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Aim: To examine inter‐national and regional variations in persistence of oral anticoagulation (OAC) therapy and incidence of clinical outcomes and mortality, among patients with incident atrial fibrillation (AF) in the Nordic countries. Methods: We conducted a registry‐based multinational cohort study of OAC‐naïve patients diagnosed with AF that redeemed at least one prescription of OAC after AF in Denmark (N = 25 585), Sweden (N = 59 455), Norway (N = 40 046) and Finland (N = 22 415). Persistence was dispensing at least one prescription of OAC from Day 365 after the first prescription and 90 days forward. Results: Persistence was 73.6% (95% confidence interval 73.0–74.1) in Denmark, 71.1% (70.7–71.4) in Sweden, 89.3% (88.2–90.1) in Norway and 68.6% (68.0–69.3) in Finland. One‐year risk of ischemic stroke varied between 2.0% (1.8–2.1) in Norway and 1.5% (1.4–1.6) in Sweden and 1.5% (1.3–1.6) in Finland. One‐year risk of major bleeding other than intracranial bleeding varied between 2.1% (1.9–2.2) in Norway and 5.9% (5.6–6.2) in Denmark. One‐year mortality risk varied between 9.3% (8.9–9.6) in Denmark and 4.2% (4.0–4.4) in Norway. Conclusion: In OAC‐naïve patients with incident AF, persistence of OAC therapy and clinical outcomes vary across Denmark, Sweden, Norway and Finland. Initiation of real‐time efforts are warranted to ensure uniform high‐quality care across nations and regions. [ABSTRACT FROM AUTHOR]

Aims: We aimed to study initiation, adherence, and long‐term persistence to beta‐blockers (BB), renin–angiotensin system inhibitors (RASi), and mineralocorticoid receptor antagonists (MRA) in a nationwide cohort of patients with heart failure (HF). Methods: Patients aged 18–80 years in Norway with a first diagnosis of HF from 2014 until 2020 that survived ≥30 days were identified from the Norwegian Patient Registry and linked to the Norwegian Prescription Database. We collected information about BB, RASi [angiotensin‐converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and angiotensin receptor‐neprilysin inhibitors (ARNI)], and MRA. Dual HF therapy was defined as taking at least two out of three drug classes, whereas triple HF therapy was defined as taking all three. Initiation (time to initiation) and persistence (time to discontinuation using a grace period of 30 days) of HF drugs was calculated by the Kaplan–Meier method, followed to outcome of interest, death, or December 2020. One‐year adherence was measured as proportion of days covered (PDC) using a cut‐off at 80%. For adherence and persistence measurements, we allowed for maximum 60 days of stockpiling and switching within drug groups. We performed sensitivity analyses to test the robustness of our findings. Results: Out of 54 899 patients included in the cohort, 75%, 69%, and 21% initiated a BB, RASi, and MRA, respectively, whereas 13% did not receive any. Dual and triple HF therapy was prescribed to 61% and 16%, respectively. The proportion of adherent patients during the first year following initiation was 83%, 81%, 84%, and 61% for BB, RASi, ARNI, and MRA, whereas 42% and 5% were adherent to dual and triple HF therapy, respectively. From 2 to 5 years following initiation, persistence decreased from 58% to 38%, 57% to 37%, and 31% to 15% for BB, RASi, and MRA, respectively. Within the RASi group, persistence was higher for ARNI than for ACEI and ARB. There were no major changes in either initiation or adherence of the drug classes from 2014 to 2019, except for an increase in initiation and adherence of MRA. Conclusions: We found low adherence to dual and triple HF therapies in this nationwide cohort study of newly diagnosed HF patients. Efforts are needed to increase adherence and persistence to HF therapies into clinical practice, emphasizing maintenance of multiple drug therapies in patients with such an indication. [ABSTRACT FROM AUTHOR]

Aims: In clinical practice, many patients do not reach the recommended treatment targets for LDL-cholesterol levels. We aimed to examine treatment patterns and adherence for patients on lipid lowering drugs in Norway to inform future strategies to improve therapies. Methods and results: We obtained information on all dispensed statins, ezetimibe, and proprotein convertase subtilisin/-kexin 9 (PCSK9) inhibitors 2010–2019 from the Norwegian Prescription Database. Treatment gaps were assessed assuming patients take one tablet per day and were defined to occur if a patient did not refill a prescription when the previous one should have been depleted. Treatment was defined as discontinued when the preceding prescription would have been used and no new subsequent prescription was filled. The mean proportion of days covered (PDC) was calculated by aggregating the total number of tablets dispensed during each calendar year and dividing by 365. Patients 80 years were excluded. A considerable proportion of statin users in Norway had long treatment gaps or discontinuation in treatment. The 19.6% of the patients had treatment gaps of 180 days or more, and 10.8% had gaps or greater than 365 days. Similar results were found for patients on antidiabetics and hypertensives. PDC ranged from 84.9% for simvastatin to 72.2% for ezetimibe (2019). The most common lipid lowering drugs in 2019 were atorvastatin, simvastatin, and ezetimibe. Conclusion: There is a great potential for improving drug adherence and optimizing lipid lowering therapy by switching to more effective statins in greater doses, and more often add ezetimibe and PCSK9 inhibitors to treatment. Graphical abstract [ABSTRACT FROM AUTHOR]

Aims Acute myocardial infarction (AMI) is a common cause of morbidity and mortality. The aim of the present study was to assess time trends in the incidence, treatment, and outcome of AMI in a nationwide registry-based cohort of patients. Methods and results All patients with a first AMI registered in the Norwegian Myocardial Infarction Registry between 2013 and 2019 were included in this cohort study. The number of patients admitted to Norwegian hospitals with a first AMI decreased from 8933 in 2013 to 8383 in 2019. The proportion of patients with ST-elevation myocardial infarction (STEMI) was stable at 30% throughout the period, and the percentage of STEMI undergoing coronary angiography was stable at 87%. The proportion of patients with non-STEMI undergoing coronary angiography increased by 2.4% per year (95% confidence interval 1.6-3.3) from 58% in 2013 to 68% in 2019. More patients were discharged with secondary preventive medication at the end of study period. Age-adjusted 1-year mortality was reduced from 16.4% in 2013 to 15.1% in 2018. The changes over time were primarily seen in the oldest patient groups. Conclusion In the period 2013-19 in Norway, we found a reduction in hospitalizations due to a first AMI. Both the percentage of patients undergoing coronary angiography as well as the percentage discharged with recommended secondary preventive therapy increased during the period, and the age-adjusted 1-year mortality after AMI decreased. A national AMI register provides important information about trends in incidence, treatment, and outcome, and may improve adherence to guideline recommendations. [ABSTRACT FROM AUTHOR]

