Search

Objective: To evaluate the cardiometabolic outcomes associated with discordant visceral adipose tissue (VAT) and liver fat (LF) phenotypes in 2 cohorts. Patients and Methods: Participants in the Dallas Heart Study underwent baseline imaging from January 1, 2000, through December 31, 2002, and were followed for incident cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM) through 2013. Associations between VAT-LF groups (low-low, high-low, low-high, and high-high) and outcomes were assessed using multivariable- adjusted regression and were replicated in the independent UK Biobank. Results: The Dallas Heart Study included 2064 participants (mean SD age, 449 years; 54% female; 47% black). High VATehigh LF and high VATelow LF were associated with prevalent atheroscle- rosis, whereas low VATehigh LF was not. Of 1731 participants without CVD/T2DM, 128 (7.4%) developed CVD and 95 (5.5%) T2DM over a median of 12 years. High VATehigh LF and high VATelow LF were associated with increased risk of CVD (hazard ratios [HRs], 2.0 [95% CI, 1.3 to 3.2] and 2.4 [95% CI, 1.4 to 4.1], respectively) and T2DM (odds ratios [ORs], 7.8 [95% CI, 3.8 to 15.8] and 3.3 [95% CI, 1.4 to 7.8], respectively), whereas low VATehigh LF was associated with T2DM (OR, 2.7 [95% CI, 1.1 to 6.7]). In the UK Biobank (N1⁄422,354; April 2014-May 2020), only high VATelow LF remained associated with CVD after multivariable adjustment for age and body mass index (HR, 1.5 [95% CI, 1.2 to 1.9]). Conclusion: Although VAT and LF are each associated with cardiometabolic risk, these observations demonstrate the importance of separating their cardiometabolic implications when there is presence or absence of either or both in an individual. Funding: National Institute of Diabetes and Digestive and Kidney Diseases [K23 DK106520]; National Center for Advancing Translational Sciences [UL1TR001105]; Swedish Research Council [VR-2019-04751]

Background: Masked hypertension is associated with cardiovascular disease (CVD). However, previous large studies have not used the same device to measure office and home blood pressure (BP) and adhered to current home BP measurement recommendations of the European Society of Hypertension. We aimed to characterize masked hypertension and explore its relation to manifestations of CVD. Methods: A randomly selected cohort of 5057 participants aged 50–64 years from the Swedish CardioPulmonary BioImage Study (SCAPIS) was evaluated with office and home BP using the semi-automatic Omron M10-IT oscillometric device. Additional analyses included pulse wave velocity (PWV) and coronary artery calcium score (CACS). Results: Of participants, 4122 did not have current antihypertensive treatment, and were thus included in our analyses. Of these, 2634 (63.9%) had sustained normotension, and 172 (4.2%) had masked hypertension. Participants with masked hypertension vs. sustained normotension were more often men (66.9 vs. 46.2%, P < 0.001). Those with masked hypertension had higher mean PWV [9.3 (95% confidence interval, 95% CI 9.1–9.5) vs. 8.3 (95% CI 8.2–8.4) m/s, P < 0.001] and odds ratio for CACS at least 100 [1.65 (95% CI 1.02–2.68), P = 0.040]. These associations were similar in a posthoc analysis of masked hypertension and sustained normotension, matched for age, sex and systolic office BP. Conclusion: Masked hypertension was associated with markers of CVD. This suggests that home BP is a better predictor of risk, even when the recordings are performed with the same measurement device, in a population-based setting with randomized recruitment. Funding: Swedish Heart and Lung Foundation [20160315]; Knut and Alice Wallenberg Foundation [20140047]; Swedish Research Council [82220132000]; VINNOVA (Swedens Innovation agency) [201204476]; University of Gothenburg; Sahlgrenska University Hospital; Karolinska Institutet; Stockholm County council; Linkoping University; Linkoping University Hospital; Lund University; Skane University Hospital; Umea~University; Umea University Hospital; Uppsala University; Uppsala University Hospital; Strategic Research Network in Circulation and Metabolism at Linkoping University (LiU-CircM); King Gustaf V and Queen Victoria Freemason Foundation

Objectives: Chronic limb-threatening ischemia (CLTI) is the end-stage form of lower extremity artery disease (LEAD) whose main reason is atherosclerosis. Plasma osmolality (PO) and plasma lipid levels affect the development and progression of atherosclerosis directly. The purpose of this study was to investigate the predictive effect of PO and atherogenic index of plasma (AIP) for the development of CLTI. Methods: A total of 324 patients who were diagnosed with LEAD were analyzed retrospectively. The clinical stage of the disease was evaluated according to the Rutherford classification, and patients without CLTI were defined as “Group 1” and patients with CLTI as “Group 2”. Results: There were 248 patients (mean age 64.44 ± 9.05 years and 73.4% male) in Group 1, and 76 patients (mean age 66.62 ± 8.22 years and 76.3% male) in Group 2. In the multivariate regression analysis, CAD, PO, CRP and AIP were defined as independent predictive factors for the development of CLTI (p = 0.015, p < 0.001, p = 0.007, p < 0.001; respectively). ROC curve analysis showed that, PO cut-off value for CLTI development was 293.28 mOsm/kg (AUC: 0.821, p < 0.001) with 75% sensitivity and 74.2% specificity, and AIP cut-off value was 0.23 (AUC: 0.740, p < 0.001) with 67.1% sensitivity and 68.5% specificity. Conclusions: The PO and AIP values in LEAD patients may be used as the new biomarkers of atherosclerosis progression, and therefore as predictive factors for the development of CLTI.

Background: Patients with heart failure (HF) are often cared for by non-cardiologists. The implications are unknown. Methods: In a nationwide HF cohort with reduced ejection fraction (HFrEF), we compared demographics, clinical characteristics, guideline-based therapy use and outcomes in non-cardiology vs. cardiology in-patient and outpatient care. Results: Between 2000 and 2016, 36,076 patients with HFrEF were enrolled in the Swedish HF registry (19,337 [54%] in-patients overall), with 44% of in-patients and 45% of out-patients managed in non-cardiology settings. Predictors of treatment in non-cardiology were age > 75 years (adjusted odds ratio for non-cardiology 1.20; 95% confidence interval 1.14-1.27), lower education level (0.71; 0.66-0.76 for university vs. compulsory), valve disease (1.24; 1.18-1.31) and systolic blood pressure (SBP) >120 mmHg (1.05; 1.00-1.10). Non-cardiology care was significantly associated with lower use of beta-blockers (0.80; 0.74-0.86) and devices (intracardiac defibrillator [ICD] and/or cardiac resynchronization therapy [CRT]: 0.63; 0.56-0.71), and less frequent specialist follow-up (0.61; 0.57-0.65). Over 1-year follow-up the risk of all-cause mortality (adjusted hazard ratio 1.09; 1.03-1.15) was higher but the risk of first HF (re-) hospitalization was lower (0.93; 0.89-0.97) in non-cardiology vs. cardiology care. Conclusions: In HFrEF, non-cardiology care was independently associated with older ageand lower education. After covariate adjustment, non-cardiology care was associated with lower use of beta-blockers and devices, higher mortality, and lower risk of HF hospitalization. Access to cardiology care may not be equitable and this may have implications for use of guideline-based care and outcomes. Funding Agencies|Karolinska InstitutetKarolinska Institutet; Swedish Research CouncilSwedish Research CouncilEuropean Commission [523-2014-2336]; Swedish Heart Lung FoundationSwedish Heart-Lung Foundation [20150557, 20190310]; Stockholm County CouncilStockholm County Council [20170112, 20190525]

Objective: to evaluate clinical efficacy, safety and tolerability of long-term inhaled iloprost treatment in the daily practice for the management of pulmonary arterial hypertension (PAH). Methods: a total of 115 patients with PAH on inhaled iloprost treatment were included. New York Heart Association (NYHA) functional class, brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and 6-minute walk distance (6MWD) were recorded at baseline and at 3rd to 24th month visits. Safety and tolerability of iloprost treatment were also evaluated during follow-up, as were the survival, clinical worsening, and the related risk factors. Results: the treatment was associated with an increase in the percentage NYHA functional class II (from 0.0% at enrolment to 36.2% at 24th month visit) patients but no significant difference was noted in 6MWD values. Clinical worsening was observed in 63.5% patients, while survival rate was 69.6%. NT-proBNP levels were significantly higher in non-survivors than in survivors (p=0.042). Cox regression analysis revealed the association of female sex [odds ratio (OR)=0.318; 95% confidence interval (CI), 0.128-0.792; p=0.014] and scleroderma-related PAH (OR=0.347; 95% CI, 0.140-0.860; p=0.022) with significantly lower risk (3.14 fold and 2.88 fold, respectively) of mortality. Conclusion: our findings indicate favorable efficacy, safety, and tolerability of long-term iloprost treatment in the management of PAH, whereas improved NYHA functional class was not accompanied with a significant change in 6MWD values. Patient age was a risk factor for clinical worsening, while female sex, scleroderma subtype, and lower NT-proBNP levels were associated with significantly lower mortality risk., Bayer Türk

