral anticoagulant underuse in atrial fibrillation with heart failure.
  • 2018
  • In: Heart. - : BMJ. - 1355-6037 .- 1468-201X. ; 104:13, s. 1093-1100
  • Journal article (peer-reviewed)abstract
    • OBJECTIVE: Atrial fibrillation (AF) is common in patients with heart failure (HF), and oral anticoagulants (OAC) are indicated. The aim was to assess prevalence of, predictors of and consequences of OAC non-use.METHODS: We included patients with AF, HF and no previous valve replacement from the Swedish Heart Failure Registry. High and low CHA2DS2-VASc and HAS-BLED scores were defined as above/below median. Multivariable logistic regressions were used to assess the associations between baseline characteristics and OAC use and between CHA2DS2-VASc and HAS-BLED scores and OAC use. Multivariable Cox regressions were used to assess associations between CHA2DS2-VASc and HAS-BLED scores, OAC use and two composite outcomes: all-cause death/stroke and all-cause death/major bleeding.RESULTS: Of 21 865 patients, only 12 659 (58%) received OAC. Selected predictors of OAC non-use were treatment with platelet inhibitors, less use of HF treatments, paroxysmal AF, history of bleeding, no previous stroke, planned follow-up in primary care, older age, living alone, lower income and variables associated with more severe HF. For each 1-unit increase in CHA2DS2-VASc and HAS-BLED, the ORs (95% CI) of OAC use were 1.24 (1.21-1.27) and 0.32 (0.30-0.33), and the HRs for death/stroke were 1.08 (1.06-1.10) and for death/major bleeding 1.18 (1.15-1.21), respectively. For high versus low CHA2DS2-VASc and HAS-BLED, the ORs of OAC use were 1.23 (1.15-1.32) and 0.20 (0.19-0.21), and the HRs for death/stroke were 1.25 (1.19-1.30) and for death/major bleeding 1.28 (1.21-1.34), respectively.CONCLUSIONS: Patients with AF and concomitant HF do not receive OAC on rational grounds. Bleeding risk inappropriately affects decision-making more than stroke risk.
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41.
  • Schnabel, Renate B., et al. (author)
  • Searching for Atrial Fibrillation Poststroke : A White Paper of the AF-SCREEN International Collaboration
  • 2019
  • In: Circulation. - 1524-4539. ; 140:22, s. 1834-1850
  • Journal article (peer-reviewed)abstract
    • Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non-vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non-vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.
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42.
  • Själander, Sara, et al. (author)
  • Atrial fibrillation patients do not benefit from acetylsalicylic acid
  • 2014
  • In: Europace. - : Oxford University Press (OUP). - 1532-2092 .- 1099-5129. ; 16:5, s. 631-638
  • Journal article (peer-reviewed)abstract
    • Oral anticoagulation is the recommended treatment for stroke prevention in patients with atrial fibrillation. Notwithstanding, many patients are treated with acetylsalicylic acid (ASA) as monotherapy. Our objective was to investigate if atrial fibrillation patients benefit from ASA as monotherapy for stroke prevention. Retrospective study of patients with a clinical diagnosis of atrial fibrillation between 1 July 2005 and 1 January 2009 in the National Swedish Patient register, matched with data from the National Prescribed Drugs register. Endpoints were ischaemic stroke, thrombo-embolic event, intracranial haemorrhage, and major bleeding. The study population consisted of 115 185 patients with atrial fibrillation, of whom 58 671 were treated with ASA as monotherapy and 56 514 were without any antithrombotic treatment at baseline. Mean follow-up was 1.5 years. Treatment with ASA was associated with higher risk of ischaemic stroke and thrombo-embolic events compared with no antithrombotic treatment. Acetylsalicylic acid as monotherapy in stroke prevention of atrial fibrillation has no discernable protective effect against stroke, and may even increase the risk of ischaemic stroke in elderly patients. Thus, our data support the new European guidelines recommendation that ASA as monotherapy should not be used as stroke prevention in atrial fibrillation.
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43.
