Search

Background and Aims: The burden and outcomes of inflammation in patients with atherosclerotic cardiovascular disease (ASCVD) are not well defined beyond the controlled settings of trials and research cohorts., Methods: This was an observational study of ASCVD adults undergoing C-reactive protein testing in Stockholm's healthcare (2007-21). After excluding C-reactive protein tests associated with acute illness or medications/conditions that bias C-reactive protein interpretation, systemic inflammation was evaluated over a 3-month ascertainment window. Determinants of C-reactive protein ≥ 2 mg/L were explored with logistic regression. C-reactive protein categories were compared via negative-binomial/Cox regression for subsequent healthcare resource utilization and occurrence of major adverse cardiovascular events, heart failure hospitalization, and death., Results: A total of 84 399 ASCVD adults were included (46% female, mean age 71 years, 59% with C-reactive protein ≥ 2 mg/L). Female sex, older age, lower kidney function, albuminuria, diabetes, hypertension, and recent anaemia were associated with higher odds of C-reactive protein ≥ 2 mg/L. The use of renin-angiotensin system inhibitors, antiplatelets, and lipid-lowering therapy was associated with lower odds. Over a median of 6.4 years, compared with C-reactive protein < 2 mg/L, patients with C-reactive protein ≥ 2 mg/L had higher rates of hospitalizations, days spent in hospital, outpatient consultations, and dispensed medications (P < .05 for all). They also had a higher rate of major adverse cardiovascular events [hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.27-1.33], heart failure (HR 1.24; 95% CI 1.20-1.30), and death (HR 1.35; 95% CI 1.31-1.39). Results were consistent across subgroups and granular C-reactive protein categories and robust to the exclusion of extreme C-reactive protein values or early events., Conclusions: Three in five adults with ASCVD have systemic inflammation, which is associated with excess healthcare resource utilization and increased rates of cardiovascular events and death., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Whereas autonomic dysfunction and the metabolic syndrome are clinically associated, the relationships with the plasma metabolome is unknown. We explored the association between orthostatic blood pressure responses and 818 plasma metabolites in middle-aged subjects from the general population. We included 3803 out of 6251 subjects (mean age, 57 years; 52% women) from the Malmö sub-cohort of The Swedish CardioPulmonary bioImage Study with information on smoking habits, diabetes, antihypertensive drug treatment, anthropometrics, hemodynamic measurements and 818 plasma metabolites (mass-spectrometry). The associations between each metabolite and orthostatic systolic blood pressure responses were determined using multivariable linear regression analysis and p values were corrected using the Bonferroni method. Six amino acids, five vitamins, co-factors and carbohydrates, nine lipids and two xenobiotics were associated with orthostatic blood pressure after adjusting for age, gender and systolic blood pressure. After additional adjustments for BMI, diabetes, smoking and antihypertensive treatment, the association remained significant for six lipids, four amino acids and one xenobiotic. Twenty-two out of 818 plasma metabolites were associated with orthostatic blood pressure responses. Eleven metabolites, including lipids in the dihydrosphingomyelin and sphingosine pathways, were independently associated with orthostatic systolic blood pressure responses after additional adjustment for markers of cardio-metabolic disease., (© 2023. Springer Nature Limited.)

Introduction: This study utilized continuous glucose monitoring data to analyze the effects of switching to treatment with fast-acting insulin aspart (faster aspart) in adults with type 1 diabetes (T1D) in clinical practice., Methods: A noninterventional database review was conducted in Sweden among adults with T1D using multiple daily injection (MDI) regimens who had switched to treatment with faster aspart as part of basal-bolus treatment. Glycemic data were retrospectively collected during the 26 weeks before switching (baseline) and up to 32 weeks after switching (follow-up) to assess changes in time in glycemic range (TIR; 70-180 mg/dL), mean sensor glucose, glycated hemoglobin (HbA1c) levels, coefficient of variation, time in hyperglycemia (level 1, > 180 to ≤ 250 mg/dL; level 2, > 250 mg/dL), and time in hypoglycemia (level 1, ≥ 54 to < 70 mg/dL; level 2, < 54 mg/dL) (ClinicalTrials.gov Identifier NCT03895515)., Results: Overall, 178 participants were included in the study cohort. The analysis population included 82 individuals (mean age 48.5 years) with adequate glucose sensor data. From baseline to follow-up, statistically significant improvements were reported for TIR (mean increase 3.3%-points [approximately 48 min/day]; p = 0.006) with clinically relevant improvement (≥ 5%) in 43% of participants. Statistically significant improvements from baseline were observed for mean sensor glucose levels, HbA1c levels, and time in hyperglycemia (levels 1 and 2), with no statistically significant changes in time spent in hypoglycemia., Conclusions: Switching to faster aspart was associated with improvements in glycemic control without increasing hypoglycemia in adults with T1D using MDI in this real-world setting., (© 2023. The Author(s).)

