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Background Exposure to many contacts is the main risk factor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, while risk of serious disease and death is chiefly determined by old age and comorbidities. Relative and population-attributable fractions (PAFs) of multiple medical and social exposures for COVID-19 outcomes have not been evaluated among older adults. Objectives We describe the effect of multiple exposures on the odds of testing positive for the virus and of severe disease (hospital care or death) and PAFs in Swedish citizens aged 55 years and above. Methods We used national registers to follow all citizens aged 55 years and above with respect to (1) testing positive, (2) hospitalization, and (3) death between 31 January 2020 and 1 February 2021. Results Of 3,410,241 persons, 156,017 (4.6%, mean age 68.3 years) tested positive for SARS-CoV-2, while 35,999 (1.1%, mean age 76.7 years) were hospitalized or died (12,384 deaths, 0.4%, mean age 84.0 years). Among the total cohort, the proportion living without home care or long-term care was 98.8% among persons aged 55-64 and 22.1% of those aged 95 and above. After multiple adjustment, home care and long-term care were associated with odds ratios of 7.9 (95% confidence interval [CI] 6.8-9.1) and 22.5 (95% CI 19.6-25.7) for mortality, with PAFs of 21.9% (95% CI 20.9-22.9) and 33.3% (95% CI 32.4-34.3), respectively. Conclusion Among Swedish residents aged 55 years and above, those with home care or long-term care had markedly increased risk for COVID-19 death during the first year of the pandemic, with over 50% of deaths attributable to these factors. Funding Agencies|Swedish Heart and Lung Foundation [2018-0366]; Swedish Research Council [2018-0366, 2020-05792, 2021-06545]; Swedish state [ALFGBG717211, AFGBG-965885]; VRREG [2019-00193, 2019-00198, 201900245, 2019-00209]; Science for Life Laboratory from the Knut and Alice Wallenberg Foundation [2020.0241]; Swedish Research Council for Health, Working Life and Welfare [2021-00304]

Background As opposed to the decreasing overall rates of coronary heart disease (CHD) incidence and overall cardiovascular disease (CVD) mortality, heart failure (HF) and stroke incidence are increasing in young people, potentially due to rising rates of obesity and reduced cardiorespiratory fitness (CRF). Objectives We investigated trends in early major CVD outcomes in a large cohort of young men. Methods Successive cohorts of Swedish military conscripts from 1971 to 1995 (N = 1,258,432; mean age, 18.3 years) were followed, using data from the National Inpatient and Cause of Death registries. Cox proportional hazard models were used to analyse changes in 21-year CVD event rates. Results 21-year CVD and all-cause mortality and incidence of acute myocardial infarction (AMI) decreased progressively. Compared with the cohort conscripted in 1971-1975 (reference), the hazard ratios (HRs) for the last 1991-1995 cohort were 0.50 [95% confidence interval (CI) 0.42-0.59] for CVD mortality; 0.57 (95% CI 0.54-0.60) for all-cause mortality; and 0.63 (95% CI 0.53-0.75) for AMI. In contrast, the incidence of ischaemic stroke, intracerebral haemorrhage and HF increased with HRs of 1.43 (95% CI 1.17-1.75), 1.30 (95% CI 1.01-1.68) and 1.84 (95% CI 1.47-2.30), respectively. During the period, rates of obesity increased from 1.04% to 2.61%, whilst CRF scores decreased slightly. Adjustment for these factors influenced these secular trends only moderately. Conclusion Secular trends of young-onset CVD events demonstrated a marked shift from AMI and CVD mortality to HF and stroke incidence. Trends were significantly, though moderately, influenced by changing baseline BMI and CRF.

Introduction We examined the long‐term risk of dementia after coronary artery bypass grafting (CABG) in relation to age and sex. Methods All CABG patients in Sweden 1992–2015 (n = 111,335), and matched controls (n = 222,396) were included in a population‐based study. Adjusted hazard ratios (aHR) for all‐cause dementia, vascular dementia, and Alzheimer's disease were calculated. Results There was no difference in the risk for all‐cause dementia between CABG patients and control subjects (aHR 0.98 [95% confidence interval 0.95 to 1.02]). CABG patients

Background People with severe mental illness often have a small or no network of friends and limited contact with their family and live social isolated lives. We developed a social skills training programme to be administered by public mental health professionals in helping those with mental illness to overcome their social isolation. Methods The programme was developed over three years in close collaboration among psychologists, service users, municipal mental health professionals, mental health service researchers and a local firm providing virtual reality (VR) training. Results The mental health professionals acknowledge the potential this technology represents, and the first pilot study is currently being conducted. Even before the pilot study is completed, some of the staff have been able to use VR technology in meetings with service users when deemed suitable. Conclusion Several factors made adoption and implementation of VR technology possible in a relatively short timeframe: namely, the municipality and service users were involved from the beginning of the process, efforts were made to introduce VR to mental health professionals and allow them to reflect on its usability, solutions were low-tech and low cost, and the long-term research collaboration was established without municipal financial obligations.

