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  • 1.
    Adielsson, Anna
    et al.
    Sahlgrenska University Hospital.
    Aune, Solveig
    Sahlgrenska University Hospital.
    Ravn-Fischer, Annica
    Sahlgrenska University Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Measurements of time intervals after in-hospital cardiac arrest give important information but can be further improved.2016In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754Article in journal (Refereed)
  • 2.
    Adielsson, Anna
    et al.
    Sahlgrenska University Hospital.
    Karlsson, Thomas
    University of Gothenburg.
    Aune, Solveig
    Sahlgrenska University Hospital.
    Lundin, Stefan
    Sahlgrenska University Hospital.
    Hirlekar, Geir
    Sahlgrenska University Hospital.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Ravn-Fischer, Annica
    Sahlgrenska University Hospital.
    A 20-year perspective of in hospital cardiac arrest: Experiences from a university hospital with focus on wards with and without monitoring facilities.2016In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 216, p. 194-199Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Knowledge about change in the characteristics and outcome of in hospital cardiac arrests (IHCAs) is insufficient.

    AIM: To describe a 20year perspective of in hospital cardiac arrest (IHCA) in wards with and without monitoring capabilities.

    SETTINGS: Sahlgrenska University Hospital (800 beds). The number of beds varied during the time of survey from 850-746 TIME: 1994-2013.

    METHODS: Retrospective registry study. Patients were assessed in four fiveyear intervals.

    INCLUSION CRITERIA: Witnessed and nonwitnessed IHCAs when cardiopulmonary resuscitation (CPR) was attempted.

    EXCLUSION CRITERIA: Age below 18years.

    RESULTS: In all, there were 2340 patients with IHCA during the time of the survey. 30-Day survival increased significantly in wards with monitoring facilities from 43.5% to 55.6% (p=0.002) for trend but not in wards without such facilities (p=0.003 for interaction between wards with/without monitoring facilities and time period). The CPC-score among survivors did not change significantly in any of the two types of wards. In wards with monitoring facilities there was a significant reduction of the delay time from collapse to start of CPR and an increase in the proportion of patients who were defibrillated before the arrival of the rescue team. In wards without such facilities there was a significant reduction of the delay from collapse to defibrillation. However, the latter observation corresponds to a marked decrease in the proportion of patients found in ventricular fibrillation.

    CONCLUSION: In a 20year perspective the treatment of in hospital cardiac arrest was characterised by a more rapid start of treatment. This was reflected in a significant increase in 30-day survival in wards with monitoring facilities. In wards without such facilities there was a decrease in patients found in ventricular fibrillation.

  • 3. Bengtsson, A
    et al.
    Karlsson, T
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare. [external].
    On the waiting list for possible coronary revascularisation. Symptoms relief during the first year and association between quality of life and the very long-term mortality risk2008In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 123, no 3, p. 271-276Article in journal (Refereed)
    Abstract [en]

    AIM: To describe: a/ the improvement in quality of life (QoL) among patients on the waiting list for coronary revascularisation and b/ the association between QoL and very long-term mortality. PATIENTS: All patients on the waiting list for possible coronary revascularisation in western Sweden during one week in September 1990. METHODS: QoL was assessed at the start of the survey and one year later among patients who both were and were not revascularised. Survival data were gathered for the subsequent 14 years. RESULTS: From the start, 883 patients were evaluated in the survey. Among patients who were revascularised, an improvement was seen in all the aspects of QoL that were studied during the first year as compared with patients who were not revascularised, in whom only minor changes in QoL were seen during the first year. After one year, there were seven aspects of QoL which were significantly associated with the risk of death during the subsequent 14 years, when adjusting for age, sex, previous history and extent of coronary artery disease. They were: tiredness (OR=1.4), weakness (OR=1.5), lack of energy (OR=1.5), inability to react (OR=1.7), use of sedatives (OR=3.2), dyspnea when dressing (OR=2.1) and chest pain when dressing (OR=1.9). CONCLUSION: Among patients on the waiting list for possible coronary revascularisation, there was a marked improvement in QoL among those who were revascularised. In a variety of aspects of QoL, an association with the very long-term risk of death was observed.

  • 4. Bengtsson, I
    et al.
    Karlson, B
    Herlitz, Johan
    University of Borås, School of Health Science.
    Haglid Evander, M
    Währborg, P
    A 14-year follow-up study of chest pain patients including stress hormones and mental stress at index event2012In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 154, no 3, p. 306-311Article in journal (Refereed)
    Abstract [en]

    Background Knowledge of long-term outcome in chest pain patients is limited. We reinvestigated patients who 14 years earlier had visited the emergency department due to chest pain, and were discharged without hospitalization. Extensive examinations were made at that time on 484 patients including full medical history, exercise test, a battery of stress questions and stress hormone sampling. Methods From a previously conducted chest pain study patients still alive after 14 years were approached. Hospitalization or deaths with a diagnosis of ischemic heart disease or cerebrovascular disease were used as end point. Results During the follow-up period 24 patients had died with a diagnosis of ischemic heart or cerebrovascular disease, and 50 patients had been given such a diagnosis at hospital discharge. Age (OR 1.12, CI 1.06–1.19), previous history of angina pectoris (OR 9.69, CI 2.06–71.61), pathological ECG at emergency department visit (OR 3.27, CI 1.23–8.67), hypertension (OR 5.03, CI 1.90–13.76), smoking (OR 3.04, CI 1.26–7.63) and lipid lowering medication (OR 14.9, CI 1.60–152.77) were all associated with future ischemic heart or cerebrovascular events. Noradrenalin levels were higher in the event group than in the non-event group, mean (SD) 2.44 (1.02) nmol/L versus 1.90 (0.75) nmol/L. When noradrenalin was included in the regression model high maximal exercise capacity was protective of an event (OR 0.986, CI 0.975–0.997). Conclusion In chest pain patients previous history of angina pectoris, hypertension, smoking, pathological ECG at primary examination, and age were the main risk factors associated with future cardiovascular or cerebrovascular events.

  • 5. Berglind, L
    et al.
    Karlsson, T
    Hirlekar, G
    Albertsson, P
    Herlitz, J
    University of Borås, School of Health Science.
    Ravn-Fischer, A
    Delay and inequality in treatment of the elderly with suspected acute coronary syndrome2014In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 176, no 3, p. 946-950Article in journal (Refereed)
    Abstract [en]

    BACKGROUND/OBJECTIVES: The aim of this study is to determine differences between elderly patients (≥80 years) and younger patients with suspected acute coronary syndrome (ACS) regarding delay times before diagnostic tests and treatments. METHODS: All patients with chest pain who were admitted to a hospital in the Gothenburg area were included consecutively over a 3-month period. They were divided into an elderly group (≥80 years) and a reference group (<80 years). Previous medical history, ECG findings, treatments, diagnostic tests, and delay times were registered. RESULTS: Altogether, 2588 patients were included (478 elderly and 2110 reference). There were no significant differences in delay time to hospital ward admission, to first medical therapy with aspirin, or to investigation with coronary angiography (CA) between the two groups. The elderly patients had a significantly shorter median time from first medical contact to first ECG (12 vs. 14 min, p=0.002) but after adjustment for confounding factors, especially mode of transport, the opposite was found to be the case (p=0.002). Elderly hospitalized patients with ACS were less often investigated with CA (44% vs. 89%, p<0.0001) and received less medical treatment with P2Y12 antagonists and lipid lowering drugs. CONCLUSIONS: Elderly individuals with chest pain could not be shown to have a delay to hospital admission compared to their younger counterparts. Nevertheless, higher age was associated with a longer time to first ECG. The elderly patients received less active therapy, and fear of age-related side effects might explain this difference.

  • 6. Bäck, M
    et al.
    Cider, Å
    Gillström, J
    Herlitz, J
    University of Borås, School of Health Science.
    Physical activity in relation to cardiac risk markers in secondary prevention of coronary artery disease2013In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 168, no 1, p. 478-483Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The relationship between physical activity and cardiac risk markers in secondary prevention for patients with coronary artery disease (CAD) is uncertain. The aims of the study were therefore to examine the level of physical activity in patients with CAD, and to investigate the association between physical activity and cardiac risk markers. METHODS: In total, 332 patients, mean age, 65 ± 9.1 years, diagnosed with CAD at a university hospital were included in the study 6 months after their cardiac event. Physical activity was measured with a pedometer (steps/day) and two questionnaires. Investigation of cardiac risk markers included serum lipids, oral glucose-tolerance test, twenty-four hour blood pressure and heart rate monitoring, smoking, body-mass index (BMI), waist-hip ratio, and muscle endurance. The study had a cross-sectional design. RESULTS: The patients performed a median of 7,027 steps/day. After adjustment for confounders, statistically significant correlations between steps/day and risk markers were found with regard to; high-density lipoprotein cholesterol (HDL-C) (r=0.19, p<0.001), muscle endurance measures (r ranging from 0.19 to 0.25, p=0.001 or less) triglycerides (r=-0.19, p<0.001), glucose-tolerance (r=-0.23, p<0.001), BMI (r=-0.21, p<0.001), 24-h heart rate recording during night (r=-0.17, p=0.004), and average 24-h heart rate (r=-0.13, p=0.02). CONCLUSIONS: A relatively high level of physical activity was found among patients with CAD. There was a weak, but significant, association between pedometer steps/day and HDL-C, muscle endurance, triglycerides, glucose-tolerance, BMI and 24-h heart rate, indicating potential positive effects of physical activity on these parameters. However, before clinical implications can be formed, more confirmatory data are needed.

