Patrik Tydén

Fatality of Future Coronary Events Is Related to Inflammation-Sensitive Plasma Proteins A Population-Based Prospective Cohort Study

Background—Approximately 40% of men suffering a first acute coronary event die the first day; most of them never reach hospital. It is largely unknown whether a low-grade inflammation in healthy men predicts the fatality of future coronary events. Methods and Results—Five inflammation-sensitive plasma proteins (ISPs; fibrinogen, orosomucoid, &agr;1-antitrypsin, haptoglobin, and ceruloplasmin) were measured in 6075 apparently healthy men, 680 of whom had a first coronary event [nonfatal myocardial infarction (MI) or death from coronary heart disease (CHD)] over a mean follow-up of 19 years. Of the 680 men who had a coronary event, 197 died the first day and 228 died within 28 days. Elevated ISPs were significantly associated with both nonfatal MI and CHD death, but the relative risks for CHD death were higher than for nonfatal MI. Among men who subsequently had a coronary event, the proportion of fatal events was related to the number of elevated ISPs at the baseline examination. The proportions who died the first day were 26%, 25%, 29%, and 35%, respectively, among men with 0, 1, 2, and ≥3 elevated ISPs (trend:P = 0.01, adjusted for risk factors). The corresponding proportions who died within 28 days were 30%, 31%, 34%, and 38%, respectively (trend:P = 0.03). Conclusions—Men who have been exposed to a low-grade inflammation many years earlier have higher fatality in future coronary events, with a higher proportion of CHD deaths and less nonfatal MI. This relation should be regarded when inflammatory markers are considered for risk assessment in primary prevention.

Distribution and determinants of ischaemic heart disease in an urban population. A study from the myocardial infarction register in Malmö, Sweden

Abstract. Engström G, Berglund G, Göransson M, Hansen O, Hedblad B, Merlo J, Tydén P, Janzon L (Malmö University Hospital, Malmö, Sweden). Distribution and determinants of ischaemic heart disease in an urban population. A study from the myocardial infarction register in Malmö, Sweden. J Intern Med 2000: 247; 588–596.

Inflammation-sensitive plasma proteins and incidence of myocardial infarction in men with low cardiovascular risk.

Objective—Myocardial infarction (MI) is sometimes experienced by individuals without any traditional risk factor. This prospective study explored whether incidence of MI in nonsmoking, nondiabetic men with normal blood pressure and serum lipids is related to inflammation-sensitive plasma proteins (ISPs). Methods and Results—Five ISPs (&agr;1-antitrypsin, haptoglobin, ceruloplasmin, fibrinogen, orosomucoid) were analyzed in 6075 men, 47±3.6 years old. A low-risk group (no traditional risk factor, n=1108) and a high-risk group (≥2 major risk factors, n=1011) were defined. Incidence of MI (n=227) was monitored over 18.1±4.3 years of follow-up. In the low-risk group, the age-adjusted relative risks (RRs) were 1.00 (reference), 1.9 (95% CI, 0.8 to 4.2), 1.8 (95% CI, 0.6 to 5.4), and 2.9 (95% CI, 1.05 to 8.1), respectively, for men with 0, 1, 2 and ≥3 ISPs in the top quartile (trend:P =0.03). In this group, the increased risk was observed only after ≥10 years of follow-up. In the high-risk group, the age-adjusted RRs were 1.00, 1.4 (95% CI, 0.9 to 2.2), 1.9 (95% CI, 1.2 to 3.1), and 2.0 (95% CI, 1.3 to 3.1), respectively, for men with 0, 1, 2, and ≥3 ISPs in the top quartile (trend:P =0.0004). Conclusion—Incidence of MI in nonsmoking, nondiabetic men with normal blood pressure and lipids was related to ISPs. The causes for this relationship remain to be explored.

Incidence of myocardial infarction in women. A cohort study of risk factors and modifiers of effect

