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  • 51. Perers, E
    et al.
    Caidahl, K
    Herlitz, Johan
    [external].
    Karlson, BW
    Karlsson, T
    Hartford, M
    Treatment and short-term outcome in women and men with acute coronary syndromes.2005Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 103, nr 2, s. 120-127Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVE: To study differences in treatment and early morbidity and mortality in relation to gender, type of acute coronary syndrome (ACS) and age in patients under 80 years of age. METHODS: We studied 1744 consecutive patients with ACS with assumed decreasing order of severity [ST-elevation myocardial infarction (MI), non-ST-elevation MI and unstable angina of high- and low-risk types] admitted to the coronary care unit at Sahlgrenska University Hospital. RESULTS: The use of thrombolysis and percutaneous coronary interventions (PCI) did not differ significantly between gender groups and women did not suffer from more severe complications than men. Treatment with beta-blockers, ACE inhibitors and aspirin was used on a similar scale among women and men. In-hospital complications and use of intravenous drugs were strongly associated with severity of disease in a similar way among women and men. The mortality rates at 30 days were 12.4% and 7.4% in MI with and without ST-segment elevation, but only 1.3% and 1.0% in unstable angina of high- and low-risk types. The use of primary PCI decreased with age, as did coronary angiography and PCI in the subacute phase, irrespective of gender. CONCLUSION: Among patients <80 years with ACS admitted to a coronary care unit, the suspicion that women are treated less aggressively than men could not be verified. Nor did women suffer from more complications or have a significantly higher 30-day mortality than men. Elderly patients were significantly less likely to undergo invasive procedures than those of a younger age, irrespective of gender.

  • 52. Petursson, P
    et al.
    Herlitz, Johan
    [external].
    Caidahl, K
    Gudbjörnsdottir, S
    Karlsson, T
    Perers, E
    Sjöland, H
    Hartford, M
    Admission glycaemia and outcome after acute coronary syndrome.2007Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 116, nr 3, s. 315-320Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Acute phase hyperglycaemia has been associated with increased mortality in patients with acute coronary syndrome. We investigated whether the predictive value of admission hyperglycaemia for mortality differs between diabetics and non-diabetics with acute coronary syndrome. METHODS: Patients with acute coronary syndrome (n=1957) were followed up prospectively for 45 months. Patients were stratified into quartile groups defined by admission plasma glucose and hyperglycaemia was defined as plasma glucose of >9.4 mmol/l, which was the cut-off value for the 4th quartile. The relationship between admission hyperglycaemia and short-term (< or =30 day) and late (>30 day) mortality was analysed. RESULTS: Of 1957 patients, 22% had a history of diabetes. Among patients without diabetes, those with hyperglycaemia had both a higher 30-day mortality rate (20.2% vs. 3.5%, p<0.0001) and late mortality rate (19.1% vs. 11.7%, p=0.007). Hyperglycaemic patients with diabetes had a higher late mortality rate than diabetic patients with plasma glucose of < or =9.4 mmol/l (29.3% vs. 14.9%, p=0.001). Of patients with hyperglycaemia at admission, those without diabetes had a higher 30-day mortality rate compared with those with diabetes (p=0.002). CONCLUSION: Admission hyperglycaemia is a strong risk factor for mortality in patients with acute coronary syndrome and may be even stronger than a previous history of diabetes. Hyperglycaemic patients without recognised diabetes have a higher short-term mortality risk than hyperglycaemic patients with known diabetes.

  • 53. Ravn-Fischer, A
    et al.
    Caidahl, K
    Hartford, M
    Karlsson, T
    Kihlgren, S
    Perers, E
    Rashed, H
    Johanson, P
    Herlitz, Johan
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Community-based gender perspectives of triage and treatment in suspected myocardial infarction2012Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 156, nr 2, s. 139-143Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background The gender perspectives of the triage of acute coronary syndromes (ACS) in a community are insufficiently explored. Methods Patients (n = 3224) with symptoms of ACS, in whom ECG was sent by the ambulance crew to a coronary care unit (CCU)/ cath lab, were investigated in the municipality of Göteborg in 2004–2007. Background, triage priority, investigations and treatment were analysed (p-values age adjusted) in relation to gender. Data were compared with three published studies (1995–2002: Surveys 1–3). Results Women were directly admitted to the CCU significantly less frequently than men (23 versus 35%, p < 0.0001). Adjusted for ECG findings, age, symptoms and medical history, odds ratio and 95% confidence limits (for direct admission; men versus women) were 0.61; 0.46–0.82. Survey 1 Patients with ACS, aged < 80, in CCU at a university hospital (n = 1744). Only minor differences between women and men, with regard to investigations and treatment, were found. Survey 2 Patients discharged from hospital (dead or alive) with AMI, regardless of type of ward (n = 1423). Fewer women than men were admitted to CCU and fewer women underwent coronary angiography (21% versus 40%; p = 0.02) and coronary revascularisation (12% versus 27%; p = 0.004). Survey 3 Patients with symptoms of AMI (n = 930) and patients with a confirmed AMI (n = 130) from a pre-hospital perspective. Women tended to be given lower priority than men both by the ambulance dispatchers and by the ambulance crew. Conclusion In our practice setting, men are given priority over women in admission to CCU, but no gender differences are seen thereafter.