Background/Aim: Atherosclerosis plays a significant role in cardiovascular diseases. Dyslipidemia, inflammation, genetics, and environmental factors greatly impact the development and progression of atherosclerosis. This study aimed to investigate the importance of triglyceride-glucose ratio in primary cardiovascular event prevention.Methods: Our retrospective cohort study included 56 patients (39 males, 17 females). Coronary computed tomography angiography (CCTA) images of the individuals were examined, and calcium score was calculated using the Agatston score. Those with a score of zero and those with scores>0 were included in Groups 1 and 2, respectively. Triglyceride/glucose (TyG) ratio and atherosclerotic cardiovascular disease (ASCVD) risk were calculated for all individuals. Results: Among all patients, 69.6% had coronary artery calcium scores (CACs) of greater than zero. The TyG ratios were 0.92 (0.33) and 1.77 (0.83) in Groups 1 and 2, respectively (P

Aims Iron deficiency (ID) is associated with poor prognosis regardless of anaemia. Intravenous iron improves quality of life and outcomes in patients with ID and heart failure (HF) with reduced ejection fraction (HFrEF). In the Swedish HF registry, we assessed (i) frequency and predictors of ID testing; (ii) prevalence and outcomes of ID with/without anaemia; (iii) use of ferric carboxymaltose (FCM) and its predictors in patients with ID. Methods and results We used multivariable logistic regressions to assess patient characteristics independently associated with ID testing/FCM use, and Cox regressions to assess risk of outcomes associated with ID. Of 21 496 patients with HF and any ejection fraction enrolled in 2017-2018, ID testing was performed in 27%. Of these, 49% had ID and more specifically 36% had ID-/anaemia-, 15% ID-/anaemia+, 29% ID+/anaemia-, and 20% ID+/anaemia+ (48%, 39%, 13%, 30% and 18% in HFrEF, respectively). Risk of recurrent all-cause hospitalizations was higher in patients with ID regardless of anaemia. Of 1959 patients with ID, 19% received FCM (24% in HFrEF). Important independent predictors of ID testing and FCM use were anaemia, higher New York Heart Association class, having HFrEF, and referral to HF specialty care. Conclusion In this nationwide HF registry, ID testing occurred in only about a quarter of the patients. Among tested patients, ID was present in one half, but only one in five patients received FCM indicating low adherence to current guidelines on screening and treatment. Funding Agencies|Vifor Pharma

Objectives: Cardiovascular diseases and risk factors are associated with adverse cardiac events following kidney transplant. Therefore, pre-transplant evaluation of cardiovascular diseases and risk factors is important for determining the cardiac risk. The objective of this study is to determine the prevalence of cardiovascular diseases and risk factors in kidney transplant candidates. Methods: This is a single-center and observational study which includes 174 end-stage renal disease patients (male: 55.2% and mean age: 49 ± 13 years) who underwent kidney transplant. Preoperative clinical characteristics, cardiovascular diseases and risk factors of the patients were examined retrospectively. Results: The study population had multiple cardiovascular risk factors such as hypertension (66.7%), diabetes (28.2%), dyslipidemia (29.9%) and smoking (30.5%) in the evaluation conducted prior to kidney transplant. The most common cardiovascular diseases were detected as congestive heart failure (10.9%) and coronary artery disease (8.6%). The rate of the patients who underwent myocardial revascularization (percutaneous coronary intervention or coronary artery bypass grafting) before kidney transplant was 6.9%. The patients’ mean left ventricular mass index was 114 ± 32 g/m2, and 55.5% of the study population had left ventricular hypertrophy. Conclusions: In our study, the prevalence of cardiovascular diseases and risk factors in the patients who underwent kidney transplant was found to be high.

Objectives: The aim of this study was to evaluate the relationship between carotid intima-media thickness and the presence of fragmented QRS in end-stage renal disease patients. Methods: The study included 100 end-stage renal disease patients who received hemodialysis treatment. Two groups were formed according to the presence of electrocardiography and fragmented QRS: the fragmented QRS (+) (Group I) and the fragmented QRS (-) (Group II). Echocardiographic measurements of the cardiac dimensions and carotid intima-media thickness were examined. Results: The study population included 41 end-stage renal disease patients with fragmented QRS (48.8% male) and a control group of 59 end-stage renal disease patients without fragmented QRS (35.6% male) on electrocardiography. Left ventricular end systolic diameters (p = 0.012),left ventricular end diastolic diameters (p < 0.001), left atrial diameter (p = 0.001), interventricular septal thickness (p < 0.001), posterior wall thickness (p < 0.001) and left ventricular hypertrophy (p < 0.001), blood urea nitrogen (p = 0.011), creatinine (p = 0.014), uric acid (p < 0.05) and parathyroid hormone (p < 0.05) values were found to be significantly increased in the fragmented QRS (+) group. The right and left carotid intima-media thickness values were significantly higher in fragmented QRS (+) patients than fragmented QRS (-) patients (right:[0.81 ± 0.19] vs [0.62 ± 0.14] mm, p < 0.001) and left: [0.83 ± 0.19 vs 64 ± 0.14], p < 0.001; respectively). Conclusions: In end-stage renal disease patients, the presence of fragmented QRS, left ventricular hypertrophy and increased carotid intima-media thickness are important markers in the evaluation of the inflammatory process of atherosclerosis.

Background and aims Inflammation has been revealed to facilitate thrombogenesis and to increase the risk of venous thromboembolism (VTE). However, limited data are available on the association between the anti-inflammatory diet and incident VTE. We conducted a cohort analysis to examine this association and to further examine whether this association is modified by smoking status, a trigger of systemic inflammation. Methods and results We used data from two cohorts including 81,507 middle-aged and older Swedish adults without previous VTE at baseline. An empirically validated anti-inflammatory diet index (AIDI), based on 12 foods with anti-inflammatory potential and 5 foods with pro-inflammatory potential, was employed to estimate the anti-inflammatory potential of diet. Hazard ratios (HRs), with corresponding 95% confidence intervals (CIs), of VTE were estimated by Cox proportional hazards regression models. During a mean follow-up of 17.8-years, 5241 VTE cases were diagnosed. Compared with individuals in the lowest quartile of the AIDI (score ≤4), those in the highest quartile (score ≥8) had a 9% (95% CI, 0–17%) lower risk of VTE. The inverse association was observed in current and past smokers (HR between the two extreme quartiles, 0.80, 95% CI, 0.70–0.91) but not in never smokers (HR, 1.03, 95% CI, 0.91–1.17). French fries (HR per serving, 1.33, 95% CI, 1.06, 1.67) but no other foods included in AIDI was associated with VTE. Conclusion The study suggests that a consumption of foods with high anti-inflammatory potential may play a role in the prevention of VTE in smokers.

Background/Aim: The performance of the right ventricular myocardium is crucial in various pathological states and the right ventricular dysfunction has a prognostic value in pulmonary embolism. We sought to bring out which parameters were helpful in predicting a normal right ventricular function in patients with acute pulmonary embolism.Methods: Consecutive 100 acute pulmonary embolism patients, who were hospitalized and confirmed by computed tomography angiography, were enrolled in this cohort study. All patients’ demographics, symptoms on admission, risk factors, electrocardiography and laboratory findings, and hemodynamic parameters were assessed. Echocardiography was performed in the first 24 hours. The study group of pulmonary embolism patients was divided into two groups based on their basic characteristics: Patients with normal right ventricular function and patients with right ventricular failure.Results: The average age of the patients was 63 (16) years, with 48 (48%) of them being male. Twenty three patients (23%) had normal RV functions. According to the multiple logistic regression analysis, age (P=0.041, OR: 1.174, 95% CI: 1.007 to 1.368), oxygen saturation (P=0.026, OR: 1.372, 95% CI: 1.039 to 1.812) and heart rate (P=0.049, OR: 1.160, 95% CI: 1.001 to 1.346) were independent predictors of normal RV function. The setting in which all three parameters (Age, Heart rate, Oxygen saturation) were positive was considered AHO index=1, with a positive predictive value of 100% a sensitivity of 44%, a negative predictive value of 85.6% and a specificity of 100% (AUC: 0.717, 95% CI: 0.619 to 0.803) for normal RV function.Conclusion: In acute pulmonary embolism patients who were younger than 53 years of age with a heart rate of ≤118 bpm and an oxygen saturation of >90% (AHO index=1), right ventricular functions were normal. Accordingly, without the need of computed tomography angiography or echocardiography, the clinician may predict normal right ventricular function with available demographic and noninvasive hemodynamic parameters.

