Search

Background: Takotsubo syndrome (TTS) is an acute heart failure syndrome with symptoms similar to acute myocardial infarction. TTS is often triggered by acute emotional or physical stress and is a significant cause of morbidity and mortality. Predictors of mortality in patients with TS are not well understood, and there is a need to identify high-risk patients and tailor treatment accordingly. This study aimed to assess the importance of various clinical factors in predicting 30-day mortality in TTS patients using a machine learning algorithm. Methods: We analyzed data from the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR) for all patients with TTS in Sweden between 2015 and 2022. Gradient boosting was used to assess the relative importance of variables in predicting 30-day mortality in TTS patients. Results: Of 3,180 patients hospitalized with TTS, 76.0% were women. The median age was 71.0 years (interquartile range 62–77). The crude all-cause mortality rate was 3.2% at 30 days. Machine learning algorithms by gradient boosting identified treating hospitals as the most important predictor of 30-day mortality. This factor was followed in significance by the clinical indication for angiography, creatinine level, Killip class, and age. Other less important factors included weight, height, and certain medical conditions such as hyperlipidemia and smoking status. Conclusions: Using machine learning with gradient boosting, we analyzed all Swedish patients diagnosed with TTS over seven years and found that the treating hospital was the most significant predictor of 30-day mortality. [ABSTRACT FROM AUTHOR]

Purpose: The Nordic Nutrition Recommendations (NNR) are developed to prevent diet-related diseases. This study aimed to examine adherence to the NNR and risk of myocardial infarction (MI) and stroke among women and men in Sweden. Methods: We followed 34,898 adults from 1997 to 2016. Dietary intake was assessed once at baseline using a food frequency questionnaire. Adherence scores corresponding to NNR-editions from 2023, 2012, 2004 and 1996 were calculated. Scores were categorized into low (reference category), moderate and high adherence. Cox proportional hazards regression models adjusted for potential confounders were used to estimate hazards ratios (HR) with 95% confidence intervals (CI). Results: We identified 1649 incident cases of MI and 2071 incident cases of stroke during follow-up (mean 17.9 years). For each 1-point increase in the NNR2023-score (range 0–9), the rate of MI decreased by 14% (HR: 0.86; 95% CI 0.78–0.95). High adherence was associated with a lower rate of MI (HR: 0.72; 95% CI 0.59–0.87) (p-trend = 0.01). Moderate adherence was associated with a lower rate of stroke (HR: 0.88; 95% CI 0.78–0.99) (p-trend = 0.31). Among women, a 23% lower rate of MI (HR: 0.77; 95% CI 0.67–0.89) was observed for each 1-point increase, and high adherence was associated with a lower rate of MI (HR: 0.59; 95% CI 0.45–0.78). No associations were found in men. The results were similar, though attenuated, for earlier NNR-editions. Conclusion: Adherence to the NNR was associated with a reduced risk of MI. This association was more pronounced among women than among men and in more recent NNR-editions. The findings for stroke need further investigation. [ABSTRACT FROM AUTHOR]

The number of myocardial infarctions declined during the early COVID-19 pandemic but mechanisms behind these declines are poorly understood. COVID-19 infection is also associated with an increased risk of myocardial infarction which could lead to higher incidence rates in the population. This study aims to shed light on the seemingly paradoxical relationship between COVID-19 and myocardial infarction occurrence on the population level by exploring long-term trends in incidence rates, case fatality, and proportion of patients dying before reaching a hospital. Our work is based on a linkage of administrative registers covering the entire population aged 60 + in Sweden. Considering both long-term trends since 2015 and seasonal variability, we compared observed incidence, case fatality, and proportions of patients hospitalized to expected values during 2020–2022. Despite more than 200 laboratory-confirmed COVID-19 cases per 1000 inhabitants by the end of 2022, incidence rates of myocardial infarction continued to decline, thus following the long-term trend observed already before 2020. During the first pandemic wave there was an additional incidence decline corresponding to 13% fewer myocardial infarctions than expected. This decline was neither accompanied by increasing case fatality nor by lower shares of patients being hospitalized. We found no increase in the population-level incidence of myocardial infarction despite large-scale exposure to COVID-19, which suggests that the effect of COVID-19 on myocardial infarction risk is not substantial. Increased pressure on the Swedish health care system has not led to increased risks or poorer outcomes for patients presenting with acute myocardial infarction. [ABSTRACT FROM AUTHOR]

BACKGROUND Most trials that have shown a benefit of beta-blocker treatment after myocardial infarction included patients with large myocardial infarctions and were conducted in an era before modern biomarker-based diagnosis of myocardial infarction and treatment with percutaneous coronary intervention, antithrombotic agents, high-intensity statins, and renin-angiotensin-aldosterone system antagonists. METHODS In a parallel-group, open-label trial performed at 45 centers in Sweden, Estonia, and New Zealand, we randomly assigned patients with an acute myocardial infarction who had undergone coronary angiography and had a left ventricular ejection fraction of at least 50% to receive either long-term treatment with a beta-blocker (metoprolol or bisoprolol) or no beta-blocker treatment. The primary end point was a composite of death from any cause or new myocardial infarction. RESULTS From September 2017 through May 2023, a total of 5020 patients were enrolled (95.4% of whom were from Sweden). The median follow-up was 3.5 years (interquartile range, 2.2 to 4.7). A primary end-point event occurred in 199 of 2508 patients (7.9%) in the beta-blocker group and in 208 of 2512 patients (8.3%) in the no-beta-blocker group (hazard ratio, 0.96; 95% confidence interval, 0.79 to 1.16; P=0.64). Beta-blocker treatment did not appear to lead to a lower cumulative incidence of the secondary end points (death from any cause, 3.9% in the beta-blocker group and 4.1% in the no-beta-blocker group; death from cardiovascular causes, 1.5% and 1.3%, respectively; myocardial infarction, 4.5% and 4.7%; hospitalization for atrial fibrillation, 1.1% and 1.4%; and hospitalization for heart failure, 0.8% and 0.9%). With regard to safety end points, hospitalization for bradycardia, second- or third-degree atrioventricular block, hypotension, syncope, or implantation of a pacemaker occurred in 3.4% of the patients in the beta-blocker group and in 3.2% of those in the no-beta-blocker group; hospitalization for asthma or chronic obstructive pulmonary disease in 0.6% and 0.6%, respectively; and hospitalization for stroke in 1.4% and 1.8%. CONCLUSIONS Among patients with acute myocardial infarction who underwent early coronary angiography and had a preserved left ventricular ejection fraction (>50%), long-term beta-blocker treatment did not lead to a lower risk of the composite primary end point of death from any cause or new myocardial infarction than no beta-blocker use. [ABSTRACT FROM AUTHOR]

Information on standards including structure- and process-based metrics and how exercise-based cardiac rehabilitation (EBCR) is delivered in relation to guidelines is lacking. The aims of the study were to evaluate standards and adherence to guidelines at Swedish CR centers and to conduct a cost analysis of the physiotherapy-related activities of EBCR. EBCR standards at all 78 CR centers in Sweden in 2016 were surveyed. The questions were based on guideline-recommended core components of EBCR for patients after a myocardial infarction (MI). The cost analysis included the identification, quantification, and valuation of EBCR-related cost items. Patients were offered a pre-discharge consultation with a physiotherapist at n = 61, 78% of the centers. A pre-exercise screening visit was routinely offered at n = 64, 82% of the centers, at which a test of aerobic capacity was offered in n = 58, 91% of cases, most often as a cycle ergometer exercise test n = 55, 86%. A post-exercise assessment was offered at n = 44, 56% of the centers, with a functional test performed at n = 30, 68%. Almost all the centers n = 76, 97% offered supervised EBCR programs. The total cost of delivering physiotherapy-related activities of EBCR according to guidelines was approximately 437 euro (4,371 SEK) per patient. Delivering EBCR to one MI patient required 11.25 hours of physiotherapy time. While the overall quality of EBCR programs in Sweden is high, there are several areas of potential improvement to reach the recommended European standards across all centers. To improve the quality of EBCR, further compliance with guidelines is warranted. [ABSTRACT FROM AUTHOR]

Background: Incident cases of stroke, myocardial infarction, and preterm birth have established exposure-response functions associated with air pollution. However, there are no studies reporting detailed costs per case for these health outcomes that are adapted to the cost-benefit tools that guide the regulation of air pollution. Objectives: The primary objective was to establish non-fatal per-case monetary estimates for stroke, myocardial infarction, and preterm birth attributable to air pollution in Sweden, and the secondary objective was to ease the economic evaluation process of air pollution morbidity effects and their inclusion in cost-benefit assessments. Methods: Based on recommendations from the literature, the case-cost analysis considered direct and indirect medical costs, as well as production losses and informal costs relevant for the calculation of the net present value. A literature search was conducted to estimate the costs of each category for each incident case in Sweden. Informal costs were estimated using the quality-adjusted life-years approach and the corresponding willingness-to-pay in the Swedish population. The total average per-case cost was estimated based on specific health outcome durations and severity and was discounted by 3.5% per year. Sensitivity analysis included varying discount rates, severity of health outcome, and the range of societal willingness to pay for quality-adjusted life years. Results: The average net present value cost estimate was €2016 460k (185k–1M) for non-fatal stroke, €2016 24k (16k–38k) for myocardial infarction, and €2016 34k (19k–57k) for late preterm birth. The main drivers of the per-case total cost estimates were health outcome severity and societal willingness to pay for risk reduction. Varying the discount rate had the largest effect on preterm birth, with costs changing by ±30% for the discount rates analysed. Recommendation: Because stroke, myocardial infarction, and preterm birth have established exposure-response functions linking these to air pollution, cost-benefit analyses should include the costs for these health outcomes in order to adequately guide future air pollution and climate change policies. [ABSTRACT FROM AUTHOR]