  • 54. Ravn-Fischer, A
    et al.
    Karlsson, T
    Johansson, P
    Herlitz, J
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Prehospital ECG signs of acute coronary occlusion are associated with reduced one-year motality2013Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 168, nr 4, s. 3594-3598Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: We wanted to evaluate predictors of direct admittance to a coronary care unit (CCU) and predictors of death in patients with suspected acute coronary syndromes (ACS). METHODS: During 2004-2007, all consecutive prehospitally triaged patients with suspected ACS were prospectively included. Prehospital and emergency data were collected at point of care. Data from medical records, ECG-, echocardiography- and laboratory databases was collected retrospectively. RESULTS: In all, 2757 patients were included. Out of these 858 were directly admitted to the CCU or cath/lab. Predictors for direct admittance to the CCU were ST-segment elevation on the initial ECG; odds ratio (OR) 46.11, left bundle branch block; OR 3.30, ongoing symptoms; OR 2.90, current smoking; OR 2.18 and ST-segment depression; OR 2.05. Independent predictors for 1-year mortality were cardiogenic shock; OR 14.40, increasing age OR (per year) 1.08, diabetes; OR 2.09 and chronic heart failure; OR 1.67. ST-segment elevation was associated with a lower 1-year mortality rate; OR 0.52. CONCLUSIONS: Among patients with a suspected ACS, prehospital ECG-signs indicating an acute coronary occlusion were not only a predictor for direct admission to acute coronary care but also a predictor for increased survival. To improve future outcome in acute ischemic heart diseases we must find and treat not only the STEMI's but also the high-risk NSTEMIs that otherwise would have a poor prognosis.

  • 55. Ravn-Fischer, A
    et al.
    Karlsson, T
    Santos, M
    Bergman, B
    Johasson, P
    Herlitz, J
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Chain of care in chest pain-differenes beteen three hospitals in an urban area.2013Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 166, nr 2, s. 440-7Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    AIM: To describe differences in treatment and delay times in acute chest pain at the three hospitals in Göteborg, Sweden. METHODS: All patients admitted to the three hospitals within Sahlgrenska University (SU) (Sahlgrenska: SU/S, Östra: SU/Ö and Mölndal: SU/M) with acute chest pain during 3 months in 2008 were evaluated for diagnosis, early treatment and outcome. RESULTS: In all, 2588 visits by 2393 patients were included (visits n=1253 SU/S; n=853 SU/Ö; n=482 SU/M) of which 50%, 63% and 51% were hospitalised (p<0.0001). Among hospitalised patients, a diagnosis of ACS was reported in 26%, 9% and 22% respectively (p<0.0001). Among ACS patients, 83%, 66% and 57% respectively underwent coronary angiography (p=0.004). The median delay to coronary angiography in ST-elevation myocardial infarction (STEMI) was 42 min at SU/S, 3h 47 min at SU/Ö and 2h 34 min at SU/M (p=0.008). The corresponding values for coronary angiography in unstable coronary artery disease were 42h 7min, 48h 35 min and 123h 42 min (p=0.007). Overall mortality at 30 days was 3.6%, 3.2% and 1.5% (NS) and, at 1 year, it was 9.9%, 9.6% and 7.3% respectively (NS). CONCLUSION: In acute chest pain in the Municipality of Göteborg, there was a marked difference between hospitals in: 1) the percentage of hospitalised patients, 2) the percentage of ACS among hospitalised patients and 3) the delay to and rate of coronary angiography. The clinical consequences of these deviations remain to be proven.

