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  • 1. Adielsson, A
    et al.
    Hollenberg, J
    Karlsson, T
    Lindqvist, J
    Lundin, S
    Silfverstolpe, J
    Svensson, L
    Herlitz, Johan
    University of Borås, School of Health Science.
    Increase in survival and bystander CPR in out-of-hospital shockable arrhythmia: bystander CPR and female gender are predictors of improved outcome. Experiences from Sweden in an 18-year perspective2011In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 97, no 17, p. 1391-1396Article in journal (Refereed)
    Abstract [en]

    Objectives In a national perspective, to describe survival among patients found in ventricular fibrillation or pulseless ventricular tachycardia witnessed by a bystander and with a presumed cardiac aetiology and answer two principal questions: (1) what are the changes over time? and (2) which are the factors of importance? Design Observational register study. Setting Sweden. Patients All patients included in the Swedish Out of Hospital Cardiac Arrest Register between 1 January 1990 and 31 December 2009 who were found in bystander-witnessed ventricular fibrillation with a presumed cardiac aetiology. Interventions Bystander cardiopulmonary resuscitation (CPR) and defibrillation. Main outcome measures Survival to 1 month. Results In all, 7187 patients fulfilled the set criteria. Age, place of out-of-hospital cardiac arrest (OHCA) and gender did not change. Bystander CPR increased from 46% to 73%; 95% CI for OR 1.060 to 1.081 per year. The median delay from collapse to defibrillation increased from 12 min to 14 min (p for trend 0.0004). Early survival increased from 28% to 45% (95% CI 1.044 to 1.065) and survival to 1 month increased from 12% to 23% (95% CI 1.058 to 1.086). Strong predictors of early and late survival were a short interval from collapse to defibrillation, bystander CPR, female gender and OHCA outside the home. Conclusion In a long-term perspective in Sweden, survival to 1 month after ventricular fibrillation almost doubled. This was associated with a marked increase in bystander CPR. Strong predictors of outcome were a short delay to defibrillation, bystander CPR, female gender and place of collapse.

  • 2. Bengtson, A
    et al.
    Herlitz, Johan
    [external].
    Karlsson, T
    Hjalmarson, Å
    Distress correlates with the degree of chest pain: a description of patients awaiting revascularisation1996In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 75, no 3, p. 257-260Article in journal (Refereed)
    Abstract [en]

    AIM: To describe various symptoms other than pain among consecutive patients on the waiting list for possible coronary revascularisation in relation to estimated severity of chest pain. DESIGN: All patients were sent a postal questionnaire for symptom evaluation. SUBJECTS: All patients in western Sweden on the waiting list in September 1990 who had been referred for coronary angiography or coronary revascularisation (n = 904). RESULTS: 88% of the patients reported chest pain symptoms that limited their daily activities to a greater or lesser degree. Various psychological symptoms including anxiety and depression were strongly associated with the severity of pain (P < 0.001), as were sleep disturbances (P < 0.001), and dyspnoea and various psychosomatic symptoms (P < 0.001). Nevertheless only 44% of the patients reported chest pain as the major disruptive symptom, whereas the remaining 56% reported uncertainty about the future, fear, or unspecified symptoms as being the most disturbing. CONCLUSIONS: In a consecutive series of patients on the waiting list for possible coronary revascularisation, half the participants reported that uncertainty and fear were more disturbing than chest pain.

  • 3. Berglin Blohm, M
    et al.
    Hartford, M
    Karlson, BW
    Luepker, RV
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. [external].
    An evaluation of the results of media and educational campaigns designed to shorten the time taken by patients with acute myocardial infarction to decide to go to hospital1996In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 76, no 5, p. 430-434Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the benefits and pitfalls of educational campaigns designed to reduce the delay between the onset of acute myocardial infarction (AMI) and its treatment. METHODS: All seven educational campaigns reported between 1982 and 1994 were evaluated. RESULTS: The impact on delay time ranged from a reduction of patient decision time by 35% to no reduction. One study reported a sustained reduction that resulted in the delay time being halved during the three years after the campaign. The use of ambulances did not increase. Only one study reported that survival was unaffected. There was a temporary increase in the numbers of patients admitted to the emergency department with non-cardiac chest pain in the initial phase of educational campaigns. CONCLUSION: The challenge of shortening the delay between the onset of infarction and the start of treatment remains. The campaigns so far have not been proved to be worthwhile and it is not certain that further campaigns will do better. New media campaigns should be run to establish whether a different type of message is more likely to change the behaviour of people in this life-threatening situation.

