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Low density lipoprotein cholesterol (LDL-C) goals post-myocardial infarction (MI) are debated, and the significance of achieved blood lipid levels for predicting a first recurrent atherosclerotic cardiovascular disease (rASCVD) event post-MI is unclear. This was a cohort study on first-ever MI survivors aged ≤76 years attending 4–14 week revisits throughout Sweden 2005–2013. Personal-level data was collected from SWEDEHEART and linked national registries. Exposures were quintiles of LDL-C, high density lipoprotein cholesterol (HDL-C), total cholesterol (TC), and triglycerides (TGs) at the revisit. Group level associations with rASCVD (nonfatal MI or coronary heart disease death or fatal or nonfatal ischemic stroke) were estimated in Cox regression models. Predictive capacity was estimated by differences in C-statistic, integrated discriminatory improvement, and net reclassification improvement when adding each blood lipid to a validated risk prediction model. 25,643 patients, 96.9% on statin therapy, were followed during a mean of 4.1 years. rASCVD occurred in 2173 patients (8.5%). For LDL-C and TC, moderate associations with rASCVD were observed only in the 5th vs. the lowest (referent) quintiles. For TGs and HDL-C increased risks were observed in quintiles 3–5 vs. the lowest. Minor predictive improvements were observed when lipid fractions were added to the risk model but the discrimination overall was poor (C-statistics <0.6). Our data question the importance of LDL-C levels achieved at first revisit post-MI for decisions on continued treatment intensity considering the weak association with rASCVD observed in this post-MI cohort. • After a first myocardial infarction (MI) the annual recurrence of MI or stroke was 2%. • 96.9% of the 25,643 patients were on statin therapy at study baseline. • Blood lipid levels were poorly predictive of a recurrent MI or stroke. • Associations with recurrence were weakest for LDL-C and strongest for triglycerides. [ABSTRACT FROM AUTHOR]

Abstract Background We aimed to evaluate the diagnostic sensitivity for myocardial infarction (MI) when using an undetectable level of high-sensitivity cardiac troponin T (hs-cTnT < 5 ng/L) at presentation combined with a non-ischemic electrocardiogram (ECG), to rule out MI in a non-ST-segment elevation MI (NSTEMI) cohort presenting ≤2 h from symptom onset. We also aimed to compare baseline characteristics and 30-day outcome in NSTEMI patients presenting with and without hs-cTnT < 5 ng/L. Methods All patients admitted to five centers in Sweden 2011–2015, after the introduction of hs-cTnT, who presented ≤2 h from symptom onset and received a final diagnosis of NSTEMI, were identified through the SWEDEHEART registry. These data and data of hs-cTnT levels were verified in the hospitals' medical records. The registry provided baseline and outcome data. Results Twenty-four (2.6%) of 911 NSTEMI patients presented with hs-cTnT < 5 ng/L. In patients presenting >1–≤2 h from symptom onset the sensitivity for MI when combining hs-cTnT and ECG was 99.4% (95% CI 98.4%–99.8%). In patients presenting ≤1 h, and in patients aged ≤65 years without prior MI, the sensitivity was insufficient. NSTEMI patients presenting with hs-cTnT < 5 ng/L were younger and had less often a prior MI. A total of 62.5 vs. 63.5% of the NSTEMI patients presenting with and without hs-cTnT < 5 ng/L underwent revascularization within 30 days and 4.5 and 3.2% died respectively. Conclusions Hs-cTnT < 5 ng/L at presentation combined with a non-ischemic ECG may be used to rule out MI in patients presenting as early as >1 h from symptom onset with a sufficient sensitivity. Highlights • High-sensitivity troponin T < 5 ng/L combined with a non-ischemic ECG can rule out NSTEMI. • The rule-out algorithm may be used in the second hour from symptom onset. • Younger patients with no prior myocardial infarction should be assessed with caution. • NSTEMI patients with and without T < 5 ng/L have a similar 30-day outcome. [ABSTRACT FROM AUTHOR]

