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  • 101.
    Erlinge, D.
    et al.
    Department of Cardiology, Lund University, Sweden.
    Koul, S.
    Department of Cardiology, Lund University, Sweden.
    Omerovic, E.
    Department of Cardiology, Sahlgrenska University Hospital, Sweden.
    Fröbert, O.
    Department of Cardiology, Örebro University, Sweden.
    Linder, R.
    Department of Cardiology, Danderyd Hospital, Sweden.
    Danielewicz, M.
    PCI-Unit, Karlstad Hospital, Sweden.
    Hamid, M.
    Department of Cardiology, Mälarsjukhuset, Sweden.
    Venetsanos, Dimitrios
    Department of Cardiology, Karolinska University Hospital, Sweden.
    Henareh, L.
    Department of Cardiology, Karolinska University Hospital, Sweden.
    Pettersson, B.
    Department of Cardiology, Umeå University, Sweden.
    Wagner, H.
    Department of Cardiology, Helsingborg Lasarett, Sweden.
    Grimfjärd, P.
    Department of Internal Medicine, Västmanlands Sjukhus, Sweden.
    Jensen, J.
    Department of Cardiology, Capio S:t Görans Hospital AB, Sweden.
    Hofmann, R.
    Department of Clinical Science and Education, Södersjukhuset, Sweden.
    Ulvenstam, A.
    Department of Cardiology, Östersund Hospital, Sweden.
    Völz, S.
    Department of Cardiology, Sahlgrenska University Hospital, Sweden.
    Petursson, P.
    Department of Cardiology, Sahlgrenska University Hospital, Sweden.
    Östlund, O.
    Department of Medical Sciences, Uppsala University, Sweden.
    Sarno, G.
    Department of Medical Sciences, Uppsala University, Sweden.
    Wallentin, L.
    Department of Medical Sciences, Uppsala University, Sweden.
    Scherstén, F.
    Department of Cardiology, Lund University, Sweden.
    Eriksson, P.
    Department of Cardiology, Umeå University, Sweden.
    James, S.
    Department of Medical Sciences, Uppsala University, Sweden.
    Bivalirudin versus heparin monotherapy in non-ST-segment elevation myocardial infarction.2018In: European Heart Journal. Acute Cardiovascular Care, ISSN 2048-8734Article in journal (Refereed)
    Abstract [en]

    Background: The optimal anti-coagulation strategy for patients with non-ST-elevation myocardial infarction treated with percutaneous coronary intervention is unclear in contemporary clinical practice of radial access and potent P2Y12-inhibitors. The aim of this study was to investigate whether bivalirudin was superior to heparin monotherapy in patients with non-ST-elevation myocardial infarction without routine glycoprotein IIb/IIIa inhibitor use.less thanbr /greater thanMethods: In a large pre-specified subgroup of the multicentre, prospective, randomised, registry-based, open-label clinical VALIDATE-SWEDEHEART trial we randomised patients with non-ST-elevation myocardial infarction undergoing percutaneous coronary intervention, treated with ticagrelor or prasugrel, to bivalirudin or heparin monotherapy with no planned use of glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention. The primary endpoint was the rate of a composite of all-cause death, myocardial infarction or major bleeding within 180 days.less thanbr /greater thanResults: A total of 3001 patients with non-ST-elevation myocardial infarction, were enrolled. The primary endpoint occurred in 12.1% (182 of 1503) and 12.5% (187 of 1498) of patients in the bivalirudin and heparin groups, respectively (hazard ratio of bivalirudin compared to heparin treatment 0.96, 95% confidence interval 0.78-1.18, p=0.69). The results were consistent in all major subgroups. All-cause death occurred in 2.0% versus 1.7% (hazard ratio 1.15, 0.68-1.94, p=0.61), myocardial infarction in 2.3% versus 2.5% (hazard ratio 0.91, 0.58-1.45, p=0.70), major bleeding in 8.9% versus 9.1% (hazard ratio 0.97, 0.77-1.24, p=0.82) and definite stent thrombosis in 0.3% versus 0.2% (hazard ratio 1.33, 0.30-5.93, p=0.82).less thanbr /greater thanConclusion: Bivalirudin as compared to heparin during percutaneous coronary intervention for non-ST-elevation myocardial infarction did not reduce the composite of all-cause death, myocardial infarction or major bleeding in non-ST-elevation myocardial infarction patients receiving current recommended treatments with modern P2Y12-inhibitors and predominantly radial access.

  • 102.
    Erlinge, D.
    et al.
    Lund University, Sweden.
    Omerovic, E.
    Sahlgrens University Hospital, Sweden.
    Frobert, O.
    Örebro University, Sweden.
    Linder, R.
    Danderyd Hospital, Sweden.
    Danielewicz, M.
    Karlstad Hospital, Sweden.
    Hamid, M.
    Mälarsjukhuset, Sweden.
    Swahn, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Henareh, L.
    Karolinska University Hospital, Sweden.
    Wagner, H.
    Helsingborg Lasarett, Sweden.
    Hardhammar, P.
    Halmstad County Hospital, Sweden.
    Sjogren, I.
    Falun Central Hospital, Sweden.
    Stewart, J.
    Skaraborgs Hospital, Sweden.
    Grimfjard, P.
    Västmanlands Sjukhus, Sweden.
    Jensen, J.
    Karolinska Institute, Sweden.
    Aasa, M.
    Södersjukhuset AB, Sweden.
    Robertsson, L.
    Södra Älvsborgs Sjukhus, Sweden.
    Lindroos, P.
    Karolinska Institute, Sweden.
    Haupt, J.
    Sunderby Sjukhus, Sweden.
    Wikstrom, H.
    Kristianstad Hospital, Sweden.
    Ulvenstam, A.
    Östersund Hospital, Sweden.
    Bhiladvala, P.
    Lund University, Sweden.
    Lindvall, B.
    Sundsvall Hospital, Sweden.
    Lundin, A.
    Lund University, Sweden.
    Todt, T.
    Lund University, Sweden.
    Ioanes, D.
    Sahlgrens University Hospital, Sweden.
    Ramunddal, T.
    Sahlgrens University Hospital, Sweden.
    Kellerth, T.
    Örebro University, Sweden.
    Zagozdzon, L.
    Örebro University, Sweden.
    Gotberg, M.
    Lund University, Sweden.
    Andersson, J.
    Umeå University, Sweden.
    Angeras, O.
    Sahlgrens University Hospital, Sweden.
    Ostlund, O.
    Uppsala University, Sweden.
    Lagerqvist, B.
    Uppsala University, Sweden.
    Held, C.
    Uppsala University, Sweden.
    Wallentin, L.
    Uppsala University, Sweden.
    Schersten, F.
    Lund University, Sweden.
    Eriksson, P.
    Umeå University, Sweden.
    Koul, S.
    Lund University, Sweden.
    James, S.
    Uppsala University, Sweden.
    Bivalirudin versus Heparin Monotherapy in Myocardial Infarction2017In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 377, no 12, p. 1132-1142Article in journal (Refereed)
    Abstract [en]

    BACKGROUND The comparative efficacy of various anticoagulation strategies has not been clearly established in patients with acute myocardial infarction who are undergoing percutaneous coronary intervention (PCI) according to current practice, which includes the use of radial-artery access for PCI and administration of potent P2Y 12 inhibitors without the planned use of glycoprotein IIb/IIIa inhibitors. METHODS In this multicenter, randomized, registry-based, open-label clinical trial, we enrolled patients with either ST-segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) who were undergoing PCI and receiving treatment with a potent P2Y(12) inhibitor (ticagrelor, prasugrel, or cangrelor) without the planned use of glycoprotein IIb/IIIa inhibitors. The patients were randomly assigned to receive bivalirudin or heparin during PCI, which was performed predominantly with the use of radial-artery access. The primary end point was a composite of death from any cause, myocardial infarction, or major bleeding during 180 days of follow-up. RESULTS A total of 6006 patients (3005 with STEMI and 3001 with NSTEMI) were enrolled in the trial. At 180 days, a primary end-point event had occurred in 12.3% of the patients (369 of 3004) in the bivalirudin group and in 12.8% (383 of 3002) in the heparin group (hazard ratio, 0.96; 95% confidence interval [CI], 0.83 to 1.10; P = 0.54). The results were consistent between patients with STEMI and those with NSTEMI and across other major subgroups. Myocardial infarction occurred in 2.0% of the patients in the bivalirudin group and in 2.4% in the heparin group (hazard ratio, 0.84; 95% CI, 0.60 to 1.19; P = 0.33), major bleeding in 8.6% and 8.6%, respectively (hazard ratio, 1.00; 95% CI, 0.84 to 1.19; P = 0.98), definite stent thrombosis in 0.4% and 0.7%, respectively (hazard ratio, 0.54; 95% CI, 0.27 to 1.10; P = 0.09), and death in 2.9% and 2.8%, respectively (hazard ratio, 1.05; 95% CI, 0.78 to 1.41; P = 0.76). CONCLUSIONS Among patients undergoing PCI for myocardial infarction, the rate of the composite of death from any cause, myocardial infarction, or major bleeding was not lower among those who received bivalirudin than among those who received heparin monotherapy. (Funded by the Swedish Heart-Lung Foundation and others;

  • 103.
    Escaned, Javier
    et al.
    Hosp Clin San Carlos, Spain; Univ Complutense Madrid, Spain.
    Ryan, Nicola
    Hosp Clin San Carlos, Spain; Univ Complutense Madrid, Spain.
    Mejia-Renteria, Hernan
    Hosp Clin San Carlos, Spain; Univ Complutense Madrid, Spain.
    Cook, Christopher M.
    Imperial Coll London, England.
    Dehbi, Hakim-Moulay
    UCL, England.
    Alegria-Barrero, Eduardo
    Hosp Univ Torrejon, Spain; Univ Francisco de Vitoria, Spain.
    Alghamdi, Ali
    King Abdulaziz Med City Cardiac Ctr, Saudi Arabia.
    Al-Lamee, Rasha
    Imperial Coll London, England.
    Altman, John
    Colorado Heart and Vasc, CO USA.
    Ambrosia, Alphonse
    Mesa, Arizona, USA.
    Baptista, Sergio B.
    Hosp Prof Doutor Fernando Fonseca, Portugal.
    Bertilsson, Maria
    Uppsala Univ, Sweden.
    Bhindi, Ravinay
    Royal North Shore Hosp, Australia.
    Birgander, Mats
    Lund Univ, Sweden.
    Bojara, Waldemar
    Kemperhof Koblenz, Germany.
    Brugaletta, Salvatore
    Inst Invest Biomed August Pi and Sunyer, Spain.
    Buller, Christopher
    St Michaels Hosp, Canada.
    Calais, Fredrik
    Orebro Univ, Sweden.
    Silva, Pedro Canas
    Hosp Santa Maria, Portugal.
    Carlsson, Jorg
    Kalmar Cty Hosp, Sweden; Linnaeus Univ, Sweden.
    Christiansen, Evald H.
    Aarhus Univ Hosp, Denmark.
    Danielewicz, Mikael
    Karlstad Hosp, Sweden.
    Di Mario, Carlo
    Imperial Coll London, England; Univ Florence, Italy.
    Doh, Joon-Hyung
    Inje Univ, South Korea.
    Erglis, Andrejs
    Pauls Stradins Clin Univ Hosp, Latvia.
    Erlinge, David
    Lund Univ, Sweden.
    Gerber, Robert T.
    Conquest Hosp, England.
    Going, Olaf
    Sana Klinikum Lichtenberg, Germany.
    Gudmundsdottir, Ingibjorg
    Reykjavik Univ Hosp, Iceland.
    Haerle, Tobias
    Carl von Ossietzky Univ Oldenburg, Germany.
    Hauer, Dario
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Hellig, Farrel
    Sunninghill Hosp, South Africa.
    Indolfi, Ciro
    Magna Graecia Univ Catanzaro, Italy.
    Jakobsen, Lars
    Aarhus Univ Hosp, Denmark.
    Janssens, Luc
    Imelda Hosp, Belgium.
    Jensen, Jens
    Karolinska Inst, Sweden; Capio St Gorans Sjukhus, Sweden; Sundsvall Hosp, Sweden.
    Jeremias, Allen
    SUNY Stony Brook, NY 11794 USA.
    Karegren, Amra
    Vastmanland Hosp Vasteras, Sweden.
    Karlsson, Ann-Charlotte
    Halmstad Cty Hosp, Sweden.
    Kharbanda, Rajesh K.
    Oxford Univ Hosp Fdn Trust, England.
    Khashaba, Ahmed
    Ain Shams Univ, Egypt.
    Kikuta, Yuetsu
    Fukuyama Cardiovasc Hosp, Japan.
    Krackhardt, Florian
    Univ Med, Germany.
    Koo, Bon-Kwon
    Seoul Natl Univ Hosp, South Korea.
    Koul, Sasha
    Lund Univ, Sweden.
    Laine, Mika
    Helsinki Univ Hosp, Finland.
    Lehman, Sam J.
    Flinders Univ S Australia, Australia.
    Lindroos, Pontus
    St Goran Hosp, Sweden.
    Malik, Iqbal S.
    Imperial Coll London, England.
    Maeng, Michael
    Aarhus Univ Hosp, Denmark.
    Matsuo, Hitoshi
    Gifu Heart Ctr, Japan.
    Meuwissen, Martijn
    Amphia Hosp, Netherlands.
    Nam, Chang-Wook
    Keimyung Univ, South Korea.
    Niccoli, Giampaolo
    Univ Cattolica Sacro Cuore, Italy.
    Nijjer, Sukhjinder S.
    Imperial Coll London, England.
    Olsson, Hans
    Karlstad Hosp, Sweden.
    Olsson, Sven-Erik
    Helsingborg Hosp, Sweden; Helsingborg Hosp, Sweden.
    Omerovic, Elmir
    Sahlgrenska Univ Gothenburg, Sweden.
    Panayi, Georgios
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Petraco, Ricardo
    Imperial Coll London, England.
    Piek, Jan J.
    Acad Med Ctr, Netherlands.
    Ribichini, Flavo
    Univ Hosp Verona, Italy.
    Samady, Habib
    Emory Univ, GA 30322 USA.
    Samuels, Bruce
    Cedars Sinai Heart Inst, CA USA.
    Sandhall, Lennart
    Helsingborg Hosp, Sweden; Helsingborg Hosp, Sweden.
    Sapontis, James
    MonashHeart, Australia; Monash Univ, Australia.
    Sen, Sayan
    Imperial Coll London, England.
    Seto, Arnold H.
    Vet Affairs Long Beach Healthcare Syst, CA USA.
    Sezer, Murat
    Istanbul Univ, Turkey.
    Sharp, Andrew S. P.
    Royal Devon and Exeter Hosp, England; Univ Exeter, England.
    Shin, Eun-Seok
    Univ Ulsan, South Korea.
    Singh, Jasvindar
    Washington Univ, MO USA.
    Takashima, Hiroaki
    Aichi Med Univ Hosp, Japan.
    Talwar, Suneel
    Royal Bournemouth Gen Hosp, England.
    Tanaka, Nobuhiro
    Tokyo Med Univ, Japan.
    Tang, Kare
    Essex Cardiothorac Ctr, England; Anglia Ruskin Univ, England.
    Van Belle, Eric
    Lille Univ Hosp, France; INSERM, France.
    van Royen, Niels
    Vrije Univ Amsterdam Med Ctr, Netherlands.
    Varenhorst, Christoph
    Uppsala Univ, Sweden.
    Vinhas, Hugo
    Hosp Garcia de Horta, Portugal.
    Vrints, Christiaan J.
    Antwerp Univ Hosp, Belgium.
    Walters, Darren
    Prince Charles Hosp, Australia.
    Yokoi, Hiroyoshi
    Fukuoka Sannou Hosp, Japan.
    Frobert, Ole
    Orebro Univ, Sweden.
    Patel, Manesh R.
    Duke Univ, NC USA.
    Serruys, Patrick
    Imperial Coll London, England.
    Davies, Justin E.
    Imperial Coll London, England.
    Gotberg, Matthias
    Lund Univ, Sweden.
    Safety of the Deferral of Coronary Revascularization on the Basis of Instantaneous Wave-Free Ratio and Fractional Flow Reserve Measurements in Stable Coronary Artery Disease and Acute Coronary Syndromes2018In: JACC: Cardiovascular Interventions, ISSN 1936-8798, E-ISSN 1876-7605, Vol. 11, no 15, p. 1437-1449Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES The aim of this study was to investigate the clinical outcomes of patients deferred from coronary revascularization on the basis of instantaneous wave-free ratio (iFR) or fractional flow reserve (FFR) measurements in stable angina pectoris (SAP) and acute coronary syndromes (ACS). BACKGROUND Assessment of coronary stenosis severity with pressure guidewires is recommended to determine the need for myocardial revascularization. METHODS The safety of deferral of coronary revascularization in the pooled per-protocol population (n = 4,486) of the DEFINE-FLAIR (Functional Lesion Assessment of Intermediate Stenosis to Guide Revascularisation) and iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trials was investigated. Patients were stratified according to revascularization decision making on the basis of iFR or FFR and to clinical presentation (SAP or ACS). The primary endpoint was major adverse cardiac events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or unplanned revascularization at 1 year. RESULTS Coronary revascularization was deferred in 2,130 patients. Deferral was performed in 1,117 patients (50%) in the iFR group and 1,013 patients (45%) in the FFR group (p amp;lt; 0.01). At 1 year, the MACE rate in the deferred population was similar between the iFR and FFR groups (4.12% vs. 4.05%; fully adjusted hazard ratio: 1.13; 95% confidence interval: 0.72 to 1.79; p = 0.60). A clinical presentation with ACS was associated with a higher MACE rate compared with SAP in deferred patients (5.91% vs. 3.64% in ACS and SAP, respectively; fully adjusted hazard ratio: 0.61 in favor of SAP; 95% confidence interval: 0.38 to 0.99; p = 0.04). CONCLUSIONS Overall, deferral of revascularization is equally safe with both iFR and FFR, with a low MACE rate of about 4%. Lesions were more frequently deferred when iFR was used to assess physiological significance. In deferred patients presenting with ACS, the event rate was significantly increased compared with SAP at 1 year. (C) 2018 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

  • 104.
    Escobar Kvitting, John-Peder
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Oslo Univ Hosp, Norway.
    Hermansson, Ulf
    Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Vanhanen, Ingemar
    Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Resection of a plasma cell granuloma combining a conventional posterolateral left-sided thoracotomy with a minimally invasive valve approach2019In: GENERAL THORACIC AND CARDIOVASCULAR SURGERY, ISSN 1863-6705, Vol. 67, no 10, p. 894-896Article in journal (Refereed)
    Abstract [en]

    Plasma cell granuloma (PCG) is a rare benign tumor that is difficult to differentiate from malignancy. Depending on the location of the PCG, surgical management can be challenging. We describe a patient with a PCG involving the left lower lobe extending into the left atrium, that was resected en bloc using a conventional posterolateral thoracotomy combined with a surgical approach predominantly used for minimally invasive mitral valve surgery. This case illustrates how it is possible to utilize a technique used for cardiac surgery for tumors of pulmonary origin involving the heart.

  • 105.
    E:son Jennersjö, Pär
    Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Risk factors in type 2 diabetes with emphasis on blood pressure, physical activity and serum vitamin D2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background

    Type 2 diabetes is a common chronic disease with a two-fold increased risk for cardiovascular morbidity and mortality and has an increasing prevalence worldwide. This thesis is based on a study conducted in primary health care in Östergötland and Jönköping, Sweden. The aim of the thesis was to evaluate new risk markers to identify patients with high risk of developing cardiovascular disease in middle-aged men and women with type 2 diabetes.