Aim To compare risk algorithms (HCMRisk-Kids, ECG Risk-score) in hypertrophic cardiomyopathy (HCM) without syndrome association (ns-HCM) and with Noonan-like syndromes (RAS-HCM). Methods A national paediatric HCM cohort (n = 151), presenting = 6% at diagnosis had C-statistic of 0.69 for predicting SCD/CA during first 5 years of follow-up and positive predictive value (PPV) of 22%. After 7 years of age (HCMRisk-Kids7plus), C-statistic was 0.76. ECG Risk-score >= 6 at diagnosis had C-statistic 0.87 and PPV of 31%. Independent risk factors for SCD/CA were HCMRisk-Kids7plus score (p = 0.005) and ECG risk-score (p < 0.001), whereas early beta-blocker dose (p = 0.001) and myectomy (p = 0.004) reduced risk. The sum of HCMRisk-Kids7yplus and ECG Risk-score7yplus >= 14 best predicted SCD/CA within 5 years in ns-HCM with C-statistic of 0.90 [0.83-0.96], sensitivity 100% and PPV 38%. Conclusion Combining the ECG Risk-score with HCMRisk-Kids improves risk stratification in ns-HCM and shows promise in RAS-HCM. Funding Agencies|Swedish Heart-and Lung FoundationSwedish Heart-Lung Foundation [20080510]; Swedish government; ALF agreement [ALFgbg-544981]; Region Ostergotland (ALF); Strategic Research Area in Forensic Science; FORSS (Medical Research Council of Southeast Sweden)

Aims The aim of this article was to compare rates of all-cause death at 10 years following coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in patients with or without diabetes. Methods and results The SYNTAXES study evaluated up to 10-year survival of 1800 patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) randomized to receive either PCI or CABG in the SYNTAX trial. Ten-year all-cause death according to diabetic status and revascularization strategy was examined. In diabetics (n = 452), the risk of mortality was numerically higher with PCI compared with CABG at 5 years [19.6% vs. 13.3%, hazard ratio (HR): 1.53, 95% confidence interval (CI): 0.96, 2.43, P = 0.075], with the opposite seen between 5 and 10 years (PCI vs. CABG: 20.8% vs. 24.4%, HR: 0.82, 95% CI: 0.52, 1.27, P = 0.366). Irrespective of diabetic status, there was no significant difference in all-cause death at 10 years between patients receiving PCI or CABG, the absolute treatment difference was 1.9% in diabetics (PCI vs. CABG: 36.4% vs. 34.5%, difference: 1.9%, 95% CI: −7.6%, 11.1%, P = 0.551). Among insulin-treated patients (n = 182), all-cause death at 10 years was numerically higher with PCI (47.9% vs. 39.6%, difference: 8.2%, 95% CI: −6.5%, 22.5%, P = 0.227). Conclusions The treatment effects of PCI vs. CABG on all-cause death at 10 years in patients with 3VD and/or LMCAD were similar irrespective of the presence of diabetes. There may, however, be a survival benefit with CABG in patients with insulin-treated diabetes. The association between revascularization strategy and very long-term ischaemic and safety outcomes for patients with diabetes needs further investigation in dedicated trials. Trial registration SYNTAX: ClinicalTrials.gov reference: NCT00114972 and SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050., Graphical Abstract The treatment effects of PCI versus CABG on all-cause death at 10 years in 3VD/LMCAD patients with pharmacologically treated diabetes and insulin-treated diabetes.

Background The aim of the present study was to compare the quantitative flow responses of regadenoson against adenosine using cardiac 15O-water PET imaging in patients with suspected or known coronary artery disease (CAD). Methods Hyperemic myocardial blood flow (MBF) after adenosine and regadenoson was compared using correlation and Bland–Altman analysis in 21 patients who underwent rest and adenosine 15O-water PET scans followed by rest and regadenoson 15O-water PET scans. Results Global mean (± SD) MBF values at rest and stress were 0.92 ± 0.27 and 2.68 ± 0.80 mL·g·min for the adenosine study and 0.95 ± 0.29 and 2.76 ± 0.79 mL·g·min for the regadenoson study (P = 0.55 and P = 0.49). The correlations between global and regional adenosine- and regadenoson-based stress MBF were strong (r = 0.80 and r = 0.77). The biases were small for both global and regional MBF comparisons (0.08 and 0.09 mL·min·g), but the limits of agreement were wide for stress MBF. Conclusion The correlation between regadenoson- and adenosine-induced hyperemic MBF was strong but the agreement was only moderate indicating that established cut-off values for 150-water PET should be used cautiously if using regadenoson as vasodilator.

ObjectiveTo evaluate if proton pump inhibitor (PPI) treatment reduces the risk of upper gastrointestinal bleeding (UGIB) in patients with atrial fibrillation (AF) treated with non-vitamin K antagonist oral anticoagulants (NOACs).DesignWe used a common protocol, common data model approach to conduct a cohort study including patients with AF initiated on a NOAC in Stockholm, Denmark and the Netherlands from April 2011 until July 2018. The outcome of interest was a UGIB diagnosed in a secondary care inpatient setting. We used an inverse probability weighted (IPW) Poisson regression to calculate incidence rate ratios (IRRs), contrasting PPI use to no PPI use periods.ResultsIn 164 290 NOAC users with AF, providing 272 570 years of follow-up and 39 938 years of PPI exposure, 806 patients suffered a UGIB. After IPW, PPI use was associated with lower UGIB rates (IRR: 0.75; 95% CI: 0.59 to 0.95). On an absolute scale, the protective effect was modest, and was found to be largest in high-risk patients, classified as age 75–84 years (number needed to treat for 1 year (NNTY): 787), age ≥85 years (NNTY: 667), HAS-BLED score ≥3 (NNTY: 378) or on concomitant antiplatelet therapy (NNTY: 373).ConclusionConcomitant treatment with a PPI in NOAC-treated patients with AF is associated with a reduced risk of severe UGIB. This indicates that PPI cotreatment can be considered, in particular among the elderly patients, patients with a HAS-BLED score ≥3, and/or in patients on concomitant antiplatelet therapy.

Background Higher body mass index (BMI) is associated with better outcome compared with normal weight in patients with HF and other chronic diseases. It remains uncertain whether the apparent protective role of obesity relates to the absence of comorbidities. Therefore, we investigated the effect of BMI on outcome in younger patients without co-morbidities as compared to older patients with co-morbidities in a large heart failure (HF) population. Methods In an individual patient data analysis from pooled cohorts, 5,819 patients with chronic HF and data available on BMI, co-morbidities and outcome were analysed. Patients were divided into four groups based on BMI (i.e. ≤ 18.5 kg/m2, 18.5–25.0 kg/m2; 25.0–30.0 kg/m2; 30.0 kg/m2). Primary endpoints included all-cause mortality and HF hospitalization-free survival. Results Mean age was 65 ± 12 years, with a majority of males (78%), ischaemic HF and HF with reduced ejection fraction. Frequency of all-cause mortality or HF hospitalization was significantly worse in the lowest two BMI groups as compared to the other two groups; however, this effect was only seen in patients older than 75 years or having at least one relevant co-morbidity, and not in younger patients with HF only. After including medications and N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin concentrations into the model, the prognostic impact of BMI was largely absent even in the elderly group with co-morbidity. Conclusions The present study suggests that obesity is a marker of less advanced disease, but does not have an independent protective effect in patients with chronic HF. Graphic abstract Categories of BMI are only predictive of poor outcome in patients aged > 75 years or with at least one co-morbidity (bottom), but not in those aged

BACKGROUND: The prevalence of atrial fibrillation(AF) and diabetes mellitus is rising to epidemic proportions. We aimed to assess the impact of diabetes on the management and outcomes of patients with AF.METHODS: The EORP-AF General Long-Term Registry is a prospective, observational registry from 250 centres across 27 European countries. Outcomes of interest were as follows: i)rhythm control interventions; ii)quality of life; iii)healthcare resource utilisation; and iv)major adverse events.RESULTS: Of 11,028 patients with AF, the median age was 71 (63-77) years and 2537 (23.0%) had diabetes. Median follow-up was 24 months. Diabetes was related to increased use of anticoagulation but less rhythm control interventions. Using multivariable analysis, at 2-year follow-up, patients with diabetes were associated with greater levels of anxiety (p = 0.038) compared to those without diabetes. Overall, diabetes was associated with worse health during follow-up, as indicated by Health Utility Score and Visual Analogue Scale. Healthcare resource utilisation was greater with diabetes in terms of length of hospital stay (8.1 (±8.2) vs. 6.1 (±6.7) days); cardiology and internal medicine/general practitioner visits; and emergency room admissions. Diabetes was an independent risk factor of major adverse cardiovascular event (MACE; HR 1.26 [95% CI, 1.04-1.52]), all-cause mortality (HR 1.28 [95% CI, 1.08-1.52]), and cardiovascular mortality (HR 1.41 [95% CI, 1.09-1.83]).CONCLUSION: In this contemporary AF cohort, diabetes was present in 1 in 4 patients and it served as an independent risk factor for reduced quality of life, greater healthcare resource utilisation and excess MACE, all-cause mortality and cardiovascular mortality. There was increased use of anticoagulation therapy in diabetes but with less rhythm control interventions.

