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Introduction Acute coronary syndrome (ACS) is one of the leading causes of death in the world and timeliness of treatment and diagnosis is of utmost importance to reduce mortality and morbidity. Emergency department (ED) crowding results in longer waiting times and length of stay in the ED and is a globally growing phenomenon with clear negative consequences for patients. Low socioeconomic status (SES) has previously been associated with poor prognosis after ACS, but it remains unclear if treatment and diagnostics in the acute state is a contributing factor. ED length of stay has been linked to crowding and poor patient outcomes whereas mechanisms for generally worse prognosis in low SES remains poorly understood. Purpose To investigate whether SES, measured as disposable income, is associated with ED waiting times among patients with the most common chief complaint in ACS, chest pain. Methods A registry-based cohort study on all 140,388 patients arriving at 14 Swedish emergency departments between 2015 and 2019 with chest pain as their chief complaint registered in the Swedish Emergency Registry (SVAR). Individual-level sociodemographic and clinical data were linked from multiple national registries. The associations between disposable income quintiles and ED length of stay and time to doctor were assessed using multivariable regression models adjusting for age, sex, education, comorbidities (diabetes, hypertension, hyperlipidemia, obesity and cardiovascular disease) and ED-visit characteristics (arrival mode, triage level, arrival time (day, evening or night as well as weekday or weekend) and hospital type). Results Median length of stay was 11 minutes (4.4%) longer among patients in the lowest income quintile, 4:04 [hours:minutes] (95% confidence interval [CI] 4:02–4:05), compared to patients in the highest income quintile (3:53, 95% CI 3:52–3:55). Similarly, time to doctor was 6 min (8.7%) longer among patients in the lowest income quintile (1:15 min, 95% CI 1:14–1:16) than patients in the highest income quintile (1:09, 95% CI 1:08–1:10). The associations were independent of adjustment for studied confounders and mediators. Conclusions Among ED chest pain patients, low income was associated with longer length of stay and time to doctor which may impact negatively on patients with serious cardiovascular diagnosis such as ACS. Longer waiting times may delay diagnosis and timely treatment for the individual patient such as anti-ischemic and antithrombotic therapy. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by grants provided by Region Stockholm (ALF-project)

Background Survival from out-of-hospital cardiac arrest (OHCA) is higher if the arrest occurs in relation to physical activity,however there is contradicting data on prognosis with regards to gender and age. The purpose of the study was to compare prognosis and circumstances of exercise-related OHCA in different age-groups as well as between genders in a large unselected population. Methods Observational data from exercise-related OHCA occurring outside of home reported to the Swedish Register of Cardiopulmonary Resuscitation (SRCR) from 2011 to 2014 and from 2016 to 2018 was analyzed. Comparing analyses were made for three different age-groups (0–35, 36–65 and >65 years) and for males versus females. Results A total number of 9607 cases of OHCA outside of home where resuscitation was attempted occurred during the study period, 635 (6.6%) were exercise-related. Mean age was similar between males and females (59.1 years in both groups). The 30-day survival rate was significantly higher among exercise-related OHCAs compared to non-exercise-related OHCAs (44.5% vs 18.8%, p65 years respectively (59.6% vs 46.0% and 40.4% respectively, p=0.01). A sub-group analysis of victims aged 0–25 years (n=32) showed a survival rate of 68.8%. Exercise-related OHCA in women (9.1% of total) were bystander witnessed to a lower extent than in men (66.7% vs 79.6%, p=0.03). Both men and women received bystander CPR at the same extent but median time to CPR was 1min longer for women (2.0 vs 1.0 min, p=0.001). Women had lower rates of ventricular fibrillation as initial rhythm (43.4% vs 64.7%, p=0.003) and 30-day survival was lower among women (29.3% vs 46.0%, p=0.02). Conclusion Women seem to be protected from exercise-related OHCA but in case of occurrence the prognosis is actually worse compared to men. This may partly be explained by lower grade of bystander witnesses and longer time to CPR, but the results indicate the need for further studies on additional factors, such as variances in underlying disease pattern and exercise habits of women. In addition, this study presents an exceptionally high survival rate for exercise-related OHCA in the youngest age-groups, especially in victims 0–25 years of age which is a novel finding. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The Swedish Heart-Lung Foundation, Laerdal Foundation