  • 4.
    Herlitz, Johan
    et al.
    [external].
    Albertsson, P
    Brandrup-Wognsen, G
    Emanuelsson, H
    Haglid, M
    Hartford, M
    Hjalmarson, Å
    Karlsson, T
    Karlson, BW
    Sandén, W
    Predictors of hospital readmission two years after coronary artery bypass grafting1997In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 77, no 5, p. 437-442Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To determine the clinical factors before, and in association with, coronary artery bypass grafting (CABG) that increase the risk of readmission to hospital in the first two years after surgery. PATIENTS: All patients in western Sweden who had CABG without simultaneous valve surgery between 1 June 1988 and 1 June 1991. METHODS: All patients who were readmitted to hospital were evaluated by postal inquiry and hospital records. RESULTS: A total of 2121 patients were operated on, of whom 2037 were discharged from hospital. Information regarding readmission was missing in four patients, leaving 2033 patients; 44% were readmitted to hospital. The most common reasons for readmission were angina pectoris and congestive heart failure. There were 12 independent significant predictors for readmission: clinical history (a previous history of either congestive heart failure or myocardial infarction, or CABG); acute operation; postoperative complications (time in intensive care unit greater than two days, neurological complications); clinical findings four to seven days after the operation (arrhythmia, systolic murmur equivalent to mitral regurgitation); medication four to seven days after the operation (antidiabetics, diuretics for heart failure, other antiarrhythmics (other than beta blockers, calcium antagonists, and digitalis), and lack of treatment with aspirin). CONCLUSION: 44% of patients were readmitted to hospital two years after CABG. The most common reasons for readmission were angina pectoris and congestive heart failure. Four clinical markers predicted readmission: clinical history; acute operation status; postoperative complications; and clinical findings and medication four to seven days after operation.

  • 5.
    Herlitz, Johan
    et al.
    [external].
    Bång, A
    [external].
    Gunnarsson, J
    Engdahl, J
    Karlson, BW
    Lindqvist, J
    Waagstein, L
    Factors associated with survival to hospital discharge among patients hospitalized alive after out-of-hospital cardiac arrest: change in outcome over 20 years in the community of Göteborg2003In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 89, no 1, p. 25-30Article in journal (Refereed)
    Abstract [en]

    Objective: To describe the change in survival and factors associated with survival during a 20 year period among patients suffering from out of hospital cardiac arrest and being hospitalised alive. Patients: All patients hospitalised alive in the community of Göteborg after out of hospital cardiac arrest between 1 October 1980 and 1 October 2000 were included. Methods: Patient data were prospectively computerised with regard to factors at resuscitation. Data on medical history and hospitalisation were retrospectively recorded. Patients were divided into two groups (the first and second 10 year periods). Setting: Community of Göteborg, Sweden. Results: 5505 patients suffered from cardiac arrest during the time of the survey. Among them 1310 patients (24%) were hospitalised alive. Survival (discharged alive) was 37.5% during the first part and 35.1% during the second part (NS). The following were independent predictors of an increased chance of survival: ventricular fibrillation/tachycardia as the first recorded rhythm (odds ratio (OR) 3.46, 95% confidence interval (CI) 2.36 to 5.07); witnessed arrest (OR 2.50, 95% CI 1.52 to 4.10); bystander initiated cardiopulmonary resuscitation (OR 2.00, 95% CI 1.42 to 2.80); the patient being conscious on admission to hospital (OR 6.43, 95% CI 3.61 to 11.45); sinus rhythm on admission to hospital (OR 1.53, 95% CI 1.12 to 2.10); and treatment with lidocaine in the emergency department (OR 1.64, 95% CI 1.16 to 2.31). The following were independent predictors of a low chance of survival: age > 70 years (median) (OR 0.65, 95% CI 0.47 to 0.88); atropine required in the emergency department (OR 0.35, 95% CI 0.16 to 0.75); and chronic treatment with diuretics before hospital admission (OR 0.59, 95% CI 0.43 to 0.81). Conclusion: There was no improvement in survival over time among initial survivors of out of hospital cardiac arrest during a 20 year period. Major indicators for an increased chance of survival were initial ventricular fibrillation/tachycardia, bystander cardiopulmonary resuscitation, arrest being witnessed, and the patient being conscious on admission. Major indicators for a lower chance were high age, requirement for atropine in the emergency department, and chronic treatment with diuretics before cardiac arrest.

  • 6. Herlitz, Johan
    et al.
    Bång, Angela
    Gunnarsson, J
    Engdahl, J
    Karlsson, BW
    Lindqvist, J
    Waagstein, L
    Factors associated with survival to hospital discharge among patients hospitalized alive after out-of-hospital cardiac arrest and change in outcome over time. Experiences during 20 years in the community of Göteborg2003In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 89, no 1, p. 25-30Article in journal (Refereed)
    Abstract [en]