Aims The association between the use of statins, renin–angiotensin system (RAS) inhibitors, and/or β-blockers and long-term mortality in patients with aortic stenosis (AS) who underwent surgical aortic valve replacement (SAVR) is unknown. Methods and results All patients with AS who underwent isolated first-time SAVR in Sweden from 2006 to 2017 and survived 6 months after discharge were included. Individual patient data from four mandatory nationwide registries were merged. Cox proportional hazards models, with time-updated data on medication status and adjusted for age, sex, comorbidities, type of prosthesis, and year of surgery, were used to investigate associations between dispensed statins, RAS inhibitors, and β-blockers and all-cause mortality. In total, 9553 patients were included, and the median follow-up time was 4.9 years (range 0–11); 1738 patients (18.2%) died during follow-up. Statins were dispensed to 49.1% and 49.0% of the patients within 6 months of discharge from the hospital and after 10 years, respectively. Corresponding figures were 51.4% and 53.9% for RAS inhibitors and 79.3% and 60.7% for β-blockers. Ongoing treatment was associated with lower mortality risk for statins {adjusted hazard ratio (aHR) 0.67 [95% confidence interval (95% CI) 0.60–0.74]; P 0.05). Conclusions The results of this large population-based real-world study support the use of statins and RAS inhibitors for patients who underwent SAVR due to AS.

BACKGROUND As the population of obese and severely obese young adults grows, it is becoming increasingly important to recognize the long-term risks associated with adolescent obesity. OBJECTIVES This study aimed to determine the association between body mass index (BMI) in young men at enlistment for military service and later risk of venous thromboembolism (VTE). METHODS Nationwide register-based prospective cohort study of men enlisting 1969 to 2005, followed through the Swedish National Patient and Cause of Death registries. We identified 1 639 838 men (mean age, 18.3 years) free of prior venous thromboembolism, of whom 29 342 were obese (BMI 30 to

BACKGROUND: There is no consensus on the choice of aortic valve prosthesis for patients with end-stage renal failure. We analyzed short- and long-term complications in dialysis patients who underwent aortic valve replacement (AVR) with either a biological (bAVR) or a mechanical (mAVR) prosthesis. METHODS: All patients on dialysis who underwent bAVR or mAVR in Sweden from 1995 to 2017 (n=335) were included in a nationwide, population-based, observational, cohort study. Short and long-term complications were compared. Long-term mortality was compared with multivariable Cox regression analysis adjusted for age, sex, comorbidities, and a propensity score-matched model. Median follow-up was 2.8 (range, 0–16) years. RESULTS: Biological and mechanical valves were implanted in 253 (75.5%) and 82 (24.5%) patients, respectively. The bAVR patients were older and had more comorbidities. There was no significant difference in early complication rate. Thirty-day mortality was 9.1% in bAVR and 7.3% in mAVR patients (P=0.62). The multivariable Cox regression model did not show significant difference in mortality risk between bAVR and mAVR patients [adjusted hazard ratio (aHR) 1.33; 95% CI: 0.84–2.13; P=0.22]. The results were confirmed in the propensity-score matched model. The rate of aortic valve reoperations did not differ significantly between the bAVR and mAVR group. CONCLUSIONS: The short- and long-term complication rate is high, and the expected life expectancy limited, in dialysis patients undergoing AVR, without significant difference between biological and mechanical prostheses. The results suggest that biological valve prosthesis, avoiding systemic anticoagulation, is appropriate in most dialysis patients.

Overweight and obesity have been identified as risk factors for severe COVID-19; however, prospective cohort studies investigating the association between overweight early in life and severity of COVID-19 are lacking.This study included 1,551,670 Swedish men, born between 1950 and 1987, with BMI registered at age 18 years. They were followed until January 9, 2021. COVID-19 cases and comorbidities were identified through the National Patient, Intensive Care, and Cause of Death registries. Outcomes included the following: 1) hospitalization; 2) intensive care unit admission; and 3) death.The study found 4,315 cases (mean age = 56.4 years [SD 8.8]) of patients hospitalized because of COVID-19, of which 729 were admitted to an intensive care unit, and altogether there were 224 deaths. The risk for hospital admission increased with higher values of BMI at age 18 years, despite adjustment for comorbidities, from an odds ratio (OR) of 1.19 (95% CI: 1.08-1.31) at BMI = 22.5 to 25 to an OR of 1.68 (95% CI: 1.39-2.02) at BMI ≥ 30, compared with BMI = 18.5 to 20. ORs for intensive care unit admission were 1.44 (95% CI: 1.13-1.84) at BMI = 22.5 to 25 and 2.61 (95% CI: 1.73-3.93) at BMI ≥ 30.Higher BMI in early adulthood was associated with severe COVID-19 many years later, with a risk increase starting already at BMI ≥ 22.5. This underlines the necessity of preventive actions against overweight in youth to offer protection against coming viral pandemics.