STUDY OBJECTIVE To assess whether the increased incidence of myocardial infarction and death associated with smoking, hypertension, hyperlipidaemia and diabetes varies significantly between groups defined in terms of occupation, education and marital status. SETTING Malmö, Sweden. PARTICIPANTS 9351 women, aged 28–55, with a mean follow up of 10.7 years. MAIN RESULTS Smoking, hypertension (⩾160/95 mm Hg or treatment), hyperlipidaemia (cholesterol ⩾6.5 mmol/l or triglycerides ⩾2.3 mmol/l), diabetes, low occupation and education levels were significantly more common among women who experienced a fatal or non-fatal myocardial infarction during the follow up (n=104) than in other women (n=9247). Exposure to smoking, hypertension and hyperlipidaemia showed substantial differences between groups defined in terms of education, occupation and marital status. The association between low occupation and myocardial infarction remained statistically significant after adjustments for several potential confounders (RR=2.6, 95%CI 1.1, 6.0). Single women had similarly higher adjusted mortality rates than married women (RR=1.4, 95%CI 1.1, 1.8). When other major risk factors were taken into account, the relative risk for mortality and myocardial infarction associated with smoking was 2.6 (95%CI 2.0, 3.4) and 7.8 (95%CI 4.4, 13.9), respectively. CONCLUSION In this urban female population, short education and low occupation level were both associated with an increased prevalence of smoking, hypertension, hyperlipidaemia and diabetes. Low occupation level increases the rate of cardiac events caused by exposure to these four risk factors.

Concomitant use of warfarin and ticagrelor as an alternative to triple antithrombotic therapy after an acute coronary syndrome

INTRODUCTION Treatment with warfarin in combination with clopidogrel has been shown to reduce the incidence of major bleeding as compared to triple antithrombotic therapy (TT; warfarin, clopidogrel and aspirin). However, there are uncertainties regarding the risk for thrombosis since poor-responsiveness to clopidogrel is common. Ticagrelor is a more potent platelet inhibitor, but data supporting concurrent use of ticagrelor and warfarin (dual antithrombotic therapy, DT) is limited. This study therefore sought to evaluate the risk of bleeding and thrombosis associated with DT after an acute coronary syndrome (ACS). MATERIALS AND METHODS We identified all ACS patients on DT upon discharge from Helsingborg Hospital and Skåne University Hospital in Malmö and Lund, Sweden, during 2013. Patients on DT were compared with historical controls discharged with TT. Major bleeding was defined in accordance with the HAS-BLED derivation study. Patients were retrospectively followed for three months. RESULTS In total, 107 DT patients were identified and compared with 159 controls on TT. Mean HAS-BLED bleeding risk score and duration of treatment were similar between the groups (HAS-BLED 2.2+/-0.8 vs 2.2+/-1.0 units, p=NS; duration 2.7+/-0.8 vs 2.5+/-0.9months, p=NS; DT vs TT). The incidence of spontaneous major bleeding was similar between the groups, as was a composite of all thrombotic events, i.e. peripheral embolism, stroke/TIA and acute coronary syndrome (bleeding 8/106 (7.5%) vs 11/157 (7.0%), p=NS; thrombosis 5/106 (4.7%) vs 5/157 (3.2%), p=NS; DT vs TT). CONCLUSIONS Rates of thrombotic and bleeding events were similar in patients with TT and patients with ticagrelor and warfarin.

Myocardial infarction in an urban population: worse long term prognosis for patients from less affluent residential areas

Study objective: The objective in this follow up study from the Malmö myocardial infarction register has been to assess whether long term survival following discharge after first myocardial infarction has any relation with the socioeconomic environment and to assess to what extent intra-urban differences in mortality from ischaemic heart disease can be accounted for by covariance with long term survival following discharge after acute myocardial infarction. Design: Register based surveillance study. Setting: Seventeen residential areas in the city of Malmö, Sweden. Participants: The cohort contains all 2931 male and 2083 female patients with myocardial infarction who were discharged for the first time between 1986–95 from Malmö University Hospital. Main results: During the on average 4.9 years of follow up 55% of the patients died. The sex adjusted and age adjusted all cause mortality rate/1000 patient years ranged between residential areas from 85.5 to 163.6. The area specific relative risk of death after discharge was associated with a low socioeconomic score, r=−0.56, p=0.018. Major risk factors for cardiovascular disease were more prevalent in areas with low socioeconomic score and low rates of survival. Of the intra-urban differences in mortality from ischaemic heart disease, 41% could be accounted for by differences with regard to the survival rate after discharge. Conclusions: The results are compatible with the hypothesis that the socioeconomic environment plays an important part in the survival rate of patients with myocardial infarction. To assess the preventive potential, the extent to which socioeconomic circumstances covary with severity of disease, respectively with the use and compliance with secondary preventive measures, needs to be evaluated.