    Methods

    Data from the cohort study CArdiovascular Risk in type 2 DIabetes – a Prospective study in Primary care (CARDIPP) was used. In paper III data were also used from CARDIPP-Revisited where all participants in the CARDIPP study were invited four years after the baseline investigation for a re-investigation. In paper IV data were used from CAREFUL which is a control group of 185 subjects without diabetes. The investigation included a standard medical history including data on diabetes duration and on-going medication. Anthropometric data were recorded and both office and ambulatory blood pressure were measured. The patients filled out a detailed questionnaire and physical activity was measured by using waist-mounted pedometers. Pedometer-determined physical activity was classified in four groups: Group 1: <5000 steps/day (‘sedentary’); Group 2: 5000-7499 steps/day (‘low active’); Group 3: 7500-9999 steps/day (‘somewhat active’); Group 4: and ≥10 000 steps/day (‘active’). Blood samples were drawn for routine analyses and also frozen for later analyses. The investigations at the departments of physiology included echocardiography, measurements of the carotid intima-media thickness, applanation tonometry and measurements of  sagittal abdominal diameter.

    Results

    Paper 1:

    Patients with a non-dipping systolic blood pressure pattern showed higher left ventricular mass index and pulse wave velocity (PWV) compared with patients with ≥10% decline in nocturnal systolic blood pressure. Patients with <10% decline in nocturnal systolic blood pressure had higher BMI and sagittal abdominal diameter, lower GFR and higher albumin:creatinine ratio and also higher levels of NT-proBNP than patients with a dipping pattern of the nocturnal blood pressure.

    Paper 2:

    The number of steps/day were inversely significantly associated with BMI, waist circumference and sagittal abdominal diameter, levels of CRP, levels of interleukin-6 and PWV.

    Paper 3:

    At the 4-year follow-up the change in PWV (ΔPWV) from baseline was calculated. The group with the lowest steps/day had a significantly higher increase in ΔPWV compared with the group with the highest steps/day. The associations between baseline steps/day and ΔPWV remained after further adjustment in a multivariate linear regression statistically significant (p=0.005). 23% of the variation in the study could be explained by our model. Every 1000 extra steps at baseline reduced the change in ΔPWV by 0.103 m/s between baseline and follow-up.

    Paper 4:

    Low vitamin D levels were associated with significantly increased risk for premature mortality in men with type 2 diabetes. High levels of parathyroid hormone were associated with significantly increased risk for premature mortality in women with type 2 diabetes. These relationships were still statistically significant also when two other well-established risk markers for mortality, PWV and carotid intima-media thickness, were added to the analyses.

    Conclusions

    Ambulatory blood pressure recording can by addressing the issue of diurnal blood pressure variation, explore early cardiovascular organ damage and microvascular complications that goes beyond effects of standardised office blood pressure measurements. Pedometer-determined physical activity may serve as a surrogate marker for inflammation and subclinical organ damage in patients with type 2 diabetes. There is novel support for the durable vascular protective role of a high level of daily physical activity, which is independent of BMI and systolic blood pressure. The use of pedometers is feasible in clinical practice and provides objective information not only about physical activity but also the future risk for subclinical organ damage in middle-aged people with type 2 diabetes. Our results indicate that low vitamin D levels in men or high parathyroid hormone levels in women give independent prognostic information of an increased risk for total mortality.

    List of papers
    1. Circadian blood pressure variation in patients with type 2 diabetes - relationship to macro- and microvascular subclinical organ damage
    Open this publication in new window or tab >>Circadian blood pressure variation in patients with type 2 diabetes - relationship to macro- and microvascular subclinical organ damage
    Show others...
    2011 (English)In: Primary Care Diabetes, ISSN 1751-9918, E-ISSN 1878-0210, Vol. 5, no 3, p. 167-173Article in journal (Refereed) Published
    Abstract [en]

    Aims

    To explore the association between nocturnal blood pressure (BP) dipper status and macro- and microvascular organ damage in type 2 diabetes.

    Methods

    Cross-sectional data from 663 patients with type 2 diabetes, aged 55–66 years, were analysed. Nurses measured office BP and ambulatory BP during 24 h. Individuals with ≥10% difference in nocturnal systolic blood pressure (SBP) relative to daytime values were defined as dippers. Non-dippers were defined as <10% nocturnal decrease in SBP. Estimated glomerular filtration rate (GFR) was calculated and microalbuminuria was measured by albumin:creatinine ratio (ACR). Aortic pulse wave velocity (PWV) was measured with applanation tonometry over the carotid and femoral arteries.

    Results

    We identified 433 dippers and 230 subjects with a nocturnal non-dipping pattern. Nocturnal SBP dipping was independently of office SBP associated with decreased PWV (p = 0.008), lower ACR (p = 0.001) and NT-proBNP (p = 0.001) and increased GFR (p < 0.001).

    Conclusions

    We conclude that diurnal BP variation provides further information about early macro- and microvascular subclinical organ damage that goes beyond standardized office BP measurements in patients with type 2 diabetes.

    Place, publisher, year, edition, pages
    Elsevier, 2011
    Keywords
    Type 2 diabetes mellitus ambulatory blood pressure arterial stiffness microalbuminuria diurnal blood pressure variation
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-75571 (URN)10.1016/j.pcd.2011.04.001 (DOI)000304279600004 ()
    Note

    funding agencies|Medical Research Council of Southeast Sweden||Center for Medical Image Science and Visualization (CMIV)||Linkoping University||GE Healthcare||Swedish Heart-Lung Foundation||Swedish Research Council| 12661 |

    Available from: 2012-03-08 Created: 2012-03-08 Last updated: 2017-12-07Bibliographically approved
    2. Pedometer-determined physical activity is linked to low systemic inflammation and low arterial stiffness in Type 2 diabetes
    Open this publication in new window or tab >>Pedometer-determined physical activity is linked to low systemic inflammation and low arterial stiffness in Type 2 diabetes
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    2012 (English)In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 29, no 9, p. 1119-1125Article in journal (Refereed) Published
    Abstract [en]

    Diabet. Med. 29, 11191125 (2012) Abstract Aims The aim of this study was to explore the association between pedometer-determined physical activity versus measures of obesity, inflammatory markers and arterial stiffness in people with Type 2 diabetes. Methods We analysed data from 224 men and 103 women with Type 2 diabetes, aged 5466 years. Physical activity was measured with waist-mounted pedometers during three consecutive days and the number of steps/day were calculated and classified in four groups: andlt; 5000 steps/day, 50007499 steps/day, 75009999 steps/day and andgt;= 10000 steps/day. Blood samples were analysed for lipids, HbA1c, inflammatory markers including C-reactive protein and interleukin-6. Nurses measured blood pressure and anthropometrics. Aortic pulse wave velocity was measured with applanation tonometry over the carotid and femoral arteries. Results Mean steps/day was 7683 +/- 3883 (median 7222, interquartile range 486910 343). There were no differences in age, diabetes duration, blood pressure, lipids or glycaemic control between the four groups of pedometer-determined physical activity. Subjects with higher steps/day had lower BMI (28.8 vs. 31.5 kg/m2, P andlt; 0.001), waist circumference (101.7 vs. 108.0 cm, P andlt; 0.001), lower levels of C-reactive protein (1.6 vs. 2.6 mg/l, P = 0.007), lower levels of interleukin-6 (1.9 vs. 3.8 pg ml, P andlt; 0.001) and lower pulse wave velocity (10.2 vs. 11.0 m/s, P = 0.009) compared with less physically active people. Conclusions We conclude that physical activity measured with pedometer was associated not only with less abdominal obesity, but also with decreased systemic low-grade inflammation as well as with low arterial stiffness, in people with Type 2 diabetes.

    Place, publisher, year, edition, pages
    Wiley-Blackwell, 2012
    Keywords
    arterial stiffness, exercise, inflammation, obesity, pedometer, Type 2 diabetes
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-81816 (URN)10.1111/j.1464-5491.2012.03621.x (DOI)000307470200021 ()
    Note

    Funding Agencies|Medical Research Council of Southeast Sweden||Center for Medical Image Science and Visualization (CMIV), Linkoping University||GE Healthcare||Swedish Heart-Lung Foundation||Swedish Research Council|12661|

    Available from: 2012-09-26 Created: 2012-09-24 Last updated: 2017-12-07Bibliographically approved
    3. Pedometer-determined physical activity level and change in arterial stiffness in Type 2 diabetes over 4 years
    Open this publication in new window or tab >>Pedometer-determined physical activity level and change in arterial stiffness in Type 2 diabetes over 4 years
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    2016 (English)In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 33, no 7, p. 992-997Article in journal (Refereed) Published
    Abstract [en]

    Aim To explore prospectively the correlation between the level of pedometer-determined physical activity at the start of the study and the change in pulse wave velocity from baseline to 4 years later in people with Type 2 diabetes.

    Methods We analysed data from 135 men and 53 women with Type 2 diabetes, aged 54–66 years. Physical activity was measured with waist-mounted pedometers on 3 consecutive days and the numbers of steps/day at baseline were classified into four groups: <5000 steps/day, 5000–7499 steps/day, 7500–9999 steps/day and ≥10 000 steps/day. Pulse wave velocity was measured using applanation tonometry over the carotid and femoral arteries at baseline and after 4 years.

    Results The mean (±sd; range) number of steps/day was 8022 (±3765; 956–20 921). The participants with the lowest level of physical activity had a more pronounced increase in the change in pulse wave velocity compared with the participants with the highest. When change in pulse wave velocity was analysed as a continuous variable and adjusted for sex, age, diabetes duration, HbA1c, BMI, systolic blood pressure, pulse wave velocity at baseline, β-blocker use, statin use, unemployment, smoking and diabetes medication, the number of steps/day at baseline was significantly associated with a less steep increase in change in pulse wave velocity (P=0.005). Every 1000 extra steps at baseline corresponded to a lower increase in change in pulse wave velocity of 0.103 m/s.

    Conclusions We found that a high level of pedometer-determined physical activity was associated with a slower progression of arterial stiffness over 4 years in middle-aged people with Type 2 diabetes.

    Place, publisher, year, edition, pages
    John Wiley & Sons, 2016
    National Category
    Endocrinology and Diabetes General Practice Geriatrics Sport and Fitness Sciences Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-125910 (URN)10.1111/dme.12873 (DOI)000379930900018 ()26227869 (PubMedID)
    Note

    Funding agencies: Medical Research Council of Southeast Sweden; Centre for Medical Image Science and Visualization (CMIV), Linkoping University; GE Healthcare; Swedish Heart-Lung Foundation; Swedish Research Council [12661]; King Gustaf V and Queen Victoria Freemason Found

    Available from: 2016-03-08 Created: 2016-03-08 Last updated: 2019-11-11Bibliographically approved
    4. A prospective observational study of all-cause mortality in relation to serum 25-OH vitamin D-3 and parathyroid hormone levels in patients with type 2 diabetes
    Open this publication in new window or tab >>A prospective observational study of all-cause mortality in relation to serum 25-OH vitamin D-3 and parathyroid hormone levels in patients with type 2 diabetes
    Show others...
    2015 (English)In: Diabetology and Metabolic Syndrome, ISSN 1758-5996, E-ISSN 1758-5996, Vol. 7, no 53Article in journal (Refereed) Published
    Abstract [en]

    Background: Low levels of vitamin D have been related to increased mortality and morbidity in several non-diabetic studies. We aimed to prospectively study relationships between serum 25-OH vitamin D-3 (vitamin D) and of serum parathyroid hormone (PTH) to total mortality in type 2 diabetes. We also aimed to compare the levels of these potential risk-factors in patients with and without diabetes. Methods: The main study design was prospective and observational. We used baseline data from 472 men and 245 women who participated in the "Cardiovascular Risk factors in Patients with Diabetes-a Prospective study in Primary care" study. Patients were 55-66 years old at recruitment, and an age-matched non-diabetic sample of 129 individuals constituted controls for the baseline data. Carotid-femoral pulse-wave velocity (PWV) was measured with applanation-tonometry and carotid intima-media thickness (IMT) with ultrasound. Patients with diabetes were followed for all-cause mortality using the national Swedish Cause of Death Registry. Results: Levels of vitamin D were lower in patients with diabetes than in controls, also after correction for age and obesity, while PTH levels did not differ. Nine women and 24 men died during 6 years of median follow up of the final cohort (n = 698). Vitamin D levels were negatively related to all-cause mortality in men independently of age, PTH, HbA1c, waist circumference, 24-h systolic ambulatory-blood pressure (ABP) and serum-apoB (p = 0.049). This finding was also statistically significant when PWV and IMT were added to the analyses (p = 0.028) and was not affected statistically when medications were also included in the regression-analysis (p = 0.01). In the women with type 2 diabetes, levels of PTH were positively related with all-cause mortality in the corresponding calculations (p = 0.016 without PWV and IMT, p = 0.006 with PWV and IMT, p = 0.045 when also adding medications to the analysis), while levels of vitamin D was without statistical significance (p greater than 0.9). Conclusions: Serum vitamin D in men and serum PTH in women give prognostic information in terms of total-mortality that are independent of regular risk factors in addition to levels of ABP, IMT and PWV.

    Place, publisher, year, edition, pages
    BioMed Central, 2015
    Keywords
    Arteriosclerosis; Calcium; Mortality; Parathyroid hormone; Type 2 diabetes; Vitamin D
    National Category
    Endocrinology and Diabetes
    Identifiers
    urn:nbn:se:liu:diva-120044 (URN)10.1186/s13098-015-0049-9 (DOI)000356219100001 ()26078787 (PubMedID)
    Note

    Funding Agencies|Medical Research Council of Southeast Sweden; Futurum; King Gustaf V and Queen Victoria Freemason Foundation; GE Healthcare; Swedish Heart-Lung Foundation; Swedish Research Council [12661]; County Council of Ostergotland; Linkoping University, Department of Medical and Health Sciences

    Available from: 2015-07-06 Created: 2015-07-06 Last updated: 2019-11-11
  • 106.
    Fabris, Enrico
    et al.
    Cardiology Department, Isala Heart Center, the Netherlands, Cardiovascular Department, University of Trieste, Italy.
    van 't Hof, Arnoud
    Isala Heart Center, Maastricht University Medical Center, Zuyderland Hospital, the Netherlands,.
    Hamm, Christian W
    Kerckhoff Heart and Thorax Center, Germany.
    Lapostolle, Frédéric
    Hôpital Avicenne, France.
    Lassen, Jens F
    Aarhus University Hospital, Denmark.
    Goodman, Shaun G
    Canadian Heart Research Centre, University of Toronto, Canada.
    Ten Berg, Jurriën M
    St Antonius Hospital Nieuwegein, the Netherlands.
    Bolognese, Leonardo
    Cardiovascular and Neurological Department, Azienda Ospedaliera Arezzo, Italy.
    Cequier, Angel
    Heart Disease Institute, University of Barcelona, Spain.
    Chettibi, Mohamed
    Centre Hospito-universitaire Frantz Fanon, Algeria.
    Hammett, Christopher J
    Royal Brisbane and Women's Hospital, Australia.
    Huber, Kurt
    Wilhelminen Hospital, Austria, Sigmund Freud Private University, Austria.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Merkely, Béla
    Heart and Vascular Center, Semmelweis University, Hungary.
    Storey, Robert F
    Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, UK.
    Zeymer, Uwe
    Klinikum Ludwigshafen and Institut für Herzinfarktforschung, Germany.
    Cantor, Warren J
    Southlake Regional Health Centre, University of Toronto, Canada.
    Tsatsaris, Anne
    Astra Zeneca, UK.
    Kerneis, Mathieu
    ACTION Study Group, Sorbonne Université Paris 6, France.
    Diallo, Abdourahmane
    ACTION Study Group, Hospital Lariboisiere, France..
    Vicaut, Eric
    ACTION Study Group, Hospital Lariboisiere, France..
    Montalescot, Gilles
    ACTION Study Group, Sorbonne Université Paris 6, France.
    Clinical impact and predictors of complete ST segment resolution after primary percutaneous coronary intervention: A subanalysis of the ATLANTIC Trial2019In: European heart journal. Acute cardiovascular care., ISSN 2048-8726, Vol. 8, no 3, p. 208-217Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In the ATLANTIC (Administration of Ticagrelor in the catheterization laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery) trial the early use of aspirin, anticoagulation, and ticagrelor coupled with very short medical contact-to-balloon times represent good indicators of optimal treatment of ST-elevation myocardial infarction and an ideal setting to explore which factors may influence coronary reperfusion beyond a well-established pre-hospital system.

    METHODS: This study sought to evaluate predictors of complete ST-segment resolution after percutaneous coronary intervention in ST-elevation myocardial infarction patients enrolled in the ATLANTIC trial. ST-segment analysis was performed on electrocardiograms recorded at the time of inclusion (pre-hospital electrocardiogram), and one hour after percutaneous coronary intervention (post-percutaneous coronary intervention electrocardiogram) by an independent core laboratory. Complete ST-segment resolution was defined as ≥70% ST-segment resolution.

    RESULTS: Complete ST-segment resolution occurred post-percutaneous coronary intervention in 54.9% ( n=800/1456) of patients and predicted lower 30-day composite major adverse cardiovascular and cerebrovascular events (odds ratio 0.35, 95% confidence interval 0.19-0.65; p<0.01), definite stent thrombosis (odds ratio 0.18, 95% confidence interval 0.02-0.88; p=0.03), and total mortality (odds ratio 0.43, 95% confidence interval 0.19-0.97; p=0.04). In multivariate analysis, independent negative predictors of complete ST-segment resolution were the time from symptoms to pre-hospital electrocardiogram (odds ratio 0.91, 95% confidence interval 0.85-0.98; p<0.01) and diabetes mellitus (odds ratio 0.6, 95% confidence interval 0.44-0.83; p<0.01); pre-hospital ticagrelor treatment showed a favorable trend for complete ST-segment resolution (odds ratio 1.22, 95% confidence interval 0.99-1.51; p=0.06).

    CONCLUSIONS: This study confirmed that post-percutaneous coronary intervention complete ST-segment resolution is a valid surrogate marker for cardiovascular clinical outcomes. In the current era of ST-elevation myocardial infarction reperfusion, patients' delay and diabetes mellitus are independent predictors of poor reperfusion and need specific attention in the future.

  • 107.
    Fabris, Enrico
    et al.
    Isala Clinics, Zwolle, the Netherlands, University of Trieste, Trieste, Italy.
    Van't Hof, Arnoud
    Isala Clinics, Zwolle, the Netherlands.
    Hamm, Christian W
    Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.
    Lapostolle, Frédéric
    Hôpital Avicenne, Bobigny, France.
    Lassen, Jens Flensted
    Aarhus University Hospital, Aarhus N, Denmark.
    Goodman, Shaun G
    St. Michael’s Hospital, University of Toronto, Toronto, Canada.
    Ten Berg, Jurriën M
    Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands.
    Bolognese, Leonardo
    Cardiovascular and Neurological Department, Azienda Ospedaliera Arezzo, Arezzo, Italy.
    Cequier, Angel
    University of Barcelona, Barcelona, Spain.
    Chettibi, Mohamed
    Centre Hospitalo Universitaire Frantz Fanon, Blida, Algeria.
    Hammett, Christopher H
    Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia.
    Huber, Kurt
    Wilhelminen Hospital and Sigmund Freud Private University, Medical School, Vienna, Austria.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Merkely, Béla
    Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
    Storey, Robert F
    University of Sheffield, Sheffield, United Kingdom.
    Zeymer, Uwe
    Klinikum Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen, Germany.
    Cantor, Warren J
    University of Toronto, Newmarket, Ontario, Canada;.
    Rousseau, Hélène
    Hospital Lariboisiere, ACTION Study Group, Paris, France.
    Vicaut, Eric
    Hospital Lariboisiere, ACTION Study Group, Paris, France.
    Montalescot, Gilles
    Sorbonne Université Paris 6, ACTION Study Group, Hospital Pitie-Salpetriere (AP-HP), Paris, France.
    Impact of presentation and transfer delays on complete ST-segment resolution before primary percutaneous coronary intervention: insights from the ATLANTIC trial.2017In: EuroIntervention, ISSN 1774-024X, E-ISSN 1969-6213, Vol. 13, no 1, p. 69-77, article id EIJ-D-16-00965Article in journal (Refereed)
    Abstract [en]

    AIMS: The aim of this study was to identify predictors of complete ST-segment resolution (STR) pre-primary percutaneous coronary intervention (PCI) in patients enrolled in the ATLANTIC trial.

