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Holm, Anna
Publications (7 of 7) Show all publications
Holm, A., Henriksson, M., Alfredsson, J., Janzon, M., Johansson, T., Swahn, E., . . . Sederholm Lawesson, S. (2021). Long term risk and costs of bleeding in men and women treated with triple antithrombotic therapy: An observational study. PLOS ONE, 16(3), Article ID e0248359.
Open this publication in new window or tab >>Long term risk and costs of bleeding in men and women treated with triple antithrombotic therapy: An observational study
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2021 (English)In: PLOS ONE, E-ISSN 1932-6203, Vol. 16, no 3, article id e0248359Article in journal (Refereed) Published
Abstract [en]

Objectives Bleeding is the most common non-ischemic complication in patients with coronary revascularisation procedures, associated with prolonged hospitalisation and increased mortality. Many factors predispose for bleeds in these patients, among those sex. Anyhow, few studies have characterised the population receiving triple antithrombotic therapy (TAT) as well as long term bleeds from a sex perspective. We investigated the one year rate of bleeds in patients receiving TAT, potential sex disparities and premature discontinuation of TAT. We also assessed health care costs in bleeders vs non-bleeders. Setting Three hospitals in the County of ostergotland, Sweden during 2009-2015. Participants All patients discharged with TAT registered in the SWEDEHEART registry. Primary and secondary outcome measures All bleeds receiving medical attention during one-year follow-up were collected by retrieving relevant information about each patient from medical records. Resource use associated with bleeds was assigned unit cost to estimate the health care costs associated with bleeding episodes. Results Among 272 patients, 156 bleeds occurred post-discharge, of which 28.8% were gastrointestinal. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p = 0.01) and bled more (48.6 vs. 37.1%, p = 0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively. Conclusion The high bleeding incidence in patients with TAT, especially in women, is a cause of concern. There is a need for an adequately sized randomised, controlled trial to determine a safe but still effective treatment for these patients.

Place, publisher, year, edition, pages
Public Library of Science, 2021
National Category
General Practice
Identifiers
urn:nbn:se:liu:diva-175450 (URN)10.1371/journal.pone.0248359 (DOI)000634832800066 ()33764988 (PubMedID)
Note

Funding Agencies|County Council of Ostergotland

Available from: 2021-05-05 Created: 2021-05-05 Last updated: 2022-05-23Bibliographically approved
Holm, A., Swahn, E., Sederholm Lawesson, S., Gustafsson, K., Janzon, M., Jonasson, L., . . . Alfredsson, J. (2021). Sex differences in platelet reactivity in patients with myocardial infarction treated with triple antiplatelet therapy-results from assessing platelet activity in coronary heart disease (APACHE). Platelets, 32(1), 524-532
Open this publication in new window or tab >>Sex differences in platelet reactivity in patients with myocardial infarction treated with triple antiplatelet therapy-results from assessing platelet activity in coronary heart disease (APACHE)
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2021 (English)In: Platelets, ISSN 0953-7104, E-ISSN 1369-1635, Vol. 32, no 1, p. 524-532Article in journal (Refereed) Published
Abstract [en]

)Several earlier studies have reported increased risk of bleeding in women with myocardial infarction, (MI) compared to men. The reasons for the observed difference are incompletely understood, but one suggested explanation has been excess dosing of antithrombotic drugs in women. The aim of this prospective observational study was to assess sex differences in platelet activity in patients treated with three different platelet inhibitors. We recruited 125 patients (37 women and 88 men) with MI, scheduled for coronary angiography. All patients received clopidogrel and aspirin. A subgroup of patients received glycoprotein (GP) IIb/IIIa-inhibitor. Platelet aggregation in whole blood was assessed at several time points, using impedance aggregometry. SolubleP-selectin was measured 3 days after admission. There were no significant differences between women and men in baseline features or comorbidities except higher frequency of diabetes, lower hemoglobin value, and lower estimated glomerular filtration rate, in women on admission. We observed significantly more in-hospital bleeding events in women compared to men (18.9% vs. 6.8%,p= .04). There were no differences in platelet aggregation using three different agonists, reflecting treatment effect of GPIIb/IIIa-inhibitors, clopidogrel, and aspirin, 6-8 hours, 3 days, 7-9 days, or 6 months after loading dose. Moreover, there was no significant difference in solubleP-selectin. The main finding of this study was a consistent lack of difference between the sexes in platelet aggregation, using three different agonists at several time-points. Our results do not support excess dosing of anti-platelet drugs as a major explanation for increased bleeding risk in women.

