| 1. |
- Bentzel, Sara, et al.
(author)
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Long-term secondary prevention and outcome following acute coronary syndrome: Real-world results from the Swedish Primary Care Cardiovascular Database (SPCCD)
- 2024
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In: European journal of preventive cardiology. - 2047-4881. ; 31:7, s. 812-821
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Journal article (peer-reviewed)abstract
- Most studies of treatment adherence after acute coronary syndrome (ACS) are based on prescribed drugs and lack long-term follow-up or consecutive data on risk factor control. We studied the long-term treatment adherence, risk factor control and its association to recurrent ACS and death.We retrospectively included 3765 patients (mean age 75 years, 40% women) with incident ACS from 1 January 2006 until 31 December 2010 from the SPCCD-SKA database. All patients were followed until 31 December 2014 or death. We recorded blood pressure (BP), low density lipoprotein-cholesterol (LDL-C), recurrent ACS and death. We used data on dispensed drugs to calculate proportion of days covered for secondary prevention medications. Cox regressions were used to analyse the association of achieved BP and LDL-C to recurrent ACS and death.The median follow-up time was 4.8 years. Proportion of patients that reached BP <140/90mmHg was 58% year 1 and 66% year 8. 65% of the patients reached LDL-C<2.5mmol/L at year 1 and 56% at year 8, however adherence to statins varied from 43% to 60%. Only 62% of the patients had yearly measured BP, and only 28% yearly measured LDL-C. SBP was not associated with a higher risk of recurrent ACS or death. LDL-C of 3.0mmol/L were associated with a higher risk of recurrent ACS [HR 1.19 (95% CI 1.00-1.40)] and death HR 1.26 [(95% CI 1.08-1.47)] compared to an LDL-C 1.8mmol/L.This observational long-term real-world study demonstrates low drug adherence and potential for improvement of risk factors after ACS. Furthermore, the study confirms that uncontrolled LDL-C is associated with adverse outcome even in this older population.
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| 2. |
- Hellqvist, Henrik, et al.
(author)
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Estimation of aortic stiffness by finger photoplethysmography using enhanced pulse wave analysis and machine learning
- 2024
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In: Frontiers in Cardiovascular Medicine. - : Frontiers Media SA. - 2297-055X. ; 11
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Journal article (peer-reviewed)abstract
- Introduction: Aortic stiffness plays a critical role in the evolution of cardiovascular diseases, but the assessment requires specialized equipment. Photoplethysmography (PPG) and single-lead electrocardiogram (ECG) are readily available in healthcare and wearable devices. We studied whether a brief PPG registration, alone or in combination with single-lead ECG, could be used to reliably estimate aortic stiffness. Methods: A proof-of-concept study with simultaneous high-resolution index finger recordings of infrared PPG, single-lead ECG, and finger blood pressure (Finapres) was performed in 33 participants [median age 44 (range 21–66) years, 19 men] and repeated within 2 weeks. Carotid–femoral pulse wave velocity (cfPWV; two-site tonometry with SphygmoCor) was used as a reference. A brachial single-cuff oscillometric device assessed aortic pulse wave velocity (aoPWV; Arteriograph) for further comparisons. We extracted 136 established PPG waveform features and engineered 13 new with improved coupling to the finger blood pressure curve. Height-normalized pulse arrival time (NPAT) was derived using ECG. Machine learning methods were used to develop prediction models. Results: The best PPG-based models predicted cfPWV and aoPWV well (root-mean-square errors of 0.70 and 0.52 m/s, respectively), with minor improvements by adding NPAT. Repeatability and agreement were on par with the reference equipment. A new PPG feature, an amplitude ratio from the early phase of the waveform, was most important in modelling, showing strong correlations with cfPWV and aoPWV (r = −0.81 and −0.75, respectively, both P < 0.001). Conclusion: Using new features and machine learning methods, a brief finger PPG registration can estimate aortic stiffness without requiring additional information on age, anthropometry, or blood pressure. Repeatability and agreement were comparable to those obtained using non-invasive reference equipment. Provided further validation, this readily available simple method could improve cardiovascular risk evaluation, treatment, and prognosis.
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| 3. |
- Norrman, Anders, et al.
