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Differences between the sexes among the non-elderly with heart failure (HF) have been insufficiently evaluated. This study aims to investigate sex-related differences in early-onset HF. Patients aged 18 to 54 years who were registered from 2003 to 2014 in the Swedish Heart Failure Register were included. Each patient was matched with two controls from the Swedish Total Population Register. Data on comorbidities and outcomes were obtained through the National Patient Register and Cause of Death Register. We identified 3752 patients and 7425 controls. Of the patients, 971 (25.9%) were women and 2781 (74.1%) were men with a mean (standard deviation) age of 44.9 (8.4) and 46.4 (7.3) years, respectively. Men had more hypertension and ischemic heart disease, whereas women had more congenital heart disease and obesity. During the median follow-up of 4.87 years, 26.5 and 24.7 per 1000 person-years male and female patients died, compared with 3.61 and 2.01 per 1000 person-years male and female controls, respectively. The adjusted hazard ratios for all-cause mortality, compared with controls, were 4.77 (3.78–6.01) in men and 7.84 (4.85–12.7) in women (p for sex difference = 0.11). When HF was diagnosed at 30, 35, 40, and 45 years, women and men lost up to 24.6 and 24.2, 24.4 and 20.9, 20.5 and 18.3, and 20.7 and 16.5 years of life, respectively. Long-term mortality was similar between the sexes. Women lost more years of life than men. • Women and men with HF <55 years had different co-morbidities that were important determinants of prognosis • Mortality risk relative to controls was almost twice as high in women than in men although the difference was not significant • Women also lost more life-years than men with heart failure <55 years [ABSTRACT FROM AUTHOR]

Background: Overweight and obesity are increasing globally with aging, as are life expectancy and aging-associated disorders, including calcific aortic stenosis (AS). Studies investigating the correlation between high body mass index (BMI) and AS are contradictory and inconclusive. This study examines a potential association between BMI and AS in women., Methods and Results: By linking the Swedish Medical Birth Register and the Swedish National Patient Register, we included women aged 18 to 55 years with a first childbirth from 1981 to 2020. Diagnosis of AS and comorbidities were defined according to the International Classification of Diseases ( ICD ) codes. The women were divided into groups on the basis of BMI. Cox proportional hazards regression models were used to investigate the difference in the risk of being diagnosed with AS, with reference BMI 20 to <22.5 kg/m 2 . Among the 1 722 625 included women, the mean age was 28 years, and mean BMI was 24 kg/m 2 , with 21% being overweight (BMI 25 to <30 kg/m 2 ) and 8.5% obese (BMI ≥30 kg/m 2 ). During median follow-up of 19.5 years, 2488 women (0.14%) were diagnosed with AS. The age-adjusted risk of being diagnosed with AS increased with higher BMI to 2.82 (95% CI, 2.44-3.25) times higher in women with BMI 30 to <35 kg/m 2 , and to 3.72 (95% CI, 2.95-4.70) times higher in those with BMI ≥35 kg/m 2 . Similar results were found after excluding AS of rheumatic pathogenesis., Conclusions: An increase in BMI from its upper normal range was consistently and independently associated with the risk of developing AS in women.

Objectives: This study is aimed to compare the effectiveness of modern therapy including angiotensin receptor-neprilysin inhibitor (ARNI) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) with conventional heart failure treatment in the real world., Background: Since ARNI and SGLT2i were introduced to treat heart failure (HF), its therapeutic regimen has modernized from previous treatment with beta-blocker (BB) and angiotensin-converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB) with mineralocorticoid receptor antagonist (MRA) as added-on in HF with reduced ejection fraction (HFrEF). However, a comparison between conventional and modern treatment strategies with drugs in combination has not been performed., Methods: This observational study (2013-2020), using the Swedish HF Registry, involved 20,849 HF patients. Patients received either conventional (BB, ACEi/ARB, with/without MRA, n = 20,140) or modern (BB, ACEi/ARB, MRA, SGLT2i or BB, ARNI, MRA with/without SGLT2i, n = 709) treatment at the index visit. The endpoints were all-cause and cardiovascular (CV) mortality., Results: Modern HF therapy was associated with a significant 28% reduction in all-cause mortality (adjusted HR [aHR], 0.72 (0.54-0.96); p = 0.024) and a significant 62% reduction in CV mortality (aHR, 0.38 (0.21-0.68); p = 0.0013) compared to conventional HF treatment. Similar results emerged in a sensitivity analysis using propensity score matching. The interaction analyses did not reveal any trends for EF (< 40% and ≥ 40%), sex, age (< 70 and ≥ 70 years), eGFR (< 60 and ≥ 60 ml/min/1.73 m 2 ), and etiology of HF subgroups., Conclusion: In this nationwide study, modern HF therapy was associated with significantly reduced all-cause and CV mortality, regardless of EF, sex, age, eGFR, and etiology of HF., (© 2024. The Author(s).)

Aims: Knowledge of long-term outcomes in patients with atrial fibrillation (AF) remains limited. We sought to evaluate the risk of new-onset heart failure (HF) in patients with AF and a low cardiovascular risk profile., Methods and Results: Data from the Swedish National Patient Register were used to identify all patients with a first-time diagnosis of AF without underlying cardiovascular disease at baseline between 1987 and 2018. Each patient was compared with two controls without AF from the National Total Population Register. In total, 227 811 patients and 452 712 controls were included. During a mean follow-up of 9.1 (standard deviation 7.0) years, the hazard ratio (HR) for new-onset HF was 3.55 [95% confidence interval (CI) 3.51-3.60] in patients compared with controls. Women with AF (18-34 years) had HR for HF onset 24.6 (95% CI 7.59-80.0) and men HR 9.86 (95% CI 6.81-14.27). The highest risk was within 1 year in patients 18-34 years, HR 103.9 (95% CI 46.3-233.1). The incidence rate within 1 year increased from 6.2 (95% CI 4.5-8.6) per 1000 person-years in young patients (18-34 years) to 142.8 (95% CI 139.4-146.3) per 1000 person-years among older patients (>80 years)., Conclusions: Patients studied had a three-fold higher risk of developing HF compared with controls. Young patients, particularly women, carry up to 100-fold increased risk to develop HF within 1 year after AF. Further studies in patients with AF and low cardiovascular risk profile are needed to prevent serious complications such as HF., (© 2023 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Aim: Heart failure (HF) is predominantly a disorder of the elderly. During the last decades, cardiovascular primary and secondary prevention and life expectancy have improved. Accordingly, trends in incidence and prevalence of HF are dynamic and may differ over time by age and gender. We aim to investigate the overall and age-specific and sex-specific trends, in incidence, prevalence, and the proportion with co-morbidities of HF over a 10 year period in Region Västra Götaland, Sweden., Methods and Results: The VEGA database is an administrative database of all patients managed in hospital and/or in primary care (private and public) living in Region Västra Götaland. All patients with a main or contributory diagnosis of HF (I50) aged 18 years or older between 2008 and 2017 were included. Incidence and prevalence of HF were calculated based on the entire adult population of Region Västra Götaland. The adult population in Region Västra Götaland increased by 8% from 2008 (n = 1 234 609) to 2017 (n = 1 338 906). Half the population was female and 69% < 60 years of age, both constant over time. In total, 62 228 incident cases of HF were identified. In 2008, we identified 6464 cases, mean age 78.7 (11.5) years, and 49.8% (n = 3222) men, while in 2017, 5727 cases were identified, mean age 78.3 (11.8) years, and 52.5% (n = 3006) men. The overall yearly incidence rate of HF decreased by 3%, RR 0.97 (95% CI 0.96-0.97) per year, P < 0.0001, mainly driven by the age categories >75 years. A constantly higher incidence of HF was seen for men compared with women in all age categories, RR 1.46 (95% CI 1.44-1.49), P < 0.0001. During the same period, we observed a steady increase in overall prevalence from 1.8% for women and 2.0% for men in 2008, to 2.4% in women and 2.8% in men in 2017, particularly in those >85 years of age who had a prevalence of 16.5% (men) and 14.6% (women) in 2008 and 23.5% (men) and 21.5% (women) in 2017. The overall 1 year mortality rate was 22.7%. When adjusted for age, women had a lower risk for death by 13% compared with men [hazard ratio 0.87 (95% CI 0.84-0.90, P < 0.0001)]., Conclusion: We saw a decrease in overall incidence, but incidence of HF remains high, particularly in the oldest age groups. Prevalence of HF keeps increasing particularly in those aged >85 years. Our findings emphasize the need for implementation of effective preventive strategies for HF., (© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Clinical phenotype and prognosis of heart failure (HF) may be variable among different racial populations. Therefore, a patient-level comparison of hospitalized HF patients in two university hospitals from China and Sweden was performed., Methods and Results: This study was a pooled data analysis of the patients prospectively enrolled in two single-center studies in China (n = 949) and Sweden (n = 1639) from 2011 to 2015. Clinical characteristics and 6-month all-cause mortality were collected. Higher systolic blood pressure (126.1 ± 20.3 vs. 114.2 ± 15.4 mmHg, p < 0.001) and NT-proBNP level (4540 vs. 3251 pg/mL, p = 0.013) were found in the Swedish cohort, also more patients with ischemic heart disease (32.0% vs. 19.2%), hypertension (64.2% vs. 36.8%), valvular heart disease (40.9% vs.31.6%) and atrial fibrillation (55.3% vs. 39.6%) (all p < 0.001). The use of ACEIs/ARBs (48.8% vs. 80.8%) or beta-blockers (58.8% vs. 86.5%) (both p < 0.001) was lower in Chinese cohort. Given younger age in Chinese cohort (61.6 vs. 76.4 years, p < 0.001), age-stratified analyses were conducted, as there were similar patient numbers in 50-74 years in Chinese (n = 550) and Swedish (n = 554) cohorts, therefore baseline characteristics and prognosis were further compared. The age- and sex-adjusted outcome (HR 0.80 [95% CI 0.55-1.19], p = 0.273) was comparable between the two populations. The NT-proBNP and eGFR independently predicted 6-month mortality in both Chinese (HR [95% CI] 1.006 [1.003-1.008], 0.986 [0.976-0.999]) and Swedish cohort (1.003 [1.000-1.007], 0.988 [0.976-0.999])., Conclusions: Patient-level comparison of real-world HF populations from China and Sweden demonstrated different clinical phenotypes and therapy but similar prognosis and their predictors., (© 2022. The Author(s).)