Aims To determine whether supplemental oxygen in patients with ST-elevation myocardial infarction (STEMI) impacts on procedure-related and clinical outcomes. Methods and results The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial randomized patients with suspected myocardial infarction (MI) to receive oxygen at 6 L/min for 6-12 h or ambient air. In this pre-specified analysis, we included only STEMI patients who underwent percutaneous coronary intervention (PCI). In total, 2807 patients were included, 1361 assigned to receive oxygen, and 1446 assigned to ambient air. The pre-specified primary composite endpoint of all-cause death, rehospitalization with MI, cardiogenic shock, or stent thrombosis at 1 year occurred in 6.3% (86 of 1361) of patients allocated to oxygen compared to 7.5% (108 of 1446) allocated to ambient air [hazard ratio (HR) 0.85, 95% confidence interval (95% CI) 0.64-1.13; P = 0.27]. There was no difference in the rate of death from any cause (HR 0.86, 95% CI 0.61-1.22; P = 0.41), rate of rehospitalization for MI (HR 0.92, 95% CI 0.57-1.48; P = 0.73), rehospitalization for cardiogenic shock (HR 1.05, 95% CI 0.21-5.22; P = 0.95), or stent thrombosis (HR 1.27, 95% CI 0.46-3.51; P = 0.64). The primary composite endpoint was consistent across all subgroups, as well as at different time points, such as during hospital stay, at 30 days and the total duration of follow-up up to 1356 days. Conclusions Routine use of supplemental oxygen in normoxemic patients with STEMI undergoing primary PCI did not significantly affect 1-year all-cause death, rehospitalization with MI, cardiogenic shock, or stent thrombosis.

Background The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial did not find any benefit of oxygen therapy compared to ambient air in normoxemic patients with suspected acute myocardial infarction (AMI). Patients with chronic obstructive pulmonary disease (COPD) may both benefit and be harmed by supplemental oxygen. Thus, we evaluated the effect of routine oxygen therapy compared to ambient air in normoxemic COPD patients with suspected AMI. Methods and results A total of 6629 patients with suspected AMI were randomized in the DETO2X-AMI trial to oxygen or ambient air. In the oxygen group (n=3311) and the ambient air group (n=3318), 155 and 141 patients, respectively, had COPD (prevalence of 4.5%). Patients with COPD were older, had more comorbid conditions and experienced a two-fold higher risk of death at one year (COPD: 32/296 [10.8%] vs. non-COPD 302/6333 [4.8%]). Oxygen therapy compared to ambient air was not associated with improved outcomes at 365 days (COPD: all-cause mortality HR 0.99 [95% CI 0.50–1.99, interaction-p=0.96]; cardiovascular death HR 0.80 [0.32–2.04, interaction-p=0.59]; rehospitalization with AMI or death HR 1.27 [0.71–2.28, interaction-p=0.46]; hospitalization for heart failure or death HR 1.08 [0.61–1.91, interaction-p=0.77]); there were no significant treatment-by-COPD interactions. Outcome Conclusions Although COPD patients had twice the mortality rate compared to non-COPD patients, this prespecified subgroup analysis from the DETO2X-AMI trial on oxygen therapy versus ambient air in normoxemic COPD patients with suspected AMI revealed no evidence for benefit of routine oxygen therapy consistent with the main trial's findings.