Background: Participation in cardiac rehabilitation in patients with coronary artery disease (CAD) remains underutilised. Digital educational programmes, as part of cardiac rehabilitation, are emerging as a means of increasing accessibility, but healthcare professionals' perceptions of implementing and using these programmes are not known. The aim of the study was therefore to explore healthcare professionals ̓ perceptions and experiences of implementing and using a digital patient educational programme (DPE) as part of cardiac rehabilitation after acute CAD. Methods: Individual semi-structured interviews were performed with 12 nurses and physiotherapists, ten women with a median age of 49.5 (min 37- max 59) years, with experience of using the DPE as part of a phase II cardiac rehabilitation programme in Region Västra Götaland, Sweden. The interviews were transcribed verbatim and analysed with inductive content analysis according to Graneheim and Lundman. Results: An overall theme was identified throughout the unit of analysis: "Digital patient education – a complement yet not a replacement". Within this theme, three main categories were identified: "Finding ways that make implementation work", "Accessibility to information for confident and involved patients" and "Reaching one another in a digital world". Each main category contains a number of sub-categories. Conclusions: This study adds new knowledge on healthcare professionals' perceptions of a digital patient educational programme as a valuable and accessible alternative to centre-based education programmes as part of cardiac rehabilitation for patients with CAD. The participants highlighted the factors necessary for a successful implementation, such as support through the process and sufficient time from the employer to learn the system and to create new routines in daily practice. Future research is needed to further understand the impact of digital education systems in the secondary prevention of CAD. Ultimately, hybrid models, where the choice of delivery depends on the preferences of the individual patient, would be the optimal model of care for the future. [ABSTRACT FROM AUTHOR]

Myocardial infarction (MI) with obstructive coronary artery disease (MI-CAD) and MI in the absence of obstructive coronary artery disease (MINOCA) affect different populations and may have separate pathophysiological mechanisms, with greater inflammatory activity in MINOCA compared to MI-CAD. Helicobacter pylori (Hp) can cause systemic inflammation and has been associated with cardiovascular disease (CVD). We aimed to investigate whether Hp infection is associated with concentrations of protein biomarkers of inflammation and CVD. In a case-control study, patients with MINOCA (n = 99) in Sweden were included, complemented by matched subjects with MI-CAD (n = 99) and controls (n = 100). Protein biomarkers were measured with a proximity extension assay in plasma samples collected 3 months after MI. The seroprevalence of Hp and cytotoxin-associated gene A (CagA) was determined using ELISA. The associations between protein levels and Hp status were studied with linear regression. The prevalence of Hp was 20.2%, 19.2%, and 16.0% for MINOCA, MI-CAD, and controls, respectively (p = 0.73). Seven proteins were associated with Hp in an adjusted model: tissue plasminogen activator (tPA), interleukin-6 (IL-6), myeloperoxidase (MPO), TNF-related activation-induced cytokine (TRANCE), pappalysin-1 (PAPPA), soluble urokinase plasminogen activator receptor (suPAR), and P-selectin glycoprotein ligand 1 (PSGL-1). Hp infection was present in one in five patients with MI, irrespective of the presence of obstructive CAD. Inflammatory proteins were elevated in Hp-positive subjects, thus not ruling out that Hp may promote an inflammatory response and potentially contribute to the development of CVD. [ABSTRACT FROM AUTHOR]

Despite decreasing mortality from cardiovascular disease (CVD), there are persistent inequities in mortality between socioeconomic groups. Primary preventative medications reduce mortality in CVD; thus, inequitable treatments will contribute to unequal outcomes. Physicians might contribute to inequality by prescribing preventative medication for CVD to themselves in a biased manner. To determine whether primary medications for preventing CVD were prescribed inequitably between physicians and non-physicians. This retrospective study retrieved registry data on prescribed medications for all physicians in Sweden aged 45–74 years, during 2013, and for reference non-physician individuals, matched by sex, age, residence, and level of education. The outcome was any medication for preventing CVD, received at least once during 2013. Age and the sex-specific prevalence of myocardial infarction (MI) among physicians and non-physicians were used as a proxy for the need for medication. Thereafter, to limit the analysis to preventative medication, we excluded individuals that were diagnosed with CVD or diabetes. To analyse differences in medication usage between physicians and matched non-physicians, we estimated odds ratios (ORs) with conditional logistic regression and adjusted for need and household income. MI prevalences were 5.7% for men and 2.3% for women, among physicians, and 5.4% for men and 1.8% for women, among non-physicians. We included 25,105 physicians and 44,366 non-physicians. The OR for physicians receiving any CVD preventative medication, compared to non-physicians, was 1.65 (95% confidence interval 1.59–1.72). We found an inequity in prescribed preventative CVD medications, which favoured physicians over non-physicians. Groups with low socioeconomic status have lower rates of using medication that prevents cardiovascular disease, compared to groups with high socioeconomic status. Physicians are responsible for prescribing all medicines to prevent cardiovascular disease; thus, biased prescriptions could have effects on the equality of care in the population. Compared to individuals with equivalent education, physicians had higher rates of using medication that prevents cardiovascular disease. This study highlights the need for systematic population-based evaluation of CVD risk in order to promote equitable CVD outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Individuals with type 2 diabetes (T2D) are at high risk of experiencing atherosclerotic cardiovascular disease (ASCVD), which is associated with morbidity, mortality and healthcare resource utilisation. Clinical guidelines recommend the use of glucose-lowering medications with cardiovascular benefits in individuals with T2D and cardiovascular disease, but there is evidence that this is not reflected in clinical practice. We used linked national registry data from Sweden to compare outcomes in people with T2D and ASCVD against matched controls with T2D without ASCVD, over 5 years. Direct costs (inpatient, outpatient and selected drug costs), indirect costs resulting from work absence, early retirement, cardiovascular events and mortality were examined. Methods: Individuals with T2D who were at least 16 years old and were alive and resident in Sweden on 1 January 2012 were identified in an existing database. In four separate analyses, individuals with a record indicating ASCVD according to a broad definition, peripheral artery disease (PAD), stroke or myocardial infarction (MI) before 1 January 2012 were identified using diagnosis and/or procedure codes and propensity score matched 1:1 to controls with T2D and without ASCVD, using covariates for birth, sex and level of education in 2012. Follow-up continued until death, migration from Sweden or the end of the study period in 2016. Results: In total, 80,305 individuals with ASCVD, 15,397 individuals with PAD, 17,539 individuals with previous stroke and 25,729 individuals with previous MI were included. Total mean annual costs per person were €14,785 for PAD (2.7 × costs for controls), €11,397 for previous stroke (2.2 × controls), €10,730 for ASCVD (1.9 × controls) and €10,342 for previous MI (1.7 × controls). Indirect costs and costs of inpatient care were the major cost drivers. ASCVD, PAD, stroke and MI were all associated with an increased likelihood of early retirement, cardiovascular events and mortality. Conclusions: ASCVD is associated with considerable costs, morbidity and mortality in individuals with T2D. These results support structured assessment of ASCVD risk and broader implementation of guideline-recommended treatments in T2D healthcare. [ABSTRACT FROM AUTHOR]

This study found no association between exposure to hand-arm vibrations (HAV) and myocardial infarction. Data was gathered from the Swedish National Cohort on Work and Health and consists of all individuals born in Sweden from 1930 to 1990, with demographic, occupational, and MI data available between 1968 and 2017. All workers in Sweden with an occupational code between 1985 and 2013 were matched to the job-exposure matrix on occupational exposures. The model was adjusted for demographic data and other occupational exposures. The hazard ratio with a 95% confidence interval was 1.01 (0.92-1.11) for those exposed above the daily equivalent HAV level of 5 m/s². [ABSTRACT FROM AUTHOR]

A randomized clinical study in the USA examined the effects of pharmacogenetic testing on medication selection and symptom remission in severe depressive disorders. The results showed that the use of these tests reduced the prescription of antidepressants with known gene-drug interactions. However, the effects on symptom remission did not persist over time. The study had advantages and disadvantages, and it was found that pharmacogenetic testing is only beneficial for about 20% of those affected overall. A study from Sweden and Norway examined the effects of early introduction of potentially allergenic foods on the development of food allergies in infants. The risk of food allergies was significantly reduced in the group with early introduction of complementary foods compared to the group without intervention. Another study examined the effects of ezetimibe and PCSK9 inhibitors on cardiovascular risk. The study shows that adding ezetimibe to the maximum tolerated statin dose reduces the risk of myocardial infarction and stroke. [Extracted from the article]

Aims: Most cases of acute myocardial infarction (MI) in Sweden are treated with long-term β-blocker therapy as secondary prevention. Case studies and patient reports have indicated negative effects of β-blockers including symptoms of depression, fatigue, sexual dysfunction, and general low mood, all related to reduced quality of life (QoL). To date, no recent large-scale, randomized trial has explored the effects of β-blockers on these factors. Methods and results: The ongoing Randomized Evaluation of Decreased Usage of beta-bloCkErs after myocardial infarction (REDUCE): quality of life (RQoL) study is a multicentre, prospective, randomized pre-specified substudy aiming to evaluate the effects of β-blockers on self-reported measures of QoL. Following randomized allocation to long-term β-blocker or no β-blocker treatment, patients complete a total of six baseline measures pertaining to QoL, sexual functioning, and perceived side effects. Data collection is optionally carried out online through a unique and secure portal and repeated again at two follow-up time points. Recruitment began in July 2018. Data from the first 100 patients showed that at the first follow-up, 93% had completed the questionnaires, which decreased to 81% at the second follow-up. The method of digital data collection was utilized by over half of the patients recruited so far. Conclusion: Data from the first 100 patients indicate success in terms of study design and recruitment. The RQoL substudy investigates the effects of β-blockers on self-reported measures of QoL in MI patients and will potentially contribute to the limited knowledge of QoL-related side effects reported in conjunction with β-blocker use. Clinical trial registration: Eudra CT number, 2017-002336-17; Clinical trial.gov identifier, NCT03278509 Graphical abstract [ABSTRACT FROM AUTHOR]

Aim: The study aim was to further clarify the relationship between psychological factors and myocardial infarction (MI) by simultaneously examining anger, depression, and anxiety as risk factors for incident MI in a healthy working sample. Subject and method: Baseline measurements of psychological variables were assessed through a self-reported questionnaire in a healthy cohort of 968 middle-aged men working at the Volvo Corporation. Single-item questions assessed depression and anxiety. Anger was assessed by the Trait Anger subscale of the Spielberger State-Trait Anger Expression Inventory. The endpoint was incident MI verified by national registers or medical records with follow up after 22 years. The main outcome was computed through logistic regression, reported as odds ratios. Additional correlation analyses were performed between psychological variables and coronary risk factors. Results: None of the psychological variables was significantly associated with the outcome; thus, the results failed to show an association between anger, depression, or anxiety and incident MI in this sample. There were some significant, but weak, correlations between psychological factors and negative health behaviors. Other components of traditional risk scoring instruments did not correlate with the psychological factors. Conclusion: A cohort restricted to middle-age healthy men limits applicability. However, our failure to replicate earlier results of population samples suggests a need for further research on associations between psychological factors and MI in healthy samples. [ABSTRACT FROM AUTHOR]