Background: Acquired aortic stenosis (AS) increases with age and has high mortality without intervention. Factors predicting its development are unclear, although atherosclerotic factors are assumed to be involved. Our aim in this study is to estimate the lifetime cumulative incidence and predictors of AS in middle-aged men., Methods: We included a random sample of men (n = 9998) born 1915-1925 in Gothenburg, Sweden. From them, 7,494 were examined and followed until a diagnosis of AS or death (maximum follow-up time 42.8 years). We identified AS diagnosis from the Swedish National Patient Registry and deaths from the Swedish Cause of Death Registry by using International Classification of Disease (ICD) diagnostic criteria. To study time-dependent relationships between AS and risk factors with death as the competing risk, we divided the cohort into three overlapping follow-up groups: 25-43, 30-43 and 35-43 years. We used age-adjusted Cox proportional hazards model to identify predictors of AS., Results: The lifelong cumulative incidence of AS was 3.2%. At baseline, participants in the third group had a healthier lifestyle, lower body mass index (BMI), blood pressure, and serum cholesterol levels. Higher BMI, obesity, cholesterol, hypertension, atrial fibrillation, smoking and heredity for stroke were associated with AS. With BMI of 20-22.5 as a reference, hazard ratios of being diagnosed with AS for men with a baseline BMI of 25-27.5 kg/m 2 , 27.5-30 kg/m 2 and > 30 kg/m 2 were 1.99 (95% CI 1.12-3.55), 2.98 (95% CI 1.65-5.40) and 3.55 (95% CI 1.84-6.87), respectively., Conclusions: The lifetime cumulative incidence of AS in middle-aged male population was 3.2%. Multiple atherosclerotic risk factors, particularly high BMI might be associated with a higher risk of developing AS., (© 2022. The Author(s).)

Investigate trends in myocarditis incidence and prognosis in Sweden during 2000-2014. Little data exist concerning population-trends in incidence of hospitalizations for myocarditis and subsequent prognosis. Linking Swedish National Patient and Cause of Death Registers, we identified individuals ≥ 16 years with first-time diagnosis of myocarditis during 2000-2014. Reference population, matched for age and birth year (n = 16,622) was selected from Swedish Total Population Register. Among the 8 679 cases (75% men, 64% < 50 years), incidence rate/100,000 inhabitants rose from 6.3 to 8.6 per 100,000, mostly in men and those < 50 years. Incident heart failure/dilated cardiomyopathy occurred in 6.2% within 1 year after index hospitalization and in 10.2% during 2000-2014, predominantly in those ≥ 50 years (12.1% within 1 year, 20.8% during 2000-2014). In all 8.1% died within 1 year, 0.9% (< 50 years) and 20.8% (≥ 50 years). Hazard ratios (adjusted for age, sex) for 1-year mortality comparing cases and controls were 4.00 (95% confidence interval 1.37-11.70), 4.48 (2.57-7.82), 4.57 (3.31-6.31) and 3.93 (3.39-4.57) for individuals aged < 30, 30 to < 50, 50 to < 70, and ≥ 70 years, respectively. The incidence of myocarditis during 2000-2014 increased, predominantly in men < 50 years. One-year mortality was low, but fourfold higher compared with reference population., (© 2022. The Author(s).)

Aims: This study was performed to compare trends in home-time for patients with heart failure (HF) between those of working age and those of retirement age in Sweden from 1992 to 2012., Methods and Results: The National Inpatient Register (IPR) was used to identify all patients aged 18 to 84 years with a first hospitalization for HF in Sweden from 1992 to 2012. Information on date of death, comorbidities, and sociodemographic factors were collected from the Swedish National Register on Cause of Death, the IPR, and the longitudinal integration database for health insurance and labour market studies, respectively. The patients were divided into two groups according to their age: working age (<65 years) and retirement age (≥65 years). Follow-up was 4 years. In total, following exclusions, 388 775 patients aged 18 to 84 years who were alive 1 day after discharge from a first hospitalization for HF were included in the study. The working age group comprised 62 428 (16%) patients with a median age of 58 (interquartile range, 53-62) years and 31.2% women, and the retirement age group comprised 326 347 (84%) patients with a median age of 77 (interquartile range, 73-81) years and 47.4% women. Patients of working age had more home-time than patients of retirement age (83.8% vs. 68.2%, respectively), mainly because of their lower 4 year mortality rate (14.2% vs. 29.7%, respectively). Home-time increased over the study period for both age groups, but the increase levelled off for older women after 2007, most likely because of less reduction in mortality in older women than in the other groups., Conclusions: This nationwide study showed increasing home-time over the study period except for women of retirement age and older for whom the increase stalled after 2007, mainly because of a lower mortality reduction in this group. Efforts to improve patient-related outcome measures specifically targeted to this group may be warranted., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Among patients with heart failure and reduced ejection fraction (HFrEF), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB), β-blockers (BB) and mineralocorticoid receptor antagonist (MRA) are known as guideline-directed medical therapy to improve prognosis. However, low blood pressure (BP) and renal dysfunction are often challenges prevent clinical implementation, so we investigated the association of different combinations of GDMT treatments with all-cause mortality in HFrEF population with low BP and renal dysfunction., Methods: This study initially included 51, 060 HF patients from the Swedish Heart Failure Registry, and finally 1464 HFrEF patients with low BP (systolic BP ≦ 100 mmHg) and renal dysfunction (estimated glomerular filtration rate (eGFR) ≦ 60 ml/min/1.73m 2 ) were ultimately enrolled. Patients were receiving oral medication for HF at study enrollment, and divided into four groups (group 1-4: ACEI/ARB + BB + MRA, ACEI/ARB + BB, ACEI/ARB + MRA or ACEI/ARB only, and other). The outcome is time to all-cause mortality., Results: Among the study patients, 485 (33.1%), 672 (45.9%), 109 (7.4%) and 198 (13.5%) patients were in group 1-4. Patients in group 1 were younger, had highest hemoglobin, and most with EF < 30%. During a median of 1.33 years follow-up, 937 (64%) patients died. After adjustment for age, gender, LVEF, eGFR, hemoglobin when compared with the group 1, the hazard ratio for all-cause mortality in group 2 was 1.04 (0.89-1.21) (p = 0.62), group 3 1.40 (1.09-1.79) (p = 0.009), and group 4 1.71 (1.39-2.09) (p < 0.001)., Conclusions: In real-world HFrEF patients with low BP and renal dysfunction, full medication of guideline-directed medical therapy is associated with improved survival. The benefit was larger close to the index date and decreased with follow-up time.