    METHODS AND RESULTS: ECGs recorded at the time of inclusion (pre-hospital [pre-H]-ECG) and in the catheterisation laboratory before angiography (pre-PCI-ECG) were analysed by an independent core laboratory. Complete STR was defined as ≥70%. Complete STR occurred pre-PCI in 12.8% (204/1,598) of patients and predicted lower 30-day composite MACCE (OR=0.10, 95% CI: 0.002-0.57, p=0.001) and total mortality (OR=0.16, 95% CI: 0.004-0.95, p=0.035). Independent predictors of complete STR included the time from index event to pre-H-ECG (OR=0.94, 95% CI: 0.89-1.00, p=0.035), use of heparins before pre-PCI-ECG (OR=1.75, 95% CI: 1.25-2.45, p=0.001) and time from pre-H-ECG to pre-PCI-ECG (OR=1.09, 95% CI: 1.03-1.16, p=0.005). In the pre-H ticagrelor group, patients with complete STR had a significantly longer delay between pre-H-ECG and pre-PCI-ECG compared to patients without complete STR (median 53 [44-73] vs. 49 [38.5-61] mins, p=0.001); however, this was not observed in the control group (in-hospital ticagrelor) (50 [40-67] vs. 49 [39-61] mins, p=0.258).

    CONCLUSIONS: Short patient delay, early administration of anticoagulant and ticagrelor if a long transfer delay is expected may help to achieve reperfusion prior to PCI. Pre-H treatment may be beneficial in patients with longer transfer delays, allowing the drug to become biologically active.

  • 108.
    Fabris, Enrico
    et al.
    Cardiology Department, Isala Heart Center, Zwolle, the Netherlands, , Cardiovascular Department, University of Trieste, Trieste, Italy.
    Van't Hof, Arnoud
    Cardiology Department, Isala Heart Center, Zwolle, the Netherlands, Maastricht University Medical Center, Maastricht, the Netherlands, Zuyderland Hospital, Heerlen, the Netherlands.
    Hamm, Christian W
    Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.
    Lapostolle, Frédéric
    SAMU 93 Hôpital Avicenne, Bobigny, France.
    Lassen, Jens Flensted
    Department of Cardiology B, Aarhus University Hospital, Aarhus, Denmark.
    Goodman, Shaun G
    Canadian Heart Research Centre, Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Canada.
    Ten Berg, Jurriën M
    Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands.
    Bolognese, Leonardo
    Cardiovascular and Neurological Department, Azienda Ospedaliera Arezzo, Arezzo, Italy.
    Cequier, Angel
    Heart Disease Institute, Hospital Universitario de Bellvitge, University of Barcelona, Spain.
    Chettibi, Mohamed
    Centre Hospito-universitaire Frantz Fanon, Blida, Algeria.
    Hammett, Christopher J
    Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
    Huber, Kurt
    3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen hospital and Sigmund Freud University, Medical School, Vienna, Austria..
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Merkely, Béla
    Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
    Storey, Robert F
    Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.
    Zeymer, Uwe
    Klinikum Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen, Germany.
    Cantor, Warren J
    Southlake Regional Health Centre, University of Toronto, Ontario, Canada.
    Kerneis, Mathieu
    Sorbonne Université, ACTION Study Group, Hospital Pitie-Salpetriere (AP-HP), Paris, France.
    Diallo, Abdourahmane
    Hospital Lariboisiere, ACTION Study Group, Paris, France.
    Vicaut, Eric
    Hospital Lariboisiere, ACTION Study Group, Paris, France.
    Montalescot, Gilles
    Sorbonne Université, ACTION Study Group, Hospital Pitie-Salpetriere (AP-HP), Paris, France.
    Pre-hospital administration of ticagrelor in diabetic patients with ST-elevation myocardial infarction undergoing primary angioplasty: A sub-analysis of the ATLANTIC trial2019In: Catheterization and cardiovascular interventions, ISSN 1522-1946, E-ISSN 1522-726X, Vol. 93, no 7, p. E369-E377Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: We investigated, in the contemporary era of ST-elevation myocardial infarction (STEMI) treatment, the influence of diabetes mellitus (DM) on cardiovascular outcomes, and whether pre-hospital administration of ticagrelor may affect these outcomes in a subgroup of STEMI patients with DM.

    BACKGROUND: DM patients have high platelet reactivity and a prothrombotic condition which highlight the importance of an effective antithrombotic regimen in this high-risk population.

    METHODS: In toal 1,630 STEMI patients enrolled in the ATLANTIC trial who underwent primary percutaneous coronary intervention (PCI) were included. Multivariate analysis was used to explore the association of DM with outcomes and potential treatment-by-diabetes interaction was tested.

    RESULTS: A total of 214/1,630 (13.1%) patients had DM. DM was an independent predictor of poor myocardial reperfusion as reflected by less frequent ST-segment elevation resolution (≥70%) after PCI (OR 0.59, 95% CI 0.43-0.82, P < 0.01) and was an independent predictor of the composite 30-day outcomes of death/new myocardial infarction (MI)/urgent revascularization/definite stent thrombosis (ST) (OR 2.80, 95% CI 1.62-4.85, P < 0.01), new MI or definite acute ST (OR 2.46, 95% CI 1.08-5.61, P = 0.03), and definite ST (OR 10.00, 95% CI 3.54-28.22, P < 0.01). No significant interaction between pre-hospital ticagrelor vs in-hospital ticagrelor administration and DM was present for the clinical, electrocardiographic and angiographic outcomes as well as for thrombolysis in myocardial infarction major bleeding.

    CONCLUSIONS: DM remains independently associated with poor myocardial reperfusion and worse 30-day clinical outcomes. No significant interaction was found between pre-hospital vs in-hospital ticagrelor administration and DM status. Further approaches for the treatment of DM patients are needed.

    CLINICAL TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01347580.

  • 109.
    Feldt, Kari
    et al.
    Karolinska Inst, Sweden; Karolinska Univ Hosp, Sweden.
    De Palma, Rodney
    Buckinghamshire NHS Trust, England; Karolinska Inst, Sweden.
    Bjursten, Henrik
    Lund Univ, Sweden.
    Petursson, Petur
    Gothenburg Univ, Sweden.
    Nielsen, Niels Erik
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Kellerth, Thomas
    Orebro Univ Hosp, Sweden.
    Jonsson, Anders
    Univ Hosp, Sweden.
    Nilsson, Johan
    Umea Univ Hosp, Sweden.
    Ruck, Andreas
    Karolinska Inst, Sweden; Karolinska Univ Hosp, Sweden.
    Settergren, Magnus
    Karolinska Inst, Sweden; Karolinska Univ Hosp, Sweden.
    Change in mitral regurgitation severity impacts survival after transcatheter aortic valve replacement2019In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 294, p. 32-36Article in journal (Refereed)
    Abstract [en]

    Background: The impact of a change in mitral regurgitation (MR) following TAVR is unknown. We studied the impact of baseline MR and early post-procedural change in MR on survival following TAVR. Methods: The SWEDEHEART registry included all TAVRs performed in Sweden. Patients were dichotomized into no/mild and moderate/severe MR groups. Vital status, echocardiographic data at baseline and within 7 days after TAVR were analyzed. Results: 1712 patients were included. 1404 (82%) had no/mild MR and 308 (18%) had moderate/severe MR. Baseline moderate/severe MR conferred a higher mortality rate at 5-year follow-up (adjusted HR 1.29, CI 1.01-1.65, p = 0.04). Using persistent amp;lt;= mild MR as the reference, when moderate/severe MR persisted or if MR worsened from amp;lt;= mild at baseline to moderate/severe after TAVR, higher 5-year mortality rates were seen (adjusted HR 1.66, CI 1.17-2.34, p = 0.04; adjusted HR 1.97, CI 1.29-3.00, p = 0.002, respectively). If baseline moderate/severe MR improved to = mild after TAVR no excess mortality was seen (HR 1.09, CI 0.75-1.58, p = 0.67). Paravalvular aortic regurgitation (PVL) was inversely associated with MR improvement after TAVR (OR 0.4, 95%: CI 0.17-0.94; p = 0.034). Atrial fibrillation (OR 2.1, 95% CI: 1.27-3.39, p = 0.004), self-expanding valve (OR 3.8, 95% CI: 2.08-7.14, p amp;lt; 0.0001), and PVL (4.3, 95% CI 2.32-7.78. p amp;lt; 0.0001) were associated with MR worsening. Conclusions: Moderate/severe baseline MR in patients undergoing TAVR is associated with a mortality increase during 5 years of follow-up. This risk is offset if MR improves to amp;lt;= mild, whereas worsening of MR after TAVR is associated with a 2-fold mortality increase. (C) 2019 Elsevier B.V. All rights reserved.

  • 110.
    Fernlund, Eva
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Children's and Women's health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, H.K.H. Kronprinsessan Victorias barn- och ungdomssjukhus. Lund University, Sweden.
    Gyllenhammar, T.
    Lund University, Sweden.
    Jablonowski, R.
    Lund University, Sweden.
    Carlsson, M.
    Lund University, Sweden.
    Larsson, A.
    Uppsala University, Sweden.
    Arnlov, J.
    Uppsala University, Sweden; Karolinska Institute, Sweden.
    Liuba, P.
    Lund University, Sweden.
    Serum Biomarkers of Myocardial Remodeling and Coronary Dysfunction in Early Stages of Hypertrophic Cardiomyopathy in the Young2017In: Pediatric Cardiology, ISSN 0172-0643, E-ISSN 1432-1971, Vol. 38, no 4, p. 853-863Article in journal (Refereed)
    Abstract [en]

    Hypertrophic cardiomyopathy (HCM) remains the leading cause of sudden cardiac death in the young. Early markers for HCM are important to identify individuals at risk. The aim of this study was to investigate novel serum biomarkers reflecting myocardial remodeling, microfibrosis, and vascular endotheliopathy in the early stages of familial HCM in young patients. Twenty-three HCM patients, 16 HCM-risk individuals, and 66 controls (median 15 years) underwent echocardiography and serum analysis for cathepsin S, endostatin, myostatin, type I collagen degradation marker (ICTP), matrix metalloproteinase (MMP)-9, vascular endothelial growth factor receptor (VEGFR)-1, and vascular and intercellular adhesion molecules (VCAM, ICAM). In a subset of the population, global myocardial perfusion was performed by magnetic resonance imaging. Cathepsin S (p = 0.0009), endostatin (p amp;lt; 0.0001), MMP-9 (p = 0.008), and VCAM (p = 0.04) were increased in the HCM group and correlated to left ventricular mass index and mitral E/e (p amp;lt; 0.01). In the HCM-risk group, myostatin was decreased (p = 0.004), whereas ICAM was increased (p = 0.002). Global perfusion was decreased in the HCM group (p amp;lt; 0.05) versus controls. Endostatin and mitral E/e correlated inversely to myocardial perfusion (p aeamp;lt;currencyamp;gt; 0.05). This is the first study demonstrating adverse changes in biomarkers reflecting myocardial matrix remodeling, microfibrosis, and vascular endotheliopathy in early stage of hypertrophic cardiomyopathy in the young.

  • 111.
    Fernlund, Eva
    et al.
    Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Paediatrics in Linköping. Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Medicine and Health Sciences. Skåne University Hospital, Sweden; Lund University, Sweden.
    Liuba, P.
    Skåne University Hospital, Sweden; Lund University, Sweden.
    Carlson, J.
    Lund University, Sweden; Skåne University Hospital, Sweden.
    Platonov, P. G.
    Lund University, Sweden; Skåne University Hospital, Sweden.
    Schlegel, T. T.
    Karolinska University Hospital, Sweden; Karolinska Institute, Sweden; Nicollier Schlegel SARL, Switzerland.
    MYBPC3 hypertrophic cardiomyopathy can be detected by using advanced ECG in children and young adults2016In: Journal of Electrocardiology, ISSN 0022-0736, E-ISSN 1532-8430, Vol. 49, no 3, p. 392-400Article in journal (Refereed)
    Abstract [en]

    Introduction: The conventional ECG is commonly used to screen for hypertrophic cardiomyopathy (HCM), but up to 25% of adults and possibly larger percentages of children with HCM have no distinctive abnormalities on the conventional ECG, whereas 5 to 15% of healthy young athletes do. Recently, a 5-min resting advanced 12-lead ECG test ("A-ECG score") showed superiority to pooled criteria from the strictly conventional ECG in correctly identifying adult HCM. The purpose of this study was to evaluate whether in children and young adults, A-ECG scoring could detect echocardiographic HCM associated with the MYBPC3 genetic mutation with greater sensitivity than conventional ECG criteria and distinguish healthy young controls and athletes from persons with MYBPC3 HCM with greater specificity. Methods: Five-minute 12-lead ECGs were obtained from 15 young patients (mean age 13.2 years, range 0-30 years) with MYBPC3 mutation and phenotypic HCM. The conventional and A-ECG results of these patients were compared to those of 198 healthy children and young adults (mean age 13.2, range 1 month-30 years) with unremarkable echocardiograms, and to those of 36 young endurance-trained athletes, 20 of whom had athletic (physiologic) left ventricular hypertrophy. Results: Compared with commonly used, age-specific pooled criteria from the conventional ECG, a retrospectively generated A-ECG score incorporating results from just 2 derived vectorcardiographic parameters (spatial QRS-T angle and the change in the vectorcardiographic QRS azimuth angle from the second to the third eighth of the QRS interval) increased the sensitivity of ECG for identifying MYBPC3 HCM from 46% to 87% (p amp;lt; 0.05). Use of the same score also demonstrated superior specificity in a set of 198 healthy controls (94% vs. 87% for conventional ECG criteria; p amp;lt; 0.01) including in a subset of 36 healthy, young endurance-trained athletes (100% vs. 69% for conventional ECG criteria, p amp;lt; 0.001). Conclusions: In children and young adults, a 2-parameter 12-lead A-ECG score is retrospectively significantly more sensitive and specific than pooled, age-specific conventional ECG criteria for detecting MYBPC3-HCM and in distinguishing such patients from healthy controls, including endurance-trained athletes. (C) 2016 Elsevier Inc. All rights reserved.

  • 112.
    Fernlund, Eva
    et al.
    Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Paediatrics in Linköping. Lund University, Sweden.
    Schlegel, Todd T.
    Karolinska Institute, Sweden; Karolinska University Hospital, Sweden.
    Platonov, Pyotr G.
    Lund University, Sweden.
    Carlson, Jonas
    Lund University, Sweden.
    Carlsson, Marcus
    Lund University, Sweden.
    Liuba, Petru
    Lund University, Sweden.
    Peripheral microvascular function is altered in young individuals at risk for hypertrophic cardiomyopathy and correlates with myocardial diastolic function2015In: American Journal of Physiology. Heart and Circulatory Physiology, ISSN 0363-6135, E-ISSN 1522-1539, Vol. 308, no 11, p. H1351-H1358Article in journal (Refereed)
    Abstract [en]

    Hypertrophic cardiomyopathy (HCM) is a major cause of sudden cardiac death in the young. Based on previous reports of functional abnormalities in not only coronary but also peripheral vessels in adults with HCM, we aimed to assess both peripheral vascular and myocardial diastolic function in young individuals with an early stage of HCM and in individuals at risk for HCM. Children, adolescents, and young adults (mean age: 12 yr) with a family history of HCM who either had (HCM group; n = 36) or did not have (HCM-risk group; n = 30) echocardiography-documented left ventricular (LV) hypertrophy as well as healthy matched controls (n = 85) and healthy young athletes (n = 12) were included in the study. All underwent assessment with 12-lead electrocardiography, two-dimensional echocardiography, tissue Doppler imaging and laser Doppler with transdermal iontophoresis of ACh and sodium nitroprusside. LV thickness and mass were increased in HCM and athlete groups compared with control and HCM-risk groups. The mitral E-to-e ratio, measured via tissue Doppler, was increased in HCM (P less than 0.0001) and HCM-risk (P less than 0.01) groups compared with control and athlete groups, as were microvascular responses to ACh (HCM group: P less than 0.045 and HCM- risk group: P less than 0.02). Responses to ACh correlated with the E-to-e ratio (r = 0.5, P = 0.001). Microvascular responses to sodium nitroprusside were similar in all groups (P = 0.2). HCM-causing mutations or its familial history are associated with changes in cardiac diastolic function and peripheral microvascular function even before the onset of myocardial hypertrophy. Tissue Doppler can be used to differentiate HCM from physiological LV hypertrophy in young athletes.

  • 113.
    Folkesson, Maggie
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences.
    Vorkapic, Emina
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences.
    Gulbins, Erich
    University of Duisburg-Essen, University of Cincinnati.
    Japtok, Lukasz
    The department of Toxicology, Institute of Nutritional Science, University of Potsdam.
    Kleuser, Burkhard
    The department of Toxicology, Institute of Nutritional Science, University of Potsdam.
    Welander, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Länne, Toste
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Wågsäter, Dick
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences.
    Inflammatory cells, ceramides, and expression of proteases in perivascular adipose tissue adjacent to human abdominal aortic aneurysms2017In: Journal of Vascular Surgery, ISSN 0741-5214, E-ISSN 1097-6809, Vol. 65, no 4, p. 1171-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Abdominal aortic aneurysm (AAA) is a deadly irreversible weakening and distension of the abdominal aortic wall. The pathogenesis of AAA remains poorly understood. Investigation into the physical and molecular characteristics of perivascular adipose tissue (PVAT) adjacent to AAA has not been done before and is the purpose of this study.

    METHODS AND RESULTS: Human aortae, periaortic PVAT, and fat surrounding peripheral arteries were collected from patients undergoing elective surgical repair of AAA. Control aortas were obtained from recently deceased healthy organ donors with no known arterial disease. Aorta and PVAT was found in AAA to larger extent compared with control aortas. Immunohistochemistry revealed neutrophils, macrophages, mast cells, and T-cells surrounding necrotic adipocytes. Gene expression analysis showed that neutrophils, mast cells, and T-cells were found to be increased in PVAT compared with AAA as well as cathepsin K and S. The concentration of ceramides in PVAT was determined using mass spectrometry and correlated with content of T-cells in the PVAT.

    CONCLUSIONS: Our results suggest a role for abnormal necrotic, inflamed, proteolytic adipose tissue to the adjacent aneurysmal aortic wall in ongoing vascular damage.

  • 114.
    Forsberg, Lena M
    et al.
    Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Nylander, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Clinical Physiology in Linköping. Linköping University, Center for Medical Image Science and Visualization (CMIV).
    Tamés, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Exercise echocardiography predicts postoperative left ventricular remodeling in aortic regurgitation2014In: SCANDINAVIAN CARDIOVASCULAR JOURNAL, ISSN 1401-7431, Vol. 48, no 1, p. 4-12Article in journal (Refereed)
    Abstract [en]

    Objective. We aimed to investigate if preoperative left ventricular (LV) function assessed by exercise echocardiography could predict late postoperative LV function in aortic regurgitation (AR) patients and to evaluate how LV long-axis function is affected late after aortic valve surgery. Design. A total of 21 male chronic AR patients, aged 49 (12) years, accepted for surgery were examined preoperatively, 6 months-, and 4 years postoperatively, at rest and during exercise. Besides conventional echocardiographic parameters, the atrioventricular plane displacement (AVPD) by M-mode and peak systolic velocity (s) in the basal LV by color tissue Doppler were measured. Results. Preoperatively EFrest and EFexercise, were 55(7)% and 54(9)%, respectively, and Delta EF 0(8)%. LV dimensions and volumes indexed to BSA had decreased at the 6-month follow-up and were stable at late follow-up. s(rest), s(exercise), AVPD(rest), and AVPD(exercise) were unchanged at both the postoperative examinations (all P >= 0.05). Preoperative EFexercise and AVPD(exercise) showed inverse correlation to late postoperative indexed LV enddiastolic volume (r = -0.68, p < 0.004 and r = -0.86, P < 0.001) and indexed LV endsystolic volume (r = -0.68, P = 0.004 and r = -0.81, P < 0.001), while there was no correlation to preoperative EFrest and AVPD(rest) (all r < 0.2). Conclusions. Preoperative exercise echocardiography can detect AR patients with suboptimal LV remodeling late postoperatively.