(author)
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Predicting new cases of hypertension in Swedish primary care with a machine learning tool
- 2024
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In: Preventive Medicine Reports. - : Elsevier. - 2211-3355. ; 44
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Journal article (peer-reviewed)abstract
- Background: Many individuals with hypertension remain undiagnosed. We aimed to develop a predictive model for hypertension using diagnostic codes from prevailing electronic medical records in Swedish primary care.Methods: This sex- and age-matched case-control (1:5) study included patients aged 30 -65 years living in the Stockholm Region, Sweden, with a newly recorded diagnosis of hypertension during 2010 -19 (cases) and individuals without a recorded hypertension diagnosis during 2010 -19 (controls), in total 507,618 individuals. Patients with diagnoses of cardiovascular diseases or diabetes were excluded. A stochastic gradient boosting machine learning model was constructed using the 1,309 most registered ICD-10 codes from primary care for three years prior the hypertension diagnosis.Results: The model showed an area under the curve (95 % confidence interval) of 0.748 (0.742 -0.753) for females and 0.745 (0.740 -0.751) for males for predicting diagnosis of hypertension within three years. The sensitivity was 63 % and 68 %, and the specificity 76 % and 73 %, for females and males, respectively. The 25 diagnoses that contributed the most to the model for females and males all exhibited a normalized relative influence >1 %. The codes contributing most to the model, all with an odds ratio of marginal effects >1 for both sexes, were dyslipidaemia, obesity, and encountering health services in other circumstances.Conclusions: This machine learning model, using prevailing recorded diagnoses within primary health care, may contribute to the identification of patients at risk of unrecognized hypertension. The added value of this predictive model beyond information of blood pressure warrants further study.
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| 4. |
- Salzinger, Barbara, et al.
(author)
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Associations between inflammatory and angiogenic proteomic biomarkers, and cardiovascular events and mortality in relation to kidney function
- 2024
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In: Clinical Kidney Journal. - : Oxford University Press. - 2048-8505 .- 2048-8513. ; 17:3
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Journal article (peer-reviewed)abstract
- BackgroundThe links between chronic kidney disease (CKD) and the high burden of cardiovascular disease remain unclear. We aimed to explore the association between selected inflammatory and angiogenic biomarkers, kidney function and long-term outcome in patients with an acute coronary syndrome (ACS) and to test the hypothesis that CKD status modifies this association.MethodsA total of 1293 ACS patients hospitalized between 2008 and 2015 were followed until 31 December 2017. Plasma was collected on days 1–3 after admission. A total of 13 biomarkers were a priori identified and analysed with two proteomic methods, proximity extension assay or multiple reaction monitoring mass spectrometry. Boxplots and multiple linear regression models were used to study associations between biomarkers and kidney function and adjusted standardized Cox regression with an interaction term for CKD was used to assess whether CKD modified the association between biomarkers and major adverse cardiovascular events and death (MACE+).ResultsThe concentrations of nine biomarkers—endothelial cell-specific molecule-1 (ESM-1), fibroblast growth factor 23 (FGF-23), fractalkine (CX3CL1), interleukin-1 receptor antagonist (IL-1RA), interleukin-18 (IL-18), monocyte chemotactic protein-1 (MCP-1), placenta growth factor (PlGF), transmembrane immunoglobulin 1 (TIM-1) and vascular endothelial growth factor A (VEGFA)—were inversely associated with kidney function. ESM-1, FGF-23 and TIM-1 showed associations with MACE+. Only FGF23 remained independently associated after adjustment for the other biomarkers (hazard ratio per standard deviation increase 1.34; 95% Bonferroni corrected confidence interval 1.19–1.50). None of the biomarkers showed an interaction with CKD.ConclusionsThe concentrations of 9 of the 13 prespecified inflammatory and angiogenic proteomic biomarkers increased when kidney function declined. Only FGF-23 demonstrated an independent association with MACE+, and this association was not modified by CKD status. These findings further support FGF-23 as an independent prognostic marker in ACS patients with and without CKD.
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| 5. |
- Malkon, Salpe, et al.