Purpose Due to shared hepatic metabolism, concomitant medication with a proton pump inhibitor (PPI) and clopidogrel might reduce the effectiveness of clopidogrel in the prevention of cardiovascular events after percutaneous coronary intervention (PCI). We aimed to examine the risk of major cardiovascular events after PCI comparing patients who used clopidogrel together with PPI with those who used clopidogrel alone. Methods This Swedish nationwide cohort study included patients who received clopidogrel after primary PCI in 2005–2019. Patients were followed for up to 12 months after PCI. Data were retrieved from the Swedish Prescribed Drug Registry, Patient Registry, Cancer Registry, and Cause of Death Registry. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs) for cardiovascular events comparing PPI users (exposed) with non-users of PPI (non-exposed). The HRs were adjusted for sex, age, comorbidity, calendar period, obesity, diabetes, anti-diabetic medication, tobacco-related diseases, hypertension, and congestive heart failure. Results The cohort included 99,836 patients who received clopidogrel after primary PCI. Among these, 35,772 (35.8%) received concomitant PPI. Compared to non-users, PPI users had increased adjusted HRs of all study outcomes, i.e., the main outcome myocardial infarction (HR = 1.23, 95% CI 1.15–1.32) and the secondary outcomes coronary heart disease (HR = 1.28, 95% CI 1.24–1.33), stroke (HR = 1.21, 95% CI 1.05–1.40), and death due to coronary heart disease (HR = 1.52, 95% CI 1.37–1.69). The results were similar in analyses including both primary and secondary PCIs. Conclusions In patients who receive clopidogrel after PCI, concomitant use of PPI seems to increase the risk of major cardiovascular events.

Background: Post-implantation syndrome (PIS) is defined as non-infectious continuous fever and a concomitant rise in inflammatory markers shortly after endovascular aortic repair. PIS occurrence after hybrid procedures, such as the frozen elephant trunk (FET) technique, has not been adequately investigated. The current study aims to define the incidence of PIS after the FET and to identify possible risk factors associated with its occurrence. Methods: The clinical charts of 59 patients undergoing the FET between February 2015 and April 2020 were reviewed retrospectively. The occurrence of PIS was defined as the presence of fever (>38 degrees C lasting longer than one day during the hospitalisation) and leucocytosis (white blood cell count >12,000/mu L). Patients with concomitant conditions possibly leading to fever and/or leucocytosis were excluded. Beside demographic and procedure-related data, serum/plasma inflammatory markers were evaluated before surgery and daily up to seven days postoperatively. Computed tomography scans (CT) were examined to calculate the volume of pre-existent and new-onset mural thrombus after the FET. Results: Thirty-eight patients met the inclusion criteria. The study cohort was divided into two groups based on the occurrence of PIS (17 cases; 44.7%). Patients with PIS were significantly younger than those without PIS (53.5 +/- 8.9 vs. 62.5 +/- 9.6 years; P=0.005). Female patients were less likely to develop PIS (5.2% vs. 26.3%, P=0.018). Patients with PIS had a higher volume of new-onset thrombus in the postoperative CT (P

Background/Aim: Diabetes Mellitus (DM), considered the equivalent of coronary artery disease, is one cause of ventricular repolarization (VR) dispersion. Retinopathy is one of the vascular consequences of diabetes. The association between myocardial repolarization dispersion and diabetic retinopathy is not fully elucidated. We aimed to evaluate ventricular repolarization using Tp-e interval and corrected (c) Tp-e/QT ratio in DM patients with and without retinopathy.Methods: A total of 124 diabetic subjects were included in this retrospective cohort study. All medical data were obtained from the electronic database of our university hospital. The subjects were divided into the no diabetic retinopathy (NDR) group (n=45), and the diabetic retinopathy (DR) group (n=79), which were compared in terms of demographic features, clinic and laboratory findings, and electrocardiographic findings such as QT, QTc, Tp-e, Tp-e/QT, Tp-e/QTc.Results: The groups were similar in terms of demographic features (P>0.05). Both Tp-e interval and Tp-e/QTc were significantly prolonged in the DR group compared to the NDR group. There were significant correlations between Tp-e, Tp-e/QTc, DM duration, and age. In multivariate logistic regression analysis, Tp-e (OR=6.01, %95 CI=4.17-7.52, P=0.012), Tp-e/QTc (OR=1.215, 95% CI=0.874-1.612, P=0.029), and DM duration (OR=1.422, 95% CI= 1.146–1.712, P

AIMS/BACKGROUND: Transthyretin amyloid (ATTR) amyloidosis cardiomyopathy is an underdiagnosed, causatively treatable cause of heart failure. The aim of this study was to evaluate the efficacy of electrocardiography (ECG) and echocardiography on patients with increased interventricular septum diameter (IVSd) to identify ATTR cardiac amyloidosis (ATTR-CA) patients. METHODS: We investigated 58 patients with heart failure and an IVSd >14mm. Included were 33 ATTR-CA patients and 25 controls that consisted of non-amyloidosis heart failure (HF) patients with negative 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy. We used echocardiography including 2D speckle tracking strain and a 12-lead ECG to test the accuracy to differentiate the groups. RESULTS: We found high diagnostic accuracy (98%) for differentiating ATTR-CA from HF controls using a combination of R amplitude in -aVR from ECG and relative wall thickness acquired from echocardiography. With this combined model (RWT/ R in -aVR), the sensitivity was 100% and specificity was 95% using a cut off value of 0.90. Furthermore, the area under the curve was 99% and the negative predictive value was 100%. CONCLUSION: We found that a simple combination of ECG and echocardiographic parameters used in clinical settings was able to differentiate ATTR-CA from other etiologies of HF with increased interventricular septum thickness. The high sensitivity and negative predictive value render the algorithm useful for selection of patients for further diagnostic procedures for ATTR-CA.

Aims Participation in exercise-based cardiac rehabilitation (exCR) increases aerobic capacity and improves outcomes in patients following myocardial infarction (MI) and is therefore universally recommended. While meta-analyses consistently report that participation in exCR reduces cardiovascular mortality, there are conflicting results regarding effects on total mortality. Presently, many eligible patients do not receive exCR in clinical practice. We aimed to investigate the relation between participation in exCR post-MI and total mortality in men and women in a nationwide real-world cohort from the SWEDEHEART registry. Design Longitudinal, observational cohort study. Methods and results In total, 20 895 patients from the SWEDEHEART registry were included. Mortality data were obtained from the Swedish National Population Registry. During a mean of 4.55 (±2.33) years of follow-up, 1000 patients died. Using Cox regression for proportional odds and taking a wide range of potential confounders into consideration, participation in exCR was related to significantly lower total mortality [hazard ratio (HR) 0.72, 95% confidence interval 0.62–0.83]. Excluding patients with shorter follow-up than 2 years did not alter the results. Exercise-based CR participation was related to lowered total mortality in most of the investigated subgroups. The risk reduction was more pronounced in women than in men (HR 0.54 vs. 0.81, respectively). Conclusion Participation in exCR was associated with reduced total mortality, and more pronounced in women, compared with men. Our results further support the recommendations to participate in exCR, and hence we argue that exCR should be a mandatory part of comprehensive CR programmes, offered to all patients post-MI.