Background: The incidence of heart failure (HF) has declined in Europe during the past two decades. However, incidence estimates from registry-based studies may vary, partly because they depend on retrospective searches to exclude previous events. The aim of this study was to assess to what extent different lookback periods (LPs) affect temporal trends in incidence, and to identify the minimal acceptable LP. Further, we wanted to estimate temporal trends in incidence and prevalence of HF in a nationwide population, using the minimal acceptable LP.Methods: We identified all in- and out-patient contacts for HF in Norway during 2008 to 2018 from the Norwegian Patient Registry. To calculate the influence of varying LP on incident cases, we defined 2018 with 10 years of LP as a reference and calculated the relative difference by using one through 9 years of lookback. Temporal trends in incidence rates were estimated with sensitivity analyses applying varying LPs and different case definitions. Standardised incidence rates and prevalence were calculated by applying direct age- and sex-standardization to the 2013 European Standard Population.Results: The overestimation of incident cases declined with increasing number of years included in the LP. Compared to a 10-year LP, application of 4, 6, and 8 years resulted in an overestimation of incident cases by 13.5%, 6.2% and 2.3%, respectively. Temporal trends in incidence were affected by the number of years in the LP and whether the LP was fixed or varied. Including all available data mislead to conclusions of declining incidence rates over time due to increasing LPs.Conclusions: When taking the number of years with available data and HF mortality and morbidity into consideration, we propose that 6 years of fixed lookback is sufficient for identification of incident HF cases. HF incidence rates and prevalence increased from 2014 to 2018.Trial Registration: Retrospectively registered. [ABSTRACT FROM AUTHOR]

Objectives: To assess the risk of stroke/systemic embolism (SE) and major bleeding associated with the use of oral anticoagulants in elderly patients with atrial fibrillation (AF) in a real-world population.Methods: We identified all anticoagulant-naive initiators of warfarin, dabigatran, rivaroxaban and apixaban for the indication AF in Norway between January 2013 and December 2017. Multivariate competing risk regression was used to calculate subhazard ratios (SHRs) describing associations between non-vitamin K antagonist oral anticoagulants (NOACs) compared with warfarin for risk of stroke/SE and major bleeding.Results: Among 30 401 patients ≥75 years identified (median age 82 years, 53% women, mean CHA2DS2-VaSc score 4.5), 3857 initiated dabigatran, 6108 rivaroxaban, 13 786 apixaban and 6650 warfarin. Reduced dose was initiated in 11 559 (49%) of the NOAC-treated patients. For stroke, the SHRs for standard dose NOAC against warfarin were 0.80 (95% CI 0.57 to 1.13) for dabigatran; 1.07 (95% CI 0.89 to 1.30) for rivaroxaban and 0.95 (95% CI 0.78 to 1.15) for apixaban. For major bleeding, the SHRs against warfarin were 0.75 (95% CI 0.52 to 1.08) for dabigatran; 0.96 (95% CI 0.78 to 1.16) for rivaroxaban and 0.74 (95% CI 0.60 to 0.91) for apixaban. Comparing reduced doses of NOACs with warfarin yielded similar results. Sensitivity analyses were in accordance with the main results.Conclusion: In this nationwide cohort study of patients ≥75 years initiating oral anticoagulation for AF, standard and reduced dose NOACs were associated with similar risks of stroke/SE as warfarin and lower or similar risks of bleeding. The NOACs seem to be a safe option also in elderly patients. [ABSTRACT FROM AUTHOR]

Background. Heart rhythm disorders, especially atrial fibrillation (AF), are increasing global health challenges. Conventional diagnostic tools for assessment of rhythm disorders suffer from limited availability, limited test duration time, and usability challenges. There is also a need for out-of-hospital investigation of arrhythmias. Therefore, the Norwegian ECG247 Smart Heart Sensor has been developed to simplify the assessment of heart rhythm disorders. The current study aimed to evaluate the diagnostic accuracy and usability of the ECG247 Smart Heart Sensor compared to conventional Holter monitors. Methods. Parallel tests with ECG247 Smart Heart Sensor and a Holter monitor were performed in 151 consecutive patients referred for out-of-hospital long-term ECG recording at Sorlandet Hospital Arendal, Norway. All ECG data were automatically analysed by both systems and evaluated by hospital physicians. Participants were asked to complete a questionnaire scoring usability parameters after the test. Results. A total of 150 patients (62% men, age 54 (±17) years) completed the study. The ECG quality from both monitors was considered satisfactory for rhythm analysis in all patients. AF was identified in 9 (6%) patients during the period with parallel tests. The diagnostic accuracy for automatic AF detection was 95% (95% CI 91–98) for the ECG247 Smart Heart Sensor and 81% (95% CI 74–87) for the Holter system. The proportion of false-positive AF was 4% in tests analysed by the ECG247 algorithm and 16% in tests analysed by the Holter algorithm. Other arrhythmias were absent/rare. The system usability score was significantly better for ECG247 Smart Heart Sensor compared to traditional Holter technology (score 87.4 vs. 67.5, p < 0.001). Conclusions. The ECG247 Smart Heart Sensor showed at least comparable diagnostic accuracy for AF and improved usability compared to conventional Holter technology. ECG247 allows for prolonged monitoring and may improve detection of AF. This trial is registered with https://clinicaltrials.gov/ct2/show/NCT04700865. [ABSTRACT FROM AUTHOR]

Objective: The decline in the incidence and mortality of acute myocardial infarction (AMI) has been less among younger compared with older individuals. The aim of this nationwide study was to assess the current incidence, risk factors and outcome of AMI in patients <45 years of age.Methods: All patients ≤80 years of age registered in the Norwegian Myocardial Infarction Register in 2013-2016 were included in this observational, nationwide cohort study. Follow-up was conducted through linkage with the Norwegian Patient Registry through 2017.Results: Among a total of 33 439 patients ≤80 years with AMI, 1468 (4.4%) were <45 years old. The incidence of AMI was 2.1 per 100 000 person-years in people aged 20-29 years, 16.9 in people aged 30-39 years and 97.6 in people aged 40-49 years. Compared with older patients, patients <45 years were more likely to be male (81%), current smokers (56%), obese (30%) and have a family history of premature AMI (44%), and their low-density lipoprotein-cholesterol levels were higher. Patients <45 years were more likely to have non-obstructive coronary artery disease (14% vs 10%, p<0.001) compared with older patients. During a median follow-up time of 2.4 years, 135 (9%) patients <45 years experienced a new AMI, stroke or death, and 58 (4%) patients died.Conclusions: The rate of AMI was low in people <45 years old in Norway, but almost one in ten patients with AMI <45 years old died or experienced a new cardiovascular event during follow-up. Increased efforts to improve risk factor control in these patients are warranted. [ABSTRACT FROM AUTHOR]