Objective: Orthostatic hypotension and resting heart rate (RHR) are associated with cardiovascular disease (CVD). However, it is unknown how these factors relate to subclinical CVD. We examined the relationship between orthostatic blood pressure (BP) response, RHR and cardiovascular risk factors, including coronary artery calcification score (CACS) and arterial stiffness, in the general population., Methods: We included 5493 individuals (age 50-64 years; 46.6% men) from The Swedish CArdioPulmonary-bio-Image Study (SCAPIS). Anthropometric and haemodynamic data, biochemistry, CACS and carotid-femoral pulse wave velocity (PWV) were retrieved. Individuals were categorized into binary variables that manifest orthostatic hypotension and in quartiles of orthostatic BP responses and RHR, respectively. Differences across the various characteristics were tested using χ 2 for categorical variables and analysis of variance and Kruskal-Wallis test for continuous variables., Results: The mean (SD) SBP and DBP decrease upon standing was -3.8 (10.2) and -9.5 (6.4) mmHg, respectively. Manifest orthostatic hypotension (1.7% of the population) associated with age ( P  = 0.021), systolic, diastolic and pulse pressure ( P  < 0.001), CACS (<0.001), PWV ( P  = 0.004), HbA1c ( P  < 0.001) and glucose levels ( P  = 0.035). Age ( P  < 0.001), CACS ( P  = 0.045) and PWV ( P  < 0.001) differed according to systolic orthostatic BP, with the highest values seen in those with highest and lowest systolic orthostatic BP-responses. RHR was associated with PWV ( P  < 0.001), SBP and DBP ( P  < 0.001) as well as anthropometric parameters ( P  < 0.001) but not CACS ( P  = 0.137)., Conclusion: Subclinical abnormalities in cardiovascular autonomic function, such as impaired and exaggerated orthostatic BP response and increased resting heart rate, are associated with markers of increased cardiovascular risk in the general population., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Self-care behavior is important in avoiding hospitalization for patients with heart failure (HF) and refers to those activities performed with the intention of improving or restoring health and well-being, as well as treating or preventing disease. The purpose was to study the effects of a home-based mobile device on self-care behavior and hospitalizations in a representative HF-population., Methods and Results: SMART-HF is a randomized controlled multicenter clinical trial, where patients were randomized 1:1 to receive standard care (control group [CG]) or intervention with a home-based tool designed to enhance self-care behavior (intervention group [IG]) and followed for 240 days. The tool educates the patient about HF, monitors objective and subjective symptoms and adjusts loop diuretics. The primary outcome is self-care as measured by the European Heart Failure Self-care behavior scale and the secondary outcome is HF related in-hospital days.A total of 124 patients were recruited and 118 were included in the analyses (CG: n = 60, IG: n = 58). The mean age was 79 years, 39% were female, and 45% had an ejection fraction of less than 40%. Self-care was significantly improved in the IG compared to the CG (median (interquartile range) (21.5 [13.25; 28] vs 26 [18; 29.75], p = 0.014). Patients in the IG spent significantly less time in the hospital admitted for HF (2.2 days less, relative risk 0.48, 95% confidence interval 0.32-0.74, P = .001)., Conclusions: The device significantly improved self-care behavior and reduced in-hospital days in a relevant HF population., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Many patients with atrial fibrillation (AF) or atrial flutter (AFL) and rapid ventricular response (RVR) have elevated high-sensitivity troponin T (hsTnT) values. Elevated hsTnT is an independent risk marker for cardiovascular events and mortality. The aim was to examine if AF/AFL patients with RVR and elevated hsTnT have an increased incidence of pathological cardiac stress tests, indicating need of further evaluation for coronary artery disease (CAD). Design: We prospectively included 90 AF/AFL patients without known heart failure and CAD presenting with AF/AFL and RVR. Half of the patients had elevated hsTnT (cases) and half had levels below the 99th percentile (controls). All patients were discharged in sinus rhythm. After approximately one week in sinus rhythm a new hsTnT was analysed and the patients performed a bicycle exercise stress test within the 30 day follow-up. The primary endpoint was a pathological stress test confirmed by a pathological SPECT myocardial perfusion imaging or a coronary angiography. Results: None of the controls reached the primary endpoint. Two patients (4%) out of the 45 cases reached the primary endpoint ( p  = .49 vs controls), but only one was found to have significant CAD at subsequent coronary angiography. Conclusion: Patients with paroxysmal AF/AFL, without a history of CAD and heart failure, who present with a RVR and minor hsTnT elevations were not found to have an increased incidence of pathological stress tests compared to patients with hsTnT values below the 99th percentile.