  • 115.
    Fredriksson, Alexandru Grigorescu
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Örebrö University Hospital, Örebro, Sweden.
    Svalbring, Emil
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Eriksson, Jonatan
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Faculty of Medicine and Health Sciences.
    Dyverfeldt, Petter
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Alehagen, Urban
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping. Linköping University, Faculty of Medicine and Health Sciences.
    Engvall, Jan
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Clinical Physiology in Linköping. Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Faculty of Medicine and Health Sciences.
    Ebbers, Tino
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Department of Science and Technology, Media and Information Technology. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Faculty of Science & Engineering. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Carlhäll, Carl-Johan
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Clinical Physiology in Linköping. Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Faculty of Medicine and Health Sciences.
    4D flow MRI can detect subtle right ventricular dysfunction in primary left ventricular disease.2016In: Journal of Magnetic Resonance Imaging, ISSN 1053-1807, E-ISSN 1522-2586, Vol. 43, no 3, p. 558-565Article in journal (Refereed)
    Abstract [en]

    PURPOSE: To investigate whether 4D flow magnetic resonance imaging (MRI) can detect subtle right ventricular (RV) dysfunction in primary left ventricular (LV) disease.

    MATERIALS AND METHODS: 4D flow and morphological 3T MRI data were acquired in 22 patients with mild ischemic heart disease who were stratified into two groups based on LV end-diastolic volume index (EDVI): lower-LVEDVI and higher-LVEDVI, as well as in 11 healthy controls. The RV volume was segmented at end-diastole (ED) and end-systole (ES). Pathlines were emitted from the ED volume and traced forwards and backwards in time to ES. The blood volume was separated into flow components. The Direct Flow (DF) component was defined as RV inflow passing directly to outflow. The kinetic energy (KE) of the DF component was calculated. Echocardiographic conventional RV indices were also assessed.

    RESULTS: The higher-LVEDVI group had larger LVEDVI and lower LV ejection fraction (98 ± 32 ml/m(2) ; 48 ± 13%) compared to the healthy (67 ± 12, P = 0.002; 64 ± 7, P < 0.001) and lower-LVEDI groups (62 ± 10; 68 ± 7, both P < 0.001). The RV 4D flow-specific measures "DF/EDV volume-ratio" and "DF/EDV KE-ratio at ED" were lower in the higher-LVEDVI group (38 ± 5%; 52 ± 6%) compared to the healthy (44 ± 6; 65 ± 7, P = 0.018 and P < 0.001) and lower-LVEDVI groups (44 ± 6; 64 ± 7, P = 0.011 and P < 0.001). There was no difference in any of the conventional MRI and echocardiographic RV indices between the three groups.

    CONCLUSION: We found that in primary LV disease mild impairment of RV function can be detected by 4D flow-specific measures, but not by the conventional MRI and echocardiographic indices. J. Magn. Reson. Imaging 2015.

  • 116.
    Fredriksson, Alexandru Grigorescu
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Trzebiatowska-Krzynska, Aleksandra
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Dyverfeldt, Petter
    Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Engvall, Jan
    Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping. Linköping University, Faculty of Medicine and Health Sciences.
    Ebbers, Tino
    Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Carlhäll, Carljohan
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Center for Medical Image Science and Visualization (CMIV). Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Turbulent kinetic energy in the right ventricle: Potential MR marker for risk stratification of adults with repaired Tetralogy of Fallot2018In: Journal of Magnetic Resonance Imaging, ISSN 1053-1807, E-ISSN 1522-2586, Vol. 47, no 4, p. 1043-1053Article in journal (Refereed)
    Abstract [en]

    Purpose: To assess right ventricular (RV) turbulent kinetic energy (TKE) in patients with repaired Tetralogy of Fallot (rToF) and a spectrum of pulmonary regurgitation (PR), as well as to investigate the relationship between these 4D flow markers and RV remodeling.

    Materials and Methods: Seventeen patients with rToF and 10 healthy controls were included in the study. Patients were divided into two groups based on PR fraction: one lower PR fraction group (11%) and one higher PR fraction group (>11%). Field strength/sequences: 3D cine phase contrast (4D flow), 2D cine phase contrast (2D flow), and balanced steady-state free precession (bSSFP) at 1.5T. Assessment: The RV volume was segmented in the morphologic short-axis images and TKE parameters were computed inside the segmented RV volume throughout diastole. Statistical tests: One-way analysis of variance with Bonferroni post-hoc test; unpaired t-test; Pearson correlation coefficients; simple and stepwise multiple regression models; intraclass correlation coefficient (ICC).

    Results: The higher PR fraction group had more remodeled RVs (140 6 25 vs. 107 6 22 [lower PR fraction, P < 0.01] and 93 6 15 ml/m2[healthy, P < 0.001] for RV end-diastolic volume index [RVEDVI]) and higher TKE values (5.95 6 3.15 vs. 2.23 6 0.81 [lower PR fraction, P < 0.01] and 1.91 6 0.78 mJ [healthy, P < 0.001] for Peak Total RV TKE). Multiple regression analysis between RVEDVI and 4D/2D flow parameters showed that Peak Total RV TKE was the strongest predictor of RVEDVI (R25 0.47, P 5 0.002).

    Conclusion: The 4D flow-specific TKE markers showed a slightly stronger association with RV remodeling than conventional 2D flow PR parameters. These results suggest novel hemodynamic aspects of PR in the development of late complications after ToF repair.

  • 117.
    Frobert, Ole
    et al.
    Örebro University, Sweden.
    Gotberg, Matthias
    University Hospital Lund, Sweden.
    Angeras, Oskar
    Sahlgrens University Hospital, Sweden.
    Jonasson, Lena
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Erlinge, David
    University Hospital Lund, Sweden.
    Engstrom, Thomas
    University of Copenhagen, Denmark.
    Persson, Jonas
    Karolinska Institute, Sweden.
    Jensen, Svend E.
    Aalborg University Hospital, Denmark.
    Omerovic, Elmir
    Sahlgrens University Hospital, Sweden.
    James, Stefan K.
    University Hospital Uppsala, Sweden.
    Lagerqvist, Bo
    University Hospital Uppsala, Sweden.
    Nilsson, Johan
    Umeå University, Sweden.
    Karegren, Amra
    Västerås County Hospital, Sweden.
    Moer, Rasmus
    Feiring Clin, Norway.
    Yang, Cao
    Örebro University, Sweden; Karolinska Institute, Sweden.
    Agus, David B.
    University of Southern Calif, CA 90089 USA.
    Erglis, Andrejs
    Pauls Stradins Clin University Hospital, Latvia.
    Jensen, Lisette O.
    Odense University Hospital, Denmark.
    Jakobsen, Lars
    Aarhus University Hospital, Denmark.
    Christiansen, Evald H.
    Aarhus University Hospital, Denmark.
    Pernow, John
    Karolinska Institute, Sweden.
    Design and rationale for the Influenza vaccination After Myocardial Infarction (IAMI) trial. A registry-based randomized clinical trial2017In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 189, p. 94-102Article in journal (Refereed)
    Abstract [en]

    Background Registry studies and case-control studies have demonstrated that the risk of acute myocardial infarction (AMI) is increased following influenza infection. Small randomized trials, underpowered for clinical end points, indicate that future cardiovascular events can be reduced following influenza vaccination in patients with established cardiovascular disease. Influenza vaccination is recommended by international guidelines for patients with cardiovascular disease, but uptake is varying and vaccination is rarely prioritized during hospitalization for AMI. Methods/design The Influenza vaccination After Myocardial Infarction (IAMI) trial is a double-blind, multicenter, prospective, registry-based, randomized, placebo-controlled, clinical trial. A total of 4,400 patients with ST-segment elevation myocardial infarction (STEMI) or non-STEMI undergoing coronary angiography will randomly be assigned either to in-hospital influenza vaccination or to placebo. Baseline information is collected from national heart disease registries, and follow-up will be performed using both registries and a structured telephone interview. The primary end point is a composite of time to all cause death, a new AMI, or stent thrombosis at 1 year. Implications The IAMI trial is the largest randomized trial to date to evaluate the effect of in-hospital influenza vaccination on death and cardiovascular outcomes in patients with STEMI or non-STEMI. The trial is expected to provide highly relevant clinical data on the efficacy of influenza vaccine as secondary prevention after AMI.

  • 118.
    Gabrielson, Marike
    et al.
    Karolinska Institute, Sweden.
    Vorkapic, Emina
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences.
    Folkesson, Maggie
    Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine.
    Welander, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Matussek, Andreas
    University of Coll Health Science, Sweden.
    Dimberg, Jan
    University of Coll Health Science, Sweden.
    Länne, Toste
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Linköping University, Center for Medical Image Science and Visualization (CMIV).
    Skogberg, Josefin
    Karolinska Institute, Sweden.
    Wågsäter, Dick
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences.
    Altered PPAR gamma Coactivator-1 Alpha Expression in Abdominal Aortic Aneurysm: Possible Effects on Mitochondrial Biogenesis2016In: Journal of Vascular Research, ISSN 1018-1172, E-ISSN 1423-0135, Vol. 53, no 1-2, p. 17-26Article in journal (Refereed)
    Abstract [en]

    Introduction: Abdominal aortic aneurysm (AAA) is a complex and deadly vascular disorder. The pathogenesis of AAA includes destruction and phenotypic alterations of the vascular smooth muscle cells (VSMCs) and aortic tissues. PPAR gamma coactivator-1 alpha (PGC1 alpha) regulates VSMC migration and matrix formation and is a major inducer of mitochondrial biogenesis and function, including oxidative metabolism. Methods: Protein and gene expression of PGC1 alpha and markers for mitochondria biogenesis and cell type-specificity were analysed in AAA aortas from humans and mice and compared against control aortas. Results: Gene expression of PPARGC1 A was decreased in human AAA and angiotensin (Ang) II-induced AAA in mice when compared to control vessels. However, high expression of PGC1 alpha was detected in regions of neovascularisation in the adventitia layer. In contract, the intima/media layer of AAA vessel exhibited defective mitochondrial biogenesis as indicated by low expression of PPARGC1 A, VDAC, ATP synthase and citrate synthase. Conclusion: Our results suggest that mitochondrial biogenesis is impaired in AAA in synthetic SMCs in the media, with the exception of newly formed supporting vessels in the adventitia where the mitochondrial markers seem to be intact. To our knowledge, this is the first study investigating PGC1 alpha and mitochondria biogenesis in AAA. (C) 2016 S. Karger AG, Basel

  • 119.
    Gaipov, Abduzhappar
    et al.
    Natl Sci Med Res Ctr, Kazakhstan.
    Molnar, Miklos Z.
    Methodist Univ Hosp, TN USA; Semmelweis Univ, Hungary.
    Potukuchi, Praveen K.
    Natl Sci Med Res Ctr, Kazakhstan.
    Sumida, Keiichi
    Natl Sci Med Res Ctr, Kazakhstan; Toranomon Hosp Kajigaya, Japan.
    Canada, Robert B.
    Natl Sci Med Res Ctr, Kazakhstan.
    Akbilgic, Oguz
    Kazakh Natl Med Univ, Kazakhstan.
    Kabulbayev, Kairat
    Kazakh Natl Med Univ, Kazakhstan.
    Szabo, Zoltán
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Koshy, Santhosh K. G.
    Univ Tennessee, TN 38104 USA.
    Kalantar-Zadeh, Kamyar
    Univ Calif Irvine, CA 92668 USA.
    Kovesdy, Csaba P.
    Natl Sci Med Res Ctr, Kazakhstan; Memphis VA Med Ctr, TN 38104 USA.
    Predialysis coronary revascularization and postdialysis mortality2019In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 157, no 3, p. 976-+Article in journal (Refereed)
    Abstract [en]

    Objectives: Coronary artery bypass grafting (CABG) is associated with better survival than percutaneous coronary intervention (PCI) in patients with mild-to-moderate chronic kidney disease (CKD) and end-stage renal disease (ESRD). However, the optimal strategy for coronary artery revascularization in patients with advanced CKD who transition to ESRD is unclear. Methods: We examined a contemporary national cohort of 971 US veterans with incident ESRD who underwent first CABG or PCI up to 5 years before dialysis initiation. We examined the association of a history of CABG versus PCI with all-cause mortality following transition to dialysis using Cox proportional hazards models adjusted for time between procedure and dialysis initiation, sociodemographics, comorbidities, and medications. Results: In total, 582 patients underwent CABG and 389 patients underwent PCI. The mean age was 64 +/- 8 years, 99% of patients were male, 79% were white, 19% were African American, and 84% had diabetes. The all-cause post-dialysis mortality rates after CABG and PCI were 229 per 1000 patient-years (95% confidence interval [CI], 205-256) and 311 per 1000 patient years (95% CI, 272-356), respectively. Compared with PCI, patients who underwent CABG had 34% lower risk of death (multivariable adjusted hazard ratio, 0.66; 95% CI, 0.51-0.86, P = .002) after initiation of dialysis. Results were similar in all subgroups of patients stratified by age, race, type of intervention, presence/absence of myocardial infarction, congestive heart failure, and diabetes. Conclusions: CABG in patients with advanced CKD was associated lower risk of death after initiation of dialysis compared with PCI.

  • 120.
    Galiè, Nazzareno
    et al.
    University of Bologna, Italy.
    Barberà, Joan A
    University of Barcelona and Biomedical Research Networking Center on Respiratory Diseases, Madrid, Spain.
    Frost, Adaani E
    Baylor College of Medicine, Houston, USA.
    Ghofrani, Hossein-Ardeschir
    University of Giessen and Marbury Lung Center, Giessen, Germany.
    Hoeper, Marius M
    Hanover Medical School and German Center of Lung Research, Hanover, Germany.
    McLaughlin, Vallerie V
    University of Michigan, USA.
    Peacock, Andrew J
    Regional Heart and Lung Center, Glasgow, Scotland.
    Simonneau, Gérald
    University Paris-Sud, Paris, France.
    Vachiery, Jean-Luc
    Hospital Erasme, Brussels, Belgium.
    Grünig, Ekkehard
    University Hospital Heidelberg, Heidelberg, Germany.
    Oudiz, Ronald J
    UCLA Medical Center, Torrance,USA.
    Vonk-Noordegraaf, Anton
    University Medical Center, Amsterdam, Netherlands.
    White, R James
    University of Rochester, NY, USA.
    Blair, Christiana
    Gilead Sciences, Foster City.
    Gillies, Hunter
    Gilead Sciences, Foster City.
    Miller, Karen L
    Gilead Sciences, Foster City.
    Harris, Julia H N
    GlaxoSmith Kline, Uxbridge, UK.
    Langley, Jonathan
    GlaxoSmith Kline, Uxbridge, UK.
    Rubin, Lewis J
    University of California at San Diego, USA.
    Initial Use of Ambrisentan plus Tadalafil in Pulmonary Arterial Hypertension2015In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 373, no 9Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Data on the effect of initial combination therapy with ambrisentan and tadalafil on long-term outcomes in patients with pulmonary arterial hypertension are scarce.

    METHODS: In this event-driven, double-blind study, we randomly assigned, in a 2:1:1 ratio, participants with World Health Organization functional class II or III symptoms of pulmonary arterial hypertension who had not previously received treatment to receive initial combination therapy with 10 mg of ambrisentan plus 40 mg of tadalafil (combination-therapy group), 10 mg of ambrisentan plus placebo (ambrisentan-monotherapy group), or 40 mg of tadalafil plus placebo (tadalafil-monotherapy group), all administered once daily. The primary end point in a time-to-event analysis was the first event of clinical failure, which was defined as the first occurrence of a composite of death, hospitalization for worsening pulmonary arterial hypertension, disease progression, or unsatisfactory long-term clinical response.

    RESULTS: The primary analysis included 500 participants; 253 were assigned to the combination-therapy group, 126 to the ambrisentan-monotherapy group, and 121 to the tadalafil-monotherapy group. A primary end-point event occurred in 18%, 34%, and 28% of the participants in these groups, respectively, and in 31% of the pooled-monotherapy group (the two monotherapy groups combined). The hazard ratio for the primary end point in the combination-therapy group versus the pooled-monotherapy group was 0.50 (95% confidence interval [CI], 0.35 to 0.72; P<0.001). At week 24, the combination-therapy group had greater reductions from baseline in N-terminal pro-brain natriuretic peptide levels than did the pooled-monotherapy group (mean change, -67.2% vs. -50.4%; P<0.001), as well as a higher percentage of patients with a satisfactory clinical response (39% vs. 29%; odds ratio, 1.56 [95% CI, 1.05 to 2.32]; P=0.03) and a greater improvement in the 6-minute walk distance (median change from baseline, 48.98 m vs. 23.80 m; P<0.001). The adverse events that occurred more frequently in the combination-therapy group than in either monotherapy group included peripheral edema, headache, nasal congestion, and anemia.

    CONCLUSIONS: Among participants with pulmonary arterial hypertension who had not received previous treatment, initial combination therapy with ambrisentan and tadalafil resulted in a significantly lower risk of clinical-failure events than the risk with ambrisentan or tadalafil monotherapy. (Funded by Gilead Sciences and GlaxoSmithKline; AMBITION ClinicalTrials.gov number, NCT01178073.).

  • 121.
    Gheorghiade, Mihai
    et al.
    Northwestern University Feinberg School of Medicine, Chicago, USA.
    Greene, Stephen J
    Duke University Medical Center, Durham, North Carolina, USA.
    Butler, Javed
    Stony Brook University, Stony Brook, New York, USA.
    Filippatos, Gerasimos
    Athens University Hospital Attikon and Kapodistrian University of Athens, Athens, Greece.
    Lam, Carolyn S P
    National Health Center, Singapore and Duke, National University of Singapore, Singapore.
    Maggioni, Aldo P
    Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy.
    Ponikowski, Piotr
    Medical University, Wroclaw, Poland.
    Shah, Sanjiv J
    Northwestern University Feinberg School of Medicine, Chicago, USA.
    Solomon, Scott D
    Brigham and Women's Hospital Boston, Massachusetts, USA.
    Kraigher-Krainer, Elisabeth
    Charite University Medicine Berlin-Campus Virchow Klinikum, Berlin, Germany.
    Samano, Eliana T
    Bayer, Sao Paulo, Brazil.
    Müller, Katharina
    Bauer Pharma, Wuppertal, Germany.
    Roessig, Lothar
    Bauer Pharma, Wuppertal, Germany.
    Burkert, Pieske
    Charité University Medicine Berlin–Campus Virchow Klinikum and German Heart Center Berlin, Germany.
    Effect of Vericiguat, a Soluble Guanylate Cyclase Stimulator, on Natriuretic Peptide Levels in Patients With Worsening Chronic Heart Failure and Reduced Ejection Fraction: The SOCRATES-REDUCED Randomized Trial.2015In: Journal of the American Medical Association (JAMA), ISSN 0098-7484, E-ISSN 1538-3598, Vol. 314, no 21, p. 2251-2262Article in journal (Refereed)
    Abstract [en]

    IMPORTANCE: Worsening chronic heart failure (HF) is a major public health problem.

    OBJECTIVE: To determine the optimal dose and tolerability of vericiguat, a soluble guanylate cyclase stimulator, in patients with worsening chronic HF and reduced left ventricular ejection fraction (LVEF).

    DESIGN, SETTING, AND PARTICIPANTS: Dose-finding phase 2 study that randomized 456 patients across Europe, North America, and Asia between November 2013 and January 2015, with follow-up ending June 2015. Patients were clinically stable with LVEF less than 45% within 4 weeks of a worsening chronic HF event, defined as worsening signs and symptoms of congestion and elevated natriuretic peptide level requiring hospitalization or outpatient intravenous diuretic.

    INTERVENTIONS: Placebo (n = 92) or 1 of 4 daily target doses of oral vericiguat (1.25 mg [n = 91], 2.5 mg [n = 91], 5 mg [n = 91], 10 mg [n = 91]) for 12 weeks.

    MAIN OUTCOMES AND MEASURES: The primary end point was change from baseline to week 12 in log-transformed level of N-terminal pro-B-type natriuretic peptide (NT-proBNP). The primary analysis specified pooled comparison of the 3 highest-dose vericiguat groups with placebo, and secondary analysis evaluated a dose-response relationship with vericiguat and the primary end point.

