Niels Peter Sand

Women with acute coronary syndrome are less invasively examined and subsequently less treated than men

AIMS To investigate if gender bias is present in todays setting of an early invasive strategy for patients with acute coronary syndrome in Denmark (population 5 million). METHODS AND RESULTS We identified all patients admitted to Danish hospitals with acute coronary syndrome in 2005-07 (9561 women and 16 406 men). Cox proportional hazard models were used to estimate the gender differences in coronary angiography (CAG) rate and subsequent revascularization rate within 60 days of admission. Significantly less women received CAG (cumulative incidence 64% for women vs. 78% for men, P < 0.05), with a hazard ratio (HR) of 0.68 (95% CI 0.65-0.70, P < 0.0001) compared with men. The difference was narrowed after adjustment for age and comorbidity, but still highly significant (HR 0.82, 95% CI 0.80-0.85, P < 0.0001). Revascularization after CAG was less likely in women with an HR of 0.68 (95% CI 0.66-0.71, P < 0.0001) compared with men. More women (22%) than men (10%) (P < 0.0001) had no significant stenosis on their coronary angiogram. However, after adjustment for the number of significant stenoses, age, and comorbidity women were still less likely to be revascularized (HR 0.91, 95% CI 0.87-0.95, P < 0.0001). CONCLUSION Women with ACS are approached in a much less aggressively invasive way and receive less interventional treatment than men even after adjusting for differences in comorbidity and number of significant stenoses.

Discrepancy between coronary artery calcium score and HeartScore in middle-aged Danes: the DanRisk study

Background: Coronary artery calcification (CAC) is an independent and incremental risk marker. This marker has previously not been compared to the HeartScore risk model. Design: A random sample of 1825 citizens (men and women, 50 or 60 years of age) was invited for screening. Methods: Using the HeartScore model, the 10-year risk of fatal cardiovascular events based on gender, age, smoking, systolic blood pressure, and total cholesterol was estimated. A low risk was defined as <5%. The CAC score was calculated from a non-contrast enhanced cardiac-CT scan and given in Agatston U. Results: A total of 1257 (69%) of the invited subjects were interested in the screening. Due to previous cardiovascular disease or diabetes mellitus, 101 were excluded. Of the remaining 1156, 47% were men and 53% women; one half were 50 years old and the other half 60 years old. A low HeartScore was found in 901 of which 334 (37%) had CAC. A high HeartScore was recorded in 251 of which 80 (32%) did not have any CAC. High HeartScores and CAC were significantly more common in males than females. Conclusions: CAC is common in healthy middle-aged Danes with a low HeartScore, and, on the contrary, high-risk subjects very frequently do not have CAC. The therapeutic and prognostic implications of these observations remain to be clarified.

In-hospital resuscitation evaluated by in situ simulation: a prospective simulation study

BackgroundInterruption in chest compressions during cardiopulmonary resuscitation can be characterized as no flow ratio (NFR) and the importance of minimizing these pauses in chest compression has been highlighted recently. Further, documentation of resuscitation performance has been reported to be insufficient and there is a lack of identification of important issues where future efforts might be beneficial. By implementing in situ simulation we created a model to evaluate resuscitation performance. The aims of the study were to evaluate the feasibility of the applied method, and to examine differences in the resuscitation performance between the first responders and the cardiac arrest team.MethodsA prospective observational study of 16 unannounced simulated cardiopulmonary arrest scenarios was conducted. The participants of the study involved all health care personel on duty who responded to a cardiac arrest. We measured NFR and time to detection of initial rhythm on defibrillator and performed a comparison between the first responders and the cardiac arrest team.ResultsData from 13 out of 16 simulations was used to evaluate the ability of generating resuscitation performance data in simulated cardiac arrest. The defibrillator arrived after median 214 seconds (180-254) and detected initial rhythm after median 311 seconds (283-349). A significant difference in no flow ratio (NFR) was observed between the first responders, median NFR 38% (32-46), and the resuscitation teams, median NFR 25% (19-29), p < 0.001. The difference was significant even after adjusting for pulse and rhythm check and shock delivery.ConclusionThe main finding of this study was a significant difference between the first responders and the cardiac arrest team with the latter performing more adequate cardiopulmonary resuscitation with regards to NFR. Future research should focus on the educational potential for in-situ simulation in terms of improving skills of hospital staff and patient outcome.

