Circulating endostatin has been linked to increased mortality, cardiovascular comorbidities, and renal impairment. However, its role as a cardiovascular risk marker in the general population remains largely unexplored. This study investigates the association between plasma endostatin and atherosclerosis, inflammation, and kidney function in a cohort of 5,026 randomly selected middle-aged individuals from the Swedish CArdioPulmonary bioImage Study (SCAPIS). Plasma levels of endostatin, C-reactive protein (CRP), HbA1c, lipids, and creatinine were analyzed, and their associations with atherosclerosis and related markers were assessed. Coronary artery atherosclerosis was evaluated using coronary computed tomography. Blood pressure, body mass index, and waist circumference were measured, and medication use for diabetes, hyperlipidemia, and hypertension was recorded. Smoking habits were also documented. The following main results were significantly associated with endostatin. Severe coronary atherosclerosis was positively associated in men. Being on hypertensive medication or not, as reported by the participants at the interview at study inclusion, was significantly associated with endostatin. Hypertensive medication increased from 12% to 26% from the lowest to the highest quartile of endostatin. Waist circumference was positively associated, where endostatin increases, on average, 0.21±SD for a 1±SD increase of waist circumference. Kidney function, measured as eGFR, was negatively associated, where endostatin decreases, on average, 0.22±SD for a 1±SD increase in eGFR. Elevated endostatin levels were associated with advanced coronary atherosclerosis in men, antihypertensive treatment, systemic inflammation (increased CRP), increased waist circumference, and impaired kidney function (lower eGFR).

Importance Upper gastrointestinal bleeding is common after myocardial infarction. Objective To determine whether routine screening for Helicobacter pylori infection during hospitalization for myocardial infarction reduces bleeding events and improves clinical outcomes. Design, Setting, and Participants A nationwide, open-label, 2-period, 2-sequence, cluster randomized, crossover clinical trial using a clinical registry for study population definition and data collection merged with national Swedish health data registries. From November 17, 2021, through January 17, 2024, thirty-five Swedish hospitals grouped into 18 clusters were randomized to a sequence of 1 year with routine H pylori screening of all patients with acute myocardial infarction followed by a washout period of 2 months before crossing over to 1 year with usual care or vice versa. Patients were followed up until January 17, 2025. Intervention Routine addition of H pylori screening by urea breath test to standard care in all patients hospitalized for myocardial infarction during the screening periods. Main Outcome and Measure Upper gastrointestinal bleeding, analyzed by a negative binomial model in the intention-to-treat population. Results A total of 18 466 patients (median age, 71 years [IQR, 61-79], 13 138 males [71%]) with myocardial infarction were followed up: 9245 during the screening periods and 9221 during the nonscreening periods. At admission, 2284 during the screening periods and 2275 during the nonscreening periods (both 24.7%) reported proton pump inhibitor use. During screening periods, 6480 patients (70%) had undergone testing, of those 1532 (23.6%) tested positive for H pylori. After a median follow-up of 1.9 years, 299 patients in the screening group (incidence rate, 16.8 events per 1000 person-years; cumulative hazard at 3 years, 4.1%) and 336 in the usual care group (incidence rate, 19.2 events per 1000 person-years; cumulative hazard at 3 years, 4.6%) experienced the primary end point of upper gastrointestinal bleeding (rate ratio [RR], 0.90; 95% CI, 0.77-1.05; P = .18). Predefined nonmultiplicity adjusted subgroup analyses showed a heterogeneous intervention effect; for no anemia (RR, 0.98; 95% CI, 0.80-1.21), mild anemia (RR, 0.64; 95% CI, 0.42-0.98), and moderate to severe anemia (RR, 0.44; 95% CI, 0.23-0.87; P for interaction = .03). Conclusions and Relevance Among unselected patients with acute myocardial infarction, routine H pylori screening did not significantly reduce the risk of upper gastrointestinal bleeding.

Background: The advances in the management of cancer in children, adolescents, and young adults (CAYAs) over recent decades have greatly improved prognosis. However, the risk of long-term complications persists. (1,2) It is known that cancer treatment such as chemotherapy and radiotherapy as well as conventional cardiovascular risk factors increase the risk of ischemic heart disease (IHD). (3)

Purpose: The aim was to study IHD among CAYAs and investigate mortality and revascularization compared to controls.

Method: This study utilizes the Rebuc study, a retrospective matched cohort study that includes all young (<25 years) cancer patients in Sweden between 1958 and 2021, comprising a total of 65,173 CAYAs and 312,935 controls. From the Rebuc study population, 1,486 CAYAs and 6,258 controls with IHD (ICD-10: I20-I25) were identified and compared regarding all-cause mortality, cardiovascular mortality, and revascularization (percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)).