Soluble urokinase plasminogen activator receptor (suPAR) is intensively studied as a biomarker of inflammation and disease outcome in various diseases. In rheumatoid arthritis (RA), suPAR have shown an association with inflammation and swollen joints, but data on suPAR in relation to early disease course and disease progression are lacking. This study investigates the potential of suPAR to predict or reflect disease outcome in early RA. Serum suPAR was measured by enzyme-linked immunosorbent assay at disease onset and after 3 and 36 months in 252 patients from a Swedish prospective observational early RA cohort. Levels and changes of suPAR were analyzed in relation to the 28-joint disease activity score (DAS28) and joint damage according to the Larsen score at inclusion and during follow-up. 100 healthy blood donors served as controls. Circulating levels of suPAR were higher in RA patients at all time points as compared to healthy controls. Baseline suPAR was significantly associated with baseline disease activity whereas suPAR levels at 36 months were associated with joint damage at 36 months. No predictive value of suPAR levels or changes in suPAR levels over time were found. In conclusion, suPAR levels associate with disease activity in early untreated RA and reflects joint damage at later stages. Increased suPAR in established RA could indicate patients in need of frequent monitoring of joint status, irrespective of disease activity. In the view of suPAR as a rapidly emerging biomarker, it is important to be aware of its ability to reflect both inflammation and subsequent damage. (Translational Research 2021; 232:142-149) Funding Agencies|Swedish Society of Medicine; Reinhold Sund foundation; King Gustaf V 80-year foundation; Swedish Rheumatism association; Ostergotland county council

Background: Severe alpha-1-antitrypsin deficiency (AATD), phenotype PiZZ, is associated with increased risk of liver disease and chronic obstructive pulmonary disease (COPD), but the risk of venous thromboembolism (VTE) is unknown. Our aim was to evaluate the risk of VTE in individuals with severe AATD compared with control subjects from the general population. Methods: Individuals with severe AATD (n = 1577) were recruited from the Swedish national AATD register. Control subjects (n = 5969) were selected from the OLIN (Obstructive Lung Disease in Northern Sweden) studies, that include a random general population sample. Longitudinal data on VTE and diagnoses were obtained from the Swedish National Patient Registry. Associations were analyzed using multivariable Cox regression. Results: At inclusion, 46% of the AATD individuals and 53% of the controls were never-smokers. COPD was present in 46% of the AATD individuals compared with 4% of the controls. During a median follow-up of 18 years, 116 (7%) of the AATD individuals and 89 (1%) of the control subjects developed VTE, unadjusted hazard ratio 6.5 (95% confidence interval 4.9–8.6). Risk factors for incident VTE were male gender, age, COPD, cancer, and liver disease. Adjusting for these factors, the AATD individuals had a significantly higher risk of incident VTE, adjusted hazard ratio 4.2 (95% confidence interval 2.9–6.2) as compared with the controls. Conclusion: Subjects with severe AATD have considerably increased risk of developing VTE compared with the general population, even after accounting for risk factors. This calls for optimized risk factor management and clinical follow-up of this patient group. (Less)

Aims To study clinical phenotype, prognosis for all-cause and cardiovascular (CV) mortality and predictive factors in patients with incident heart failure (HF) after aortic valvular intervention (AVI) for aortic stenosis (AS). Methods and results In this retrospective, observational study we included patients from the Swedish Heart Failure Registry (SwedeHF) recorded 2003-2016, with AS diagnosis and AVI before HF diagnosis. The AS diagnosis was established according to International Classification of Diseases 10th revision (ICD-10) codes, thus without information concerning clinical or echocardiographical data on the aortic valve disease. The patients were divided into two subgroups: left ventricular ejection fraction (LVEF) >= 50% (AS-HFpEF) and Funding Agencies|Swedish government [ALFGBG-72900, 73400]; Swedish County Councils, the ALF agreement [ALFGBG-72900, 73400]; Regional Development Fund, Vastra Gotaland County, Sweden [VGFOUREG-931060, VGFOUREG-849081]; Gothenburg Society of Medicine [20/935037]

Background Sleep-related breathing disorders (SRBDs), particularly obstructive sleep apnoea, are associated with increased cardiovascular (CV) risk. However, it is not known whether individual questions used for SRBD screening are associated with major adverse CV events (MACE) and death specifically in patients with chronic coronary syndrome (CCS). Methods Symptoms associated with SRBD were assessed by a baseline questionnaire in 15,640 patients with CCS on optimal secondary preventive therapy in the STABILITY trial. The patients reported the frequency (never/rarely, sometimes, often and always) of: 1) loud snoring; 2) more than one awakening/night; 3) morning tiredness (MT); 4) excessive daytime sleepiness (EDS); or 5) gasping, choking or apnoea when asleep. In adjusted Cox regression models, associations between the frequency of SRBD symptoms and CV outcomes were assessed with never/rarely as reference. Results During a median follow-up time of 3.7 years, 1,588 MACE events (541 CV deaths, 749 nonfatal myocardial infarctions [MI] and 298 nonfatal strokes) occurred. EDS was associated (hazard ratio [HR], 95% confidence interval [CI]) with increased risk of MACE (sometimes 1.14 [1.01-1.29], often 1.19 [1.01-1.40] and always 1.43 [1.15-1.78]), MI (always 1.61 [1.17-2.20]) and all-cause death (often 1.26 [1.05-1.52] and always 1.71 [1.35-2.15]). MT was associated with higher risk of MACE (often 1.23 [1.04-1.45] and always 1.46 [1.18-1.81]), MI (always 1.61 [1.22-2.14]) and all-cause death (always 1.54 [1.20-1.98]). The other SRBD-related questions were not consistently associated with worse outcomes. Conclusions In patients with CCS, gradually higher levels of EDS and MT were independently associated with increased risk of MACE, including mortality.

Objective: To identify causal pathophysiological mechanisms for atherosclerosis and incident cardiovascular events using protein measurements. Approach and Results: Carotid artery atherosclerosis was assessed by ultrasound, and 86 cardiovascular-related proteins were measured using the Olink CVD-I panel in 7 Swedish prospective studies (11 754 individuals). The proteins were analyzed in relation to intima-media thickness in the common carotid artery (IMT-CCA), plaque occurrence, and incident cardiovascular events (composite end point of myocardial infarction or ischemic stroke) using a discovery/replication approach in different studies. After adjustments for traditional cardiovascular risk factors, 11 proteins remained significantly associated with IMT-CCA in the replication stage, whereas 9 proteins were replicated for plaque occurrence and 17 proteins for incident cardiovascular events. NT-proBNP (N-terminal pro-B-type natriuretic peptide) and MMP (matrix metalloproteinase)-12 were associated with both IMT-CCA and incident events, but the overlap was considerably larger between plaque occurrence and incident events, including MMP-12, TIM-1 (T-cell immunoglobulin and mucin domain 1), GDF (growth/differentiation factor)-15, IL (interleukin)-6, U-PAR (urokinase plasminogen activator surface receptor), LOX-1 (lectin-like oxidized LDL [low-density lipoprotein] receptor 1), and TRAIL-R2 (TNF [tumor necrosis factor]-related apoptosis-inducing ligand receptor 2). Only MMP-12 was associated with IMT-CCA, plaque, and incident events with a positive and concordant direction of effect. However, a 2-sample Mendelian randomization analysis suggested that increased MMP-12 may be protective against ischemic stroke ( P =5.5×10 −7 ), which is in the opposite direction of the observational analyses. Conclusions: The present meta-analysis discovered several proteins related to carotid atherosclerosis that partly differed in their association with IMT-CCA, plaque, and incident atherosclerotic disease. Mendelian randomization analysis for the top finding, MMP-12, suggests that the increased levels of MMP-12 could be a consequence of atherosclerotic burden rather than the opposite chain of events.

Objective: To study risk in white-coat hypertension (WCH) by measurement of coronary artery calcium score (CACS), carotid--femoral pulse-wave velocity (PWV) and carotid plaques. Methods: Cross-sectional population-based cohort with randomized selection of participants from Linkoping, Sweden. An Omron m10-IT oscillometric device was used for clinic and home blood pressures (HBP) in the morning and evening for 1 week. Results: We recruited 5029 middle-aged and mainly defined WCH as SBP at least 140 mmHg and/or DBP at least 90 mmHg with HBP less than 135/85 mmHg. There were 2680 normotensive participants and 648 had WCH after exclusion of treated participants. More women (59.5%) than men (42.8%, P < 0.001) had WCH. We found higher prevalence of CACS greater than 100 compared with less than 100 (12.4 vs. 7.2%, P < 0.001), PWV (11.5 +/- 1.5 vs. 10.4 +/- 1.3 m/s, P < 0.001) and a higher prevalence of one or more carotid plaques (59.5 vs. 48%, P < 0.001) in participants with WCH than in normotension. Participants with WCH also had more dyslipidemia and higher glucose levels. Normotensive women scored lower on nervousness than women with WCH (P = 0.022). After matching of 639 participants with WCH to normotensive participants according to age, gender and systolic HBP the prevalence of a high CACS (12.1 vs. 8.6%, P = 0.003,) PWV (11.0 +/- 0.068 vs. 11.5 +/- 0.068 m/s, estimated marginal means +/- SE, P < 0.001 by ANOVA) but not more carotid plaques (59.5 vs. 55.6%, P = 0.23), remained in the participants with WCH compared with the matched normotensive participants. Conclusion: WCH is particularly common in middle-aged women, and it displays metabolic dysfunction and increased prevalence of arteriosclerotic manifestations in both genders. As markers of increased cardiovascular risk were present also after matching normotensive and WCH participants according to systolic HBP, age and gender, the presence of WCH signals an increased cardiovascular risk burden that is not fully explained by elevated BP levels at home. Funding Agencies|Swedish Heart-Lung FoundationSwedish Heart-Lung Foundation; FORSS, the Medical Research Council of Southeast Sweden