  • Själander, Sara, et al. (author)
  • Atrial fibrillation patients with CHA2DS2-VASc > 1 benefit from oral anticoagulation prior to cardioversion
  • 2016
  • In: International Journal of Cardiology. - : Elsevier BV. - 0167-5273 .- 1874-1754. ; 215, s. 360-363
  • Journal article (peer-reviewed)abstract
    • Background: Electrical cardioversion of atrial fibrillation is associated with an increased risk of embolic stroke, but is generally considered safe if performed within 48 h after onset. Our objective was to investigate if thromboembolism and bleeding in association with cardioversion of atrial fibrillation differed between patients with and without oral anticoagulation.Methods: Retrospective study of patients with atrial fibrillation undergoing electrical cardioversion from national Swedish health registries from January 1st 2006 until December 1st 2010. Main outcome measures were thromboembolism and bleeding.Results: In total 22,874 atrial fibrillation patients underwent electrical cardioversion, 10,722 with and 12,152 without oral anticoagulation pre-treatment. Patients with low stroke risk (CHA(2)DS(2)-VASc 0-1) did not suffer from any thromboembolic complications within 30 days after cardioversion. After adjustment for factors included in CHA(2)DS(2)-VASc and after propensity score matching, patients without oral anticoagulation had higher risk for thromboembolic complications, odds ratio 2.54 (95% confidence interval 1.70-3.79) and odds ratio 2.51 (95% confidence interval 1.69-3.75). There were no significant differences regarding bleeding complications between patients with or without anticoagulation after adjustment for factors included in HAS-BLED, odds ratio 1.08 (95% confidence interval 0.51-2.25), nor after propensity score matching, odds ratio 1.00 (95% confidence interval 0.48-2.10).Conclusion: The results suggest that electrical cardioversion without prior anticoagulation may not be safe for patients with risk factors for thromboembolism (CHA(2)DS(2)-VASc score >1 point).
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44.
  • Sjögren, Vilhelm, et al. (author)
  • Safety and efficacy of well managed warfarin : A report from the Swedish quality register Auricula
  • 2015
  • In: Thrombosis and Haemostasis. - 0340-6245 .- 2567-689X. ; 113:6, s. 1370-1377
  • Journal article (peer-reviewed)abstract
    • The safety and efficacy of warfarin in a large, unselected cohort of warfarin-treated patients with high quality of care is comparable to that reported for non-vitamin K antagonists. Warfarin is commonly used for stroke prevention in atrial fibrillation, as well as for treatment and prevention of venous thromboembolism. While reducing risk of thrombotic/embolic incidents, warfarin increases the risk of bleeding. The aim of this study was to elucidate risks of bleeding and thromboembolism for patients on warfarin treatment in a large, unselected cohort with rigorously controlled treatment. This was a retrospective, registry-based study, covering all patients treated with warfarin in the Swedish national anticoagulation register Auricula, which records both primary and specialised care. The study included 77,423 unselected patients with 100,952 treatment periods of warfarin, constituting 217,804 treatment years. Study period was January 1, 2006 to December 31, 2011. Atrial fibrillation was the most common indication (68%). The mean time in therapeutic range of the international normalised ratio (INR) 2.0-3.0 was 76.5%. The annual incidence of I severe bleeding was 2.24% and of thromboembolism 2.65%. The incidence of intracranial bleeding was 0.37% per treatment year in the whole population, and 0.38% among patients with atrial fibrillation. In conclusion, warfarin treatment where patients spend a high proportion of time in the therapeutic range is safe and effective, and will continue to be a valid treatment option in the era of newer oral anticoagulants.
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45.
  • Sjöstrand, Torbjörn, et al. (author)
  • High-energy-physics event generation with PYTHIA 6.1
  • 2001
  • In: Computer Physics Communications. - 0010-4655. ; 135:2, s. 238-259
  • Journal article (peer-reviewed)abstract
    • Pythia version 6 represents a merger of the Pythia 5, Jetset 7 and SPythia programs, with many improvements. It can be used to generate high-energy-physics 'events', i.e. sets of outgoing particles produced in the interactions between two incoming particles. The objective is to provide as accurate as possible a representation of event properties in a wide range of reactions. The underlying physics is not understood well enough to give an exact description; the programs therefore contain a combination of analytical results and various models. The emphasis in this article is on new aspects, but a few words of general introduction are included. Further documentation is available on the web.
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46.
  • Sultanian, Pedram, et al. (author)
  • Cardiac arrest in COVID-19 : characteristics and outcomes of in- and out-of-hospital cardiac arrest. A report from the Swedish Registry for Cardiopulmonary Resuscitation.