Background: The management of patients with psychiatric disease and chest pain in the emergency department (ED) in the era of high‐sensitivity cardiac troponin assays is unexplored. Objectives: To investigate differences in management and outcomes comparing patients with versus without psychiatric disorders who present with chest pain in the ED. Methods: All visits to seven different EDs in Sweden from 9 December 2010 to 31 December 2016 by patients with chest pain were included. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to estimate differences in clinical management. Hazard ratios with 95% CIs were used for comparisons of all‐cause mortality and risk of cardiovascular events. Results: Altogether, 216,653 visits were identified, of which 40,054 (18%) occurred in patients with psychiatric disorders. The risk of a myocardial infarction (MI) was reduced almost by half in patients with an affective (OR 0.63; 95% CI: 0.59–0.68) or psychotic disorder (OR 0.57; 95% CI: 0.47–0.70). These patients were less likely to be treated with any cardiovascular medication or to undergo percutaneous coronary intervention. Contrastingly, patients with psychiatric disease had a 1.8‐ to 2.6‐fold increased risk of being diagnosed with an MI registered after the index visit but within 30 days. Conclusions: Patients with psychiatric disease and chest pain undergo less intense investigation and are less likely to receive cardiovascular medications compared with patients without psychiatric disease, even in the presence of myocardial injury. In addition, they experience a higher risk of being diagnosed with an MI within 30 days after a visit with no MI. [ABSTRACT FROM AUTHOR]

Background: Despite improvements in the treatment and prevention of cardiovascular disease since the 1960s, the incidence of cardiovascular diseases among young people has remained the same for many years. This study aimed to compare the clinical and psychosocial attributes of young persons affected by myocardial infarction under the age of 50 years compared to middle-aged myocardial infarction patients 51–65 years old. Methods: Data from patients with a documented STEMI or NSTEMI elevated acute myocardial infarction in the age groups up to 65 years, were collected from cardiology clinics at three hospitals in southeast Sweden. The Stressheart study comprised a total of 213 acute myocardial infarction patients, of which n = 33 (15.5%) were under 50 years of age and n = 180 (84.5%) were middle-aged, (51–65 years). These acute myocardial infarction patients filled in a questionnaire at discharge from the hospital and further information through documentation of data in their medical records. Results: Blood pressure was significantly higher in young compared to middle-aged patients. For diastolic blood pressure (p = 0.003), systolic blood pressure (p = 0.028), and mean arterial pressure (p = 0.005). Young AMI patients had a higher (p = 0.030) body mass index (BMI) than the middle-aged. Young AMI patients were reported to be more stressed (p = 0.042), had more frequently experienced a serious life event the previous year (p = 0.029), and felt less energetic (p = 0.044) than middle-aged AMI patients. Conclusions: This study revealed that persons under the age of 50 affected by acute myocardial infarction exhibit traditional cardiovascular risk factors like high blood pressure, and higher BMI, and were more exposed to some psychosocial risk factors. The risk profile of young persons under age 50 affected by AMI was in these respects more exaugurated than for middle-aged persons with AMI. This study underlines the importance of the early discovery of those at increased risk and encourages preventative actions to focus on both clinical and psychosocial risk factors. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to estimate risks of cardiovascular and cerebrovascular events in patients treated with lisdexamfetamine dimesylate (LDX) compared with patients previously treated with other attention-deficit/hyperactivity disorder (ADHD) medications (amphetamine, dexamphetamine, methylphenidate or atomoxetine). Methods: This population-based cohort study used data from Danish and Swedish medical and administrative national registers. The LDX cohort included adult patients initiating LDX with at least 12 months' data preceding first LDX dispensing (index date). A random sample of patients treated with at least one non-LDX ADHD medication in the 6–24 months (but not less than 6 months) before index date (previous-users cohort) were matched to LDX users on age, sex, region and calendar year. The primary outcome, a composite of major adverse cardiovascular and cerebrovascular events (MACE), included first hospitalisation for acute myocardial infarction or stroke and out-of-hospital coronary heart disease or cerebrovascular disease death. Incidence rates (IRs) and IR ratios (IRRs) with 95% confidence intervals (CIs) of MACE were estimated using Poisson regression. Results: From Denmark/Sweden, 5516/40,163 LDX users and 27,494/200,389 previous users were included. In Denmark, IRs of MACE/1000 person-years (95% CI) were similar for LDX (1.63 [0.85–3.14]) and previous users (1.61 [1.28–2.01]). In Sweden, IRs (95% CI) were 1.40 (1.09–1.79) in LDX users and 1.17 (1.00–1.38) in previous users. Adjusted MACE IRRs (95% CI) for LDX versus previous use were 1.01 (0.48–2.13) in Denmark, 1.13 (0.75–1.71) in Sweden, and 1.10 (0.77–1.58) in the pooled analysis. Conclusion: Our findings suggest little to no increased risk of cardiovascular and cerebrovascular events in patients treated with LDX compared with patients previously treated with other ADHD medications. [ABSTRACT FROM AUTHOR]

Background The implication of calcium and magnesium in drinking water for cardiovascular disease is unclear. Objectives To assess the association of the concentration of calcium and magnesium in drinking water with incidence of myocardial infarction and stroke, accounting for dietary mineral intake. Methods We linked drinking water monitoring data to residential information of 26,733 women from the population-based Swedish Mammography Cohort, who completed a 96-item FFQ at baseline. Drinking water was categorized into low (magnesium <10 mg/L and calcium <50 mg/L) or high (magnesium ≥10 mg/L or calcium ≥50 mg/L) mineral concentration. Incident cases of myocardial infarction and stroke types were ascertained 1998–2019 using the National Patient Register. Results The mean ± SD concentration of calcium and magnesium in drinking water was 29 ± 7 mg/L and 5 ± 1 mg/L in the low-exposed area and 52 ± 20 mg/L and 10 ± 3 mg/L in the high-exposed area, respectively. During 16 years of follow-up, we ascertained 2023, 2279, and 452 cases of myocardial infarction, ischemic stroke, and hemorrhagic stroke, respectively. High drinking water calcium and magnesium was associated with lower risk of ischemic and hemorrhagic stroke HRs of 0.87 (95% CI: 0.80, 0.95) and 0.78 (95% CI: 0.65, 0.95), whereas the HR for myocardial infarction was 0.93 (95% CI: 0.85, 1.02). In separate analyses, only drinking water magnesium, not calcium, remained associated with ischemic stroke (HR: 0.69; 95% CI: 0.54, 0.88). Conclusions Drinking water with a high concentration of calcium and magnesium, particularly magnesium, may lower the risk of stroke in postmenopausal women. [ABSTRACT FROM AUTHOR]

Background and Aims: Few population-based cohort studies, including both men and women, have explored circulating proteins associated with incident myocardial infarction (MI). This study investigated the relationships between circulating cardiometabolic-related proteins and MI risk using cohort-based and Mendelian randomization (MR) analyses and explored potential sex-specific differences., Methods: The discovery cohort included 11 751 Swedish adults (55-93 years). Data on 259 proteins assessed with Olink proximity extension assays, biochemical, and questionnaire-based information were used. Participants were followed up for incident MI and death over 8 years through linkage to Swedish registers. Replication analyses were conducted on the UK Biobank sample (n = 51 613). In MR analyses, index cis-genetic variants strongly related to the proteins were used as instrumental variables. Genetic association summary statistic data for MI were obtained from the CARDIoGRAMplusC4D consortium and FinnGen., Results: Forty-five proteins were associated with incident MI in discovery and replication samples following adjustment for potential confounders and multiple testing. In the secondary analysis, 13 of the protein associations were sex-specific, with most associations identified among women. In MR analysis, genetically predicted higher levels of renin, follistatin, and retinoic acid receptor responder protein 2 were linked to an increased risk of MI. Tissue factor pathway inhibitor, tumor necrosis factor receptors 1 and 2, placenta growth factor had an inverse association with MI., Conclusions: This study identified both new and confirmed previously established associations between circulating proteins and incident MI and, for the first time, suggested sex-specific patterns in multiple protein-MI associations., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The effect of milk on the risk of ischemic heart disease (IHD) and acute myocardial infarction (MI) is unclear. We aimed to examine the association between non-fermented and fermented milk consumption on these endpoints and investigate the relationship between milk intake and cardiometabolic-related proteins in plasma., Methods: Our study is based on two Swedish prospective cohort studies that included 59,998 women and 40,777 men without IHD or cancer at baseline who provided repeated measures of diet and lifestyle factors and plasma proteomics data in two subcohorts. Through registry linkage, 17,896 cases with IHD were documented during up to 33 years of follow-up, including 10,714 with MI. We used time-updated multivariable Cox regression analysis to examine non-fermented or fermented milk intake with time to IHD or MI. Using high-throughput multiplex immunoassays, 276 cardiometabolic plasma proteins were measured in two subcohorts. We applied multivariable-adjusted regression models using a discovery-replication design to examine protein associations with increasing consumption of non-fermented or fermented milk., Results: The results for non-fermented milk differed by sex (p-value for interaction = 0.01). In women, we found a pattern of successively greater risk of IHD and MI at non-fermented milk intake levels higher than 1.5 glasses/day. Compared with an intake of 0.5 glass/day (100 mL/day), non-fermented milk intake of 2 glasses/day in women conferred a multivariable-adjusted hazard ratio (HR) of 1.05 (95% CI 1.01-1.08) for IHD, an intake of 3 glasses/day an HR of 1.12 (95% CI 1.06-1.19), and an intake of 4 glasses/day an HR of 1.21 (95% CI 1.10-1.32). Findings were similar for whole, medium-fat, and low-fat milk. We did not detect higher risks of IHD with increasing milk intakes in men. Fermented milk intake was unrelated to the risk of IHD or MI in either sex. Increasing non-fermented milk intake in women was robustly associated with a higher concentration of plasma ACE2 and a lower concentration of FGF21., Conclusions: We show a positive association between high amounts of non-fermented milk intake and IHD in women but not men. We suggest metabolic pathways related to ACE2 and FGF21 potentially underlie the association., (© 2024. The Author(s).)