    Objective: To describe the change in survival and factors associated with survival during a 20 year period among patients suffering from out of hospital cardiac arrest and being hospitalised alive. Patients: All patients hospitalised alive in the community of Göteborg after out of hospital cardiac arrest between 1 October 1980 and 1 October 2000 were included. Methods: Patient data were prospectively computerised with regard to factors at resuscitation. Data on medical history and hospitalisation were retrospectively recorded. Patients were divided into two groups (the first and second 10 year periods). Setting: Community of Göteborg, Sweden. Results: 5505 patients suffered from cardiac arrest during the time of the survey. Among them 1310 patients (24%) were hospitalised alive. Survival (discharged alive) was 37.5% during the first part and 35.1% during the second part (NS). The following were independent predictors of an increased chance of survival: ventricular fibrillation/tachycardia as the first recorded rhythm (odds ratio (OR) 3.46, 95% confidence interval (CI) 2.36 to 5.07); witnessed arrest (OR 2.50, 95% CI 1.52 to 4.10); bystander initiated cardiopulmonary resuscitation (OR 2.00, 95% CI 1.42 to 2.80); the patient being conscious on admission to hospital (OR 6.43, 95% CI 3.61 to 11.45); sinus rhythm on admission to hospital (OR 1.53, 95% CI 1.12 to 2.10); and treatment with lidocaine in the emergency department (OR 1.64, 95% CI 1.16 to 2.31). The following were independent predictors of a low chance of survival: age > 70 years (median) (OR 0.65, 95% CI 0.47 to 0.88); atropine required in the emergency department (OR 0.35, 95% CI 0.16 to 0.75); and chronic treatment with diuretics before hospital admission (OR 0.59, 95% CI 0.43 to 0.81). Conclusion: There was no improvement in survival over time among initial survivors of out of hospital cardiac arrest during a 20 year period. Major indicators for an increased chance of survival were initial ventricular fibrillation/tachycardia, bystander cardiopulmonary resuscitation, arrest being witnessed, and the patient being conscious on admission. Major indicators for a lower chance were high age, requirement for atropine in the emergency department, and chronic treatment with diuretics before cardiac arrest.

  • 7.
    Herlitz, Johan
    et al.
    [external].
    Eek, M
    Holmberg, M
    Engdahl, J
    Holmberg, S
    Characteristics and outcome among patients having out of hospital cardiac arrest at home compared with elsewhere.2002In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 88, no 6, p. 579-582Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To describe the characteristics and outcome of patients who have a cardiac arrest at home compared with elsewhere out of hospital. PATIENTS: Subjects were patients included in the Swedish cardiac arrest registry between 1990 and 1999. The registry covers about 60% of all ambulance organisations in Sweden. METHODS: The study sample comprised patients reached by the ambulance crew and in whom resuscitation was attempted out of hospital. There was no age limit. Crew witnessed cases were excluded. The patients were divided into two groups: cardiac arrest at home and cardiac arrest elsewhere. RESULTS: Among a study population of 24 630 patients the event took place at home in 16 150 (65.5%). Those in whom the arrest took place at home differed from the remainder in that they were older, were more often women, less often had a witnessed cardiac arrest, were less often exposed to bystander cardiopulmonary resuscitation (CPR), were less often found in ventricular fibrillation, and had a longer interval between collapse and call for ambulance, arrival of ambulance, start of CPR, and first defibrillation. Of patients in whom the arrest took place at home, 11.3% were admitted to hospital alive, v 19.4% in the elsewhere group (p < 0.0001); corresponding figures for survival after one month were 1.7% v 6.2% (p < 0.0001). The adjusted odds ratio for survival after one month (at home v not at home; considering age, sex, initial arrhythmia, bystander CPR, aetiology, and whether the arrest was witnessed) was 0.40 (95% confidence interval 0.33 to 0.49; p < 0.0001). CONCLUSIONS: Sixty five per cent of out of hospital cardiac arrests in Sweden occur at home. The patients differed greatly from those with out of hospital cardiac arrests elsewhere, and fewer than 2% were alive after one month. Having an arrest at home was a strong independent predictor of adverse outcome. Further research is needed to identify the reasons for this.

  • 8.
    Herlitz, Johan
    et al.
    [external].
    Engdahl, J
    Svensson, L
    Young, M
    Ängquist, KA
    Holmberg, S
    Can we define patients with no chance of survival after out-of-hospital cardiac arrest?2004In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 90, no 10, p. 1114-1118Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate whether subgroups of patients with no chance of survival can be defined among patients with out-of-hospital cardiac arrest. PATIENTS: Patients in the Swedish cardiac arrest registry who fulfilled the following criteria were surveyed: cardiopulmonary resuscitation (CPR) was attempted; the arrest was not crew witnessed; and patients were found in a non-shockable rhythm. SETTING: Various ambulance organisations in Sweden. DESIGN: Prospective observational study. RESULTS: Among the 16,712 patients who fulfilled the inclusion criteria, the following factors were independently associated with a lower chance of survival one month after cardiac arrest: no bystander CPR; non-witnessed cardiac arrest; cardiac arrest occurring at home; increasing interval between call for and arrival of the ambulance; and increasing age. When these factors were considered simultaneously two groups with no survivors were defined. In both groups patients were found in a non-shockable rhythm, no bystander CPR was attempted, the arrest was non-witnessed, the arrest took place at home. In one group the interval between call for and arrival of ambulance exceeded 12 minutes. In the other group patients were older than 80 years and the interval between call for and arrival of the ambulance exceeded eight minutes. CONCLUSION: Among patients who had an out-of-hospital cardiac arrest and were found in a non-shockable rhythm the following factors were associated with a low chance of survival: no bystander CPR, non-witnessed cardiac arrest, the arrest took place at home, increasing interval between call for and arrival of ambulance, and increasing age. When these factors were considered simultaneously, groups with no survivors could be defined. In such groups the ambulance crew may refrain from starting CPR.

