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Aims To evaluate the long-term use of secondary prevention medications [statins, β-blockers, renin–angiotensin–aldosterone system (RAAS) inhibitors, and platelet inhibitors] after coronary artery bypass grafting (CABG) and the association between medication use and mortality. Methods and results All patients who underwent isolated CABG in Sweden from 2006 to 2015 and survived at least 6 months after discharge were included (n = 28 812). Individual patient data from SWEDEHEART and other mandatory nationwide registries were merged. Multivariable Cox regression models using time-updated data on dispensed prescriptions were used to assess associations between medication use and long-term mortality. Statins were dispensed to 93.9% of the patients 6 months after discharge and to 77.3% 8 years later. Corresponding figures for β-blockers were 91.0% and 76.4%, for RAAS inhibitors 72.9% and 65.9%, and for platelet inhibitors 93.0% and 79.8%. All medications were dispensed less often to patients ≥75 years. Treatment with statins [hazard ratio (HR) 0.56, 95% confidence interval (95% CI) 0.52–0.60], RAAS inhibitors (HR 0.78, 95% CI 0.73–0.84), and platelet inhibitors (HR 0.74, 95% CI 0.69–0.81) were individually associated with lower mortality risk after adjustment for age, gender, comorbidities, and use of other secondary preventive drugs (all P Conclusion The use of secondary prevention medications after CABG was high early after surgery but decreased significantly over time. The results of this observational study, with inherent risk of selection bias, suggest that treatment with statins, RAAS inhibitors, and platelet inhibitors is essential after CABG whereas the routine use of β-blockers may be questioned.

Coxiella burnetii is the causative agent of Q fever. It can manifest in both acute and chronic forms. Culture-negative endocarditis is the most common and serious presenting form of chronic Q fever. This occurs almost exclusively in patients with a pre-existing valvulopathy including valve prosthesis or immunocompromised patients as well as in pregnant women. Diagnosis is often delayed or missed due to the nonspecific symptoms of the condition. Without the proper antimicrobial therapy, the mortality is high. Q fever endocarditis should be suspected especially in people who recently had acute Q fever, people who come from endemic areas as well as people with occupational contact with sheep, goats and cattle and endocarditis symptoms. In this article we present a case with a patient who died of unknown cause and where PCR performed on autopsy of the valve revealed Q fever endocarditis.