Aims: Large‐scaled population studies of incidence and prevalence of heart failure (HF) are needed for the development of healthcare policies and priorities. The aim of this study was to estimate the incidence, prevalence, and all‐cause mortality of HF in Norway from 2013 to 2016 on the basis of a national registry. Methods and results: Using data from the nationwide Norwegian Prescription Database, we identified all patients ≥18 years of age in Norway with at least one drug prescription with HF during 2013–2016, defined by 10th revision of the International Classification of Diseases (ICD‐10) codes I50, I11, I13, or I42. The individual index date was the date of the first prescription. Patients were followed up until death or end of follow‐up (31 October 2017). Annual incidence and prevalence were estimated from 2013 to 2016, using a look‐back period starting from 1 March 2008. We calculated standardized estimates by applying direct age and sex standardization to the 2013 European standard population. All‐cause mortality from 2013 to 2016 was calculated among the prevalent HF patients. Standardized mortality ratio (SMR) was calculated by indirect standardization using general mortality in the Norwegian population as reference. We identified 54 542 unique patients (58% men) with a first‐time diagnosis of HF. The median age was 72 ±14 years, and women were older than men (median age 76 vs. 70 years, respectively). The crude (standardized) incidence of HF was 3.44/1000 (4.23/1000) person‐years in 2016 and did not increase over the 4 year period, while the prevalence increased from 2.0% (2.3%) to 2.4% (2.8%). Both incidence and prevalence were higher in men than in women and strongly associated with age. Crude mortality rates in the HF population declined from 94 to 82/1000 person‐years from 2013 to 2016, and SMR declined from 2.01 to 1.84. Age‐adjusted mortality rates were higher in men than in women. Conclusions: This nationwide registry study in Norway showed an increase in the prevalence of HF from 2013 to 2016, with stable incidence rates and improved survival. [ABSTRACT FROM AUTHOR]

Patients with familial hypercholesterolemia (FH) have an increased risk of premature myocardial infarction (MI). The objective of the study is to investigate the prevalence of FH among young patients hospitalized with acute MI. Data were collected from medical charts of all patients aged <45 years admitted with acute MI to the Department of Cardiology, Oslo University Hospital Ullevål, in the period 2012 to 2016. Patients who had not already been genetically tested for FH were contacted and offered genetic testing if the pretreatment or the statin-adjusted low-density lipoprotein cholesterol level was >4.0 mmol/L (155 mg/dL). Of 9332 patients admitted with acute MI, 357 were aged <45 years. Sixteen patients were deceased, and 13 patients did not have MI on an atherosclerotic basis. Of the remaining 328 patients eligible for investigation, 130 had the pretreatment or statin-adjusted low-density lipoprotein cholesterol level >4.0 mmol/L (155 mg/dL). Of these, data from 52 patients genetically tested for FH were available. Eleven patients had genetically verified FH constituting 3.4% of the total eligible population (n = 328), 8.5% of those with indications for genetic testing (n = 130), and 21.2% of those actually tested (n = 52). A Dutch Lipid Clinic Network score for clinical FH diagnosis of "definite FH" identified only 5 of the 11 patients with positive genetic test (45%). Including a score of "probable FH" identified all patients with FH but also 17 of the 41 patients (41%) with a negative genetic test. The prevalence of FH in young patients with acute MI was higher than in the general population. Routine evaluation of FH diagnosis among these patients could identify more patients with FH, thereby increasing the possibility of initiating early and adequate treatment also among affected relatives. • Three hundred twenty-eight patients aged <45 years had myocardial infarction (MI); 130 had low-density lipoprotein cholesterol level >4.0 mmol/L (155 mg/dL). • 52 patients were genetically tested, of whom 11 had a positive genetic test. • Prevalence of familial hypercholesterolemia (FH) in young patients with MI was higher than in the general population. • Routine evaluation of FH in patients with MI could identify more patients with FH. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether exposure to hyperemesis gravidarum (hyperemesis) is associated with subsequent maternal cardiovascular morbidity. Design: Nationwide cohort study. Setting: Medical Birth Registry of Norway (1967–2002) linked to the nationwide Cardiovascular Disease in Norway project 1994–2009 (CVDNOR) and the Cause of Death Registry. Population: Women in Norway with singleton births from 1967 to 2002, with and without hyperemesis, were followed up with respect to cardiovascular outcomes from 1994 to 2009. Methods: Cox proportional hazards regression model was applied to estimate hazard ratios (HRs) with 95% confidence interval (CI). Main outcome measures: The first hospitalisation due to nonfatal stroke, myocardial infarction or angina pectoris, or cardiovascular death. Results: Among 989 473 women with singleton births, 13 212 (1.3%) suffered from hyperemesis. During follow-up, a total of 43 482 (4.4%) women experienced a cardiovascular event. No association was found between hyperemesis and the risk of a fatal or nonfatal cardiovascular event (adjusted HR 1.08; 95% CI 0.99–1.18). Women with hyperemesis had higher risk of hospitalisation due to angina pectoris (adjusted HR 1.28; 95% CI 1.15–1.44). The risk of cardiovascular death was lower among hyperemetic women in age-adjusted analysis (HR 0.73; 95% CI 0.59–0.91), but the association was no longer significant when adjusting for possible confounders. Conclusion: Women with a history of hyperemesis did not have increased risk of a cardiovascular event (nonfatal myocardial infarction or stroke, angina pectoris or cardiovascular death) compared to women without. [ABSTRACT FROM AUTHOR]

Objective: To assess midlife cardiovascular risk profiles in women with a history of hyperemesis or hypertensive disorders in pregnancy compared to women with none of the studied pregnancy complications.Study Design: Population-based study. Cardiovascular risk factors at the age of 40-45 among women with previous singleton births only were studied through linkage of the Norwegian Birth Registry and a Norwegian screening program (the Age 40 Program).Main Outcome Measures: Family history of coronary heart disease, body mass index, smoking, physical activity, systolic and diastolic blood pressure, heart rate, cholesterol, triglycerides, antihypertensive treatment and diabetes.Results: Among 178,231 women participating in the Age 40 Program with previous singleton births; 2140 (1.2%) had experienced hyperemesis and 13,348 (7.5%) hypertensive disorders in pregnancy. Women who had suffered from hyperemesis were less physically active. The differences in mean systolic blood pressure and body mass index were probably clinically irrelevant. In women with a history of hypertensive disorders in pregnancy, systolic and diastolic blood pressure and body mass index were higher, and they were more likely to report diabetes in midlife. Women who had suffered from hyperemesis or hypertensive disorders in pregnancy were less likely to be daily smokers.Conclusion: Women with hypertensive disorders in pregnancy seemed to have an unfavorable cardiovascular risk profile in midlife compared to women with uncomplicated pregnancies. In contrast there was no consistent evidence of increased risk subsequent to hyperemesis gravidarum. The proportion of daily smokers was lower in women with either of the two pregnancy complications. [ABSTRACT FROM AUTHOR]