Soluble urokinase plasminogen activator receptor is in contrast to high-sensitive C-reactive-protein associated with coronary artery calcifications in healthy middle-aged subjects

OBJECTIVE The main objective of this study was to investigate the association between two markers of low-grade inflammation; soluble urokinase plasminogen activator receptor (suPAR) and high-sensitive C-reactive protein (hs-CRP); and coronary artery calcification (CAC) score detected by cardiac computed tomography (CT) scan. DESIGN A cross sectional study of 1126 randomly sampled middle-aged men and women. METHODS CAC score was measured by a non-contrast cardiac CT scan and total 10-year cardiovascular mortality risk was estimated using the Systematic Coronary Risk Evaluation (SCORE). Plasma samples were analysed for suPAR and hs-CRP. The association of suPAR and hs-CRP to CAC was evaluated by logistic regression analyses adjusting for categorised SCORE. The additive effect of suPAR to SCORE was evaluated by comparing area under curve (AUC) and net reclassification improvement (NRI). RESULTS The odds of being in a higher CAC category, i.e. having more severe CAC, increased 16% (odds ratio (OR) 1.16, p = 0.02) when plasma suPAR concentration increased 1 ng/ml, and this was more pronounced in women (OR 1.30, p = 0.01) than in men (OR 1.15, p = 0.05). In comparison, hs-CRP was not associated with CAC category (OR 1.00, p = 0.90). When adding suPAR to categorised SCORE, AUC increased from 0.66 to 0.70 (p = 0.04) in women and from 0.65 to 0.68 (p = 0.03) in men. NRI was significant in men (NRI 19.3%, 95% CI 6.1-32.6, p = 0.004) as well as in women (NRI 20.8%, 95%CI 1.0-40.7, p = 0.04), without significant gender difference. CONCLUSIONS suPAR, but not hs-CRP, appeared to be associated with CAC score independently of SCORE. The association was strongest in women.

The relation between coronary artery calcification in asymptomatic subjects and both traditional risk factors and living in the city centre: a DanRisk substudy

Abstract.  Lambrechtsen J, Gerke O, Egstrup K, Sand NP, Nørgaard BL, Petersen H, Mickley H, Diederichsen ACP (Svendborg Hospital, Svendborg; Odense University Hospital, Odense; SVS, Esbjerg; Institute of Regional Health Services Research, University of Southern Denmark; Vejle Hospital, Vejle; and Odense University Hospital, Odense, Denmark). The relation between coronary artery calcification in asymptomatic subjects and both traditional risk factors and living in the city centre: a DanRisk substudy. J Intern Med 2012; 271: 444–450.

The Western Denmark Cardiac Computed Tomography Registry: a review and validation study

Background As a subregistry to the Western Denmark Heart Registry (WDHR), the Western Denmark Cardiac Computed Tomography Registry (WDHR-CCTR) is a clinical database established in 2008 to monitor and improve the quality of cardiac computed tomography (CT) in Western Denmark. Objective We examined the content, data quality, and research potential of the WDHR-CCTR. Methods We retrieved 2008–2012 data to examine the 1) content; 2) completeness of procedure registration using the Danish National Patient Registry as reference; 3) completeness of variable registration comparing observed vs expected numbers; and 4) positive predictive values as well as negative predictive values of 19 main patient and procedure variables. Results By December 31, 2012, almost 22,000 cardiac CTs with up to 40 variables for each procedure have been registered. Of these, 87% were coronary CT angiography performed in patients with symptoms indicative of coronary artery disease. Compared with the Danish National Patient Registry, the overall procedure completeness was 72%. However, an additional medical record review of 282 patients registered in the Danish National Patient Registry, but not in the WDHR-CCTR, showed that coronary CT angiographies accounted for only 23% of all nonregistered cardiac CTs, indicating >90% completeness of coronary CT angiographies in the WDHR-CCTR. The completeness of individual variables varied substantially (range: 0%–100%), but was >85% for more than 70% of all variables. Using medical record review of 250 randomly selected patients as reference standard, the positive predictive value for the 19 variables ranged from 89% to 100% (overall 97%), whereas the negative predictive value ranged from 97% to 100% (overall 99%). Stratification by center status showed consistently high positive and negative predictive values for both university (96%/99%) and nonuniversity centers (97%/99%). Conclusion WDHR-CCTR provides ongoing prospective registration of all cardiac CTs performed in Western Denmark since 2008. Overall, the registry data have a high degree of completeness and validity, making it a valuable tool for clinical epidemiological research.

Prognostic assessment of stable coronary artery disease as determined by coronary computed tomography angiography: a Danish multicentre cohort study

Aims To examine the 3.5 year prognosis of stable coronary artery disease (CAD) as assessed by coronary computed tomography angiography (CCTA) in real-world clinical practice, overall and within subgroups of patients according to age, sex, and comorbidity. Methods and results This cohort study included 16,949 patients (median age 57 years; 57% women) with new-onset symptoms suggestive of CAD, who underwent CCTA between January 2008 and December 2012. The endpoint was a composite of late coronary revascularization procedure >90 days after CCTA, myocardial infarction, and all-cause death. The Kaplan–Meier estimator was used to compute 91 day to 3.5 year risk according to the CAD severity. Comparisons between patients with and without CAD were based on Cox-regression adjusted for age, sex, comorbidity, cardiovascular risk factors, concomitant cardiac medications, and post-CCTA treatment within 90 days. The composite endpoint occurred in 486 patients. Risk of the composite endpoint was 1.5% for patients without CAD, 6.8% for obstructive CAD, and 15% for three-vessel/left main disease. Compared with patients without CAD, higher relative risk of the composite endpoint was observed for non-obstructive CAD [hazard ratio (HR): 1.28; 95% confidence interval (CI): 1.01–1.63], obstructive one-vessel CAD (HR: 1.83; 95% CI: 1.37–2.44), two-vessel CAD (HR: 2.97; 95% CI: 2.09–4.22), and three-vessel/left main CAD (HR: 4.41; 95% CI :2.90–6.69). The results were consistent in strata of age, sex, and comorbidity. Conclusion Coronary artery disease determined by CCTA in real-world practice predicts the 3.5 year composite risk of late revascularization, myocardial infarction, and all-cause death across different groups of age, sex, or comorbidity burden.