Background: Temporal trends in clinical composition and outcome in dilated cardiomyopathy (DCM) are largely unknown, despite considerable advances in heart failure management. We set out to study clinical characteristics and prognosis over time in DCM in Sweden during 2003-2015., Methods: DCM patients (n = 7873) from the Swedish Heart Failure Registry were divided into three calendar periods of inclusion, 2003-2007 (Period 1, n = 2029), 2008-2011 (Period 2, n = 3363), 2012-2015 (Period 3, n = 2481). The primary outcome was the composite of all-cause death, transplantation and hospitalization during 1 year after inclusion into the registry., Results: Over the three calendar periods patients were older (p = 0.022), the proportion of females increased (mean 22.5%, 26.4%, 27.6%, p = 0.0001), left ventricular ejection fraction was higher (p = 0.0014), and symptoms by New York Heart Association less severe (p < 0.0001). Device (implantable cardioverter defibrillator and/or cardiac resynchronization) therapy increased by 30% over time (mean 11.6%, 12.3%, 15.1%, p < 0.0001). The event rates for mortality, and hospitalization were consistently decreasing over calendar periods (p < 0.0001 for all), whereas transplantation rate was stable. More advanced physical symptoms correlated with an increased risk of a composite outcome over time (p = 0.0043)., Conclusions: From 2003 until 2015, we observed declining mortality and hospitalizations in DCM, paralleled by a continuous change in both demographic profile and therapy in the DCM population in Sweden, towards a less affected phenotype.

Background: A high resting heart rate (RHR) is associated with an increase in adverse events. However, the long-term prognostic value in a general population is unclear. We aimed to investigate the impact of RHR, based on both baseline and time-updated values, on mortality in a middle-aged male cohort., Methods: A random population sample of 852 men, all born in 1913, was followed from age 50 until age 98, with repeated examinations including RHR over a period of 48 years. The impact of baseline and time-updated RHR on cause-specific mortality was assessed using Cox proportional hazard models and cubic spline models., Results: A baseline RHR of ≥ 90 beats per minute (bpm) was associated with higher all-cause mortality, as compared with an RHR of 60-70 bpm (hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.17-2.19, P = 0.003), but not with cardiovascular (CV) mortality. A time-updated RHR of < 60 bpm (HR 1.41, 95% CI 1.07-1.85, P = 0.014) and a time-updated RHR of 70-80 bpm (HR 1.34, 95% CI 1.02-1.75, P = 0.036) were both associated with higher CV mortality as compared with an RHR of 60-70 bpm after multivariable adjustment. Analyses using cubic spline models confirmed that the association of time-updated RHR with all-cause and CV mortality complied with a U-shaped curve with 60 bpm as a reference., Conclusion: In this middle-aged male cohort, a time-updated RHR of 60-70 bpm was associated with the lowest CV mortality, suggesting that a time-updated RHR could be a useful long-term prognostic index in the general population.

Aims: This study aims to investigate hospital readmissions and timing, as well as risk factors in a real world heart failure (HF) population., Methods and Results: All patients discharged alive in 2016 from Sahlgrenska University Hospital/Östra, Gothenburg, Sweden, with a primary diagnosis of HF were consecutively included. Patient characteristics, type of HF, treatment, and follow-up were registered. Time to first all-cause or HF readmission, as well as number of 1 year readmissions from discharge were recorded. In total, 448 patients were included: 273 patients (mean age 78 ± 11.8 years) were readmitted for any cause within 1 year (readmission rate of 60.9%), and 175 patients (mean age 76.6 ± 13.7) were never readmitted. Among readmissions, 60.1% occurred during the first quarter after index hospitalization, giving a 3 month all-cause readmission rate of 36.6%. HF-related 1 year readmission rate was 38.4%. Patients who were readmitted had significantly more renal dysfunction (52.4% vs. 36.6%, P = 0.001), pulmonary disease (25.6% vs. 15.4%, P = 0.010), and psychiatric illness (24.9% vs. 12.0%, P = 0.001). Number of co-morbidities and readmissions were significantly associated (P < 0.001 for all cause readmission rate and P = 0.012 for 1 year HF readmission rate). Worsening HF constituted 63% of all-cause readmissions. Psychiatric disease was an independent risk factor for 1 month and 1 year all-cause readmissions. Poor compliance to medication was an independent risk factor for 1 month and 1 year HF readmission., Conclusions: In our real world cohort of HF patients, frequent hospital readmissions occurred in the early post-discharge period and were mainly driven by worsening HF. Co-morbidity was one of the most important factors for readmission., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Ischaemic heart disease (IHD) often develops after decades of preceding subclinical coronary atherosclerosis. Biomarkers are useful prognostic predictors of IHD, but their long-term predictive value in a general population has not been adequately studied., Purpose: To investigate the early predictive value of multi-modality biomarkers in addition to clinical risk factors in incident IHD in a random male general population sample followed from 50 to 71 years of age., Method: "The Study of Men Born in 1943" is a longitudinal cohort study during follow-up. All the men underwent a baseline examination in 1993, where a panel of biomarkers were analysed and incident IHD was registered during 21-year follow-ups., Results: Of 739 participants, 97 men (13.1%) developed an IHD event. For time to first occurrence of IHD, univariable analyses showed that elevated levels of high sensitivity troponin T (hs-TNT), high sensitivity-C reactive protein (hs-CRP) and interleukin-6 (IL-6) were significant predictors of IHD. In addition, a high number of biomarkers with elevated levels (hs-TNT > 10 ng/L, hs-CRP > 1 mg/L, IL-6 > 8 ng/L and N-terminal pro b-type natriuretic peptide (NT-proBNP) > 100 pg/mL) increased predictive ability. In univariable and multivariable analysis high-density lipoprotein-cholesterol (HDL-C) had the highest predictive ability. Hs-TNT provided better predictive ability than smoking, body mass index and glucose, and was an independent significant predictor when adjusted for HDL-C, total cholesterol and hypertension. Addition of biomarkers on top of clinical risk factors provided significantly better prediction as tested by likelihood ratio test (p = 0.033), but did not significantly enhance the model's discriminative ability However, it appeared contributing to higher sensitivity in the late phase of follow-up., Conclusion: In this random, middle-aged male population sample, the addition of biomarker hs-TNT was an independent significant predictor of IHD and significantly improved prediction, indicating the probability of a better prediction of long-term risk of IHD in a low-risk population., Trial Registration: The study is registered at Clinical Trials.gov Identifier number: NCT03138122.