Place, publisher, year, edition, pages
Taylor & Francis, 2021
Keywords
Gender; myocardial infarction; platelet aggregation; sex
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-167751 (URN)10.1080/09537104.2020.1771550 (DOI)000543070400001 ()32493086 (PubMedID)2-s2.0-85088856352 (Scopus ID)
Note

Funding Agencies|Linkoping University; County Council of Ostergotland

Available from: 2020-07-21 Created: 2020-07-21 Last updated: 2022-05-25Bibliographically approved
Holm, A., Andersen, K., Hofmann, R. & Bäck, M. (2020). Stabil kranskärlssjukdom « blir »kroniskt koronart syndrom« [Stable coronary artery disease becomes chronic coronary syndrome]. Läkartidningen, 117
Open this publication in new window or tab >>Stabil kranskärlssjukdom « blir »kroniskt koronart syndrom« [Stable coronary artery disease becomes chronic coronary syndrome]
2020 (English)In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 117Article in journal (Refereed) Published
Abstract [en]

New guidelines from the European Society of Cardiology (ESC) recommend that »chronic coronary syndrome« (CCS) replaces the previously used term »stable coronary artery disease«. The background for this recommendation is that the coronary artery atherosclerosis process is a dynamic process that, although stable under long periods, may become unstable and result in an acute coronary syndrome (ACS). In this commentary, the Working Group on Coronary Artery Disease of the Swedish Society of Cardiology points out what is new in the 2019 CCS guidelines.

Place, publisher, year, edition, pages
Stockholm, Sweden: Sveriges Lakarforbund, 2020
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-174251 (URN)32068878 (PubMedID)
Available from: 2021-03-17 Created: 2021-03-17 Last updated: 2021-03-24Bibliographically approved
Holm, A. (2019). Acute coronary syndrome: bleeding, platelets and gender. (Doctoral dissertation). Linköping: Linköping University Electronic Press
Open this publication in new window or tab >>Acute coronary syndrome: bleeding, platelets and gender
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

BACKGROUND

Bleeding complications increase mortality in patients with acute coronary syndrome (ACS). Potential gender difference in bleeding regarding prevalence, location, severity and prognostic impact is still controversial and not well investigated. In regard to this aspect the relevance of triple antithrombotic therapy (TAT) is questioned. There is an ongoing debate on the clinical implications of TAT and furthermore assumed that bleeding complications, except impact on outcome, also are associated with great influence on health economy.

The main focus of this thesis was to further investigate the incidence and impact of bleeding complications in patients treated for ACS, with special reference to gender disparities, TAT and health economics. The thesis will highlight the importance of improved bleeding prevention strategies for both men and women.

METHOD

Paper I, II and III

Observational studies from the SWEDEHEART register.

In paper I we investigated patients hospitalised with myocardial infarction (MI) during 2006–2008. Outcomes were in-hospital bleedings, in-hospital mortality and one-year mortality in hospital survivors.

In paper II, all patients with MI, in the County of Östergötland, Sweden during 2010 were included and followed for one year. The patients' medical records were evaluated, in relation to short and long-term bleeding complications, bleeding location, withdrawal of platelet inhibiting drugs and nonfatal MI and death.

Paper III included all patients discharged with (TAT) in the County of Östergötland 2009-2015. Information about bleeds and ischemic complications during one-year follow-up were retrieved from the medical records. Estimation of the health care costs associated with bleeding episodes were added to the evaluation.

Paper IV

Patients with MI, scheduled for coronary angiography were recruited. All patients received clopidogrel and aspirin. A subgroup of patients received GP IIb/IIIa-inhibitor. Outcomes were platelet aggregation assessed at several time points, using a Multiplate impedance aggregometer, measurement of P-selectin in plasma, evaluation of high residual platelet reactivity (HRPR) and low residual platelet reactivity (LRPR) respectively and incidence of bleeding complications. A comparison between women and men was performed.

RESULTS

Paper I

A total number of 50.399 patients were included, 36.6% women. In-hospital bleedings were more common in women (1.9% vs. 3.1%, p<0.001) even after multivariable adjustment (OR 1.17, 95%, CI 1.01–1.37). The increased risk for women was found in STEMI (OR 1.46, 95% CI 1.10–1.94) and in those who underwent PCI (OR 1.80, 95% CI 1.45–2.24).