High body mass index (BMI) is associated with severe COVID-19 but findings regarding the need of intensive care (IC) and mortality are mixed. Using electronic health records, we identified all patients in western Sweden hospitalised with COVID-19 to evaluate 30-day mortality or assignment to IC. Adjusted logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals (CI) for outcomes. Of totally 9761 patients, BMI was available in 7325 (75%), included in the study. There was a marked inverse association between BMI and age (underweight and normal weight patients were on average 78 and 75 years, whereas overweight and obese were 68 and 62 years). While older age, male sex and several comorbidities associated with higher mortality after multivariable adjustment, BMI did not. However, BMI ≥ 30 kg/m2 (OR 1.46, 95% CI 1.21–1.75) was associated with need of IC; this association was restricted to women (BMI ≥ 30; OR 1.96 (95% CI 1.41–2.73), and not significant in men; OR 1.22 (95% CI 0.97–1.54). In this comprehensive hospital population with COVID-19, BMI was not associated with 30-day mortality risk. Among the obese, women, but not men, had a higher risk of assignment to IC.

Aims Beta blockers are associated with improved outcomes for selected patients with cardiovascular disease. We assessed long-term utilization of beta blockers after coronary artery bypass grafting (CABG) and its association with outcome. Methods and results All 35 184 patients in Sweden who underwent first-time isolated CABG between 1 January 2006 and 31 December 2017 and were followed for at least 6 months were included in a nationwide observational study. Multivariable Cox regression models using time-updated data on dispensed prescriptions were used to assess associations between different types of beta blockers and outcomes. The primary outcome was major adverse cardiovascular events (MACEs), a composite of all-cause mortality, stroke, and myocardial infarction (MI). Subgroup analyses were performed in patients with and without previous MI, heart failure, and reduced left ventricular ejection fraction (LVEF). Median follow-up was 5.2 years (range 0–11). At baseline, 33 159 (94.2%) patients were dispensed beta blockers, 30 563 (92.2%) of which were cardioselective beta blockers. After 10 years, the dispensing of cardioselective beta blockers had declined to 73.7% of all patients. Ongoing treatment with cardioselective beta blockers was associated with a slight reduction in MACEs [hazard ratio (HR) 0.93, 95% confidence interval (CI) 0.89–0.98, P = 0.0063]. The reduction was largely driven by a reduced risk of MI (HR 0.83, 95% CI 0.75–0.92, P = 0.0003), while there was no significant reduction in all-cause mortality (HR 0.99, 95% CI 0.93–1.05) and stroke (HR 0.96, 95% CI 0.87–1.05). The reduced risk for MI was consistent in all the investigated subgroups. Conclusion Ongoing treatment with cardioselective beta blockers after CABG is associated with a reduction in MACEs, mainly because of reduced long-term risk for MI. The association between cardioselective beta blockers and MI was consistent in patients with and patients without previous MI, heart failure, atrial fibrillation, or reduced LVEF.

Aims This study was performed to compare trends in home‐time for patients with heart failure (HF) between those of working age and those of retirement age in Sweden from 1992 to 2012. Methods and results The National Inpatient Register (IPR) was used to identify all patients aged 18 to 84 years with a first hospitalization for HF in Sweden from 1992 to 2012. Information on date of death, comorbidities, and sociodemographic factors were collected from the Swedish National Register on Cause of Death, the IPR, and the longitudinal integration database for health insurance and labour market studies, respectively. The patients were divided into two groups according to their age: working age (

Background Heart failure (HF) is increasing in people of working age in Sweden (1). Given high morbidity and reduced quality of life among HF patients (2, 3), working capacity could be greatly affected, however, studies are scarce. Purpose To determine trends in sick leave rates following a first hospitalization for HF in Sweden 1995–2015 compared to controls matched by age and sex. Methods In Sweden, people who cannot work receive sickness benefit. Sickness benefit pay days are registered by Statistics Sweden. We identified all patients aged 18–60 years with a first hospitalization for HF in Sweden 1995–2012 in the National Patient Register (NPR). For each case we selected 2 controls matched for age and sex. Cases and controls were split into age groups, Results A total of 24,677 cases and 65,923 controls were included, mean age for the younger and older age group 36.6 and 54.5 years, and proportion of women 35.3% and 23.8%, respectively. In 1995, the proportion of time on sickness benefit in patients Conclusion Patients had a longer time on sick leave than controls over the study period. Time on sickness benefit initially declined over the course of the study period for both patients and controls, but the last years of the study period this decline stalled for both patients and controls. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the Swedish state under an agreement between the Swedish government and the County Councils Concerning Economic Support of Research and Education of Doctors [ALFGBG-717211, ALFGBG-433211, ALFGBG-725081]; the Swedish Heart and Lung Foundation [2013-0307, 2018-0419, 2018-0589]. Figure 1Figure 2