Aims: We investigated the 2 year rate of ischaemic stroke/transient ischaemic attack (IS) in patients with heart failure (HF) who were in sinus rhythm (HF-SR) and aimed to develop a score for stratifying risk of IS in this population., Methods and Results: A total of 15 425 patients (mean age 71.5 years, 39% women) with HF-SR enrolled in the Swedish Heart Failure Register were included; 28 815 age-matched and sex-matched controls, without a registered diagnosis of HF, were selected from the Swedish Population Register. The 2 year rate of IS was 3.0% in patients and 1.4% in controls. In the patient group, a risk score including age (1p for 65-74 years; 2p for 75-84 years; 3p for ≥85 years), previous IS (2p), ischaemic heart disease, diabetes, hypertension, kidney dysfunction, and New York Heart Association III/IV class (1p each) was generated. Over a mean follow-up of 20.1 (SD 7.5) months, the cumulative incidences (per 1000 person-years) of IS in patients with score 0 to ≥7 were 2.2, 5.3, 8.9, 13.2, 15.7, 20.4, 26.4, and 33.0, with hazard ratios for score 1 to ≥7 (with 0 as reference): 2.4, 4.1, 6.1, 7.2, 9.4, 12.2, and 15.3. The risk score performed modestly (area under the curve 63.7%; P = 0.4711 for lack of fit with a logistic model; P = 0.7062 with Poisson, scaled by deviance)., Conclusions: In terms of absolute risk, only 27.6% of patients had an annual IS incidence of ≤1%. To which extent this would be amenable to anticoagulant treatment remains conjectural. A score compiling age and specific co-morbidities identified HF-SR patients with increased risk of IS with modest discriminative ability., (©2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Objective: To compare two cohorts of middle-aged men from the general population born 30 years apart for incidence and predictors of heart failure (HF)., Methods: Two population samples of men, born in 1913 (n=855) and in 1943 (n=797), were examined at 50 years of age and followed up for 21 years (1963-1994 and 1993-2014). Cox regression analysis was used to examine the impact of different factors on the risk of developing HF., Results: Eighty men born in 1913 (9.4%) and 42 men born in 1943 (5.3%) developed HF during follow-up; adjusted HRs comparing the two cohorts (born 1943 vs 1913) were: 0.46 (95% CI 0.28 to 0.74, p=0.002). In both cohorts, higher body mass index, higher diastolic blood pressure, treatment for hypertension, onset of either atrial fibrillation (AF), ischaemic heart disease and diabetes mellitus were associated with higher risk of HF. Higher heart rate was associated with an increased risk only in men born in 1913, whereas higher systolic blood pressure (SBP), smoking, higher glucose, higher cholesterol and physical inactivity were associated with an increased risk in men born in 1943. AF contributed higher risk of incident HF, whereas SBP and physical inactivity contributed lower risk in men born in 1943 compared with men born in 1913., Conclusions: Men born in 1943 had half the risk of HF after their 50s than those born 30 years earlier. AF, obesity, ischaemic heart disease, diabetes and hypertension remain important precursors of HF., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Severe electrocardiographic (ECG) abnormalities in asymptomatic subjects correlate with cardiovascular risk., Hypothesis: The role of minor ECG abnormalities is less well-known. We evaluated the association between a negative T-wave and mortality, as a possible marker for prognosis., Methods: A prospective, population-based cohort, examined at 50 years, and followed until death. Time to death (event rates) and predictive role of a negative T-wave (Cox regression) were analyzed., Results: Participants (n = 839) with a negative T-wave (7.3%) had significantly higher blood pressure (BP) (mean systolic 157.9 mmHg vs 136.8 mmHg without negative T-wave, P = <.0001). A negative T-wave correlated with elevated risk (hazard ratio [HR] [95% CI] [confidence interval]) for all-cause and cardiovascular (CV) death (1.59 (1.20-2.11) P = .0012 vs 1.91 (1.34-2.73) P = .0004). The association remained after excluding coexisting Q/QS patterns and ST-junction/segment depression ECG abnormalities (1.66 [1.13-2.44] P = .0098 for all-cause vs 1.87 [1.13-3.09] P = .015 for CV death). Death from other causes was not associated with a negative T-wave. A major negative T-wave carried higher risk than a minor (2.17 [1.25-3.76] P = .0062 vs 1.78 [1.13-2.79] P = .012) for CV death., Conclusion: A negative T-wave at 50 years, in asymptomatic individuals, carried an increased risk of all-cause and CV death during lifetime follow-up., (© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Aims: The aim of this study was to investigate whether the readmission of heart failure (HF) patients has decreased over time and how it differs among HF with preserved ejection fraction (EF) (HFpEF) vs. reduced EF (HFrEF) and mid-range EF (HFmrEF)., Methods and Results: We evaluated HF patients index hospitalized from January 2004 to December 2011 in the Swedish Heart Failure Registry with 1 year follow-up. Outcome measures were the first occurring all-cause, cardiovascular (CV), and HF readmissions. A total of 20 877 HF patients (11 064 HFrEF, 4215 HFmrEF, and 5562 HFpEF) were included in the study. All-cause readmission was the highest in patients with HFpEF, whereas CV and HF readmissions were the highest in HFrEF. From 2004 to 2011, HF readmission rates within 6 months (from 22.3% to 17.3%, P = 0.003) and 1 year (from 27.7% to 23.4%, P = 0.019) in HFpEF declined, and the risk for 1 year HF readmission in HFpEF was reduced by 7% after adjusting for age and sex (P = 0.022). Likewise, risk factors for HF readmission in HFpEF changed. However, no significant changes were observed in all-cause or CV readmission rates in HFpEF, and no significant changes in cause-specific readmissions were observed in HFrEF. Time to the first readmission did not change significantly from 2004 to 2011, regardless of EF subgroup (all P-values > 0.05)., Conclusions: Declining temporal trend in HF readmission rates was found in HFpEF, but all-cause readmission still remained the highest in HFpEF vs. HFrEF and HFmrEF. More efforts are needed to reduce the non-HF-related readmission in patients with HFpEF., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Background: A declining trend in mean cholesterol levels and smoking has been observed in high-income western countries during the last few decades, whereas obesity rates have increased. Simultaneously, mortality from coronary heart disease has decreased. The aim of the present study was to determine whether the trends in cardiovascular risk factors have continued in successive cohorts of middle-aged women over a period of 34 years., Methods: Six population-based, cross-sectional samples of women (n = 2294) mean age: 49.8 years (range: 45-54), living in Gothenburg, Sweden, were investigated between 1980 and 2014., Results: Body mass index (BMI) increased over time, with a mean BMI of 24.7 kg/m 2 in 1980 to 25.7 kg/m 2 in 2013-2014, corresponding to a weight gain of 4.5 kg, together with an increase in the proportion of obese individuals (BMI ≥ 30 kg/m 2 ) from 10.4 to 16.6% (p = 0.0012). The proportion of smokers and women with hypertension decreased from 34.5 to 12.8% (p = 0.0006) and from 37.7 to 24.5% (p < 0.0001) respectively. Mean total serum cholesterol levels decreased from 6.23 (SD 1.09) mmol/L in 1980 to 5.43 (SD 0.98) mmol/L in 2013-2014 (p < 0.0001). Self-reported leisure time regular exercise increased from 7.8% in 1980 to 35.6% in 2013-2014 (p < 0.0001). For women born in 1963, the prevalence ratio of not having any of five major cardiovascular risk factors was 1.82 (95% confidence interval (CI) 1.38-2.41), compared with women born in 1925-1934., Conclusion: The trend towards increasing obesity, more leisure-time physical activity and less smoking remains, while the decrease in serum cholesterol appears to have abated.