In contrast the risk was lower in medically treated women (OR 0.79, 95% CI 0.62–1.00). After adjustment, in-hospital bleeding was associated with higher risk of oneyear mortality in men (OR 1.35, 95% CI 1.04–1.74), whereas this was not the case in women (OR 0.97, 95% CI 0.72–1.31).

Paper II

In total 850 consecutive patients were included. The total incidence of bleeding events was 24.4% (81 women and 126 men, p=ns). The incidence of all in hospital bleeding events was 13.2%, with no gender difference. Women had significantly more minor nonsurgery related bleeding events than men (5% vs 2.2%, p=0.02). During follow-up, 13.5% had a bleeding, with more non-surgery related bleeding events among women, 14.7% vs 9.7% (p=0.03). The most common bleeding localisation was the gastrointestinal tract, more in women than men (12.1% vs 7.6%, p=0.03). Women also had more access site bleeding complications (4% vs 1.7%, p=0.04), while men had more surgery related bleeding complications (6.4% vs 0.9%, p≤0.001). Increased mortality was found only in men with non-surgery related bleeding events (p=0.008).

Paper III

Among 272 identified patients, 156 bleeds occurred post-discharge, of which 28.8% were of gastrointestinal origin. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post-discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p=0.01) and bled more (48.6 vs. 37.1%, p=0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively.

Paper IV

We recruited 125 patients (37 women and 88 men). We observed significantly more inhospital bleeding events in women as compared to men (18.9% vs 6.8%, p=0.04). There were no differences in platelet aggregation using three different agonists, reflecting treatment of GPIIb/IIIa inhibitors, clopidogrel and aspirin, at four different time-points nor were there any differences in p-selectin in plasma 3 days after admission.

CONCLUSION

There is a remarkably high bleeding incidence among patients treated with DAPT and even more so if treated with TAT. Female gender is an independent risk factor of inhospital bleeding after myocardial infarction, this higher bleeding risk in women appears to be restricted to invasively treated patients and STEMI patients. Even if women had higher short- and long-term mortality, there was no difference between the genders among those who bled. After multivariable adjustment the prognostic impact of bleeding complications was higher in men

Women seem to experience more minor/minimal bleeding complications than men, predominantly GI bleeding events and access site bleeding events, with no apparent impact on outcome.

In contrast men with non-surgery related bleeding complications had higher mortality. There is a lack of differences between the genders concerning platelet aggregation. Our results do not support gender disparities in platelet reactivity and excess dosing as a major explanation for increased bleeding risk in women. Improved bleeding prevention strategies are warranted for both men and women.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. p. 74
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1654
National Category
Cardiac and Cardiovascular Systems Surgery Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-153621 (URN)10.3384/diss.diva-153621 (DOI)9789176851654 (ISBN)
Public defence
2019-02-01, Hugo Theorell salen, Campus US, Linköpings universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-01-04 Created: 2019-01-04 Last updated: 2021-05-11Bibliographically approved
Johnston, N., Bergdahl, E., Samnegard, A., Kenttä, L., Holm, A., Petursson, P. & Bäck, M. (2018). ST-höjningsinfarkt och dubbel trombocythämning: nya riktlinjer [ST-elevation myocardial infarction and dual antiplatelet therapy: new guidelines]: Europeiska kardiologföreningens rekommendationer kommenteras av Svenska kardiologföreningens arbetsgrupp. Läkartidningen, 115
Open this publication in new window or tab >>ST-höjningsinfarkt och dubbel trombocythämning: nya riktlinjer [ST-elevation myocardial infarction and dual antiplatelet therapy: new guidelines]: Europeiska kardiologföreningens rekommendationer kommenteras av Svenska kardiologföreningens arbetsgrupp
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2018 (Swedish)In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 115Article, review/survey (Refereed) Published
Abstract [en]

This report summarizes some of the most important changes and new recommendations from the ESC ST-elevation myocardial infarction and double antiplatelet therapy guidelines for 2017, which are of interest for physicians managing patients with coronary artery disease.