Background: Gender differences in short-term mortality in acute myocardial infarction (AMI) have been studied extensively, whereas gender differences in long-term mortality and cause of death largely remain unknown. The aim of this study was to assess the long-term risk of all-cause, cardiovascular and cancer death after AMI in women compared to men.Methods: Consecutive AMI patients were enrolled in a prospective registry between 2005 and 2011. Date and cause of death were obtained by linkage with the Norwegian Cause of Death Registry, with censoring date 31 December 2012. AMI patients with ST-segment elevation (STEMI, n = 5159) and without (NSTEMI, n = 4899) were analysed separately.Results: The 5-years all-cause mortality rates in STEMI were 29% in women vs. 17% in men, and 42% vs. 29% in NSTEMI, respectively. After adjustment for age and other confounders, women with STEMI had similar (HR 1.13 [95% CI: 0.98-1.32]) and women with NSTEMI lower (HR 0.82 [95% CI: 0.73-0.92]) risk of long-term all-cause mortality compared to men. Competing-risks analysis showed no significant gender differences in age-adjusted risk of cardiovascular death nor of cancer death. In both genders, the annual risk of cardiovascular death was low after 1 year, but exceeded annual risk of cancer death throughout follow-up.Conclusion: During long-term follow-up, women with STEMI had similar and women with NSTEMI lower adjusted risk of all-cause mortality compared to men. Age-adjusted risk of death due to cardiovascular disease was similar in both genders and higher than risk of death due to cancer throughout the follow-up period. [ABSTRACT FROM AUTHOR]

Background: Secondary preventive drug therapy following acute myocardial infarction (AMI) is recommended to reduce the risk of new cardiovascular events. The aim of this nationwide cohort study was to examine the initiation and long-term use of secondary preventive drugs after AMI.Methods: The prescription of drugs in 42,707 patients < 85 years discharged alive from hospital after AMI in 2009-2013 was retrieved by linkage of the Norwegian Patient Register, the Norwegian Prescription Database, and the Norwegian Cause of Death Registry. Patients were followed for up to 24 months.Results: The majority of patients were discharged on single or dual antiplatelet therapy (91 %), statins (90 %), beta-blockers (82 %), and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor II blockers (ARB) (60 %). Patients not undergoing percutaneous coronary intervention (PCI) (42 %) were less likely to be prescribed secondary preventive drugs compared with patients undergoing PCI. This was particular the case for dual antiplatelet therapy (43 % vs. 87 %). The adherence to prescribed drugs was high: 12 months after index AMI, 84 % of patients were still on aspirin, 84 % on statins, 77 % on beta-blockers and 57 % on ACEI/ARB. Few drug and dose adjustments were made during follow-up.Conclusion: Guideline-recommended secondary preventive drugs were prescribed to most patients discharged from hospital after AMI, but the percentage receiving such therapy was significantly lower in non-PCI patients. The long-time adherence was high, but few drug adjustments were performed during follow-up. More attention is needed to secondary preventive drug therapy in AMI patients not undergoing PCI. [ABSTRACT FROM AUTHOR]

Objectives. The aim of this study was to compare health-related quality of life (HRQoL) scores obtained from the instrument Short Form (SF)-36 through the so-called SF-6D utilities, and those obtained from 15D, in patients with ST-elevation myocardial infarction (STEMI), and to evaluate the consequences in estimation of quality adjusted life years (QALYs). Design. This was a sub-study of the Norwegian District Treatment of STEMI, in which patients with STEMI treated with tenecteplase, were randomized to early angioplasty or standard management ( n = 266). HRQoL data were collected at all visits (0, 1, 3, 7 and 12 months). All patients with complete data were included ( n = 248). Results. The score range was 0.33-1.0 for SF-6D and 0.49-1.0 for 15D. Mean utility scores from 15D were higher and had different distribution compared to scores from SF-6D. Mean QALY for the whole group was higher using 15D than SF-6D (0.89 vs. 0.77). The incremental number of QALYs with early angioplasty compared to standard treatment was 0.005 (95% CI: − 0.018 to 0.028) using SF-6D, and 0.004 (95% CI: − 0.010 to 0.018) using the 15D instrument. Conclusions. Choice of instrument may influence HRQoL scores, but not necessarily the gain in QALYs. [ABSTRACT FROM AUTHOR]

• Venous thromboembolism (VTE) is a major cause of mortality and morbidity worldwide. • Data on VTE patients was extracted from the Norwegian Patient Registry. • Recently the incidence and prevalence of VTE in Norway has been relatively stable. • The incidence of PE has increased, whereas DVT incidence has decreased slightly. [ABSTRACT FROM AUTHOR]

Aim: To compare short- and long-term survival in patients admitted to hospital after acute myocardial infarction (AMI) with and without out-of-hospital cardiac arrest (OHCA).Methods: Prospective cohort study of all AMI patients admitted to Oslo University Hospital Ulleval from September 1, 2005 to December 31, 2011. All-cause mortality was obtained from the Norwegian Cause of Death Registry with censoring date December 31, 2013. Cumulative survival was assessed with the Kaplan-Meier and the Life-table method. Logistic- and Cox regression were used for risk comparisons.Results: We identified 404 AMI patients with OHCA and 9425 AMI patients without. AMI patients without OHCA were categorized as ST-elevation myocardial infarction (STEMI, n=4522) or non-STEMI (NSTEMI, n=4903). Mean age was 63.6±standard deviation (SD) 12.5, 63.8±13.1 and 69.7±13.6 years in OHCA, STEMI and NSTEMI, respectively. Coronary angiography with subsequent percutaneous coronary intervention if indicated, was performed in 87% of OHCA, 97% of STEMI and 80% of NSTEMI patients. Thirty-day survival was 63%, 94% and 94%, and 8-year survival was 49%, 74%, and 57%, respectively. Among patients surviving the first 30days, no significant difference in risk during long-term follow-up was found (adjusted Hazard Ratio (aHR)OHCAvsSTEMI 1.15 [95% CI 0.82-1.60], aHROHCAvsNSTEMI 0.89 [95% CI 0.64-1.24]).Conclusions: Long-term survival after OHCA due to AMI was good, with 49% of admitted patients being alive after eight years. Although short-term mortality remained high, OHCA patients alive after 30days had similar long-term risk as AMI patients without OHCA. [ABSTRACT FROM AUTHOR]