Aims: The prevalence and hospitalizations of patients with heart failure (HF) aged <55 years have increased in Sweden during the last decades. We aimed to compare characteristics of younger and older patients with HF, and examine survival in patients <55 years compared with matched controls., Methods and Results: All patients ≥18 years in the Swedish Heart Failure Register from 2003 to 2014 were included. Data were merged with National Patient and Cause of Death Registers. Among 60 962 patients, 3752 (6.2%) were <55 years, and were compared with 7425 controls from the Population Register. Compared with patients ≥55 years, patients <55 years more frequently had registered diagnoses of obesity, dilated cardiomyopathy, congenital heart disease, and an ejection fraction <40% (9.8% vs. 4.7%, 27.2% vs. 5.5%, 3.7% vs. 0.8%, 67.9% vs. 45.1%, respectively; all P < 0.001). One-year all-cause mortality was 21.2%, 4.2%, and 0.3% in patients ≥55 years, patients <55 years, and controls <55 years, respectively (all P < 0.001). Patients <55 years had a five times higher mortality risk compared with controls [hazard ratio (HR) 5.48, 95% confidence interval (CI) 4.45-6.74]; the highest HR was in patients 18-34 years (HR 38.3, 95% CI 8.70-169; both P < 0.001). At the age of 20, the estimated life-years lost was up to 36 years for 50% of patients, with declining estimates with increasing age., Conclusion: Patients with HF <55 years had different comorbidities than patients ≥55 years. The highest mortality risk relative to that of controls was among the youngest patients., (© 2020 The Authors. European Journal of Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: It remains unclear whether readmissions of patients with heart failure (HF) have decreased over time in an era of improved therapy and management of HF. This study aimed to determine the temporal short- and long-term trends of cause-specific rehospitalization and their risk factors in a Swedish context., Methods: HF patients in the Swedish Heart Failure Registry (SwedeHF) were investigated. Maximum follow-up time was 1 year. Outcomes included the first occurrence of all-cause, cardiovascular (CV) and HF rehospitalizations. Cox proportional hazards models were performed to determine the impact of increasing years on risk for rehospitalization and its known risk factors., Results: Totally, 25,644 index-hospitalized HF patients in SwedeHF from 2004 to 2011 were enrolled in the study. For 8 years, the incidence risk of 1-year all-cause rehospitalization remained unchanged, whereas the incidence risk of CV (P = 0.038) or HF (P = 0.0038) rehospitalization decreased. After adjustment for age and sex, a 3% decrease per every second year was observed for 1-year CV and HF rehospitalizations (P < 0.05). However, time to the first occurring all-cause, CV and HF rehospitalization did not change significantly from 2004 to 2011 (P-values 0.13-0.87). When two study periods (2004-2005 vs. 2010-2011) were compared, the risk factor profile for rehospitalization was found to change., Conclusions: Throughout the 8-year study period, CV- and HF-related rehospitalizations decreased, whereas all-cause rehospitalization remained unchanged, indicating a parallel increase in non-CV rehospitalization in the HF patients., Competing Interests: Declaration of competing interest Dr. Ulf Dahlström declares no conflicts of interest related to the present manuscript; outside the present manuscript, he receives a research grant from AstraZeneca and consultancies/honoraria from AstraZeneca, Novartis and Amgen. The other authors report no conflicts., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Knowledge about long-term risk factors and the prevalence of heart failure stages in general population is limited. We aimed to study the prevalence of cardiac dysfunction and heart failure in 71-year-old men and potential risk factors in the past two decades., Design: This research was based on a randomized selected population study with longitudinal follow-up., Methods: A random sample of men born in 1943 in Gothenburg, Sweden were examined in 1993 (at 50 years of age) and re-examined 21 years later in 2014 (at 71 years of age). Cardiac dysfunction or heart failure was classified into four stages (A-D) according to American Heart Association/American College of Cardiology guidelines on heart failure., Results: Of the 798 men examined in 1993 (overall cohort), 535 (67%) were re-examined in 2014 (echo cohort). In the echo cohort 122 (23%) men had normal cardiac function, 135 (25%) were at stage A, 207 (39%) men were at stage B, 66 (12%) men were at stage C, and five (1%) men were at stage D. Multivariable logistic regression demonstrated that elevated body mass index at 50 years old was the only independent risk factor for developing heart failure/cardiac dysfunction during the subsequent 21 years. For each unit (1 kg/m 2 ) of increased body mass index, the odds ratio for stages C/D heart failure vs no heart failure/stage A increased by 1.20 (95% confidence interval, 1.11-1.31, p  < 0.001), after adjustment for smoking, sedentary life style, systolic blood pressure, diabetes, and hyperlipidemia., Conclusion: In a random sample of men at 71 years of age, half presented with either cardiac dysfunction or clinical heart failure. High body mass index was associated with an increased risk for developing cardiac dysfunction or heart failure over a 21-year period.

The relationship between various categories of blood pressure (BP), subtypes of hypertension, and development of cardiovascular disease (CVD) have not been extensively studied. Therefore, our study aimed to explore this relationship in a random population sample of men born in 1943, living in Sweden and followed over a 21-year period.Participants were examined for the first time in 1993 (age 50 years), where data on medical history, concomitant diseases, and general health were collected. The examination was repeated in 2003 and with additional echocardiography also in 2014. Classification of participants according to their BP at the age of 50 years was as follows: optimal-normal BP (systolic blood pressure [SBP] <130 and diastolic BP [DBP] <85 mmHg), high-normal BP (130 ≤ SBP < 140, 85 ≤ DBP < 90 mmHg), isolated systolic-diastolic hypertension (ISH-IDH) (SBP ≥140 and DBP <90 or SBP <140 and DBP ≥90 mmHg), and systolic-diastolic hypertension (SDH) (SBP ≥140 and DBP ≥90 mmHg).During the follow-up, the incidence of heart failure (HF), CVD, and coronary heart disease were all lowest for those with optimal-normal BP. Participants with high-normal BP showed greater wall thickness and left ventricular mass index, larger LV size and larger left atrial size when compared with the optimal-normal BP group. Furthermore, those with high-normal BP, ISH-IDH, and SDH had a higher risk of CVD than those with optimal-normal BP. The adjusted relative risk of CVD was highest for SDH (hazard ratio [HR] 1.95; 95% confidence interval [95% CI] 1.37-2.79), followed by ISH-IDH (HR 1.34; 95% CI 0.93-1.95) and high-normal BP (HR 1.31; 95% CI 0.91-1.89).Over a 21-year follow-up, the participants with high-normal BP or ISH-IDH had a higher relative risk of CVD than those with optimal-normal BP.