  • 7. Bäck, Maria
    et al.
    Cider, Åsa
    Herlitz, Johan
    University of Borås, School of Health Science.
    Lundberg, Mari
    Jansson, Bengt
    The impact on kinesiophobia (fear of movement) by clinical variables for patients with coronary artery disease2013In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 167, no 2, p. 391-397Article in journal (Refereed)
    Abstract [en]

    Background: The impact on kinesiophobia (fear of movement) for patients with coronary artery disease (CAD) is not known. The aims were to describe the occurrence of kinesiophobia in patients with CAD, and to investigate the influence on kinesiophobia by clinical variables. Material and methods: In total, 332 patients, mean age, 65±9.1 years diagnosed with CAD at a university hospital were included in the study. The Tampa Scale for Kinesiophobia Heart (TSK-SV Heart) was used to assess kinesiophobia. Comparisons between high versus low levels of kinesiophobia were measured for each variable. Binary logistic regression analyses were performed with a high level of kinesiophobia (TSK-SV Heart >37) as dependent variable, and with the observed variables as independent. The study had an exploratory, cross-sectional design. Results: A high level of kinesiophobia was found in 20% of the patients. The following variables decreased the odds ratio (OR) for a high level of kinesiophobia: Attending cardiac rehabilitation (yes vs no; -56.7%), level of physical activity (medium vs high; -80.2%), Short Form-36: general health (-4,3%), physical functioning (-1.8%). Two variables increased the OR for a high level of kinesiophobia: heart failure as complication at hospital (yes vs no; 418.7%), anxiety (19.2%). Previous heart failure (yes vs no) was unexpectedly found to reduce kinesiophobia (-88.3%) due to suppression. Conclusions: Several important clinical findings with impact on rehabilitation and prognosis for patients with CAD were found to be associated with a high level of kinesiophobia. Therefore, kinesiophobia needs to be considered in secondary prevention for patients with CAD.

  • 8.
    Bång, A
    et al.
    University of Borås, School of Health Science.
    Grip, L
    Herlitz, Johan
    University of Borås, School of Health Science.
    Kihlgren, S
    Karlsson, T
    Caidahl, K
    Hartford, M
    Lower mortality after prehospital recognition and treatment followed by fast tracking to coronary care compared with admittance via emergency department in patients with ST-elevation myocardial infarction.2008In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 129, no 3, p. 325-332Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To describe the short-and long-term outcome among patients with an ST-elevation myocardial infarction (STEMI), assessed and treated by the emergency medical services (EMS) in relation to whether they were fast tracked to a coronary care unit (CCU) or admitted via the emergency department (ED). METHODS: Consecutive patients admitted to the CCU at Sahlgrenska University Hospital with ST elevations on admission ECG were analysed with respect to whether they by the EMS were fast tracked to the CCU or the adjacent coronary angiography laboratory (direct CCU group; n=261) or admitted via the ED (ED group; n=235). RESULTS: Whereas the two groups were similar with regard to age and previous history, those who were fast tracked to CCU were more frequently than the ED patients diagnosed and treated as STEMI already prior to hospital admission. Reperfusion therapy was more commonly applied in the CCU group compared with the ED group (90% vs 67%; <0.0001). The delay times (median) were shorter in the direct CCU group than in the ED group, with a difference of 10 min from the onset of symptoms to arrival in hospital and 25 min from hospital arrival to the start of reperfusion treatment (primary PCI or in-hospital fibrinolysis). Patients in the direct CCU group had lower 30-day mortality (7.3% vs. 15.3%; p=0.004), as well as late mortality (>30 days to five years) (11.6% vs. 20.6%; p=0.008). CONCLUSION: Among patients transported with ambulance due to STEMI there was a significant association between early recognition and treatment followed by fast tracking to the CCU and long term survival. A higher rate of and a more rapid revascularisation were probably of significant importance for the outcome.

  • 9. Bång, A
    et al.
    Herlitz, Johan
    University of Borås, School of Health Science.
    Grip, L
    Caidahl, K
    Karlsson, T
    Kihlgren, S
    Hartford, M
    The relative influence of age, previous history and therapeutic strategies prior to hospital admission among ambulance transported patients with ST-elevation myocardial infarction.2009In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 136, no 2, p. 213-214Article in journal (Refereed)
    Abstract [en]

    Among 388 patients with ST-elevation and myocardial infarction admitted to hospital with ambulance, we found the following to be independent predictors of the short term (30 days) mortality rate; Age and treatment with aspirin prior to hospital admission. The following were associated with long term (30 days to 5 years) mortality rate; age, a history of diabetes and fast track to CCU.

  • 10.
    Bång, Angela
    et al.
    University of Borås, School of Health Science.
    Grip, Lars
    Herlitz, Johan
    University of Borås, School of Health Science.
    Kihlgren, Stefan
    Karlsson, Thomas
    Caidahl, Kenneth
    Hartford, Marianne
    Lower mortality after prehospital recognition and treatment by fast tracking to coronary care compared with admittance via emergency department in patients with ST-elevation myocardial infarction2008In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 129, no 3, p. 325-332Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To describe the short-and long-term outcome among patients with an ST-elevation myocardial infarction (STEMI), assessed and treated by the emergency medical services (EMS) in relation to whether they were fast tracked to a coronary care unit (CCU) or admitted via the emergency department (ED). METHODS: Consecutive patients admitted to the CCU at Sahlgrenska University Hospital with ST elevations on admission ECG were analysed with respect to whether they by the EMS were fast tracked to the CCU or the adjacent coronary angiography laboratory (direct CCU group; n=261) or admitted via the ED (ED group; n=235). RESULTS: Whereas the two groups were similar with regard to age and previous history, those who were fast tracked to CCU were more frequently than the ED patients diagnosed and treated as STEMI already prior to hospital admission. Reperfusion therapy was more commonly applied in the CCU group compared with the ED group (90% vs 67%; <0.0001). The delay times (median) were shorter in the direct CCU group than in the ED group, with a difference of 10 min from the onset of symptoms to arrival in hospital and 25 min from hospital arrival to the start of reperfusion treatment (primary PCI or in-hospital fibrinolysis). Patients in the direct CCU group had lower 30-day mortality (7.3% vs. 15.3%; p=0.004), as well as late mortality (>30 days to five years) (11.6% vs. 20.6%; p=0.008). CONCLUSION: Among patients transported with ambulance due to STEMI there was a significant association between early recognition and treatment followed by fast tracking to the CCU and long term survival. A higher rate of and a more rapid revascularisation were probably of significant importance for the outcome.

  • 11.
    Bång, Angela
    et al.
    University of Borås, School of Health Science.
    Herlitz, Johan
    University of Borås, School of Health Science.
    Grip, L
    Caidahl, K
    Karlsson, T
    Kihlgren, S
    Hartford, M
    The Relative Influence of Age, Previous History and Therapeutic Strategies Prior to Hospital Admission among Ambulance Transported Patients with ST-elevation Myocardial Infarction2009In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 136, no 2, p. 213-214Article in journal (Refereed)
    Abstract [en]

    Among 388 patients with ST-elevation and myocardial infarction admitted to hospital with ambulance, we found the following to be independent predictors of the short term (30 days) mortality rate; Age and treatment with aspirin prior to hospital admission. The following were associated with long term (30 days to 5 years) mortality rate; age, a history of diabetes and fast track to CCU.

  • 12.
    Bång, Angela
    et al.
    University of Borås, School of Health Science.
    Herlitz, Johan
    University of Borås, School of Health Science.
    Grip, Lars
    Caidahl, Kenneth
    Karlsson, Thomas
    Kihlgren, Stefan
    Hartford, Marianne
    The relative influence of age, previous history and therapeutic strategies prior to hospital admission among ambulance transported patients with ST-elevation myocardial infarction2008In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 136, no 2, p. 213-214Article in journal (Refereed)
  • 13. Caidahl, K
    et al.
    Hartford, M
    Karlsson, T
    Herlitz, J
    University of Borås, School of Health Science.
    Pettersson, K
    de Faire, U
    Frostegård, J
    IGM-phosphorylcholine autoantibodies and outcome in acute coronary syndromes.2013In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 167, no 2, p. 464-469Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Antibodies against proinflammatory phosphorylcholine (anti-PC) seem to be protective and reduce morbidity. We sought to determine whether low levels of immunoglobulin-M (IgM) autoantibodies against PC add prognostic information in acute coronary syndromes (ACS). METHODS: IgM anti-PC titers were measured in serum obtained within 24h of admission from 1185 ACS patients (median age 66 years, 30% women). We evaluated major acute cardiovascular events (MACE) and all-cause mortality short--(6 months), intermediate--(18 months) and long--(72 months) terms. RESULTS: Low anti-PC titers were associated with MACE and all-cause mortality at all follow-up times. After adjusting for clinical variables, plasma troponin-I, proBNP and CRP levels, associations remained at all times with MACE, short and intermediate terms also with all-cause mortality. With anti-PC titers below median, adjusted hazard ratios at 18months were for MACE 1.79 (95% confidence interval [CI]: 1.31 to 2.44; p=0.0002) and for all-cause mortality 2.28 (95% CI: 1.32 to 3.92; p=0.003). Anti-PC and plasma CRP were unrelated and added to risk prediction. CONCLUSIONS: Serum IgM anti-PC titers provide prognostic information above traditional risk factors in ACS. The ease of measurement and potential therapeutic perspective indicate that it may be a valuable novel biomarker in ACS.

  • 14. Dellborg, M
    et al.
    Herlitz, Johan
    [external].
    Risenfors, M
    Electrocardiographic assessment of infarct size: Comparison between QRS scoring of 12-lead electrocardiography and dynamic vectorcardiography1993In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, ISSN 0167-5273, Vol. 40, no 2, p. 167-172Article in journal (Refereed)
    Abstract [en]

    Myocardial infarct size is one of the most important predictors of prognosis in patients suffering an acute myocardial infarction. It can be assessed by enzymatic and electrocardiographic methods. The present report compares dynamic vectorcardiographic monitoring, serial plasma enzyme activity measurements and QRS scoring according to Palmeri as techniques for infarct size estimation. We report the results from 74 patients with acute myocardial infarction, who participated in a randomized trial of treatment with alteplase. A good correlation was found between myocardial infarct size by estimation from enzymatic measurement and from dynamic vectorcardiography. Dynamic vectorcardiography correlated more closely with enzymatically estimated infarct size in patients with Q-wave infarction, regardless of infarct location, than did QRS scoring of the conventional 12-lead electrocardiogram. Furthermore, dynamic vectorcardiography requires no time-consuming analysis and can be used for on-line monitoring of patients with ongoing infarction to estimate the size of an acute infarction while it is developing.