Objective: Mortality caused by coronary artery disease has markedly decreased in recent years. However, a substantial proportion of patients suffering a coronary event (CE) die within the first day, most of them out of hospital. We aimed to investigate how established cardiovascular (CV) risk factors and CV autonomic indices associate with fatal versus non-fatal CEs in the population., Methods: 33 057 individuals (mean age; 45.6 years; 10 773 women) free of coronary artery disease at baseline were included. Baseline examination, including assessment of traditional CV risk factors and autonomic indices such as heart rate and orthostatic reaction, was performed during 1974-1992, after which the subjects were monitored for incident CV disease. The Lunn-McNeil competing risks approach with a prespecified multivariable model was used to assess differences in risks for fatal and non-fatal CEs in relation to baseline CV risk factors., Results: During follow-up period of 29.7 years, 5494 subjects (6.10/1000 person-years) had first CE; 1554 of these were fatal. Age, male gender, smoking, body mass index (BMI), blood pressure, pulse pressure and resting heart rate had stronger relationships with fatal CE than with non-fatal events. The effects of diabetes, serum cholesterol, antihypertensive treatment and orthostatic blood pressure responses were similar for fatal and non-fatal CE., Conclusions: Several cardiovascular risk factors, such as smoking, high BMI, blood pressure and high resting heart rate, were preferentially associated with fatal compared with non-fatal CEs. These observations may require special attention in the overall efforts to further reduce coronary artery disease mortality., Competing Interests: Competing interests: SG has been employed by Novo Nordisk after the completion of this study., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objective: The elderly are an increasing group and large consumers of care in Sweden. Development of mobile information technology shows promising results of interventions for prevention and treatment of chronic diseases. Exploring the elderly patients' beliefs, attitudes, experiences and expectations of e-health services helps us understand the factors that influence adherence to such tools in primary care., Material and Methods: We conducted focus group interviews with 15 patients from three primary health care centers (PHCCs) in Southern Sweden. Data were analysed with thematic content analysis with codes and categories emerged from data during analysis., Results: We found one comprehensive theme: 'The elderly's ambivalence towards e-health:  reluctant curiosity, a wish to join and need for information and learning support'. Eight categories emerged from the text during analysis: 'E-health - a solution for a non-existing problem?', 'The elderly's experiences of e-health', 'Lack of will, skills, self-trust or mistrust in the new technology', 'Organizational barriers', 'Wanting and needing to move forward', 'Concerns to be addressed for making e-health a good solution', 'Potential advantages with e-health versus ordinary health care' and 'Need for speed, access and correct comprehensive information'., Conclusions: Elderly patients in Sweden described feelings of ambivalence towards e-health, raising concerns as accessibility to health care, mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly. Key points Exploring the elderly patients' beliefs, experiences, attitudes and expectations of the fast developing e-health services helps us understand the factors that influence adherence to such tools in primary care. Elderly patients in Sweden reported ambivalence and different experiences and attitudes towards e-health, raising concerns as accessibility to health care, costs and mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.