Abstract Background Acquired loss of the largest von Willebrand factor multimers is a common hemostatic disturbance in patients with aortic valve stenosis (AS), resulting in impaired platelet adhesion and increased bleeding risk. AS is also associated with atherosclerosis and myocardial infarction (MI). Our aim was to study the clinical outcomes associated with AS in MI patients treated with dual antiplatelet therapy (DAPT) in a nationwide hospital-based register study. Methods Based on nationwide hospital discharge registers from Sweden (2005–2010) and Denmark (2005–2015), we calculated 1-year incidence rates and hazard ratios of bleeding, recurrent MI, and all-cause mortality in MI patients with and without AS treated with DAPT. Results from both countries were also combined in a meta-analysis. Results We included 50,460 MI patients from Sweden and 50,307 MI patients from Denmark, of which 3% had AS. The bleeding rates (per 100 person-years) in Sweden and Denmark were 3.2 and 3.3 among patients without AS vs. 9.2 and 8.3 among patients with AS. All-cause mortality rates were 7.1 vs. 28.7 in Sweden and 5.8 vs. 30.7 in Denmark among patients without and with AS, respectively. Patients with AS had an increased risk of bleeding, recurrent MI and all-cause mortality. Combined results from both countries were similar for bleeding (hazard ratio 1.59 [0.98–2.59]), recurrent MI (1.78 [1.25–2.54]), and all-cause mortality (1.76 [1.26–2.47]). Conclusion AS was associated with an increased risk of bleeding, recurrent MI and mortality after MI when treated with DAPT. Individualized selection of antiplatelet therapy may be warranted in this high-risk population. Highlights • Bleeding was more common in AS patients treated with DAPT after MI. • Recurrent MI and all-cause mortality were more frequent in AS patients. • Patients with AS represent a group with high risk after incident MI. [ABSTRACT FROM AUTHOR]

Background There is a paucity of data if there is a benefit for patients above 80 years of age with non-ST-segment elevation myocardial infarction (NSTEMI) to undergo percutaneous coronary intervention (PCI). Objectives To investigate the association between PCI or conservative treatment and outcomes in NSTEMI patients above 80 years of age. Methods From the SWEDEHEART register were included 13,854 patients above 80 years of age with NSTEMI during 2011–2014 in Sweden. Cox regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CI) for the association between PCI compared with conservative treatment for the outcome all-cause mortality. Results In total 4158 (30%) patients underwent PCI, and 9696 (70%) were treated conservatively. The mean age was 86 (±4) years. During a mean 2.2 (±1.4) years there were 6458 (47%) deaths, where of 1078 (26%) in PCI treated, and 5380 (56%) in conservatively treated patients. Treatment with PCI compared with conservative treatment was associated with a 40% lower risk of death (adjusted HR 0.60, 95% CI 0.55–0.66). Similarly, patients in the PCI group had a 60% lower 30-day, and 51% lower 1-year all-cause mortality, respectively (adjusted HR 0.40, 95% CI 0.25–0.63, and HR, 0.49 95% CI 0.42–0.57, respectively). There were no differences in risk of bleedings (1.4% versus 1.3%). Conclusions PCI compared with conservative treatment was associated with a lower mortality in patients above 80 years of age with NSTEMI without an increased risk of bleedings. PCI may be considered as the treatment of choice for elderly with NSTEMI. [ABSTRACT FROM AUTHOR]

Background Data are scarce regarding the risk, temporal trends and predictors of late-onset heart failure (LOHF) after acute myocardial infarction (AMI). We aimed at studying the risk and predictors of LOHF and the composite event of LOHF or death after AMI. Methods AMI patients first entered in the nationwide SWEDEHEART registry between 2004 and 2013 were included. Patients with a prior history of heart failure (HF) and those who died in-hospital were excluded. Dates and ICD-codes for LOHF in the national patient and death registries were used to determine time to first readmission due to LOHF and/or death. Results A total of 150,566 AMI patients were included in the analysis. The 1-year, 2-year and 5-year cumulative risk of developing LOHF were 11.4%, 14.6% and 21.8% respectively. The risk of LOHF within 2 years decreased from 15.5% to 14.4% (2004–2005 vs 2010–2011), p < 0.001. Calendar year was protective of LOHF/death after adjustment (HR 0.96, 95% CI 0.94–0.98, p < 0.001). In-hospital HF, age, diabetes mellitus, chronic kidney disease, peripheral arterial disease, chronic obstructive pulmonary disease and atrial fibrillation, were strong predictors of LOHF. Risk profile improved and use of evidence based therapies increased during the time period. Conclusions Survivors of AMI remain at a continued risk of LOHF. However, the overall risk of LOHF shows a decreasing trend after an index AMI over time. Lower risk of LOHF may relate to decreasing burden of comorbidities and increasing use of evidence based treatments. [ABSTRACT FROM AUTHOR]