Introduction . There is limited knowledge about factors associated with the development of aortic stenosis. This study aimed to examine the prevalence of aortic sclerosis or stenosis in 71-years-old men and determine which risk factors at 50 years of age predict the development of aortic sclerosis or aortic stenosis. Methods . A random sample of Swedish men from the general population, born in 1943 ( n  = 798) were followed for 21 years. Data on clinical characteristics and laboratory values were collected in 1993. An echocardiography was performed in 2014. We used logistic regression to examine the association between baseline data and the outcome. Results . Echocardiography was performed in 535 men, and aortic sclerosis or aortic stenosis was diagnosed in 27 (5.0%). 14 persons developed aortic stenosis (2.6%). Among men with aortic sclerosis or aortic stenosis, 29.6% were obese. In multivariable stepwise regression model, body mass index (odds ratio per unit increase 1.23 (95% CI 1.10-1.38; p  = .0003)) and hypercholesterolemia, combined with high sensitive C-reactive protein (odds ratio versus all other 2.66 (1.18-6.00; p  = .019)) were significantly associated with increased risk of developing aortic sclerosis or aortic stenosis. Body mass index was the only factor significantly associated with a higher risk of developing aortic stenosis. Conclusion . The prevalence of either aortic sclerosis or aortic stenosis was 5% and of aortic stenosis 2.6%. Obesity and hypercholesterolemia combined with elevated high sensitive C-reactive protein at the age of 50 predicted the development of degenerative aortic sclerosis or stenosis, whilst only obesity was correlated with the occurrence of aortic stenosis.

Aims: The aim of this study is to investigate the prognostic impact of ischaemic heart disease (IHD) in heart failure (HF) and its association to age, sex, left ventricular ejection fraction (EF), and HF duration, and furthermore, to evaluate if the impact of IHD has changed over time, in light of improved therapy., Methods and Results: We studied 30 946 patients with non-valvular HF, by accessing the Swedish Heart Failure Registry, from years 2000 to 2012. The mortality in 17 778 patients with clinical IHD was compared with 13 168 patients without IHD (non-IHD). There was a significantly worse outcome in IHD, with the crude mortality of 41.1% and the event rate per 100 person-years [95% confidence interval (CI)] of 14.8 (14.4-15.1), compared with 28.2% and 9.7 (9.4-10.0) in non-IHD. After multivariable adjustment, the hazard ratio (HR) (95% CI) for mortality, IHD vs. non-IHD, was 1.16 (1.11-1.22; P < 0.0001). Subgroup analyses showed significantly increased mortality in IHD, in all age subgroups, in all subgroups with EF < 50%, in both men and women, and regardless of heart failure duration more or less than 6 months. Analyses for the combination of age and EF showed the highest HR for time to death in the youngest with the lowest EF, HR (95% CI) 2.05 (1.59-2.64) for patients <60 years of age with EF < 30%. Although a numerical reduction of the HR for mortality was seen over time, the risk for mortality in IHD, compared with the non-IHD group, was greater throughout the study period., Conclusions: In non-valvular heart failure, IHD was associated with significantly increased mortality, compared with non-IHD, in groups of EF below 50%, in all age groups, and regardless of sex or HF duration. The risk increase associated with EF reduction diminished with increasing age. The mortality in IHD, compared with non-IHD, remained significantly higher throughout the 13 year study period., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Background: The PARADIGM-HF trial showed that sacubitril-valsartan - an angiotensin receptor-neprilysin inhibitor (ARNI) - is more effective than enalapril for some patients with heart failure. However, the eligibility of the PARADIGM-HF study to a real-world heart failure population was not well established., Methods: We made secondary analysis of patients (n = 4872) with heart failure prospectively enrolled in the Swedish Heart Failure Registry from Sahlgrenska University Hospital/Östra Hospital, Sweden during 2005-2016. The eligibility of the PARADIGM-HF trial in the real world was studied based on patients whether they were either fully or partially compatible with the PARADIGM-HF population. Patients were judged to be fully eligible for the PARADIGM-HF trial if they completely met the inclusion and exclusion criteria, and partially eligible if they did not stay on target dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), despite their having been treated with ACEI/ARB for at least 6 months., Results: Among patients who had heart failure with reduced left ventricular ejection fraction (≤40%) (HFrEF) (n = 2165), 653 (30%) and 958 (44%) patients were fully and partially compatible with PARADIGM-HF criteria, respectively. In both fully and partially eligible groups, patients were more male. Despite those fully eligible patients being younger (77.6 ± 12.7 vs. 84.0 ± 13.7 years) than noneligible patients, they were much older than in the PARADIGM-HF trial. Moreover, those fully eligible patients had lower all-cause mortality compared with both partially and noneligible patients. However, both fully and partially eligible patients had higher all-cause mortality than that in the PARADIGM-HF trial., Conclusion: In a real-world outpatient clinical setting, around 1/3-1/2 of HFrEF were eligible for treatment of Sac/Val except that they are older, sicker, and carry higher risk for all-cause mortality than the PARADIGM-HF trial population.

Background: HFmrEF has been recently proposed as a distinct HF phenotype. How HFmrEF differs from HFrEF and HFpEF according to age remains poorly defined. We aimed to investigate age-dependent differences in heart failure with mid-range (HFmrEF) vs. preserved (HFpEF) and reduced (HFrEF) ejection fraction., Methods and Results: 42,987 patients, 23% with HFpEF, 22% with HFmrEF and 55% with HFrEF, enrolled in the Swedish heart failure registry were studied. HFpEF prevalence strongly increased, whereas that of HFrEF strongly decreased with higher age. All cardiac comorbidities and most non-cardiac comorbidities increased with aging, regardless of the HF phenotype. Notably, HFmrEF resembled HFrEF for ischemic heart disease prevalence in all age groups, whereas regarding hypertension it was more similar to HFpEF in age ≥ 80 years, to HFrEF in age < 65 years and intermediate in age 65-80 years. All-cause mortality risk was higher in HFrEF vs. HFmrEF for all age categories, whereas HFmrEF vs. HFpEF reported similar risk in ≥ 80 years old patients and lower risk in < 65 and 65-80 years old patients. Predictors of mortality were more likely cardiac comorbidities in HFrEF but more likely non-cardiac comorbidities in HFpEF and HFmrEF with < 65 years. Differences among HF phenotypes for comorbidities were less pronounced in the other age categories., Conclusion: HFmrEF appeared as an intermediate phenotype between HFpEF and HFrEF, but for some characteristics such as ischemic heart disease more similar to HFrEF. With aging, HFmrEF resembled more HFpEF. Prognosis was similar in HFmrEF vs. HFpEF and better than in HFrEF.

Background: Heart failure (HF) and non-cardiac comorbidities often coexist and are known to have an adverse effect on outcome. However, the prevalence and prognostic impact of non-cardiac comorbidities in patients with HF with reduced ejection fraction (HFrEF) vs. those with preserved (HFpEF) remain inadequately studied., Methods and Results: We used data from the Swedish Heart Failure Registry from 2000 to 2012. HFrEF was defined as EF < 50% and HFpEF as EF ≥ 50%. Of 31 344 patients available for analysis, 79.3% (n = 24 856) had HFrEF and 20.7% (n = 6 488) HFpEF. The outcome was all-cause mortality. We examined the association between ten non-cardiac comorbidities and mortality and its interaction with EF using adjusted hazard ratio (HR). Stroke, anemia, gout and cancer had a similar impact on mortality in both phenotypes, whereas diabetes (HR 1.57, 95% confidence interval [CI] [1.50-1.65] vs. HR 1.39 95% CI [1.27-1.51], p = 0.0002), renal failure (HR 1.65, 95% CI [1.57-1.73] vs. HR 1.44, 95% CI [1.32-1.57], p = 0.003) and liver disease (HR 2.13, 95% CI [1.83-2.47] vs. HR 1.42, 95% CI [1.09-1.85] p = 0.02) had a higher impact in the HFrEF patients. Moreover, pulmonary disease (HR 1.46, 95% CI [1.40-1.53] vs. HR 1.66 95% CI [1.54-1.80], p = 0.007) was more prominent in the HFpEF patients. Sleep apnea was not associated with worse prognosis in either group. No significant variation was found in the impact over the 12-year study period., Conclusions: Non-cardiac comorbidities contribute significantly but differently to mortality, both in HFrEF and HFpEF. No significant variation was found in the impact over the 12-year study period. These results emphasize the importance of including the management of comorbidities as a part of a standardized heart failure care in both HF phenotypes.

