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  • 1. Aasa, M
    et al.
    Henriksson, MF
    Dellborg, M
    Grip, L
    Herlitz, Johan
    [external].
    Levin, L-Å
    Svensson, L
    Janzon, M
    Cost and health outcome of primary percutaneous coronary intervention versus thrombolysis in acute ST-segment elevation myocardial infarction-Results of the Swedish Early Decision reperfusion Study (SWEDES) trial.2010In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 160, no 2, p. 322-328Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In ST-elevation myocardial infarction, primary percutaneous coronary intervention (PCI) has a superior clinical outcome, but it may increase costs in comparison to thrombolysis. The aim of the study was to compare costs, clinical outcome, and quality-adjusted survival between primary PCI and thrombolysis. METHODS: Patients with ST-elevation myocardial infarction were randomized to primary PCI with adjunctive enoxaparin and abciximab (n = 101), or to enoxaparin followed by reteplase (n = 104). Data on the use of health care resources, work loss, and health-related quality of life were collected during a 1-year period. Cost-effectiveness was determined by comparing costs and quality-adjusted survival. The joint distribution of incremental costs and quality-adjusted survival was analyzed using a nonparametric bootstrap approach. RESULTS: Clinical outcome did not differ significantly between the groups. Compared with the group treated with thrombolysis, the cost of interventions was higher in the PCI-treated group ($4,602 vs $3,807; P = .047), as well as the cost of drugs ($1,309 vs $1,202; P = .001), whereas the cost of hospitalization was lower ($7,344 vs $9,278; P = .025). The cost of investigations, outpatient care, and loss of production did not differ significantly between the 2 treatment arms. Total cost and quality-adjusted survival were $25,315 and 0.759 vs $27,819 and 0.728 (both not significant) for the primary PCI and thrombolysis groups, respectively. Based on the 1-year follow-up, bootstrap analysis revealed that in 80%, 88%, and 89% of the replications, the cost per health outcome gained for PCI will be <$0, $50,000, and $100,000 respectively. CONCLUSION: In a 1-year perspective, there was a tendency toward lower costs and better health outcome after primary PCI, resulting in costs for PCI in comparison to thrombolysis that will be below the conventional threshold for cost-effectiveness in 88% of bootstrap replications.

  • 2. Deedwania, PC
    et al.
    Giles, TD
    Klibaner, M
    Ghali, JK
    Herlitz, Johan
    [external].
    Hildebrandt, P
    Kjekshus, J
    Spinar, J
    Vitovec, J
    Stanbrook, H
    Wikstrand, J
    Efficacy, Safety and Tolerability of Metoprolol CR/XL in Patients With Diabetes and Chronic Heart Failure: Experiences From MERIT-HF2005In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 149, no 1, p. 159-167Article in journal (Refereed)
    Abstract [en]

    Background: The objective of the current study was to examine the efficacy and tolerability of the β-blocker metoprolol succinate controlled release/extended release (CR/XL) in patients with diabetes in the Metoprolol CR/XL Randomized Intervention Trial in Chronic Heart Failure (MERIT-HF). Methods: The Cox proportional hazards model was used to calculate hazard ratios (HR) for convenience expressed as relative risks (risk reduction = 1-HR), and 95% confidence intervals (CI). Results: The risk of hospitalization for heart failure was 76% higher in diabetics compared to non-diabetics (95% CI 38% to 123%). Metoprolol CR/XL was well tolerated and reduced the risk of hospitalization for heart failure by 37% in the diabetic group (95% CI 53% to 15%), and by 35% in the non-diabetic group (95% CI 48% to 19%). Pooling of mortality data from the Cardiac Insufficiency Bisoprolol Study II (CIBIS II), MERIT-HF, and the Carvedilol Prospective Randomized Cumulative Survival Study (COPERNICUS) showed similar survival benefits in patients with diabetes (25%; 95% CI 40% to 4%) and without diabetes (36%; 95% CI 44% to 27%); test of diabetes by treatment interaction was non-significant. Adverse events were reported more often on placebo than on metoprolol CR/XL. Conclusions: Patients with heart failure and diabetes have a much higher risk of hospitalization than patients without diabetes. Regardless of diabetic status, a highly significant reduction in hospitalizations for heart failure was observed with metoprolol CR/XL therapy, which was very well tolerated also by patients with diabetes. Furthermore, the pooled data showed a statistically significant survival benefit in patients with diabetes.

  • 3. Engdahl, J
    et al.
    Bång, A
    [external].
    Lindqvist, J
    Herlitz, Johan
    [external].
    Time trends in long-term mortality after out-of-hospital cardiac arrest in 1980-1998 and predictors for death2003In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 145, no 5, p. 826-833Article in journal (Refereed)
    Abstract [en]