Aim Wesought to study the association of alcohol consumption with the long-term risk of heart failure and all-cause mortality among adolescent men. Method We included 50 460 men (mean age 18.4 years; SD 0.72) that underwent enlistment for military service during 1968–1969. During this period, alcohol consumption was assessed with questionnaires as part of the enlistment protocol. Questionnaire data was transformed to grams of 100% ethanol/week and categorized as light (1–100 g/week), moderate (101–250 g/week), and high (>250 g/week). Follow-up was done through linkage to the nationwide Swedish patient- and cause of death registries. Risk of heart failure and all-cause mortality during follow-up was calculated with cox proportional hazard models, adjusted for age, conscription year, test centre, body mass index, systolic and diastolic blood pressure, parental education, intelligence quotient, cardiorespiratory fitness and muscle strength, and baseline comorbidities (diabetes mellitus and hypertension). Results During a median follow-up of 51 years, there were 803 incidentheart failure events (mean age at diagnosis, 61 years) and 6254 deaths (mean age: 55 years). Compared with non-drinkers (0 g/week), the adjusted hazard ratios (HR) for light, moderate and high alcohol consumption were 2.34 (1.24–4.40), 2.38 (1.22–4.68), 5.60 (2.68–11.69) for incident heart failure (Figure 1, model 4)and 1.27 (1.04–1.54), 1.66 (1.35–2.05), 2.25 (1.74–2.91) for all-cause mortality,respectively. Conclusion Alcohol consumption in adolescence is strongly associated with heart failure and all-cause mortality in adulthood. Our results suggests that even light alcohol consumption in adolescence is associated with higher long-term risk of heart failure and mortality. Funding Acknowledgement Type of funding sources: None. Figure 1. *Model 1 adjusted for age at conscription, conscription year, test center, body mass index and baseline comorbidities (diabetes mellitus and hypertension). †Model 2 as model 1 but additionally adjusted for systolic and diastolic blood pressure at baseline. ‡Model 3 as model 2 but additionally adjusted for parental education. #Model 4 as model 3 but additionally adjusted for intelligence quotient, cardiorespiratory fitness and muscle strength.

Objective: The objective of this study was to evaluate the association of statin use after coronary artery bypass grafting (CABG) and long-term adverse events in a large population-based, nationwide cohort. Methods: All 35,193 patients who underwent first-time isolated CABG in Sweden from 2006 to 2017 and survived at least 6 months after surgery were included. Individual patient data from the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) and 4 other nationwide registries were merged. Multivariable Cox regression models adjusted for age, sex, comorbidities, and time-updated treatment with other secondary preventive medications were used to evaluate the associations between statin treatment and outcomes. The primary end point was major adverse cardiovascular events (MACE). Median follow-up time to MACE was 5.3 (interquartile range, 2.5-8.2) years. Results: Statins were dispensed to 95.7% of the patients six months after discharge and to 78.9% after 10 years. At baseline, 1.4% of patients were prescribed low-, 57.6% intermediate-, and 36.7% high-dose statins. Ongoing statin treatment was associated with markedly reduced risk of MACE (adjusted hazard ratio [aHR], 0.56 [95% CI, 0.53-0.59]), all-cause mortality (aHR, 0.53 [95% CI, 0.50-0.56]), cardiovascular death (aHR, 0.54 [95% CI, 0.50-0.59]), myocardial infarction (aHR, 0.61 [95% CI, 0.55-0.69]), stroke (aHR, 0.66 [95% CI, 0.59-0.73]), new revascularization (aHR, 0.79 [95% CI, 0.70-0.88]), new angiography (aHR, 0.81 [95% CI, 0.74-0.88]), and dementia (aHR, 0.74 [95% CI, 0.65-0.85]; all P