Aims: To assess the association between atrial fibrillation (AF) and mortality, and also the association between resting heart rate (HR) and mortality in both sinus rhythm (SR) and AF in patients with heart failure with preserved ejection fraction (HFpEF)., Methods and Results: A total of 9090 patients with HFpEF (ejection fraction ≥ 50%) were included from the Swedish Heart Failure registry; 4296 (47%) had SR and 4794 (53%) had AF. Patients with AF were older (80.3 vs. 75.0 years) and more symptomatic compared with patients in SR. The outcome measure was all-cause mortality. The adjusted hazard ratio (95% confidence interval) for AF vs. SR was 1.21 (1.11-1.32). Compared with HR ≤ 60 b.p.m., the adjusted hazard ratios (95% confidence interval) were in SR: 1.06 (0.92-1.21) for HR 61-70 b.p.m., 1.30 (1.12-1.52) for HR 71-80 b.p.m., 1.27 (1.07-1.51) for HR 81-90 b.p.m., and 1.77 (1.45-2.17) for HR > 90 b.p.m. Due to non-proportional hazards in AF, hazard ratios were estimated in three time periods. Compared with HR ≤ 60 b.p.m., the adjusted hazard ratios (95% confidence interval) were in AF: 1.30 (1.07-1.57), 1.07 (0.83-1.39), and 1.01 (0.70-1.48) for HR 61-70 b.p.m., 1.35 (1.12-1.62), 0.99 (0.77-1.27), and 0.96 (0.66-1.40) for HR 71-80 b.p.m., 1.41 (1.16-1.73), 1.01 (0.76-1.36), and 0.79 (0.51-1.22) for HR 81-90 b.p.m., and 1.78 (1.46-2.17), 1.08 (0.80-1.46), and 0.73 (0.46-1.17) for HR > 90 b.p.m., during 0-2, 2-4, and 4-6 years of follow-up, respectively., Conclusion: In a large and unselected cohort of patients with HFpEF, AF was independently associated with all-cause mortality. A higher HR was associated with increased mortality in SR. In AF, the effect of a higher HR on mortality was only present during the first years of follow-up, with convergence in outcomes according to baseline HR groups over long-term follow-up., (© 2019 The Authors. European Journal of Heart Failure © 2019 European Society of Cardiology.)

Objectives: To evaluate the incidence of atrial fibrillation (AF) as well as the value of thumb electrocardiography (ECG) for identification of paroxysmal AF in a Swedish cohort of middle-aged men from the general population., Design: A population based random cohort of 798 men underwent screening at the age of 50 and re-examined at the age of 60 and 71 years. At the last examination, a thumb ECG recording was conducted for 2 weeks twice a day in 479 men from the original cohort. Registered hospital AF diagnoses were retrieved from the Swedish Patient Registry from 1993 to 2014., Results: During a 21-year follow-up, 77 men (9.6%) were diagnosed with AF; of these men, 49.4% (38 of 77) had permanent AF. Fifteen of 479 (3.1%) patients had paroxysmal AF. Of those, seven had been previously diagnosed with paroxysmal AF through Patient Registry. The incidence of AF increased from 2.2 per 1000 years at risk at the age of 50-54 years to 9.3 per 1000 years at risk at the age 65-70 years. The prevalence of AF at the age of 71 years was increased from 7.1% to 9.9% using thumb ECG., Conclusions: In addition to medical history, patient register and 12-lead -ECG, the use of thumb ECG increased the number of detected paroxysmal AF by 21%.

Background: Although several biomarkers, including natriuretic peptides and inflammatory biomarkers, have proven to be useful prognostic predictors in patients with heart failure (HF), their predictive value for incident HF has not been extensively studied., Methods and Results: The "Study of Men Born in 1943" is a longitudinal, prospective study of men living in the city of Gothenburg, Sweden. A panel of biomarkers consisting of interleukin-6 (IL-6), cystatin C, high-sensitivity C-reactive protein (hs-CRP), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) was analyzed from blood samples collected in 1993 in men aged 50 years. Incident HF was recorded from multiple sources, including an echocardiographic assessment in 2014. A total of 747 (94%) of the 798 participants with no previous history of HF were included. Of these 747 participants, 85 (11.4%) developed HF over a 21-year follow-up. After adjustment for body mass index (BMI) and hypertension at baseline, NT-proBNP ≥25 ng/L was associated with a higher risk of HF (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.30-3.36; P = .0024), as was hs-CRP >3 mg/L (OR 2.61, 95% CI 1.59-4.29; P = .0002). In a multivariable model, the expected probability of HF was 0.33 (95% CI 0.23-0.45) in hypertensive patients with hs-CRP >3 mg/L, NT-proBNP ≥25 ng/L, and BMI ≥25 kg/m 2 , compared with a probability of 0.04 (95% CI 0.02-0.07) in nonhypertensive patients with hs-CRP ≤3 mg/L, NT-proBNP <25 ng/L, and BMI <25 kg/m. 2 CONCLUSIONS: NT-proBNP ≥25 ng/L and elevated hs-CRP levels in men aged 50 years were predictive biomarkers for HF over a 2one year follow-up., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Percutaneous coronary intervention (PCI) are increasingly used in daily clinical practice in elderly patients with acute coronary syndrome (ACS) despite limited evidence. The purpose of this study was to assess the impact of PCI on short and long term survivals in a large cohort of elderly patients with ACS from a "real world"., Methods: We enrolled 491 patients aged ≥70 years admitted to our institution with ACS from 2006 to 2012. Effect of PCI on short and long term survival was evaluated in both overall and a propensity score-matched cohort., Results: The mean age of the overall cohort is 83 ± 6 years. Among them, 285 were treated with PCI, whereas 206 were not. Patients treated with PCI were younger (82 ± 5 vs. 85 ± 6), more males (67% vs. 46%), with lower heart rate (77 ± 22 vs. 84 ± 21), higher eGFR (58 ± 20 vs. 47 ± 23), and less with heart failure (29% vs. 15%) (all p < 0.001). In both overall and propensity-matched population, improved survival was associated with PCI-treatment at 1 and 3 years (p < 0.001 for all comparisons). Furthermore, by using multivariate Cox proportional-hazards regression model following factors were identified as independent predictors of 3-year all-cause mortality: age (HR 1.08, 95% CI 1.00-1.16), heart rate (HR 1.02, 95% CI 1.01-1.03), eGFR (HR 3.07, 95% CI 1.63-5.77), malignancy (HR 2.03, 95% CI 1.27-4.57), prior CABG (HR 2.033, 95% CI 1.27-4.57), medication with statin (HR 0.40, 95% CI 0.19-0.86) in PCI group, whereas age (HR 1.08, 95% CI 1.03-1.13), heart rate (HR 1.01, 95% CI 1.01-1.02), hypertension (HR 1.87, 95% CI 1.01-3.49) and using of ACEI/ARB (HR 0.46, 95% CI 0.28-0.76) in non-PCI group., Conclusions: In elderly ACS patients, PCI-treatment was associated with improved 1 and 3-year survival and PCI-treated patients had different prognostic profile compared to those without PCI treatment.