    Abstract Background We studied time trends in long-term survival after out-of-hospital cardiac arrest (OHCA) for patient characteristics and described predictors for death after discharge. Because long-term prognosis among patients with coronary heart disease has improved in the last decades, we hypothesized that the prognosis after OHCA would improve with time. Methods We analyzed data that were prospectively collected from all patients discharged from the hospital after OHCA in the community of Göteborg, Sweden, from 1980 to 1998 and divided the data into 2 time periods, 1980 to 1991 and 1991 to1998, with an equal number of patients. Results A total of 430 patients were included in the survey. Age, sex proportions, cardiovascular comorbidity, resuscitation factors, and inhospital complications did not change with time. A diagnosis of a precipitating myocardial infarction was more common during period 1 (66% vs 54%). The prescription of aspirin (22% vs 52%), angiotensin-converting enzyme inhibitors (7% vs 29%), anticoagulants (13% vs 27%), and lipid-lowering agents (0% vs 6%) at discharge increased during period 2. Long-term survival did not improve with time; the 5-year mortality rates were 53% in period 1 and 52% in period 2. Independent predictors of an increased risk of death included age (risk ratio [RR] 1.06, 95% CI 1.05–1.08), history of myocardial infarction (RR 2.02, 95% CI 1.51–2.72), history of smoking (RR 1.77, 95% CI 1.29–2.44), and worse cerebral performance at discharge (RR 1.71, 95% CI 1.44–2.02). The prescription of β-blockers at discharge was independently predictive of decreased risk of death (RR 0.63, 95% CI 0.46–0.85). Conclusion The long-term survival rate after OHCA did not change. Baseline characteristics remained generally unchanged, but the drugs prescribed at discharge changed in several aspects. Age, a history of myocardial infarction, a history of smoking, cerebral performance category at discharge, and the prescription of β-blockers were independent predictors of outcome.

  • 4. Fredriksson, M
    et al.
    Aune, S
    Bång, A
    University of Borås, School of Health Science.
    Thorén, A-B
    Lindqvist, J
    Karlsson, T
    Herlitz, Johan
    University of Borås, School of Health Science.
    Cardiac arrest outside and inside hospital in a community: mechanisms behind the differences in outcome and outcome in relation to time of arrest.2010In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 159, no 5, p. 749-756Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim was to compare characteristics and outcome after cardiac arrest where cardiopulmonary resuscitation was attempted outside and inside hospital over 12 years. METHODS: All out-of-hospital cardiac arrests (OHCAs) in Göteborg between 1994 and 2006 and all in-hospital cardiac arrests (IHCAs) in 1 of the city's 2 hospitals for whom the rescue team was called between 1994 and 2006 were included in the survey. RESULTS: The study included 2,984 cases of OHCA and 1,478 cases of IHCA. Patients with OHCA differed from those with an IHCA; they were younger, included fewer women, were less frequently found in ventricular fibrillation, and were treated later. If patients were found in a shockable rhythm, survival to 1 month/discharge was 18% after OHCA and 61% after IHCA (P < .0001). Corresponding values for a nonshockable rhythm were 3% and 21% (P < .0001). Survival was higher on daytime and weekdays as compared with nighttime and weekends after IHCA but not after OHCA. Among patients found in a shockable rhythm, a multivariate analysis considering age, gender, witnessed status, delay to defibrillation, time of day, day of week, and location showed that IHCA was associated with increased survival compared with OHCA (adjusted odds ratio 3.18, 95% CI 2.07-4.88). CONCLUSION: Compared with OHCA, the survival of patients with IHCA increased 3-fold for shockable rhythm and 7-fold for nonshockable rhythm in our practice setting. If patients were found in a shockable rhythm, the higher survival after IHCA was only partly explained by a shorter treatment delay. The time and day of CA were associated with survival in IHCA but not OHCA.

  • 5. Fredriksson, M
    et al.
    Aune, S
    Bång, Angela
    University of Borås, School of Health Science.
    Thorén, A-B
    Lindqvist, J
    Karlsson, T
    Herlitz, Johan
    University of Borås, School of Health Science.
    Cardiac arrest outside and inside hospital in a community. Mechanisms behind the differences in outcome and outcome in relation to time of arrest2010In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 159, no 5, p. 749-756Article in journal (Refereed)
    Abstract [en]

    Background The aim was to compare characteristics and outcome after cardiac arrest where cardiopulmonary resuscitation was attempted outside and inside hospital over 12 years. Methods All out-of-hospital cardiac arrests (OHCAs) in Göteborg between 1994 and 2006 and all in-hospital cardiac arrests (IHCAs) in 1 of the city's 2 hospitals for whom the rescue team was called between 1994 and 2006 were included in the survey. Results The study included 2,984 cases of OHCA and 1,478 cases of IHCA. Patients with OHCA differed from those with an IHCA; they were younger, included fewer women, were less frequently found in ventricular fibrillation, and were treated later. If patients were found in a shockable rhythm, survival to 1 month/discharge was 18% after OHCA and 61% after IHCA (P < .0001). Corresponding values for a nonshockable rhythm were 3% and 21% (P < .0001). Survival was higher on daytime and weekdays as compared with nighttime and weekends after IHCA but not after OHCA. Among patients found in a shockable rhythm, a multivariate analysis considering age, gender, witnessed status, delay to defibrillation, time of day, day of week, and location showed that IHCA was associated with increased survival compared with OHCA (adjusted odds ratio 3.18, 95% CI 2.07-4.88). Conclusion Compared with OHCA, the survival of patients with IHCA increased 3-fold for shockable rhythm and 7-fold for nonshockable rhythm in our practice setting. If patients were found in a shockable rhythm, the higher survival after IHCA was only partly explained by a shorter treatment delay. The time and day of CA were associated with survival in IHCA but not OHCA.