Key Points Question Is dual antiplatelet therapy with acetylsalicylic acid (ASA) and ticagrelor associated with better clinical outcomes for patients with acute coronary syndrome treated with coronary artery bypass grafting compared with ASA monotherapy? Findings In this nationwide cohort study including 6558 patients, there was no significant risk reduction in major adverse cardiovascular events (a composite of all-cause mortality, myocardial infarction, and stroke) associated with ASA plus ticagrelor treatment compared with ASA monotherapy, although the dual therapy was associated with increased risk for major bleeding. Meaning These results suggest that further research, preferably randomized clinical trials, are warranted to define optimal antiplatelet therapy in this group., This cohort study compares clinical outcomes among patients with acute coronary syndrome treated with aspirin and ticagrelor vs aspirin alone after artery bypass grafting., Importance Guidelines recommend dual antiplatelet therapy after coronary artery bypass grafting (CABG) for patients with acute coronary syndrome (ACS). However, the evidence for these recommendations is weak. Objective To compare midterm outcomes after CABG in patients with ACS treated postoperatively with acetylsalicylic acid (ASA) and ticagrelor or with ASA monotherapy. Design, Setting, and Participants This cohort study used merged data from several national registries of Swedish patients who were diagnosed with ACS and subsequently underwent CABG. All included patients underwent isolated CABG in Sweden between 2012 and 2017 with an ACS diagnosis less than 6 weeks before the procedure, survived 14 days after discharge from hospital, and were treated postoperatively with ASA plus ticagrelor or ASA monotherapy. A multivariable Cox regression model was used for the main analysis, and propensity score-matched models were performed as sensitivity analysis. Data were analyzed between May and September 2020. Exposures Postoperative antiplatelet treatment, defined as filled prescriptions, with either ASA and ticagrelor or ASA only. Main Outcomes and Measures Major adverse cardiovascular events (MACE), defined as all-cause mortality, myocardial infarction, and stroke, and major bleeding, at 12 months and at the end of follow-up. Results A total of 6558 patients (5281 [80.5%] men; mean [SD] age at surgery, 67.6 [9.3] years) were included; 1813 (27.6%) were treated with ASA plus ticagrelor and 4745 (72.4%) were treated with ASA monotherapy. Crude MACE rate was 3.0 per 100 person years (95% CI, 2.5-3.6 per 100 person years) in the ASA plus ticagrelor group and 3.8 per 100 person years (95% CI, 3.5-4.1 per 100 person years) in the ASA group. After adjustment, there was no significant difference in MACE risk between ASA plus ticagrelor vs ASA only, neither during the first 12 months (adjusted hazard ratio [aHR], 0.84; 95% CI, 0.58-1.21; P = .34) or during total follow-up (aHR, 0.89; 95% CI, 0.71-1.11; P = .29). The use of ASA plus ticagrelor was associated with a significantly increased risk for major bleeding during the first 12 months (aHR, 1.90; 95% CI, 1.16-3.13; P = .011). Sensitivity analyses confirmed the results. Conclusions and Relevance In patients with ACS who survived 2 weeks after CABG, no significant difference in the risk of death or ischemic events could be demonstrated between ASA plus ticagrelor and patients treated with ASA only, while the risk for major bleeding was higher in patients treated with ASA plus ticagrelor. Sufficiently powered prospective randomized trials comparing different antiplatelet therapy strategies after CABG are warranted.

Purpose – Despite their efficacy, some recommended therapies are underused. The purpose of this paper is to describe clinical decision support system (CDSS) development and its impact on clinical guideline adherence. Design/methodology/approach – A new CDSS was developed and introduced in a cardiac intensive care unit (CICU) in 2003, which provided physicians with patient-tailored reminders and permitted data export from electronic patient records into a national quality registry. To evaluate CDSS effects in the CICU, process indicators were compared to a control group using registry data. All CICUs were in the same region and only patients with acute coronary syndrome were included. Findings – CDSS introduction was associated with increases in guideline adherence, which ranged from 16 to 35 per cent, depending on the therapy. Statistically significant associations between guideline adherence and CDSS use remained over the five-year period after its introduction. During the same period, no relapses occurred in the intervention CICU. Practical implications – Guideline adherence and healthcare quality can be enhanced using CDSS. This study suggests that practitioners should turn to CDSS to improve healthcare quality. Originality/value – This paper describes and evaluates an intervention that successfully increased guideline adherence, which improved healthcare quality when the intervention CICU was compared to the control group.

Background Cardiovascular disease is the most common cause of death for both genders. Debates are ongoing as to whether gender‐specific differences in clinical course, diagnosis, and management of acute myocardial infarction (MI) exist. Methods and Results We compared all men and women who were treated for acute MI at cardiac care units in Västra Götaland, Sweden, between January 1995 and October 2014 by obtaining data from the prospective SWEDEHEART (Swedish Web‐System for Enhancement of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) registry. We performed unadjusted and adjusted Cox proportional hazards and logistic regression analyses on complete case data and on imputed data sets. Overall, 48 118 patients (35.4% women) were diagnosed with acute MI. Women as a group had better age‐adjusted prognosis than men, but this survival benefit was absent for younger women (aged P P P 12 antagonists). Differences in treatment between the genders did not decrease over the study period ( P >0.1 for all treatments). Conclusions Women on average have better adjusted prognosis than men after acute MI; however, younger women and women with ST‐segment elevation MI have disproportionately poor prognosis and are less likely to be prescribed evidence‐based treatment.