  • 56. Rawshani, A
    et al.
    Larsson, A
    Gelang, C
    Lindqvist, J
    Gellerstedt, M
    Bång, A
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Herlitz, J
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Characteristics and outcome among patients who dial for the EMS due to chest pain2014Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 176, nr 3, s. 859-865Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: This study aims to describe patients who called for the emergency medical service (EMS) due to chest discomfort, in relation to gender and age. METHODS: All patients who called the emergency dispatch centre of western Sweden due to chest discomfort, between May 2009 and February 2010, were included. Initial evaluation, aetiology and outcome are described as recorded in the databases at the dispatch centre, the EMS systems and hospitals. Patients were divided into the following age groups: ≤50, 51-64 and ≥65 years. RESULTS: In all, 14,454 cases were enrolled. Equal proportions of men (64%) and women (63%) were given dispatch priority 1. The EMS clinicians gave priority 1 more frequently to men (16% versus 12%) and older individuals (10%, 15% and 14%, respective of age group). Men had a significantly higher frequency of central chest pain (83% versus 81%); circulatory compromise (34% versus 31%); ECG signs of ischaemia (17% versus 11%); a preliminary diagnosis of acute coronary syndrome (40% versus 34%); a final diagnosis of acute myocardial infarction (14% versus 9%) and any potentially life-threatening condition (18% versus 12%). Individuals aged ≥65 years were given a lower priority than individuals aged 51-64 years, despite poorer characteristics and outcome. In all, 78% of cases with a potentially life-threatening condition and 67% of cases that died within 30 days of enrolment received dispatch priority 1. Mortality at one year was 1%, 4% and 18% in each individual age group. CONCLUSION: Men and the elderly were given a disproportionately low priority by the EMS.

  • 57.
    Rawshani, Araz
    et al.
    Sahlgrenska University Hospital.
    Rawshani, Nina
    Sahlgrenska University Hospital.
    Gelang, Carita
    Sahlgrenska University Hospital.
    Andersson, Jan-Otto
    Sahlgrenska University Hospital.
    Larsson, Anna
    University of Gothenburg.
    Bång, Angela
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Gellerstedt, Martin
    University West.
    Emergency medical dispatch priority in chest pain patients due to life threatening conditions: A cohort study examining circadian variations and impact of the education.2017Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 236, s. 43-48, artikkel-id S0167-5273(16)32916-3Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND AND AIMS: We examined the accuracy in assessments of emergency dispatchers according to their education and time of the day. We examined this in chest pain patients who were diagnosed with a potentially life-threatening condition (LTC) or died within 30days.

    METHODS: Among 2205 persons, 482 died, 1631 experienced an acute coronary syndrome (ACS), 1914 had a LTC. Multivariable logistic regression was used to study how time of the call and the dispatcher's education were associated with the risk of missing to give priority 1 (the highest).

    RESULTS: Among patients who died, a 7-fold increase in odds of missing to give priority 1 was noted at 1.00pm, as compared with midnight. Compared with assistant nurses, odds ratio for dispatchers with no (medical) training was 0.34 (95% CI 0.14 to 0.77). Among patients with an ACS, odds ratio for calls arriving before lunch was 2.02 (95% CI 1.22 to 3.43), compared with midnight. Compared with assistant nurses, odds ratio for operators with no training was 0.23 (95% CI 0.13 to 0.40). Similar associations were noted for those with any LTC. Dispatcher's education was not associated with the patient's survival.

    CONCLUSIONS: In this group of patients, which experience substantial mortality and morbidity, the risk of not obtaining highest dispatch priority was increased up to 7-fold during lunchtime. Dispatch operators without medical education had the lowest risk, compared with nurses and assistant nurses, of missing to give priority 1, at the expense of lower positive predictive value.

    KEY MESSAGES: What is already known about this subject? Use of the emergency medical service (EMS) increases survival among patients with acute coronary syndromes. It is unknown whether the efficiency - as judged by the ability to identify life-threatening cases among patients with chest pain - varies according to the dispatcher's educational level and the time of day. What does this study add? We provide evidence that the dispatcher's education does not influence survival among patients calling the EMS due to chest discomfort. However, medically educated dispatchers are at greatest risk of missing to identify life-threatening cases, which is explained by more parsimonious use of the highest dispatch priority. We also show that the risk of missing life-threatening cases is at highest around lunch time. How might this impact on clinical practice? Dispatch centers are operated differently all over the world and chest discomfort is one of the most frequent symptoms encountered; we provide evidence that it is safe to operate a dispatch center without medically trained personnel, who actually miss fewer cases of acute coronary syndromes. However, non-medically trained dispatchers consume more pre-hospital resources.