Background Cardiogenic shock remains the leading cause of in hospital death in acute myocardial infarction (AMI) and is associated with a mortality rate of approximately 50%. Here we investigated the 17-year trends in incidence and prognosis of AMI-induced cardiogenic shock in Västra Götaland in western Sweden, an area with approximately 1.6 million inhabitants. The study period includes the transition from thrombolysis to primary percutaneous coronary intervention (PCI) as the region-wide therapy of choice for patients with ST-elevation myocardial infarction (STEMI). Methods Data on patients hospitalized in cardiac care units in Västra Götaland, Sweden between 1995 and 2013 were obtained from the Swedish Websystem for Enhancement of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). We determined the incidence of cardiogenic shock among patients diagnosed with AMI and the risk of death associated with developing cardiogenic shock. We fitted logistic regression models to study which factors predicted post-AMI cardiogenic shock. Analyses were performed on complete case data as well as after multiple imputation of missing data. Results Incidence of cardiogenic shock as a complication of AMI declined in western Sweden in the past decade, from 14% in 1995 to 4% in 2012. The risk of dying once cardiogenic shock had developed increased during the study period (p < 0.01). Patients presenting with STEMI were more likely to develop cardiogenic shock than patients presenting with non STEMI (p < 0.001). Conclusions The incidence of cardiogenic shock has declined but cardiogenic shock carries a worse prognosis today than in 1995. [ABSTRACT FROM AUTHOR]

Background Fish consumption may promote cardiovascular health. The role of major food contaminants, such as polychlorinated biphenyls (PCBs) common in fatty fish, is unclear. We assessed the association between dietary PCB exposure and risk of myocardial infarction taking into account the intake of long-chain omega-3 fish fatty acids. Methods In the prospective population-based Swedish Mammography Cohort, 33,446 middle-aged and elderly women, free from cardiovascular disease, cancer and diabetes at baseline (1997) were followed-up for 12 years. Validated estimates of dietary PCB exposure and intake of fish fatty acids (eicosapentaenoic acid and docosahexaenoic acid; EPA-DHA) were obtained via a food frequency questionnaire at baseline. Results During follow-up 1386 incident cases of myocardial infarction were ascertained through register-linkage. Women in the highest quartile of dietary PCB exposure (median 286 ng/day) had a multivariable-adjusted RR of myocardial infarction of 1.21 (95% confidence interval [CI], 1.01-1.45) compared to the lowest quartile (median 101 ng/day) before, and 1.58 (95% CI, 1.10-2.25) after adjusting for EPA-DHA. Stratification by low and high EPA-DHA intake, resulted in RRs 2.20 (95% CI, 1.18-4.12) and 1.73 (95% CI, 0.81-3.69), respectively comparing highest PCB tertile with lowest. The intake of dietary EPA-DHA was inversely associated with risk of myocardial infarction after but not before adjusting for dietary PCB. Conclusion Exposure to PCBs was associated with increased risk of myocardial infarction, while some beneficial effect was associated with increasing EPA and DHA intake. To increase the net benefits of fish consumption, PCB contamination should be reduced to a minimum. [ABSTRACT FROM AUTHOR]

Introduction Previous studies have established a relationship between socioeconomic status (SES) and survival in coronary heart disease. Acute cardiac care in Sweden is considered to be excellent and independent of SES. We studied the influence of area-level socioeconomic status on mortality after hospitalization for acute myocardial infarction (AMI) between 1995 and 2013 in the Gothenburg metropolitan area, which has little over 800,000 inhabitants and includes three city hospitals. Methods Data were obtained from the SWEDEHEART registry (Swedish Websystem for Enhancement of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) and the Swedish Central Bureau of Statistics for patients hospitalized for ST-elevation myocardial infarction (STEMI) and non-STEMI in the city of Gothenburg in Western Sweden. The groups were compared using Cox proportional hazards regression and logistic regression. Results 10,895 (36% female) patients were hospitalized due to AMI during the study period. Patients residing in areas with lower SES had higher rates of smoking and diabetes (P < 0.001), and were also at increased risk of developing complications, including heart failure and cardiogenic shock (P < 0.05). Living in an area with lower SES associated with increased risk of dying after an AMI also in models adjusted for risk factors (P < 0.05). Conclusion Also in a country with strong egalitarian traditions, lower SES associates with worse prognosis after AMI, an association that persists after adjustments for differences in traditional cardiovascular risk factors. [ABSTRACT FROM AUTHOR]