  • 6. Gardtman, M
    et al.
    Dellborg, M
    Brunnhage, Ch
    Lindqvist, J
    Waagstein, L
    Herlitz, Johan
    [external].
    Effects of intravenous metoprolol before hospital admission on chest pain in susptected acute myocardial infarction1999In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 137, no 5, p. 821-829Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The aim of this study was to describe the effect of intravenous metoprolol on the intensity of chest pain before hospital admission in patients with suspected acute myocardial infarction AMI). METHODS AND RESULTS: Two hundred sixty-two patients with acute chest pain and suspected AMI were randomly assigned before hospital admission to either 5 mg morphine plus metoprolol 5 mg x 3 intravenously or 5 mg morphine plus intravenous placebo. Chest pain was evaluated on a 10-grade scale before and for 60 minutes after intravenous injection. One hundred thirty-four patients were randomly assigned to metoprolol and 128 to placebo. Among all patients randomized to metoprolol, the mean chest pain score was reduced by 3.0 +/- 1.9 arbitrary units AU) from before to after intravenous injection compared with 2.6 +/- 2.1 AU for placebo not significant). Among patients with an initially confirmed or strong suspicion of AMI, the corresponding figures were 3.1 +/- 1.8 AU for metoprolol and 2.2 +/- 1.6 AU for placebo P =.02). Among patients with only a vague or moderate suspicion of AMI, there was no difference. The treatment was well tolerated. CONCLUSIONS: When all patients were included in the analyses, there was no significant difference with regard to reduction of chest pain in the patients randomly assigned to metoprolol compared with placebo. A retrospective subgroup analysis indicated a beneficial effect of metoprolol among patients with an initially strong suspicion of or confirmed AMI. Further investigations are warranted to confirm this finding.

  • 7.
    Herlitz, Johan
    et al.
    [external].
    Brandrup Wognsen, G
    Caidahl, K
    Haglid Evander, M
    Hartford, M
    Karlson, BW
    Karlsson, T
    Sjöland, H
    Symptoms of chest pain and dyspnea and factors associated with chest pain and dyspnea 10 years after coronary artery bypass grafting.2008In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 156, no 3, p. 580-587Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The purpose of the study is to describe (a) changes in physical activity and symptoms of chest pain and dyspnea during 10 years after coronary artery bypass grafting (CABG) and (b) risk indicators for chest pain and dyspnea 10 years after CABG. METHODS: This is a prospective observational study in Western Sweden. The study includes all patients who underwent CABG without simultaneous valve surgery and with no previous CABG between June 1, 1988, and June 1, 1991. All patients were prospectively followed up for 10 years. Evaluation of symptoms took place via postal inquiries before, 5, and 10 years after the operation. RESULTS: In all, 2,000 patients participated in a survey evaluating chest pain and dyspnea during 10 years after CABG. The overall 10-year mortality was 32%. The proportion of patients with no chest pain increased from 3% before surgery to 56% 5 years after the operation and 54% after 10 years. There was only one predictor for chest pain after 10 years and that was the duration of angina pectoris before surgery. The proportion of patients with no dyspnea increased from 12% before surgery to 40% after 5 years but decreased to 31% after 10 years. The most significant predictors for dyspnea after 10 years were female sex, obesity, diabetes mellitus, high age, duration of angina pectoris, functional class before CABG, and number of days in intensive care unit after CABG. CONCLUSION: During 10 years after CABG, one third died. After 10 years, 54% of the survivors were free from chest pain and 31% were free from dyspnea. Predictors for chest pain and dyspnea could be defined and reflected age, history, sex, obesity, preoperative complications, and symptom severity.

  • 8.
    Herlitz, Johan
    et al.
    [external].
    Dellborg, M
    Karlson, BW
    Karlsson, T
    Prognosis after acute myocardial infarction continues to improve in the reperfusion era in the community of Göteborg2002In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 144, no 1, p. 89-94Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The objective of this study was to compare the prognosis of nonselected patients who had an acute myocardial infarction (AMI) during 2 time periods in the thrombolytic era and to describe coronary heart disease (CHD) mortality rates in the community of Göteborg during 1990 to 1995. METHODS: Patients aged <75 years who were hospitalized in the community of Göteborg for AMI during 1990 to 1991 (period 1) and 1995 to 1996 (period 2) were compared in terms of history, treatment for AMI, and outcome. Information on CHD mortality rates in the community of Göteborg was gathered from the National Registry of Deaths. RESULTS: The numbers of patients in the 2 cohorts were 926 and 861, respectively. The incidence rate for AMI per 100,000 inhabitants and year was 200 for period 1 and 183 during period 2. During period 2, there was an increased use of percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, angiotensin-converting enzyme inhibitors, heparin, and intravenous nitroglycerin. On the other hand, there was a decreased use of thrombolytic agents, diuretic agents, digitalis, long-acting nitrates, calcium-channel blockers, and lidocaine. The hospital case-fatality rates were 9.4% during period 1 and 6.0% during period 2 (P =.01). The adjusted risk ratio for period 2 versus period 1 was 0.65, with 95% confidence limits of 0.45 to 0.94. The mortality rate over a period of 3 years was 26.5% during period 1 and 17.8% during period 2 (P <.0001). The adjusted risk ratio for period 2 versus period 1 was 0.67, with 95% confidence limits of 0.54 to 0.82. Among inhabitants aged 30 to 74 years in the community of Göteborg, the CHD mortality rate decreased in 1995 as compared with 1990 (age-adjusted odds ratio 0.79, 95% confidence limits 0.68 to 0.92). CONCLUSIONS: For consecutive patients aged <75 years who were hospitalized for AMI in the community of Göteborg, we found that in the thrombolytic era, major changes in medical and nonmedical treatment still took place associated with a continuing decrease in mortality rates during 3 years of follow-up. A similar reduction of CHD mortality rates was seen in the same age group within the community of Göteborg.