Background: General practitioners (GPs) often fail to correctly adhere to guidelines for the treatment of hypertension. The reasons for this are unclear, but could be related to lack of knowledge in assessing individual patients' cardiovascular disease risk. Our aim was to investigate how GPs in southern Sweden adhere to clinical guidelines for the treatment of hypertension when major cardiovascular risk factors are taken into consideration., Method: A questionnaire with five genuine cases of hypertension with different cardiovascular risk profiles was sent to a random sample of GPs in southern Sweden (n=109) in order to investigate the attitude towards blood pressure (BP) treatment when major cardiovascular risk factors were present., Results: In general, GPs who responded tended to focus on the absolute target BP rather than assessing the entire cardiovascular risk factor profile. Thus, cases with the highest risk of cardiovascular disease were not treated accordingly. However, there was also a tendency to overtreat the lowest risk individuals. Furthermore, the BP levels for initiating pharmacological treatment varied widely (systolic BP 140-210 mmHg). ACE inhibitors (70%) were the most common first choice of pharmacological treatment., Conclusion: In this study, GPs in Southern Sweden were suggesting, for different cases, either under- or overtreatment in relation to current guidelines for treatment of hypertension. On reason may be that they failed to correctly assess individual cardiovascular risk factor profiles.

Aims: In western countries out-of-hospital ischaemic heart disease (IHD) deaths account for approximately 50-70% of all IHD deaths. The objective was to examine the trends in out-of-hospital IHD deaths in the Region of Skåne in southern Sweden, in different sex- and age-groups., Methods: All 14,347 persons (range 24-110 years) in Skåne who died out-of-hospital between 1992 and 2003 from IHD (I410-I414; I20-I25) as the underlying cause of death. Subjects with previous admission for IHD since 1970 were excluded. Data were retrieved from the Swedish National Cause of Death and Patient Register. Age-standardized IHD mortality rates and trends were calculated using Poisson regression analysis., Results: Age-standardized annual out-of-hospital IHD mortality rates from 1992-2003 decreased in men from 177±13 to 103±9/100,000 inhabitants (-4.7%; p<0.001) and in women from 142±11 to 96±9/100,000 (-2.7%; p<0.001). In men, the annual change in age-standardized IHD mortality rates were -5.3 % (p<0.001), -4.0 % (p<0.001) and -4.7 % (p<0.001), respectively, in the age groups 20-64 years, 65-74 years and ≥75 years. Corresponding figures in women were -4.4 % (p<0.001), -2.4 % (p=0.003) and -2.5 % (p<0.001). The proportion of IHD deaths occurring out-of-hospital was in these age groups 50%, 40% and 35% respectively., Conclusions: In Skåne, out-of-hospital mortality in IHD deaths decreased significantly between 1992 and 2003. The decrease is more pronounced in men than women, and at the end of the study period in 2003, rates were almost equal. The proportion of IHD deaths occurring outside hospital was higher in younger people than in older people.

Background: Although marital status and low occupation level has been associated with mortality, the relationship with case fatality rates (CFR) after a coronary event (CE) is unclear. This study explored whether incidence of CE and short-term CFR differ between groups defined in terms of marital status and occupation, and if this could be explained by biological and life-style risk factors., Methods: Population-based cohort study of 33,224 subjects (67% men), aged 27 to 61 years, without history of myocardial infarction, who were enrolled between 1974 and 1992. Incidence of CE, and CFR (death during the first day or within 28 days after CE, including out-of-hospital deaths) was examined over a mean follow-up of 21 years., Results: A total of 3,035 men (6.0 per 1000 person-years) and 507 women (2.4 per 1000) suffered a first CE during follow-up. CFR (during the 1st day) was 29% in men and 23% in women. After risk factor adjustments, unmarried status in men, but not in women, was significantly associated with increased risk of suffering a CE [hazard ratios (HR) 1.10, 95% CI: 0.97-1.24; 1.42: 1.27-1.58 and 1.77: 1.31-2.40 for never married, divorced and widowed, respectively, compared to married]. Unmarried status, in both gender, was also related with an increased CFR (1st day), taking potential confounders into account (odds ratio (OR) 2.14, 95% CI: 1.63-2.81; 1.91: 1.50-2.43 and 1.49: 0.77-2.89 for never married, divorced and widowed, respectively, compared to married men. Corresponding figures for women was 2.32: 0.93-5.81; 1.87: 1.04-3.36 and 2.74: 1.03-7.28. No differences in CFR (1st day) were observed between occupational groups in neither gender., Conclusions: In this population-based Swedish cohort, short-term CFR was significantly related to unmarried status in men and women. This relationship was not explained by biological-, life-style factors or occupational level.