Background In diabetes, there is an interaction between hyperglycaemia and cellular hypoxia, which may induce oxidative stress. Oxygen therapy in patients with diabetes and myocardial infarction (MI) has not been studied. Purpose Our aim was to determine the effects of supplemental oxygen in MI patients with or without diabetes. Methods The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial randomised 6629 patients with suspected myocardial infarction (MI) to receive oxygen at 6 L/min for 6–12 hours or ambient air. In this prespecified analysis involving 5010 patients with confirmed MI, 934 had known diabetes (19%). The main composite endpoint was the effect of supplemental oxygen on all-cause death, rehospitalisation with MI, or heart failure at one year in patients with diabetes. Key secondary endpoint was the comparison between patients with or without diabetes. Results In patients with diabetes, the main composite endpoint occurred in 16.2% (72 of 445) of patients allocated to oxygen compared to 16.6% (81 of 489) allocated to ambient air (hazard ratio [HR] 0.93; 95% confidence interval [CI], 0.67–1.27, P=0.81) at one year (figure). There was no statistically significant difference for the individual components of the main composite endpoint, or the rate of cardiovascular death up to one year. In comparison, corresponding endpoints in patients without diabetes were similar between the treatment groups. However, when comparing patients according to diabetes status, event rates were significantly higher in the diabetic population (main composite endpoint: HR 1.60; 95% CI, 1.32–1.93, P Kaplan-Meier curves for main endpoint Conclusions Oxygen therapy in normoxemic MI patients did not significantly affect 1-year all-cause death, cardiovascular death, rehospitalisation with MI or heart failure, irrespective of underlying diabetes. Noteworthy, despite that the incidence of cardiovascular outcomes has declined substantially in patients with diabetes over the last decades, we still observed markedly increased event rates in patients with diabetes. Acknowledgement/Funding Swedish Heart-Lung Foundation; Swedish Research Council; Stockholm County Council

Patients with diabetes have an unfavourable prognosis after an acute myocardial infarction. In the first DIGAMI study, an insulin-based glucose management improved survival. In DIGAMI 2, three treatment strategies were compared: group 1, acute insulin-glucose infusion followed by insulin-based long-term glucose control; group 2, insulin-glucose infusion followed by standard glucose control; and group 3, routine metabolic management according to local practice.DIGAMI 2 recruited 1253 patients (mean age 68 years; 67% males) with type 2 diabetes and suspected acute myocardial infarction randomly assigned to groups 1 (n=474), 2 (n=473), and 3 (n=306). The primary endpoint was all-cause mortality between groups 1 and 2, and a difference was hypothesized as the primary objective. The secondary objective was to compare total mortality between groups 2 and 3, whereas morbidity differences served as tertiary objectives. The median study duration was 2.1 (interquartile range 1.03-3.00) years. At randomization, HbA1c was 7.2, 7.3, and 7.3% in groups 1, 2, and 3, respectively, whereas blood glucose was 12.8, 12.5, and 12.9 mmol/L, respectively. Blood glucose was significantly reduced after 24 h in all groups, more in groups 1 and 2 (9.1 and 9.1 mmol/L) receiving insulin-glucose infusion than in group 3 (10.0 mmol/L). Long-term glucose-lowering treatment differed between groups with multidose insulin (or =3 doses/day) given to 15 and 13% of patients in groups 2 and 3, respectively compared with 42% in group 1 at hospital discharge. By the end of follow-up, HbA1c did not differ significantly among groups 1-3 ( approximately 6.8%). The corresponding values for fasting blood glucose were 8.0, 8.3, and 8.6 mmol/L. Hence, the target fasting blood glucose for patients in group 1 of 5-7 mmol/L was never reached. The study mortality (groups 1-3 combined) was 18.4%. Mortality between groups 1 (23.4%) and 2 (22.6%; primary endpoint) did not differ significantly (HR 1.03; 95% CI 0.79-1.34; P=0.831), nor did mortality between groups 2 (22.6%) and 3 (19.3%; secondary endpoint) (HR 1.23; CI 0.89-1.69; P=0.203). There were no significant differences in morbidity expressed as non-fatal reinfarctions and strokes among the three groups.DIGAMI 2 did not support the fact that an acutely introduced, long-term insulin treatment improves survival in type 2 diabetic patients following myocardial infarction when compared with a conventional management at similar levels of glucose control or that insulin-based treatment lowers the number of non-fatal myocardial reinfarctions and strokes. However, an epidemiological analysis confirms that the glucose level is a strong, independent predictor of long-term mortality in this patient category, underlining that glucose control seems to be an important part of their management.