Abstract: Background: Previous studies of patients admitted for ST-elevation myocardial infarction [STEMI] have indicated that women have a higher risk of early mortality than do men. These studies have presented limited information on gender related differences in the short term and almost no information on the long term. Methods and results: We analysed a prospective, consecutively included STEMI population consisting of 54,146 patients (35% women). This population consists of almost all patients hospitalised in Sweden between January 1, 1995 and December 31, 2006 as recorded in the SWEDEHEART register (formerly RIKS-HIA). Follow-up time ranged from one to 13years (mean 4.6). Women had a lower probability of being given reperfusion therapy, odds ratio [OR] 0.83 (95% confidence interval [CI] 0.79–0.88). During the time these STEMI patients were in the hospital, 13% of the women and 7% of men died, multivariable adjusted OR 1.21 (95% CI 1.11–1.32). During the follow up period, 46% of the women died as compared with 32% of the men. There was, however, no gender difference in age-adjusted risk of long term mortality (hazard ratio [HR] 0.98, 95% CI 0.95–1.01) whereas the multivariable adjusted risk was lower in women (HR 0.92, 95% CI 0.89–0.96). The long term risk of re-infarction was the same in men and women (HR 0.98, 95% CI 0.93–1.03) whereas men in the youngest group had a higher risk than women in that age group (HR 0.82, 95% CI 0.72–0.94). Conclusion: In STEMI, women had a higher risk of in-hospital mortality but the long-term risk of death was higher in men. More studies are needed in the primary percutaneous coronary intervention (pPCI) era that are designed to determine why women fare worse than men after STEMI during the first phase when they are in hospital. [Copyright &y& Elsevier]

Abstract: Aim: To describe differences in treatment and delay times in acute chest pain at the three hospitals in Göteborg, Sweden. Methods: All patients admitted to the three hospitals within Sahlgrenska University (SU) (Sahlgrenska: SU/S, Östra: SU/Ö and Mölndal: SU/M) with acute chest pain during 3months in 2008 were evaluated for diagnosis, early treatment and outcome. Results: In all, 2588 visits by 2393 patients were included (visits n=1253 SU/S; n=853 SU/Ö; n=482 SU/M) of which 50%, 63% and 51% were hospitalised (p<0.0001). Among hospitalised patients, a diagnosis of ACS was reported in 26%, 9% and 22% respectively (p<0.0001). Among ACS patients, 83%, 66% and 57% respectively underwent coronary angiography (p=0.004). The median delay to coronary angiography in ST-elevation myocardial infarction (STEMI) was 42min at SU/S, 3h 47min at SU/Ö and 2h 34min at SU/M (p=0.008). The corresponding values for coronary angiography in unstable coronary artery disease were 42h 7min, 48h 35min and 123h 42min (p=0.007). Overall mortality at 30days was 3.6%, 3.2% and 1.5% (NS) and, at 1year, it was 9.9%, 9.6% and 7.3% respectively (NS). Conclusion: In acute chest pain in the Municipality of Göteborg, there was a marked difference between hospitals in: 1) the percentage of hospitalised patients, 2) the percentage of ACS among hospitalised patients and 3) the delay to and rate of coronary angiography. The clinical consequences of these deviations remain to be proven. [Copyright &y& Elsevier]

Abstract: Background: Recent population-based estimates for long-term cardiovascular disease (CVD) mortality after hospitalization for a first acute myocardial infarction (AMI) are not well established. Methods: Data from the Swedish hospital discharge and death registries were used to record all first-ever hospital admissions in patients (n=348,772) 35–84years with AMI from 1987 to 2006 and subsequent all-cause and CVD case fatality during up to 5years. Results: During the 20-year period, 28-day case fatality was reduced by almost two thirds in patients aged <75years. For cases with a first AMI 1999–2002 long-term case fatality for men surviving the first 28days and <55years was 10.3/1000 person years, with rates of 23.6, 58.0 and 137.0 for men aged 55–64, 65–74 and 75–84years. Corresponding figures for women were 10.5, 24.3, 51.8, 124.1 deaths/1000years. In 1999–2002 estimated long-term risk of fatal CVD (based on survival until 2007) for men below 55years was 6.1/1000years, and 13.8, 34.6, 92.9 for men aged 55–64, 65–74, and 75–84years, respectively. Corresponding figures for women were 4.8, 11.9, 30.1, 86.2/1000years. The total reduction in CVD case fatality was two thirds among patients aged <55 and approximately one third among those aged 75–84. Conclusions: Long-term case fatality after hospitalization for AMI decreased markedly from 1987 to 2006, particularly with respect to CVD mortality and in younger patients. However, because of a steep increase in case fatality with age and a large proportion of older patients, long-term prognosis overall still remains poor. [Copyright &y& Elsevier]