  • 58.
    Rawshani, Nina
    et al.
    Sahlgrenska University Hospital.
    Rawshani, Araz
    Sahlgrenska University Hospital.
    Gelang, Carita
    Sahlgrenska University Hospital.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Bång, Angela
    Sahlgrenska University Hospital.
    Andersson, Jan-Otto
    Department of Ambulance and Prehospital Emergency Care.
    Gellerstedt, Martin
    University West.
    Association between use of pre-hospital ECG and 30-day mortality: A large cohort study of patients experiencing chest pain.2017Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 248, s. 77-81, artikkel-id S0167-5273(17)30115-8Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: In the assessment of patients with chest pain, there is support for the use of pre-hospital ECG in the literature and in the care guidelines. Using propensity score methods, we aim to examine whether the mere acquisition of a pre-hospital ECG among patients with chest pain affects the outcome (30-day mortality).

    METHODS: The association between pre-hospital ECG and 30-day mortality was studied in the overall cohort (n=13151), as well as in the one-to-one matched cohort with 2524 patients not examined with pre-hospital ECG and 2524 patients examined with pre-hospital ECG.

    RESULTS: In the overall cohort, 21% (n=2809) did not undergo an ECG tracing in the pre-hospital setting. Among those who had pain during transport, 14% (n=1159) did not undergo a pre-hospital ECG while 32% (n=1135) of those who did not have pain underwent an ECG tracing. In the overall cohort, the OR for 30-day mortality in patients who had a pre-hospital ECG, as compared with those who did not, was 0.63 (95% CI 0.05-0.79; p<0.001). In the matched cohort, the OR was 0.65 (95% CI 0.49-0.85; p<0.001). Using the propensity score, in the overall cohort, the corresponding HR was 0.65 (95% CI 0.58-0.74).

    CONCLUSION: Using propensity score methods, we provide real-world data demonstrating that the adjusted risk of death was considerably lower among the cases in whoma pre-hospital ECG was used. The PH-ECG is underused among patients with chest discomfort and the mere acquisition of a pre-hospital ECG may reduce mortality.

  • 59. Rawshani, Nina
    et al.
    Rawshani, Araz
    Gelang, Carita
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Bång, Angela
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Andersson, Jan-Otto
    Gellerstedt, Martin
    Could ten questions asked by the dispatch center predict the outcome for patients with chest discomfort?2016Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 209, s. 223-225Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND AND AIMS: From 2009 to 2010, approximately 14,000 consecutive persons who called for the EMS due to chest discomfort were registered. From the seventh month, dispatchers ask 2285 patient ten pre-specified questions. We evaluate which of these questions was independently able to predict an acute coronary syndrome (ACS), life-threatening condition (LTC) and death.

    METHODS: The questions asked mainly dealt with previous history and type of symptoms, each with yes/no answers. The dispatcher took a decision on priority; 1) immediately with sirens/blue light; 2) EMS on the scene within 30min; 3) normal waiting time.We examined the relationship between the answers to these questions and subsequent dispatch priority, as well as outcome, in terms of ACS, LTC and all-cause mortality.

    RESULTS: 2285 patients (mean age 67years, 49% women) took part, of which 12% had a final diagnosis of ACS and 15% had a LTC. There was a significant relationship between all the ten questions and the priority given by dispatchers. Localisation of the discomfort to the center of the chest, more intensive pain, history of angina or myocardial infarction as well as experience of cold sweat were the most important predictors when evaluating the probability of ACS and LTC. Not breathing normally and having diabetes were related to 30-day mortality.

    CONCLUSIONS: Among individuals, who call for the EMS due to chest discomfort, the intensity and the localisation of the pain, as well as a history of ischemic heart disease, appeared to be the most strongly associated with outcome.