Background Heart failure (HF) reduces survival and is one of the most common causes of hospitalizations in the elderly, imposing a major economic burden on the health care system, with frequency of rehospitalizations often used in interventional and observational studies in patients with HF. Home-time is a novel end-point measuring time spent alive and out of hospital and is easier for both clinicians and patients to relate to. Given the advances in treatment of HF over the last decades we postulated that an increase in home-time would follow. Purpose To investigate whether home-time for patients with HF has changed over the last decades in Sweden and if home-time differs between patients of working age and those retired, or between men and women. Methods Patients aged 18–84 years with a first hospitalization for HF in Sweden between 1992 and 2008 were identified using the National Inpatient Register which was linked to the Swedish Cause of Death Register. Information on rehospitalizations and mortality was collected and followed over a time period of 4 years. The patients were divided into two age groups: (i) 65 years. The cut off 65 years was chosen being the official age of retirement over the study period in Sweden. Results A total of 324,907 patients were included in this study, mean age 73.5 years (standard deviation 9.3). Only 15.6% were Conclusion Home-time for patients in Sweden increased over the study period and the increase was more marked for younger patients, where men spent more time at home than women. Figure 1 Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swedish state (ALF), The Swedish Heart and Lung Foundation, Västra Götaland Region, The Göteborg Medical Society

Background Previous studies investigating the association between coronary artery bypass grafting (CABG) and risk for dementia show conflicting results. Purpose To compare the long-term risk for dementia in CABG patients to matched individuals in the general population, and to identify independent predictors for developing dementia after CABG. Methods Data from the SWEDEHEART registry and three other mandatory national registries were merged to compare all patients who underwent isolated CABG in Sweden from 1992 to 2015 (n=111.335) with an age- and sex-matched control individuals from the general population (n=222.396). Cumulative incidence adjusted for the competing risk for death and Cox regression models with Hazard Ratio (HR) and 95% confidence interval (CI) adjusted for age, gender, co-morbidity and socioeconomic variables, were used to calculate the risk of dementia. Median follow-up was 10.1 years (IQR 2.5–14.7) among CABG patients and 10.7 years (5.6–15.7) among the controls. Identified interactions of the excess risk for dementia with sex and age categories ( Results The overall cumulative incidence at 20 years follow up of all-cause dementia was 9.6% (95% CI 9.4–9.9) among CABG patients and 9.0 (8.8–9.2) among individuals in the general population. The adjusted relative risk for all-cause dementia was increased among CABG patients Conclusion CABG patients younger than 75 years at the time of surgery have an increased risk of all-cause dementia compared to an age- and sex-matched population. Women younger than 65 years that underwent CABG had also a markedly higher risk for Alzheimer disease. Increased awareness of the higher risk for dementia in younger CABG patients is warranted to avoid delay of diagnosis and treatment. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swedish Heart and Lung Foundation, Swedish State

Background Heart failure in the young is increasing. Increasing prevalence of overweight and obesity may be of importance. While alcohol and drugs are known to have cardiotoxic effects, few studies have investigated the prevalence of alcohol- or substance abuse among young patients with HF. Aim To investigate the prevalence of alcohol- and substance abuse in a cohort of young patients with heart failure. Methods All patients that received a diagnosis of heart failure at Sahlgrenska University Hosital (Sweden) between 1997 and 2016, ages 18–54, with a previously documented transthoracic echocardiogram were included. A systematic evaluation of participants electronic health records was performed, where predefined details about the use of alcohol, narcotic drugs and anabolic steroids, as well as echocardiographic findings were recorded. Result A total of 1363 patients were included (1001 men and 366 women, mean age 45 years), 190 (14%) of which were Conclusion There was a high prevalence of alcohol- and/or drug-abuse among young adults with heart failure, especially in male patients. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swedish state under the agreement concerning research and education of doctors [grant number ALFGBG-427301]; The Swedish Society for Physicians, the Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, Sweden, and the Swedish Heart and Lung Foundation [grant number 2015-0438]

Supplemental Digital Content is available in the text., Background: Incidence rates of cardiomyopathies, which are a common cause of heart failure in young people, have increased during the last decades. An association between body weight in adolescence and future cardiomyopathy among men was recently identified. Whether or not this holds true also for women is unknown. The aim was therefore to determine whether for young women being overweight or obese is associated with a higher risk of developing cardiomyopathy. Methods: This was a registry-based national prospective cohort study with data collected from the Swedish Medical Birth Register, 1982 to 2014, with up to 33 years of follow-up. Included women were of childbearing age (18–45 years) during the initial antenatal visit in their first or second pregnancy (n=1 393 346). We obtained baseline data on body mass index (BMI), smoking, education, and previous disorders. After exclusions, mainly because of previous disorders, the final sample was composed of 1 388 571 women. Cardiomyopathy cases were identified by linking the Medical Birth Register to the National Patient and Cause of Death registers. Results: In total, we identified 1699 cases of cardiomyopathy (mean age at diagnosis, 46.2 [SD 9.1] years) during the follow-up with an incidence rate of 5.9 per 100 000 observation years. Of these, 481 were diagnosed with dilated cardiomyopathy, 246 had hypertrophic cardiomyopathy, 61 had alcohol/drug-induced cardiomyopathy, and 509 had other forms. The lowest risk for being diagnosed with a cardiomyopathy was detected at a BMI of 21 kg/m2, with a gradual increase in risk with higher BMI, particularly for dilated cardiomyopathy, where a hazard ratio of 4.71 (95% CI, 2.81–7.89) was found for severely obese subjects (BMI ≥35 kg/m2), as compared with BMI 20 to