Background: European guidelines recommend the use of a 0h/1h hs-cTn (high-sensitivity cardiac troponin) protocol in patients with acute chest pain. We aimed to determine the performance of this protocol in routine care when supplemented with patient history and ECG and a recommendation to refrain from noninvasive testing in low-risk patients., Methods and Results: This was a pre- and postimplementation study with concurrent controls. Patients with chest pain were enrolled at 5 Swedish emergency departments (EDs) during a 10-month period in both 2017 and 2018. All hospitals used a 0h/3h hs-cTnT protocol in 2017 and 3 EDs implemented a 0h/1h hs-cTnT protocol during 10 months in 2018. The 2 coprimary outcomes were the incidence of acute myocardial infarction and all-cause death within 30 days and ED length of stay. The study included 26 040 consecutive patients. In the intervention hospitals, 21 (0.40%) of the discharged patients had an acute myocardial infarction/death event during the control period (0h/3h testing) and 22 (0.45%) in the intervention period (0h/1h testing), which met the criteria for noninferiority. There was no significant difference in ED length of stay (ratio 0.99, P =0.48) or ED discharge rate between the periods in the intervention versus the control hospitals. A total of 3142 patients met low-risk 0h/1h hs-cTnT criteria and were discharged, of whom 2 had an acute myocardial infarction/death event., Conclusions: A 0h/1h hs-cTnT protocol incorporating patient history and ECG was as safe as using a 0h/3h protocol but did not reduce ED length of stay or increase the discharge rate. Refraining from noninvasive testing in patients identified as low risk was safe., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03421873.

Background and Aims: Non-HDL-C provides an estimate of lipid-associated risk and is a secondary treatment target after myocardial infarction (MI). The aim was to study the relationship between non-HDL-C levels after MI and risk of adverse outcomes., Methods: From the SWEDEHEART registry, 56 262 patients with MI were included. Outcomes were major adverse cardiovascular event (MACE: death, MI, and ischaemic stroke), death, and non-fatal MI. Non-HDL-C was assessed at admission, 2 months, and 1 year. Target achievement (<2.2 mmol/L) of non-HDL-C, timing thereof, and outcomes were assessed., Results: During median follow-up of 5.4 years, 9549 had MACE, 5427 died, and 3946 had MI. Long-term hazard ratio (HR) for MACE in the lowest vs. the highest quartile of achieved non-HDL-C at 1 year was 0.76 [95% confidence interval (CI) 0.71-0.81]. Short-term results were consistent also when assessing non-HDL-C levels at 2 months, including early events up to 1 year (HR 0.80, 95% CI 0.68-0.92). Similar results were observed for all outcomes. Patients achieving both early and sustained targets had lowest risk of outcomes (HR 0.80, 95% CI 0.74-0.86) vs. patients achieving target early or late (HR for both 0.86, 95% CI 0.79-0.93)., Conclusions: The lowest achieved levels both at 2 months and at 1 year of non-HDL-C were associated with better outcome. The lowest risk was observed when target was achieved within 2 months of MI and sustained thereafter. These findings challenge the current stepwise approach for cholesterol lowering after MI, which inevitably results in delaying goal attainment and possible harm., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Lower air temperature and cold spells have been associated with an increased risk of various diseases. However, the short-term effect of lower air temperature and cold spells on myocardial infarction (MI) remains incompletely understood., Objectives: The purpose of this study was to investigate the short-term effects of lower air temperature and cold spells on the risk of hospitalization for MI in Sweden., Methods: This population-based nationwide study included 120,380 MI cases admitted to hospitals in Sweden during the cold season (October to March) from 2005 to 2019. Daily mean air temperature (1 km 2 resolution) was estimated using machine learning, and percentiles of daily temperatures experienced by individuals in the same municipality were used as individual exposure indicators to account for potential geographic adaptation. Cold spells were defined as periods of at least 2 consecutive days with a daily mean temperature below the 10th percentile of the temperature distribution for each municipality. A time-stratified case-crossover design incorporating conditional logistic regression models with distributed lag nonlinear models using lag 0 to 1 (immediate) and 2 to 6 days (delayed) was used to evaluate the short-term effects of lower air temperature and cold spells on total MI, non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI)., Results: A decrease of 1-U in percentile temperature at a lag of 2 to 6 days was significantly associated with increased risks of total MI, NSTEMI, and STEMI, with ORs of 1.099 (95% CI: 1.057-1.142), 1.110 (95% CI: 1.060-1.164), and 1.076 (95% CI: 1.004-1.153), respectively. Additionally, cold spells at a lag of 2 to 6 days were significantly associated with increased risks for total MI, NSTEMI, and STEMI, with ORs of 1.077 (95% CI: 1.037-1.120), 1.069 (95% CI: 1.020-1.119), and 1.095 (95% CI: 1.023-1.172), respectively. Conversely, lower air temperature and cold spells at a lag of 0 to 1 days were associated with decreased risks for MI., Conclusions: This nationwide case-crossover study reveals that short-term exposures to lower air temperature and cold spells are associated with an increased risk of hospitalization for MI at lag 2 to 6 days., Competing Interests: Funding Support and Author Disclosures This study has received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement no. 820655 (EXHAUSTION). This work was supported by a scholarship under the State Scholarship Fund by the China Scholarship Council (File No. 201906010316). The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Previous studies on disparities in healthcare and outcomes have shown conflicting results. The aim of this study was to assess differences in baseline characteristics, management, and outcomes in myocardial infarction (MI) patients, by country of birth., Methods and Results: In total, 194 259 MI patients (64% male, 15% foreign-born) from the nationwide SWEDEHEART (The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry were included and compared by geographic region of birth. The primary outcome was 1-year major adverse cardiovascular events (MACEs) including all-cause death, MI, and stroke. Secondary outcomes were long-term MACE (up to 12 years), the individual components of MACE, 30-day mortality, management, and risk factors. Logistic regression, Cox proportional hazard models, and propensity score match (PSM), accounting for baseline differences, were used. Foreign-born patients were younger, often male, and had a higher cardiovascular (CV) risk factor burden, including smoking, diabetes, and hypertension. In PSM analyses, Asia-born patients had higher likelihood of revascularization [odds ratio 1.16, 95% confidence interval (CI) 1.04-1.30], statins and beta-blocker prescription at discharge, and a 34% lower risk of 30-day mortality. Furthermore, no statistically significant differences were found in primary outcomes except for Asia-born patients having lower risk of 1-year MACE [hazard ratio (HR) 0.85, 95% CI 0.73-0.98], driven by lower mortality (HR 0.72, 95% CI 0.57-0.91). The results persisted over the long-term follow-up., Conclusion: This study shows that in a system with universal healthcare coverage in which acute and secondary preventive treatments do not differ by country of birth, foreign-born patients, despite higher CV risk factor burden, will do at least as well as native-born patients., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objective: Despite the prevalence of emergency medical service assignments related to chest discomfort, limited research delves into nurses' experiences of caring for such patients. This study aimed to illuminate prehospital emergency nurses' (PENs') experiences of caring for patients with suspected acute myocardial infarction (AMI)., Design: A qualitative interview study., Setting: Two Swedish emergency medical service organisations in two different regions., Participants: Consecutive inclusion of 12 PENs., Data Analysis: An inductive content analysis according to Elo and Kyngäs., Results: The results underline the active role of PENs in providing care for patients with AMI in the emergency medical service. They emphasise the ability to identify classic symptoms and the need for an open-minded approach to diffuse presentations. Ensuring patient security, projecting knowledge and composure are decisive for instilling a sense of safety. Healthcare providers feel profound responsibility and a fear of errors, especially in critical situations with potential patient deterioration. Prioritisation in time-sensitive cases leans towards medical interventions and immediate transportation. Continuing education is essential to enhance patient management and safety. Effective communication and trust are vital for urgent patient care, and prompt activation of the ST-elevation myocardial infarction pathway is recognised as imperative. Malfunctions result in frustration, underlining the importance of pathway functionality., Conclusions: PENs have immense responsibility for the swift and knowledgeable management of patients with suspected AMI. Balancing patient involvement and urgent medical measures is challenging, emphasising the critical role of mental preparedness and comprehensive education. The study underlines the significance of effective communication and trust between healthcare providers, particularly in time-sensitive scenarios. Establishing feedback mechanisms for prehospital staff is important for advancing prehospital emergency care in this patient category., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The effect of myocardial infarction (MI) on life expectancy is difficult to study because the prevalence of MI hinders direct comparison with the life expectancy of the general population. We sought to assess this in relation to age, sex, and left ventricular ejection fraction (LVEF) by comparing individuals with MI with matched comparators without previous MI., Methods: We included patients with a first MI between 1991 and 2022 from the nationwide SWEDEHEART registry (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies), each matched with up to 5 comparators on age, sex, and region of residence. Flexible parametric survival models were used to estimate excess mortality and mean loss of life expectancy (LOLE) depending on index year, age, sex, and LVEF, and adjusted for differences in characteristics., Results: A total of 335 748 cases were matched to 1 625 396 comparators. A higher LOLE was observed in younger individuals, women, and those with reduced LVEF (<50%). In 2022, the unadjusted and adjusted mean LOLE spanned from 11.1 and 9.5 years in 50-year-old women with reduced LVEF to 5 and 3.7 months in 80-year-old men with preserved LVEF. Between 1992 and 2022, the adjusted mean LOLE decreased by 36% to 55%: from 4.4 to 2.0 years and from 3.3 to 1.9 years in 50-year-old women and men, respectively, and from 1.7 to 1.0 years and from 1.4 to 0.9 years in 80-year-old women and men, respectively., Conclusions: LOLE is higher in younger individuals, women, and those with reduced LVEF, but is attenuated when adjusting for comorbidities and risk factors. Advances in MI treatment during the past 30 years have almost halved LOLE, with no clear sign of leveling off to a plateau., Competing Interests: Dr Reitan reports participation in research funded by MSD and AstraZeneca. Dr Andell has participated in research funded by and has received lecture fees to the institution from AstraZeneca. Dr Alfredsson has received lecture or advisory board fees from Boehringer Ingelheim, AstraZeneca, Novartis, Bayer, and MSD. Dr Erlinge has received speaker or advisory board fees from AstraZeneca, Novo Nordisk, Sanofi, Bayer, and Amgen. Dr Hofmann reports lecture fees to the institution from AstraZeneca, Pfizer, and BMS. Dr Lindahl reports no conflict of interest. Dr Simonsson reports lecture fees to the institution from Amgen, Novo Nordisk, and AstraZeneca. Dr Dickman reports no conflict of interest. Dr Jernberg reports research grants from MSD and consulting fees in a research project to the institution from Amgen.