Aim To describe the relative impact on survival of the delay from estimated time of collapse to call for an ambulance among patients who suffer from a bystander witnessed out of hospital cardiac arrest of a cardiac aetiology. Methods A majority of all ambulance organizations in Sweden (covering 85% of Sweden inhabitants) participate in a National survey of out of hospital cardiac arrest. Results In all there were 9340 patients with a bystander witnessed cardiac arrest of a cardiac aetiology in whom cardiopulmonary resuscitation (CPR) was attempted participating in this survey. Survival at one month among patients with a delay between estimated time of collapse and call for ambulance of less than or equal to4 min (median) was 6.9% versus 2.8% among patients with a median of >4 min (P

The Task Force on the management of chest pain was created by the committee for Scientific and Clinical Initiatives on 28 June 1997 after formal approval by the Board of the European Society of Cardiology. The document was circulated to the members of the Committee for Scientific and Clinical Initiatives, to the members of the Board and to the following reviewers: J. Adgey, C. Blomstro¨m-Lundqvist, R. Erbel, W. Klein, J. L. Lopez-Sendon, L. Ryde´n, M. L. Simoons, C. Stefanadis, M. Tendera, K. Thygesen. After further revision it was submitted for approval to the Committee for Practise Guidelines and Policy Conferences. The Task Force Report was supported financially in its entirety by The European Society of Cardiology and was developed without any involvement of the pharmaceutical industry.

Aim To describe possible factors modifying the effect of bystander cardiopulmonary resuscitation on survival among patients suffering an out-of-hospital cardiac arrest. Patients A national survey in Sweden among patients suffering out-of-hospital cardiac arrest and in whom resuscitative efforts were attempted. Sixty per cent of ambulance organizations were included. Design Prospective evaluation. Survival was defined as survival 1 month after cardiac arrest. Results In all, 14065 reports were included in the evaluation. Of these, resuscitation efforts were attempted in 10966 cases, of which 1089 were witnessed by ambulance crews. The report deals with the remaining 9877 patients, of whom bystander cardiopulmonary resuscitation was attempted in 36%. Survival to 1 month was 8·2% among patients who received bystander cardiopulmonary resuscitation vs 2·5% among patients who did not receive it (odds ratio 3·5, 95% confidence interval 2·9–4·3). The effect of bystander cardiopulmonary resuscitation on survival was related to: (1) the interval between collapse and the start of bystander cardiopulmonary resuscitation (effect more marked in patients who experienced a short delay); (2) the quality of bystander cardiopulmonary resuscitation (effect more marked if both chest compressions and ventilation were performed than if either of them was performed alone); (3) the category of bystander (effect more marked if bystander cardiopulmonary resuscitation was performed by a non-layperson); (4) interval between collapse and arrival of the ambulance (effect more marked if this interval was prolonged); (5) age (effect more marked in bystander cardiopulmonary resuscitation among the elderly); and (6) the location of the arrest (effect more marked if the arrest took place outside the home). Conclusion The effect of bystander cardiopulmonary resuscitation on survival after an out-of-hospital cardiac arrest can be modified by various factors. Factors that were associated with the effect of bystander cardiopulmonary resuscitation were the interval between the collapse and the start of bystander cardiopulmonary resuscitation, the quality of bystander cardiopulmonary resuscitation, whether or not the bystander was a layperson, the interval between collapse and the arrival of the ambulance, age and the place of arrest.