(author)
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A Qualitative Study on Patients' Views on Hypertension and Antihypertensive Medications
- 2023
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In: Patient Preference and Adherence. - : Dove Medical Press. - 1177-889X. ; 17, s. 3331-3339
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Journal article (peer-reviewed)abstract
- Purpose: Few studies explored what patients initiated on blood pressure medication in primary care think about their disease and their medications. The aim of this study was to gain an understanding of hypertensive patients’ views on and experiences of hypertension and the use of antihypertensive medications.Methods: A qualitative study based on open-ended questions from a survey on medication adherence, which captured treated hypertensive patients’ perspective on their condition and treatment. Data were collected for 219 patients on antihypertensive medication, ≥ 30 years old, who consulted 25 primary health care centers in Stockholm, Sweden, during 2016. Thematic analysis with both inductive and deductive approach was applied.Results: We identified 21 codes from the data and grouped them under the World Health Organization’s five dimensions of adherence: condition-, therapy-, health care team and system-, patient-, and socioeconomic-related factors. The analyses revealed that many patients with hypertension have limited knowledge of their disease, are afraid of drug side effects and experience various issues in primary health care that may negatively impact adherence, including short doctor appointments, prescribing without communication and room for improvement in individualization of therapy and a person-centered approach.Conclusion: Many patients with hypertension have limited understanding of their hypertension and fear of adverse events from their antihypertensive medications. There is also room for improvement in how the patients are managed in primary health care. Interventions should focus on these issues to promote a better blood pressure target achievement.
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| 6. |
- Mörtberg, Josefin, et al.
(author)
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Prognostic importance of biomarkers associated with haemostatic, vascular and endothelial disturbances in acute coronary syndrome patients in relation to kidney function
- 2023
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In: International Journal of Cardiology. - : Elsevier BV. - 0167-5273 .- 1874-1754. ; 373, s. 64-71
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Journal article (peer-reviewed)abstract
- BACKGROUND: Patients with kidney failure have a high risk for cardiovascular events. We aimed to evaluate the prognostic importance of selected biomarkers related to haemostasis, endothelial function, and vascular regulation in patients with acute coronary syndrome (ACS), and to study whether this association differed in patients with renal dysfunction.METHODS: Plasma was collected in 1370 ACS patients included between 2008 and 2015. Biomarkers were analysed using a Proximity Extension Assay and a Multiple Reaction Monitoring mass spectrometry assay. To reduce multiplicity, biomarkers correlating with eGFR were selected a priori among 36 plasma biomarkers reflecting endothelial and vascular function, and haemostasis. Adjusted Cox regression were used to study their association with the composite outcome of myocardial infarction, ischemic stroke, heart failure or death. Interaction with eGFR strata above or below 60 ml/min/1.73 m 2 was tested. RESULTS: Tissue factor, proteinase-activated receptor, soluble urokinase plasminogen activator surface receptor (suPAR), thrombomodulin, adrenomedullin, renin, and angiotensinogen correlated inversely with eGFR and were selected for the Cox regression. Mean follow-up was 5.2 years during which 428 events occurred. Adrenomedullin, suPAR, and renin were independently associated with the composite outcome. Adrenomedullin showed interaction with eGFR strata (p = 0.010) and was associated with increased risk (HR 1.88; CI 1.44-2.45) only in patients with eGFR ≥60 ml/min/ 1.73 m 2. CONCLUSIONS: Adrenomedullin, suPAR, and renin were associated with the composite outcome in all. Adrenomedullin, involved in endothelial protection, showed a significant interaction with renal function and outcome, and was associated with the composite outcome only in patients with preserved kidney function.
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| 7. |
- Thorén, Anna, et al.
(author)
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Rapid response team activation prior to in-hospital cardiac arrest: Areas for improvements based on a national cohort study
- 2023
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In: Resuscitation. - 0300-9572 .- 1873-1570. ; 193
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Journal article (peer-reviewed)abstract
- Introduction: Rapid response teams (RRTs) are designed to improve the "chain of prevention" of in-hospital cardiac arrest (IHCA). We studied the 30-day survival of patients reviewed by RRTs within 24 hours prior to IHCA, as compared to patients not reviewed by RRTs.Methods: A nationwide cohort study based on the Swedish Registry of Cardiopulmonary Resuscitation, between January 1st, 2014, and December 31st, 2021. An explorative, hypothesis-generating additional in-depth data collection from medical records was performed in a small subgroup of general ward patients reviewed by RRTs.Results: In all, 12,915 IHCA patients were included. RRT-reviewed patients (n = 2,058) had a lower unadjusted 30-day survival (25% vs 33%, p < 0.001), a propensity score based Odds ratio for 30-day survival of 0.92 (95% Confidence interval 0.90-0.94, p < 0.001) and were more likely to have a respiratory cause of IHCA (22% vs 15%, p < 0.001). In the subgroup (n = 82), respiratory distress was the most common RRT trigger, and 24% of the RRT reviews were delayed. Patient transfer to a higher level of care was associated with a higher 30-day survival rate (20% vs 2%, p < 0.001).Conclusion: IHCA preceded by RRT review is associated with a lower 30-day survival rate and a greater likelihood of a respiratory cause of cardiac arrest. In the small explorative subgroup, respiratory distress was the most common RRT trigger and delayed RRT activation was frequent. Early detection of respiratory abnormalities and timely interventions may have a potential to improve outcomes in RRT-reviewed patients and prevent further progress into IHCA.