  • 15. Gellerstedt, Martin
    et al.
    Rawshani, Nina
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Bång, Angela
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Gelang, Carita
    Andersson, Jan-Otto
    Larsson, Anna
    Rawshani, Araz
    Could prioritisation by emergency medicine dispatchers be improved by using computer-based decision support? A cohort of patients with chest pain.2016In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 220, p. 734-738Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: To evaluate whether a computer-based decision support system could improve the allocation of patients with acute coronary syndrome (ACS) or a life-threatening condition (LTC). We hypothesised that a system of this kind would improve sensitivity without compromising specificity.

    METHODS: A total of 2285 consecutive patients who dialed 112 due to chest pain were asked 10 specific questions and a prediction model was constructed based on the answers. We compared the sensitivity of the dispatchers' decisions with that of the model-based decision support model.

    RESULTS: A total of 2048 patients answered all 10 questions. Among the 235 patients with ACS, 194 were allocated the highest prioritisation by dispatchers (sensitivity 82.6%) and 41 patients were given a lower prioritisation (17.4% false negatives). The allocation suggested by the model used the highest prioritisation in 212 of the patients with ACS (sensitivity of 90.2%), while 23 patients were underprioritised (9.8% false negatives). The results were similar when the two systems were compared with regard to LTC and 30-day mortality. This indicates that computer-based decision support could be used either for increasing sensitivity or for saving resources. Three questions proved to be most important in terms of predicting ACS/LTC, [1] the intensity of pain, [2] the localisation of pain and [3] a history of ACS.

    CONCLUSION: Among patients with acute chest pain, computer-based decision support with a model based on a few fundamental questions could improve sensitivity and reduce the number of cases with the highest prioritisation without endangering the patients.

  • 16.
    Glantz, Helena
    et al.
    Skaraborg Hospital, Lidköping.
    Johansson, Magnus C
    Sahlgrenska Academy, University of Gothenburg.
    Thunström, Erik
    Sahlgrenska Academy, University of Gothenburg.
    Guron, Cecilia Wallentin
    Sahlgrenska Academy, University of Gothenburg.
    Uzel, Harun
    Sahlgrenska University Hospital.
    Saygin, Mustafa
    Süleyman Demirel University, Isparta, Turkey.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Peker, Yüksel
    Sahlgrenska Academy, University of Gothenburg.
    Effect of CPAP on diastolic function in coronary artery disease patients with nonsleepy obstructive sleep apnea: A randomized controlled trial.2017In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 241, p. 12-18, article id S0167-5273(16)34469-2Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Obstructive sleep apnea (OSA) has been associated with worse diastolic function in patients with coronary artery disease (CAD). This analysis determined whether continuous positive airway pressure (CPAP) treatment would improve diastolic function in CAD patients with nonsleepy OSA.

    METHODS: Between December 2005 and November 2010, 244 revascularized CAD patients with nonsleepy OSA (apnea-hypopnea index (AHI) ≥15/h, Epworth Sleepiness Scale [ESS] score<10) were randomly assigned to CPAP or no-CPAP. Echocardiographic measurements were obtained at baseline, and after 3 and 12months.

    RESULTS: A total of 171 patients with preserved left ventricular ejection fraction (≥50%), no atrial fibrillation or severe valve abnormalities, and technically adequate echocardiograms at baseline and follow-up visits were included (CPAP, n=87; no-CPAP, n=84). In the intention-to-treat analysis, CPAP had no significant effect on echocardiographic parameters of mild (enlarged left atrium or decreased diastolic relaxation velocity) or worse (increased E/é filling index [presumed elevated left ventricular filling pressure]) diastolic function. Post-hoc analysis revealed a significant association between CPAP usage for ≥4h/night and an increase in diastolic relaxation velocity at 12months' follow-up (odds ratio 2.3, 95% confidence interval 1.0-4.9; p=0.039) after adjustment for age, sex, body mass index, and left atrium diameter at baseline.

    CONCLUSIONS: CPAP did not improve diastolic dysfunction in CAD patients with nonsleepy OSA. However, good CPAP adherence was significantly associated with an increase in diastolic relaxation velocity after one year.

  • 17. Hartford, M
    et al.
    Wiklund, O
    Mattsson-Hultén, L
    Perers, E
    Person, A
    Herlitz, Johan
    [external].
    Hurt-Camejo, E
    CRP, interleukin-6, secretory phospholipase A2 group IIA, and intercellular adhesion molecule-1 during the early phase of acute coronary syndromes and long-term follow-up.2006In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 108, no 1, p. 55-62Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: The objectives of this study were to examine the time course of the inflammatory response in acute coronary syndromes (ACS) and to assess the markers of inflammation and their relation to disease severity. METHODS: We prospectively studied 134 patients with ACS who survived for at least 30 months. The patients were divided into four groups: acute myocardial infarction (MI) with (n=54) or without (n=46) ST-segment elevation and unstable angina with (n=14) or without (n=20) increased risk. Plasma levels of C-reactive protein (CRP), interleukin-6 (IL-6), secretory phospholipase A2 group IIA (sPLA2-IIA), and intercellular adhesion molecule-1 (ICAM-1) were measured on days 1 and 4 and after 3 and 30 months. RESULTS: The highest levels of CRP and sPLA2-IIA were seen on day 4 but for IL-6 on day 1. These three markers, but not ICAM-1, were significantly related to disease severity, CKMB, and ejection fraction. Patients in Killip class II-IV had higher levels than those in Killip class I. The individual acute-phase responses correlated with marker levels at 3 and 30 months. ICAM-1 correlated with the development of congestive heart failure. CONCLUSIONS: In ACS there seems to be an individual predisposition to inflammatory response. Plasma IL-6 is the first marker to rise, while sPLA2-IIA and CRP peak later. All three markers, especially CRP, may discriminate between MI and non-MI. ICAM-1 seems to reflect other aspects of the inflammatory processes than the other markers. The results emphasize the complexity of the inflammatory response in ACS and stress the need for further studies involving multiple markers.

  • 18. Henriksson, C
    et al.
    Larsson, M
    Arnetz, J
    Berglin-Jarlov, M
    Herlitz, Johan
    University of Borås, School of Health Science.
    Karlsson, JE
    Svensson, L
    Thuresson, M
    Zedigh, C
    Wernroth, L
    Lindahl, Berit
    Knowledge and Attitudes toward Seeking Medical Care for AMI symptoms2011In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 147, no 2, p. 224-227Article in journal (Refereed)
    Abstract [en]

    Background Time is crucial when an acute myocardial infarction (AMI) occurs, but patients often wait before seeking medical care. Aim To investigate and compare patients' and relatives' knowledge of AMI, attitudes toward seeking medical care, and intended behaviour if AMI-symptoms occur. Methods The present study was a descriptive, multicentre study. Participants were AMI-patients ≤ 75 years (n = 364) and relatives to AMI-patients (n = 319). Questionnaires were used to explore the participants' knowledge of AMI and attitudes toward seeking medical care. Results Both patients and relatives appeared to act more appropriate to someone else's chest pain than to their own. Patients did not have better knowledge of AMI-symptoms than relatives. Women would more often contact someone else before seeking medical care. A greater percentage of elderly (65–75 years), compared to younger individuals, reported that they would call for an ambulance if chest pain occurred. Conclusions There were only minor differences between patients and relatives, regarding both knowledge and attitudes. It seems easier to act correctly as a bystander than as a patient. Therefore, in order to decrease patients' delay time it is important to educate relatives as well as patients on how to respond to symptoms of an AMI

  • 19. Henriksson, C
    et al.
    Larsson, M
    Arnetz, J
    Berglin-Jarlöv, M
    Herlitz, Johan
    [external].
    Karlsson, JE
    Svensson, L
    Thuresson, M
    Zedigh, C
    Wernroth, L
    Lindahl, B
    Knowledge and attitudes toward seeking medical care for AMI-symptoms2009In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 147, no 2, p. 224-227Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Time is crucial when an acute myocardial infarction (AMI) occurs, but patients often wait before seeking medical care. AIM: To investigate and compare patients' and relatives' knowledge of AMI, attitudes toward seeking medical care, and intended behaviour if AMI-symptoms occur. METHODS: The present study was a descriptive, multicentre study. Participants were AMI-patients ≤ 75 years (n = 364) and relatives to AMI-patients (n = 319). Questionnaires were used to explore the participants' knowledge of AMI and attitudes toward seeking medical care. RESULTS: Both patients and relatives appeared to act more appropriate to someone else's chest pain than to their own. Patients did not have better knowledge of AMI-symptoms than relatives. Women would more often contact someone else before seeking medical care. A greater percentage of elderly (65-75 years), compared to younger individuals, reported that they would call for an ambulance if chest pain occurred. CONCLUSIONS: There were only minor differences between patients and relatives, regarding both knowledge and attitudes. It seems easier to act correctly as a bystander than as a patient. Therefore, in order to decrease patients' delay time it is important to educate relatives as well as patients on how to respond to symptoms of an AMI.

  • 20.
    Herlitz, Johan
    et al.
    [external].
    Bengtsson, A
    Hjalmarson, Å
    Early use of metoprolol and serum potassium in suspected acute myocardial infarction1989In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 22, no 2, p. 169-175Article in journal (Refereed)
    Abstract [en]

    In 1350 patients with suspected acute myocardial infarction, serum potassium was analysed in the emergency ward. The effect of metoprolol was compared with placebo in a double-blind randomized trial. Metoprolol increased serum potassium from 4.11 ± 0.02 mmol/l to 4.27 ± 0.02 mmol/l (P<0.001) during the 1st day after hospital admission, whereas serum potassium levels remained fairly constant in patients given placebo during the same time (4.11 ± 0.02 to 4.14 ± 0.02 mmol/l; P>0.2). Similar results were obtained when analysing patients with a confirmed myocardial infarction separately. The effects appeared homogeneously distributed in subgroups related to sex, clinical history, infarct site, infarct size and delay time from onset of symptoms to start of treatment. We conclude that early treatment with the beta-1-selective blocker metoprolol in patients with suspected acute myocardial infarction increases serum potassium.