Background/Introduction Elevated resting heart rate (RHR) is a known risk factor for HF. Whether elevated RHR is also associated with cardiomyopathy (CM), a common cause of heart failure in the young, is unknown. Purpose To investigate the association of resting heart rate (RHR) measured in late adolescence with long term risk of various subtypes of CM with special attention to cardiorespiratory fitness (CRF), an important predictor of RHR and myocardial dysfunction. Methods We followed a cohort of Swedish men enrolled for conscription in 1968–2005 (n=1,008,485; mean age=18.3 years) until December 2014. Outcomes of CM were collected from the national inpatient- (IPR), outpatient- (OPR) and cause of death registries and were divided into categories: 1) dilated, 2) hypertrophic, 3) alcohol/drug-induced, and 4) other. Cox proportional hazard models were used to analyze the longitudinal association between RHR and outcomes while adjusting for potential confounders, including body mass index (BMI), arterial blood pressure and cardiorespiratory fitness (CRF). CRF was measured by maximum capacity ergometer testing as part of the enlistment protocol. Results During a mean follow up of 34 years, there were 3500 cases of a first hospitalization for CM (mean age at diagnosis, 50.1 years). Comparing the highest with the lowest quintile of the RHR distribution, we found a positive association between RHR and dilated CM (hazard ratio (HR) = 1.58 [confidence interval (CI) = 1.37–1.82]) after adjustment for BMI, age at conscription, conscription year, test center, and baseline comorbidities (diabetes, hypertension, congenital heart disease). There no significant association with alcohol/drug-induced (HR=1.32 [CI=0.94–1.85]) or other categories of CM. Conclusion Adolescent RHR is associated with future risk CM, independently of blood pressure, BMI and CRF. The association was driven by dilated CM. These findings are suggestive of a causal pathway between elevated heart rate and adverse cardiac remodeling that warrants further investigation. Acknowledgement/Funding The Swedish Heart and Lung Foundation, the Swedish Research Council, the Swedish Council for Health, Working Life and Welfare

Background Cardiovascular disease (CVD) mortality is decreasing in Western countries, including Sweden. However, there are reports of increases in incidence in young people with respect to heart failure (HF) and atrial fibrillation (AF). The magnitude and causes of these changes are only partly known. Aims We investigated secular trends in incidence in CVD outcomes and their attenuation by changes in body mass index (BMI). The outcomes were risk of acute myocardial infarction (AMI), heart failure (HF) and atrial fibrillation (AF) as well as cardiovascular and all-cause death in a population of Swedish adolescents. Methods We followed a cohort of Swedish men enrolled for military service conscription in 1969–1996 (n=1,326,082; mean age=18.3) until December 2016, collected from the national inpatient (IPR) and outpatient registries (OPR). Cox-proportional hazard models were used to analyse the longitudinal change in incidence by with respect to early (0–21 years) of follow-up for subgroups with conscription 1968–1971, 1971–1976, 1976–1981, 1981–1986, 1986–1991, 1991–1996 (with the group born 1971–1976 as reference). Adjustments for potential confounders including BMI were performed. Results We found that CVD and all-cause mortality and MI decreased progressively during the follow-up with hazard ratios (HR) of 0.51, 95% confidence interval (CI) 0.43–0.62, HR 0.51 CI 0.57–0.62, and 0.60 CI 0.50–0.72, respectively. In contrast, we found increases in the incidence of HF (HR 1.86, CI 1.48–2.33], and AF (HR 8.26, CI 6.87–9.92). Adjustments for changes in BMI partly attenuated the changes in secular trends. Cubic spline models showed where the changes in secular trends were most prominent. Conclusion The incidences of cardiovascular outcomes show diverging secular changes. While MI and cardiovascular mortality are continually decreasing, there is an increase in HF and AF. The associations appear to be partly explained by changes in index BMI over time. Acknowledgement/Funding grants from the Swedish Government and the county councils, the ALF–GBG-719761, ALFGBG-751111, Swedish Stroke Association, Göteborg Medical Society