International studies provide an opportunity to compare treatment approaches and outcomes. The present study compares elderly hospitalized acute myocardial infarction (AMI) patients in Minneapolis/St. Paul, USA (MSP) and Göteborg, Sweden (GB).A population-based sample of hospitalized AMI (ICD-9 410) patients aged ≥75 in MSP and GB in 2001-02 was abstracted by trained nurses. Mortality was ascertained from medical records and death certificates. Demographics, cardiovascular procedures, and prescription medications were compared using sex-specific generalized linear models. Adjusted hazard ratios (HR) were calculated with Cox regression. In MSP 839 (387 men, 452 women) and in GB 564 (275 men, 289 women) patients were identified. Age was similar (men: MSP 83 ± 7, GB 82 ± 5; women: MSP 84 ± 6, GB 84 ± 6) yet MSP patients had more previous cardiovascular comorbidities and procedures (PCI/CABG). Guideline-based medication use was high in both locations. MSP patients were significantly more likely to undergo PCI (men: MSP 33%, GB 7%; women: MSP 30%, GB 7%). Survival at 7.5 years was 27.8% among MSP patients (men: 26.6%, women: 28.8%) and 17.2% among GB patients (men: 17.5%, women: 17.0%). After adjustment for baseline characteristics and guideline-based therapies, survival was higher among MSP men [HR: 0.66, 95% confidence interval (CI): 0.50-0.88] and women (HR: 0.49, 95% CI: 0.36-0.67) compared with GB.In MSP and GB, guideline-based therapy use was high. However, PCI use was markedly higher in MSP. Long-term survival was better among elderly men and women in MSP compared with GB possibly related to greater utilization of PCI.

Aims: To describe out-of-hospital cardiac arrest (OHCA) in Sweden from a long-term perspective in terms of changes in outcome and circumstances at resuscitation. Methods and results: All cases of OHCA (n = 59 926) reported to the Swedish Cardiac Arrest Register from 1992 to 2011 were included. The number of cases reported (n/100 000 person-years) increased from 27 (1992) to 52 (2011). Crew-witnessed cases, cardiopulmonary resuscitation prior to the arrival of the emergency medical service (EMS), and EMS response time increased (P < 0.0001). There was a decrease in the delay from collapse to calling for the EMS in all patients and from collapse to defibrillation among patients found in ventricular fibrillation (P< 0.0001). The proportion of patients found in ventricular fibrillation decreased from 35 to 25% (P < 0.0001). Thirty-day survival increased from 4.8 (1992) to 10.7% (2011) (P < 0.0001), particularly among patients found in a shockable rhythm and patients with return of spontaneous circulation (ROSC) at hospital admission. Among patients hospitalized with ROSC in 2008–2011, 41% underwent therapeutic hypothermia and 28% underwent percutaneous coronary intervention. Among 30-day survivors in 2008–2011, 94% had a cerebral performance category score of 1 or 2 at discharge from hospital and the results were even better if patients were found in a shockable rhythm. Conclusion: From a long-term perspective, 30-day survival after OHCA in Sweden more than doubled. The increase in survival was most marked among patients found in a shockable rhythm and those hospitalized with ROSC. There were improvements in all four links in the chain of survival, which might explain the improved outcome.

To describe the occurrence of death, development of acute myocardial infarction and need for hospitalization among patients on the waiting list for coronary artery bypass grafting and percutaneous transluminal coronary angioplasty.All the patients on the waiting list for possible coronary revascularization in September 1990 in western Sweden.Of 718 patients waiting for either coronary artery bypass grafting or percutaneous transluminal coronary angioplasty, 15 (2.1%) died between the actual week in September 1990 and prior to revascularization and 12 (1.7%) developed a non-fatal acute myocardial infarction during the same period. All 15 patients who died before undergoing revascularization died a cardiac death. Death and/or the development of an acute myocardial infarction was significantly more frequent among the elderly, among patients with a low ejection fraction and among patients with a history of diabetes mellitus. In all, 29% required hospitalization prior to the procedure. The most common reason was symptoms of angina pectoris requiring hospitalization in 23% of the patients.Among patients on the waiting list before either coronary artery bypass grafting or percutaneous transluminal coronary angioplasty, 15 (2.1%) died prior to the procedure and 1.7% developed a non-fatal acute myocardial infarction. The risk of either death or developing an acute myocardial infarction was highest among patients in the older age groups, among patients with a history of diabetes mellitus and among patients with a lower ejection fraction.