Time trends and gender differences in prevention guideline adherence and outcome after myocardial infarction: Data from the SWEDEHEART registry

Background While secondary prevention improves prognosis after acute myocardial infarction (AMI), previous studies have suggested suboptimal guideline adherence, lack of improvement over time and gender differences. This study contributes contemporary data from a large national cohort. Method We identified 51,620 patients <75 years examined at two and/or twelve months post AMI in the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART). Risk factor control and readmissions at one year were compared between the 2005 and 2012 cohorts, and between genders. Results Lipid control (LDL-cholesterol <2.5 mmol/L) improved from 67.9% to 71.1% (p = 0.016) over time, achieved by 67.9% vs 63.3%, p < 0.001 of men vs women. Blood pressure control (<140 mmHg systolic) increased over time (59.1% vs 69.5%, p < 0.001 in 2005 and 2012 cohorts) and was better in men (66.4% vs 61.9%, p < 0.001). Smoking cessation rate was 55.6% without differences between genders or over time. Cardiac readmissions occurred in 18.2% of women and 15.5% of men, decreasing from 2005 to 2012 (20.8% vs 14.9%). Adjusted odds ratio was 1.22 (95% CI 1.14–1.32) for women vs men and 0.94 (95% CI 0.92–0.96) for the 2012 vs the 2005 cohort. Conclusions Although this study compares favourably to previous studies of risk factor control post AMI, improvement over time was mainly seen regarding blood pressure, revealing substantial remaining preventive potential. The reasons for gender differences seen in risk factor control and readmissions require further analysis.

Marital status and occupation in relation to short-term case fatality after a first coronary event--a population based cohort.

BackgroundAlthough marital status and low occupation level has been associated with mortality, the relationship with case fatality rates (CFR) after a coronary event (CE) is unclear. This study explored whether incidence of CE and short-term CFR differ between groups defined in terms of marital status and occupation, and if this could be explained by biological and life-style risk factors.MethodsPopulation-based cohort study of 33,224 subjects (67% men), aged 27 to 61 years, without history of myocardial infarction, who were enrolled between 1974 and 1992. Incidence of CE, and CFR (death during the first day or within 28 days after CE, including out-of-hospital deaths) was examined over a mean follow-up of 21 years.ResultsA total of 3,035 men (6.0 per 1000 person-years) and 507 women (2.4 per 1000) suffered a first CE during follow-up. CFR (during the 1st day) was 29% in men and 23% in women. After risk factor adjustments, unmarried status in men, but not in women, was significantly associated with increased risk of suffering a CE [hazard ratios (HR) 1.10, 95% CI: 0.97-1.24; 1.42: 1.27-1.58 and 1.77: 1.31-2.40 for never married, divorced and widowed, respectively, compared to married]. Unmarried status, in both gender, was also related with an increased CFR (1st day), taking potential confounders into account (odds ratio (OR) 2.14, 95% CI: 1.63-2.81; 1.91: 1.50-2.43 and 1.49: 0.77-2.89 for never married, divorced and widowed, respectively, compared to married men. Corresponding figures for women was 2.32: 0.93-5.81; 1.87: 1.04-3.36 and 2.74: 1.03-7.28. No differences in CFR (1st day) were observed between occupational groups in neither gender.ConclusionsIn this population-based Swedish cohort, short-term CFR was significantly related to unmarried status in men and women. This relationship was not explained by biological-, life-style factors or occupational level.

Dietary habits after myocardial infarction – results from a cross‐sectional study

Objective.  Comparing habitual nutrient intakes in persons with a history of acute myocardial infarction (AMI), and age‐matched controls.

The impact of personality factors on delay in seeking treatment of acute myocardial infarction

BackgroundEarly hospital arrival and rapid intervention for acute myocardial infarction is essential for a successful outcome. Several studies have been unable to identify explanatory factors that slowed decision time. The present study examines whether personality, psychosocial factors, and coping strategies might explain differences in time delay from onset of symptoms of acute myocardial infarction to arrival at a hospital emergency room.MethodsQuestionnaires on coping strategies, personality dimensions, and depression were completed by 323 patients ages 26 to 70 who had suffered an acute myocardial infarction. Tests measuring stress adaptation were completed by 180 of them. The patients were then categorised into three groups, based on time from onset of symptoms until arrival at hospital, and compared using logistic regression analysis and general linear models.ResultsNo correlation could be established between personality factors (i.e., extraversion, neuroticism, openness, agreeableness, conscientiousness) or depressive symptoms and time between onset of symptoms and arrival at hospital. Nor was there any significant relationship between self-reported patient coping strategies and time delay.ConclusionsWe found no significant relationship between personality factors, coping strategies, or depression and time delays in seeking hospital after an acute myocardial infraction.