Background: Despite a decline in mortality rates from cardiovascular disease (CVD) in the past few decades, the burden of CVD in a contemporary population remains inadequately addressed. Therefore, this study was aimed to investigate secular trends in mortality from coronary artery disease and all-cause mortality over 2 decades, by comparing 2 cohorts of men born 30 years apart and evaluate the prediction of the risk of CVD and all-cause death in a contemporary random sample of Swedish men., Methods and Results: Two cohorts of randomly selected men born in 1913 (855 men) and 1943 (798 men) were first examined at age 50 in 1963 and 1993, respectively, and followed longitudinally over 21 years. All-cause mortality and coronary artery disease death were lower in 50- to 71-year-old men born in 1943 compared with those born in 1913, with unadjusted hazard ratios of 0.57 (0.45-0.71) and 0.34 (0.22-0.53), respectively. After adjustment for risk factors (smoking, serum cholesterol, hypertension, systolic blood pressure, diabetes mellitus, body mass index, and physical activity), the differences between the cohorts remained significant for coronary artery disease, hazard ratios 0.57 (0.34-0.94), P =0.029, but not for all-cause mortality hazard ratios 0.82 (0.62-1.07), P =0.14. However, the rate of CVD events during follow-up was still high (30.7%) for the men born in 1943. No statistically significant interaction by birth cohort in contribution of risk factors to death was found between 2 cohorts except physical inactivity., Conclusions: Despite a marked reduction in the rate of coronary artery disease death over the past 30 years, the burden of CVD events and all-cause mortality remains high. Therefore, intensified efforts to modify contributing risk factors are still required., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Left atrial enlargement has been shown to be associated with obstructive sleep apnea in patients with coronary artery disease and in sleep clinic cohorts. However, data from the general population are limited. The aim of this study was to investigate whether there is an association between obstructive sleep apnea and left atrial enlargement in a random sample from a general population of 71-year-old men. As part of the longitudinal population study The Study of Men Born in 1943, we analysed cross-sectional data for 411 men, all 71 years old, who had participated in an overnight home sleep study and a standardized echocardiographic examination. Of the 411 men, 29.4% had moderate to severe obstructive sleep apnea [apnea-hypopnea index score of ≥15 (n = 121)]. These participants showed a significantly higher frequency of systolic heart failure, hypertension, overweight, had greater waist circumference as well as higher left atrial areas compared with men with no or mild obstructive sleep apnea (23.7 ± 5.5 cm 2 versus 21.6 ± 4.5 cm 2 , P < 0.001). In a linear regression analysis, obstructive sleep apnea was significantly associated with left atrial enlargement after adjusting for overweight, atrial fibrillation, heart failure with reduced ejection fraction, hypertension and mitral regurgitation. Compared with individuals without obstructive sleep apnea, the mean left atrial area was 1.7 ± 1.5 cm 2 larger in men with severe obstructive sleep apnea (P < 0.05) and 1.3 ± 1.1 cm 2 larger among men with moderate obstructive sleep apnea (P < 0.05). In this cross-sectional study of 71-year-old men from the general population, left atrial area was independently associated with prevalence and severity of obstructive sleep apnea., (© 2017 European Sleep Research Society.)

Background: A number of registry studies have reported suboptimal adherence to guidelines for cardiovascular prevention during the first year after acute myocardial infarction (AMI). However, only a few studies have addressed long-term secondary prevention after AMI. This study evaluates prevention guideline adherence and outcome of guideline-directed secondary prevention in patients surviving 2 years after AMI., Methods: Patients aged 18-85 years at the time of their index AMI were consecutively identified from hospital discharge records between July 2010 and December 2011 in Gothenburg, Sweden. All patients who agreed to participate in the study (16.2%) were invited for a structured interview, physical examinations and laboratory analysis 2 years after AMI. Guideline-directed secondary preventive goals were defined as optimally controlled blood pressure, serum cholesterol, glucose, regular physical activity, smoking cessation and pharmacological treatment., Results: The mean age of the study cohort (n = 200) at the index AMI was 63.0 ± 9.7 years, 79% were men. Only 3.5% of the cohort achieved all six guideline-directed secondary preventive goals 2 years after infarction. LDL < 1.8 mmol/L was achieved in 18.5% of the cohort, regular exercise in 45.5% and systolic blood pressure <140 mmHg in 57.0%. Anti-platelet therapy was used by 97% of the patients, beta-blockers by 83.0%, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers by 76.5% and statins by 88.5%. During follow-up, non-fatal adverse cardiovascular events (cardiac hospitalization, recurrent acute coronary syndrome, angina pectoris, new percutaneous coronary intervention, new onset of atrial fibrillation, post-infarct heart failure, pacemaker implantation, stroke/transient ischemic attack (TIA), cardiac surgery and cardiac arrest) occurred in 47% of the cohort and readmission due to cardiac causes in 30%., Conclusions: Our data showed the failure of secondary prevention in our daily clinical practice and high rate of non-fatal adverse cardiovascular events 2 years after AMI.

Background: Cardiovascular disease and renal impairment are common in cirrhotic transplant candidates. We aimed to investigate potential association between pretransplant renal function impairment and cardiac events after liver transplantation., Methods: Adult cirrhotic patients undergoing first-time liver transplantation between 1999 and 2007 in a single institution with available glomerular filtration rate (GFR), assessed by Cr-EDTA clearance at pre-transplant evaluation, were retrospectively enrolled (n=202). Impaired renal function was defined as GFR less than 60 mL/min/1.73 sqm. Pretransplant QT-time corrected by heart rate (QTc) and left-ventricular dysfunction was also registered. Mortality and cardiac events were analyzed, until death or last follow-up (end 2009)., Results: Renal impairment was present in 24% (48/202). Cardiac events occurred in 28% (56/202) after transplantation, mean follow-up time of 3.8 years (2.2). Events were more common in patients with renal impairment compared with those without (48% versus 21%, P<0.001). In Cox regression analysis, pretransplant renal impairment was found to be an independent predictor of posttransplant cardiac events (HR 2.19, 95% CI 1.25-3.85) and reduced cardiac event-free survival (HR 2.27, 95% CI 1.31-3.94). Prolonged QTc interval was an independent predictor of posttransplant cardiac events in the subgroup with pretransplant electrocardiogram and echocardiogram (n=166 and n=112, HR 4.75, 95% CI 2.07-10.9); however, left-ventricular diastolic dysfunction was not (P>0.05). A pretransplant score comprising renal impairment, prolonged QTc interval, and age older than 52 was developed for prediction of 3- and 12-month cardiac events (c-statistic 0.73 and 0.75, respectively)., Conclusions: Pretransplant renal impairment is a predictor of cardiac event after liver transplantation together with prolonged QTc interval.

Aims: To investigate trends in absolute numbers and prevalence from 1990 to 2007 of patients hospitalized with heart failure (HF) in Sweden., Methods and Results: National inpatient and cause-specific death registers were used to calculate age- and sex-specific trends in absolute numbers and prevalence from 1990 to 2007 of patients hospitalized with HF in Sweden. Absolute numbers increased from 105 449 in 1990 to 144 925 in 2007, with a 77% increase in patients aged 85-99 years. The overall age-adjusted prevalence in 1990 was 1.73%, and this increased with an estimated annual percentage change (EAPC) of 4.3% [95% confidence interval (CI) 3.6-4.9%] from 1990 to 1995, with no further significant change until 2002. The single year with the highest prevalence was 1998, when it peaked at 2.13%. The prevalence then declined slowly from 2002 (EAPC -1.1, 95% CI -1.5% to -0.6%) to 1.99% in 2007. The decrease in prevalence was not found in persons <65 years, where, instead, an increase was found throughout the period., Conclusion: Fears of an impending HF 'epidemic' could not be confirmed in this analysis of trends in prevalence for the period 1990-2007 of patients hospitalized with HF in Sweden. An overall slight decrease in age-adjusted prevalence was observed from 2002. The prevalence in patients <65 years increased markedly. In absolute numbers, there was a substantial increase among the very old, consistent with demographic changes., (© 2014 The Authors. European Journal of Heart Failure © 2014 European Society of Cardiology.)