  • 21.
    Herlitz, Johan
    et al.
    [external].
    Bengtsson, A
    Hjalmarson, Å
    Wilhelmsen, L
    Body temperature in acute myocardial infarction and its relation to early intervention with metoprolol1988In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 20, no 1, p. 65-71Article in journal (Refereed)
    Abstract [en]

    In a subsample of 223 patients participating in a double-blind trial with metoprolol in suspected acute myocardial infarction, body temperature during the first 5 days in hospital was recorded. Patients developing infarction had a mean temperature of 37.3°C compared with 36.8° C for those with no infarction (P < 0.001). A positive association was observed between enzyme-estimated infarct size and body temperature (P < 0.001). Patients given metoprolol had a mean temperature of 37.0° C as compared with 37.2° C in those given placebo (P = 0.03). The most marked difference between metoprolol and placebo was observed among those treated very early. We conclude that early treatment with metoprolol in suspected acute myocardial infarction appears to lower body temperature during the following days. This might reflect limitation of the infarct size.

  • 22.
    Herlitz, Johan
    et al.
    [external].
    Brandrup-Wognsen, G
    Caidahl, K
    Haglid Evander, M
    Hartford, M
    Karlson, BW
    Karlsson, T
    Sjöland, H
    Determinants of an impaired quality of life ten years after coronary artery bypass surgery2005In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 98, no 3, p. 447-452Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To identify determinants of an inferior quality of life (QoL) 10 years after coronary artery bypass grafting (CABG). SETTING: Sahlgrenska University Hospital, Göteborg, Sweden. PARTICIPANTS: All patients from Western Sweden who underwent CABG between 1988 and 1991 without simultaneous valve surgery and no previous CABG. MAIN OUTCOME MEASURES: Questionnaires for evaluating QoL 10 years after the operation. Three different instruments were used: The Nottingham health profile (NHP), the psychological general wellbeing index (PGWI), and the Physical Activity Score (PAS). RESULTS: 2000 patients underwent CABG, of whom 633 died during 10 years of follow-up. Information on QoL at 10 years was available in 976 patients (71% of survivors). A history of diabetes and chronic obstructive pulmonary disease were the two independent predictors for an inferior QoL with all three instruments. Furthermore, there were three predictors of an inferior QoL with two of the instruments: high age, female sex and a history of hypertension. A number of factors predicted an inferior QoL with one of the instruments. These were the duration of angina pectoris and functional class prior to CABG, renal dysfunction, a history of cerebrovascular disease, obesity, height, duration of respirator treatment and requirement of inotropic drugs postoperatively. In addition, when introducing preoperative QoL into the model a low QoL before surgery was a strong independent predictor also of an inferior QoL 10 years after CABG. CONCLUSION: Variables independently predictive of an impaired QoL 10 years after CABG, irrespective of the instrument used, were an impaired QoL prior to surgery, chronic obstructive pulmonary disease and a history of diabetes. However, other factors reflecting gender, the previous history as well as postoperative complications were also associated with the QoL 10 years later in at least one of these instruments.

  • 23.
    Herlitz, Johan
    et al.
    [external].
    Brandrup-Wognsen, G
    Haglid, M
    Karlson, BW
    Hartford, M
    Karlsson, T
    Predictors of death during 5 years after coronary artery bypass grafting1998In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 64, no 1, p. 15-23Article in journal (Refereed)
    Abstract [en]

    Aim: To describe predictors of death during five years of follow-up after coronary artery bypass grafting (CABG). Methods: All patients who underwent CABG during a period of three years in Western Sweden were included in the analysis and were prospectively followed for five years. Mortality was related to preoperative and peroperative factors as well as findings at physical examination and medication 4–7 days after the operation. Results: In all 2121 patients underwent CABG without simultaneous valve surgery during the study period. The overall five-year mortality was 14.6%. The following appeared as independent predictors of death during five years but >30 days after CABG: Current smoking (relative risk ratio 2.43 [95% Ci 1.64–3.61]) degree of impairment of left ventricular function (1.51 [1.23–1.86]), a history of congestive heart failure (1.91 [1.35–2.70]), age (1.04 [1.02–1.06]) arrhythmia 4–7 days after CABG (1.89 [1.26–2.83]), intermittent claudication (1.73 [1.19–2.52]), a history of diabetes (1.71 [1.16–2.51]), time in respirator (1.43 [1.13–1.81]), a history of cerebrovascular disease (1.72 [1.13–2.64]), treatment with digitalis at day 4–7 (1.48 [1.07–2.05]), enzyme release (1.49 [1.03–2.16]). Conclusion: Among patients who underwent CABG 11 independent predictors for mortality were found including smoking habits at CABG, history of cardiovascular diseases, left ventricular dysfunction, age, post operative complications and medication after CABG.

  • 24.
    Herlitz, Johan
    et al.
    [external].
    Dellborg, M
    Hartford, M
    Karlson, BW
    Karlsson, T
    Impact of early thrombolysis on chest pain score reflecting myocardial ischemia in relation to various markers of ischemic damage1993In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 41, no 2, p. 123-131Article in journal (Refereed)
    Abstract [en]

    We randomized 352 patients with pain suggestive of acute myocardial infarction who were seen less than 3 h after onset of symptoms to either tissue plasminogen activator or placebo. The impact of treatment on chest pain score was assessed during the first 24 h and related to limitation of final myocardial damage as assessed by various indirect markers. The most marked effect of tissue plasminogen activator was observed in the chest pain score being reduced by 43% in the tissue plasminogen activator group as compared with placebo. Limitation of infarct size with tissue plasminogen activator reached the following percentage values when various methods were used: maximum serum lactate dehydrogenase I activity, 32%; vectorcardiography (QRS vector difference), 20%; electrocardiography (Palmeri score), 20%; ejection fraction, 9%. We conclude that early thrombolysis in acute myocardial infarction reduces the severity of chest pain by nearly 50%. The effect on chest pain is much more marked as compared with the effect on various markers of the final ischemic damage.

  • 25.
    Herlitz, Johan
    et al.
    University of Borås, School of Health Science.
    Dellborg, M
    Karlsson, T
    Evander, MH
    Hartford, M
    Perers, E
    Caidahl, K
    Treatment and Outcome in Acute Myocardial Infarction in a Community in Relation to Gender2009In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 135, no 3, p. 315-22Article in journal (Refereed)
  • 26.
    Herlitz, Johan
    et al.
    [external].
    Dellborg, M
    Karlsson, T
    Haglid Evander, M
    Berger, A
    Luepker, R
    Epidemiology of acute myocardial infarction with the emphasis on patients who did not reach the coronary care unit and non-AMI admissions2008In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 128, no 3, p. 342-349Article in journal (Refereed)
    Abstract [en]

    Objectives To describe the characteristics and outcome of patients with acute myocardial infarction (AMI) in a community, with particular emphasis on those who never reached a Coronary Care Unit (CCU) and those in whom the primary diagnosis was something other than a heart attack. Methods Patients hospitalised in the city of Göteborg, Sweden, and discharged (dead or alive) with a diagnosis of AMI. Results Among 1423 patient admissions the mean overall age was 75 years (81 years and 79 years in the two subsets). Among all patients, 33% had a history of heart failure and 20% had a history of cerebrovascular disease. The figures were even higher in the two subsets which were evaluated. In overall terms, an invasive strategy (coronary angiography) was used in 32% (in 5% and 9% in the two subsets respectively). The overall one-year and three-year mortality rate was 30% and 44% respectively. The three-year mortality rate among patients not admitted to a CCU was 65% and, among patients with no suspicion of a heart attack on admission, it was 68%. Conclusion Even in the 21st century, patients with AMI who reach hospital alive run a high risk of death and nearly half are dead within the first three years. In overall terms, patients are characterised by high age and high co-morbidity. Among patients who do not reach a CCU and among patients with no suspicion of AMI on admission, approximately two thirds are dead within the subsequent three years.

  • 27.
    Herlitz, Johan
    et al.
    [external].
    Dellborg, M
    Karlsson, T
    Haglid Evander, M
    Hartford, M
    Perers, E
    Caidahl, K
    Treatment and outcome in acute myocardial infarction in a community in relation to gender.2009In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 153, no 3, p. 315-322Article in journal (Refereed)
    Abstract [en]

    AIM: To describe treatment and outcome in all patients in a community with acute myocardial infarction (AMI) in relation to gender. METHODS: All patients discharged from hospital between 2001 and 2002 in Göteborg, Sweden, with a diagnosis of AMI underwent a survey to find possible gender differences. All p-values are age adjusted. RESULTS: Among 1423 admissions, women comprised 41% and were older than men (mean 79 versus mean 72 years). Women were admitted to a coronary care unit less frequently than men (49% versus 67%; p=0.005). Women underwent coronary angiography less frequently (21% versus 40%; p=0.02). Percutaneous coronary intervention (PCI) was performed in 10% of the women and 18% of the men (p=0.36). Coronary artery bypass grafting (CABG) was performed in 2% of the women and in 9% of the men (p<0.0001). Female gender was associated with a lower risk of reinfarction during first year after hospital discharge (12% versus 16%; p=0.003). The cumulative three-year mortality was 49% in women and 41% in men. However, when adjusting for age, admittance to CCU, coronary angiography and coronary revascularisation, risk of death during 3 years was lower in women than men (odds ratio 0.72; 95% confidence interval 0.60-0.85; p=0.0001). CONCLUSION: In the community of Göteborg women (mean age 79 years) with AMI are prioritised differently than men (mean age 72 years), prior to admission to a CCU. This results in a less invasive strategy in women, particularly with regard to CABG. When adjusting for difference in age, admittance to CCU and coronary revascularisation female gender was associated with a low risk of death during the subsequent 3 years.