  • 9.
    Herlitz, Johan
    et al.
    [external].
    Engdahl, J
    Svensson, L
    Ängquist, KA
    Young, M
    Factors associated with an increased chance of survival among patients suffering from an out-of-hospital cardiac arrest in a national perspective in Sweden.2005In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 149, no 1, p. 61-66Article in journal (Refereed)
    Abstract [en]

    AIM: To describe factors associated with an increased chance of survival among patients suffering from an out-of-hospital cardiac arrest in Sweden. PATIENTS AND METHODS: All patients suffering from an out-of-hospital cardiac arrest, which were not crew witnessed, in Sweden and in whom cardiopulmonary resuscitation (CPR) was attempted and who were registered in the Swedish Cardiac Arrest Registry. This registry covers about 85% of the Swedish population and has been running since 1990. RESULTS: In all, 33,453 patients, 71% of whom had a cardiac etiology, were included in the survey. The following were independent predictors for an increased chance of survival in order of magnitude: (1) patients found in ventricular fibrillation (odds ratio [OR] 5.3, 95% confidence limits [CL] 4.2-6.8), (2) the interval between call for and arrival of the ambulance less than or equal to the median (OR 3.6, 95% CL 2.9-4.6), (3) cardiac arrest occurred outside the home (OR 2.2, 95% CL 1.9-2.7), (4) cardiac arrest was witnessed (OR 2.0, 95% CL 1.6-2.7), (5) bystanders performing CPR before the arrival of the ambulance (OR 2.0, 95% CL 1.7-2.4), and (6) age less than or equal to the median (OR 1.6, 95% CL 1.4-2.0). When none of these factors were present, survival to 1 m was 0.4%; when all factors were present, survival was 23.8%. CONCLUSION: Among patients suffering from an out-of-hospital cardiac arrest, which were not crew witnessed, in Sweden and in whom CPR was attempted, 6 factors for an increased chance of survival could be defined. These include (1) initial rhythm, (2) delay to arrival of the rescue team, (3) place of arrest, (4) witnessed status, (5) bystander CPR, and (6) age.

  • 10.
    Herlitz, Johan
    et al.
    [external].
    Hjalmarson, Å
    Lomsky, M
    Wiklund, I
    The relationship between infarct size and morbidity and mortality during short-term and long-term follow-up after acute myocardial infarction1988In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 116, no 5, p. 1378-1382Article in journal (Refereed)
  • 11.
    Herlitz, Johan
    et al.
    [external].
    Hjalmarson, Å
    Waagstein, F
    Beta blockade and chest pain in acute myocardial infarction1986In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 112, no 5, p. 1120-1126Article in journal (Refereed)
  • 12.
    Herlitz, Johan
    et al.
    [external].
    Hjalmarson, Å
    Waldenström, J
    Five-year mortality rate in relation to enzyme-estimated infarct size in acute myocardial infarction1987In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 114, no 4 pt 1, p. 731-737Article in journal (Refereed)
    Abstract [en]

    In 727 patients with acute myocardial infarction, different enzyme variables reflecting infarct size were related to the 5-year mortality rate. The maximum activity of serum heat-stable lactate dehydrogenase (LD), analyzed every 12 hours for 48 to 108 hours, was significantly associated with the 5-year mortality rate when patients with a first myocardial infarction were evaluated (p less than 0.001), and similarly (p less than 0.001) when patients with a previous myocardial infarction were included in the analyses. Very similar results were found when the maximum activity of aspartate aminotransferase (ASAT) analyzed once daily for 3 days was related to the mortality rate over 5 years, whereas the maximum activity of creatine kinase (CK) and CK subunit B analyzed every 6 hours for 48 hours in a subset of patients did not predict the outcome to the same extent. The results from LD and ASAT analyses clearly indicated that the association between infarct size and 5-year mortality rate was caused by the much higher mortality rate in patients with larger infarcts during the first year after onset of infarction, whereas after the first year, incidence of death appeared to be independent of the original infarct size. Thus we conclude that although a highly significant relationship between infarct size and overall 5-year survival was found, the mortality rate seemed to be higher in patients with larger infarcts, particularly during the first year after infarction.

  • 13.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Lindqvist, J
    Sjölin, M
    Important factors for the 10-year mortality rate in patients with acute chest pain or other symptoms consistent with acute myocardial infarction with particular emphasis on the influence of age2001In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 142, no 4, p. 624-632Article in journal (Refereed)
    Abstract [en]

    Objective Our purpose was to describe the mortality rate and mode of death over 10 years and factors associated with death among patients admitted to the emergency department with acute chest pain or other symptoms consistent with acute myocardial infarction (AMI). Methods All patients who came to the emergency department at Sahlgrenska University Hospital in Göteborg, Sweden, with acute chest pain or other symptoms consistent with AMI during a 21-month period were studied. Results In all, 5362 patients were registered, for whom information on 10-year mortality was available in 5158 (96.2%). In all, there were 2126 deaths (41.2%). Fifty-two percent of patients were ≤65 years old. Independent predictors of death registered on admission to hospital during the subsequent 10 years were age (relative risk 1.08, 95% CI 1.07-1.09), male sex (1.38, 1.25-1.52), initial degree of suspicion of AMI (1.13, 1.06-1.19), a pathologic initial electrocardiogram (1.76, 1.56-1.98), symptoms of congestive heart failure (1.66, 1.39-1.98), “other” nonspecific symptoms (1.22, 1.07-1.39), a history of diabetes mellitus (1.65, 1.44-1.88), a history of congestive heart failure (1.42, 1.26-1.60), a history of previous myocardial infarction (1.26, 1.12-1.40), and a history of hypertension (1.14, 1.03-1.26). For all these predictors there was a strong interaction with age, thus a much more marked influence on outcome among patients ≤65 years old than among patients >65 years old. When the above risk indicators were simultaneously considered, development of AMI during the first 3 days after hospital admission was still an independent predictor of death (1.63, 1.43-1.86). Conclusion For patients admitted to the emergency department with acute chest pain or other symptoms consistent with AMI, several predictors based on clinical history and clinical presentation are related to the 10-year prognosis. They are more strongly associated with outcome among patients aged ≤65 years. However, whether the patients have an AMI during the subsequent days will independently influence the long-term prognosis from observations on admission.