Objective Patients with rheumatoid arthritis (RA) are at increased risk of coronary artery disease (CAD) and seem to develop more severe acute coronary syndromes (ACS) than the general population. Because few studies have investigated the CAD distribution in the context of acute or stable CAD in RA, the objective was to investigate whether this risk is due to a different distribution and severity of coronary stenoses (versus non-RA), resulting in clinical manifestation of CAD. Methods We performed a population-based study using linkages of nationwide clinical, health, and demographics registers. We compared 1 cohort of patients with RA, and 1 matched cohort of patients without RA, undergoing a first coronary angiography from 2006 through 2015. Cardiovascular (CV) characteristics and the presence and distribution of clinically significant stenoses were compared (through odds ratios [ORs]), stratified by indication (stable CAD, ST-elevation myocardial infarction [STEMI], and non–ST-elevation ACS [NSTACS]), using logistic regression. Results We identified 2,985 patients with RA and 10,290 patients without RA who underwent a first coronary angiography. A higher proportion of patients with RA (75% versus 69%) had STEMI and NSTACS as indication for angiography. We found no difference in the presence and distribution of clinically significant coronary stenoses in RA compared with the patients without RA, regardless of the CAD type (for having any significant stenosis in stable CAD OR 0.9, STEMI OR 0.8, and NSTACS OR 1.1), stratification by RA duration, sex, or burden of concomitant CV risk factors. Conclusion Although RA may accelerate the development of clinical CAD events, the underlying angiographic characteristics are similar to those in patients without RA.

Background Historically, the incidence of cardiovascular disease and mortality in persons with Type I diabetes (TID) has been increased compared to the general population. Contemporary studies on time trends of mortality and cardiovascular disease are sparse. Methods In this observational study, TID persons were identified in the Swedish National Diabetes Registry (n=45,575) and compared with matched controls from the general population (n=220,141). Incidence rates from 2002 to 2019 were estimated with respect to mortality and cardiovascular disease in persons with TID overall and when stratified for prevalent cardiovascular and renal disease relative to controls. Findings Mean age in persons with TID was 32.4 years and 44.9% (20,446/45,575) were women. Age- and sex-adjusted mortality rates declined over time in both groups but remained significantly higher in those with TID compared to controls during 2017-2019, 7.62 (95% CI 7.16; 8.08) vs. 2.23 (95% CI 2.13; 2.33) deaths per 1,000 person years. Myocardial infarction, heart failure and stroke decreased over time in both groups, with persistent excess risks in the range of 3.4 -5.0 times from 2017 to 2019 in those with TID. TID persons >= 45 years without previous renal or cardiovascular complications had standardized mortality rates similar or even lower than controls 5.55 (4.51; 6.60) vs.7.08 (6.75; 7.40) respectively in the last time period. Interpretation Excess mortality persisted over time in persons with TID, largely in patients with cardiorenal complications. Improved secondary prevention with a focus on individualized treatment is needed to dose the gap in mortality for individuals with TID. Copyright (C) 2022 The Authors. Published by Elsevier Ltd. Funding Agencies|ALF-agreement; Novo Nordisk Foundation; Swedish Heart and Lung Foundation

ispartof: JOURNAL OF HYPERTENSION vol:40 issue:6 pages:1245-1246 ispartof: location:Netherlands status: published

ispartof: JOURNAL OF HYPERTENSION vol:40 issue:6 pages:1244-1245 ispartof: location:Netherlands status: published

In this international study, we (1) compared patient-reported outcomes (PROs) in adults with congenital heart disease (CHD) who had versus had not been hospitalized during the previous 12 month, (2) contrasted PROs in patients who had been hospitalized for cardiac surgery versus nonsurgical reasons, (3) assessed the magnitude of differences between the groups (i.e., effect sizes), and (4) explored differential effect sizes between countries. APPROACH-IS was a cross-sectional, observational study that enrolled 4,028 patients from 15 countries (median age 32 years; 53% females). Self-report questionnaires were administered to measure PROs: health status; anxiety and depression; and quality of life. Overall, 668 patients (17%) had been hospitalized in the previous 12 months. These patients reported poorer outcomes on all PROs, with the exception of anxiety. Patients who underwent cardiac surgery demonstrated a better quality of life compared with those who were hospitalized for nonsurgical reasons. For significant differences, the effect sizes were small, whereas they were negligible in nonsignificant comparisons. Substantial intercountry differences were observed. For various PROs, moderate to large effect sizes were found comparing different countries. In conclusion, adults with CHD who had undergone hospitalization in the previous year had poorer PROs than those who were medically stable. Researchers ought to account for the timing of recruitment when conducting PRO research as hospitalization can impact results. ispartof: AMERICAN JOURNAL OF CARDIOLOGY vol:145 pages:135-142 ispartof: location:United States status: published

The influence of age and gender on delay to treatment and its association with survival after out of hospital cardiac arrest.

Background/Aim: Covid-19 is a new coronavirus disease with high mortality that has reached all parts of the world. This study aimed to prospectively compare individual characteristics, echocardiographic findings, and laboratory findings in patients with Covid-19 according to the need for intensive care unit (ICU) admission and mortality. Methods: In this single-center prospective cohort study, patients hospitalized with the diagnosis of Covid-19 between June and November 2020 were examined in terms of echocardiographic and laboratory results. Early in-hospital findings that might affect mortality, cardiac injury and thrombotic complications were evaluated and compared. Results: A total of 214 patients who were hospitalized due to Covid-19 were included in our study, 80 (37.3%) of which needed hospitalization in the ICU and 134 (62.6%) of which did not. The mean ages of patients treated in the ICU unit and the ward were 69.5 (57.5-80.5) years and 40 (29-58) years, respectively (P

Amaç: Bu çalışmanın amacı, oral antikoagülan (OAK) kullanan atriyal fibrilasyon (AF) hastalarında spontan dişeti kanaması (SDK) ve buna bağlı ilaç bırakma sıklığının değerlendirilmesidir.Gereç ve Yöntem: OAK ilaç kullanan 457 AF hastası taranarak spontan dişeti kanaması olan 32 hasta tespit edildi. Bu hastalar, spontan dişeti kanaması olmayan 32 AF hastası ile yaş, cinsiyet ve OAK tedavi protokolü açısından eşleştirilerek periodontal parametreleri karşılaştırıldı.Bulgular: Çalışmaya dahil edilen total popülasyonda, 32 hastada (32/457; % 7.0) SDK saptandı ve bu hastaların 13'ünde (% 40.6) kanamaya bağlı OAK ilaç kullanımını bıraktığı tespit edildi. Plak indeksi (PI), gingival indeks (GI) ve cep derinlikleri (CD) SDK olan hastalarda anlamlı olarak daha yüksek bulundu. Gingival indeksin, hastaların OAK ilacı bırakma riskini bağımsız olarak etkilediği tespit edildi.Sonuç: OAK tedavisi altındaki AF hastalarında, önceden var olan periodontal hastalık nedeniyle önemli oranda SDK ve buna bağlı hastanın OAK ilaç kullanımını bıraktığı gözlendi. Ayrıca gingival indeks skorları, SDK ve OAK ilacın bırakılmasında risk indikatörüdür. OAK tedavisinden önce hastaların periodontal muayenesi ve / veya tedavisi yapılması önerilir., Purpose: The aim of this study was to investigate the frequency of gingival bleeding (GB) and associated drug-withdrawal in atrial fibrillation (AF) patients using oral anti-coagulants (OAC).Materials and Methods: 457 patients with AF receiving OAC were screened. The periodontal parameters and OAC drug-withdrawal of 32 patients with spontaneous GB were compared with 32 patients without bleeding who were matched for age, sex and OAC treatment protocol.Results: GB was detected in 32 patients (7.0%) and 13 of these patients (40.6%) had OAC drug-withdrawal due to bleeding. The plaque index (PI), gingival index (GI) and probing pocket depths (PPD) were significantly higher in patients with GB. The GI scores independently determined the risk of OAC drug-withdrawal. Conclusion: AF patients under OAC treatment may have significant rates of GB and subsequent OAC withdrawal due to pre-existing periodontal disease. The GI scores and GB can predict the risk of OAC drug-withdrawal. The periodontal examination and/or treatment of these patients should be performed before OAC treatment.