  • 9.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Sjölin, M
    Lindqvist, J
    Ten year mortality in subsets of patients with an acute coronary syndrome2001In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 86, no 4, p. 391-396Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE—To describe the mortality during the subsequent 10 years for subsets of patients hospitalised for suspected acute coronary syndrome. PATIENTS AND METHODS—All patients who were admitted to the emergency department in one hospital during 21 months for chest pain or other symptoms raising suspicion of an acute coronary syndrome were registered. From this baseline population three subgroups were defined among those being hospitalised: patients who developed a Q wave acute myocardial infarction (AMI) (n = 306); patients who developed a non-Q wave AMI (n = 527); and patients who developed confirmed or possible myocardial ischaemia (unstable angina pectoris) (n = 1274). These three groups were compared in terms of 10 year mortality. RESULTS—Patients who developed a non-Q wave AMI had the highest 10 year mortality (70.3%), significantly higher than those who developed a Q wave AMI (60.1%; p = 0.004) and those who had confirmed or possible myocardial ischaemia (50.1%; p < 0.0001). There was no difference between patients with confirmed and those with possible myocardial ischaemia (50.0% and 50.1%, respectively). After correction for dissimilarities in age, sex, and history the adjusted risk ratio for death in patients with a non-Q wave AMI compared with Q wave AMI was 1.01 (95% confidence interval (CI) 0.82 to 1.25). The corresponding risk ratio for death in patients with a non-Q wave AMI compared with confirmed or possible myocardial ischaemia was 1.91 (95% CI 1.64 to 2.23). There was also an imbalance in drug regimens among groups. CONCLUSION—This study shows that in a non-selected population of patients hospitalised with a suspected acute coronary syndrome, the highest risk of death is found in those with a non-Q wave AMI and the lowest in those with confirmed or possible myocardial ischaemia. Thus, patients with a Q wave AMI have a long term mortality risk intermediate between the two fractions defined as having unstable coronary artery disease. However, adjusting these results for age and history of cardiovascular disease eliminated the observed difference in mortality between non-Q wave and Q wave AMI. Furthermore, an imbalance in drug regimens might have affected the outcome.

  • 10.
    Herlitz, Johan
    et al.
    [external].
    Wiklund, I
    Caidahl, K
    Karlson, BW
    Sjöland, H
    Hartford, M
    Haglid, M
    Karlsson, T
    Determinants of an impaired quality of life five years after coronary artery bypass surgery1999In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 81, no 4, p. 342-346Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE—To identify determinants of an inferior quality of life (QoL) five years after coronary artery bypass grafting (CABG). SETTING—University hospital. PARTICIPANTS—Patients from western Sweden who underwent CABG between 1988 and 1991. MAIN OUTCOME MEASURES—Questionnaires for evaluating QoL before CABG and five years after operation. Three different instruments were used: the Nottingham health profile (NHP), the psychological general wellbeing index (PGWI), and the physical activity score (PAS). RESULTS—2121 patients underwent CABG, of whom 310 died during five years' follow up. Information on QoL after five years was available in 1431 survivors (79%). There were three independent predictors for an inferior QoL with all three instruments: female sex, a history of diabetes mellitus, and a history of chronic obstructive pulmonary disease. Multivariate analysis showed that a poor preoperative QoL was a strong independent predictor for an impaired QoL five years after CABG. An impaired QoL was also predicted by previous disease. CONCLUSIONS—Female sex, an impaired QoL before surgery, and other diseases such as diabetes mellitus are independent predictors for an impaired QoL after CABG in survivors five years after operation.

  • 11. Holmgren, C
    et al.
    Bergfeldt, L
    Edvardsson, N
    Karlsson, T
    Lindqvist, J
    Silfverstolpe, J
    Svensson, L
    Herlitz, Johan
    University of Borås, School of Health Science.
    Analysis of initial rhythm, witnessed status and delay to treatment among survivors of out-of-hospital cardiac arrest in Sweden2010In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 96, no 22, p. 1826-1830Article in journal (Refereed)
    Abstract [en]