  • 2021
  • In: European Heart Journal. - : Oxford University Press (OUP). - 0195-668X .- 1522-9645. ; 42:11, s. 1094-1106
  • Journal article (peer-reviewed)abstract
    • AIM: To study the characteristics and outcome among cardiac arrest cases with COVID-19 and differences between the pre-pandemic and the pandemic period in out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA).METHOD AND RESULTS: We included all patients reported to the Swedish Registry for Cardiopulmonary Resuscitation from 1 January to 20 July 2020. We defined 16 March 2020 as the start of the pandemic. We assessed overall and 30-day mortality using Cox regression and logistic regression, respectively. We studied 1946 cases of OHCA and 1080 cases of IHCA during the entire period. During the pandemic, 88 (10.0%) of OHCAs and 72 (16.1%) of IHCAs had ongoing COVID-19. With regards to OHCA during the pandemic, the odds ratio for 30-day mortality in COVID-19-positive cases, compared with COVID-19-negative cases, was 3.40 [95% confidence interval (CI) 1.31-11.64]; the corresponding hazard ratio was 1.45 (95% CI 1.13-1.85). Adjusted 30-day survival was 4.7% for patients with COVID-19, 9.8% for patients without COVID-19, and 7.6% in the pre-pandemic period. With regards to IHCA during the pandemic, the odds ratio for COVID-19-positive cases, compared with COVID-19-negative cases, was 2.27 (95% CI 1.27-4.24); the corresponding hazard ratio was 1.48 (95% CI 1.09-2.01). Adjusted 30-day survival was 23.1% in COVID-19-positive cases, 39.5% in patients without COVID-19, and 36.4% in the pre-pandemic period.CONCLUSION: During the pandemic phase, COVID-19 was involved in at least 10% of all OHCAs and 16% of IHCAs, and, among COVID-19 cases, 30-day mortality was increased 3.4-fold in OHCA and 2.3-fold in IHCA.
  •  
47.
  • Svennberg, Emma, et al. (author)
  • N-terminal pro B-type natriuretic peptide in systematic screening for atrial fibrillation
  • 2017
  • In: Heart. - : BMJ. - 1355-6037 .- 1468-201X. ; 103:16, s. 1271-1277
  • Journal article (peer-reviewed)abstract
    • Objective Screening for atrial fibrillation (AF) in individuals aged 65 and above is recommended by the European Society of Cardiology. Increased levels of the biomarker N-terminal pro B-type natriuretic peptide (NT-proBNP) has in cohort studies been associated with incident AF. The aim of this study was to assess whether NT-proBNP could be useful for AF detection in systematic screening.Methods The Strokestop study entailed 7173 Swedish residents aged 75/76 that were screened for AF using twice daily intermittent ECG recordings during 2 weeks. In a substudy of 886 participants, the last 815 consecutive participants and 71 individuals with newly detected AF, levels of NT-proBNP were determined.Results Participants with newly detected AF (n=96) had a median NT-proBNP of 330 ng/L (IQR 121; 634). In individuals without AF (n=742), median NT-proBNP was 171 ng/L (IQR 95; 283), p<0.001. The CHA2DS2-VASc parameters did not differ significantly between individuals with newly detected AF and without AF nor between newly detected AF in the NT-proBNP cohort compared with the cohort where NT-proBNP was not assessed. Using an NT-proBNP cut-off of >= 125 ng/L in a non-acute setting yielded a negative predictive value of 92%, meaning that 35% fewer participants would need to be screened when applied to systematic AF screening. Adding weight to NT-proBNP further reduced participants needed to be screened with a preserved sensitivity.Conclusions NT-proBNP was increased in individuals with newly detected AF. Prospective studies could clarify if NT-proBNP can be used to correctly select individuals that benefit most from AF screening.
  •  
48.
  • Svennberg, Emma, et al. (author)
  • Safe automatic one-lead electrocardiogram analysis in screening for atrial fibrillation
  • 2017
  • In: Europace. - : Oxford University Press (OUP). - 1099-5129 .- 1532-2092. ; 19:9, s. 1449-1453
  • Journal article (peer-reviewed)abstract
    • Aims Screening for atrial fibrillation (AF) using intermittent electrocardiogram (ECG) recordings can identify individuals at risk of AF-related morbidity in particular stroke. We aimed to validate the performance of an AF screening algorithm compared with manual ECG analysis by specially trained nurses and physicians (gold standard) in 30 s intermittent one-lead ECG recordings. Methods and results The STROKESTOP study is a mass-screening study for AF using intermittent ECG recordings. All individuals in the study without known AF registered a 30-s ECG recording in Lead I two times daily for 2 weeks, and all ECGs were manually interpreted. A computerized algorithm was used to analyse 80 149 ECG recordings in 3209 individuals. The computerized algorithm annotated 87.1% (n = 69 789) of the recordings as sinus rhythm/minor rhythm disturbances. The manual interpretation (gold standard) was that 69 758 ECGs were normal, making the negative predictive value of the algorithm 99.9%. The number of ECGs requiring manual interpretation in order to find one pathological ECG was reduced from 288 to 35. Atrial fibrillation was diagnosed in 84 patients by manual interpretation, in all of whom the algorithm indicated pathology. On an ECG level, 278 ECGs were manually interpreted as AF, and of these the algorithm annotated 272 ECGs as pathological (sensitivity 97.8%). Conclusion Automatic ECG screening using a computerized algorithm safely identifies normal ECGs in Lead I and reduces the need for manual evaluation of individual ECGs with >85% with 100% sensitivity on an individual basis.