  • 60. Sjöland, H
    et al.
    Caidahl, K
    Karlson, BW
    Karlsson, T
    Herlitz, Johan
    [external].
    Limitation of physical activity, dyspnea and chest pain before and two years after coronary artery bypass grafting in relation to sex1997Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 61, nr 2, s. 123-133Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Aim: To describe the limitation of physical activity and its causes, and symptoms of dyspnea and chest pain prior to and during two years after coronary artery bypass grafting (CABG) in relation to sex. Methods: All patients from western Sweden who underwent CABG between June 1988 and June 1991 were approached with a questionnaire prior to, three months and two years after CABG evaluating the issues raised above. Results: In all, 2121 patients were operated on, of which 81% were males. Physical activity was significantly improved and symptoms of chest pain and dyspnea were significantly reduced in both men and women after CABG. The improvement was significantly greater in males than in females even after adjustment for preoperative differences between the sexes. Conclusion: There was an improvement for both men and women in terms of limitations for physical activity and cardiovascular symptoms three months and two years after CABG as compared with prior to the operation. Female patients suffered from significantly more symptoms of chest pain and dyspnea and limitations in physical activity after CABG than men, also when adjustment was made for preoperative differences between the sexes.

  • 61. Sjöland, H
    et al.
    Wiklund, I
    Caidahl, K
    Albertsson, P
    Herlitz, Johan
    [external].
    Relationship between quality of life and exercise test findings after coronary artery bypass surgery1995Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 51, nr 3, s. 221-232Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    We studied the correlation between quality of life and exercise testing in 554 patients 2 years after coronary artery bypass surgery. Quality of life constitutes a person's perceptions of physical and mental functional capacity, health and symptoms. Traditionally, evaluations after coronary bypass surgery have focused on physical performance, medication and anginal symptoms, which cannot be said to represent quality of life. We used the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index for evaluation of quality of life. Significant correlations were found between quality of life and exercise capacity (P < 0.0001), and quality of life and chest pain at exercise for all questionnaires (P < 0.0001). Significant correlations, although of small or moderate magnitude, were found between exercise capacity, chest pain and most subscales of quality of life, with the highest correlation coefficients for dimensions reflecting physical abilities and pain. We conclude that quality of life correlates significantly with exercise capacity and chest pain during exercise 2 years after coronary bypass surgery. However, only dimensions of pain and physical performance are reasonably well correlated with exercise test results. Several aspects of quality of life are only weakly related to exercise test results and may escape identification in an exercise test.

  • 62. Svensson, A-M
    et al.
    Dellborg, M
    Abrahamsson, P
    Karlsson, T
    Herlitz, Johan
    Högskolan i Borås, Institutionen för Vårdvetenskap. [external].
    Duval, SJ
    Berger, AK
    Luepker, RV
    The influence of a history of diabetes on treatment and outcome in acute myocardial infarction, during two time periods and in two different countries.2007Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 119, nr 3, s. 319-325Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    AIMS: The aim of this study was to investigate the influence of diabetes on treatment and outcome in acute myocardial infarction (AMI), during two time periods, in two countries, and to assess whether this influence has changed over the past decades. METHODS: Patients, aged 30 to 74, with a diagnosis of AMI in two urban areas--Göteborg, Sweden and Minneapolis-St. Paul, Minnesota, USA--hospitalized during 1990-1991 and 1995-1996 were included. The primary endpoint was 7-year all-cause mortality. RESULTS: The study included 3824 patients, 734 (19%) had diabetes. Age-adjusted in-hospital mortality of diabetic patients was nearly twofold higher compared with non-diabetic patients (9.8% vs. 5.0%, p<0.05). Between 1990-1991 and 1995-1996 in-hospital mortality declined for both diabetic (11.9% vs. 7.6%, p=0.07) and non-diabetic (6.3% vs. 3.6%, p=0.002) patients. A history of diabetes was associated with nearly twofold higher long-term mortality rate (48.5% vs. 26%, p<0.05). Seven-year mortality was reduced between 1990-1991 and 1995-1996 in both diabetic (51.6% vs. 45.2%, p=0.13) and non-diabetic patients (29.3% vs. 22.1%, p<0.0001) (The results did not reach statistical significance for diabetic patients, due to smaller sample size.) During their hospital stay, diabetic patients received significantly less aspirin, beta-blockers and thrombolysis. After adjustment, a history of diabetes remained significantly associated with 7-year mortality following AMI, doubling the hazard of death (hazard ratio (HR)=2.11; 95% confidence interval (CI): 1.80-2.46). CONCLUSION: A history of diabetes is associated with nearly twofold higher long-term mortality rate and is independently associated with 7-year mortality following AMI. Short- and long-term mortality decreased from 1990 to 1995 in both non-diabetic and diabetic patients. Underutilization of evidence-based treatments contributes to the remaining increased mortality in diabetic patients with acute coronary disease.