Background: There are no previous studies investigating when and where those who die pre-hospitally after an AMI paid their last visit to medical care., Methods and Results: Incidence of AMI, pre-hospital and 28-day case fatality rates were monitored over 13 years of follow-up, in relation to sex-specific quartiles of annual income in all inhabitants aged 40-64 years in Malmö, Sweden. Both incidence and short-term case fatality were inversely related to income. In all, 60-70% of all deaths within 28 days after the AMI were pre-hospital deaths. As compared with the lowest income group, the highest income group had lower odds of pre-hospital death with an age- and time-to-event-adjusted odds ratio of 0.5 (95% CI 0.4-0.8) for men and 0.3 (95% CI 0.1-0.6) for women. On the other hand, while 72% of those in the lowest two income groups had paid a visit to the medical services during the three months before death, only 59% had done so in the two highest income groups (P < 0.05)., Conclusions: Poor socioeconomic circumstances increase the risk of pre-hospital death after an AMI. Of the pre-hospital deaths, the proportion who had visited the medical services during the 3 months preceding their AMI was higher among those from lower income groups. However, many of those suffering a pre-hospital death had visited clinics that normally do not treat coronary symptoms. If more patients were identified at an earlier stage this might increase the number of patients reaching hospital alive.

Objective: To evaluate barriers to adherence to hypertension guidelines among publicly employed general practitioners (GPs)., Design: Questionnaire-based survey distributed to GPs in 24 randomly selected primary care centres in the Region of Skåne in southern Sweden., Subjects: A total of 109 GPs received a self-administered questionnaire and 90 of them responded., Main Outcome Measures: Use of risk assessment programmes. Reasons to postpone or abstain from pharmacological treatment for the management of hypertension., Results: Reported managing of high blood pressure (BP) varied. In all, 53% (95% CI 42-64%) of the GPs used risk assessment programmes and nine out of 10 acknowledged blood pressure target levels. Only one in 10 did not inform the patients about these levels. The range for immediate initiating pharmacological treatment was a systolic BP 140-220 (median 170) mmHg and diastolic BP 90-110 (median 100) mmHg. One-third (32%; 95% CI 22-42%) of the GPs postponed or abstained from pharmacological treatment of hypertension due to a patient's advanced age. No statistically significant associations were observed between GPs' gender, professional experience (i.e. in terms of specialist family medicine and by number of years in practice), and specific reasons to postpone or abstain from pharmacological treatment of hypertension., Conclusion: These data suggest that GPs accept higher blood pressure levels than recommended in clinical guidelines. Old age of the patient seems to be an important barrier among GPs when considering pharmacological treatment for the management of hypertension.

Objective: To study to what extent geographical differences of the mortality from ischaemic heart disease (IHD) can be accounted for by the 28-day case fatality rate (CFR) following first hospital admittance for acute myocardial infarction (MI) and whether the geographical pattern of survival has any relationship with socio-economic circumstances., Design: Register-based surveillance study., Setting: Seventeen residential areas in Malmö, Sweden., Subjects: All 5533 patients were admitted during 1986-1995 for a first acute MI at Malmö University Hospital. Main outcome measures. CFR is based on record linkage with national registers. Area-specific cardiovascular and socio-economic scores (SES) are based on previous cross-sectional studies., Results: In patients below 75 years of age, differences of the 28-day CFR accounted for 20-30% of the geographical variance in mortality from IHD. No corresponding association was found in older age groups. Patients from areas with low SES had the highest CFR, 23.8%. The odds ratios of fatal outcome for patients from areas with median and low SES (versus high SES) were 1.23 (95% CI: 1.01-1.50) and 1.25 (95% CI: 1.03-1.52), respectively (P for trend: 0.060). The strongest correlation was observed in men below 75 years of age (P for trend: 0.007). During the study period there was an improvement of the survival rate for patients from high and medium SES areas but no corresponding change for patients coming from areas having a low SES., Conclusions: In patients below 75 years, geographical differences of the mortality from IHD were related to differences of the 28-day CFR following hospital admittance for a first MI. Rates of survival were inversely related to socio-economic circumstances in the patient's residential area.