Background and Aims: Proper prescription and high adherence to intensive lipid lowering drugs (LLD) in patients with coronary heart disease (CHD) are crucial and strongly recommended. The aim of this study is to investigate long-term treatment patterns and adherence to LLD following hospitalization for a CHD event., Methods: Patients admitted to two Norwegian hospitals with a CHD event from 2011 to 2014 (N = 1094) attended clinical examination and completed a questionnaire, median 16 months later. Clinical data were linked to pharmacy dispensing data from 2010 to 2020. The proportions using high-intensity statin therapy (atorvastatin 40/80 mg or rosuvastatin 20/40 mg) and non-statin LLD after the CHD event were assessed. Adherence was evaluated by proportion of days covered (PDC) and gaps in treatment., Results: Median age at hospitalization was 63 (IQR 12) years, 21 % were female. Altogether, 1054 patients (96 %) were discharged with a statin prescription, while treatment was dispensed in 85 % within the following 90 days. During median 8 (SD 2.5) years follow-up, the proportion using high-intensity statin therapy ranged 62-68 %, whereas the use of ezetimibe increased from 4 to 26 %. PDC <0.8 was found in 22 % of statin users and 26 % of ezetimibe users. The proportions with a treatment gap exceeding 180 days were 22 % for statins and 28 % for ezetimibe. Smoking at hospitalization and negative affectivity were significantly associated with reduced statin adherence, regardless of adherence measure., Conclusions: In this long-term follow-up of patients with CHD, less than 70 % used high-intensity statin therapy with only small changes over time, and only 25 % used additional treatment with ezetimibe. We identified factors associated with reduced statin adherence that may be target for interventions., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:IE and CB are affiliated with Oslo Economics and have completed consultancy assignments outside the submitted work for several public and private institutions in recent years. HS is affiliated with Steno Diabetes Center Aarhus and has received consultancy fees from Novartis, Arla Foods AMBA, Bristol-Myers Squibb, Pfizer and Neumirna outside the submitted work. EH, ES and TD reports no conflicts of interest. SH has received lecture fees from Sanofi, Novartis, and Pfizer outside the submitted work. JM received lecture fees from Sanofi, Novartis, Boehringer Ingelheim, and Bayer outside the submitted work., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background and Aims: The evidence for beta-blocker therapy after myocardial infarction (MI) is randomized trials conducted more than 30 years ago, and the continued efficacy has been questioned., Design and Methods: The ongoing Danish (DANBLOCK) and Norwegian (BETAMI) randomized beta-blocker trials are joined to evaluate the effectiveness and risks of long-term beta-blocker therapy after MI. Patients with normal or mildly reduced left ventricular ejection fraction (LVEF ≥ 40%) will be randomized to open-label treatment with beta-blockers or no such therapy. The event-driven trial will randomize ∼5700 patients and continue until 950 primary endpoints have occurred. As of July 2023, 5228 patients have been randomized. Of the first 4000 patients randomized, median age was 62 years, 79% were men, 48% had a ST-segment elevation myocardial infarction (STEMI), and 84% had a normal LVEF. The primary endpoint is a composite of adjudicated recurrent MI, incident heart failure (HF), coronary revascularization, ischaemic stroke, all-cause mortality, malignant ventricular arrhythmia, or resuscitated cardiac arrest. The primary safety endpoint includes a composite of recurrent MI, HF, all-cause mortality, malignant ventricular arrhythmia, or resuscitated cardiac arrest 30 days after randomization. Secondary endpoints include each of the components of the primary endpoint, patient-reported outcomes, and other clinical outcomes linked to beta-blocker therapy. The primary analysis will be conducted according to the intention-to-treat principle using a Cox proportional hazards regression model. End of follow-up is expected in December 2024., Conclusion: The combined BETAMI-DANBLOCK trial will have the potential to affect current clinical practice for beta-blocker therapy in patients with normal or mildly reduced LVEF after MI., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objective: This study aims to compare the rule-out safety of a single high-sensitivity cardiac troponin T (hs-cTnT) with the History, ECG, Age, Risk factors and Troponin (HEART) score in a low-prevalence primary care setting of acute myocardial infarction (AMI)., Participants: Patients with non-specific symptoms suggestive of AMI were consecutively enroled at a primary care emergency clinic in Oslo, Norway from November 2016 to October 2018., Methods: After initial assessment by a general practitioner, hs-cTnT samples were drawn. AMI was ruled-out by a single hs-cTnT <5 ng/L measured ≥3 hours after symptom onset. The HEART score was calculated retrospectively; a score ≤3 of 10 points was considered low risk. We also calculated a modified HEART score using more sensitive hs-cTnT thresholds. The primary outcome was the diagnostic performance for the rule-out of AMI at the index event; the secondary the composite of AMI or all-cause death at 90 days., Results: Among 1711 patients, 61 (3.6%) were diagnosed with AMI, and 569 (33.3%) patients were assigned to single rule-out (<5 ng/L). With no AMIs in this group, the negative predictive value (NPV) and sensitivity were both 100.0% (95% CI 99.4% to 100.0% and 94.1% to 100.0%, respectively), and the specificity 34.5% (32.2% to 36.8%). The original HEART score triaged more patients as low risk (n=871), but missed five AMIs (NPV 99.4% (98.7% to 99.8%); sensitivity 91.8% (81.9% to 97.3%) and specificity 52.5% (50.0% to 54.9%)). The modified HEART score increased the low-risk sensitivity to 98.4% (91.2% to 100.0%), with specificity 38.7% (36.3% to 41.1%). The 90-day incidence of AMI or death in the single rule-out and the original and modified low-risk HEART groups were 0.0%, 0.7%, and 0.2%, respectively., Conclusion: In a primary care emergency setting, a single hs-cTnT strategy was superior to the HEART score in ruling out AMI. This rapid and safe approach may enhance the assessment of patients with chest pain outside of hospitals., Trial Registration Number: NCT02983123., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The European Society of Cardiology 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) has demonstrated high rule-out safety in large hospital validation cohorts. We aimed to validate the algorithm in a primary care setting, where patients have a lower pretest probability for acute coronary syndrome., Methods: This prospective, observational, diagnostic study included patients with acute non-specific chest pain admitted to a primary care emergency clinic in Oslo, Norway, from November 2016 to October 2018. hs-cTnT was measured after 0, 1 and 4 hours. The primary outcome measure was the diagnostic performance of the 0/1-hour algorithm, the 90-day incidence of AMI or all-cause death the secondary., Results: Among 1711 included patients, 61 (3.6%) were diagnosed with AMI. By applying the algorithm, 1311 (76.6%) patients were assigned to the rule-out group. The negative predictive value was 99.9% (95% CI 99.5% to 100.0%), the sensitivity and specificity 98.4% (91.2-100.0) and 79.4% (77.4-81.3), respectively. Sixty-six (3.9%) patients were triaged towards rule-in, where 45 were diagnosed with AMI. The corresponding positive predictive value was 68.2% (58.3-76.7), sensitivity 73.8% (60.9-84.2), and specificity 98.7% (98.1-99.2). Among 334 (19.5%) patients assigned to the observation group in need of further tests, 15 patients had an AMI. The following 90 days, five new patients experienced an AMI and nine patients died, with a low incidence in the rule-out group (0.3%)., Conclusion: The 0/1-hour algorithm for hs-cTnT seems safe, efficient and applicable for an accelerated assessment of patients with non-specific chest pain in a primary care emergency setting., Trial Registration Number: NCT02983123., Competing Interests: Competing interests: DA has received speaker’s honoraria and consultancy fees from Amgen, Astra Zeneca, Bayer Healthcare, BMS, Boehringer-Ingelheim, Merck, Novartis, Pfizer and Sanofi-Aventis, and research grants from the institution by Medtronic and BMS. SH has received speaker’s honoraria and consultancy fees from Amgen, Astra Zeneca, Bayer Healthcare, BMS, Boehringer-Ingelheim, Merck, Novartis, Pfizer and Sanofi-Aventis, and has no conflicts in relation to this study., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: The aim of this study was to compare the risk of stroke or systemic embolism (SE) and major bleeding in patients with atrial fibrillation (AF) using dabigatran, rivaroxaban, and apixaban in routine clinical practice., Methods and Results: Using nationwide registries in Norway from January 2013 to December 2017, we established a cohort of 52 476 new users of non-vitamin K antagonist oral anticoagulants (NOACs) with AF. Users of individual NOACs were matched 1:1 on the propensity score to create three pairwise-matched cohorts: dabigatran vs. rivaroxaban (20 504 patients), dabigatran vs. apixaban (20 826 patients), and rivaroxaban vs. apixaban (27 398 patients). Hazard ratios (HRs) for the risk of stroke or SE and major bleeding were estimated. In the propensity-matched comparisons of the risk of stroke or SE, the HRs were 0.88 [95% confidence interval (CI) 0.76-1.02] for dabigatran vs. rivaroxaban, 0.88 (95% CI 0.75-1.02) for dabigatran vs. apixaban, and 1.00 (95% CI 0.89-1.14) for apixaban vs. rivaroxaban. For the risk of major bleeding, the HRs were 0.75 (95% CI 0.64-0.88) for dabigatran vs. rivaroxaban, 1.03 (95% CI 0.85-1.24) for dabigatran vs. apixaban, and 0.79 (95% CI 0.68-0.91) for apixaban vs. rivaroxaban., Conclusion: In this nationwide study of patients with AF in Norway, we found no statistically significant differences in risk of stroke or SE in propensity-matched comparisons between dabigatran, rivaroxaban, and apixaban. However, dabigatran and apixaban were both associated with significantly lower risk of major bleeding compared with rivaroxaban., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Secondary prophylactic drugs are important for avoiding further cardiovascular events after myocardial infarction. We have examined whether patients collect these drugs from pharmacies and whether there are differences in survival between those who collect versus do not collect the drugs., Material and Method: All patients <80 years registered in the Norwegian Myocardial Infarction Registry in 2013-16 were included in the study. The Norwegian Prescription Database was used to determine whether patients collected their prescriptions from pharmacies., Results: During the study period, 32 328 patients under the age of 80 were registered in the Norwegian Myocardial Infarction Registry, of whom 96 % were discharged alive. The proportion of patients who were prescribed acetylsalicylic acid was 95 %, two antiplatelet agents, 83 %; a statin, 90 %; beta-blockers, 76 %; and ACE inhibitors/AII receptor blockers, 55 %. The proportions of patients who collected each of these drugs from a pharmacy within six months were 94 %, 90 %, 96 %, 95 % and 94 %, respectively. The combined incidence of death, stroke and myocardial infarction during the follow-up period (median 944 days) was higher among patients who did not collect all of their prescribed drugs (adjusted HR 1.7; 95 % CI 1.6-1.8). Among patients who died, the median time to death was 509 days for those who collected all of their prescribed drugs versus 126 days for those who did not (p <0.001)., Interpretation: Most patients do collect prescribed drugs from a pharmacy after myocardial infarction. A shorter time to death among patients who do not collect the drugs may suggest a high degree of general morbidity in this group.