    Background The characteristics of patients who survive out-of-hospital cardiac arrest (OHCA) are incompletely known. The characteristics of survivors of OHCA during a period of 16 years in Sweden are described. Methods All the patients included in the Swedish Cardiac Arrest Registry between 1992 and 2007 in whom cardiopulmonary resuscitation was attempted and who were alive after 1 month were included in the survey. Results In all, 2432 survivors were registered. Information on initial rhythm at their first ECG recording was missing in 11%. Of the remaining 2165 survivors, 80% had a shockable rhythm and 20% had a non-shockable rhythm. Only a minority with a shockable rhythm among the bystander-witnessed cases were defibrillated within 5 min after cardiac arrest. This proportion did not change during the entry period. Among survivors found in a non-shockable rhythm, the majority were bystander-witnessed cases and a few had a delay from cardiac arrest to ambulance arrival of <5 min. Of all survivors, more women (27%) than men (18%) were found in a non-shockable rhythm (p<0.0001). During the 16 years in which the register was used for this study, the proportion of survivors found in a shockable rhythm did not change significantly. The cerebral performance categories score indicated better cerebral function among patients found in a shockable rhythm than in those found in a non-shockable rhythm. Conclusion Among survivors of OHCA, a substantial proportion was found in a non-shockable rhythm and this occurred more frequently in women than in men. The proportion of survivors found in a shockable rhythm has not changed markedly over time. Survivors found in a shockable rhythm had a better cerebral performance than survivors found in a non-shockable rhythm. The proportion of survivors who were bystander-witnessed and found in a shockable rhythm and defibrillated early is still remarkably low.

  • 12. Holmgren, C
    et al.
    Bergfeldt, L
    Edvardsson, N
    Karlsson, T
    Lindqvist, J
    Silfverstolpe, J
    Svensson, L
    Herlitz, Johan
    [external].
    Analysis of initial rhythm, witnessed status and delay to treatment among survivors of out-of-hospital cardiac arrest in Sweden2010In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 96, p. 1826-1830Article in journal (Refereed)
    Abstract [en]

    Background The characteristics of patients who survive out-of-hospital cardiac arrest (OHCA) are incompletely known. The characteristics of survivors of OHCA during a period of 16 years in Sweden are described. Methods All the patients included in the Swedish Cardiac Arrest Registry between 1992 and 2007 in whom cardiopulmonary resuscitation was attempted and who were alive after 1 month were included in the survey. Results In all, 2432 survivors were registered. Information on initial rhythm at their first ECG recording was missing in 11%. Of the remaining 2165 survivors, 80% had a shockable rhythm and 20% had a non-shockable rhythm. Only a minority with a shockable rhythm among the bystander-witnessed cases were defibrillated within 5 min after cardiac arrest. This proportion did not change during the entry period. Among survivors found in a non-shockable rhythm, the majority were bystander-witnessed cases and a few had a delay from cardiac arrest to ambulance arrival of <5 min. Of all survivors, more women (27%) than men (18%) were found in a non-shockable rhythm (p<0.0001). During the 16 years in which the register was used for this study, the proportion of survivors found in a shockable rhythm did not change significantly. The cerebral performance categories score indicated better cerebral function among patients found in a shockable rhythm than in those found in a non-shockable rhythm. Conclusion Among survivors of OHCA, a substantial proportion was found in a non-shockable rhythm and this occurred more frequently in women than in men. The proportion of survivors found in a shockable rhythm has not changed markedly over time. Survivors found in a shockable rhythm had a better cerebral performance than survivors found in a non-shockable rhythm. The proportion of survivors who were bystander-witnessed and found in a shockable rhythm and defibrillated early is still remarkably low.

  • 13.
    Jonsson, Martin
    et al.
    Center for Resuscitation Science, Department for Medicine, Karolinska Institutet.
    Härkönen, Juho
    Department of Political and Social Sciences, European University Institute.
    Ljungman, Petter
    Institute of Environmental Medicine, Karolinska Institutet.
    Rawshani, Araz
    Department of Molecular and Clinical Medicine, Gothenburg University.
    Nordberg, Per
    Center for Resuscitation Science, Department for Medicine, Karolinska Institutet.
    Svensson, Leif
    Center for Resuscitation Science, Department for Medicine, Karolinska Institutet.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Hollenberg, Jacob
    Center for Resuscitation Science, Department for Medicine, Karolinska Institutet.
    Survival after out-of-hospital cardiac arrest is associated with area-level socioeconomic status.2018In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, article id heartjnl-2018-313838Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Out-of-hospital cardiac arrest (OHCA) is a major cause of death in the Western world. In this study we aimed to investigate the relationship between area-level socioeconomic status (SES) and 30-day survival after OHCA. We hypothesised that high SES at an area level is associated with an improved chance of 30-day survival.

    METHODS: Patients with OHCA in Stockholm County between 1 January 2006 and 31 December 2015 were analysed retrospectively. To quantify area-level SES, we linked the patient's home address to 250 × 250/1000 × 1000 meter grids with aggregated information about income and education. We constructed multivariable logistic regression models in which area-level SES measures were adjusted for age, sex, emergency medical services response time, witnessed status, initial rhythm, aetiology, location and year of cardiac arrest.