  • 28.
    Herlitz, Johan
    et al.
    [external].
    Hjalmarson, Å
    Swedberg, K
    Vedin, A
    Waagstein, F
    Waldenström, A
    Wilhelmsson, C
    The influence of early intervention in acute myocardial infarction on long-term mortality and morbidity as assessed in the Göteborg metoprolol trial1986In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 10, no 3, p. 291-301Article in journal (Refereed)
    Abstract [en]

    The mortality and morbidity were assessed during a 2-year follow-up in an acute intervention trial in suspected acute myocardial infarction with metoprolol (a selective beta 1-blocker). On admission to the trial, the 1395 participating patients were randomly allocated to metoprolol or placebo for 3 months. Thereafter, if there was no contraindication, patients with infarction and/or angina pectoris were continued on metoprolol for 2 years. A lower mortality was observed after 3 months in patients randomised to metoprolol. The difference remained after 2 years. The difference in 2-year mortality rate was restricted to patients randomised early after onset of pain. Late infarction was observed more often in the placebo group during the first 3 months. When the two groups thereafter were treated similarly, the difference successively declined and did not remain after 2 years. A similar incidence of angina pectoris was observed in the two groups at each check up. During the early recovery period, more patients in the metoprolol group returned to work. No such difference was observed later on.

  • 29.
    Herlitz, Johan
    et al.
    [external].
    Hjalmarson, Å
    Swedberg, K
    Waagstein, F
    Waldenström, J
    Relationship between infarct size and incidence of severe ventricular arrhythmias in a double-blind trial with metoprolol in acute myocardial infarction1984In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 6, no 1, p. 47-60Article in journal (Refereed)
    Abstract [en]

    In 585 patients having an acute myocardial infarction for the first time the relationship was investigated between estimated infarct size and the incidence of ventricular fibrillation and treated ventricular tachycardia during hospitalization. The size of the infarct was estimated from analyses of heat stable lactate dehydrogenase (LD) (EC 1.1.1.27.) in serum collected every 12 hr for 48–108 hr. All patients participated in a double-blind comparison of the β1-selective blocker metoprolol with placebo in suspected acute myocardial infarction. A correlation was observed between the enzymatically estimated infarct size and the incidence of ventricular fibrillation and treated ventricular tachycardia in patients on placebo (P < 0.001), while this could not be demonstrated in patients on the beta-blocker (P > 0.2). In placebo treated patients there was a correlation between the maximum heat stable LD activity and early ventricular fibrillation (P = 0.034), late ventricular fibrillation (P < 0.001), primary ventricular fibrillation (P = 0.002) as well as secondary ventricular fibrillation (P = 0.034). It is concluded that there seems to be a relatively strong correlation between the final size of the infarction and the occurrence of severe ventricular arrhythmias. Treatment with beta-blockade appeared to disturb this correlation.

  • 30.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Hjalmarson, Å
    Ten-year mortality rate among patients in whom acute myocardial infarction was not confirmed in relation to clinical history and observations during hospital stay: experiences from the Göteborg Metoprolol Trial1994In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 44, no 3, p. 217-224Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The majority of patients hospitalized due to suspected acute myocardial infarction (AMI) will eventually not develop infarction. Information about the long-term prognosis in this patient population is limited. AIM: To describe the mortality during 10 years of follow-up in patients hospitalized due to an initially strong suspicion of AMI, but in whom the diagnosis of AMI could not be confirmed. PATIENTS: All patients participating in an early intervention trial with metoprolol in suspected AMI, but in whom the diagnosis was not confirmed. Patients were included during 1976-1981. RESULTS: In all 1395 patients were included in the study, of whom 586 did not fulfil the criteria for confirmed AMI. The overall mortality during 10 years of follow-up in this population was 26%. In a multivariate analysis considering age, sex, history of cardiovascular diseases, initial heart rate and various complications during the hospital stay, including congestive heart failure, severe ventricular arrhythmias, tachycardia, hypotension, high degree AV-block and severe chest pain, the following appeared as independent predictors of death: previous infarction (P < 0.001), age (P < 0.001), history of diabetes mellitus (P < 0.001) history of smoking (P < 0.05), history of hypertension (P < 0.05), male sex (P < 0.05), and the initial heart rate (P < 0.05). CONCLUSION: Among patients in whom AMI was not confirmed the major risk indicators for death during 10 years of follow-up were: a history of cardiovascular diseases and smoking, age, male sex and high heart rate on admission to hospital.

  • 31.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Karlsson, T
    Lindqvist, J
    Sjölin, M
    Predictors of death during 5 years after hospital discharge among patients with a suspected acute coronary syndrome with particular emphasis on whether an infarction was developed1998In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 66, no 1, p. 73-80Article in journal (Refereed)
    Abstract [en]

    Aim: To describe predictors of death after hospital discharge during 5 years of follow-up in a consecutive series of patients surviving hospitalization for symptoms and signs of a confirmed or suspected acute coronary syndrome. Patients and methods: All patients who between February 15, 1986 and November 9, 1987, were hospitalized at Sahlgrenska University Hospital in Göteborg, Sweden, and fulfilled the above given criteria. Results: In all, 1948 patients were included of whom 731 (38%) had a confirmed acute myocardial infarction (AMI). Independent risk indicators for death were: age (P=0.0001); male sex (P=0.005); a history of previous AMI (P=0.0001), diabetes mellitus (P=0.003) and smoking (P=0.0001); development of AMI during first 3 days in hospital (P=0.0001); in-hospital signs of congestive heart failure (P=0.0001); prescription of digitalis (P=0.001) and diuretics (P=0.02) at hospital discharge. A history of smoking interacted significantly (P=0.02) with the relationship between development of AMI and prognosis. Thus, the difference between patients who did and who did not develop an AMI was more pronounced among non-smokers than smokers. Other factors which interacted significantly with this relationship were a history of angina pectoris, and development of ventricular fibrillation and hypotension while in hospital. Conclusion: Among hospital survivors of a confirmed or suspected acute coronary syndrome predictors of death during 5 years were: age, male sex, history of AMI, diabetes mellitus and smoking, development of AMI and congestive heart failure while in hospital and prescription of digitalis and diuretics at hospital discharge. A history of smoking and angina pectoris as well as development of hypotension and ventricular fibrillation while in hospital interacted significantly with the relationship between development of AMI and prognosis.

  • 32.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Karlsson, T
    Svensson, L
    Zehlertz, E
    Kalin, B
    A description of the characteristics and outcome of patients hospitalized for acute chest pain in relation to whether they were admitted to the coronary care unit or not in the thrombolytic era2002In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 82, no 3, p. 279-287Article in journal (Refereed)
    Abstract [en]

    bjectives: To describe the characteristics and outcome of patients hospitalized for acute chest pain in relation to whether they were admitted to the coronary care unit (CCU) or not. Design: Prospective observational study with a follow-up of 2 years. Setting: Sahlgrenska University Hospital in Göteborg, Sweden. Subjects: All patients hospitalized due to acute chest pain during 6 months. Main outcome measures: Mortality, use of medical resources, complications and previous history. Results: In all 1.592 patients were admitted to hospital for chest pain, of whom 1.136 (71%) were not directly admitted to the CCU. These patients differed from those directly admitted to the CCU, being older, including more women, having a higher prevalence of known congestive heart failure and a lower degree of initial suspicion of acute myocardial infarction (AMI). Among all patients with confirmed AMI only 58% were directly admitted to CCU. Overall, the occurrence of complications and the use of medical resources were less frequent in the patients not admitted to the CCU. The mortality during the subsequent 2 years was 16.8% for patients not admitted to the CCU and 18.5% for patients admitted to the CCU. When adjusting for various factors at baseline, patients admitted to the CCU had a relative risk of death during 2 years of follow-up being 1.23 0.87–1.73 (P=0.24) as compared with those not admitted to the CCU. Conclusion: In a Swedish university hospital, more than two thirds of patients hospitalized for acute chest pain were not directly admitted to the CCU. They differed from those admitted to the CCU in several aspects. However, their unadjusted and adjusted mortality during the subsequent 2 years did not significantly differ from those admitted to CCU.

  • 33.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Lindqvist, J
    Sjölin, M
    Prognosis and risk indicators of death during a period of 10 years for women admitted to the emergency department with a suspected acute coronary syndrome2002In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 82, no 3, p. 259-268Article in journal (Refereed)
    Abstract [en]

    Aim: To describe the 10-year prognosis and risk indicators of death in women admitted to the emergency department with acute chest pain or other symptoms raising a suspicion of acute myocardial infarction (AMI). Particular interest was paid to women of ≤75 years of age surviving 1 month after admission, who were judged to have suffered a possible or confirmed acute ischemic event with signs of either minor or no myocardial damage. Patients: All women admitted to the emergency department at Sahlgrenska University Hospital, Göteborg, during a period of 21 months, due to acute chest pain or other symptoms raising a suspicion of AMI. Methods: All the women were followed prospectively for 10 years. The subset described previously underwent a bicycle exercise tolerance test and metabolic screening 3 and 4 weeks, respectively, after admission to the emergency department. Results: In all, 5362 patients were admitted to the emergency department on 7157 occasions during the time of the survey and 2387 (45%) of them were women. Of these women, 61% were hospitalised and 39% were sent home directly. The overall 10-year mortality for women was 42.5% (55.5% among those hospitalised and 21.8% among those not hospitalised). Of the variables recorded at the emergency department, the following were independently associated with 10-year mortality: age, history of angina pectoris, history of hypertension, history of diabetes, history of congestive heart failure, pathological ECG on admission, degree of initial suspicion of AMI on admission, symptoms of congestive heart failure on admission and other non-specific symptoms on admission. The majority of these risk factors were more markedly associated with prognosis in women discharged directly from the emergency department than in those hospitalised. In the subset aged ≤75 years defined above (n=241), the following were independent predictors of death: a history of AMI and working capacity in a bicycle exercise tolerance test. Conclusion: Among women admitted to hospital due to chest pain or other symptoms raising a suspicion of AMI, 42.5% had died after 10 years. Major risk indicators of death were age, history of cardiovascular disease, pathological ECG on admission and symptoms of congestive heart failure on admission. Women presenting with an acute coronary syndrome but minimal myocardial damage, work capacity and a history of AMI predicted a poor outcome.