Results: The median age at index was 22 years (IQR 19–23), and at the end of the study 66 years (IQR 59–72). 801 CAYAs (54%) and 3,265 controls (52%) had myocardial infarction (ICD-10: I21)

The risk for all-cause mortality after diagnosis of IHD was 1.26-fold higher for CAYAs (Hazard ratio (HR) 95% CI 1.14-1.40, p<0.0001) and 1.20-fold higher for cardiovascular mortality (HR 95% CI 1.06-1.37, p<0.001) compared to controls. Revascularisation of any kind was registered among 47% of CAYAs and 48% of controls (p = 0.8). PCI was registered among 39% of CAYAs and 42% of controls (p = 0.045), while CABG was registered among 14% of CAYAs and 11% of controls (p = 0.001).

Conclusion: CAYAs with IHD had a higher risk of all-cause and cardiovascular mortality compared to controls. There was no difference regarding revascularization between the groups, however, CABG was more common among CAYAs while PCI was more common among controls.

Background Patients benefit from antiplatelet therapy after coronary-artery bypass grafting (CABG) for an acute coronary syndrome. Whether the addition of ticagrelor to aspirin, as compared with aspirin alone, further reduces the risk of adverse cardiovascular outcomes is unclear.Methods In this open-label, registry-based, clinical trial conducted at 22 Nordic cardiothoracic surgery centers, we randomly assigned patients in a 1:1 ratio to receive either ticagrelor plus aspirin or aspirin alone for 1 year after CABG for an acute coronary syndrome. The primary outcome was a composite of death, myocardial infarction, stroke, or repeat revascularization, evaluated at 1 year. A key secondary outcome was net adverse clinical events, defined as a primary-outcome event or major bleeding.Results A total of 2201 patients were randomly assigned to receive ticagrelor plus aspirin (1104 patients) or aspirin alone (1097 patients). The mean age of the patients was 66 years, and 14.4% were women. A primary-outcome event occurred in 53 patients (4.8%) in the ticagrelor-plus-aspirin group and 50 (4.6%) in the aspirin-alone group (hazard ratio, 1.06; 95% confidence interval [CI], 0.72 to 1.56; P=0.77). Net adverse clinical events occurred in 9.1% of patients in the ticagrelor-plus-aspirin group and 6.4% in the aspirin-alone group (hazard ratio, 1.45; 95% CI, 1.07 to 1.97). Major bleeding occurred in 4.9% of patients in the ticagrelor-plus-aspirin group and 2.0% in the aspirin-alone group (hazard ratio, 2.50; 95% CI, 1.52 to 4.11).Conclusions Among patients who underwent CABG for an acute coronary syndrome, ticagrelor plus aspirin did not result in a lower incidence of death, myocardial infarction, stroke, or repeat coronary revascularization than aspirin alone at 1 year. (Funded by the Swedish Research Council and others; TACSI ClinicalTrials.gov number, NCT03560310; EudraCT number, 2017-001499-43; EU Clinical Trials number, 2023-508551-40-00.) After coronary bypass for acute coronary syndrome, adding ticagrelor to aspirin did not reduce cardiovascular events but increased major bleeding at 1 year, as compared with aspirin alone.