Objective To describe mortality and morbidity during a period of 2 years after coronary artery bypass grafting in relation to gender. Design Prospective follow-up study. Setting Two regional cardiothoracic centres which performed all the coronary artery bypass operations in western Sweden at the time. Sub|ects A total of 2129 (1727 (81%) men and 402 (19%) women) consecutive patients undergoing coronary artery bypass surgery between June 1988 and June 1991 without concomitant procedures. Results Females were older and more frequently had a history of hypertension, diabetes mellitus, congestive heart failure, renal dysfunction and obesity. In a multivariate analysis, taking account of age, history of cardiovascula r diseases and renal dysfunction, female sex appeared as a significant independent predictor of mortality during the 30 days after coronary artery bypass grafting (/>

Diabetic patients with acute myocardial infarction have a poor prognosis, which has been attributed to a higher incidence of congestive heart failure and fatal reinfarction. This study reports on the one-year morbidity and mortality in a randomized study with the aim of testing whether insulin-glucose infusion initiated as soon as possible after onset of myocardial infarction and followed by long-term subcutaneous insulin treatment may have a beneficial effect on outcome in diabetic patients. In all, 306 patients were recruited to the insulin-treated group, while 314 patients served as controls. The overall mortality after one year was 19% in the insulin group compared to 26% among controls (P < 0.05). The treatment effect was most pronounced in patients without prior insulin medication and at low cardiovascular risk. In this stratum the in-hospital mortality was reduced by 58% (P < 0.05) and the one-year mortality by 52% (P < 0.02). The most frequent cause of death in all patients was congestive heart failure (66%), but cardiovascular mortality (congestive heart failure, fatal reinfarction, sudden death and stroke) tended to be decreased in insulin-treated patients. However, this difference did not reach the level of statistical significance. The number of reinfarctions was 53 (28% fatal) in the insulin group compared to 55 (45% fatal) in the control group. The two groups did not differ as regards need for hospital care or coronary revascularization during the year of follow-up. In summary, left ventricular failure and fatal reinfarctions contribute to increased mortality in diabetic patients following acute myocardial infarction. Intensive insulin treatment lowered this mortality during one year of follow-up.

It has been recognized that there is a group of patients with severe disabling angina and coronary artery disease who are refractory to conventional forms of treatment. Although this issue has already been debated at the level of the National Societies, we felt that it was appropriate to also tackle it at the European level. This is particularly important in view of the rapid pace of growth of this problem and the lack of a standardized approach. This has encouraged the development of a variety of treatments that vary considerably in terms of cost-effectiveness and safety and require proper validation procedures. The aim of this paper is to draw attention to the problem and start a process that will lead to improvement and harmonization of the care of patients with refractory angina.

This study aims at describing the in-hospital prognosis of patients admitted with suspected acute myocardial infarction, focusing on the possibility of emergency room prediction of the risk for death and severe complications. From 7157 consecutive patients with chest pain or other symptoms suggestive of acute myocardial infarction in the emergency room, 4690 were hospitalized. Of these, 246 (5%) died in hospital, with a mortality rate among the 921 patients who developed myocardial infarction of 14%, and among those without infarction of 3%. From the clinical history, examination and electrocardiogram in the emergency room, independent predictors of death and death or any severe complication were determined by logistic regression analysis. These included age, initial degree of suspicion of infarction, electrocardiographic pattern, history of diabetes mellitus, history of congestive heart failure and on admission arrhythmias, loss of consciousness, acute congestive heart failure, or unspecific symptoms. From these analyses the probability of death or death or any severe complication can be calculated. Thus, 18% of patients hospitalized due to suspected acute myocardial infarction suffered a severe complication or died in hospital. From a statistical model it is possible to predict the in-hospital prognosis of every such patient.