Aim The Prevention of Arrhythmia Device Infection Trial (PADIT) infection risk score, developed based on a large prospectively collected data set, identified five independent predictors of cardiac implantable electronic device (CIED) infection. We performed an independent validation of the risk score in a data set extracted from U.S. healthcare claims. Methods and results Retrospective identification of index CIED procedures among patients aged ≥18 years with at least one record of a CIED procedure between January 2011 and September 2014 in a U.S health claims database. PADIT risk factors and major CIED infections (with system removal, invasive procedure without system removal, or infection-attributable death) were identified through diagnosis and procedure codes. The data set was randomized by PADIT score into Data Set A (60%) and Data Set B (40%). A frailty model allowing multiple procedures per patient was fit using Data Set A, with PADIT score as the only predictor, excluding patients with prior CIED infection. A data set of 54 042 index procedures among 51 623 patients with 574 infections was extracted. Among patients with no history of prior CIED infection, a 1 unit increase in the PADIT score was associated with a relative 28% increase in infection risk. Prior CIED infection was associated with significant incremental predictive value (HR 5.66, P, Graphical Abstract

Background/Aim: Inflammation and inflammatory parameters are known to have unfavorable effects both on the surgical success and survival. The reference point of the present study are the results of an investigation of the effects of blood proteins such as albumin and fibrinogen, which affect blood viscosity, and other hematological parameters, on the success of arteriovenous fistula operations. Methods: This retrospective cohort study includes the data of 135 patients who underwent arteriovenous fistula surgery by the same surgeon in the same center. The patients were divided into two groups, as those with an active fistula 8–12 weeks after surgery and those with a dysfunctional fistula. After applying the exclusion criteria, the remaining data were compared using appropriate statistical methods to evaluate the influence on fistula maturation rates. Results: A statistical analysis performed after the evaluation of the fitness of the data to a normal distribution revealed fistula maturation to be associated with fibrinogen (P

Aims Heart failure (HF) is a leading cause of hospitalization and is associated with high morbidity and mortality. We examined the impact of recurrent HF hospitalizations (HFHs) on cardiovascular (CV) mortality among patients with HF in Sweden. Methods and results Adults with incident HF were identified from linked national health registers and electronic medical records from 01 January 2005 to 31 December 2013 for Uppsala and until 31 December 2014 for Västerbotten. CV mortality and all‐cause mortality were evaluated. A time‐dependent Cox regression model was used to estimate relative CV mortality rates for recurrent HFHs. Assessment was also done for ejection fraction‐based HF phenotypes and for comorbid atrial fibrillation, diabetes, or chronic renal impairment. Overall, 3878 patients with HF having an index hospitalization were included, providing 9691.9 patient‐years of follow‐up. Patients were relatively old (median age: 80 years) and were more frequently male (55.5%). Compared with patients without recurrent HFHs, the adjusted hazard ratio (HR [95% confidence interval; CI]) for CV mortality and all‐cause mortality were statistically significant for patients with one, two, three, and four or more recurrent HFHs. The risk of CV mortality and all‐cause mortality increased approximately six‐fold in patients with four or more recurrent HFHs vs. those without any HFHs (HR [95% CI]: 6.26 [5.24–7.48] and 5.59 [4.70–6.64], respectively). Similar patterns were observed across the HF phenotypes and patients with comorbidities. Conclusions There is a strong association between recurrent HFHs and CV and all‐cause mortality, with the risk increasing progressively with each recurrent HFH.

Background/Aim: Hypertension (HT) may modulate left ventricular (LV) geometry. Electrocardiographic Tp-Te, QT and QTc interval, and Tp-Te/QTc ratio are among the parameters of ventricular repolarization (VR) that may predict ventricular arrhytmogenic potential and possess prognostic significance. It is well known that left ventricular hypertrophy is associated with increase in the parameters of VR; however, little is known about the association of these parameters with other forms of LV geometry in HT. Our aim was to assess this association.Methods: A total of 162 newly diagnosed essential HT patients were enrolled and divided into those with concentric LV remodeling (n=79) and those with normal LV geometry (n=83). Healthy normotensive subjects (n=76) comprised the control group. Data were gathered retrospectively from electrocardiographic, echocardiographic, and demographic records.Results: QT interval, P-wave duration, and QRS duration were similar among the 3 groups (P>0.05). Tp-Te, QTc and Tp-Te/QTc were greater in the HT group compared with the controls (P0.05). There was no correlation between Tp-Te interval, LV mass and LV mass index among the study population.Conclusion: Tp-Te may be useful in prognostic stratification of HT. Regardless of the LV geometry, HT patients have prolonged Tp-Te and QTc intervals, and increased Tp-Te/QTc ratio compared to the healthy subjects. Our findings may suggest possible utilization of Tp-Te as HT-related end-organ damage in the future.

INTRODUCTION: Stroke, especially ischemic stroke's (IS) link with Alzheimer's disease (AD) remains unclear. METHODS: This prospective cohort study included 2459 AD- and cerebrovascular disease-free older adults at baseline (mean age 71.9 ± 10.3 years, Stockholm, Sweden). Using Cox regressions, shared risk factors (SRFs) and shared protective factors (SPFs) between AD and IS were recognized when their hazard ratios in both AD and IS models were significant and in the same direction. RESULTS: During the follow-up period of up to 15 years, 132 AD and 260 IS mutually exclusive cases were identified. SRFs were low education, sedentary lifestyle, and heart diseases. High levels of psychological well-being, actively engaging in leisure activities, and a rich social network were SPFs. Having ≥1 SPF reduced 47% of AD and 28% of IS risk among people with a low risk profile (

The impact of most, but not all, cardiovascular risk factors decline by age. We investigated how the metabolic syndrome (MetS) was related to cardiovascular disease (CVD) during 40 years follow-up in the Uppsala Longitudinal Study of Adult Men (ULSAM, 2,123 men all aged 50 at baseline with reinvestigations at age 60, 70, 77 and 82). The strength of MetS as a risk factor of incident combined end-point of three outcomes (CVD) declined with ageing, as well as for myocardial infarction, ischemic stroke and heart failure when analysed separately. For CVD, the risk ratio declined from 2.77 (95% CI 1.90–4.05) at age 50 to 1.30 (95% CI 1.05–1.60) at age 82. In conclusion, the strength of MetS as a risk factor of incident CVD declined with age. Since MetS was significantly related to incident CVD also at old age, our findings suggest that the occurrence of MetS in the elderly should not be regarded as innocent. However, since our data were derived in an observational study, any impact of MetS in the elderly needs to be verified in a randomized clinical intervention trial.

Background/Aim: In recent years, prolonged corrected QT (QTc) interval is thought to be an independent risk factor in patients with Acute Coronary Syndrome (ACS). Our aim in this study is to determine whether there is a relationship between the Neutrophil/Lymphocyte Ratio (NLR), which is a new inflammatory parameter, and prolonged QTc corrected (QTc) interval in patients with ACS. Methods: In a retrospective cohort study, 649 patients with ACS were enrolled from January 2017 to July 2019, out of which ninety-two patients died during follow-up. Patients were divided into two groups according to the prolonged QTc interval (QTc ≥450 msec). The relationship between QTc interval prolongation and NLR was evaluated. The primary endpoint was early all-cause death. Results: Thirty-one of 135 patients (22.9% P=0.002) with QTc interval prolongation and 61 of 514 patients without QTc prolongation (11.8% P=0.002) died. Prolonged QTc interval was positively correlated with NLR (r=0.20, P=0.001). Both NLR (OR: 1,016; 95% CI: 1.004–1.028; P=0.01) and QTc interval (OR: 1.016; 95% CI: 1.004–1.028; P=0.006) independently predicted early mortality. In the ROC curve analysis, the AUC value of QTc interval to predict in-hospital mortality was 0.680 (95% CI: 0.597-0.763; P=0.001), with a sensitivity of 35%, a specificity of 82% and an optimum cut-off value of ≥450 msec. The AUC value of NLR to predict in-hospital mortality was 0.711 (95% CI: 0.653-0.769; P

AIMS: To examine the associations of disrupted circadian rest-activity rhythm (CRAR) with cardiovascular diseases and mortality among people with type 2 diabetes. METHODS: A total of 3147 participants with baseline type 2 diabetes (mean age 65.21 years, 39.78% female; mean HbA1c 50.02 mmol/mol) from UK Biobank were included. The following CRAR parameters were derived from acceleration data: interdaily stability (IS), intradaily variability (IV), relative amplitude (RA), most active 10 h period onset (M10 onset), and least active 5 h period onset (L5 onset). We used Cox proportional hazards models to estimate the associations of CRAR with cardiovascular diseases and mortality, adjusting for sociodemographic, lifestyle, and health characteristics. RESULTS: Participants in the lowest quartile of IS and RA exhibited the greatest risk of developing cardiovascular disease (IS, hazard ratio [HR]Q1 vs. Q4 1.40 [95% confidence interval (CI) 1.04, 1.88]; RA, HRQ1 vs. Q4 2.45 [95% CI 1.73, 3.49]). However, the association between delayed L5 onset and cardiovascular disease risk did not reach statistical significance. Additionally, we found that high IV and low RA were associated with all-cause and cardiovascular mortality. CONCLUSION: Objectively determined CRAR disturbances may increase the risk of cardiovascular diseases and mortality among people with type 2 diabetes.