    RESULTS: Overall, 351 patients (77.0%) completed treatment with the study drug with valid 12-week NT-proBNP levels and no major protocol deviation and were eligible for primary end point evaluation. In primary analysis, change in log-transformed NT-proBNP levels from baseline to week 12 was not significantly different between the pooled vericiguat group (log-transformed: baseline, 7.969; 12 weeks, 7.567; difference, -0.402; geometric means: baseline, 2890 pg/mL; 12 weeks, 1932 pg/mL) and placebo (log-transformed: baseline, 8.283; 12 weeks, 8.002; difference, -0.280; geometric means: baseline, 3955 pg/mL; 12 weeks, 2988 pg/mL) (difference of means, -0.122; 90% CI, -0.32 to 0.07; ratio of geometric means, 0.885, 90% CI, 0.73-1.08; P = .15). The exploratory secondary analysis suggested a dose-response relationship whereby higher vericiguat doses were associated with greater reductions in NT-proBNP level (P < .02). Rates of any adverse event were 77.2% and 71.4% among the placebo and 10-mg vericiguat groups, respectively.

    CONCLUSIONS AND RELEVANCE: Among patients with worsening chronic HF and reduced LVEF, compared with placebo, vericiguat did not have a statistically significant effect on change in NT-proBNP level at 12 weeks but was well-tolerated. Further clinical trials of vericiguat based on the dose-response relationship in this study are needed to determine the potential role of this drug for patients with worsening chronic HF.

    TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01951625.

  • 122.
    Gijsberts, Crystel M.
    et al.
    ICIN Netherlands Heart Institute, Netherlands; University of Medical Centre Utrecht, Netherlands.
    Benson, Lina
    Karolinska Institute, Sweden.
    Dahlström, Ulf
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Sim, David
    Singhealth, Singapore.
    Yeo, Daniel P. S.
    Tan Tock Seng Hospital, Singapore.
    Yee Ong, Hean
    Khoo Teck Puat Hospital, Singapore.
    Jaufeerally, Fazlur
    Singapore Gen Hospital, Singapore; Duke NUS, Singapore.
    Leong, Gerard K. T.
    Changi Gen Hospital, Singapore.
    Ling, Lieng H.
    National University of Singapore, Singapore; National University of Health Syst, Singapore.
    Mark Richards, A.
    National University of Singapore, Singapore; National University of Health Syst, Singapore; National University of Singapore, Singapore; University of Otago, New Zealand.
    de Kleijn, Dominique P. V.
    ICIN Netherlands Heart Institute, Netherlands; University of Medical Centre Utrecht, Netherlands; National University of Singapore, Singapore; National University of Singapore, Singapore.
    Lund, Lars H.
    Karolinska Institute, Sweden; Karolinska Institute, Sweden.
    Lam, Carolyn S. P.
    Singhealth, Singapore; National University of Singapore, Singapore; National University of Singapore, Singapore.
    Ethnic differences in the association of QRS duration with ejection fraction and outcome in heart failure2016In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 102, no 18, p. 1464-1471Article in journal (Refereed)
    Abstract [en]

    Background QRS duration (QRSd) criteria for device therapy in heart failure (HF) were derived from predominantly white populations and ethnic differences are poorly understood. Methods We compared the association of QRSd with ejection fraction (EF) and outcomes between 839 Singaporean Asian and 11221 Swedish white patients with HF having preserved EF (HFPEF)and HF having reduced EF (HFREF) were followed in prospective population-based HF studies. Results Compared with whites, Asian patients with HF were younger (62 vs 74years, pamp;lt;0.001), had smaller body size (height 163 vs 171cm, weight 70 vs 80kg, both pamp;lt;0.001) and had more severely impaired EF (EF was amp;lt;30% in 47% of Asians vs 28% of whites). Overall, unadjusted QRSd was shorter in Asians than whites (101 vs 104ms, pamp;lt;0.001). Lower EF was associated with longer QRSd (pamp;lt;0.001), with a steeper association among Asians than whites (p(interaction)amp;lt;0.001), independent of age, sex and clinical covariates (including body size). Excluding patients with left bundle branch block (LBBB) and adjusting for clinical covariates, QRSd was similar in Asians and whites with HFPEF, but longer in Asians compared with whites with HFREF (p=0.001). Longer QRSd was associated with increased risk of HF hospitalisation or death (absolute 2-year event rate for 120ms was 40% and for amp;gt;120ms it was 52%; HR for 10ms increase of QRSd was 1.04 (1.03 to 1.06), pamp;lt;0.001), with no interaction by ethnicity. Conclusion We found ethnic differences in the association between EF and QRSd among patients with HF. QRS prolongation was similarly associated with increased risk, but the implications for ethnicity-specific QRSd cut-offs in clinical decision-making require further study.

  • 123.
    Gilljam, Thomas
    et al.
    University of Gothenburg, Sweden.
    Haugaa, Kristina H.
    Oslo University Hospital, Norway; University of Oslo, Norway.
    Jensen, Henrik K.
    Aarhus University, Denmark; Aarhus University, Denmark.
    Svensson, Anneli
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Bundgaard, Henning
    University of Copenhagen, Denmark.
    Hansen, Jim
    University of Copenhagen, Denmark.
    Dellgren, Goran
    University of Gothenburg, Sweden.
    Gustafsson, Finn
    University of Copenhagen, Denmark.
    Eiskjaer, Hans
    Aarhus University, Denmark; Aarhus University, Denmark.
    Andreassen, Arne K.
    Oslo University Hospital, Norway.
    Sjogren, Johan
    Lund University, Sweden.
    Edvardsen, Thor
    Oslo University Hospital, Norway; University of Oslo, Norway.
    Holst, Anders G.
    University of Copenhagen, Denmark.
    Hastrup Svendsen, Jesper
    University of Copenhagen, Denmark.
    Platonov, Pyotr G.
    Lund University, Sweden; Skåne University Hospital, Sweden.
    Heart transplantation in arrhythmogenic right ventricular cardiomyopathy - Experience from the Nordic ARVC Registry2018In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 250, p. 201-206Article in journal (Refereed)
    Abstract [en]

    Objective: There is a paucity of data on heart transplantation (HTx) in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC), and specific recommendations on indications for listing ARVC patients for HTx are lacking. In order to delineate features pertinent to HTx assessment, we explored the pre-HTx characteristics and clinical history in a cohort of ARVC patients who received heart transplants. Methods: Data from 31 ARVC/HTx patients enrolled in the Nordic ARVC Registry, transplanted between 1988 and 2014 at a median age of 46 years (14-65), were compared with data from 152 non-transplanted probands with Definite ARVC according to 2010 Task Force Criteria from the same registry. Results: The HTx patients were younger at presentation, median 31 vs. 38 years (p = 0.001). Therewas no difference in arrhythmia-related events. The indication for HTx was heart failure in 28 patients (90%) and ventricular arrhythmias in 3 patients (10%). During median follow-up of 4.9 years (0.04-28), there was one early death and two late deaths. Survival was 91% at 5 years after HTx. Age at first symptoms under 35 years independently predicted HTx in our cohort (OR = 7.59, 95% CI 2.69-21.39, p amp;lt; 0.001). Conclusion: HTx in patientswith ARVC is performed predominantly due to heart failure. This suggests that current 2016 International Society for Heart and Lung Transplantation heart transplant listing recommendations for other cardiomyopathies could be applicable in many cases when taking into account the haemodynamic consequences of right ventricular failure in conjunction with ventricular arrhythmia. (C) 2017 Elsevier B.V. All rights reserved.

  • 124.
    Goetze, Jens P
    et al.
    Rigshospitalet, University of Copenhagen, Denmark .
    Hilsted, Linda M
    Rigshospitalet, University of Copenhagen, Denmark .
    Rehfeld, Jens F
    Rigshospitalet, University of Copenhagen, Denmark .
    Alehagen, Urban
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Plasma chromogranin A is a marker of death in elderly patients presenting with symptoms of heart failure2014In: Endocrine Connections, ISSN 2049-3614, E-ISSN 2049-3614, Vol. 3, no 1, p. 47-56Article in journal (Refereed)
    Abstract [en]

    Cardiovascular risk assessment remains difficult in elderly patients. We examined whether chromogranin A (CgA) measurement in plasma may be valuable in assessing risk of death in elderly patients with symptoms of heart failure in a primary care setting. A total of 470 patients (mean age 73 years) were followed for 10 years. For CgA plasma measurement, we used a two-step method including a screening test and a confirmative test with plasma pre-treatment with trypsin. Cox multivariable proportional regression and receiver-operating curve (ROC) analyses were used to assess mortality risk. Assessment of cardiovascular mortality during the first 3 years of observation showed that CgA measurement contained useful information with a hazard ratio (HR) of 5.4 (95% CI 1.7–16.4) (CgA confirm). In a multivariate setting, the corresponding HR was 5.9 (95% CI 1.8–19.1). When adding N-terminal proBNP (NT-proBNP) to the model, CgA confirm still possessed prognostic information (HR: 6.1; 95% CI 1.8–20.7). The result for predicting all-cause mortality displayed the same pattern. ROC analyses in comparison to NT-proBNP to identify patients on top of clinical variables at risk of cardiovascular death within 5 years of follow-up showed significant additive value of CgA confirm measurements compared with NT-proBNP and clinical variables. CgA measurement in the plasma of elderly patients with symptoms of heart failure can identify those at increased risk of short- and long-term mortality.

  • 125.
    Gotberg, M.
    et al.
    Lund University, Sweden.
    Christiansen, E. H.
    Aarhus University Hospital, Denmark.
    Gudmundsdottir, I. J.
    Reykjavik University Hospital, Iceland.
    Sandhall, L.
    Helsingborg Hospital, Sweden.
    Danielewicz, M.
    Karlstad Hospital, Sweden.
    Jakobsen, L.
    Aarhus University Hospital, Denmark.
    Olsson, S. -E.
    Helsingborg Hospital, Sweden.
    Ohagen, P.
    Uppsala University, Sweden.
    Olsson, H.
    Karlstad Hospital, Sweden.
    Omerovic, E.
    Sahlgrenska University, Sweden.
    Calais, F.
    Örebro University, Sweden.
    Lindroos, P.
    St Goran Hospital, Sweden.
    Maeng, M.
    Aarhus University Hospital, Denmark.
    Todt, T.
    Lund University, Sweden.
    Venetsanos, Dimitrios
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    James, S. K.
    Uppsala University, Sweden.
    Karegren, A.
    Västmanland Hospital Västerås, Sweden.
    Nilsson, M.
    Lund University, Sweden.
    Carlsson, J.
    Kalmar County Hospital, Sweden; Linnaeus University, Sweden.
    Hauer, D.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Jensen, J.
    Karolinska Institute, Sweden; Capio St Gorans Sjukhus, Sweden; Sundsvall Hospital, Sweden.
    Karlsson, A. -C.
    Halmstad County Hospital, Sweden.
    Panayi, G.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Erlinge, D.
    Lund University, Sweden.
    Frobert, O.
    Örebro University, Sweden.
    Instantaneous Wave-free Ratio versus Fractional Flow Reserve to Guide PCI2017In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 376, no 19, p. 1813-1823Article in journal (Refereed)
    Abstract [en]

    BACKGROUND The instantaneous wave-free ratio (iFR) is an index used to assess the severity of coronary-artery stenosis. The index has been tested against fractional flow reserve (FFR) in small trials, and the two measures have been found to have similar diagnostic accuracy. However, studies of clinical outcomes associated with the use of iFR are lacking. We aimed to evaluate whether iFR is noninferior to FFR with respect to the rate of subsequent major adverse cardiac events. METHODS We conducted a multicenter, randomized, controlled, open-label clinical trial using the Swedish Coronary Angiography and Angioplasty Registry for enrollment. A total of 2037 participants with stable angina or an acute coronary syndrome who had an indication for physiologically guided assessment of coronary-artery stenosis were randomly assigned to undergo revascularization guided by either iFR or FFR. The primary end point was the rate of a composite of death from any cause, nonfatal myocardial infarction, or unplanned revascularization within 12 months after the procedure. RESULTS A primary end-point event occurred in 68 of 1012 patients (6.7%) in the iFR group and in 61 of 1007 (6.1%) in the FFR group (difference in event rates, 0.7 percentage points; 95% confidence interval [CI], -1.5 to 2.8; P = 0.007 for noninferiority; hazard ratio, 1.12; 95% CI, 0.79 to 1.58; P = 0.53); the upper limit of the 95% confidence interval for the difference in event rates fell within the prespecified noninferiority margin of 3.2 percentage points. The results were similar among major subgroups. The rates of myocardial infarction, target-lesion revascularization, restenosis, and stent thrombosis did not differ significantly between the two groups. A significantly higher proportion of patients in the FFR group than in the iFR group reported chest discomfort during the procedure. CONCLUSIONS Among patients with stable angina or an acute coronary syndrome, an iFR-guided revascularization strategy was noninferior to an FFR-guided revascularization strategy with respect to the rate of major adverse cardiac events at 12 months.

  • 126.
    Granfeldt, Hans
    et al.
    Linköping University, Department of Medical and Health Sciences, Thoracic Surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery.
    Bansi, Bansi
    Linköping University, Department of Biomedical Engineering, Medical Informatics. Linköping University, Faculty of Health Sciences.
    Wiklund, Lars
    University Hospital, Lund, Sweden.
    Peterzén, Bengt
    Linköping University, Department of Medical and Health Sciences, Vascular surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery.
    Lönn, Urban
    University Hospital, Gothenburg, Sweden.
    Babic, Ankica
    University Hospital, Uppsala, Sweden.
    Ahn, Henrik
    Linköping University, Department of Medicine and Care, Vascular surgery. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Thoracic and Vascular Surgery.
    Risk Factor Analysis of Swedish Left Ventricular Assist Device (LVAD) Patients2003In: Annals of Thoracic Surgery, ISSN 0003-4975, E-ISSN 1552-6259, Vol. 76, no 6, p. 1993-1998Article in journal (Refereed)
    Abstract [en]

    Background. The use of left ventricular assist devices (LVADs) is established as a bridge to heart transplantation. Methods. All Swedish patients on the waiting list for heart transplantation, treated with LVAD since 1993 were retrospectively collected into a database and analyzed in regards to risk factors for mortality and morbidity. Results. Fifty-nine patients (46 men) with a median age of 49 years (range, 14 to 69 years), Higgins score median of 9 (range, 3 to 15), EuroScore median of 10 (range, 5 to 17) were investigated. Dominating diagnoses were dilated cardiomyopathy in 61% (n = 36) and ischemic cardiomyopathy in 18.6% (n = 11). The patients were supported with LVAD for a median time of 99.5 days (range, 1 to 873 days). Forty-five (76%) patients received transplants, and 3 (5.1%) patients were weaned from the device. Eleven patients (18.6%) died during LVAD treatment. Risk factor analysis for mortality before heart transplantation showed significance for a high total amount of autologous blood transfusions (p < 0.001), days on mechanical ventilation postoperatively (p < 0.001), prolonged postoperative intensive care unit stay (p = 0.007), and high central venous pressure 24 hours postoperatively and at the final measurement (p = 0.03 and 0.01, respectively). Mortality with LVAD treatment was 18.6% (n = 11). High C-reactive protein (p = 0.001), low mean arterial pressure (p = 0.03), and high cardiac index (p = 0.03) preoperatively were risk factors for development of right ventricular failure during LVAD treatment. Conclusions. The Swedish experience with LVAD as a bridge to heart transplantation was retrospectively collected into a database. This included data from transplant and nontransplant centers. Figures of mortality and morbidity in the database were comparable to international experience. Specific risk factors were difficult to define retrospectively as a result of different protocols for follow-up among participating centers. © 2003 by The Society of Thoracic Surgeons.

  • 127.
    Grigorescu Fredriksson, Alexandru
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Blood flow specific assessment of ventricular function: Visualization and quantification using 4D flow CMR2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The spectrum of cardiovascular diseases is the leading cause of morbidity and mortality globally. Early assessment and treatment of these conditions, acquired as well as congenital, is therefore of paramount importance.

     

    The human heart has a great ability to adapt to various hemodynamic conditions by cardiac remodeling. Pathologic cardiac remodeling can occur as a result of cardiovascular disease in an effort to maintain satisfactory cardiac function. With time, cardiac function diminishes leading to disease progression and subsequent heart failure, the end-point of many heart diseases, associated with very poor prognosis.

     

    Within the normal cardiac ventricles blood flows in highly organized patterns, and changes in cardiac configuration or function will affect these flow patterns. Conversely, altered flows and pressures can bring about cardiac remodeling. In congenital heart disease, even after corrective surgery, cardiac anatomy and thereby intracardiac blood flow patterns are inherently altered. The clinically most available imaging technique, ultrasound with Doppler, allows only for one-directional flow assessment and is limited by the need of clear examination windows, thus failing to fully assess the complex three-dimensional blood flow within the beating heart. Cardiovascular magnetic resonance imaging (CMR) with phase-contrast has the ability to acquire three-dimensional (3D), three-directional time resolved velocity data (3D + time = 4D flow data) from which visualization and quantification of blood flow patterns over the complete cardiac cycle can be performed. Four functional blood flow components have previously been defined based on the blood route and distribution through the ventricle, where the inflowing blood that passes directly to the outflow is called Direct flow. From these components, various quantitative measures can be derived, such as component volumes and kinetic energy (KE) throughout the cardiac cycle. In addition, the 4D flow technique has the ability to quantify and visualize turbulent flow with increased velocity fluctuations in the heart and vessels, turbulent kinetic energy (TKE).

     

    The technique has been developed and evaluated for assessment of left ventricular (LV) blood flow in healthy subjects and in patients with dilated dysfunctional left ventricles, showing significant changes in blood flow patterns and energetics with disease. There is however still no study addressing the gap in the spectrum from the healthy cohorts to patients with moderate to severe left ventricular remodeling. In Paper III, 4D flow CMR was utilized to assess LV blood flow in patients with subtle LV dysfunction, and a shift in blood flow component volumes and KE was seen from the Direct flow to the non-ejecting blood flow components.

     

    In patients with both left- and right-sided acquired and congenital heart disease, right ventricular (RV) function is of great prognostic significance, however this ventricle has historically been somewhat overseen. With its complex geometry, advanced physiology and retrosternal location, assessment of the RV is still challenging and the right ventricular blood flow is still incompletely described. In Paper I, the RV blood flow in healthy subjects was assessed, and the proportionally larger Direct flow component was located in the most basal region of the ventricle and possessed higher levels of KE at end-diastole than the other flow components suggesting that this portion of blood was prepared for efficient systolic ejection. In Paper II, the blood flow was assessed in the RV of patients with subtle primary LV disease, and even if conventional echocardiographic or CMR RV parameters did not show any RV dysfunction, alterations of flow patterns suggestive of RV impairment were found in the patients with the more remodeled LVs.

     

    With improvements of the cardiovascular health care, including the surgical techniques, the number of adult patients with surgically corrected complex congenital heart diseases increases, one of which is tetralogy of Fallot (ToF). Surgical repair of ToF involves widening of the pulmonary stenosis, which postoperatively may cause pulmonary insufficiency and regurgitation (PR). Disturbed or turbulent flow patterns are rare in the healthy cardiovascular system. With pathological changes, such as valvular insufficiency, increased amounts of TKE have been demonstrated. Turbulence is known to be harmful to organic tissues and could be significant in the development of ventricular remodeling, such as dilation and other complications seen in Fallot patients. In Paper IV, the RV intraventricular TKE levels were assessed in relation to conventional measures of PR. Results showed that RV TKE was increased in ToF patients with PR compared to healthy controls, and that these 4D flow-specific measures related slightly stronger to indices of RV remodeling than the conventional measures of PR.

     

    4D flow CMR analysis of the intracardiac blood flow has the potential of adding to pathophysiological understanding, and thereby provide useful diagnostic information and contribute to optimization of treatment of heart disease at earlier stages before irreversible and clinically noticeable changes occur. The flow specific measures used in this thesis could be utilized to detect these alterations of intracardiac blood flow and could thus act as potential markers of progressing ventricular dysfunction, pathological remodeling or used for risk stratification in adults with early repair tetralogy of Fallot. Visualizations of intracardiac flow patterns could provide useful information to cardiac/thoracic surgeons pre- and post-operatively.