Background: The prevalence of atrial fibrillation in patients with acute myocardial infarction is largely unknown. The aims of the present study were to assess the prevalence of atrial fibrillation in a nationwide cohort of patients with acute myocardial infarction, to assess the prescription of anticoagulation therapy, and to study the long-term outcomes., Design: A nationwide registry-based cohort study., Methods: All patients registered in the Norwegian Myocardial Infarction Registry between 2013 and 2016 were included and followed up through 2017. Stroke rates during follow-up were obtained through linkage with the Norwegian Patient Registry., Results: In total, 47,204 patients were registered in the Norwegian Myocardial Infarction Registry. Atrial fibrillation on admission was recorded in 5393 (11%) patients, and 2190 (5%) additional patients developed atrial fibrillation during their hospital stay. Only 45% of patients with atrial fibrillation on admission and CHA 2 DS 2 -VASc score ≥ 2 were treated with anticoagulation therapy prior to myocardial infarction, and 56% of patients with atrial fibrillation and CHA 2 DS 2 -VASc score ≥ 2 were prescribed anticoagulation therapy at discharge. Patients with myocardial infarction and atrial fibrillation had an increased risk of stroke or death during 822 (426, 1278) days of follow-up compared with patients without atrial fibrillation (multivariate adjusted hazard ratio 1.4, 95% confidence interval 1.3-1.4)., Conclusions: Almost half of patients with atrial fibrillation and myocardial infarction were not prescribed the guideline recommended treatment with anticoagulation therapy at discharge, and their long-term risk of stroke and death was increased compared with patients without atrial fibrillation. Increased efforts to improve the treatment of patients with myocardial infarction and atrial fibrillation are needed.

Background: Patients with established coronary artery disease (CAD) have an increased risk of new cardiovascular events. An underuse of secondary preventive drugs has been observed, and many patients may not attain the treatment goals for secondary prevention. The aims of the present nationwide register-based cohort study were to assess the degree of risk factor control and long-term outcomes in patients < 80 years with Type 1 myocardial infarction (MI) with and without prior CAD., Methods: Data concerning all patients with MI admitted to hospitals in Norway from 2013 to 2016 were retrieved from the Norwegian Myocardial Infarction Register (NORMI). Long-term mortality was obtained through linkage with the Norwegian Cause of Death Registry., Results: In total, 47,204 patients were registered in the NORMI from 2013 to 2016. Prior CAD was recorded in 7219 (25.2%) of the 28,607 patients < 80 years old with Type 1 MIs. On average, 3 of the 6 defined treatment targets for secondary preventive therapy were attained, and only 1% of the patients achieved all targets. Patients with MI and prior CAD had increased risk of death or new MI compared to patients without prior CAD during long-term follow-up (adjusted HR 1.6, 95% CI 1.5-1.7)., Conclusions: Prior CAD was frequent in patients with acute MI. The attainment of secondary preventive treatment targets in patients with MI and prior CAD was not optimal, and the long-term outcomes were reduced compared to patients without prior CAD. Increased efforts to improve risk factor control are needed.