  •  
49.
  • Szummer, Karolina, et al. (author)
  • Time in therapeutic range and outcomes after warfarin initiation in newly diagnosed atrial fibrillation patients with renal dysfunction
  • 2017
  • In: Journal of the American Heart Association. - : WILEY. - 2047-9980. ; 6:3
  • Journal article (peer-reviewed)abstract
    • BACKGROUND: It is unknown whether renal dysfunction conveys poor anticoagulation control in warfarin-treated patients with atrial fibrillation and whether poor anticoagulation control associates with the risk of adverse outcomes in these patients.METHODS AND RESULTS: This was an observational study from the Stockholm CREatinine Measurements (SCREAM) cohort including all newly diagnosed atrial fibrillation patients initiating treatment with warfarin (n=7738) in Stockholm, Sweden, between 2006 and 2011. Estimated glomerular filtration rate (eGFR; mL/min per 1.73 m(2)) was calculated from serum creatinine. Time-in-therapeutic range (TTR) was assessed from international normalized ratio (INR) measurements up to warfarin cessation, adverse event, or end of follow-up (2 years). Adverse events considered a composite of intracranial hemorrhage, ischemic stroke, myocardial infarction, or death. During median 254 days, TTR was 83%, based on median 21 INR measurements per patient. TTR was 70% among patients with eGFR <30, around 10% lower than in those with normal renal function. During observation, adverse events occurred in 4.0% of patients, and those with TTR ≤75% were at higher adverse event risk. This was independent of patient characteristics, comorbidities, number of INR tests, days exposed to warfarin, and, notably, independent of eGFR: adjusted odds ratio (OR) 1.84 (95% CI, 1.41-2.40) for TTR 75% to 60% and adjusted OR 2.09 (1.59-2.74) for TTR <60%. No interaction was observed between eGFR and TTR in association to adverse events (P=0.2).CONCLUSION: Severe chronic kidney disease (eGFR <30) patients with atrial fibrillation have worse INR control while on warfarin. An optimal TTR (>75%) is associated with lower risk of adverse events, independently of underlying renal function.
  •  
50.
  • Taha, Amar, 1978, et al. (author)
  • New-Onset Atrial Fibrillation After Coronary Artery Bypass Grafting and Long-Term Outcome: A Population-Based Nationwide Study From the SWEDEHEART Registry.
  • 2021
  • In: Journal of the American Heart Association. - 2047-9980. ; 10:1
  • Journal article (peer-reviewed)abstract
    • Background The long-term impact of new-onset postoperative atrial fibrillation (POAF) after coronary artery bypass grafting and the benefit of early-initiated oral anticoagulation (OAC) in patients with POAF are uncertain. Methods and Results All patients who underwent coronary artery bypass grafting without preoperative atrial fibrillation in Sweden from 2007 to 2015 were included in a population-based study using data from 4 national registries: SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies), National Patient Registry, Dispensed Drug Registry, and Cause of Death Registry. POAF was defined as any new-onset atrial fibrillation during the first 30 postoperative days. Cox regression models (adjusted for age, sex, comorbidity, and medication) were used to assess long-term outcome in patients with and without POAF, and potential associations between early-initiated OAC and outcome. In a cohort of 24523 patients with coronary artery bypass grafting, POAF occurred in 7368 patients (30.0%), and 1770 (24.0%) of them were prescribed OAC within 30days after surgery. During follow-up (median 4.5years, range 0‒9years), POAF was associated with increased risk of ischemic stroke (adjusted hazard ratio [aHR] 1.18 [95% CI, 1.05‒1.32]), any thromboembolism (ischemic stroke, transient ischemic attack, or peripheral arterial embolism) (aHR 1.16, 1.05‒1.28), heart failure hospitalization (aHR 1.35, 1.21‒1.51), and recurrent atrial fibrillation (aHR 4.16, 3.76‒4.60), but not with all-cause mortality (aHR 1.08, 0.98‒1.18). Early initiation of OAC was not associated with reduced risk of ischemic stroke or any thromboembolism but with increased risk for major bleeding (aHR 1.40, 1.08‒1.82). Conclusions POAF after coronary artery bypass grafting is associated with negative prognostic impact. The role of early OAC therapy remains unclear. Studies aiming at reducing the occurrence of POAF and its consequences are warranted.
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