Background: Despite the detrimental impact of abnormal glucose metabolism on cardiovascular prognosis after myocardial infarction (MI), diabetes is both underdiagnosed and undertreated. We investigated associations between structured diabetes care routines in cardiac rehabilitation (CR) and detection and treatment of diabetes at one-year post-MI., Methods: Center-level data was derived from the Perfect-CR survey, which evaluated work routines applied at Swedish CR centers (n = 76). Work routines involving diabetes care included: (1) routine assessment of fasting glucose and/or HbA1c, (2) routine use of oral glucose tolerance test (OGTT), (3) having regular case rounds with diabetologists, and (4) whether glucose-lowering medication was adjusted by CR physicians. Patient-level data was obtained from the national MI registry SWEDEHEART (n = 7601, 76% male, mean age 62.6 years) and included all post-MI patients irrespective of diabetes diagnosis. Using mixed-effects regression we estimated differences between patients exposed versus. not exposed to the four above-mentioned diabetes care routines. Outcomes were newly detected diabetes and the proportion of patients receiving oral glucose-lowering medication at one-year post-MI., Results: Routine assessment of fasting glucose/HbA1c was performed at 63.2% (n = 48) of the centers, while 38.2% (n = 29) reported using OGTT for detecting glucose abnormalities. Glucose-lowering medication adjusted by CR physicians (n = 13, 17.1%) or regular case rounds with diabetologists (n = 7, 9.2%) were less frequently reported. In total, 4.0% of all patients (n = 304) were diagnosed with diabetes during follow-up and 17.9% (n = 1361) were on oral glucose-lowering treatment one-year post-MI. Routine use of OGTT was associated with a higher rate of newly detected diabetes at one-year (risk ratio [95% confidence interval]: 1.62 [1.26, 1.98], p = 0.0007). At one-year a higher proportion of patients were receiving oral glucose-lowering medication at centers using OGTT (1.22 [1.07, 1.37], p = 0.0046) and where such medication was adjusted by CR physicians (1.31 [1.06, 1.56], p = 0.0155). Compared to having none of the structured diabetes care routines, the more routines implemented the higher the rate of newly detected diabetes (from 0 routines: 2.7% to 4 routines: 6.3%; p for trend = 0.0014)., Conclusions: Having structured routines for diabetes care implemented within CR can improve detection and treatment of diabetes post-MI. A cluster-randomized trial is warranted to ascertain causality., (© 2024. The Author(s).)

Background: The registry-based randomized VALIDATE-SWEDEHEART trial (NCT02311231) compared bivalirudin vs. heparin in patients undergoing percutaneous coronary intervention (PCI) for myocardial infarction (MI). It showed no difference in the composite primary endpoint of death, MI, or major bleeding at 180 days. Here, we report outcomes at two years., Methods: Analysis of primary and secondary endpoints at two years of follow-up was prespecified in the study protocol. We report the study results for the extended follow-up time here., Results: In total, 6006 patients were enrolled, 3005 with ST-segment elevation MI (STEMI) and 3001 with Non-STEMI (NSTEMI), representing 70 % of all eligible patients with these diagnoses during the study. The primary endpoint occurred in 14.0 % (421 of 3004) in the bivalirudin group compared with 14.3 % (429 of 3002) in the heparin group (hazard ratio [HR] 0.97; 95 % confidence interval [CI], 0.85-1.11; P = 0.70) at one year and in 16.7 % (503 of 3004) compared with 17.1 % (514 of 3002), (HR 0.97; 95 % CI, 0.96-1.10; P = 0.66) at two years. The results were consistent in patients with STEMI and NSTEMI and across major subgroups., Conclusions: Until the two-year follow-up, there were no differences in endpoints between patients with MI undergoing PCI and allocated to bivalirudin compared with those allocated to heparin., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT02311231., Competing Interests: Declaration of competing interest Elmir Omerovic reports grants from Astra Zeneca, personal fees from Astra Zeneca, MSD, Bayer, Janssen outside the submitted work. Stefan James reports grants from Astra Zeneca, grants from The Medicines Company, grants from Swedish Heart and Lung Foundation, and grants from Swedish Research Council during the conduct of the study; personal fees from Bayer and grants from Jansen outside the submitted work. Truls Råmunddal reports personal fees from Boston Scientific and personal fees from Abbot outside the submitted work. Ole Fröbert reports personal fees from GE Medical and from Astra Zeneca outside the submitted work. Pontus Lindroos reports personal fees from Astra Zeneca outside the submitted work. Anders Ulvenstam reports personal fees from Boston Scientific outside the submitted work. Matthias Götberg reports grants and personal fees from Volcano Corporation, personal fees from Boston Scientific, and personal fees from Medtronic Corporation outside the submitted work. Oskar Angerås Dr. reports personal fees from Astra Zeneca outside the submitted work. Olie Östlund reports grants from AstraZeneca, grants from The Medicines Company. Cleas Held reports grants and personal fees from AstraZeneca, grants from GlaxoSmithKline, grants from BristolMyers Squibb, and grants from Merck outside the submitted work. Sasha Koul reports personal fees from Pfizer, personal fees from BMS, and personal fees from Astra Zeneca outside the submitted work. David Erlinge reports personal fees from Astrazeneca and The Medicines Company outside the submitted work. All others co-authors have nothing to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Prodromal cardiac symptoms are warning signals preceding cardiac disease. Previous studies have shown some gender differences in prodromal symptoms as well as established risk factors for MI. This study aims to map possible gender differences in social factors and established risk factors preceding myocardial infarction (MI).Methods: The study includes data of N = 213 middle-aged men and women, all diagnosed with myocardial infarction (ICD-10 I21.9) from the region of south-east Sweden. They answered a questionnaire at discharge from the cardiologic clinic and additional clinical data from medical records were merged from the National Swedeheart Register.Results: The dominant prodromal symptom for both sexes were experience of chest pain at the onset of MI. The major gender differences were that significantly more females (p = 0.015) had a hyperlipidemia diagnose. Females also reported to have experienced higher stress load the year preceding myocardial infarction with serious life events (p = 0.019), strained economy (p = 0.003), and reports of sadness/depression (p < 0.001). Females reported higher perceived stress load than men (p = 0.006). Men had higher systolic blood pressure than women at hospital admission and a higher systolic- and diastolic blood pressure at discharge.Conclusions: Influences of the social environment, such as serious life events, strained economy, depression, stress, and sleep deprivation were stronger as potential risk factors for myocardial infarction in women than among men. Of the traditional risk factors only, hyperlipidemia was more frequent among women. These findings could contribute to a deeper understanding of diagnostic differences between gender, as well as a more gender-oriented cardiovascular preventive work. [ABSTRACT FROM AUTHOR]

Background: Oral lipid-lowering treatment (LLT) is the standard of care for patients with cardiovascular disease (CVD). However, insufficient treatment intensity and poor adherence can lead to suboptimal treatment benefit, rendering patients at increased risk of CVD. Aims: The objective of this study was to evaluate trends in LLT intensity and adherence in Sweden over time, and their association with major adverse cardiovascular events (MACE) after recent myocardial infarction (MI), and also to assess the impact of transition from secondary to primary care on intensity and adherence. Methods and results: This retrospective observational cohort study used data from Swedish nationwide patient registers and included patients on LLT after an MI in the years 2010-2016 (n = 50,298; mean age, 68 years; 69% men). LLT intensity was evaluated over time (overall, for 2010-2013 and for 2014-2016) as the proportion of patients prescribed low-, moderate-, and high-intensity LLT. Adherence was assessed as the proportion of days covered. A combined measure of intensity and adherence was also considered. Differences in treatment patterns and MACE were assessed. Initiation of high-intensity LLT increased over the two time periods studied (2010-2013, 32%; 2014-2016, 91%). Adherence varied by LLT intensity and was highest in patients receiving high-intensity LLT (>80%), especially during the first time period. Little change in treatment intensity or the combined measure of intensity and adherence was observed after transition to primary care. There was a significant association between the combined measure of intensity and adherence and MACE reduction (hazard ratio [95% confidence interval] per 10% increase in the combined measure: 0.84 [0.82-0.86]; P < 0.01). Conclusion: The proportion of post-MI patients with high LLT intensity and adherence has increased in recent years, with little change after transfer from specialist to primary care. The combination of LLT intensity and adherence is important for preventing future cardiovascular events. [ABSTRACT FROM AUTHOR]

Background: We investigated the prevalence of ECG abnormalities and their association with mortality, organ dysfunction and cardiac biomarkers in a cohort of COVID-19 patients admitted to the intensive care unit (ICU). Methods: This cohort study included patients with COVID-19 admitted to the ICU of a tertiary hospital in Sweden. ECG, clinical data and laboratory findings during ICU stay were extracted from medical records and ECGs obtained near ICU admission were reviewed by two independent physicians. Results: Eighty patients had an acceptable ECG near ICU-admission. In the entire cohort 30-day mortality was 28%. Compared to patients with normal ECG, among whom 30-day mortality was 16%, patients with ECG fulfilling criteria for prior myocardial infarction had higher mortality, 63%, odds ratio (OR) 9.61 (95% confidence interval (CI) 2.02–55.6) adjusted for Simplified Acute Physiology Score 3 and patients with ST-T abnormalities had 50% mortality and OR 6.05 (95% CI 1.82–21.3) in univariable analysis. Both prior myocardial infarction pattern and ST-T pathology were associated with need for vasoactive treatment and higher peak plasma levels of troponin-I, NT-pro-BNP (N-terminal pro-Brain Natriuretic Peptide), and lactate during ICU stay compared to patients with normal ECG. Conclusion: ECG with prior myocardial infarction pattern or acute ST-T pathology at ICU admission is associated with death, need for vasoactive treatment and higher levels of biomarkers of cardiac damage and strain in severely ill COVID-19 patients, and should alert clinicians to a poor prognosis. [ABSTRACT FROM AUTHOR]