  • 34.
    Herlitz, Johan
    et al.
    [external].
    Karlson, BW
    Sjöland, H
    Brandrup-Wognsen, G
    Haglid, M
    Karlsson, T
    Caidahl, K
    Long term prognosis after CABG in relation to preoperative left ventricular ejection fraction2000In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 72, no 2, p. 163-171Article in journal (Refereed)
    Abstract [en]

    AIM: To evaluate the mortality rate, risk indicators for death, mode of death and symptoms of angina pectoris during 5 years after coronary artery by pass grafting (CABG) in relation to the preoperative left ventricular ejection fraction (LVEF). PATIENTS: All patients in western Sweden who underwent CABG without concomitant valve surgery and without previously performed CABG between June 1988 and June 1991. RESULTS: In all 1904 patients were included in the analysis, of whom 173 (9%) had a LVEF < 40%. Patients with LVEF > or = 40% had a 5-year mortality of 12.5%. LVEF < 40% was associated with an increased risk of death (RR 2.3; 95% cl 1.7-3.1). There was no significant interaction between age, sex or any other factor in terms of clinical history and LVEF. However, left main stenosis was a strong independent predictor of death among patients with LVEF < 40% but not in those with a higher LVEF. Patients with a low LVEF more frequently died a cardiac death and a death associated with myocardial infarction (AMI). Furthermore they more frequently died in association with congestive heart failure and ventricular fibrillation. Among survivors, symptoms of angina pectoris were similar regardless of the preoperative LVEF. CONCLUSION: Patients with a low preoperative LVEF have a more than two-fold increased risk of death during 5 years after CABG. Their increased risk of death includes cardiac death, death associated with AMI, congestive heart failure and ventricular fibrillation.

  • 35.
    Herlitz, Johan
    et al.
    [external].
    Richter, A
    Hjalmarson, Å
    Holmberg, S
    Variability of chest pain in suspected acute myocardial infarction according to subjective assessment and requirement of narcotic analgesics1986In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 13, no 1, p. 9-22Article in journal (Refereed)
    Abstract [en]

    In 653 patients with suspected acute myocardial infarction the course of pain according to subjective assessment and morphine requirement is described. Patients were asked to score pain from 0-10 until a pain-free interval of 12 hours appeared. Different categories of patients constructed from clinical aspects were compared. Although the variability between groups was fairly small, subgroups were found in which the initial intensity of pain was more marked and the duration of pain was longer. Thus patients with larger infarcts according to maximum serum enzyme activity and patients with Q-wave infarction had more severe pain initially and also a longer duration and a higher morphine requirement compared with patients with a lower serum enzyme activity or a non-Q-wave infarction. Other groups with a more severe course of chest pain were those with more intensive pain at home, electrocardiographic signs of acute myocardial infarction on admission to hospital, and finally those with a high systolic blood pressure or a high rate-pressure product on admission to the Coronary Care Unit. We thus conclude that there is a variability of chest pain in suspected acute myocardial infarction and that there are defined groups of patients in which a more severe course of chest pain could be expected.

  • 36.
    Herlitz, Johan
    et al.
    [external].
    Thuresson, M
    Svensson, L
    Lindqvist, J
    Lindahl, B
    Zedigh, C
    Jarlöv, M
    Factors of importance for patients' decision time in acute coronary syndrome.2010In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 141, no 3, p. 236-242Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Not much is known about the patients' decision time in acute coronary syndrome (ACS). The aim of the survey was therefore to describe patients' decision time and factors associated with this parameter in ACS. METHODS: We conducted a national survey comprising intensive cardiac care units at 11 hospitals in Sweden in which patients with ACS diagnosis and symptoms onset outside hospital participated. Main outcome measures were patients' decision time and factors associated with patients' decision time. RESULTS: In all, 1939 patients took part in the survey. The major factors associated with a shorter patient decision time were: 1) ST-elevation ACS, 2) associated symptoms such as vertigo or near syncope, 3) interpreting the symptoms as cardiac in origin, 4) pain appearing suddenly and reaching a maximum within minutes, 5) having knowledge of the importance of quickly seeking medical care and 6) experiencing the symptoms as frightening. The following aspects of the disease were associated with a longer decision time: 1) pain was localised in the back and 2) symptom onset at home when alone. CONCLUSION: A number of factors, including the type of ACS, the type and localisation of symptoms, the place where symptoms occurred, patients' interpretation of symptoms and knowledge were all associated with patients' decision time in connection with ACS.

  • 37.
    Herlitz, Johan
    et al.
    University of Borås, School of Health Science.
    Thuresson, M
    Svensson, L
    Lindqvist, J
    Lindahl, B
    Zeidigh, C
    Jarlov, M
    Factors of Importance for Patients' Decision Time in Acute Coronary Syndrome2010In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 141, no 3, p. 236-242Article in journal (Refereed)
    Abstract [en]

    Background Not much is known about the patients' decision time in acute coronary syndrome (ACS). The aim of the survey was therefore to describe patients' decision time and factors associated with this parameter in ACS. Methods We conducted a national survey comprising intensive cardiac care units at 11 hospitals in Sweden in which patients with ACS diagnosis and symptoms onset outside hospital participated. Main outcome measures were patients' decision time and factors associated with patients' decision time. Results In all, 1939 patients took part in the survey. The major factors associated with a shorter patient decision time were: 1) ST-elevation ACS, 2) associated symptoms such as vertigo or near syncope, 3) interpreting the symptoms as cardiac in origin, 4) pain appearing suddenly and reaching a maximum within minutes, 5) having knowledge of the importance of quickly seeking medical care and 6) experiencing the symptoms as frightening. The following aspects of the disease were associated with a longer decision time: 1) pain was localised in the back and 2) symptom onset at home when alone. Conclusion A number of factors, including the type of ACS, the type and localisation of symptoms, the place where symptoms occurred, patients' interpretation of symptoms and knowledge were all associated with patients' decision time in connection with ACS.

  • 38.
    Herlitz, Johan
    et al.
    University of Borås, School of Health Science.
    Wireklint Sundström, Birgitta
    University of Borås, School of Health Science.
    Bång, Angela
    University of Borås, School of Health Science.
    Omerovic, E
    Is pre-hospital treatment of chest pain optimal in acute coronary syndrome? Both relief of pain and anxiety are needed2011In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 149, no 2, p. 147-151Article in journal (Refereed)
    Abstract [en]

    Background Many patients who suffer from acute chest pain are transported by ambulance. It is not known how often treatment prior to hospital admission is optimal and how optimal pain-relieving treatment is defined. It is often difficult to delineate pain from anxiety. Aim To describe various aspects of chest pain in the pre-hospital setting with the emphasis on a) treatment and b) presumed acute coronary syndrome. Methods In the literature search, we used PubMed and the appropriate key words. We included randomised clinical trials and observational studies. Results Four types of drug appear to be preferred: 1) narcotic analgesics, 2) nitrates, 3) beta-blockers and 4) benzodiazepines. Among narcotic analgesics, morphine has been associated with the relief of pain at the expense of side-effects. Alfentanil was reported to produce more rapid pain relief. Nitrates have been associated with the relief of pain with few side-effects. Beta-blockers have been reported to increase the relief of pain when added to morphine. The combination of beta-blockers and morphine has been reported to be as effective as beta-blockers alone in pain relief, but this combination therapy was associated with more side-effects. Experience from anxiety-relieving drugs such as benzodiazepines is limited. It is not known how these 4 drugs should be combined. The results indicate that various pain-relieving treatments might modify the disease. Conclusion Our knowledge of the optimal treatment of chest pain and associated anxiety in the pre-hospital setting is insufficient. Recommendations from existing guidelines are limited. Large randomised clinical trials are warranted.

  • 39.
    Hessulf, Fredrik
    et al.
    University of Gothenburg.
    Karlsson, Thomas
    University of Gothenburg.
    Lundgren, Peter
    University of Gothenburg.
    Aune, Solveig
    University of Gothenburg.
    Strömsöe, Annelie
    University of Dalarna.
    Södersved Källestedt, Marie-Louise
    Department of Research and Development, Västmanland County Council.
    Djärv, Therese
    Karolinska Institutet.
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Engdahl, Johan
    Danderyd Hospital.
    Factors of importance to 30-day survival after in-hospital cardiac arrest in Sweden - A population-based register study of more than 18,000 cases.2017In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, article id S0167-5273(16)32344-0Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND OBJECTIVE: In-hospital cardiac arrest (IHCA) constitutes a major contributor to cardiovascular mortality. The aim of the present study was to investigate factors of importance to 30-day survival after IHCA in Sweden.

    METHODS: A retrospective register study based on the Swedish Register of Cardiopulmonary Resuscitation (SRCPR) 2006-2015. Sixty-six of 73 hospitals in Sweden participated. The inclusion criterion was a confirmed cardiac arrest in which resuscitation was attempted among patients aged >18years.

    RESULTS: In all, 18,069 patients were included, 39% of whom were women. The median age was 75years. Thirty-day survival was 28.3%, 93% with a CPC score of 1-2. One-year survival was 25.0%. Overall IHCA incidence in Sweden was 1.7 per 1000 hospital admissions. Several factors were found to be associated with 30-day survival in a multivariable analysis. They included cardiac arrest (CA) at working days during the daytime (08-20) compared with weekends and night-time (20-08) (OR 1.51 95% CI 1.39-1.64), monitored CA (OR 2.18 95% CI 1.99-2.38), witnessed CA (OR 2.87 95% CI 2.48-3.32) and if the first recorded rhythm was ventricular fibrillation/tachycardia, especially in combination with myocardial ischemia/infarction as the assumed aetiology of the CA (OR for interaction 4.40 95% CI 3.54-5.46).