  • 128.
    Gréen, Anna
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Cell Biology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Pathology and Clinical Genetics.
    Green, Henrik
    Linköping University, Department of Medical and Health Sciences, Division of Drug Research. Linköping University, Faculty of Medicine and Health Sciences. Natl Board Forens Med, Dept Forens Genet & Forens Toxicol, Linkoping, Sweden; Royal Institute Technology, Sweden; Science for Life Laboratory,{ School of Biotechnology, Division of Gene Technology, Royal Institute of Technology, Stockholm, Sweden.
    Rehnberg, Malin
    Linköping University, Department of Clinical and Experimental Medicine, Division of Cell Biology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Pathology and Clinical Genetics.
    Svensson, Anneli
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Gunnarsson, Cecilia
    Linköping University, Department of Clinical and Experimental Medicine, Division of Cell Biology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Pathology and Clinical Genetics.
    Jonasson, Jon
    Linköping University, Department of Clinical and Experimental Medicine, Division of Cell Biology. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Pathology and Clinical Genetics.
    Assessment of HaloPlex Amplification for Sequence Capture and Massively Parallel Sequencing of Arrhythmogenic Right Ventricular Cardiomyopathy-Associated Genes2015In: Journal of Molecular Diagnostics, ISSN 1525-1578, E-ISSN 1943-7811, Vol. 17, no 1, p. 31-42Article in journal (Refereed)
    Abstract [en]

    The genetic basis of arrhythmogenic right ventricular cardiomyopathy (ARVC) is complex. Mutations in genes encoding components of the cardiac desmosomes have been implicated as being causally related to ARVC. Next-generation sequencing allows parallel sequencing and duplication/deletion analysis of many genes simultaneously, which is appropriate for screening of mutations in disorders with heterogeneous genetic backgrounds. We designed and validated a next-generation sequencing test panel for ARVC using HaloPlex. We used SureDesign to prepare a HaloPlex enrichment system for sequencing of DES, DSC2, DSG2, DSP, JUP, PKP2, RYR2, TGFB3, TMEM43, and TIN from patients with ARVC using a MiSeq instrument. Performance characteristics were determined by comparison with Sanger, as the gold standard, and TruSeq Custom Amplicon sequencing of DSC2, DSG2, DSP, JUP, and PKP2. All the samples were successfully sequenced after HaloPlex capture, with greater than99% of targeted nucleotides covered by greater than20x. The sequences were of high quality, although one problematic area due to a presumptive context-specific sequencing error causing motif Located in exon 1 of the DSP gene was detected. The mutations found by Sanger sequencing were also found using the HaloPlex technique. Depending on the bioinformatics pipeline, sensitivity varied from 99.3% to 100%, and specificity varied from 99.90/0 to 100%. Three variant positions found by Sanger and HaloPlex sequencing were missed by TruSeq Custom Amplicon owing to Loss of coverage.

  • 129.
    Gustafsson, Mikael
    et al.
    Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine.
    Alehagen, Urban
    Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Johansson, Peter
    Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Imaging congestion with a pocket ultrasound device - prognostic implications in patients with chronic heart failure.2015In: Journal of Cardiac Failure, ISSN 1071-9164, E-ISSN 1532-8414, Vol. 21, no 7, p. 548-554Article in journal (Refereed)
    Abstract [en]

    AIMS: Venous congestion is common in patients with chronic heart failure (HF). We used a pocket-sized ultrasound imaging device (PID) to assess the patient's congestive status and related our findings to prognosis.

    METHODS AND RESULTS: 104 consecutive outpatients from an HF outpatient clinic were studied. Interstitial lung water (ILW), pleural effusion (PE) and the diameter of the vena cava inferior (VCI) were assessed using a PID. ILW was assessed by demonstration of B-lines (comet tail artefact (CTA). Out of the 104 patients, 28 had CTA, and eight had PE. Median VCI diameter was 18 mm, ±14/22 mm (quartiles). Each of these parameters correlated weakly (r= 0.26-0.37, p< 0.05) with the HF biomarker NT-proBNP. During the median follow-up time of 530 days, 14 hospitalizations deaths and 7 deaths were registered. Findings of CTA, PE or a composite of both, increased the risk of death or hospitalization (hazard ratio 3-4, p< 0.05). After adjustment for age, cardiac systolic function and NT-proBNP, this difference remained significant for CTA alone and CTA + PE combined, but not for PE alone.

    CONCLUSION: By using a handheld ultrasound device, signs of pulmonary congestion could be demonstrated. When found, these had a significant prognostic impact in clinically stable HF.

  • 130.
    Gustafsson, Mikael
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Alehagen, Urban
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Johansson, Peter
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart and Medicine Center, Department of Cardiology in Linköping.
    Pocket-sized ultrasound examination of fluid imbalance in patients with heart failure: A pilot and feasibility study of heart failure nurses without prior experience of ultrasonography.2015In: European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology, ISSN 1873-1953, Vol. 14, no 4, p. 294-302Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Detecting fluid imbalance in patients with chronic heart failure can be challenging. Use of a pocket-sized ultrasound device (PSUD) in addition to physical examination can be helpful to assess this important information.

    AIM: To evaluate the feasibility for nurses without prior experience of ultrasonography to examine fluid imbalance by the use of a PSUD on heart failure patients.

    METHOD: Four heart failure nurses and an expert cardiologist participated. The nurses underwent a four-hour PSUD training programme. One hundred and four heart failure outpatients were included. The examinations obtained information of pulmonary congestion, pleural effusion and the diameter of the vena cava inferior.

    RESULTS: Examinations took nine minutes on average. In 28% and 14% of the patients, pulmonary congestion and pleural effusion respectively were found by the nurses. The sensitivities and specificities for nurses' findings were 79% and 91%, and, 88% and 93% respectively. The inter-operator agreement between the nurses and the cardiologist reached a substantial level (kappa values: 0.71 and 0.66). The inter-operator agreement for vena cava inferior reached a fair level (kappa value=0.39). Bland-Altman plots of the level of agreement revealed a mean difference of vena cava inferior diameter of 0.11 cm, while the 95% lower and upper limits ranged from -0.78 cm to 1.00 cm.

    CONCLUSION: After brief training, heart failure nurses can reliably identify pulmonary congestion and pleural effusion with a PSUD. Assessment of vena cava inferior was less valid. PSUD readings, when added to the history and a physical examination, can improve nurse assessment of fluid status in patients with heart failure.

  • 131.
    Hadimeri, Henrik
    et al.
    Department of Nephrology, Sahlgrenska University Hospital, Göteborg, Sweden.
    Hadimeri, Ursula
    Department of Radiology, Höglandssjukhuset, Eksjö, Sweden.
    Attman, Per-Ola
    Department of Nephrology, Sahlgrenska University Hospital, Göteborg, Sweden.
    Nyberg, Gudrun
    Transplant Unit, Sahlgrenska University Hospital, Göteborg, Sweden.
    Dimensions of Arteriovenous Fistulas in Patients with Autosomal Dominant Polycystic Kidney Disease2000In: Nephron. Clinical practice, ISSN 1660-8151, E-ISSN 2235-3186, Vol. 85, no 1, p. 50-53Article in journal (Refereed)
    Abstract [en]

    Background/Aim: Aneurysms are known manifestations of autosomal dominant polycystic kidney disease (ADPKD). We investigated whether the dimensions of arteriovenous fistulas created for performance of haemodialysis were affected by the original disease.

    Methods: The lumen diameter of the fistula was studied by ultrasound in 19 patients with ADPKD and in 19 control patients. The patients’ sex, age, the duration of their fistulas, haemoglobin values and blood pressure levels were similar in both groups. The monitoring was performed along the forearm part of the vein, and the maximal diameter was measured. The diameters at the two needle insertion sites were also measured.

    Results: The ADPKD patients had a significantly higher fistula diameter than the control patients: 12 (range 8–19) mm versus 8 (range 6–24) mm at the widest level (p = 0.003). There were no significant differences in the diameters at the needle insertion sites.

    Conclusion: The receiving veins of arteriovenous fistulas in patients with ADPKD have an abnormality that causes a greater than normal dilatation in response to the arterialization. We postulate that this phenomenon is linked with the increased prevalence of aneurysms in ADPKD.

  • 132.
    Hadimeri, Ursula
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Factors affecting the physical characteristics of arterio-venous fistula in patients with renal failure2019Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background and Purpose

    A patent access is vital for a dialysis patient. The arterio-venous fistula (AVF), the most important access for haemodialysis (HD), is frequently affected by extensive complications such as stenosis and occlusions.

    Study I: To investigate whether the dimensions of AVFs used for performing haemodialysis were affected by the original disease.

    Study II: To investigate if the diameter of the distal radiocephalic fistula could influence left ventricular variables in stable haemodialysis patients.

    Study III: To investigate whether a single Far Infrared (FIR) light treatment could alter blood velocity, AVF diameter or inflammatory markers.

    Study IV: To evaluate in what extent the renal diagnosis and radiological interventions affected the dysfunction of AVF and results of percutaneous transluminal angioplasty (PTA).

    Materials and methods

    Study I: The lumen diameter of the AVF was studied by ultrasound in 19 patients with autosomal dominant polycystic kidney disease (ADPKD) and in 19 control patients. The monitoring was performed along the forearm part of the vein, the maximal diameter was measured. The diameters of the two needle insertion sites were also measured.

    Study II: Nineteen patients were investigated with echocardiography, using M-mode recordings and measurements in the 2D image. Ultrasound and doppler ultrasound were performed. Transsonic measurements were performed after the ultrasound investigation. Measurements of the diameter of the AVF were performed in four locations. Heart variables were analysed regarding left ventricular (LV) criteria.

    Study III: Thirty patients with native AVF in the forearm were included. Each patient was his/her own control. Ultrasound examinations of the AVF diameter and blood flow velocity were performed before and after a single Far Infrared light (FIR) treatment.

    Study IV: 522 radiological investigations and endovascular treatments between January 1, 2006 and December 31, 2014 were analysed in 174 patients, retrospectively. All investigations had been performed due to clinical suspicion of impaired AVF function. All stenoses were evaluated and the number, degree, length, location and relation to anastomosis were recorded. After PTA the remaining stenoses were evaluated again and complications were recorded.

    Results

    Study I: The diameter of the AVF at the maximal site in patients with ADPKD was significantly wider than that for the control patients.

    Study II: A larger AVF mean and maximal diameter worsened left ventricular characteristics.

    Study III: A single FIR treatment resulted in a significant increase in blood velocity over the AV fistula from a mean of 2.1±1.0 m/s to 2.3±1.0 m/s. The diameter of the arterialized vein became wider, i.e. 0.72±0.02 to 0.80±0.02 cm. The increase in fistula blood velocity correlated positively with baseline serum-urate and the increase in venous diameter correlated positively with the baseline plasma orosomucoid concentration.

    Study IV: The degree of AVF stenosis before PTA correlated significantly with the degree of remaining stenosis after intervention. Arterial stenosis was significantly more frequent among patients with diabetic nephropathy and interstitial nephritis. A shorter life span between PTAs was related to diabetic nephropathy.

    Conclusions

    Study I: The receiving veins of AVF in patients with ADPKD have an abnormality that causes a greater than normal dilatation in response to the arterialization.

    Study II: The maximal diameter of the distal AVF seems to be a sensitive marker of LV impairment in stable haemodialysis patients.

    Study III: A single FIR treatment increased AVF blood velocity and vein diameter. Thus, one FIR treatment can help maturation of AVF in the early postoperative course.

    Study IV: Repeated PTA was performed significantly more often in patients with diabetic nephropathy. Clinically significant stenosis should be dilated as soon as possible. Occlusion of the AVF should be thrombolyzed and/or dilated when diagnosed.

    List of papers
    1. Dimensions of Arteriovenous Fistulas in Patients with Autosomal Dominant Polycystic Kidney Disease
    Open this publication in new window or tab >>Dimensions of Arteriovenous Fistulas in Patients with Autosomal Dominant Polycystic Kidney Disease
    2000 (English)In: Nephron. Clinical practice, ISSN 1660-8151, E-ISSN 2235-3186, Vol. 85, no 1, p. 50-53Article in journal (Refereed) Published
    Abstract [en]

    Background/Aim: Aneurysms are known manifestations of autosomal dominant polycystic kidney disease (ADPKD). We investigated whether the dimensions of arteriovenous fistulas created for performance of haemodialysis were affected by the original disease.

    Methods: The lumen diameter of the fistula was studied by ultrasound in 19 patients with ADPKD and in 19 control patients. The patients’ sex, age, the duration of their fistulas, haemoglobin values and blood pressure levels were similar in both groups. The monitoring was performed along the forearm part of the vein, and the maximal diameter was measured. The diameters at the two needle insertion sites were also measured.

    Results: The ADPKD patients had a significantly higher fistula diameter than the control patients: 12 (range 8–19) mm versus 8 (range 6–24) mm at the widest level (p = 0.003). There were no significant differences in the diameters at the needle insertion sites.

    Conclusion: The receiving veins of arteriovenous fistulas in patients with ADPKD have an abnormality that causes a greater than normal dilatation in response to the arterialization. We postulate that this phenomenon is linked with the increased prevalence of aneurysms in ADPKD.

    Place, publisher, year, edition, pages
    Basel: S. Karger, 2000
    National Category
    Rheumatology and Autoimmunity Surgery Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-154621 (URN)10.1159/000045629 (DOI)
    Available from: 2019-02-22 Created: 2019-02-22 Last updated: 2019-02-22Bibliographically approved
    2. Fistula diameter correlates with echocardiographic characteristics in stable hemodialysis patients
    Open this publication in new window or tab >>Fistula diameter correlates with echocardiographic characteristics in stable hemodialysis patients
    Show others...
    2015 (English)In: Nephrology @ Point of Care, ISSN 2059-3007, Vol. 1, no 1, p. e44-e48Article in journal (Refereed) Published
    Abstract [en]

    Left ventricular hypertrophy (LVH) is a common finding in hemodialysis patients. The aim of the present study was to investigate if the diameter of the distal radiocephalic fistula could influence left ventricular variables in stable hemodialysis patients.

    Methods

    Nineteen patients were investigated. Measurements of the diameter of the arteriovenous (AV) fistula were performed in 4 different locations. The patients were investigated using M-mode recordings and measurements in the 2D image. Doppler ultrasound was also performed. Transonic measurements were performed after ultrasound investigation.

    Results

    Fistula mean and maximal diameter correlated with left ventricular characteristics. Fistula flow correlated neither with the left ventricular characteristics nor with fistula diameters.

    Conclusions

    The maximal diameter of the distal AV fistula seems to be a sensitive marker of LVH in stable hemodialysis patients.

    Place, publisher, year, edition, pages
    Wichtig Publishing, 2015
    National Category
    Cardiac and Cardiovascular Systems Radiology, Nuclear Medicine and Medical Imaging
    Identifiers
    urn:nbn:se:liu:diva-130611 (URN)
    Note

    DOI does not work: 10.5301/pocj.5000193

    Available from: 2016-08-18 Created: 2016-08-18 Last updated: 2019-02-22
    3. A single treatment, using Far Infrared light improves blood flow conditions in arteriovenous fistula
    Open this publication in new window or tab >>A single treatment, using Far Infrared light improves blood flow conditions in arteriovenous fistula
    2017 (English)In: Clinical hemorheology and microcirculation, ISSN 1386-0291, E-ISSN 1875-8622, Vol. 66, no 3, p. 211-217Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: A native arteriovenous fistula (AVF) is recommended for angio access in patients on chronic hemodialysis (HD). Fistula patency has been improved by exposure to Far Infrared light (FIR). OBJECTIVE: To investigate whether a single FIR treatment could alter blood velocity, AVF diameter or inflammatory markers. METHODS: Thirty patients with a native AVF in the forearm were included. Each patient was his/her own control. Ultrasound (US) examinations were performed before and after a single FIR treatment. RESULTS: A single FIR treatment resulted in a significant increase in blood velocity over the AV fistula from a mean of 2.1 +/- 1.0 m/s to 2.3 +/- 1.0 m/s (p = 0.02). The diameter of the arterialized vein became wider; 0,72 cm +/- 0.02 to 0,80 cm +/- 0.02, (p = 0.006). The increase in fistula blood velocity correlated positively with base line serum-urate p = 0.004) and the increase in venous diameter with the base line plasma orosomucoid concentration (p = 0.005). CONCLUSIONS: This study shows that a single FIR treatment significantly increased AVF blood velocity and vein diameter. Thus, one FIR treatment can help maturation of AVF in the early postoperative course.

    Place, publisher, year, edition, pages
    IOS PRESS, 2017
    Keywords
    Ultrasound; vascular access; Far Infrared therapy; hemodialysis
    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-139673 (URN)10.3233/CH-170254 (DOI)000404475300004 ()28527196 (PubMedID)
    Available from: 2017-08-16 Created: 2017-08-16 Last updated: 2019-02-22
  • 133.
    Hadimeri, Ursula
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Faculty of Medicine and Health Sciences. Department of Radiology, Kärnsjukhuset, Skövde, Sverige.
    Smedby, Örjan
    Linköping University, Department of Medical and Health Sciences, Division of Radiological Sciences. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Center for Medical Image Science and Visualization (CMIV). Östergötlands Läns Landsting, Center for Diagnostics, Department of Radiology in Linköping.
    Fransson, Sven-Göran
    Public Health and Clinical Medicine, Umea University, Umea - Sweden.
    Stegmayr, Bernd
    Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
    Hadimeri, Henrik
    Department of Nephrology, Kärnsjukhuset, Skövde, Sweden.
    Fistula diameter correlates with echocardiographic characteristics in stable hemodialysis patients2015In: Nephrology @ Point of Care, ISSN 2059-3007, Vol. 1, no 1, p. e44-e48Article in journal (Refereed)
    Abstract [en]

    Left ventricular hypertrophy (LVH) is a common finding in hemodialysis patients. The aim of the present study was to investigate if the diameter of the distal radiocephalic fistula could influence left ventricular variables in stable hemodialysis patients.

    Methods

    Nineteen patients were investigated. Measurements of the diameter of the arteriovenous (AV) fistula were performed in 4 different locations. The patients were investigated using M-mode recordings and measurements in the 2D image. Doppler ultrasound was also performed. Transonic measurements were performed after ultrasound investigation.

    Results

    Fistula mean and maximal diameter correlated with left ventricular characteristics. Fistula flow correlated neither with the left ventricular characteristics nor with fistula diameters.

    Conclusions

    The maximal diameter of the distal AV fistula seems to be a sensitive marker of LVH in stable hemodialysis patients.

  • 134.
    Hadimeri, Ursula
    et al.
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Warme, Anna
    Skaraborg Hospital, Sweden.
    Stegmayr, Bernd
    Umeå University, Sweden.
    A single treatment, using Far Infrared light improves blood flow conditions in arteriovenous fistula2017In: Clinical hemorheology and microcirculation, ISSN 1386-0291, E-ISSN 1875-8622, Vol. 66, no 3, p. 211-217Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A native arteriovenous fistula (AVF) is recommended for angio access in patients on chronic hemodialysis (HD). Fistula patency has been improved by exposure to Far Infrared light (FIR). OBJECTIVE: To investigate whether a single FIR treatment could alter blood velocity, AVF diameter or inflammatory markers. METHODS: Thirty patients with a native AVF in the forearm were included. Each patient was his/her own control. Ultrasound (US) examinations were performed before and after a single FIR treatment. RESULTS: A single FIR treatment resulted in a significant increase in blood velocity over the AV fistula from a mean of 2.1 +/- 1.0 m/s to 2.3 +/- 1.0 m/s (p = 0.02). The diameter of the arterialized vein became wider; 0,72 cm +/- 0.02 to 0,80 cm +/- 0.02, (p = 0.006). The increase in fistula blood velocity correlated positively with base line serum-urate p = 0.004) and the increase in venous diameter with the base line plasma orosomucoid concentration (p = 0.005). CONCLUSIONS: This study shows that a single FIR treatment significantly increased AVF blood velocity and vein diameter. Thus, one FIR treatment can help maturation of AVF in the early postoperative course.