    RESULTS: We included 7431 OHCAs. There was significantly greater 30-day survival (p=0.003) in areas with a high proportion of university-educated people. No statistically significant association was seen between median disposable income and 30-day survival. The adjusted OR for 30-day survival among patients in the highest educational quintile was 1.70 (95% CI 1.15 to 2.51) compared with patients in the lowest educational quintile. We found no significant interaction for sex. Positive trend with increasing area-level education was seen in both men and women but the trend was only statistically significant among men (p=0.012) CONCLUSIONS: Survival to 30 days after OHCA is positively associated with the average educational level of the residential area. Area-level income does not independently predict 30-day survival after OHCA.

  • 14. Persson, A
    et al.
    Hartford, M
    Herlitz, Johan
    University of Borås, School of Health Science. [external].
    Karlsson, T
    Omland, T
    Caidahl, K
    Long-term prognostic value of mitral regurgitation in acute coronary syndromes2010In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 96, no 22, p. 1803-1808Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To determine the additional prognostic value of mitral regurgitation (MR) over B-type natriuretic peptide (BNP), left ventricular ejection fraction (LVEF) and clinical characteristics in patients with acute coronary syndromes (ACS). DESIGN: Long-term follow-up in a prospective ACS cohort with Doppler-assessed MR, echocardiographically-determined LVEF and plasma BNP levels by ELISA. SETTING: Single-centre university hospital. PATIENTS: 725 patients with ACS. MAIN OUTCOME MEASURES: Death and readmission for congestive heart failure. RESULTS: During a median follow-up of 98 months, 235 patients (32%) died. Significant MR (grade >1 of 4) was found in 90 patients (12%). In a multivariate model including MR grade >1, LVEF <0.40 and BNP >373 pg/ml (75th percentile), MR was significantly associated with long-term mortality (HR 2.28, 95% CI 1.67 to 3.12; p<0.0001). When also adjusting for conventional risk factors, MR remained significantly associated with mortality (HR 1.53, 95% CI 1.06 to 2.19; p=0.02), as well as with congestive heart failure (HR 2.08, 95% CI 1.29 to 3.35; p=0.003). CONCLUSIONS: MR is common in patients with ACS, provides independent risk information and should be taken into account in the evaluation of the long-term prognosis.

  • 15. Persson, A
    et al.
    Hartford, M
    Herlitz, Johan
    University of Borås, School of Health Science.
    Karlsson, T
    Omland, T
    Caidahl, K
    Long-term prognostic value of mitral regurgitation in acute coronary syndromes2010In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 96, no 22, p. 1803-1808Article in journal (Refereed)
    Abstract [en]

    Objectives To determine the additional prognostic value of mitral regurgitation (MR) over B-type natriuretic peptide (BNP), left ventricular ejection fraction (LVEF) and clinical characteristics in patients with acute coronary syndromes (ACS). Design Long-term follow-up in a prospective ACS cohort with Doppler-assessed MR, echocardiographically-determined LVEF and plasma BNP levels by ELISA. Setting Single-centre university hospital. Patients 725 patients with ACS. Main outcome measures Death and readmission for congestive heart failure. Results During a median follow-up of 98 months, 235 patients (32%) died. Significant MR (grade >1 of 4) was found in 90 patients (12%). In a multivariate model including MR grade >1, LVEF <0.40 and BNP >373 pg/ml (75th percentile), MR was significantly associated with long-term mortality (HR 2.28, 95% CI 1.67 to 3.12; p<0.0001). When also adjusting for conventional risk factors, MR remained significantly associated with mortality (HR 1.53, 95% CI 1.06 to 2.19; p=0.02), as well as with congestive heart failure (HR 2.08, 95% CI 1.29 to 3.35; p=0.003). Conclusions MR is common in patients with ACS, provides independent risk information and should be taken into account in the evaluation of the long-term prognosis.

  • 16. Scheiman, JM
    et al.
    Deveraux, PJ
    Herlitz, Johan
    University of Borås, School of Health Science.
    Katelaris, PH
    Lanas, A
    Veldhuyzen van Zanten, S
    Naucler, E
    Svedberg, LE
    Prevention of peptic ulcers with esomeprazole in patients at risk of ulcer developement treated with low dose acetylsalisylic acid:a randomized controlled trial(OBERON).2011In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 97, no 10, p. 797-802Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To determine whether once-daily esomeprazole 40 mg or 20 mg compared with placebo reduces the incidence of peptic ulcers over 26 weeks of treatment in patients taking low-dose acetylsalicylic acid (ASA) and who are at risk for ulcer development. DESIGN: Multinational, randomised, blinded, parallel-group, placebo-controlled trial. SETTING: Cardiology, primary care and gastroenterology centres (n=240). PATIENTS: Helicobacter pylori-negative patients taking daily low-dose ASA (75-325 mg), who fulfilled one or more of the following criteria: age ≥18 years with history of uncomplicated peptic ulcer; age ≥60 years with either stable coronary artery disease, upper gastrointestinal symptoms and five or more gastric/duodenal erosions, or low-dose ASA treatment initiated within 1 month of randomisation; or age ≥65 years. All patients were ulcer-free at study entry. INTERVENTIONS: Once-daily, blinded treatment with esomeprazole 40 mg, 20 mg or placebo for 26 weeks. MAIN OUTCOME MEASURES: The primary end point was the occurrence of endoscopy-confirmed peptic ulcer over 26 weeks. RESULTS: A total of 2426 patients (52% men; mean age 68 years) were randomised. After 26 weeks, esomeprazole 40 mg and 20 mg significantly reduced the cumulative proportion of patients developing peptic ulcers; 1.5% of esomeprazole 40 mg and 1.1% of esomeprazole 20 mg recipients, compared with 7.4% of placebo recipients, developed peptic ulcers (both p<0.0001 vs placebo). Esomeprazole was generally well tolerated. Conclusions Acid-suppressive treatment with once-daily esomeprazole 40 mg or 20 mg reduces the occurrence of peptic ulcers in patients at risk for ulcer development who are taking low-dose ASA. Clinical trial registration number ClinicalTrials.gov identifier: NCT00441727.