Coronary calcification among 3477 asymptomatic and symptomatic individuals

Background Coronary artery calcification (CAC) can be detected by cardiac computed tomography (CT), is associated to cardiovascular risk, and common in asymptomatic individuals and patients referred for cardiac CT. Design CAC was evaluated in asymptomatic individuals and symptomatic patients referred for cardiac CT, to assess whether differences in CAC may be explained by symptoms or traditional cardiovascular risk factors. Methods The presence and extent of CAC, gender, family history of coronary artery disease, hypertension, hyperlipidaemia, diabetes and tobacco were compared in 1220 asymptomatic individuals aged 49–61 years and 2257 age-matched symptomatic patients referred for cardiac CT with suspected coronary artery disease. Results Symptomatic individuals had a higher frequency of a family history of coronary artery disease (46% vs. 23%, p < 0.001), hypertension (38% vs. 21%, p < 0.001), hyperlipidaemia (42% vs. 12%, p < 0.001), a trend for more diabetes (6% vs. 5%, p = 0.05), but no significant difference was observed for the presence of CAC (Agatston > 0; 45% vs. 45%, p = 0.94) or severe calcifications (Agatston > 400; 6% vs. 5%, p = 0.36). In multivariate analyses age (odds ratio (OR) 1.09–1.18), male gender (OR 3.5–6.43), hypertension (OR 1.42–1.79), hyperlipidaemia (OR 1.86–2.09) and tobacco use (OR 1.83–2.01) were predictors for the presence and extent of CAC, whereas symptoms were not predictive for the presence of (Agatston > 0, OR 0.70 (0.59–0.83)), mild (Agatston ≥ 10; OR 0.85 (0.71–1.02)), moderate (Agatston ≥ 100; OR 0.99 (0.79–1.24)) or severe calcifications (Agatston ≥ 400; OR 0.93 (0.65–1.33)). Conclusion No difference in the presence or severity of coronary calcifications was observed between asymptomatic and symptomatic middle-aged individuals. After adjusting for cardiovascular risk factors, symptoms were not predictive for the presence or extent of CAC.

Coronary Computed Tomography Angiography Derived Fractional Flow Reserve and Plaque Stress

Fractional flow reserve (FFR) measured during invasive coronary angiography is an independent prognosticator in patients with coronary artery disease and the gold standard for decision making in coronary revascularization. The integration of computational fluid dynamics and quantitative anatomic and physiologic modeling now enables simulation of patient-specific hemodynamic parameters including blood velocity, pressure, pressure gradients, and FFR from standard acquired coronary computed tomography (CT) datasets. In this review article, we describe the potential impact on clinical practice and the science behind noninvasive coronary computed tomography (CT) angiography derived fractional flow reserve (FFRCT) as well as future applications of this technology in treatment planning and quantifying forces on atherosclerotic plaques.

Population Screening for Coronary Artery Calcification Does Not Increase Mental Distress and the Use of Psychoactive Medication

Purpose: Detection of coronary artery calcification (CAC) has been proposed for population screening. It remains unknown whether such a strategy would result in unnecessary concern among participants. Therefore, we set out to assess whether CAC screening affects the psychological well-being of screening participants. Materials and Methods: A random sample of 1825 middle-aged subjects (men and women, 50 or 60 y old) were invited for health screening. The European HeartScore was calculated, and a CAC score was measured using a cardiac computed tomography scanner. Therapeutic interventions as a result of the observations were at the discretion of the individual general practitioner. Before screening and at 6-month follow-up a depression test (Major Depression Inventory) was conducted, and the use of psychoactive medication was recorded. Results: A total of 1257 (69%) subjects agreed to participate. Because of known cardiovascular disease or diabetes mellitus, 88 persons were excluded. Of the remaining 1169, 47% were men, and one half were 50 years old. At 6-month follow-up, significant reductions were observed in the Major Depression Inventory score from 5.3 to 3.9 (P<0.0001) and in the prescription rates of psychoactive medication from 7.1% (83 of 1169) to 6.2% (72 of 1169) (P=0.003). The results were independent of sex, age, HeartScore, CAC Score, and changes in other medication. Conclusions: A population screening program including CAC score appears to have no detrimental impact on mental distress and does not increase the use of psychoactive medication.