  • 63. Svensson, L
    et al.
    Axelsson, C
    [external].
    Nordlander, R
    Herlitz, Johan
    [external].
    Prehospital identification of acute coronary syndrome/myocardial infarction in relation to ST elevation2005Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 98, nr 2, s. 237-244Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    AIM: To evaluate factors that identify patients with an acute coronary syndrome/myocardial infarction prior to hospital admission among patients with a suspected acute coronary syndrome who were transported by ambulance with and without ST elevation on the ambulance electrocardiogram (ECG). METHODS: This was a prospective observational study in the part of Stockholm that is served by South Hospital ambulance organisation and the Municipality of Goteborg. All the patients who called for an ambulance due to acute chest pain or other symptoms raising the suspicion of an acute coronary syndrome took part. Immediately after the arrival of the ambulance, a blood sample was drawn for the analysis of serum myoglobin, creatine kinase (CK) MB and troponin I. A 12-lead ECG was simultaneously recorded. Further factors that were taken into consideration were age, gender, history of cardiovascular disease, symptoms and clinical findings. RESULTS: In patients with ST elevation in prehospital ECG, the likelihood of an acute myocardial infarction increased if there were simultaneous ST depression in other leads (OR 3.94, 95% CL 1.26-12.38). For patients without an ST elevation, the likelihood of an acute myocardial infarction increased if there were: elevation of any biochemical marker OR 2.96, 95% CL 1.32-6.64; ST depression (OR 2.54, 95% CL 1.43-4.51), T-inversion (OR 2.22, 95% CL 1.10-4.48), male gender (OR 2.21, 95% CL 1.24-3.93) and increasing age (OR 1.04, 95% CL 1.01-1.06). CONCLUSION: Among patients with a suspected acute coronary syndrome, factors that increased the likelihood for an ongoing acute myocardial infarction could already be defined prior to hospital admission. For those with an ST elevation, factors were found in ECG pattern. For those without an ST elevation, such factors were found in elevation of biochemical markers, admission ECG, male gender and increasing age.

  • 64. Svensson, L
    et al.
    Karlsson, T
    Nordlander, R
    Wahlin, M
    Zedigh, C
    Herlitz, Johan
    [external].
    Implementation of prehospital thrombolysis in Sweden. Components of delay until delivery of treatment and examination of treatment feasibility2003Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 88, nr 2-3, s. 247-256Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVE: To evaluate the feasibility of prehospital thrombolysis in Sweden in terms of safety and to examine the various components of the delay between onset of symptoms and start of treatment. SETTING: A total of 16 hospitals in Sweden in both urban and less populated areas and the associated ambulance organisations. DESIGN: Prospective evaluation of patients with an ST-elevation infarction treated with reteplase. An ECG was recorded and transmitted to hospital. The ambulances were staffed by a physician in 1% of cases, a nurse in 67% and a staff nurse in 32%. RESULTS: Of the 148 patients who received treatment prior to hospital admission, six (4%) had a cardiac arrest prior to hospital admission and two (1%) died prior to arrival at hospital. One patient was given treatment despite an exclusion criterion (previous stroke) and died on the 1st day in hospital due to a cerebral haemorrhage. The overall 30-day mortality was 7.1% and 1-year mortality 9.8%. Treatment was initiated within 2 h after the onset of symptoms in 53% of patients and within 1 h in 17% of patients. The median interval between the arrival of the ambulance and sending an ECG was 13 min and the median interval between sending an ECG and the start of thrombolysis was 18 min. The delay was similar regardless of ambulance staff. CONCLUSION: Implementation of prehospital thrombolysis on a national basis in Sweden appears to be safe. More than half the patients can be given treatment less than 2 h after the onset of symptoms. There is potential for reducing this time still further.