The frequency of subjective cardiac and psychological complaints among men and women a year after a confirmed diagnosis of myocardial infarction (MI) were compared. Among 660 survivors, 595 patients completed mailed questionnaires at home one year after the MI. There were 421 men, mean age 67.1 +/- 10.7 years, and 174 women, mean age 72.1 +/- 10.6 years. Controlling for the significantly higher mean age among the women, the latter more often had a previous history of angina pectoris, 54.6% (Por = 0.05) versus 42.9%, and heart failure, 24.7% versus 13.5% (Por = 0.01). Despite these facts, the women were significantly less often referred to CCU, 82.2% versus 91.7% (Por = 0.05). One year after the MI, controlling for differences in age and co-morbidity, women reported significantly higher frequencies of psychological and psychosomatic complaints, including sleep disturbances. These differences may have clinical implications for diagnosis and treatment of women with coronary heart disease.

In 917 patients with acute myocardial infarction (AMI) we evaluated the impact of previous angina pectoris on the prognosis. Thirty-four percent of the patients had chronic angina prior to AMI, and 22% had angina pectoris of short duration. Patients with chronic angina pectoris differed from the remaining patients having a more frequent previous history of AMI, diabetes mellitus, hypertension, and congestive heart failure. They less frequently developed a Q-wave AMI, and had smaller infarcts according to maximum serum-enzyme activity as compared with the remaining patients. They had a higher one-year mortality rate (36%) as compared with those having angina pectoris of short duration (22%), and those with no angina pectoris (26%). Their reinfarction rate was also higher (26%) as compared with that in the other two groups (15% and 9% respectively). In a multivariate analysis considering age, sex, clinical history, initial symptoms, initial electrocardiogram and estimated infarct size, previous chronic angina pectoris was not an independent risk factor for death, but was independently associated with the risk of reinfarction (P < 0.001). Among patients with a history of angina pectoris the outcome was related to medication prior to onset of AMI and at discharge from hospital. Patients in whom beta-blockers were prescribed at discharge had a one-year mortality of 13% as compared with 30% in the remaining patients (P < 0.001).

Non-cardiac origin of out-of-hospital cardiac arrests : do we underestimate their frequency and prognosis?

Aim To evaluate whether long-term treatment with a fixed low dose of warfarin in combination with aspirin improves the prognosis compared with aspirin treatment alone after an acute myocardial infarction (AMI). Methods Patients who were hospitalized for AMI were randomized to either 1.25mg of warfarin plus 75mg of aspirin ( n =1659) daily or 75mg of aspirin alone ( n =1641). The study was performed according to the PROBE (Prospective Open Treatment and Blinded End Point Evaluation) design and was conducted at 31 hospitals in Sweden. The median follow-up time was 5.0 years. In the aspirin+warfarin group, 30.2% were permanently withdrawn as opposed to 14.0% in the aspirin group ( P

Aims To describe changes in different factors at resuscitation and survival in a 17-year survey of patients suffering from out-of-hospital cardiac arrest. Method The investigation was carried out in the community of Goteborg with 450000 inhabitants during 1981–1997 on all patients suffering out-of-hospital cardiac arrest in whom resuscitation was attempted. Results The number of cases per year, the proportion of witnessed arrests and the proportion of arrests of cardiac aetiology remained similar over time. There was an increase in median age from 68 to 73 years ( P