  • 14.
    Herlitz, Johan
    et al.
    [external].
    McGovern, P
    Dellborg, M
    Karlsson, T
    Duval, S
    Karlson, BW
    Seungmin, L
    Lupker, RV
    Comparison of treatment and outcomes for patients with acute myocardial infarction in Minneapolis/St. Paul, Minnesota, and Göteborg, Sweden.2003In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 146, no 6, p. 1023-1029Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Treatment of acute myocardial infarction (AMI) is changing, and differences in medical practice are observed within and between countries on the basis of local practice patterns and available technology. These differing approaches provide an opportunity to evaluate medical practice and outcomes at the population level. The primary aim of this study was to compare medical care in patients hospitalized with AMI in 2 large cities in Sweden and the United States. A secondary aim was to compare medical outcomes. METHODS: All resident patients (age range, 30-74 years) hospitalized with AMI in Göteborg, Sweden (1995-1996), and a representative population-based sample of all patients with AMI in Minneapolis/St. Paul, Minn (1995). RESULTS: Patients with AMI in Göteborg (GB) were older than patients in Minneapolis/St. Paul (MSP), but fewer patients in GB had a prior history of cardiovascular disease. During the AMI admission, coronary angiography, percutaneous coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG) were performed twice as frequently in MSP than in GB. Echocardiogram and exercise testing were more frequently performed in GB. During hospitalization, beta-blockers were more frequently prescribed in GB, whereas calcium channel blockers, long- and short-acting nitrates, intravenous nitroglycerine, digitalis, aspirin, oral anticoagulants, heparin, and lidocaine were significantly more common in MSP. Thrombolysis, acute PTCA, ACE inhibitors, and diuretics were similar. Reinfarction was higher in men in GB (4% vs 1%, P <.009) and women in GB (3% vs 1%, P = not significant). On discharge, beta-blockers and diuretics were prescribed significantly more often in GB, whereas calcium channel blockers, nitrates, and digitalis were prescribed more often in MSP. Aspirin and ACE inhibitors had similar usage rates. Despite these diagnostic and treatment contrasts, there were no differences in mortality rate at 30 days or after 3 years of follow-up after risk-adjusting for patient baseline differences. CONCLUSION: Comparing patients hospitalized with AMI in MSP and GB, we found marked differences in medical care, with invasive strategies more likely to be used in MSP. This may be the result of historical practice patterns, the healthcare system, and healthcare financing differences. Despite these differences, short- or long-term mortality rates were identical.

  • 15. Hofmann, R
    et al.
    James, SK
    Svensson, L
    Witt, N
    Frick, M
    Lindahl, B
    Östlund, O
    Ekelund, U
    Erlinge, D
    Herlitz, J
    University of Borås, School of Health Science.
    Jernberg, T
    DETermination of the role of OXygen in suspected Acute Myocardial Infarction trial2014In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 167, no 3, p. 322-328Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The use of supplemental oxygen in the setting of suspected acute myocardial infarction (AMI) is recommended in international treatment guidelines and established in prehospital and hospital clinical routine throughout the world. However, to date there is no conclusive evidence from adequately designed and powered trials supporting this practice. Existing data are conflicting and fail to clarify the role of supplemental oxygen in AMI. METHODS: A total of 6,600 normoxemic (oxygen saturation [SpO2] ≥90%) patients with suspected AMI will be randomly assigned to either supplemental oxygen 6 L/min delivered by Oxymask (MedCore Sweden AB, Kista, Sweden) for 6 to 12 hours in the treatment group or room air in the control group. Patient inclusion and randomization will take place at first medical contact, either before hospital admission or at the emergency department. The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry will be used for online randomization, allowing inclusion of a broad population of all-comers. Follow-up will be carried out in nationwide health registries and Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies. The primary objective is to evaluate whether oxygen reduces 1-year all-cause mortality. Secondary end points include 30-day mortality, major adverse cardiac events, and health economy. Prespecified subgroups include patients with confirmed AMI and certain risk groups. In a 3-month pilot study, the study concept was found to be safe and feasible. CONCLUSION: The need to clarify the uncertainty of the role of supplemental oxygen therapy in the setting of suspected AMI is urgent. The DETO2X-AMI trial is designed and powered to address this important issue and may have a direct impact on future recommendations.