Objectives: Christmas holidays have been associated with the highest incidence of myocardial infarction (MI). We wanted to assess possible triggers of MI during Christmas. Design: A nationwide, retrospective postal survey with case-control design. All individuals suffering an MI during the Christmas holidays 2018 and 2019 in Sweden were identified through the SWEDEHEART registry and a control group matched in age and gender with chronic coronary syndrome who did not seek medical attention during Christmas were asked for participation. Subjects completed a questionnaire asking them to rate 27 potential MI-triggers as having occurred more or less than usual. Results: A total of 189 patients suffering an MI on Christmas Eve, Christmas Day, or Boxing Day, and 157 patients in the control group responded to the questionnaire, representing response rates of 66% and 62%, respectively. Patients with MI on Christmas experienced more stress (37% vs. 21%, p = .002), depression (21% vs. 11%, p = .024), and worry (26% vs. 10%, p < .001) compared to the control group. The food and sweets consumption was increased in both groups, but to a greater extent in the control group (33% vs. 50%, p = .002 and 32% vs. 43%, p = .031). There were no increases in quarrels, anger, economic worries, or reduced compliance with medication. Conclusions: Patients suffering MI on Christmas holiday experienced higher levels of stress and emotional distress compared to patients with chronic coronary syndrome, possibly contributing to the phenomenon of holiday heart attack. Understanding what factors increase the number of MI on Christmas may help reduce the excess number of MIs and cardiovascular burden. [ABSTRACT FROM AUTHOR]

Background: Long-term prognosis associated with low-high-sensitivity cardiac troponin T (hs-cTnT) concentrations in patients with chest pain is unknown. We investigated these prognostic implications compared with the general population., Methods: All first visits to seven emergency departments (ED)s in Sweden were included from 9 December 2010 to 31 August, 2017 by patients presenting with chest pain and at least one hs-cTnT measured. Patients with myocardial injury (any hs-cTnT >14 ng/L), including patients with myocardial infarction (MI) were excluded. Standardised mortality ratios (SMRs) and standardised incidence ratios (SIRs) were calculated as the ratio of the number of observed to expected events. The expected number was computed by multiplying the 1-year calendar period-specific, age-specific and sex-specific follow-up time in the cohort with the corresponding incidence in the general population. HRs were calculated for all-cause mortality and major adverse cardiovascular events (MACE), defined as acute MI, heart failure hospitalisation, cerebrovascular stroke or cardiovascular death, between patients with undetectable (<5 ng/L) and low (5-14 ng/L) hs-cTnT., Results: A total of 1 11 916 patients were included, of whom 69 090 (62%) and 42 826 (38%) had peak hs-cTnT concentrations of <5 and 5-14 ng/L. Patients with undetectable peak hs-cTnT had a lower mortality risk compared with the general Swedish population (SMR 0.83, 95% CI 0.79 to 0.87), with lower risks observed in all patients ≥65 years of age, but a slightly higher risk of being diagnosed with a future MI (SIR 1.39, 95% CI 1.32 to 1.47). The adjusted risk of a first MACE associated with low versus undetectable peak hs-cTnT was 1.6-fold (HR 1.61, 95% CI 1.53 to 1.70)., Conclusion: Patients with chest pain and undetectable hs-cTnT have an overall lower risk of death compared with the general population, with risks being highly age dependent. Detectable hs-cTnT concentrations are still associated with increased long-term cardiovascular risks., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The outcome for diffuse large B‐cell lymphoma (DLBCL) patients has improved with the immunochemotherapy combination R‐CHOP. An increased rate of heart failure is well documented following this treatment, whereas incidence and outcome of other cardiac complications, for example myocardial infarction, are less well known. Method: We identified 3548 curatively treated DLBCL patients in Sweden diagnosed between 2007 and 2014, and 35474 matched lymphoma‐free general population comparators. The incidence, characteristics and outcome of acute myocardial infarctions (AMIs) were assessed using population‐based registers up to 11 years after diagnosis. The rate of AMI was estimated using flexible parametric models. Results: Overall, a 33% excess rate of AMI was observed among DLBCL patients compared with the general population (HR: 1.33, 95% CI: 1.14–1.55). The excess rate was highest during the first year after diagnosis and diminished after 2 years. High age, male sex and comorbidity were the strongest risk factors for AMI. Older patients (>70 years) with mild comorbidities (i.e. hypertension or diabetes) had a 61% higher AMI rate than comparators (HR: 1.61, 95% CI: 1.10–2.35), whereas the corresponding excess rate was 28% for patients with severe comorbidities (HR: 1.28, 95% CI: 1.01–1.64). Among younger patients (≤70), a short‐term excess rate of AMI was limited to those with severe comorbidities. There was no difference in AMI characteristics, pharmacological treatment or 30‐day survival among patients and comparators. Conclusion: DLBCL patients have an increased risk of AMI, especially during the first 2 years, which calls for improved cardiac monitoring guided by age and comorbidities. Importantly, DLBCL was not associated with differential AMI management or survival. [ABSTRACT FROM AUTHOR]

Aims To examine patient delay in seeking medical care when afflicted by an acute myocardial infarction during March–June 2020. Methods and results This was a cross-sectional study in a region in Sweden during the first wave of the COVID-19 pandemic examining patients selected from the national registry (SWEDEHEART). Eligible patients were those with acute myocardial infarction, and a total of 602 patients were invited. A self-administered psychometric evaluated questionnaire, 'Patients' appraisal, emotions, and action tendencies preceding care-seeking in acute myocardial infarction' (AMI), was sent to the patients, and questions regarding COVID-19 were added. A total of 326 patients answered the questionnaire. Of these, 19% hesitated to seek medical care because of the pandemic, which was related to a fear that the healthcare services were already overcrowded with patients with COVID-19, followed by a fear of becoming infected with COVID-19 in hospital. Characteristics of this cohort were significantly higher prevalences of women, immigrants, smokers, and patients with type 2 diabetes. Conclusions During the outbreak and first wave of the COVID-19 pandemic, women and immigrants delayed seeking medical care for AMI because of fears about overcrowded hospitals and about becoming infected themselves. Therefore, during the COVID-19 pandemic, it is especially important to convey information about how and when to seek medical care. A collaboration involving the healthcare professionals, patient organizations, and the media would be desirable. [ABSTRACT FROM AUTHOR]

Aims Underestimation of cardiovascular risk may interfere with prevention of cardiovascular diseases (CVDs). We investigate whether general health and family history of myocardial infarction (MI) are associated with underestimation of perceived cardiovascular risk, and if the participants' calculated risk modifies that association. Methods and results The analysis sample consisted of 526 individuals, 50--64 years old, from a population-based cohort study. Information on general health (poor/fairly good, good, and very good/excellent), family history of MI, and self-perceived risk relative to others of similar age and sex were collected though a web-based survey. Participants were categorized into underestimation (n = 162, 31%), accurate estimation (n = 222, 42%), and overestimation (n = 142, 27%) of cardiovascular risk by comparing calculated Systematic Coronary Risk Estimation (SCORE) with self-perceived risk. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for underestimation vs. accurate estimation of cardiovascular risk were computed using logistic regression (n = 384). Very good general health (OR 2.60, 95% CI 1.10-6.16) and lack of family history (OR 2.27, 95% CI 1.24--4.18) were associated with underestimation of cardiovascular risk. The associations were modified by the participants' calculated risk level; the association was stronger for high-risk individuals; without family history OR 22.57 (95% CI 6.17--82.54); with very good/excellent health OR 15.78 (95% CI 3.73-66.87). Conclusion A good general health and the lack of family CVD history can obscure the presence of other risk factors and lead to underestimation of cardiovascular risk, especially for high-risk individuals. It is, therefore, crucial to address the fact that the development of CV disease may be silent and multifactorial. [ABSTRACT FROM AUTHOR]

Background: The death of a child is an extreme life event with potentially long-term health consequences. Knowledge about its association with ischemic heart diseases (IHDs) and acute myocardial infarction (AMI), however, is very limited. We investigated whether the death of an offspring is associated with the risk of IHD and AMI.Methods and Findings: We studied parents of live-born children recorded in the Danish (1973 to 2016) and the Swedish (1973 to 2014) Medical Birth Registers (n = 6,711,952; mean age at baseline 31 years, 53% women). We retrieved information on exposure, outcomes, and covariates by linking individual-level information from several nationwide registers. We analyzed the abovementioned associations using Poisson regression. A total of 126,522 (1.9%) parents lost at least 1 child during the study period. Bereaved parents had a higher risk of IHD and AMI than the nonbereaved [incidence rate ratios (IRRs) (95% confidence intervals (CIs)): 1.20 (1.18 to 1.23), P < 0.001 and 1.21 (1.17 to 1.25), P < 0.001, respectively]. The association was present not only in case of losses due to CVD or other natural causes, but also in case of unnatural deaths. The AMI risk was highest in the first week after the loss [IRR (95% CI): 3.67 (2.08 to 6.46), P < 0.001], but a 20% to 40% increased risk was observed throughout the whole follow-up period. Study limitations include the possibility of residual confounding by socioeconomic, lifestyle, or health-related factors and the potentially limited generalizability of our findings outside Scandinavia.Conclusions: The death of an offspring was associated with an increased risk of IHD and AMI. The finding that the association was present also in case of losses due to unnatural causes, which are less likely to be confounded by cardiovascular risk factors clustering in families, suggests that stress-related mechanisms may also contribute to the observed associations. [ABSTRACT FROM AUTHOR]