  • 135.
    Hager, Jakob
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Surgery, Orthopaedics and Cancer Treatment, Department of Surgery in Norrköping.
    Henriksson, Martin
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Carlsson, Per
    Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
    Länne, Toste
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Linköping University, Faculty of Medicine and Health Sciences.
    Lundgren, Fredrik
    Department of Surgery, Kalmar County Hospital, Kalmar, Sweden.
    Revisiting the cost-effectiveness of screening 65-year-old men for abdominal aortic aneurysm based on data from an implemented screening programme.2017In: International Journal of Angiology, ISSN 0392-9590, E-ISSN 1827-1839, Vol. 36, no 6, p. 517-525Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Health economic analyses based on randomized trials have shown that screening for abdominal aortic aneurysm (AAA) cost-effectively decreases AAA-related, as well as all- cause mortality. However, follow-up from implemented screening programmes now reveal substantially changed conditions in terms of prevalence, attendance rate, costs and mortality after intervention. Our aim was to evaluate whether screening for AAA among 65-year-old men is cost-effective based on contemporary data on prevalence and attendance rates from an ongoing AAA screening programme.

    METHODS: A decision-analytic model, previously used to analyse the cost-effectiveness of an AAA screening programme prior to implementation in clinical practice, was updated using data collected from an implemented screening programme as well as data from contemporary published data and the Swedish register for vascular surgery (Swedvasc).

    RESULTS: The base-case analysis showed that the cost per life-year gained and quality-adjusted life year (QALY) gained were €4832 and €6325, respectively. Based on conventional threshold values of cost-effectiveness, the probability of screening being cost-effective was high.

    CONCLUSION: Despite the reduction of AAA-prevalence and changes in AAA-management over time, screening 65-year-old men for AAA still appears to yield health outcomes at a cost below conventional thresholds of cost-effectiveness.

  • 136.
    Hallberg, Inger
    et al.
    Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Ranerup, Agneta
    Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Applied IT, University of Gothenburg, Gothenburg, Sweden.
    Kjellgren, Karin I.
    Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Supporting the self-management of hypertension: Patients' experiences of using a mobile phone-based system2016In: Journal of Human Hypertension, ISSN 0950-9240, E-ISSN 1476-5527, Vol. 30, no 2, p. 141-146Article in journal (Refereed)
    Abstract [en]

    Globally, hypertension is poorly controlled and its treatment consists mainly of preventive behavior, adherence to treatment and risk-factor management. The aim of this study was to explore patients’ experiences of an interactive mobile phone-based system designed to support the self-management of hypertension. Forty-nine patients were interviewed about their experiences of using the self-management system for 8 weeks regarding: (i) daily answers on self-report questions concerning lifestyle, well-being, symptoms, medication intake and side effects; (ii) results of home blood-pressure measurements; (iii) reminders and motivational messages; and (iv) access to a web-based platform for visualization of the self-reports. The audio-recorded interviews were analyzed using qualitative thematic analysis. The patients considered the self-management system relevant for the follow-up of hypertension and found it easy to use, but some provided insight into issues for improvement. They felt that using the system offered benefits, for example, increasing their participation during follow-up consultations; they further perceived that it helped them gain understanding of the interplay between blood pressure and daily life, which resulted in increased motivation to follow treatment. Increased awareness of the importance of adhering to prescribed treatment may be a way to minimize the cardiovascular risks of hypertension.

  • 137.
    Hallberg, Inger
    et al.
    Institutionen för vårdvetenskap och hälsa, Göteborgs Universitet, Centrum för personcentrerad vård, Sahlgrenska akademin, Göteborgs Universitet.
    Taft, Charles
    Institutionen för vårdvetenskap och hälsa, Göteborgs Universitet, Centrum för personcentrerad vård, Sahlgrenska akademin, Göteborgs Universitet.
    Ranerup, Agneta
    Avdelningen för informatik, Göteborgs Universitet, Centrum för personcentrerad vård, Sahlgrenska akademin, Göteborgs Universitet.
    Bengtsson, Ulrika
    Institutionen för vårdvetenskap och hälsa, Göteborgs Universitet, Centrum för personcentrerad vård, Sahlgrenska akademin, Göteborgs Universitet.
    Hoffman, Mikael
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences. Stiftelsen NEPI, Linköping .
    Höfer, Stefan
    Department of Medical Psychology, Innsbruck Medical University, Innsbruck, Austria.
    Kasperowski, Dick
    Institutionen för filosofi, lingvistik och vetenskapsteori, Göteborgs Universitet.
    Mäkitalo, Åsa
    Institutionen för pedagogik, kommunikation och lärande, Göteborgs Universitet.
    Lundin, Mona
    Institutionen för pedagogik, kommunikation och lärande, Göteborgs Universitet.
    Ring, Lena
    Centrum för forsknings- och bioetik, Uppsala Universitet, Enheten för läkemedelsanvändning, Läkemedelsverket, Uppsala.
    Rosenqvist, Ulf
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in West Östergötland, Department of Medical Specialist in Motala.
    Kjellgren, Karin I
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Health Sciences. Institutionen för vårdvetenskap och hälsa, Göteborgs Universitet, Centrum för personcentrerad vård, Sahlgrenska akademin, Göteborgs Universitet.
    Phases in development of an interactive mobile phone-based system to support self-management of hypertension2014In: Integrated Blood Pressure Control, ISSN 1178-7104, E-ISSN 1178-7104, Vol. 7, p. 19-28Article in journal (Refereed)
    Abstract [en]

    Hypertension is a significant risk factor for heart disease and stroke worldwide. Effective treatment regimens exist; however, treatment adherence rates are poor (30%–50%). Improving self-management may be a way to increase adherence to treatment. The purpose of this paper is to describe the phases in the development and preliminary evaluation of an interactive mobile phone-based system aimed at supporting patients in self-managing their hypertension. A person-centered and participatory framework emphasizing patient involvement was used. An interdisciplinary group of researchers, patients with hypertension, and health care professionals who were specialized in hypertension care designed and developed a set of questions and motivational messages for use in an interactive mobile phone-based system. Guided by the US Food and Drug Administration framework for the development of patient-reported outcome measures, the development and evaluation process comprised three major development phases (1, defining; 2, adjusting; 3, confirming the conceptual framework and delivery system) and two evaluation and refinement phases (4, collecting, analyzing, interpreting data; 5, evaluating the self-management system in clinical practice). Evaluation of new mobile health systems in a structured manner is important to understand how various factors affect the development process from both a technical and human perspective. Forthcoming analyses will evaluate the effectiveness and utility of the mobile phone-based system in supporting the self-management of hypertension.

  • 138.
    Hammarsten, Ola
    et al.
    University of Gothenburg, Sweden.
    Theodorsson, Elvar
    Linköping University, Department of Clinical and Experimental Medicine, Division of Microbiology and Molecular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center for Diagnostics, Department of Clinical Chemistry.
    Bjurman, Christian
    University of Gothenburg, Sweden.
    Petzold, Max
    University of Gothenburg, Sweden.
    Risk of myocardial infarction at specific troponin T levels using the parameter predictive value among lookalikes (PAL)2017In: Clinical Biochemistry, ISSN 0009-9120, E-ISSN 1873-2933, Vol. 50, no 1-2Article in journal (Refereed)
    Abstract [en]

    Background: Myocardial infarction is more likely if the heart damage biomarker cardiac troponin T (cTnT) is elevated in a blood sample, indicating that cardiac damage has occurred. No method allows the clinician to estimate the risk of myocardial infarction at a specific cTnT level in a given patient. Methods: Predictive value among lookalikes (PAL) uses pre-test prevalence, sensitivity and specificity at adjacent cTnT limits based on percentiles. PAL is the pre-test prevalence-adjusted probability of disease between two adjacent cTnT limits. If a chest pain patients cTnT level is between these limits, the risk of myocardial infarction can be estimated. Results: The PAL based on percentiles had an acceptable sampling error when using 100 bootstrapped data of 18 different biomarkers from 38,945 authentic lab measurements. A PAL analysis of an emergency room cohort (n = 11,020) revealed that the diagnostic precision of a high-sensitive cTnT assay was similar among chest pain patients at different ages. The higher incidence of false positive results due to non-specific increases in cTnT in the high-age group was counterbalanced by a higher pre-test prevalence of myocardial infarction among older patients, a finding that was missed when using a conventional ROC plot analysis. Conclusions: The PAL was able to calculate the risk of myocardial infarction at specific cTnT levels and could complement decision limits. 2016 The Authors. The Canadian Society of Clinical Chemists. Published by Elsevier Inc.

  • 139.
    Hammo, Sari
    et al.
    Karolinska Inst, Sweden; Karolinska Univ Hosp, Sweden.
    Larzon, Thomas
    Orebro Univ Hosp, Sweden.
    Hultgren, Rebecka
    Karolinska Inst, Sweden; Karolinska Univ Hosp, Sweden.
    Wanhainen, Anders
    Uppsala Univ, Sweden.
    Mani, Kevin
    Uppsala Univ, Sweden.
    Resch, Timothy
    Skane Univ Hosp, Sweden.
    Falkenberg, Marten
    Sahlgrens Univ Hosp, Sweden.
    Forssell, Claes
    Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Sonesson, Bjorn
    Skane Univ Hosp, Sweden.
    Pirouzram, Artai
    Orebro Univ Hosp, Sweden.
    Roos, Hakan
    Sahlgrens Univ Hosp, Sweden.
    Hellgren, Tina
    Uppsala Univ, Sweden.
    Khan, Shazhad
    Skane Univ Hosp, Sweden.
    Hoijer, Jonas
    Karolinska Inst, Sweden.
    Wahlgren, Carl-Magnus
    Karolinska Inst, Sweden; Karolinska Univ Hosp, Sweden.
    Outcome After Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm: A National Multicentre Study2019In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 57, no 6, p. 788-794Article in journal (Refereed)
    Abstract [en]

    Objective: The purpose of this multicentre study was to analyse the outcome of thoracic endovascular aortic repair (TEVAR) in patients with ruptured descending thoracic aortic aneurysm (rDTAA). Methods: This is a nationwide retrospective study including all patients who underwent TEVAR for rDTAA at six major vascular university centres in Sweden between January 2000 and December 2015. Outcome measures were analysed using Kaplan-Meier estimator and multivariable Cox regression. Results: There were 140 patients (age [mean +/- SD] 74.1 +/- 8.8 years; 56% men; aneurysm size 64.8 +/- 19 mm), with rDTAA. In 53 patients (37.9%), the left subclavian artery was covered, and in 25 patients (17.9%) arch vessel revascularisation was performed. In total, 61/136 patients (45%) had a major complication within 30 days post TEVAR. Stroke (n = 20; 14.7%) was the most common complication, followed by paraplegia (n = 13; 9.6%) and major bleeding (n = 13; 9.6%). TEVAR related complications during follow up included endoleaks 22.1% (30/136; 14 type 1a, six type 1b, 10 not defined). In total, re-interventions (n = 31) were required in 27/137 (19.7%) patients. The median follow up time was 17.0 months (range 0-132 months). The Kaplan-Meier estimated survival was 80.0% at one month, 71.7% at three months, 65.3% at one year, 45.9% at three years, and 31.9% at five years. Age (HR 1.03; 95% CI 1.00-1.07; p = .046), history of stroke (HR 2.35; 95% CI 1.194.63; p = .014), previous aortic surgery (HR 2.11; 95% CI 1.15-3.87; p = .016) as well as post-operative major bleeding (HR 4.40; 95% CI 2.20-8.81; p = .001), stroke (HR 2.63; 95% CI 1.37-5.03; p = .004), and renal failure (HR 8.25; 95% CI 2.69-25.35; p = .001) were all associated with mortality. Conclusions: This nationwide multicentre study of patients with rDTAA undergoing TEVAR showed acceptable short- but poor long-term survival. Adequate proximal and distal aortic sealing zones are important for technical success. High risk patients and post-operative complications need to be further addressed in an effort to improve outcome.

  • 140.
    Hansson, Emma C
    et al.
    Sahlgrenska University Hospital, Gothenburg, Sweden.
    Jidéus, Lena
    University Hospital, Uppsala, Sweden.
    Åberg, Bengt
    Blekinge Hospital, Karlskrona, Sweden.
    Bjursten, Henrik
    Skåne University Hospital, Lund, Sweden.
    Dreifaldt, Mats
    University Hospital and University Health Care Research Centre, Örebro, Sweden.
    Holmgren, Anders
    University Hospital, Umeå, Sweden..
    Ivert, Torbjörn
    Karolinska Institutet, Stockholm, Sweden.
    Nozohoor, Shahab
    Skåne University Hospital, Sweden.
    Barbu, Mikael
    Blekinge Hospital, Karlskrona, Sweden.
    Svedjeholm, Rolf
    Östergötlands Läns Landsting, Heart and Medicine Center, Department of Thoracic and Vascular Surgery. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Jeppsson, Anders
    Sahlgrenska University Hospital, Gothenburg, Sweden Department of Molecular and Clinical Medicine, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden .
    Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study2016In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 37, no 2, p. 189-197Article in journal (Refereed)
    Abstract [en]

    AIMS: Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients.

    METHODS AND RESULTS: All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012-13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued <24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72-120 or >120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53-1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72-120 vs. >120 h before surgery (OR 1.71 (95% CI 1.04-2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56-0.92), P = 0.012].

    CONCLUSION: The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued <24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel.

  • 141.
    Haugaa, Kristina H
    et al.
    Oslo University Hospital, Norway.
    Bundgaard, Henning
    National University Rigshospitalet, Copenhagen, Denmark.
    Edvardsen, Thor
    Oslo University Hospital, Norway.
    Eschen, Ole
    Aalborg University Hospital, Denmark.
    Gilljam, Thomas
    Sahlgrenska Academy, University of Gothenburg, Sweden.
    Hansen, Jim
    University of Copenhagen, Denmark.
    Jensen, Henrik Kjærulf
    Aarhus University Hospital, Denmark.
    Platonov, Pyotr G
    Skåne University Hospital, Sweden.
    Svensson, Anneli
    Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping. Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Medicine and Health Sciences.
    Svendsen, Jesper H
    Univesity of Copenhagen, Denmark.
    Management of patients with Arrhythmogenic Right Ventricular Cardiomyopathy in the Nordic countries.2015In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 49, no 6, p. 299-307Article, review/survey (Refereed)
    Abstract [en]

    OBJECTIVES: Diagnostics of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) are complex, and based on the 2010 Task Force document including different diagnostic modalities. However, recommendations for clinical management and follow-up of patients with ARVC and their relatives are sparse. This paper aims to give a practical overview of management strategies, risk stratification, and selection of appropriate therapies for patients with ARVC and their family members.

    DESIGN: This paper summarizes follow-up and treatment strategies in ARVC patients in the Nordic countries. The author group represents cardiologists who are actively involved in the Nordic ARVC Registry which was established in 2009, and contains prospectively collected clinical data from more than 590 ARVC patients from Denmark, Norway, Sweden, and Finland.

    RESULTS: Different approaches of management and follow-up are required in patients with definite ARVC and in genetic-mutation-positive family members. Furthermore, ARVC patients with and without implantable cardioverter defibrillators (ICDs) require different follow-up strategies.

    CONCLUSION: Careful follow-up is required in patients with ARVC diagnosis to evaluate the need of anti-arrhythmic therapy and ICD implantation. Mutation-positive family members should be followed regularly for detection of early disease and risk stratification of ventricular arrhythmias.

  • 142.
    Hedman, Kristofer
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Cardiac function and long-term volume load: Physiological investigations in endurance athletes and in patients operated on for aortic regurgitation2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background and aims. The heart is a remarkably adaptable organ, continuously changing its output to match metabolic demands and haemodynamic load. But also in long-term settings, such as in chronic or repeated volume load, there are changes in cardiac dimensions and mass termed cardiac hypertrophy. Depending on the stimulus imposing the volume load this hypertrophy differs in extent and phenotype. We aimed to study cardiac function in two settings with long-term volume load, including patients previously operated for aortic regurgitation and healthy females performing endurance training.

    Methods. In paper I, 21 patients (age 52±12 years, all male) operated on with aortic valve replacement for aortic regurgitation (AR) underwent a cardiopulmonary exercise test (CPET) and an echocardiographic evaluation in average 49±15 months following surgery. The peak oxygen uptake (peakVO2) was compared to results from a pre-operative and a six months follow-up, and relations to echocardiographic measures were determined.

    In papers II–IV, 48 endurance trained female athletes (ATH, age 21±2 years) were compared to 46 untrained females (CON, age 21±2 years) regarding echocardiographic measures of cardiac dimensions, global and regional cardiac function and maximal aerobic capacity (VO2max) determined with CPET. Relations between VO2max and cardiac variables were explored.

    Results. In paper I, peakVO2 had decreased from 26±6 to 23±5 mL/kg/min in patients from the first to second, late follow-up. This decrease was larger than expected by their increased age alone, and a majority of patients had a cardiorespiratory fitness below average according to reference values from healthy subjects of the same age, sex and weight.

    In papers II–IV, we found that ATH (VO2max 52±5 mL/kg/min) had larger atrial, ventricular and inferior vena cava dimensions compared to CON (VO2max 39±5 mL/kg/min). ATH had increased measures of right ventricular (RV) systolic function (RV atrioventricular plane displacement indexed by cardiac length 2.5±0.3 vs. 2.3±0.3, p=0.001) and left ventricular (LV) diastolic function (mitral E-wave velocity 0.92±0.17 vs. 0.86±0.11 m/s, p=0.029). In addition, systolic synchrony was similar between groups while there were heterogeneous differences in diastolic and systolic function across different myocardial segments. VO2max was most strongly related to LV end-diastolic volume (r=0.709, p<0.001).

    Conclusions. Decreasing peakVO2 following surgery for AR, despite a normalisation in cardiac dimension could either be a result of a remaining, slight myocardial dysfunction or post-operative negative influence on cardiac performance by filling disturbances or the prosthetic valve itself, or, a sign of an inadequate post-operative level of physical activity and lack of exercise training. This stresses the importance of post-operative management and methods for increasing aerobic capacity, where exercise testing could be valuable for guiding patients and tailoring exercise protocols.

    The eccentric cardiac hypertrophy in ATH, symmetrically distributed across the heart, depicts the physiological hypertrophy in response to volume load in endurance training. Cardiac function was similar, or for some measures slightly improved in ATH compared to CON and LV dimensions, rather than cardiac function, were predictors of VO2max. As the heart of female athletes has been far less studied than that in males, our results add knowledge regarding the female athlete’s heart, and our results of differences in segmental cardiac function merits further research.

    List of papers
    1. Decreased aerobic capacity 4 years after aortic valve replacement in male patients operated upon for chronic aortic regurgitation
    Open this publication in new window or tab >>Decreased aerobic capacity 4 years after aortic valve replacement in male patients operated upon for chronic aortic regurgitation
    2012 (English)In: Clinical Physiology and Functional Imaging, ISSN 1475-0961, E-ISSN 1475-097X, Vol. 32, no 3, p. 167-171Article in journal (Refereed) Published
    Abstract [en]

    Exercise testing is underutilized in patients with valve disease. We have previously found a low physical work capacity in patients with aortic regurgitation 6 months after aortic valve replacement (AVR). The aim of this study was to evaluate aerobic capacity in patients 4 years after AVR, to study how their peak oxygen uptake (peakVO2) had changed postoperatively over a longer period of time. Twenty-one patients (all men, 52 +/- 13 years) who had previously undergone cardiopulmonary exercise testing (CPET) pre- and 6 months postoperatively underwent maximal exercise testing 49 +/- 15 months postoperatively using an electrically braked bicycle ergometer. Breathing gases were analysed and the patients physical fitness levels categorized according to angstrom strands and Wassermans classifications. Mean peakVO2 was 22.8 +/- 5.1 ml x kg-1 x min-1 at the 49-month follow-up, which was lower than at the 6-month follow-up (25.6 +/- 5.8 ml x kg-1 x min-1, P = 0.001). All but one patient presented with a physical fitness level below average using angstrom strands classification, while 13 patients had a low physical capacity according to Wassermans classification. A significant decrease in peakVO2 was observed from six to 49 months postoperatively, and the decrease was larger than expected from the increased age of the patients. CPET could be helpful in timing aortic valve surgery and for the evaluation of need of physical activity as part of a rehabilitation programme.