  • 17.
    Zijlstra, Jolande A
    et al.
    Department of Cardiology, Academic Medical Center.
    Koster, Rudolph W
    Department of Cardiology, Academic Medical Center.
    Blom, Marieke T
    Department of Cardiology, Academic Medical Center.
    Lippert, Freddy K
    Emergency Medical Services Copenhagen, University of Copenhagen.
    Svensson, Leif
    Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Kramer-Johansen, Jo
    Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) and Department of Anaesthesiology, Oslo University Hospital.
    Ringh, Mattias
    Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet.
    Rosenqvist, Mårten
    Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet.
    Palsgaard Møller, Thea
    Emergency Medical Services Copenhagen, University of Copenhagen.
    Tan, Hanno L
    Department of Cardiology, Academic Medical Center.
    Beesems, Stefanie G
    Department of Cardiology, Academic Medical Center.
    Hulleman, Michiel
    Department of Cardiology, Academic Medical Center.
    Claesson, Andreas
    Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet.
    Folke, Fredrik
    Emergency Medical Services Copenhagen, University of Copenhagen.
    Olasveengen, Theresa Mariero
    Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) and Department of Anaesthesiology.
    Wissenberg, Mads
    Department of Cardiology, Copenhagen University Hospital Gentofte.
    Hansen, Carolina Malta
    Department of Cardiology, Copenhagen University Hospital Gentofte.
    Viereck, Soren
    Emergency Medical Services Copenhagen, University of Copenhagen.
    Hollenberg, Jacob
    Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet.
    Different defibrillation strategies in survivors after out-of-hospital cardiac arrest.2018In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 104, no 23, p. 1929-1936Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In the last decade, there has been a rapid increase in the dissemination of automated external defibrillators (AEDs) for prehospital defibrillation of out-of-hospital cardiac arrest patients. The aim of this study was to study the association between different defibrillation strategies on survival rates over time in Copenhagen, Stockholm, Western Sweden and Amsterdam, and the hypothesis was that non-EMS defibrillation increased over time and was associated with increased survival.

    METHODS: We performed a retrospective analysis of four prospectively collected cohorts of out-of-hospital cardiac arrest patients between 2008 and 2013. Emergency medical service (EMS)-witnessed arrests were excluded.

    RESULTS: A total of 22 453 out-of-hospital cardiac arrest patients with known survival status were identified, of whom 2957 (13%) survived at least 30 days postresuscitation. Of all survivors with a known defibrillation status, 2289 (81%) were defibrillated, 1349 (59%) were defibrillated by EMS, 454 (20%) were defibrillated by a first responder AED and 429 (19%) were defibrillated by an onsite AED and 57 (2%) were unknown. The percentage of survivors defibrillated by first responder AEDs (from 13% in 2008 to 26% in 2013, p<0.001 for trend) and onsite AEDs (from 14% in 2008 to 30% in 2013, p<0.001 for trend) increased. The increased use of these non-EMS AEDs was associated with the increase in survival rate of patients with a shockable initial rhythm.

    CONCLUSION: Survivors of out-of-hospital cardiac arrest are increasingly defibrillated by non-EMS AEDs. This increase is primarily due to a large increase in the use of onsite AEDs as well as an increase in first-responder defibrillation over time. Non-EMS defibrillation accounted for at least part of the increase in survival rate of patients with a shockable initial rhythm.

  • 18. Ågård, A
    et al.
    Herlitz, Johan
    University of Borås, School of Health Science. [external].
    Hermerén, G
    Obtaining informed consent from patients in the early phase of acute myocardial infarction: physicians’ experiences and attitudes2004In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 90, no 2, p. 208-210Article in journal (Refereed)
    Abstract [en]

    It is possible to question whether patients suffering from the early phase of an acute myocardial infarction (AMI) are able to give free and informed consent and whether or not it is ethically defensible to include them—those patients suffering from more severe symptoms, in particular—in research projects. In fact, it has been shown that a reasonable number of patients who have given their consent in this situation are only able to recall very little of the information they received about the study and that only a minority read through the consent form before signing it. The aim of this study is to determine how physicians, who have been involved in including patients in intervention trials in the early phase of their AMIs, experienced the informed consent procedures. In our view, data obtained from those people who are actually confronted by the research subjects and who are responsible for carrying out the consent procedure should also be taken into account, when the most appropriate ways of including these patients in studies are discussed. To our knowledge no survey of physicians relating to this issue has previously been undertaken.