    CONCLUSION: 30-day survival after IHCA is associated with the time of the event, the aetiology of the CA and the degree of monitoring and this should influence decisions regarding the appropriate level of monitoring and care.

  • 40. Karlson, BW
    et al.
    Kalin, B
    Karlsson, T
    Svensson, L
    Zehlertz, E
    Herlitz, Johan
    [external].
    Use of medical resources complications and long-term outcome in patients hospitalized with acute chest pain. A comparison between a city university hospital and a county hospital2002In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 85, no 2-3, p. 229-238Article in journal (Refereed)
    Abstract [en]

    Objective: The primary aim was to test the hypothesis that there is a difference in long-term outcome after hospital discharge among patients hospitalized with acute chest pain in a university hospital and a county hospital. Secondary aims were to compare these two hospitals with regard to use of medical resources, occurrence of complications and risk indicators for death. Patients: All patients hospitalized at Sahlgrenska University Hospital in Göteborg (with a catchment population of 706 inhabitants/km2) and Uddevalla County Hospital (with a catchment population of 34 inhabitants/km2) due to symptoms of acute chest pain during a period of 6 months. Results: Complications, use of medical resources and mortality during the subsequent 2 years after discharge were compared among 1592 hospitalizations in a city hospital and 822 in a county hospital due to acute chest pain. Angina pectoris after the first event, congestive heart failure and various arrhythmias were more frequently reported in the county hospital. The use of medical resources differed. Thus, the use of betablockers, heparin, antiarrhythmics, diuretics and nipride was more frequent in the county hospital, whereas the use of nitrates, digitalis, coronary angiography, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) was more frequent in the city hospital. Despite these differences, the mortality 2 years after hospital discharge was similar (14.7% in the city hospital and 12.8% in the county hospital, P=0.26). Two factors, intravenous digitalis in hospital and a prescription of insulin at discharge, were significantly more associated with death in the county hospital compared with the city hospital. Conclusions: When comparing a city university hospital with a county hospital with regard to patients admitted with chest pain, major differences in terms of complications and use of medical resources were found. Thus, various complications were reported more frequently in the county hospital. The use of medical resources varied, some being used more frequently in the county hospital, whereas others were used more frequently in the university hospital. Despite these differences the mortality 2 years after hospital discharge was similar in the two cohorts.

  • 41. Karlson, BW
    et al.
    Lindqvist, J
    Sjölin, M
    Caidahl, K
    Herlitz, Johan
    [external].
    Which factors determine the long-term outcome among patients with a very small or non confirmed AMI2001In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 78, no 3, p. 265-275Article in journal (Refereed)
    Abstract [en]

    Aim: To describe various factors associated with the very long-term prognosis for patients with a very small or an unconfirmed acute myocardial infarction (AMI). Methods: Patients below 76 years of age, hospitalized due to suspected AMI who either developed a very small AMI (enzyme elevation<twice upper normal limit and maximum serum (S) aspartate aminotransferase (S-ASAT)<1.4 ukat/l) or an unconfirmed AMI (a suspected ischemic event with no signs of myocardial necrosis) were evaluated at our out-patient clinic. The 10-year mortality was related to the clinical history, age and sex, metabolic factors, diagnosis at hospital discharge, various psychosocial factors, use of medication, current symptoms, underlying reason to the symptoms, maximal working capacity and other observations at bicycle exercise test including signs of myocardial ischemia. Results: In all, 714 patients (33% women) with a median age of 63 years were included in the analyses. The following appeared as independent risk indicators for 10-year mortality: S-gammaglutamyl transpeptidase (GT) (P<0.0001), age (P<0.0001), current smoking (P<0.0001), a history of previous AMI (P<0.0001), maximal working capacity at bicycle exercise test (P=0.002), and current treatment with digitalis (borderline significance; P=0.022). Conclusion: Among patients with a suspected acute myocardial ischemic event with no or minimal myocardial necrosis, various factors reflecting their age, history of cardiac disease and smoking, liver function, working capacity and possibly use of medication affected their very long-term prognosis.

  • 42. Karlsson, BW
    et al.
    Herlitz, Johan
    [external].
    Emanuelsson, H
    Edvardsson, N
    Wiklund, O
    Richter, A
    Hjalmarson, Å
    One-year mortality rate after disharge from hospital in relation to whether or not a confirmed myocardial infarction was developed1991In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 32, no 3, p. 381-388Article in journal (Refereed)
    Abstract [en]

    Consecutive patients admitted to our hospital with suspected acute myocardial infarction during 21 months were prospectively evaluated. One-year mortality after discharge from hospital was related to whether or not an infarction developed (infarct versus non-infarct patients). Of patients discharged alive after developing an infarct, there was a mortality of 17% (n = 777) versus 12% (n = 1830) (P < 0.001) for all patients not developing infarction. In a high risk group (any of the following: age ≥ 75 years, previous history of myocardial infarction, diabetes mellitus or congestive heart failure) patients developing infarction had a mortality of 24% (n = 457) versus 17% (n = 1221) for those who did not (P < 0.001). In a low risk group (none of the high risk criteria), the corresponding mortality was 8% (n = 316) for patients suffering infarction and 3% (n = 603) for those not having infarction (P < 0.001). The difference in mortality between patients with and without infarction was most marked in women (21% vs 11%; P < 0.01) and in hypertensives (25% vs 12%; P < 0.001), but less marked in men (16% vs 13%; NS) and in patients without hypertension (13% vs 12%; NS). Among patients not suffering infarction, mortality was particularly high in those with previous congestive heart failure (23%) and diabetes mellitus (21%).

  • 43. Karlsson, BW
    et al.
    Herlitz, Johan
    [external].
    Emanuelsson, H
    Karlsson, T
    Hjalmarson, Å
    The prognosis of patients suspected of having acute myocardial infarction subsequent to its exclusion as the diagnosis1990In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 26, no 3, p. 251-257Article in journal (Refereed)
    Abstract [en]

    This review of the literature concerns the prognosis of patients suspected of having myocardial infarction subsequent to its exclusion as the diagnosis. Several investigations show a surprisingly bad prognosis for patients in this category, almost comparable to that of patients with a confirmed infarction. When the results of the different studies are pooled, however, there is a significant difference between those patients with true infarction, and those in whom infarction was excluded, in terms of overall mortality (12% and 7%; P < 0.0001) and the development of subsequent non-fatal infarction (11% and 6%; P < 0.05) when the results are analysed for a period of follow-up of one year. The difference was significant even when both fatal and non-fatal infarctions were taken into account over the one-year period of follow-up (13% and 8%; P < 0.0001). The analysis shows that electrocardiographic ST-T changes are a risk factor for coronary events, but the results are conflicting for other possible risk factors. The selection of patients varies between the different studies, which probably contributes to the different results reported. Prospective studies with well defined groups of patients large enough to permit analysis of subgroupings will be needed to resolve the outstanding questions.

  • 44. Libungan, B
    et al.
    Stensdotter, L
    Hjalmarson, A
    From Attebring, M
    Lindqvist, J
    Herlitz, Johan
    University of Borås, School of Health Science.
    Bäck, M
    Secondary prevention in coronary artery disease. Achieved goals and possibilities for improvements2012In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 161, no 1, p. 18-24Article in journal (Refereed)
    Abstract [en]

    Aim To describe presence of risk indicators of recurrence 6 months after hospitalisation due to coronary artery disease at a university clinic. Methods The presence of risk indicators, including tobacco use, lipid levels, blood pressure and glucometabolic status, including 24-hour blood pressure monitoring and an oral glucose-tolerance test, was analysed. Results Of 1465 patients who were screened, 402 took part in the survey (50% previous myocardial infarction and 50% angina pectoris). Mean age was 64 years (range 40–85 years) and 23% were women. Present medications were: lipid lowering drugs (statins; 94%), beta-blockers (85%), aspirin or warfarin (100%) and ACE-inhibitors or angiotensin II blockers (66%). Values above target levels recommended in guidelines were: a) low density lipoprotein (LDL) in 40%; b) mean blood pressure (day or night) in 38% and c) smoking in 13%. Of all patients, 66% had at least one risk factor (LDL or blood pressure above target levels or current smoking). An abnormal glucose-tolerance test was found in 59% of patients without known diabetes. If no history of diabetes, 85% had either LDL or blood pressure above target levels, current smoking or an abnormal glucose-tolerance test. However, with treatment intensification to patients with elevated risk factors 56% reached target levels for blood pressure and 79% reached target levels for LDL. Conclusion Six months after hospitalisation due to coronary artery disease, despite the high use of medication aimed at prophylaxis against recurrence, the majority were either above target levels for LDL or blood pressure or continued to smoke.

  • 45. Lindvall, B
    et al.
    Brorsson, B
    Herlitz, Johan
    [external].
    Albertsson, P
    Werkö, L
    Comparison of diabetic and non diabetic patients referred for coronary angiography1999In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 70, no 1, p. 33-42Article in journal (Refereed)
    Abstract [en]

    AIM: To evaluate whether diabetic patients differ from non-diabetic patients when referred for coronary angiography regarding previous history, indication for and findings at coronary angiography, use of medication, exercise test results and mortality. METHODS: Data were prospectively collected on patients referred for consideration of coronary revascularization to seven of the eight public Swedish heart centers that performed approximately 92% of all bypass operations in Sweden in 1994. RESULTS: 2762 patients were included of whom 406 (15%) had a history of diabetes mellitus. There was no difference in age or sex in the two groups. Chronic stable angina was the most common indication (73% in both groups) and only 3% were admitted due to silent ischemia. Diabetic patients had more severe symptoms (Canadian Cardiovascular Society III-IV) than non-diabetic patients (66% vs. 58%, p<0.01). They more frequently used ACE-inhibitors (33% vs. 19%, p<0.0001) and calcium channel blockers (47% vs. 40%, p<0.01) and more often had a diagnosis of arterial hypertension than non-diabetic patients (50% vs. 33%, p<0.0001). Diabetic patients more often had depressed myocardial function (EF<35%); 12% and 8%, respectively (p<0.01), and more extensive coronary artery disease (left main/3-VD; 48% vs. 37%, p<0.001). The mortality during the subsequent 21 months was 7.9% among diabetic patients and 3.6% among non-diabetic patients (p<0.001). CONCLUSION: Among patients being referred for coronary angiography in Sweden, 15% were patients with a history of diabetes. They differed from patients without such a history by more often having severe symptoms and a higher prevalence of left main/triple vessel disease. Coronary angiography may thus be underused in diabetic patients with chest pain.