    Place, publisher, year, edition, pages
    Wiley-Blackwell, 2012
    Keywords
    aortic valve insufficiency, cardiopulmonary exercise testing, exercise test, open heart surgery, peak oxygen uptake, physical capacity, physical fitness
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-77090 (URN)10.1111/j.1475-097X.2011.01072.x (DOI)000302545300001 ()
    Note

    Funding Agencies|Swedish Heart and Lung foundation||County Council of Ostergotland, Sweden||

    Available from: 2012-05-04 Created: 2012-05-04 Last updated: 2019-08-28Bibliographically approved
    2. Female athlete's heart: Systolic and diastolic function related to circulatory dimensions
    Open this publication in new window or tab >>Female athlete's heart: Systolic and diastolic function related to circulatory dimensions
    Show others...
    2015 (English)In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 25, no 3, p. 372-381Article in journal (Refereed) Published
    Abstract [en]

    There are relatively few studies on female athletes examining cardiac size and function and how these measures relate to maximal oxygen uptake (VO2max ). When determining sports eligibility, it is important to know what physiological adaptations and characteristics may be expected in female athletes, taking body and cardiac size into account. The purposes of this study were (a) to compare right and left heart dimensions and function in female endurance athletes (ATH) and in non-athletic female controls of similar age (CON); and (b) to explore how these measures related to VO2max . Forty-six ATH and 48 CON underwent a maximal bicycle exercise test and an echocardiographic examination at rest, including standard and color tissue Doppler investigation. All heart dimensions indexed for body size were larger in ATH (all P < 0.01). The diastolic mitral E/A ratio was 27% higher in ATH (P < 0.001) while systolic left and right atrio-ventricular longitudinal displacement was 7% (P = 0.002) and 15% (P < 0.001) larger in ATH, respectively. Half (50.3%) of the variability in VO2max could be explained by left ventricular end-diastolic volume. Our results could be useful in evaluating female endurance athletes with suspected cardiac disease and contribute to understanding differences between female athletes and non-athletes.

    Place, publisher, year, edition, pages
    Wiley-Blackwell, 2015
    National Category
    Clinical Medicine
    Identifiers
    urn:nbn:se:liu:diva-113770 (URN)10.1111/sms.12246 (DOI)000354568800021 ()24840312 (PubMedID)
    Available from: 2015-01-30 Created: 2015-01-30 Last updated: 2019-08-28
    3. Cardiac systolic regional function and synchrony in endurance trained and untrained females
    Open this publication in new window or tab >>Cardiac systolic regional function and synchrony in endurance trained and untrained females
    Show others...
    2015 (English)In: BMJ Open Sport & Exercise Medicine, ISSN 2055-7647, Vol. 25, no 1, article id :e000015Article in journal (Refereed) Published
    Abstract [en]

    Background Most studies on cardiac function in athletes describe overall heart function in predominately male participants. We aimed to compare segmental, regional and overall myocardial function and synchrony in female endurance athletes (ATH) and in age-matched sedentary females (CON).

    Methods In 46 ATH and 48 CON, echocardiography was used to measure peak longitudinal systolic strain and myocardial velocities in 12 left ventricular (LV) and 2 right ventricular (RV) segments. Regional and overall systolic function were calculated together with four indices of dyssynchrony.

    Results There were no differences in regional or overall LV systolic function between groups, or in any of the four dyssynchrony indices. Peak systolic velocity (s′) was higher in the RV of ATH than in CON (9.7±1.5 vs 8.7±1.5 cm/s, p=0.004), but not after indexing by cardiac length (p=0.331). Strain was similar in ATH and CON in 8 of 12 LV myocardial segments. In septum and anteroseptum, basal and mid-ventricular s′ was 6–7% and 17–19% higher in ATH than in CON (p<0.05), respectively, while s′ was 12% higher in CON in the basal LV lateral wall (p=0.013). After indexing by cardiac length, s′ was only higher in ATH in the mid-ventricular septum (p=0.041).

    Conclusions We found differences between trained and untrained females in segmental systolic myocardial function, but not in global measures of systolic function, including cardiac synchrony. These findings give new insights into cardiac adaptation to endurance training and could also be of use for sports cardiologists evaluating female athletes.

    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-122839 (URN)10.1136/bmjsem-2015-000015 (DOI)
    Available from: 2015-11-26 Created: 2015-11-26 Last updated: 2019-08-28Bibliographically approved
    4. The size and shape of the inferior vena cava in trained and untrained females in relation to maximal oxygen uptake
    Open this publication in new window or tab >>The size and shape of the inferior vena cava in trained and untrained females in relation to maximal oxygen uptake
    Show others...
    2015 (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Background. The increase in cardiac dimensions following endurance training is well acknowledged. A few studies report a larger inferior vena cava (IVC) in trained, predominatly male subjects while athlete-control studies upon females are lacking. Previous studies were constrained to long-axis measurements, and there are no reports in the literature on IVC short-axis dimensions and shape in athletes.

    Methods and Results. Forty-eight sedentary and 46 endurance trained females (mean age 21±2 years, VO2max 39±5 vs. 52±5 mL×kg-1×min-1, p<0.001) underwent echocardiographic examination including IVC diameter and cross-sectional area measured in the subcostal view. IVC shape was calculated as the ratio of short-axis major-to-minor diameter.

    Five out of eight IVC dimensions were larger in trained females, including maximal long-axis diameter (mean 24±3 vs. 20±3 mm, p<0.001) and maximal short-axis area (mean 5.5±1.5 vs. 4.7±1.4 cm2, p=0.022). Both groups presented with a slightly oval IVC with no differences between the groups in IVC shape or inspiratory decrease in any IVC dimension. The IVC long-axis diameter reflected the minor-axis diameter obtained in the short-axis view, during both expiration and inspiration. Positive correlations were seen between maximal IVC long-axis diameter and maximal oxygen uptake (r=0.52, p<0.01), left ventricular end-diastolic volume (r=0.46, p<0.01) and right atrial area (r=0.49, p<0.01).

    Conclusion. The IVC was larger in endurance trained than in untrained females but showed similar shape and inspiratory decrease in dimensions. The long-axis IVC diameter was related to maximal oxygen uptake.

    Keywords
    Inferior Vena Cava, Athlete’s heart, Exercise Training, Sports Cardiology, Maximal Oxygen Uptake
    National Category
    Cardiac and Cardiovascular Systems
    Identifiers
    urn:nbn:se:liu:diva-123315 (URN)
    Available from: 2015-12-10 Created: 2015-12-10 Last updated: 2019-08-28Bibliographically approved
  • 143.
    Hedman, Kristofer
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Bjarnegård, Niclas
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Department of Clinical Physiology, Jönköping Hospital, Jönköping, Sweden.
    Länne, Toste
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Left Ventricular Adaptation to 12 Weeks of Indoor Cycling at the Gym in Untrained Females.2017In: International Journal of Sports Medicine, ISSN 0172-4622, E-ISSN 1439-3964, Vol. 38, no 9, p. 653-658Article in journal (Refereed)
    Abstract [en]

    Cross-sectional studies provide evidence of larger cardiac dimensions and mass in endurance trained than in untrained females. Much less is known regarding adaptations in cardiac function following training in untrained subjects. We aimed to study left ventricular (LV) adaptation to indoor cycling in previously untrained females, in regard of LV dimensions, mass and function. 42 sedentary females were divided into 2 equally sized groups, either training indoor cycling at regular classes at a local gym for 12 weeks, in average 2.6 times per week, or maintaining their sedentary lifestyle. Echocardiography at rest and a maximal exercise test were performed before and after the intervention. Exercise capacity increased in average 16% in the exercise group (p<0.001), together with decreased heart rate at rest (p<0.05) and at 120 watts steady-state (p<0.001). There were no difference in systolic or diastolic function following the intervention and minimal increases in LV internal diameter in diastole (+1 mm, p<0.01). LV mass was unchanged with training (137±25 vs. 137±28 g, p=0.911). Our findings indicate that attending indoor cycling classes at a gym 2-to-3 times per week for 12 weeks is enough to improve exercise capacity, while a higher volume of training is required to elicit cardiac adaptations.

  • 144.
    Hedman, Kristofer
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Carlén, Anna
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Sunnerud, Sofia
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Nylander, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Hjärtscreening av elitidrottare: Låg följsamhet till RF:s rekommendationer2018In: Idrottsmedicin, ISSN 1103-7652, Vol. 1/18, p. 16-19Article in journal (Refereed)
  • 145.
    Hedman, Kristofer
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping. Stanford Univ, CA 94305 USA; Stanford Univ, CA 94305 USA.
    Cauwenberghs, Nicholas
    Stanford Univ, CA 94305 USA; Univ Leuven, Belgium.
    Christle, Jeffrey W.
    Stanford Univ, CA 94305 USA.
    Kuznetsova, Tatiana
    Univ Leuven, Belgium.
    Haddad, Francois
    Stanford Univ, CA 94305 USA.
    Myers, Jonathan
    Stanford Univ, CA 94305 USA; Vet Affairs Palo Alto Hlth Care Syst, CA USA.
    Workload-indexed blood pressure response is superior to peak systolic blood pressure in predicting all-cause mortality2019In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, article id UNSP 2047487319877268Article in journal (Refereed)
    Abstract [en]

    Aims The association between peak systolic blood pressure (SBP) during exercise testing and outcome remains controversial, possibly due to the confounding effect of external workload (metabolic equivalents of task (METs)) on peak SBP as well as on survival. Indexing the increase in SBP to the increase in workload (SBP/MET-slope) could provide a more clinically relevant measure of the SBP response to exercise. We aimed to characterize the SBP/MET-slope in a large cohort referred for clinical exercise testing and to determine its relation to all-cause mortality. Methods and results Survival status for male Veterans who underwent a maximal treadmill exercise test between the years 1987 and 2007 were retrieved in 2018. We defined a subgroup of non-smoking 10-year survivors with fewer risk factors as a lower-risk reference group. Survival analyses for all-cause mortality were performed using Kaplan-Meier curves and Cox proportional hazard ratios (HRs (95% confidence interval)) adjusted for baseline age, test year, cardiovascular risk factors, medications and comorbidities. A total of 7542 subjects were followed over 18.4 (interquartile range 16.3) years. In lower-risk subjects (n = 709), the median (95th percentile) of the SBP/MET-slope was 4.9 (10.0) mmHg/MET. Lower peak SBP (amp;lt;210 mmHg) and higher SBP/MET-slope (amp;gt;10 mmHg/MET) were both associated with 20% higher mortality (adjusted HRs 1.20 (1.08-1.32) and 1.20 (1.10-1.31), respectively). In subjects with high fitness, a SBP/MET-slope amp;gt; 6.2 mmHg/MET was associated with a 27% higher risk of mortality (adjusted HR 1.27 (1.12-1.45)). Conclusion In contrast to peak SBP, having a higher SBP/MET-slope was associated with increased risk of mortality. This simple, novel metric can be considered in clinical exercise testing reports.

  • 146.
    Hedman, Kristofer
    et al.
    Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA / Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA.
    Moneghetti, Kegan J.
    Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA / Stanford University, Stanford Sports Cardiology, Stanford, California, USA .
    Christle, Jeffrey W.
    Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA / Stanford University, Stanford Sports Cardiology, Stanford, California, USA.
    Bagherzadeh, Shadi P.
    Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA / Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA .
    Amsallem, Myriam
    Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA / Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA .
    Ashley, Euan
    Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA / Stanford University, Stanford Sports Cardiology, Stanford, California, USA.
    Froelicher, Victor
    Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA / Stanford University, Stanford Sports Cardiology, Stanford, California, USA.
    Haddad, Francois
    Department of Medicine, Division of Cardiovascular Medicine, Stanford, California, USA / Department of Medicine, Stanford Cardiovascular Institute, Stanford, California, USA.
    Blood pressure in athletic preparticipation evaluation and the implication for cardiac remodelling2019In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 105, no 16, p. 1223-1230Article in journal (Refereed)
    Abstract [en]

    Objectives To explore blood pressure (BP) in athletes at preparticipation evaluation (PPE) in the context of recently updated US and European hypertension guidelines, and to determine the relationship between BP and left ventricular (LV) remodelling.Methods In this retrospective study, athletes aged 13–35 years who underwent PPE facilitated by the Stanford Sports Cardiology programme were considered. Resting BP was measured in both arms; repeated once if >=140/90 mm Hg. Athletes with abnormal ECGs or known hypertension were excluded. BP was categorised per US/European hypertension guidelines. In a separate cohort of athletes undergoing routine PPE echocardiography, we explored the relationship between BP and LV remodelling (LV mass, mass/volume ratio, sphericity index) and LV function.Results In cohort 1 (n=2733, 65.5% male), 34.3% of athletes exceeded US hypertension thresholds. Male sex (B=3.17, p&lt;0.001), body mass index (BMI) (B=0.80, p&lt;0.001) and height (B=0.25, p&lt;0.001) were the strongest independent correlates of systolic BP. In the second cohort (n=304, ages 17–26), systolic BP was an independent correlate of LV mass/volume ratio (B=0.002, p=0.001). LV longitudinal strain was similar across BP categories, while higher BP was associated with slower early diastolic relaxation.Conclusion In a large contemporary cohort of athletes, one-third presented with BP levels above the current US guidelines’ thresholds for hypertension, highlighting that lowering the BP thresholds at PPE warrants careful consideration as well as efforts to standardise measurements. Higher systolic BP was associated with male sex, BMI and height and with LV remodelling and diastolic function, suggesting elevated BP in athletes during PPE may signify a clinically relevant condition.

  • 147.
    Hedman, Kristofer
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences.
    Nylander, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Center for Medical Image Science and Visualization (CMIV). Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Henriksson, Jan
    Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
    Bjarnegård, Niclas
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Department of Clinical Physiology, County Hospital Ryhov, Jönköping, Sweden.
    Brudin, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Department of Clinical Physiology, County Hospital, Kalmar, Sweden.
    Tamás, Éva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    The size and shape of the inferior vena cava in trained and untrained females in relation to maximal oxygen uptake2015Manuscript (preprint) (Other academic)
    Abstract [en]

    Background. The increase in cardiac dimensions following endurance training is well acknowledged. A few studies report a larger inferior vena cava (IVC) in trained, predominatly male subjects while athlete-control studies upon females are lacking. Previous studies were constrained to long-axis measurements, and there are no reports in the literature on IVC short-axis dimensions and shape in athletes.

    Methods and Results. Forty-eight sedentary and 46 endurance trained females (mean age 21±2 years, VO2max 39±5 vs. 52±5 mL×kg-1×min-1, p<0.001) underwent echocardiographic examination including IVC diameter and cross-sectional area measured in the subcostal view. IVC shape was calculated as the ratio of short-axis major-to-minor diameter.

    Five out of eight IVC dimensions were larger in trained females, including maximal long-axis diameter (mean 24±3 vs. 20±3 mm, p<0.001) and maximal short-axis area (mean 5.5±1.5 vs. 4.7±1.4 cm2, p=0.022). Both groups presented with a slightly oval IVC with no differences between the groups in IVC shape or inspiratory decrease in any IVC dimension. The IVC long-axis diameter reflected the minor-axis diameter obtained in the short-axis view, during both expiration and inspiration. Positive correlations were seen between maximal IVC long-axis diameter and maximal oxygen uptake (r=0.52, p<0.01), left ventricular end-diastolic volume (r=0.46, p<0.01) and right atrial area (r=0.49, p<0.01).

    Conclusion. The IVC was larger in endurance trained than in untrained females but showed similar shape and inspiratory decrease in dimensions. The long-axis IVC diameter was related to maximal oxygen uptake.

  • 148.
    Hedman, Kristofer
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Sunnerud, Sofia
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Carlén, Anna
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Janzon, Magnus
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Nylander, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    From guidelines to the sidelines: implementation of cardiovascular preparticipation evaluation in sports clubs is lagging.2019In: British Journal of Sports Medicine, ISSN 0306-3674, E-ISSN 1473-0480, Vol. 53, no 1, p. 3-4Article in journal (Other academic)
  • 149.
    Hedman, Kristofer
    et al.
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Tamás, Éva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Thoracic and Vascular Surgery.
    Bjarnegård, Niclas
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Department of Clinical Physiology, County Hospital Ryhov, Jönköping, Sweden.
    Brudin, Lars
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Department of Clinical Physiology, County Hospital, Kalmar, Sweden.
    Nylander, Eva
    Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Center for Medical Image Science and Visualization (CMIV). Region Östergötland, Heart and Medicine Center, Department of Clinical Physiology in Linköping.
    Cardiac systolic regional function and synchrony in endurance trained and untrained females2015In: BMJ Open Sport & Exercise Medicine, ISSN 2055-7647, Vol. 25, no 1, article id :e000015Article in journal (Refereed)
    Abstract [en]

    Background Most studies on cardiac function in athletes describe overall heart function in predominately male participants. We aimed to compare segmental, regional and overall myocardial function and synchrony in female endurance athletes (ATH) and in age-matched sedentary females (CON).

    Methods In 46 ATH and 48 CON, echocardiography was used to measure peak longitudinal systolic strain and myocardial velocities in 12 left ventricular (LV) and 2 right ventricular (RV) segments. Regional and overall systolic function were calculated together with four indices of dyssynchrony.

    Results There were no differences in regional or overall LV systolic function between groups, or in any of the four dyssynchrony indices. Peak systolic velocity (s′) was higher in the RV of ATH than in CON (9.7±1.5 vs 8.7±1.5 cm/s, p=0.004), but not after indexing by cardiac length (p=0.331). Strain was similar in ATH and CON in 8 of 12 LV myocardial segments. In septum and anteroseptum, basal and mid-ventricular s′ was 6–7% and 17–19% higher in ATH than in CON (p<0.05), respectively, while s′ was 12% higher in CON in the basal LV lateral wall (p=0.013). After indexing by cardiac length, s′ was only higher in ATH in the mid-ventricular septum (p=0.041).

    Conclusions We found differences between trained and untrained females in segmental systolic myocardial function, but not in global measures of systolic function, including cardiac synchrony. These findings give new insights into cardiac adaptation to endurance training and could also be of use for sports cardiologists evaluating female athletes.

  • 150.
    Hellström Angerud, Karin
    et al.
    Umeå University, Sweden.
    Thylén, Ingela
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping.
    Lawesson, Sofia
    Region Östergötland, Heart and Medicine Center, Department of Cardiology in Linköping. Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Medical and Health Sciences, Division of Cardiovascular Medicine.
    Eliasson, Mats
    Umeå University, Sweden.
    Näslund, Ulf
    Umeå University, Sweden.
    Brulin, Christine
    Umeå University, Sweden.
    Symptoms and delay times during myocardial infarction in 694 patients with and without diabetes; an explorative cross-sectional study2016In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 16, no 108, article id 108Article in journal (Refereed)
    Abstract [en]

    Background: In myocardial infarction (MI) a short pre-hospital delay, prompt diagnosis and timely reperfusion treatment can improve the prognosis. Despite the importance of timely care seeking, many patients with MI symptoms delay seeking medical care. Previous research is inconclusive about differences in symptom presentation and pre-hospital delay between patients with and without diabetes during MI. The aim of this study was to describe symptoms and patient delay during MI in patients with and without diabetes. Methods: Swedish cross-sectional multicentre survey study enrolling MI patients in 5 centres within 24 h from admittance. Results: Chest pain was common in patients both with and without diabetes and did not differ after adjustment for age and sex. Patients with diabetes had higher risk for shoulder pain/discomfort, shortness of breath, and tiredness, but lower risk for cold sweat. The three most common symptoms reported by patients with diabetes were chest pain, pain in arms/hands and tiredness. In patients without diabetes the most common symptoms were chest pain, cold sweat and pain in arms/hands. Median patient delay time was 2 h, 24 min for patients with diabetes and 1 h, 15 min for patients without diabetes (p = 0.024). Conclusion: Chest pain was common both in patients with and without diabetes. There were more similarities than differences in MI symptoms between patients with and without diabetes but patients with diabetes had considerably longer delay. This knowledge is important not only for health care personnel meeting patients with suspected MI, but also for the education of people with diabetes.

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