Background: Current guidelines on the use of β-blockers in post-acute myocardial infarction (MI) patients without reduced left ventricular ejection fraction (LVEF) are based on studies before the implementation of modern reperfusion and secondary prevention therapies. It remains unknown whether β-blockers will reduce mortality and recurrent MI in contemporary revascularized post-MI patients without reduced LVEF., Design: BETAMI is a prospective, randomized, open, blinded end point multicenter study in 10,000 MI patients designed to test the superiority of oral β-blocker therapy compared to no β-blocker therapy. Patients with LVEF ≥40% following treatment with percutaneous coronary intervention or thrombolysis and/or no clinical signs of heart failure are eligible to participate. The primary end point is a composite of all-cause mortality or recurrent MI obtained from national registries over a mean follow-up period of 3 years. Safety end points include rates of nonfatal MI, all-cause mortality, ventricular arrhythmias, and hospitalizations for heart failure obtained from hospital medical records 30 days after randomization, and from national registries after 6 and 18 months. Key secondary end points include recurrent MI, heart failure, cardiovascular and all-cause mortality, and clinical outcomes linked to β-blocker therapy including drug adherence, adverse effects, cardiovascular risk factors, psychosocial factors, and health economy. Statistical analyses will be conducted according to the intention-to-treat principle. A prespecified per-protocol analysis (patients truly on β-blockers or not) will also be conducted., Conclusions: The results from the BETAMI trial may have the potential of changing current clinical practice for treatment with β-blockers following MI in patients without reduced LVEF. EudraCT number 2018-000590-75., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The optimal management of elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) is still discussed. We aimed to study short- and long-term survival in NSTEMI patients ≥75 years managed with an invasive or a conservative strategy., Methods: NSTEMI patients admitted to Oslo University Hospital Ulleval during 2005-2011 were included consecutively in a prospective registry. Vital status until December 31, 2013, was obtained from the Norwegian Cause of Death Registry. Patients ≥75 years were identified, and 30-day and 7-year survival were analyzed. Logistic- and Cox regression was used to estimate OR and hazard ratio (HR) for death in the invasive versus conservative group, adjusting for registered confounders., Results: There were 2,064 NSTEMI patients ≥75 years (48.2% women); 1,200 (58.1%) were treated with an invasive strategy, and were younger, more likely to be male and previously revascularized compared to 864 (41.9%) patients treated conservatively (p < 0.0001 for all). Survival at 30-day was 94.9% in the invasive and 76.6% in the conservative group. For 30-day survivors, 7-year survival was 47.4% (95% CI 42.9-51.8) and 11.6% (95% CI 8.3-15.6), respectively. After multivariate adjustment, an invasive strategy was associated with lower long-term risk (adjusted HR [aHR] 0.49 [95% CI 0.41-0.59]). Actual revascularization was associated with lower risk of long-term mortality compared to angiography only (aHRPCI 0.73 [95% CI 0.59-0.90], aHRCABG 0.43 [95% CI 0.28-0.65])., Conclusion: In this real-life cohort of NSTEMI patients ≥75 years, 30-day survival was 95%, and 7-year survival was 47% with an invasive strategy. Revascularized patients had a superior long-term prognosis. With a conservative strategy, short- and long-term survival was lower, probably due to selection bias and unmeasured confounding., (The Author(s). Published by S. Karger AG, Basel.)

CCN2/Connective tissue growth factor seems to be involved in development of cardiac hypertrophy and fibrosis, but a possible cardioprotective role in left ventricular (LV) remodelling following myocardial infarction has also been suggested. The main objectives of the study were therefore to investigate whether circulating CCN2 levels were associated with infarct size, LV function, adverse remodelling or clinical outcome in two cohorts of patients with ST-elevation myocardial infarction (STEMI). CCN2 was measured in 988 patients 18 hours after PCI and clinical events were recorded after 55 months in the BAMI cohort. In the POSTEMI trial, serial measurements of CCN2 were performed in 258 STEMI patients during index hospitalisation and cardiac magnetic resonance imaging was performed in the acute phase and after 4 months. Clinical events were also recorded. There were no significant associations between levels of CCN2 and infarct size, LV ejection fraction, changes in LV end-diastolic or end-systolic volume, myocardial salvage or microvascular obstruction. There were no significant associations between CCN2 levels and clinical events including mortality, in either of the study cohorts. In conclusion, circulating levels of CCN2 measured in the acute phase of STEMI were not associated with final infarct size, left ventricular function or new clinical events.

Background: Elderly patients with ST-segment elevation myocardial infarction (STEMI) are at high risk for complications and early mortality; still, they are underrepresented in clinical trials and observational studies. We studied the risk profiles at presentation and early mortality in elderly (≥80 years) versus younger (<80 years) STEMI patients., Design: This was a prospective cohort study., Methods: The study population comprised 4,092 consecutive STEMI patients admitted to Oslo University Hospital, Ulleval from 2006 to 2010. Baseline characteristics at admission were recorded, as well as in-hospital mortality. Etiologic strategy was used in the analyses., Results: Patients ≥80 years of age (n=536) were more likely to be women and have prior myocardial infarction, angina, and stroke, but were less likely to be current smokers. The crude in-hospital mortality was 16.2% in patients aged 80 years and older versus 3.5% in those younger than 80 years. The adjusted odds ratio for mortality in patients aged 80 years and older versus those younger than 80 years increased with increasing levels of serum creatinine and total cholesterol. In patients with low levels of serum creatinine and total cholesterol, the odds ratio was 3.01 (95% confidence interval, 1.86-4.93; P=0.0001); increasing to 11.72 (95% confidence interval, 5.26-26.3; P=0.001) in patients with high levels., Conclusion: High levels of serum cholesterol and creatinine were important risk factors for early mortality in elderly patients. Depending on the levels of cholesterol and creatinine, in-hospital mortality in patients aged 80 years and older varied from a threefold to an almost twelvefold risk compared with younger patients.

Background: The Norwegian Myocardial Infarction Registry was established in 2012 as a national quality registry. This first report from the registry presents the number of myocardial infarctions, the treatment provided and the 30-day mortality rate for myocardial infarctions admitted to Norwegian hospitals., Material and Method: All patients with myocardial infarction admitted to Norwegian hospitals in 2013 and recorded in the Norwegian Myocardial Infarction Registry are included. The number of myocardial infarctions, patient characteristics and their treatment are indicated for myocardial infarctions with and without ST-segment elevation on ECG (STEMI and nSTEMI). The 30-day mortality is calculated for each health region., Results: In 2013, a total of 13,043 myocardial infarctions in 12,336 patients were recorded in the Norwegian Myocardial Infarction Registry. Altogether 3,658 (28%) of the infarctions were classified as STEMI and 9,188 (70%) as nSTEMI. The average age at the time of the infarction was 68.1 years for men and 75.9 years for women. Percutaneous coronary intervention was performed for a total of 2,798 (77%) ST-segment elevation myocardial infarctions, whereas the corresponding number for nSTEMI was 3,179 (35%). The 30-day mortality in the entire infarction population was 10% (< 60 years: 2%, 60-69 years: 4%, 70-79 years: 9%, ≥ 80 years: 20%). We found no differences in mortality between health regions or between men and women., Interpretation: This first report from the Norwegian Myocardial Infarction Registry shows that the treatment service is functioning well for most patients. Secondary prophylaxis using drug therapy and increased use of invasive examination of patients with nSTEMI appear to be areas for improvement.