Background Cardiorespiratory fitness and physical activity have well–known cardio–protective effects. Along with reports on declining levels of physical activity globally, heart failure caused by cardiomyopathy is increasing among young people. Still, it is unknown whether poor fitness in adolescence can be associated with cardiomyopathy in adulthood. Purpose To study a possible link between cardiorespiratory fitness in adolescence and being diagnosed with cardiomyopathy in adulthood. Methods A nationwide register-based prospective cohort study of 1,668,893 young men (mean age 18.3 years, SD 0.7), enlisting for compulsory military service 1969–2005. Body mass index (BMI) and blood pressure were registered at baseline, along with test results for fitness. Values were trichotomized and about 13.5% were classified as having poor cardiorespiratory fitness. Cardiomyopathy diagnoses were identified from the National Hospital Register and Cause of Death Register, during an up to 46-year follow-up, and divided into categories: 1) dilated, 2) hypertrophic, 3) alcohol/drug-induced, and 4) other. Hazard ratios (HR) were calculated with Cox proportional hazards models. Results During follow-up (median 27 years; interquartile interval 19–35 years), 4,477 cases of cardiomyopathy were registered, of which 2,631 (59%) were dilated, 673 (15%) were hypertrophic, and 480 (11%) were alcohol/drug-induced. Poor cardiorespiratory fitness was strongly associated with elevated risk of both dilated (HR 1.59, 95% confidence interval (CI) 1.38–1.83) and alcohol/drug–induced cardiomyopathy (HR 2.32, 95% CI 1.68–3.20), adjusted for BMI, age at conscription, conscription year, test center, and baseline comorbidities (diabetes, hypertension, congenital heart disease). Conclusion The present study shows that poor cardiorespiratory fitness in adolescence may be associated with both dilated and alcohol/drug–induced cardiomyopathy in adulthood. This strengthens the evidence of fitness as a cardio–protective factor, and brings further support to the importance of interventions promoting physical activity already in childhood. Acknowledgement/Funding The Swedish Research Council, The Swedish Heart and Lung Foundation

Supplemental Digital Content is available in the text., Background: Modifiable lifestyle factors in relation to risk for cardiomyopathy, a common and increasing cause of heart failure in the young, have not been widely studied. We sought to investigate a potential link between obesity, a recognized predictor of early heart failure, in adolescence and being diagnosed with cardiomyopathy in adulthood. Methods: This was a nationwide register-based prospective cohort study of 1 668 893 adolescent men (mean age, 18.3 years; SD, 0.7 years) who enlisted for compulsory military service from 1969 to 2005. At baseline, body mass index (BMI), blood pressure, and medical disorders were registered, along with test results for fitness and muscle strength. Cardiomyopathy diagnoses were identified from the National Hospital Register and Cause of Death Register during an up to 46-year follow-up and divided into categories: dilated, hypertrophic, alcohol/drug-induced, and other. Hazard ratios were calculated with Cox proportional hazards models. Results: During follow-up (median, 27 years; Q1–Q3, 19–35 years), 4477 cases of cardiomyopathy were identified, of which 2631 (59%) were dilated, 673 (15%) were hypertrophic, and 480 (11%) were alcohol/drug-induced. Increasing BMI was strongly associated with elevated risk of cardiomyopathy, especially dilated, starting at levels considered normal (BMI, 22.5–8-fold increased risk at BMI ≥35 kg/m2 compared with BMI of 18.5 to

BACKGROUND Virtual reality (VR) technology is not currently used in the treatment of severe mental health illness in Norway. OBJECTIVE We aimed to explore the potential of VR as a treatment for severe mental health illness in Norway, through collaborative research between clinicians and researchers. METHODS A collaborative research team was established, comprising researchers, the manager at a district psychiatric center, and the manager of the local municipal mental health service. An all-day workshop with eight clinicians—four from specialist mental health services and four from municipal mental health services—was conducted. The clinicians watched three different VR movies and after each one, they answered predefined questions designed to reflect their immediate thoughts about VR’s potential use in clinical practice. At the end of the workshop, two focus group interviews, each with four clinicians from each service level, were conducted. RESULTS VR technology in specialist services might be a new tool for the treatment of severe mental health illness. In municipal mental health services, VR might particularly be useful in systematic social training that would otherwise take a very long time to complete. CONCLUSIONS We found substantial potential for the use of VR in the treatment of severe mental health illness in specialist and municipal mental health services. One of the uses of VR technology with the greatest potential was helping individuals who had isolated themselves and needed training in social skills and everyday activity to enable them to have more active social lives. VR could also be used to simulate severe mental illness to provide a better understanding of how the person with severe mental illness experiences their situation.