  • 19. Ågård, A
    et al.
    Hermerén, G
    Herlitz, Johan
    [external].
    Informed consent: Are there ethically justified conditions for exceptions?2002In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 87, no 2, p. 105-106Article in journal (Other (popular science, discussion, etc.))
    Abstract [en]

    Are good clinical practice and informed consent inseparable? This depends, to some extent at least, on what is meant by “inseparable”. Does this refer to a logical relation, on the assumption that “good clinical practice” by definition includes informed consent, to an empirical generalisation about current medical practice, or a normative statement about how it ought to be? Different arguments pro and contra are relevant depending on whether the statement is interpreted as a logical statement, an empirical generalisation, or as a normative statement.We do not dispute the moral ground for the requirement of informed consent in general,1 and we agree with the statement that “the clinical duty to obtain proper informed consent is now widely believed to be an essential component of good clinical practice”. Neither do we dispute that improved training in communication skills and more time for doctors to communicate with their patients would be a good thing—and probably make more patients participate in the decision process.2What we wished to do in our paper3 was to discuss whether there might not be situations in which exceptions from the general requirement of informed consent would be acceptable. We hope that such a debate could help to define stringent and precise conditions when such exceptions could be morally and legally acceptable. One general assumption we share is the idea that such an exception is reasonable, if insisting on the requirement of informed consent causes more harm than good. In its turn, this presupposes a discussion of criteria of harm and benefit and who should decide about the relative magnitude of harm and benefit. Verification after the event by the patients in question could in certain situations be worth investigating. If there is a verification by the patients concerned, in the sense that they afterwards confirm that they think that an exception from the general requirement was ethically justified, then the concept of an exception from the general main rule is supported by referring to what the patients themselves want. If autonomy is taken seriously, references to what the patients say they want cannot be dismissed lightly.Our ambition with the study published3 was not to suggest any radical changes regarding the informed consent procedure when a patient is suffering from an acute myocardial infarction and is a potential research subject, nor to draw any general conclusions from the results obtained. Instead, we wanted to elucidate the possible problems and disadvantages associated with the process of obtaining informed consent in this particular situation. Primarily we wanted to stimulate the debate on the following two issues:1. Does a patient in the midst of a life crisis have to put his/her signature on a consent form in order to be included in an intervention trial?2. Are there ethically justified alternatives to informed consent when a researcher wants to include a patient in a study, who is not capable of giving a free and informed consent in research?We stated: “All possible measures to increase the autonomy of the patients under the prevailing circumstances should be carried out”. Thus, we do not suggest that all patients with acute myocardial infarction should be treated as incompetent. However, what we have tried to do in our study is to bring forth and highlight empirical evidence, which seems to show that in this particular situation some patients do not have the capacity to give a true informed consent for study participation.Professor Doyal adds another argument, to the effect that even if the patients afterwards do not remember anything, this does not reduce the moral importance of relevant information disclosure. The main question is what is meant by “relevant information disclosure”, and who decides what this is. Suppose (a) that it is left to the patient to decide what is relevant information disclosure, (b) that additional information does not change the decision of the patient, and (c) they do not want this additional information, which conclusion should be drawn from this?We claim that it is time to adjust the informed consent procedure to the patients' capacity in this particular situation. Moreover, the patient should be spared the “actual demand” of signing the consent form in the early phase of an acute myocardial infarction.

  • 20. Ågård, A
    et al.
    Hermerén, G
    Herlitz, Johan
    [external].
    Patients' experiences of intervention trials treatment of myocardial infarction: is it time to adjust the informed consent procedure to the patient's capacity?2001In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 86, no 6, p. 632-637Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE—To investigate how patients included in trials on treatment in the early phase of acute myocardial infarction experience the consent procedure. DESIGN—A combined qualitative and quantitative interview concerning the patients' knowledge of the trial, their feelings about being asked to participate, and their attitudes towards the consent procedure. SETTING—Tertiary referral centre. PATIENTS—31 patients who had given written informed consent for their participation in randomised intervention trials of acute myocardial infarction. RESULTS—The patients interviewed had only fragmentary knowledge about the trial they were involved in. Most considered that reading and signing a consent form was an unwanted or unnecessary procedure. Instead, they would have preferred to have been given concise verbal information about the study. Most were willing to allow a physician to decide for them in the event of their being too ill to be asked about their participation. CONCLUSIONS—Patients who are asked to participate in intervention trials in the early phase of acute myocardial infarction often appear to lack sufficient knowledge to reach an autonomous choice. There were problems and disadvantages associated with the process of obtaining written informed consent in this particular situation, especially regarding the need for the patient to sign a consent form during the acute phase of the disease.

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