  • 16. Jánosi, A
    et al.
    Ghali, J
    Herlitz, Johan
    [external].
    Gzuriga, I
    Klibaner, M
    Wikstrand, J
    Hjalmarson, Å
    Metoprolol CR/XL in post-myocardial infarction patients with chronic heart failure. Experiences from MERIT-HF2003In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 146, no 4, p. 721-728Article in journal (Refereed)
    Abstract [en]

    Abstract Background The benefit of β-blockers post-myocardial infarction (MI) was established in the late 1970s. Major advances in the treatment of MI have since occurred. However, patients with chronic heart failure (CHF) were excluded from those trials. The purpose of this study was to assess the effect of β-blockers in post-MI patients with CHF receiving contemporary management. Methods This was a prespecified subgroup analysis of a double-blind, randomized trial: the Metoprolol CR/XL Randomized Intervention Trial in Heart Failure (MERIT-HF). Patients with CHF in New York Heart Association class II to IV with an ejection fraction (EF) ≤0.40 and a history of being hospitalized for an acute MI (n = 1926) were randomized to metoprolol succinate controlled release/extended release (CR/XL) versus placebo. Mean EF was 0.28, and the mean follow-up was 1 year. Results Metoprolol CR/XL reduced total mortality by 40% (95% CI 0.20–0.55, P = .0004), and sudden death by 50% (95% CI 0.26–0.66, P = .0004). The combined end point of all-cause mortality/hospitalization for worsening CHF was reduced by 31% (95% CI 0.16–0.44, P < .0001), and cardiac death/nonfatal acute MI by 45% (95% CI 0.26–0.58, P < .0001). A post-hoc analysis showed that the outcome in patients with earlier revascularization (44%) and outcome in those with more severe CHF (20%) was similar to the entire post-MI population. Conclusions In post-MI patients with symptomatic CHF, β-blockade continues to exert a profound reduction in mortality and morbidity in the presence of contemporary management that includes early and late revascularization, angiotensin-converting enzyme inhibitors, aspirin, and statins.

  • 17. Karlson, BW
    et al.
    Hartford, M
    Herlitz, Johan
    [external].
    Prognosis in acute myocardial infarction in relation to gender1994In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 128, no 3, p. 477-483Article in journal (Refereed)
    Abstract [en]

    We studied 921 consecutive patients admitted to a single hospital for acute myocardial infarction during a period of 21 months and related their prognosis to gender. Women (n = 300, 33%) were on average 7 years older (p < 0.001) and more frequently had a previous history of hypertension (p < 0.001) and congestive heart failure (p < 0.001) than did men. They also tended to delay longer in seeking medical treatment and more often presented with only vague symptoms (p < 0.05). The in-hospital mortality for women was 19% versus 12% for men (p < 0.01). Women more often showed signs of congestive heart failure (p < 0.05) despite smaller infarcts as estimated from enzyme levels (p < 0.05). Total mortality during 1 year was 36% in women and 25% in men (p < 0.01). In a multivariate analysis, female gender did not appear as an independent risk factor for death. During 1 year of follow-up no differences in morbidity were observed between the sexes. We conclude that if women fare worse than men after suffering an acute myocardial infarction, the increased mortality is accounted for by older age.

  • 18. Karlson, BW
    et al.
    Sjölin, M
    Lindqvist, J
    Caidahl, K
    Herlitz, Johan
    [external].
    Ten year mortality rate in relation to observation at a bicycle exercise test in patients with suspected or confirmed ischemic event but with no or only minor myocardial damage2001In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 141, no 6, p. 977-984Article in journal (Refereed)
    Abstract [en]

    Aim Our purpose was to describe symptoms and electrocardiographic findings at a bicycle exercise test 4 weeks after hospitalization for a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis and its relationship to long-term prognosis and subsequent revascularization. Methods In all patients a symptom-limited bicycle exercise test was performed 4 weeks after discharge from the hospital. The total mortality rate over 10 years was registered. Results In all, 770 patients participated in the evaluation. The median age was 63 years, and 34% were women. The most frequent reason for stopping the exercise test was fatigue (69%) followed by dyspnea (33%) and angina pectoris (15%). Angina pectoris was observed in 24% of the patients. ST-segment depression ≥1 mm was observed in 50% and ST-segment depression ≥2 mm was observed in 15% of the patients. The 10-year mortality rate in patients with ST-segment depression ≥2 mm was 24.7%, in patients with ST-segment depression 1.0 to 1.9 mm 33.5%, and in patients with ST-segment depression <1 mm 26.9% (not significant [NS]). Patients with symptoms of angina pectoris had a 10-year mortality rate of 29.4% compared with 27.9% among patients without such symptoms (NS). Patients who had either a drop in systolic blood pressure or failure to raise systolic blood pressure (13%) had a 10-year mortality rate of 36.2% compared with 27.2% among patients without such signs (NS). However, there was a significant association between maximum exercise capacity (in watts) and mortality (P < .0001): 53.8% in the lowest quartile (30-70 W) and 10.2% in the highest (>120 w). When clinical history was considered simultaneously, a low exercise capacity remained as a strong independent predictor of death together with age and a history of either acute myocardial infarction, smoking, or diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted only with angina pectoris and prognosis; thus patients who had angina during the exercise test had a worse prognosis than those without if they were not being revascularized. Conclusion Among patients hospitalized with a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis, we found the maximum working capacity at a symptom-limited bicycle exercise test to be independently associated with the long-term prognosis but not other signs of myocardial ischemia. Further predictors for long-term prognosis were age, a history of acute myocardial infarction, current smoking, and diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted with the influence of symptoms of angina during test and prognosis.