Measuring heart rate variability (HRV) is a way to assess the autonomic regulation of the heart. Decreased HRV, indicating reduced parasympathetic tone, has previously been found in depression and anxiety disorders. The objective of this study was to assess HRV in women with premenstrual dysphoric disorder (PMDD). To this end, time domain variables and frequency domain variables were assessed in 28 women with PMDD and in 11 symptom-free controls during both the symptomatic luteal phase and the non-symptomatic follicular phase of the menstrual cycle. Two variables reflecting vagal activity in the time domain, the root mean square of differences of successive normal RR intervals (rMSSD) and standard deviation of normal RR intervals (SDNN) were lower in PMDD patients, but this difference was statistically significant in the follicular phase only. The most important vagal measure in the frequency domain, supine high frequency (HF), also appeared lower in PMDD subjects during the follicular phase. It is suggested that PMDD may be associated with reduced vagal tone compared to controls and that this difference is most apparent in the non-symptomatic follicular phase of the menstrual cycle.

Endoscopic transthoracic sympathicotomy (ETS) is a recently developed technique to divide sympathetic nerves. ETS has been shown to improve symptoms and reduce ischemia in patients with severe angina pectoris. Low heart rate variability (HRV) in patients with ischemic heart disease carries an adverse prognosis. HRV reflects autonomic response of the heart and a shift in the sympathovagal balance towards parasympathetic dominance could be a marker of improved prognosis. HRV might also be used as an indicator of surgical success in sympathetic heart denervation. Heart rate was recorded in 57 patients before and after ETS. Registration was recorded during controlled respiration in the supine position and at tilt test over 10 minutes and spectral analysis was performed. Twenty-four hour Holter recordings were analyzed in the time domain. During the controlled setting, the high-frequency (HF) component (0.15 to 0.40 Hz) increased significantly whereas the low-frequency (LF) component (0.04 to 0.15 Hz) did not change significantly. The LF/HF ratio at tilt test was reduced from 1.3 to 0.8 (p0.01). The time-domain analysis showed a significant increase of the mean RR interval (923 to 1,006 ms, p0.001) and indexes reflecting parasympathetic tone also increased significantly (the root-mean square of difference measured from 24.3 to 29.5 ms, p0.001 and the proportion of adjacent RR intervals50% measured from 5.5% to 8.2%, p0.01), whereas measurements reflecting global HRV did not change. In addition to relief of symptoms and reduced ischemia in severe angina pectoris, ETS caused a shift of sympathovagal balance toward parasympathetic tone. This might explain the anti-ischemic effect and have prognostic implications.

To evaluate whether there are gender differences in insomnia, sleep quality, sleep efficiency (%), general arousal, disease-specific and health-related quality of life in patients with coronary artery disease, compared with an age- and gender-matched randomly selected group from the general population.There are gender difference effects of sleep disturbances in the general population, but this perspective among patients with coronary artery disease has been poorly analysed.In this prospective study, comparative, descriptive and model testing designs were used.The patients with coronary artery disease, 556 men and 324 women aged 25-86, were compared with a matched population-based group. Data were collected by validated and reliability-tested questionnaires.The prevalence of severe insomnia varied between 17-44% in all four groups. The severe insomniac coronary artery disease patients displayed a two- or threefold higher presleep arousal, had two hours shorter nocturnal sleep duration/night and were more limited in their physical exercise level than the population-based group. Gender differences in sleep quality, sleep efficiency (%) and general arousal disappeared with increased insomnia severity.Independent of gender, age and comorbidity, physical exercise, general arousal behaviour and delayed poststress recovery after mental stress were found to have a negative impact on the coronary artery disease patients' sleep quality and sleep efficiency (%), interfering with their health-related quality of life. The variables significantly explained 41% of the sleep quality outcome and 29% of the sleep efficiency (%).Insomnia because of hyperarousal behaviour can be an important factor in the development of an individual self-care management programme supported by a healthcare team.