Place, publisher, year, edition, pages
Stockholm, Sweden: Läkartidningen Förlag AB, 2018
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-155874 (URN)29969143 (PubMedID)
Available from: 2019-04-01 Created: 2019-04-01 Last updated: 2019-05-03Bibliographically approved
Holm, A., Sederholm-Lawesson, S., Swahn, E. & Alfredsson, J. (2016). Gender difference in prognostic impact of in-hospital bleeding after myocardial infarction - data from the SWEDEHEART registry.. European Heart Journal: Acute Cardiovascular Care, 6, 463-472
Open this publication in new window or tab >>Gender difference in prognostic impact of in-hospital bleeding after myocardial infarction - data from the SWEDEHEART registry.
2016 (English)In: European Heart Journal: Acute Cardiovascular Care, ISSN 2048-8726, E-ISSN 2048-8734, Vol. 6, p. 463-472Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Bleeding complications increase mortality in myocardial infarction patients. Potential gender difference in bleeding regarding prevalence and prognostic impact is still controversial.

OBJECTIVES: Gender comparison regarding incidence and prognostic impact of bleeding in patients hospitalised with myocardial infarction during 2006-2008.

METHODS: Observational study from the SWEDEHEART register. Outcomes were in-hospital bleedings, in-hospital mortality and one-year mortality in hospital survivors.

RESULTS: A total number of 50,399 myocardial infarction patients were included, 36.6% women. In-hospital bleedings were more common in women (1.9% vs. 3.1%, p<0.001) even after multivariable adjustment (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.01-1.37). The increased risk for women was found in ST-elevation myocardial infarction (OR 1.46, 95% CI 1.10-1.94) and in those who underwent percutaneous coronary intervention (OR 1.80, 95% CI 1.45-2.24). In contrast the risk was lower in medically treated women (OR 0.79, 95% CI 0.62-1.00). After adjustment, in-hospital bleeding was associated with higher risk of one-year mortality in men (OR 1.35, 95% CI 1.04-1.74), whereas this was not the case in women (OR 0.97, 95% CI 0.72-1.31).

CONCLUSIONS: Female gender is an independent risk factor of in-hospital bleeding after myocardial infarction. A higher bleeding risk in women appeared to be restricted to invasively treated patients and ST-elevation myocardial infarction patients. Even though women have higher short- and long-term mortality, there was no difference between the genders among bleeders. After multivariable adjustment the prognostic impact of bleeding complications was higher in men.

Place, publisher, year, edition, pages
Sage Publications, 2016
Keywords
Myocardial infarction; bleeding; gender; prognosis
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-124287 (URN)10.1177/2048872615610884 (DOI)000385817800008 ()26450782 (PubMedID)
Available from: 2016-01-25 Created: 2016-01-25 Last updated: 2023-08-28
Arvola, M. & Holm, A. (2014). Device-orientation is more engaging than drag (at least in mobile computing). In: NordiCHI '14 Proceedings of the 8th Nordic Conference on Human-Computer Interaction: Fun, Fast, Foundational: . Paper presented at NordiCHINordic Conference on Human-Computer Interaction (pp. 939-942). New York: ACM Press
Open this publication in new window or tab >>Device-orientation is more engaging than drag (at least in mobile computing)
2014 (English)In: NordiCHI '14 Proceedings of the 8th Nordic Conference on Human-Computer Interaction: Fun, Fast, Foundational, New York: ACM Press, 2014, p. 939-942Conference paper, Published paper (Refereed)
Abstract [en]

Does device-orientation-based panning on mobile devices facilitate engagement? 20 users were asked to pan panoramas by turning around and changing the direction of the device, and by swiping with the finger on the touchscreen. The participants were also asked to rate how engaging they found it on the User Engagement Scale. It turned out that device-orientation-based panning was more engaging than drag-based panning. Moving your body to navigate information can pull you into an affective loop.

Place, publisher, year, edition, pages
New York: ACM Press, 2014
Keywords
Movement-based interaction, engagement, immersion, affective computing, navigation, panorama, device- orientation-based panning, user experience, information interfaces and presentation, multimedia information systems, evaluation, user interfaces
National Category
Human Computer Interaction
Identifiers
urn:nbn:se:liu:diva-118696 (URN)10.1145/2639189.2670245 (DOI)978-1-4503-2542-4 (ISBN)
Conference
NordiCHINordic Conference on Human-Computer Interaction
Available from: 2015-06-03 Created: 2015-06-03 Last updated: 2020-02-04Bibliographically approved
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