  • 19. Karlsson, BW
    et al.
    Herlitz, Johan
    [external].
    Sjölin, M
    Ekvall, H-E
    Persson, NG
    Lindqvist, J
    Hjalmarson, Å
    Clinical factors associated with delay time in suspected acute myocardial infarction1990In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 120, no 5, p. 1213-1215Article in journal (Refereed)
  • 20. Perers, E
    et al.
    Caidahl, K
    Herlitz, Johan
    [external].
    Karlsson, T
    Hartford, M
    Impact of diagnosis and sex on long-term prognosis in acute coronary syndromes.2007In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 157, no 3, p. 482-488Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There is limited information on long-term outcome in patients surviving the acute phase of an acute coronary syndrome (ACS). As yet, the effects of the type of syndrome and sex on mortality and morbidity in the long run have not been well described. METHODS: We studied 1618 patients <80 years old with ACS and alive 30 days after hospitalization in a coronary care unit. The patients were followed for 5 years. They were divided into 4 groups according to the type of ACS (ST-segment elevation myocardial infarction [STEMI], non-STEMI, unstable angina pectoris high risk, and unstable angina pectoris low risk). RESULTS: There was no significant sex difference in unadjusted 5-year mortality (P = .20). After adjustment for age, the hazard ratio with the corresponding 95% CI for a higher late 5-year mortality in women in relation to men was 0.89 (0.70-1.13, P = .34). Women were hospitalized for heart failure significantly more frequently during follow-up, a significance that disappeared after adjustment for age. Non-STEMI was associated with a significantly higher long-term mortality than STEMI, before but not after adjustment for covariates (hazard ratio [95% CI] 1.02 [0.75-1.37], P = .92). Of these, age, ST depression on admission, and early revascularization with percutaneous coronary intervention appeared to be of particular importance. Non-STEMI had a significantly higher rate of acute/subacute revascularization during follow-up, even after adjustment for age. CONCLUSIONS: Before, but not after, adjustment for covariates, a diagnosis of non-STEMI was associated with a poorer prognosis than other types of ACS. Small sex differences in long-term outcome in survivors of ACS were found.

  • 21. Svensson, L
    et al.
    Aasa, M
    Dellborg, M
    Gibson, M
    Kirtane, A
    Herlitz, Johan
    [external].
    Ohlsson, A
    Karlsson, T
    Grip, L
    Comparison of very early treatment with either fibrinolysis or percutaneous coronary intervention facilitated with abciximab with respect to ST recovery and infarct-related artery epicardial flow in patients with acute ST-segment elevation myocardial infarction: the Swedish Early Decision (SWEDES) reperfusion trial.2006In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 151, no 4, p. 798-798Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Results from a number of studies indicate that primary percutaneous coronary intervention (PCI) is superior to fibrinolysis for treatment of acute ST-elevation myocardial infarction. Modern adjunctive antithrombotic treatment with systematic use of low-molecular-weight heparins, fibrin-specific thrombolysis, and glycoprotein IIb/IIIa receptor inhibitors may improve the outcome compared with what was achieved in previous studies. METHODS: Patients with ST-elevation myocardial infarction were randomized to receive enoxaparin followed by reteplase (group A; n = 104) or enoxaparin followed by abciximab and transfer to invasive center for optional PCI (group B; n = 101). Primary end points were ST-segment resolution 120 minutes and TIMI flow at coronary angiography 5 to 7 days after randomization. RESULTS: Forty-two percent of the patients started therapy in the prehospital phase. Time from symptom to treatment was 114 minutes in group A and 202 minutes in group B. Baseline characteristics were similar in the 2 groups. Sixty-four percent in group A and 68% in group B had ST resolution of > 50% at 120 minutes (not significant). At control angiography, 54% in the fibrinolytic group and 71% in the invasive group had TIMI 3 flow (P = .04). At 30 days, the composite of death, stroke, or reinfarction occurred in 8% in the fibrinolytic group compared with 3% in the invasive group (not significant). CONCLUSIONS: Despite much shorter time delay to start of fibrinolysis than PCI, this did not result in signs of superior myocardial reperfusion. Epicardial flow in the infarct-related artery was better after invasive therapy, and there was a trend toward better clinical outcome after this treatment compared with after fibrinolysis.

  • 22. Thuresson, M
    et al.
    Berglin Jarlöv, M
    Lindahl, B
    Svensson, L
    Zedigh, C
    Herlitz, Johan
    [external].
    Factors that influence the use of ambulance in acute coronary syndrome.2008In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 156, no 1, p. 170-176Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: National guidelines recommend activation of the emergency medical service by patients who have symptoms of acute coronary syndrome (ACS). In spite of this, only 50% to 60% of persons with myocardial infarction initiate care by using the emergency medical service. The aim of this study was to define factors influencing the use of ambulance in ACS. METHODS: The method used in this study was a national survey comprising intensive cardiac care units at 11 hospitals in Sweden; 1,939 patients with diagnosed ACS and symptom onset outside the hospital completed a questionnaire a few days after admission. RESULTS: Half of the patients went to the hospital by ambulance. Factors associated with ambulance use were knowledge of the importance of quickly seeking medical care and calling for an ambulance when having chest pain (odds ratio [OR] 3.61, 95% CI 2.43-5.45), abrupt onset of pain reaching maximum intensity within minutes (OR 2.08, 1.62-2.69), nausea or cold sweat (OR 2.02, 1.54-2.65), vertigo or near syncope (OR 1.63, 1.21-2.20), ST-elevation ACS (OR 1.58, 1.21-2.06), increasing age (per year) (OR 1.03, 1.02-1.04), previous history of heart failure (OR 2.48, 1.47-4.26), and distance to the hospital of >5 km (OR 2.0, 1.55-2.59). Those who did not call for an ambulance thought self-transport would be faster or did not believe they were sick enough. CONCLUSIONS: Symptoms, patient characteristics, ACS characteristics, and perceptions and knowledge were all associated with ambulance use in ACS. The fact that knowledge increases ambulance use and the need for behavioral change pose a challenge for health-care professionals.