This editorial refers to ‘Post-discharge survival following pre-hospital cardiopulmonary arrest due to cardiac aetiology: temporal trends and impact of changes in clinical management’† by J.P. Pell et al ., on page 406 In the western world, a large percentage of patients who die do so as a result of heart disease, predominantly coronary artery disease (CAD). Among these patients, the majority die prior to hospital admission because of sudden cardiac death. During the last three decades, a tremendous effort has been made in order to increase survival from out-of-hospital cardiac arrest (OHCA) via the introduction of the chain of survival concept.1 However, short-term survival has not improved as dramatically as was forecast. In all probability, the decrease in the occurrence of ventricular fibrillation as the initial recorded rhythm in OHCA is a strong contributory factor to this observation.2 In the present article, the results also indicated a slight worsening in the short-term outcome among patients suffering from OHCA. During the last few years, a new link in the chain of survival, the fifth link, i.e. ‘post-resuscitation care’, has been introduced.3 As a result, we have learnt that factors in the early … *Corresponding author. E-mail address : johan.herlitz{at}hjl.gu.se

Purpose: To compare respondents and non-respondents in a follow-up survey of a consecutive sample of survivors from pre-hospital cardiac arrest (CA) in a region of Sweden. Methods: Follow-up with postal questionnaires was performed about one to 12 months after CA. The sample was consecutive comprising patients who had experienced a pre-hospital CA, age > 18 years, > 30 days survival and still alive and Cerebral Performance Categories scale score one or two at discharge from hospital. The patients were identified through the Swedish registry of pre-hospital cardiac arrest (SCAR). Study period was January 2008 to December 2011. To describe comorbidity among respondents the Self-reported Comorbidity Questionnaire (SCQ) was used. Results: 128 of 255 (50%) reported survivors (fulfilling inclusion criteria) were identified and responded to the follow-up survey. Meantime from CA to follow up was 188 (SD+ 196) days. Characteristics of respondents/non-respondents were: Male gender 76/76%, mean age 63.8/62,6 years, ventricular fibrillation as first rhythm 79/80%, bystander cardiopulmonary resuscitation 84/77% and cardiac etiology 83/81%. No significant differences were found. Neither was any significant differences found regarding treatment with hypothermia (43/38%), percutaneous coronary intervention (55/48%) or implantable converter defibrillator (26/18%). Among respondents, 79% reported one to three problems according to SCQ. The three most common comorbidities (SCQ) were heart disease (68%), high blood pressure (44%) and back pain (24%). 62%, 40% and 5% respectively reported treatment for their problem, while 42%, 11% and 13% respectively reported limitations according to their problem. Mean SCQ index was 4.9. Conclusions: Respondents to the follow-up survey seem to be representative of the population with regard to CA circumstances and in-hospital interventions despite low response rate. Heart disease was the most common reported comorbidity and the most frequently limiting one.

Diabetic patients with acute myocardial infarction have a poor prognosis, which has been attributed to a higher incidence of congestive heart failure and fatal reinfarction. This study reports on the one-year morbidity and mortality in a randomized study with the aim of testing whether insulin-glucose infusion initiated as soon as possible after onset of myocardial infarction and followed by long-term subcutaneous insulin treatment may have a beneficial effect on outcome in diabetic patients. In all, 306 patients were recruited to the insulin-treated group, while 314 patients served as controls. The overall mortality after one year was 19% in the insulin group compared to 26% among controls (P0.05). The treatment effect was most pronounced in patients without prior insulin medication and at low cardiovascular risk. In this stratum the in-hospital mortality was reduced by 58% (P0.05) and the one-year mortality by 52% (P0.02). The most frequent cause of death in all patients was congestive heart failure (66%), but cardiovascular mortality (congestive heart failure, fatal reinfarction, sudden death and stroke) tended to be decreased in insulin-treated patients. However, this difference did not reach the level of statistical significance. The number of reinfarctions was 53 (28% fatal) in the insulin group compared to 55 (45% fatal) in the control group. The two groups did not differ as regards need for hospital care or coronary revascularization during the year of follow-up. In summary, left ventricular failure and fatal reinfarctions contribute to increased mortality in diabetic patients following acute myocardial infarction. Intensive insulin treatment lowered this mortality during one year of follow-up.