Background: In the absence of mitral valve disease, increased left atrial volume (LAV) is a marker of diastolic dysfunction and long-standing elevated left ventricle (LV) pressure. The aim of this study was to assess the role of increased baseline LAV in predicting clinical outcome of patients presenting with acute coronary syndrome (ACS). Methods: We systematically searched all electronic databases up to September 2020 in order to select clinical trials and observational studies, which assessed the predictive role of LAV indexed (LAVI) on clinical outcome in patients with ACS. Primary clinical endpoints were as follows: major adverse cardiac events (MACE), all-cause mortality and hospitalization. Secondary endpoints were in-hospital complications. Results: A total of 2,705 patients from 11 cohort studies with a mean follow-up 18.7 +/- 9.8 months were included in the meta-analysis. Patients with low LAVI had low risk for MACE (15.9% vs. 33.7%; p < .01), long-term all-cause mortality (9.14% vs. 18.1%; p < .01), short-term mortality (3.31% vs. 9.38%; p = .02) and lower hospitalization rate (11.6% vs. 25.5%; p < .01) compared to patients with increased LAVI. Atrial fibrillation and cardiogenic shock as in-hospital events were lower (p < .05 for all) in patients with low LAVI but ventricular fibrillation/tachycardia was not different between groups (p = .14). Conclusion: Increased LAVI is an independent predictor of outcome in patients with ACS. Thus, assessment of LA index in these patients is important for better risk stratification and guidance towards optimum clinical management.

Objectives: We evaluated the efficacy and safety of single high-dose versus double high-dose intracoronary bolus tirofiban in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods: A total of 80 patients, who were admitted to our clinic and underwent primary PCI, were included in this observational cohort study. The patients were divided into the single high-dose group (n = 40) and the double high-dose group (n = 40) according to the intracoronary bolus tirofiban regime. The primary endpoint was assumed as the incidence of major adverse cardiac event (s) (MACE) defined as all-cause mortality and repeat coronary revascularization (target vessel revascularization [TVR]) at 30 days. MACE and bleeding events were evaluated at 7 and 30 days. Results: The primary endpoint was not significantly different between the single and the double high-dose groups (40.0% vs. 17.5%, p = 0.994). However, a significantly lower 30-day TVR rate was observed in the double high-dose group (27.5% vs. 7.5%, p = 0.019). No significant difference was observed in terms of 30-day all-cause mortality between the two groups (12.5% vs. 10.0%, p = 0.712). Major bleeding events were not observed in any group. Multivariate logistic regression analysis demonstrated that CRUSADE score (Hazard ratio [HR]: 5.721; 95% CI: 2.036 to 16.073, p = 0.001) and platelet count (HR: 1.009; 95% CI: 1.000 to 1.018, p = 0.048) were the independent predictors of bleeding at 7 days. Conclusions: Double high-dose intracoronary bolus tirofiban in STEMI patients undergoing primary PCI was associated with significantly lower 30-day TVR rates without an increase in bleeding events. However, it did not significantly affect MACE and all-cause mortality rates.

This study aimed to assess the relationship between different LA strain components and PCWP as well as to the relationship with other established methods. We studied 144 symptomatic patients, age 63 ± 14 years, 54 males, using conventional transthoracic echocardiography protocols, including LA and LV myocardial deformation from speckle tracking technique investigations along with simultaneous right heart catheterization (RHC) using established techniques. From RHC, pulmonary artery pressure (PAP), and pulmonary capillary wedge pressure (PCWP) were measured and pulmonary vascular resistance (PVR) calculated. LA strain rate during atrial contraction (LASRa) was the strongest correlate with PCWP (r2 = − 0.40, p 2 = 0.21 and 0.19, respectively, p 2 = 0.21 vs. r2 = 0.02, respectively). The strongest relationship between LASRa and PCWP was in patients with enlarged LA volume > 34 ml/m2 (r2 = 0.60, p 15 mmHg which was superior to recently proposed uni- and multi-variable models. LASR during atrial contraction is the strongest predictor of PCWP, particularly in patients with post-capillary PH and with dilated LA cavity. Furthermore, it proved superior to recently proposed uni- and multi-variable based algorithms. Its close relationship with LV strain rate counterpart reflects important left heart chamber interaction in patients with raised LA pressure.

Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) is common and occurs in 6–8% of all patients fulfilling the diagnostic criteria for acute myocardial infarction (AMI). This paper describes the rationale behind the trial ‘Randomized Evaluation of Beta Blocker and ACE-Inhibitor/Angiotensin Receptor Blocker Treatment (ACEI/ARB) of MINOCA patients’ (MINOCA-BAT) and the need to improve the secondary preventive treatment of MINOCA patients. Methods MINOCA-BAT is a registry-based, randomized, parallel, open-label, multicenter trial with 2:2 factorial design. The primary aim is to determine whether oral beta blockade compared with no oral beta blockade, and ACEI/ARB compared with no ACEI/ARB, reduce the composite endpoint of death of any cause, readmission because of AMI, ischemic stroke or heart failure in patients discharged after MINOCA without clinical signs of heart failure and with left ventricular ejection fraction ≥40%. A total of 3500 patients will be randomized into four groups; e.g. ACEI/ARB and beta blocker, beta blocker only, ACEI/ARB only and neither ACEI/ARB nor beta blocker, and followed for a mean of 4 years. Summary While patients with MINOCA have an increased risk of serious cardiovascular events and death, whether conventional secondary preventive therapies are beneficial has not been assessed in randomized trials. There is a limited basis for guideline recommendations in MINOCA. Furthermore, studies of routine clinical practice suggest that use of secondary prevention therapies in MINOCA varies considerably. Thus results from this trial may influence future treatment strategies and guidelines specific to MINOCA patients.

Left ventricular systolic dysfunction (LVSD) is common in patients with pre-existing ischemic heart disease (IHD) and myocardial infarction. An untargeted proteomic approach is used to improve the understanding of the molecular mechanisms associated with LVSD and to find out potential proteomic signatures in pericardial fluid. The pericardial fluid of IHD (n = 45) patients was grouped into two categories according to the left ventricular ejection fraction, LVEF ≥45 (n = 33) and LVEF 2) including 12 down-regulated and 4 up-regulated in the impaired systolic functional group (LVEF

Background: The COVID-19 outbreak has been associated with a high morbidity, mortality, and a risk of long-term sequelae, and patients with severe COVID-19 are at increased risk of acute kidney injury. CKD patients are at high risk of being exposed to COVID-19 and suffer complications and poor outcome. In Sweden, mitigation strategies did not include lockdown. During March–April of 2020, wide-spread infection occurred in Stockholm. Methods: Management and outcomes in forty hemodialysis (HD) patients and 4 peritoneal dialysis (PD) patients, with symptomatic COVID-19 in greater Stockholm during March and April of 2020 are reported. Results: Twenty-four HD patients (60%) required medical care and hospitalization, whereas 16 patients (40%) were treated at home. Nine patients died (mortality rate of 22.5%), of whom 8 were men. The median age in non-survivors (78 years) was significantly higher than in survivors (p = 0.003). The median time in dialysis (11.5 years) was also significantly longer in non-survivors (p = 0.01). C-reactive protein (CRP) at diagnosis in 7 of non-survivors (median 213 mg/L, range 86–329 mg/L) was significantly higher than the CRP in 25 survivors (median 87 mg/L, range 1–328 mg/L) (p = 0.0003). Maximum CRP also indicated poorer outcome among hospitalized patients (p = 0.0004). The gender imbalance was striking with only men dying apart from 1 elderly woman. Only 4 PD patients were hospitalized with symptomatic COVID-19. One patient died, 2 were discharged, and 1 was treated at the intensive care unit and survived. Conclusion: HD patients >70 years were reported with longer dialysis vintage, higher CRP, and males were at an increased risk of dying from COVID-19, whereas those