  • 23. Thuresson, M
    et al.
    Jarlöv, MB
    Lindahl, B
    Svensson, L
    Zedigh, C
    Herlitz, Johan
    University of Borås, School of Health Science.
    Factors that influence the use of ambulance in acute coronary syndrome2008In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 156, no 1, p. 170-176Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: National guidelines recommend activation of the emergency medical service by patients who have symptoms of acute coronary syndrome (ACS). In spite of this, only 50% to 60% of persons with myocardial infarction initiate care by using the emergency medical service. The aim of this study was to define factors influencing the use of ambulance in ACS. METHODS: The method used in this study was a national survey comprising intensive cardiac care units at 11 hospitals in Sweden; 1,939 patients with diagnosed ACS and symptom onset outside the hospital completed a questionnaire a few days after admission. RESULTS: Half of the patients went to the hospital by ambulance. Factors associated with ambulance use were knowledge of the importance of quickly seeking medical care and calling for an ambulance when having chest pain (odds ratio [OR] 3.61, 95% CI 2.43-5.45), abrupt onset of pain reaching maximum intensity within minutes (OR 2.08, 1.62-2.69), nausea or cold sweat (OR 2.02, 1.54-2.65), vertigo or near syncope (OR 1.63, 1.21-2.20), ST-elevation ACS (OR 1.58, 1.21-2.06), increasing age (per year) (OR 1.03, 1.02-1.04), previous history of heart failure (OR 2.48, 1.47-4.26), and distance to the hospital of >5 km (OR 2.0, 1.55-2.59). Those who did not call for an ambulance thought self-transport would be faster or did not believe they were sick enough. CONCLUSIONS: Symptoms, patient characteristics, ACS characteristics, and perceptions and knowledge were all associated with ambulance use in ACS. The fact that knowledge increases ambulance use and the need for behavioral change pose a challenge for health-care professionals.

  • 24. Thuresson, M
    et al.
    Jarlöv, MB
    Lindahl, B
    Svensson, L
    Zedigh, C
    Herlitz, Johan
    [external].
    Symptoms and type of symptom onset in acute coronary syndrome in relation to ST elevation, sex, age, and a history of diabetes.2005In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 150, no 2, p. 234-242Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Various efforts to reduce patient delay in acute coronary syndrome (ACS) have had limited success. One reason might be a misinterpretation of the symptoms of ACS. The aim of this study was therefore to explore the characteristics and severity of symptoms among patients with an ACS in overall terms and in relation to the type of ACS, sex, age, and diabetes. METHODS: A total of 1939 patients at 11 hospitals in Sweden answered a questionnaire containing questions relating to the localization and intensity of symptoms, the presence of associated symptoms, the characteristics and experience of pain/symptoms, and the type of symptom onset. RESULTS: Patients with ST elevation differed from those without by more frequently having associated symptoms. They had higher pain/discomfort intensity and more frequently had pain with abrupt onset reaching maximum intensity within minutes. However, this type of symptom onset was only seen in less than half the patients with ST elevation and only 1 in 5 fulfilled all the criteria usually associated with a severe heart attack. Women differed from men in a few respects. They more frequently reported pain/discomfort in the neck or jaw and back, vomiting, and scored their pain/discomfort slightly higher than men. Differences between age groups were minor and there was no difference between patients with and without diabetes. CONCLUSIONS: The most striking finding was the low proportion of patients with the type of symptoms that are commonly associated with ACS. This is important for the planning of educational campaigns/programs to reduce patient delay.

  • 25. Vargas, A
    et al.
    Doliszny, K
    Herlitz, Johan
    [external].
    Karlsson, T
    McGovern, P
    Brandrup-Wognsen, G
    Luepker, RV
    Characteristics and outcomes among patients undergoing coronary artery bypass grafting in western Sweden and Minneapolis-St Paul USA, Minnesota2001In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 142, no 6, p. 1080-1087Article in journal (Refereed)
    Abstract [en]

    Background The purpose of this study was to compare patient selection, operative factors, and survival for coronary artery bypass grafting (CABG) for coronary heart disease in Minneapolis–St Paul (MSP), Minnesota, and Western Sweden (WS). Methods and Results All patients from WS between 1988 and 1991 (n = 2365) and a 17% random sample of MSP patients between 1985 and 1990 (n = 1659) who underwent CABG surgery were studied. CABG was 3 times greater in MSP. MSP patients had significantly more obesity, cigarette smoking, prior CABG, and prior coronary angioplasty. WS patients had more and longer angina pectoris, better left ventricular function, and waited longer from previous acute MI until CABG. WS patients had more internal mammary artery graphs and a shorter aortic cross-clamp time. At discharge, WS patients received more β-blockers and antiplatelet agents, whereas MSP patients received more calcium channel blockers and digitalis. Age-adjusted mortality rate at 28 days was significantly higher in MSP but not at 3 years. Adjustment for patient characteristics and treatment factors reduced or eliminated these differences. Conclusions Although coronary heart disease rates were higher in WS, age-adjusted CABG rates were 3-fold higher in MSP. Better survival among WS patients was associated with differences in patient selection and clinical and treatment characteristics because MSP patients were more severely ill and at increased risk. Health system characteristics and practice may account for these differences.

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