  • 65. Svensson, L
    et al.
    Nordlander, E
    Axelsson, C
    [external].
    Herlitz, Johan
    [external].
    Are predictors for myocardial infarction the same for women and men when evaluated prior to hospital admission?2006Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 109, nr 2, s. 241-247Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    AIM: To describe predictors of myocardial infarction prior to hospital admission in women and men among patients with a suspected acute coronary syndrome without ST-elevation. DESIGN: Prospective observational study in Stockholm and Göteborg, Sweden. RESULTS: Of 433 patients who did fulfill the inclusion criteria 45% were women. Fewer women (17%) than men (26%) developed acute myocardial infarction (AMI) (p=0.054), particularly among patients with initial ST-depression, in whom AMI was developed in 22% of women and 54% of men (p = 0.001). Predictors for infarct development in women were: a history of AMI and advanced age. Among men they were: initial ST-depression or a Q-wave on ECG and elevation of biochemical markers (both recorded on admission of the ambulance crew). There was a significant interaction between gender and the influence of ST-depression on the risk for development of myocardial infarction (p < 0.05). CONCLUSION: Among patients transported with ambulance due to a suspected acute coronary syndrome and no ST-elevation fewer women than men seem to develop AMI particularly among patients with ST-depression. These results suggest that early prediction of myocardial infarction might differ between women and men with acute chest pain.

  • 66. Thang, ND
    et al.
    Karlsson, BW
    Bergman, B
    Santos, M
    Karlsson, T
    Benttson, A
    Johanson, P
    Rawshani, A
    Herlitz, J
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Patients admitted to hospital with chest pain-changes in a 20 year perspective.2013Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 166, nr 1, s. 141-146Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: To describe the differences in characteristics and outcome between two consecutive series of patients admitted to hospital with chest pain in a 20-year perspective. Particular emphasis is placed on changes in outcome in relation to the initial electrocardiogram (ECG). SUBJECTS: In the two periods, 1986-1987 and 2008, all patients with chest pain admitted to the study hospitals in Gothenburg, Sweden, were included. RESULTS: Five thousand and sixteen patients were registered in a period of 21 months in 1986-1987 and 2287 patients were registered during 3 months in 2008. In a comparison of the two time periods, the age of chest pain patients was not significantly different (mean age 60.1 ± 17.8 years in 1986-1987 and 59.8 ± 19.1 years in 2008, p=0.50). There was a lower prevalence of previous angina pectoris, congestive heart failure and current smoking in the second period, whereas a history of acute myocardial infarction, hypertension and diabetes mellitus had become more prevalent. The use of cardio-protective drugs increased and ECG changes indicating acute myocardial ischemia on admission to hospital decreased. Length of hospitalisation was reduced from a median of 5 days to 3 days (p<0.0001). A significant decrease in 30-day and 1-year mortality was found (3.8% in 1986-1987 vs 2.0% in 2008 and 9.9% vs 6.3% respectively, p<0.0001 for both comparisons). CONCLUSIONS: During a period of 20 years, the characteristics and outcome of patients admitted to hospital with chest pain changed. The most important changes were a lower prevalence of ECG signs indicating acute myocardial ischemia on admission, shorter hospitalisation time and a lower 30-day and 1-year mortality.

  • 67.
    Thang, Nguyen Dang
    et al.
    Göteborgs Universitet.
    Karlson, Björn Wilgot
    Wireklint Sundström, Birgitta
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Karlsson, Thomas
    Herlitz, Johan
    Pre-hospital prediction of death or cardiovascular complications during hospitalisation and death within one year in suspected acute coronary syndrome patients.2015Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 185, s. 308-312Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    OBJECTIVES: To identify pre-hospital predictors of a) death or the development of cardiovascular complications during hospitalisation (primary objective) and b) all-cause death during one year of follow-up (secondary objective), in chest pain patients with suspected acute coronary syndrome (ACS).

    METHODS: A prospective study that comprised patients in western Sweden, who were transported to hospital by the emergency medical service (EMS) due to chest pain and suspected ACS. Multiple logistic regression was used to identify independent predictors of adverse outcomes.

    RESULTS: Among all 1600 eligible patients, 21% died or had a cardiovascular complication during hospitalisation and 10% died during one year of follow-up. Nine factors were identified pre-hospitalisation as independent predictors of death or cardiovascular complications during hospitalisation. They were increasing age, a history of congestive heart failure, nausea and/or vomiting, rapid breathing rate, low oxygen saturation, high heart rate, together with ST-segment elevation, ST-segment depression and right bundle branch block on the pre-hospital electrocardiogram (ECG). For the secondary objective of death during one year of follow-up, the following five factors were identified as independent predictors: increasing age, a history of congestive heart failure, dyspnea, low oxygen saturation and left bundle branch block on the pre-hospital ECG.