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| 8. |
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| 9. |
- Johansson, Jonathan S M, et al.
(author)
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Prediabetes and incident heart failure in hypertensive patients: Results from the Swedish Primary Care Cardiovascular Database.
- 2022
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In: Nutrition, metabolism, and cardiovascular diseases : NMCD. - : Elsevier BV. - 1590-3729 .- 0939-4753. ; 32:12, s. 2803-2810
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Journal article (peer-reviewed)abstract
- The cardiovascular risk conferred by concomitant prediabetes in hypertension is unclear. We aimed to examine the impact of prediabetes on incident heart failure (HF) and all-cause mortality, and to describe time in therapeutic blood pressure range (TTR) in a hypertensive real-world primary care population.In this retrospective cohort study, 9628 hypertensive individuals with a fasting plasma glucose (FPG) in 2006-2010 but no diabetes, cardiovascular or renal disease were followed to 2016; median follow-up was 9 years. Prediabetes was defined as FPG 5.6-6.9mmol/L, and in a secondary analysis as 6.1-6.9mmol/L. Study outcomes were HF and all-cause mortality. Hazard ratios (HR) were compared for prediabetes with normoglycemia using Cox regression. All blood pressure values from 2001 to the index date (first FPG in 2006-2010) were used to calculate TTR. At baseline, 51.4% had prediabetes. The multivariable-adjusted HR (95% confidence intervals) was 0.86 (0.67-1.09) for HF and 1.06 (0.90-1.26) for all-cause mortality. For FPG defined as 6.1-6.9mmol/L, the multivariable-adjusted HR were 1.05 (0.80-1.39) and 1.42 (1.19-1.70), respectively. The prediabetic group had a lower TTR (p<0.05).Prediabetes was not independently associated with incident HF in hypertensive patients without diabetes, cardiovascular or renal disease. However, prediabetes was associated with all-cause mortality when defined as FPG 6.1-6.9mmol/L (but not as 5.6-6.9mmol/L). TTR was lower in the prediabetic group, suggesting room for improved blood pressure to reduce incident heart failure in prediabetes.
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| 10. |
- Andersson, Tobias, 1976, et al.
(author)
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Country of birth and mortality risk in hypertension with and without diabetes: the Swedish primary care cardiovascular database.
- 2021
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In: Journal of hypertension. - 1473-5598. ; 39:6, s. 1155-1162
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Journal article (peer-reviewed)abstract
- Hypertension and diabetes are common and are both associated with high cardiovascular morbidity and mortality. We aimed to investigate associations between mortality risk and country of birth among hypertensive individuals in primary care with and without concomitant diabetes, which has not been studied previously. In addition, we aimed to study the corresponding risks of myocardial infarction and ischemic stroke.This observational cohort study of 62557 individuals with hypertension diagnosed 2001-2008 in the Swedish Primary Care Cardiovascular Database assessed mortality by the Swedish Cause of Death Register, and myocardial infarction and ischemic stroke by the National Patient Register. Cox regression models were used to estimate study outcome hazard ratios by country of birth and time updated diabetes status, with adjustments for multiple confounders.During follow-up time without diabetes using Swedish-born as reference, adjusted mortality hazard ratios per country of birth category were Finland: 1.26 (95% confidence interval 1.15-1.38), high-income European countries: 0.84 (0.74-0.95), low-income European countries: 0.84 (0.71-1.00) and non-European countries: 0.65 (0.56-0.76). The corresponding adjusted mortality hazard ratios during follow-up time with diabetes were high-income European countries: 0.78 (0.63-0.98), low-income European countries: 0.74 (0.57-0.96) and non-European countries: 0.56 (0.44-0.71). During follow-up without diabetes, the corresponding adjusted hazard ratio of myocardial infarction was increased for Finland: 1.16 (1.01-1.34), whereas the results for ischemic stroke were inconclusive.In Sweden, hypertensive immigrants (with the exception for Finnish-born) with and without diabetes have a mortality advantage, as compared to Swedish-born.
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