  • 46. Lingman, M
    et al.
    Herlitz, Johan
    University of Borås, School of Health Science.
    Bergfeldt, L
    Karlsson, T
    Caidahl, K
    Hartford, M
    Acute Coronary Syndromes: The Prognostic Impact of Hypertension, Diabetes and its Combination of Long-Term Outcome2009In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 137, no 1, p. 29-36Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Knowledge about the simultaneous influence of diabetes and hypertension on outcome among patients with ischemic heart disease is limited. The objective of this survey was to describe the characteristics, treatment and outcome among patients with acute coronary syndromes (ACS) in relation to previous history of hypertension (HT), diabetes mellitus (DM) or a combination of the two. METHODS: Consecutive patients admitted to the Coronary Care Unit, Sahlgrenska University Hospital, Goteborg Sweden aged <80 years fulfilling criteria for ACS during 1995 until 2001 were followed for a median of 8 years. RESULTS: A history of HT was found in 974 (42%) of 2329 patients and a history of DM in 446 (19%). Patients with DM or HT were older, more often female and more frequently had previous atherosclerotic manifestations. Patients with DM, irrespective of HT, had a higher prevalence of prior heart failure, as well as higher Killip class and heart rate at admission. Signs of myocardial ischemia on the admission electrocardiogram (ECG) were more prevalent without HT or DM. While HT was weakly associated with impaired long-term prognosis (HR 1.18; 95% CI 1.02-1.37), DM was a strong predictor of death (HR 1.79; 95% CI 1.52-2.10) and the combination was even additive (HR 2.10, 95% CI 1.71-2.57). CONCLUSION: ACS patients with a history of HT and DM had a higher age-adjusted, long-term mortality risk than ACS patients without such a history. DM appeared to be more strongly associated with mortality than HT, but its combination was additive.

  • 47. Lingman, M
    et al.
    Herlitz, Johan
    [external].
    Bergfeldt, L
    Karlsson, T
    Caidahl, K
    Hartford, M
    Acute coronary syndromes--the prognostic impact of hypertension, diabetes and its combination on long-term outcome.2009In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 139, no 1, p. 29-36Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Knowledge about the simultaneous influence of diabetes and hypertension on outcome among patients with ischemic heart disease is limited. The objective of this survey was to describe the characteristics, treatment and outcome among patients with acute coronary syndromes (ACS) in relation to previous history of hypertension (HT), diabetes mellitus (DM) or a combination of the two. METHODS: Consecutive patients admitted to the Coronary Care Unit, Sahlgrenska University Hospital, Goteborg Sweden aged <80 years fulfilling criteria for ACS during 1995 until 2001 were followed for a median of 8 years. RESULTS: A history of HT was found in 974 (42%) of 2329 patients and a history of DM in 446 (19%). Patients with DM or HT were older, more often female and more frequently had previous atherosclerotic manifestations. Patients with DM, irrespective of HT, had a higher prevalence of prior heart failure, as well as higher Killip class and heart rate at admission. Signs of myocardial ischemia on the admission electrocardiogram (ECG) were more prevalent without HT or DM. While HT was weakly associated with impaired long-term prognosis (HR 1.18; 95% CI 1.02-1.37), DM was a strong predictor of death (HR 1.79; 95% CI 1.52-2.10) and the combination was even additive (HR 2.10, 95% CI 1.71-2.57). CONCLUSION: ACS patients with a history of HT and DM had a higher age-adjusted, long-term mortality risk than ACS patients without such a history. DM appeared to be more strongly associated with mortality than HT, but its combination was additive.

  • 48. Lingman, Markus
    et al.
    Hartford, Marianne
    Karlsson, Thomas
    Herlitz, Johan
    University of Borås, Faculty of Caring Science, Work Life and Social Welfare.
    Rubulis, Aigars
    Caidahl, Kenneth
    Bergfeldt, Lennart
    Value of the QRS-T area angle in improving the prediction of sudden cardiac death after acute coronary syndromes.2016In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 218, p. 1-11Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Prediction of sudden cardiac death (SCD) after acute coronary syndromes (ACS) remains a challenge. Although electrophysiology measures obtained by 3-D vectorcardiography (VCG) shortly after ACS may be useful predictors of SCD, they have not been adopted into clinical practice. The main objective of our study was to assess whether the VCG-derived QRS-T area angle (between area vectors) and the QRS-T angle (between maximum vectors) have additional value beyond standard risk factors in predicting SCD after ACS.

    METHODS AND RESULTS: We studied 643 consecutive ACS patients for whom data on VCG and echocardiography during the index hospitalization were available. Seventy-seven patients (12%) died, 37 (6%) from SCD and 21 (3%) from other cardiac causes during the 30-month follow-up. After adjusting for 9 standard risk factors (age, sex, diabetes, previous stroke, left ventricular ejection fraction; and estimated glomerular filtration rate, heart rate, systolic blood pressure<100mmHg, and Killip class>1 on admission), QRS-T area angle and QRS-T angle were shown to have independent predictive value for both SCD and all cardiac deaths. Reclassification analysis showed that both measures had additional predictive value beyond the 9 standard risk factors. For SCD, net reclassification improvements for QRS-T area angle and QRS-T angle were 46% and 45% and relative integrated discriminative improvements were 16% and 13% (vs the average~11% of the 9 standard risk factors).

    CONCLUSIONS: The VCG-derived QRS-T area angle and QRS-T angle improved prediction of SCD after ACS beyond standard risk factors. Further evaluation of their clinical utility and cost-effectiveness is therefore warranted.

  • 49. Nielsen, N
    et al.
    Friberg, H
    Gluud, C
    Herlitz, Johan
    University of Borås, School of Health Science.
    Wetterslev, J
    Hypothermia after cardiac arrest should be further evaluated: A systematic review of randomised trials with meta-analysis and trial sequential analysis2010In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 151, no 3Article in journal (Refereed)
    Abstract [en]

    Background Guidelines recommend mild induced hypothermia (MIH) to reduce mortality and neurological impairment after out-of-hospital cardiac arrest. Our objective was to systematically evaluate the evidence for MIH taking into consideration the risks of systematic and random error and to GRADE the evidence. Methods Systematic review with meta-analysis and trial sequential analysis of randomised trials evaluating MIH after cardiac arrest in adults. We searched CENTRAL, MEDLINE, and EMBASE databases until May 2009. Retrieved trials were evaluated with Cochrane methodology. Meta-analytic estimates were calculated with random- and fixed-effects models and random errors were evaluated with trial sequential analysis (TSA). Results Five randomised trials (478 patients) were included. All trials had substantial risk of bias. The relative risk (RR) for death was 0.84 (95% confidence interval (CI) 0.70 to 1.01) and for poor neurological outcome 0.78 (95% CI 0.64 to 0.95). For the two trials with least risk of bias the RR for death was 0.92 (95% CI 0.56 to 1.51) and for poor neurological outcome 0.92 (95% confidence interval 0.56 to 1.50). TSA indicated lack of firm evidence for a beneficial effect. The substantial risk of bias and concerns with directness rated down the quality of the evidence to low. Conclusions Evidence regarding MIH after out-of-hospital cardiac arrest is still inconclusive and associated with non-negligible risks of systematic and random errors. Using GRADE-methodology, we conclude that the quality of evidence is low. Our findings demonstrate that clinical equipoise exists and that large well-designed randomised trials with low risk of bias are needed.

  • 50. Nielsen, N
    et al.
    Friberg, H
    Gluud, C
    Herlitz, Johan
    [external].
    Wetterslev, J
    Hypothermia after cardiac arrest should be further evaluated-A systematic review of randomised trials with meta-analysis and trial sequential analysis2011In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 151, no 3, p. 333-341Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Guidelines recommend mild induced hypothermia (MIH) to reduce mortality and neurological impairment after out-of-hospital cardiac arrest. Our objective was to systematically evaluate the evidence for MIH taking into consideration the risks of systematic and random error and to GRADE the evidence. METHODS: Systematic review with meta-analysis and trial sequential analysis of randomised trials evaluating MIH after cardiac arrest in adults. We searched CENTRAL, MEDLINE, and EMBASE databases until May 2009. Retrieved trials were evaluated with Cochrane methodology. Meta-analytic estimates were calculated with random- and fixed-effects models and random errors were evaluated with trial sequential analysis (TSA). RESULTS: Five randomised trials (478 patients) were included. All trials had substantial risk of bias. The relative risk (RR) for death was 0.84 (95% confidence interval (CI) 0.70 to 1.01) and for poor neurological outcome 0.78 (95% CI 0.64 to 0.95). For the two trials with least risk of bias the RR for death was 0.92 (95% CI 0.56 to 1.51) and for poor neurological outcome 0.92 (95% confidence interval 0.56 to 1.50). TSA indicated lack of firm evidence for a beneficial effect. The substantial risk of bias and concerns with directness rated down the quality of the evidence to low. CONCLUSIONS: Evidence regarding MIH after out-of-hospital cardiac arrest is still inconclusive and associated with non-negligible risks of systematic and random errors. Using GRADE-methodology, we conclude that the quality of evidence is low. Our findings demonstrate that clinical equipoise exists and that large well-designed randomised trials with low risk of bias are needed.

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