    CONCLUSIONS: In the pre-hospital setting of chest pain and suspected ACS, we identified nine predictors of the primary adverse outcome. They were factors representing previous history, symptoms and ECG findings. This information may contribute to the development of a decision support system for the EMS, which then needs to be clinically tested.

  • 68. Wibring, Kristoffer
    et al.
    Herlitz, Johan
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Christensson, Lennart
    Lingman, Markus
    Bång, Angela
    Högskolan i Borås, Akademin för vård, arbetsliv och välfärd.
    Prehospital factors associated with an acute life-threatening condition in non-traumatic chest pain patients - A systematic review.2016Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 219, s. 373-379Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    BACKGROUND: Chest pain is a common symptom among patients contacting the emergency medical services (EMS). Risk stratification of these patients is warranted before arrival in hospital, regarding likelihood of an acute life-threatening condition (LTC).

    AIM: To identify factors associated with an increased risk of acute LTC among patients who call the EMS due to non-traumatic chest pain.

    METHODS: Several databases were searched for relevant articles. Identified articles were quality-assessed using the Scottish Intercollegiate Guidelines Network checklists. Extracted data was analysed using a semi-quantitative synthesis evaluating the level of evidence of each identified factor.

    RESULTS: In total, 10 of 1245 identified studies were included. These studies provided strong evidence for an increased risk of an acute LTC with increasing age, male gender, elevated heart rate, low systolic blood pressure and ST elevation or ST depression on a 12-lead ECG. The level of evidence regarding the history of myocardial infarction, angina pectoris or presence of a Q wave or a Left Bundle Branch Block on the ECG was moderate. The evidence was inconclusive regarding dyspnoea, cold sweat/paleness, nausea/vomiting, history of chronic heart failure, smoking, Right Bundle Branch Block or T-inversions on the ECG.

    CONCLUSIONS: Factors reflecting age, gender, myocardial ischemia and a compromised cardiovascular system predicted an increased risk of an acute life-threatening condition in the prehospital setting in cases of acute chest pain. These factors may form the basis for prehospital risk stratification in acute chest pain.

  • 69.
    Wireklint Sundström, Birgitta
    et al.
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Bång, Angela
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Karlsson, Thomas
    Winge, Karin
    Lundberg, Camilla
    Herlitz, Johan
    Högskolan i Borås, Institutionen för Vårdvetenskap.
    Anxiolytics in patients suffering a suspected acute coronary syndrome: Multi-centre randomised controlled trial in Emergency Medical Service2013Inngår i: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 168, nr 4, s. 3580-3587Artikkel i tidsskrift (Fagfellevurdert)
    Abstract [en]

    Background: The prehospital treatment of pain and discomfort among patients who suffer from acute coronary syndrome (ACS) needs a treatment strategy which combines relief of pain with relief of anxiety. Aim: The aim of the present study was to evaluate the impact on pain and anxiety of the combination of an anxiolytic and an analgesic as compared with an analgesic alone in the prehospital setting of suspected ACS. Methods: A multi-centre randomised controlled trial compared the combination of Midazolam (Mi) + Morphine (Mo) and Mo alone. All measures took part: Prior to randomisation, 15 min thereafter and on admission to a hospital. Inclusion criteria were: 1) pain raising suspicion of ACS and 2) pain score ≥4. Primary endpoint: Pain score after 15 min. Results: In all, 890 patients were randomised to Mi + Mo and 873 to Mo alone. Pain was reduced from a median of 6 to 4 and finally to 3 in both groups. The mean dose of Mo was 5.3 mg in Mi + Mo and 6.0 mg in Mo alone (p b 0.0001). Anxiety was reported in 66% in Mi + Mo and in 64% in Mo alone at randomisation (NS); 15 min thereafter in 31% and 39% (p = 0.002) and finally in 12% and 26% respectively (p b 0.0001). On admission to a hospital nausea or vomiting was reported in 9% in Mi + Mo and in 13% in Mo alone (p = 0.003). Drowsiness differed; 15% and 14% were drowsy in Mi + Mo versus 2% and 3% in Mo alone respectively (p b 0.001). Conclusion: Despite the fact that the combination of anxiolytics and analgesics as compared with analgesics alone reduced anxiety and the requirement of Morphine in the prehospital setting of acute coronary syndrome, this strategy did not reduce patients' estimation of pain (primary endpoint). More effective pain relief among these patients is warranted.

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