Reduced heart rate variability (HRV) is a risk factor for cardiac death. Animal studies have shown increased HRV and reduced mortality after physical training. We evaluated the change in exercise capacity and HRV in cardiac rehabilitation patients, randomised to routine or home-based intensive training. The design was prospective, stratified randomisation with pre-specified subgroup analysis.Maximal bicycle exercise test and 24-h Holter were performed 1 (baseline), 4 and 12 months after myocardial infarction (MI) or coronary artery by-pass surgery (CABG). Patients were randomised to physical training either two (N) or six (I) times per week for 3 months Sixty-two patients (43 MI and 19 CABG patients) were evaluated.Exercise capacity increased significantly more after 3 months of training in group I (mean (S.E.)); 29.0 (3.4) vs. 7.2 (2.6) watts, P0.001). One year later the difference in exercise capacity remained (26.5 (3.3) vs. 11.8 (3.8) watts, P0.001). Global HRV measurements SDNN and SDANN increased significantly more in group I after training (17.1 (5.6) vs. 1.7 (3.7) and 16.2 (4.9) vs. 2.8 (3.1) ms, P0.05) and 1 year later the differences were still significant. Subgroup analysis showed more pronounced HRV response in CABG than MI patients.Intensive exercise training in cardiac rehabilitation increases exercise capacity and global HRV, which could be of prognostic significance.

Background: Incidence of sudden cardiac death peaks during the early morning hours when there is a rapid withdrawal of vagal and an increase of sympathetic tone. The rate of autonomic change could be of prognostic importance. Patients and methods: A total of 65 patients with angina pectoris, free from other diseases and drug free, were Holter monitored for 24 h. A total of 30 patients were also monitored on isosorbide-5-mononitrate (IS-5-MN) and on metoprolol respectively. A total of 33 age-matched healthy subjects served as controls. Spectral components of heart rate variability (HRV) were analysed hourly, with special reference to the rapid changes of autonomic tone during the night and early morning hours. Circadian variation was assessed in two ways: (1) Mean HRV day (8 a.m.–8 p.m.) and night (0–5 a.m.) were compared. (2) For the morning/night hours (0–10 a.m.), individual hourly values for max. and min. HRV, the difference max.–min. (gradient), the rate of change per hour between max. and min. (velocity) and the largest difference between two consecutive hours (max. velocity) were recorded and the mean value for the group calculated. Results: During the night/morning hours, healthy controls demonstrated faster HF max. velocity ( P =0.002) and higher HF gradient ( P =0.011) than angina patients. Metoprolol and IS-5-MN increased the HF gradient ( P =0.008 and P =0.003, respectively), and metoprolol tended to increase the max. velocity ( P =0.02). Metoprolol substantially decreased the LF/HF gradient ( P =0.001), velocity ( P =0.008) and max. velocity ( P =0.0001). Conclusion: Rapid vagal withdrawal seemed to be a sign of a healthy autonomic nervous system in the control group but was significantly slower in angina patients. IS-5-MN and metoprolol tended to normalise vagal withdrawal and metoprolol slowed down the rapid increase in sympathetic predominance in the morning in patients.

We evaluated short and long-term effects on QT dispersion and autonomic balance after endoscopic transthoracic sympathicotomy (ETS). Heart rate variability (HRV) reflects autonomic balance of the heart. QT dispersion is a marker of cardiac electrical instability in patients with ischemic heart disease. Holter recordings for 24 h and a twelve-lead ECG were made prior to, 1 month, 1 year and 2 years after ETS. HRV was analysed in time domain and spectral analysis was performed during controlled respiration in supine position and during head up tilt. Dispersion of QT time and QTc were calculated. Of 88 patients, 62 (60) were eligible for HRV (QT-dispersion) analysis after 1 month, 39 (38) patients after 1 year and 23 (24) patients after 2 years. The HRV analysis showed a significant change of indices reflecting sympatho-vagal balance indicating significantly reduced sympathetic (LF) and increased vagal (HF, rMSSD) tone. These changes still persisted after 2 years. Global HRV increased over time with significant elevation of SDANN after 2 years. QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later. Conclusion: ETS changed HRV and QT dispersion which could imply reduced risk for malignant arrhythmias and death after ETS.