Background: Adaptation of guidelines for use at the national or local level can facilitate their implementation. We developed and evaluated an adaptation process in adherence with standards for trustworthy guidelines and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, aiming for efficiency and transparency. This article is the first in a series describing our adaptation of Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines for a Norwegian setting., Methods: Informed by the ADAPTE framework, we developed a five-step adaptation process customized to guidelines developed using GRADE: (1) planning, (2) initial assessment of the recommendations, (3) modification, (4) publication, and (5) evaluation. We developed a taxonomy for describing how and why recommendations from the parent guideline were modified and applied a mixed-methods case study design for evaluation of the process., Results: We published the adapted guideline in November 2013 in a novel multilayered format. The taxonomy for adaptation facilitated transparency of the modification process for both the guideline developers and the end users. We excluded 30 and modified 131 of the 333 original recommendations according to the taxonomy and developed eight new recommendations. Unforeseen obstacles related to acquiring a licensing agreement and procuring a publisher resulted in a 9-month delay. We propose modifications of the adaptation process to overcome these obstacles in the future., Conclusions: This case study demonstrates the feasibility of a novel guideline adaptation process. Replication is needed to further validate the usefulness of the process in increasing the organizational and methodologic efficiency of guideline adaptation.

Introduction: Both pharmacological and invasive treatment might influence the inflammatory and pro-thrombotic responses observed in acute ST-elevation myocardial infarction (STEMI). We aimed to study whether circulating levels of inflammatory and pro-thrombotic markers differ in STEMI patients treated with early angioplasty compared to standard therapy following thrombolysis. Furthermore, we wanted to study if levels of markers were related to infarct size., Materials and Methods: This was a substudy of the NORwegian study on DIstrict treatment of ST-Elevation Myocardial Infarction (NORDISTEMI), in which STEMI patients treated with thrombolysis were randomized to early invasive or standard therapy. Fasting blood samples were collected in the morning 3 days and 3 months after onset of STEMI. Commercially available ELISA methods were used for determination of inflammatory and pro-thrombotic markers. Infarct size was assessed by SPECT after 3 months., Results: 246 patients were included in this substudy. At 3 days, levels of prothrombin fragment 1+2 and D-dimer were higher in the early invasive compared to the standard treatment group, whereas levels of soluble CD40 ligand were lower (p<0.01 for all). No other differences between groups were found in any of the measured markers. Significant, although weak correlations were found between Day 3 levels of C-reactive protein, interleukin-6, prothrombin fragment 1+2 and D-dimer, and infarct size assessed by SPECT after 3 months., Conclusions: An early invasive strategy following thrombolysis for STEMI was associated with higher subacute levels of D-dimer and prothrombin fragment 1+2, and lower levels of soluble CD40 ligand than standard treatment. Further studies are needed to establish the relation between these changes and clinical outcome. The NORDISTEMI was registered at www.clinicaltrials.gov, NCT00161005., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: The goal of this study was to compare a strategy of immediate transfer for percutaneous coronary intervention (PCI) with an ischemia-guided approach after thrombolysis in patients with very long transfer distances to PCI., Background: Thrombolysis remains the treatment of choice in ST-segment elevation myocardial infarction (STEMI) when primary PCI cannot be performed within 90 to 120 min. The optimal treatment after thrombolysis is still unclear., Methods: A total of 266 patients with acute STEMI living in rural areas with more than 90-min transfer delays to PCI were treated with tenecteplase, aspirin, enoxaparin, and clopidogrel and randomized to immediate transfer for PCI or to standard management in the local hospitals with early transfer, only if indicated for rescue or clinical deterioration. The primary outcome was a composite of death, reinfarction, stroke, or new ischemia at 12 months, and analysis was by intention to treat., Results: The primary end point was reached in 28 patients (21%) in the early invasive group compared with 36 (27%) in the conservative group (hazard ratio: 0.72, 95% confidence interval: 0.44 to 1.18, p = 0.19). The composite of death, reinfarction, or stroke at 12 months was significantly reduced in the early invasive compared with the conservative group (6% vs. 16%, hazard ratio: 0.36, 95% confidence interval: 0.16 to 0.81, p = 0.01). No significant differences in bleeding or infarct size were observed., Conclusions: Immediate transfer for PCI did not improve the primary outcome significantly, but reduced the rate of death, reinfarction, or stroke at 12 months in patients with STEMI, treated with thrombolysis and clopidogrel in areas with long transfer distances. (Norwegian Study on District Treatment of ST-Elevation Myocardial Infarction; NCT00161005).

Objectives: Women with acute myocardial infarction (AMI) previously received less invasive evaluation and experienced higher mortality than men. After improvements in AMI care it is unclear whether gender differences still exist in management and outcome of AMI., Methods: All patients admitted to Ullevål University Hospital for AMI during 2006 and 2007 were included in this cohort study. Predefined data were recorded during the hospital stay, and the survival status of the patients was ascertained on June 30, 2008., Results: A total of 931 women and 2,174 men were included. No gender differences were observed in treatment delay or age-adjusted odds ratio (OR) of invasive evaluation in ST-elevation myocardial infarction (STEMI). In non-ST-elevation myocardial infarction (NSTEMI), women were less likely than men to undergo coronary angiography (adjusted OR 0.72, 95% CI 0.53-0.99, p = 0.044) and percutaneous coronary intervention (adjusted OR 0.60, 95% CI 0.47-0.76, p = 0.0001). Age-adjusted in-hospital mortality and long-term survival were similar between men and women., Conclusions: Women with STEMI experienced similar treatment delays and odds of invasive evaluation as men. However, gender differences in invasive evaluation were still observed in NSTEMI patients. No sex differences were observed in age-adjusted early and long-term mortality., (Copyright 2009 S. Karger AG, Basel.)

Objectives: To study myocardial perfusion in ST-elevation myocardial infarction (STEMI) treated successfully with primary angioplasty. Additionally, to evaluate the predictive value of perfusion on subsequent infarct size., Design: Fifty patients with acute STEMI and restoration of normal epicardial flow after primary angioplasty were included in the study. TIMI myocardial perfusion (TMP) grades were determined at the end of the procedure. Contrast enhanced magnetic resonance imaging (MRI) including first-pass perfusion and delayed enhancement imaging were performed within five days and after three months., Results: The patients were divided into two groups: A=TMP 0-1, B=TMP 2-3. The early MRI showed significantly reduced myocardial perfusion in the infarct zone compared to remote myocardium in both groups (p<0.001), but the reduction was more pronounced in group A. The infarct sizes were smaller (p=0.0017) and the ejection fractions higher (p=0.0001) in group B than in group A at follow-up., Conclusions: In STEMI, early impairments in myocardial perfusion were observed in spite of successful treatment with angioplasty. Marked early impairments in perfusion were associated with larger infarct sizes on MRI after three months.