Background: Early detection of coronary atherosclerosis using coronary computed tomography angiography (CCTA), in addition to coronary artery calcification (CAC) scoring, may help inform prevention strategies. We used CCTA to determine the prevalence, severity, and characteristics of coronary atherosclerosis and its association with CAC scores in a general population.Methods: We recruited 30 154 randomly invited individuals age 50 to 64 years to SCAPIS (the Swedish Cardiopulmonary Bioimage Study). The study includes individuals without known coronary heart disease (ie, no previous myocardial infarctions or cardiac procedures) and with high-quality results from CCTA and CAC imaging performed using dedicated dual-source CT scanners. Noncontrast images were scored for CAC. CCTA images were visually read and scored for coronary atherosclerosis per segment (defined as no atherosclerosis, 1% to 49% stenosis, or ≥50% stenosis). External validity of prevalence estimates was evaluated using inverse probability for participation weighting and Swedish register data.Results: In total, 25 182 individuals without known coronary heart disease were included (50.6% women). Any CCTA-detected atherosclerosis was found in 42.1%; any significant stenosis (≥50%) in 5.2%; left main, proximal left anterior descending artery, or 3-vessel disease in 1.9%; and any noncalcified plaques in 8.3% of this population. Onset of atherosclerosis was delayed on average by 10 years in women. Atherosclerosis was more prevalent in older individuals and predominantly found in the proximal left anterior descending artery. Prevalence of CCTA-detected atherosclerosis increased with increasing CAC scores. Among those with a CAC score >400, all had atherosclerosis and 45.7% had significant stenosis. In those with 0 CAC, 5.5% had atherosclerosis and 0.4% had significant stenosis. In participants with 0 CAC and intermediate 10-year risk of atherosclerotic cardiovascular disease according to the pooled cohort equation, 9.2% had CCTA-verified atherosclerosis. Prevalence estimates had excellent external validity and changed marginally when adjusted to the age-matched Swedish background population.Conclusions: Using CCTA in a large, random sample of the general population without established disease, we showed that silent coronary atherosclerosis is common in this population. High CAC scores convey a significant probability of substantial stenosis, and 0 CAC does not exclude atherosclerosis, particularly in those at higher baseline risk. [ABSTRACT FROM AUTHOR]

Objectives: Type 2 myocardial infarction (MI) is a heterogenous condition and whether there are differences between women and men is unknown. We evaluated sex differences in clinical characteristics, investigations and outcomes in patients with type 2 MI.Methods: In the Swedish Web based system for Enhancement and Development of Evidence based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) registry, we compared patients admitted to coronary care units with a diagnosis of type 1 or type 2 MI. Sex-stratified Cox regression models evaluated the association with all-cause death in men and women separately.Results: We included 57 264 (median age 73 years, 65% men) and 6485 (median age 78 years, 50% men) patients with type 1 and type 2 MI, respectively. No differences were observed in the proportion of men and women with type 2 MI who underwent echocardiography and coronary angiography, but women were less likely than men to have left ventricular (LV) impairment and obstructive coronary artery disease (CAD). Compared with type 1 MI, patients with type 2 MI had higher risk of death regardless of sex (men: adjusted HR 1.55 (95% CI 1.44 to 1.67); women: adjusted HR 1.34 (95% CI 1.24 to 1.45)). In those with type 2 MI, the risk of death was lower for women than men (adjusted HR 0.85 (95% CI 0.76 to 0.92) (men, reference)).Conclusions: Type 2 MI occurred in men and women equally and we found no evidence of sex bias in the selection of patients for cardiac investigations. Patients with type 2 MI had worse outcomes, but women were less likely to have obstructive CAD or severe LV impairment and were more likely to survive than men. [ABSTRACT FROM AUTHOR]

Background: COVID-19 is a complex disease targeting many organs. Previous studies highlight COVID-19 as a probable risk factor for acute cardiovascular complications. We aimed to quantify the risk of acute myocardial infarction and ischaemic stroke associated with COVID-19 by analysing all COVID-19 cases in Sweden.Methods: This self-controlled case series (SCCS) and matched cohort study was done in Sweden. The personal identification numbers of all patients with COVID-19 in Sweden from Feb 1 to Sept 14, 2020, were identified and cross-linked with national inpatient, outpatient, cancer, and cause of death registers. The controls were matched on age, sex, and county of residence in Sweden. International Classification of Diseases codes for acute myocardial infarction or ischaemic stroke were identified in causes of hospital admission for all patients with COVID-19 in the SCCS and all patients with COVID-19 and the matched control individuals in the matched cohort study. The SCCS method was used to calculate the incidence rate ratio (IRR) for first acute myocardial infarction or ischaemic stroke following COVID-19 compared with a control period. The matched cohort study was used to determine the increased risk that COVID-19 confers compared with the background population of increased acute myocardial infarction or ischaemic stroke in the first 2 weeks following COVID-19.Findings: 86 742 patients with COVID-19 were included in the SCCS study, and 348 481 matched control individuals were also included in the matched cohort study. When day of exposure was excluded from the risk period in the SCCS, the IRR for acute myocardial infarction was 2·89 (95% CI 1·51-5·55) for the first week, 2·53 (1·29-4·94) for the second week, and 1·60 (0·84-3·04) in weeks 3 and 4 following COVID-19. When day of exposure was included in the risk period, IRR was 8·44 (5·45-13·08) for the first week, 2·56 (1·31-5·01) for the second week, and 1·62 (0·85-3·09) for weeks 3 and 4 following COVID-19. The corresponding IRRs for ischaemic stroke when day of exposure was excluded from the risk period were 2·97 (1·71-5·15) in the first week, 2·80 (1·60-4·88) in the second week, and 2·10 (1·33-3·32) in weeks 3 and 4 following COVID-19; when day of exposure was included in the risk period, the IRRs were 6·18 (4·06-9·42) for the first week, 2·85 (1·64-4·97) for the second week, and 2·14 (1·36-3·38) for weeks 3 and 4 following COVID-19. In the matched cohort analysis excluding day 0, the odds ratio (OR) for acute myocardial infarction was 3·41 (1·58-7·36) and for stroke was 3·63 (1·69-7·80) in the 2 weeks following COVID-19. When day 0 was included in the matched cohort study, the OR for acute myocardial infarction was 6·61 (3·56-12·20) and for ischaemic stroke was 6·74 (3·71-12·20) in the 2 weeks following COVID-19.Interpretation: Our findings suggest that COVID-19 is a risk factor for acute myocardial infarction and ischaemic stroke. This indicates that acute myocardial infarction and ischaemic stroke represent a part of the clinical picture of COVID-19, and highlights the need for vaccination against COVID-19.Funding: Central ALF-funding and Base Unit ALF-Funding, Region Västerbotten, Sweden; Strategic funding during 2020 from the Department of Clinical Microbiology, Umeå University, Sweden; Stroke Research in Northern Sweden; The Laboratory for Molecular Infection Medicine Sweden. [ABSTRACT FROM AUTHOR]

To evaluate the diagnostic yield of the ECG criteria for ST-elevation myocardial infarction in a large cohort of emergency department chest pain patients, and to determine whether extended ECG criteria or reciprocal ST depression can improve accuracy. Design: Observational, register-based diagnostic study on the accuracy of ECG criteria for ST-elevation myocardial infarction. Between Jan 2010 and Dec 2014 all patients aged ≥30 years with chest pain who had an ECG recorded within 4 h at two emergency departments in Sweden were included. Exclusion criteria were: ECG with poor technical quality; QRS duration ≥120 ms; ECG signs of left ventricular hypertrophy; or previous coronary artery bypass surgery. Conventional and extended ECG criteria were applied to all patients. The main outcome was acute myocardial infarction (AMI) and an occluded/near-occluded coronary artery at angiography. Results: Finally, 19932 patients were included. Conventional ECG criteria for ST elevation myocardial infarction were fulfilled in 502 patients, and extended criteria in 1249 patients. Sensitivity for conventional ECG criteria in diagnosing AMI with coronary occlusion/near-occlusion was 17%, specificity 98% and positive predictive value 12%. Corresponding data for extended ECG criteria were 30%, 94% and 8%. When reciprocal ST depression was added to the criteria, the positive predictive value rose to 24% for the conventional and 23% for the extended criteria. Conclusions: In unselected chest pain patients at the emergency department, the diagnostic yield of both conventional and extended ECG criteria for ST-elevation myocardial infarction is low. The PPV can be increased by also considering reciprocal ST depression. [ABSTRACT FROM AUTHOR]

Background: Bilberries from Sweden, rich in polyphenols, have shown cholesterol-lowering effects in small studies, and the cholesterol-lowering properties of oats, with abundant beta-glucans and potentially bioactive phytochemicals, are well established. Both may provide cardiometabolic benefits following acute myocardial infarction (AMI), but large studies of adequate statistical power and appropriate duration are needed to confirm clinically relevant treatment effects. No previous study has evaluated the potential additive or synergistic effects of bilberry combined with oats on cardiometabolic risk factors. Our primary objective is to assess cardioprotective effects of diet supplementation with dried bilberry or with bioprocessed oat bran, with a secondary explorative objective of assessing their combination, compared with a neutral isocaloric reference supplement, initiated within 5 days following percutaneous coronary intervention (PCI) for AMI.Methods: The effects of Bilberry and Oat intake on lipids, inflammation and exercise capacity after Acute Myocardial Infarction (BIOAMI) trial is a double-blind, randomized, placebo-controlled clinical trial. A total of 900 patients will be randomized post-PCI to one of four dietary intervention arms. After randomization, subjects will receive beverages with bilberry powder (active), beverages with high-fiber bioprocessed oat bran (active), beverages with bilberry and oats combined (active), or reference beverages containing no active bilberry or active oats, for consumption twice daily during a 3-month intervention. The primary endpoint is the difference in LDL cholesterol change between the intervention groups after 3 months. The major secondary endpoint is exercise capacity at 3 months. Other secondary endpoints include plasma concentrations of biochemical markers of inflammation, metabolomics, and gut microbiota composition after 3 months.Discussion: Controlling hyperlipidemia and inflammation is critical to preventing new cardiovascular events, but novel pharmacological treatments for these conditions are expensive and associated with negative side effects. If bilberry and/or oat, in addition to standard medical therapy, can lower LDL cholesterol and inflammation more than standard therapy alone, this could be a cost-effective and safe dietary strategy for secondary prevention after AMI.Trial Registration: ClinicalTrials.gov NCT03620266 . Registered on August 8, 2018. [ABSTRACT FROM AUTHOR]