The present review highlights current research on the importance of PA and fitness for patients with heart failure and recommendations with respect to heart failure phenotypes and special populations. Furthermore, the evidence for various exercise types and intensities/doses as an "exercise prescription", are discussed. The strong association between heart failure and traditional risk factors, physical inactivity and low fitness, underlines the importance of regular PA and exercise for prevention and treatment of heart failure. This is illustrated by cardiac stiffness which typically accelerates in middle-life and could be reversed by aerobic exercise. In patients with HFpEF, regular PA counteracts many of the changes observed, both metabolic and functional. Indeed, exercise-based cardiac rehabilitation has received a class 1A recommendation in current guidelines [1], in order to improve functional capacity, quality of life and lower the risk of rehospitalization. An individually tailored plan based on risk stratification, clinical assessment and cardiopulmonary exercise testing is encouraged before initiation of exercise training in patients with heart failure. In general, a combination of aerobic exercise and resistance training protocols is recommended (Table 1) [2], preferably throughout life. More studies are needed, regarding the role of PA and exercise in specific populations, such as frail patients with heart failure.

Heart failure (HF) incidence appears to increase among younger individuals, raising questions of how risk factors affect the younger population. We investigated the association of cognitive performance in late adolescence with long-term risk of early HF.We followed a cohort of Swedish men enrolled in mandatory military conscription in 1968-2005 (n = 1 225 300; mean age 18.3 years) until 2014 for HF hospitalization, using data from the Swedish National Inpatient Registry. Cognitive performance (IQ) was measured through a combination of tests, separately evaluating logical, verbal, visuospatial, and technical abilities. The results were standardized, weighted, and presented as stanines of IQ. The association between IQ and risk of HF was estimated using Cox proportional hazards models. In follow-up, there were 7633 cases of a first HF hospitalization (mean age at diagnosis 50.1 years). We found an inverse relationship between global IQ and risk of HF hospitalization. Using the highest IQ stanine as reference, the adjusted hazard ratio for the lowest IQ with risk of HF was 3.11 (95% confidence interval 2.60-3.71), corresponding to a hazard ratio of 1.32 (95% CI 1.28-1.35) per standard deviation decrease of IQ. This association proved persistent across predefined categories of HF with respect to pre-existing or concomitant co-morbidities; it was less apparent among obese conscripts (P for interaction =0.0004).In this study of young men, IQ was strongly associated with increased risk of early HF. The medical profession needs to be aware of this finding so as to not defer diagnosis.

Exercise has widely documented cardioprotective effects, but the mechanisms behind these effects are still poorly understood. Here, we test the hypothesis that aerobic training lowers cardiovascular sympathetic responses to and speeds recovery from challenge. We conducted a randomized, controlled trial contrasting aerobic versus strength training on indices of cardiac (pre-ejection period, PEP) and vascular (low-frequency blood pressure variability, LF-BPV) sympathetic responses to and recovery from psychological and orthostatic challenge in 149 young, healthy, sedentary adults. Aerobic and strength training did not alter PEP or LF-BPV reactivity to or recovery from challenge. These findings, from a large randomized, controlled trial using an intent-to-treat design, show that moderate aerobic exercise training has no effect on PEP and LF-BPV reactivity to or recovery from psychological or orthostatic challenge. In healthy young adults, the cardioprotective effects of exercise training are unlikely to be mediated by changes in sympathetic activity.

Exercise has widely documented cardioprotective effects, but the mechanisms underlying these effects are not entirely known. Previously, we demonstrated that aerobic but not strength training lowered resting heart rate and increased cardiac vagal regulation, changes that were reversed by sedentary deconditioning. Here, we focus on the sympathetic nervous system and test whether aerobic training lowers levels of cardiovascular sympathetic activity in rest and that deconditioning would reverse this effect.We conducted a randomized controlled trial contrasting the effects of aerobic (A) versus strength (S) training on indices of cardiac (preejection period, or PEP) and vascular (low-frequency blood pressure variability, or LF BPV) sympathetic regulation in 149 young, healthy, and sedentary adults. Participants were studied before and after conditioning, as well as after 4 weeks of sedentary deconditioning.As previously reported, aerobic capacity increased in response to conditioning and decreased after deconditioning in the aerobic, but not the strength, training group. Contrary to prediction, there was no differential effect of training on either PEP (A: mean [SD] -0.83 [7.8] milliseconds versus S: 1.47 [6.69] milliseconds) or LF BPV (A: mean [SD] -0.09 [0.93] ln mm Hg(2) versus S: 0.06 [0.79] ln mm Hg(2)) (both p values.05).These findings, from a large randomized controlled trial using an intent-to-treat design, show that moderate aerobic exercise training has no effect on resting state cardiovascular indices of PEP and LF BPV. These results indicate that in healthy, young adults, the cardioprotective effects of exercise training are unlikely to be mediated by changes in resting sympathetic activity.Clinicaltrials.gov identifier: NCT00358137.