Objective: Type 1 diabetes (T1D) and type 2 diabetes (T2D) increase risks of cardiovascular (CV) and renal disease (CVRD) compared with diabetes-free populations. Direct comparisons between T1D and T2D are scarce. We examined this by pooling full-population cohorts in Sweden and Norway.Research Design and Methods: A total of 59,331 patients with T1D and 484,241 patients with T2D, aged 18-84 years, were followed over a mean period of 2.6 years from 31 December 2013. Patients were identified in nationwide prescribed drug and hospital registries in Norway and Sweden. Prevalence and event rates of myocardial infarction (MI), heart failure (HF), stroke, chronic kidney disease (CKD), all-cause death, and CV death were assessed following age stratification in 5-year intervals. Cox regression analyses were used to estimate risk.Results: The prevalence of CV disease was similar in T1D and T2D across age strata, whereas CKD was more common in T1D. Age-adjusted event rates comparing T1D versus T2D showed that HF risk was increased between ages 65 and 79 years, MI between 55 and 79 years, and stroke between 40 and 54 years (1.3-1.4-fold, 1.3-1.8-fold, and 1.4-1.7-fold, respectively). CKD risk was 1.4-3.0-fold higher in T1D at all ages. The all-cause death risk was 1.2-1.5-fold higher in T1D at age >50 years, with a similar trend for CV death.Conclusions: Adult patients with T1D compared with those with T2D had an overall greater risk of cardiorenal disease (HF and CKD) across ages, MI and all-cause death at middle-older ages, and stroke at younger ages. The total age-adjusted CVRD burden and risks were greater among patients with T1D compared with those with T2D, highlighting their need for improved prevention strategies. [ABSTRACT FROM AUTHOR]

An association between acute myocardial infarction (AMI) and systemic lupus erythematosus (SLE) has been suggested. The cause of AMI is presumed to be atherothrombosis. In the present study, the primary objective was to assess incident AMI cases and the secondary objective was to estimate the proportion of myocardial infarction with nonobstructive coronary arteries (MINOCA) in patients with SLE. All Swedish patients with SLE without AMI before 1996 (n = 4192) were followed for 20 years in the national patient registry. For each SLE patient, 10 age- and sex-matched controls without SLE and AMI before 1996 (n = 41 892) were identified. Data from patients and controls with AMI after 1996 were linked with the Swedish coronary angiography and angioplasty register; 549 (13%) and 3352 (8%) first AMIs occurred in patients with SLE and controls, respectively. The incidence of AMI was 9.6 (95% CI: 8.9-10.5) and 4.9 (95% CI: 4.8-5.1) events/1000 person-years in patients with SLE and controls, respectively. The proportion of MINOCA was 10.8% in patients with SLE and 13.8% in controls (P =.261), respectively. In conclusion, the incidence of AMI is increased in a European population of patients with SLE but there is no indication that the proportion of MINOCA is increased in these patients. [ABSTRACT FROM AUTHOR]

Objective: To describe cognitive impairment in out-of-hospital cardiac arrest (OHCA) survivors, with the hypothesis that OHCA survivors would perform significantly worse on neuropsychological tests of cognition than controls with acute myocardial infarction (MI). Another aim was to investigate the relationship between cognitive performance and the associated factors of emotional problems, fatigue, insomnia, and cardiovascular risk factors following OHCA. Participants and Methods: This was a prospective case control sub-study of The Targeted Hypothermia versus Targeted Normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial. Eight of 61 TTM2-sites in Sweden, Denmark, and the United Kingdom included adults with OHCA of presumed cardiac or unknown cause. A matched non-arrest control group with acute MI was recruited. We administered an extensive neuropsychological assessment at approximately 7 months post-cardiac event, including a neuropsychological test battery and questionnaires on anxiety, depression, fatigue, and insomnia, and collected information on the cardiovascular risk factors hypertension and diabetes. Z -scores of individual tests were converted to neuropsychological composite scores per cognitive domain (verbal, visual/constructive, working memory, episodic memory, processing speed, executive functions). Between-group differences on the neuropsychological composite scores were investigated with linear regression. Associations between anxiety, depression, fatigue, insomnia, hypertension, diabetes, and the neuropsychological composite scores among OHCA survivors were calculated with Spearman's rho. Results: Of 184 eligible OHCA survivors, 108 were included (mean age = 62, 88% male), with 92 MI controls enrolled (mean age = 64, 89% male). Amongst OHCA survivors, 29% performed z <-1 indicating at least borderline-mild impairment in >2 cognitive domains, and 14% performed z <-2 exhibiting major impairment in >1 cognitive domain. OHCA survivors performed significantly worse than MI controls in episodic memory (mean difference, MD = -0.37, 95% confidence intervals [-0.61, -0.12]), verbal (MD = -0.34 [-0.62, -0.07]), and visual/constructive functions (MD = -0.26 [-0.47, -0.04]) on linear regressions adjusted for educational attainment and sex. When additionally adjusting for anxiety, depression, fatigue, insomnia, hypertension, and diabetes, processing speed (MD = -0.41 [-0.74, -0.09]) and executive functions (MD = -0.69 [-1.13, -0.24]) were also worse following OHCA. Depressive symptoms were associated with worse executive functions (rs = -0.37, p <0.001) and worse processing speed (rs = -0.27, p = 0.01) post-OHCA. Anxiety symptoms (rs = -0.21, p = 0.01) and general fatigue (rs = -0.24, p = 0.01) were associated with worse executive functions. Diabetes was associated with worse processing speed (rs = -0.20, p = 0.03), visual/constructive (rs = -0.29, p <0.001) and executive functions (rs = -0.25, p = 0.02), while hypertension and insomnia were not significantly associated with neuropsychological test performance. Conclusions: Cognitive impairment is generally mild following OHCA, but most pronounced in episodic memory, executive functions, and processing speed. OHCA survivors performed worse than MI controls. We suggest that a post-OHCA follow-up service should screen for cognitive impairment, emotional problems, and fatigue. [ABSTRACT FROM AUTHOR]

Background: Providing secondary prevention through structured and comprehensive cardiac rehabilitation programmes to patients after a myocardial infarction (MI) reduces mortality and morbidity and improves health-related quality of life. Cardiac rehabilitation has the highest recommendation in current guidelines. While treatment target attainment rates at Swedish cardiac rehabilitation centres is among the highest in Europe, there are considerable differences in service delivery and variations in patient-level outcomes between centres. In this trial, we aim to study whether centre-level guideline adherence and patient-level outcomes across Swedish cardiac rehabilitation centres can be improved through a) regular audit and feedback of cardiac rehabilitation structure and processes through a national quality registry and b) supporting cardiac rehabilitation centres in implementing guidelines on secondary prevention. Furthermore, we aim to evaluate the implementation process and costs., Methods: The study is an open-label cluster-randomized effectiveness-implementation hybrid trial including all 78 cardiac rehabilitation centres (attending to approximately 10 000 MI patients/year) that report to the SWEDEHEART registry. The centres will be randomized 1:1:1 to three clusters: 1) reporting cardiac rehabilitation structure and process variables to SWEDEHEART every six months (audit intervention) and being offered implementation support to implement guidelines on secondary prevention (implementation support intervention); 2) audit intervention only; or 3) no intervention offered. Baseline cardiac rehabilitation structure and process variables will be collected. The primary outcome is an adherence score measuring centre-level adherence to secondary prevention guidelines. Secondary outcomes include patient-level secondary prevention risk factor goal attainment at one-year after MI and major adverse coronary outcomes for up to five-years post-MI. Implementation outcomes include barriers and facilitators to guideline adherence evaluated using semi-structured focus-group interviews and relevant questionnaires, as well as costs and cost-effectiveness assessed by a comparative health economic evaluation., Discussion: Optimizing cardiac rehabilitation centres' delivery of services to meet standards set in guidelines may lead to improvement in cardiovascular risk factors, including lifestyle factors, and ultimately a decrease in morbidity and mortality after MI., Trial Registration: ClinicalTrials.gov. Identifier: NCT05889416 . Registered 2023-03-23., (© 2024. The Author(s).)

Prospective benchmarking of an observational analysis against a randomized trial increases confidence in the benchmarking process as it relies exclusively on aligning the protocol of the trial and the observational analysis, while the trials findings are unavailable. The Randomized Evaluation of Decreased Usage of Betablockers After Myocardial Infarction (REDUCE-AMI, ClinicalTrials.gov ID: NCT03278509) trial started recruitment in September 2017 and results are expected in 2024. REDUCE-AMI aimed to estimate the effect of long-term use of beta blockers on the risk of death and myocardial following a myocardial infarction with preserved left ventricular systolic ejection fraction. We specified the protocol of a target trial as similar as possible to that of REDUCE-AMI, then emulated the target trial using observational data from Swedish healthcare registries. Had everyone followed the treatment strategy as specified in the target trial protocol, the observational analysis estimated a reduction in the 5-year risk of death or myocardial infarction of 0.8 percentage points for beta blockers compared with no beta blockers; effects ranging from an absolute reduction of 4.5 percentage points to an increase of 2.8 percentage points in the risk of death or myocardial infarction were compatible with our data under conventional statistical criteria. Once results of REDUCE-AMI are published, we will compare the results of our observational analysis against those from the trial. If this prospective benchmarking is successful, it supports the credibility of additional analyses using these observational data, which can rapidly deliver answers to questions that could not be answered by the initial trial. If benchmarking proves unsuccessful, we will conduct a "postmortem" analysis to identify the reasons for the discrepancy. Prospective benchmarking shifts the investigator focus away from an endeavour to use observational data to obtain similar results as a completed randomized trial, to a systematic attempt to align the design and analysis of the trial and the observational analysis., (© 2024. The Author(s).)

Long term stress exposure is typical for modern societies and might trigger different diseases. This case–control study reveals that persons who had suffered an acute myocardial infarction (AMI) had elevated cortisol concentrations in the month before the acute event. Middle-aged patients admitted to cardiology clinics with acute myocardial infarction (AMI) (n = 174) were compared to 3156 controls from a population-based cohort in southeast Sweden. The median Hair Cortisol Concentrations (HCC) for those who had suffered an AMI was 53.2 pg/mg compared to 22.2 pg/mg for the control group (p < 0.001). In bivariate analysis, higher levels of HCC were strongly (OR = 5.69) and statistically significantly associated with current AMI status. The discrimination of cases with AMI from controls remained statistically significant (OR = 5.04) even after controlling for established cardiovascular risk factors in a multivariate analysis. Middle-aged persons with acute myocardial infarction had significantly elevated cortisol levels during the month before the cardiac event. This was evident for both men and women. The biomarker cortisol concentration was independently and statistically significantly related to AMI. Chronic stress seems to be a new promising risk factor for AMI. [ABSTRACT FROM AUTHOR]