Background Most trials that have shown a benefit of beta-blocker treatment after myocardial infarction included patients with large myocardial infarctions and were conducted in an era before modern biomarker-based diagnosis of myocardial infarction and treatment with percutaneous coronary intervention, antithrombotic agents, high-intensity statins, and renin-angiotensin-aldosterone system antagonists.Methods In a parallel-group, open-label trial performed at 45 centers in Sweden, Estonia, and New Zealand, we randomly assigned patients with an acute myocardial infarction who had undergone coronary angiography and had a left ventricular ejection fraction of at least 50% to receive either long-term treatment with a beta-blocker (metoprolol or bisoprolol) or no beta-blocker treatment. The primary end point was a composite of death from any cause or new myocardial infarction.Results From September 2017 through May 2023, a total of 5020 patients were enrolled (95.4% of whom were from Sweden). The median follow-up was 3.5 years (interquartile range, 2.2 to 4.7). A primary end-point event occurred in 199 of 2508 patients (7.9%) in the beta-blocker group and in 208 of 2512 patients (8.3%) in the no-beta-blocker group (hazard ratio, 0.96; 95% confidence interval, 0.79 to 1.16; P=0.64). Beta-blocker treatment did not appear to lead to a lower cumulative incidence of the secondary end points (death from any cause, 3.9% in the beta-blocker group and 4.1% in the no-beta-blocker group; death from cardiovascular causes, 1.5% and 1.3%, respectively; myocardial infarction, 4.5% and 4.7%; hospitalization for atrial fibrillation, 1.1% and 1.4%; and hospitalization for heart failure, 0.8% and 0.9%). With regard to safety end points, hospitalization for bradycardia, second- or third-degree atrioventricular block, hypotension, syncope, or implantation of a pacemaker occurred in 3.4% of the patients in the beta-blocker group and in 3.2% of those in the no-beta-blocker group; hospitalization for asthma or chronic obstructive pulmonary disease in 0.6% and 0.6%, respectively; and hospitalization for stroke in 1.4% and 1.8%.Conclusions Among patients with acute myocardial infarction who underwent early coronary angiography and had a preserved left ventricular ejection fraction (&gt;= 50%), long-term beta-blocker treatment did not lead to a lower risk of the composite primary end point of death from any cause or new myocardial infarction than no beta-blocker use. (Funded by the Swedish Research Council and others; REDUCE-AMI ClinicalTrials.gov number, NCT03278509.) Hospitalized patients with acute myocardial infarction and preserved EF were assigned to receive open-label long-term beta-blocker therapy or not. Beta-blockers did not lead to a lower risk of death or MI.

Aims Takotsubo syndrome (TS) is a heart condition mimicking acute myocardial infarction. TS is characterized by a sudden weakening of the heart muscle, usually triggered by physical or emotional stress. In this study, we aimed to investigate the effect of pharmacological interventions on short- and long-term mortality in patients with TS. Methods and results We analysed data from the SWEDEHEART (the Swedish Web System for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry, which included patients who underwent coronary angiography between 2009 and 2016. In total, we identified 1724 patients with TS among 228 263 individuals in the registry. The average age was 66 +/- 14 years, and 77% were female. Nearly half of the TS patients (49.4%) presented with non-ST-elevation acute coronary syndrome, and a quarter (25.9%) presented with ST-elevation myocardial infarction. Most patients (79.1%) had non-obstructive coronary artery disease on angiography, while 11.7% had a single-vessel disease and 9.2% had a multivessel disease. All patients received at least one pharmacological intervention; most of them used beta-blockers (77.8% orally and 8.3% intravenously) or antiplatelet agents [aspirin (66.7%) and P2Y12 inhibitors (43.6%)]. According to the Kaplan-Meier estimator, the probability of all-cause mortality was 2.5% after 30 days and 16.6% after 6 years. The median follow-up time was 877 days. Intravenous use of inotropes and diuretics was associated with increased 30 day mortality in TS [hazard ratio (HR) = 9.92 (P &lt; 0.001) and HR = 3.22 (P = 0.001), respectively], while angiotensin-converting enzyme inhibitors and statins were associated with decreased long-term mortality [HR = 0.60 (P = 0.025) and HR = 0.62 (P = 0.040), respectively]. Unfractionated and low-molecular-weight heparins were associated with reduced 30 day mortality [HR = 0.63 (P = 0.01)]. Angiotensin receptor blockers, oral anticoagulants, P2Y12 antagonists, aspirin, and beta-blockers did not statistically correlate with mortality. Conclusions Our findings suggest that some medications commonly used to treat TS are associated with higher mortality, while others have lower mortality. These results could inform clinical decision-making and improve patient outcomes in TS. Further research is warranted to validate these findings and to identify optimal pharmacological interventions for patients with TS.

Nationella kvalitetsregister har sedan lång tid redovisat skillnader mellan vårdgivare vad gäller insatser och resultat, såsom överlevnad. Dessa fynd har varit vägledande för viktiga förbättringsarbeten i vården. Emellertid visar nationella data liknande skillnader också inom vårdgivare, mellan patienter med olika ålder eller kön samt mellan grupper med olika socioekonomisk situation (SES), särskilt utbildning och inkomst. Det är sannolikt att liknande SES skillnader i vårdens insatser och resultat, som observerats i nationella data, också kan identifieras i Östergötland. I Östergötland finns omfattande data om vårdens insatser och resultat. Dock kräver koppling av sjukvårdsdata till SCB-data avseende SES mått, såsom utbildning och yrke, idag forskningsstudier. Därför kan vi idag inte ge underlag om vårdens jämlikhet såsom skillnader i vårdens kvalitet och resultat utifrån SES, som stöd till politiska beslut om jämlik vård eller till löpnade förbättringsarbete. Denna rapport beskriver ett pilotprojekt som har analyserat en forskningsdatabas där data, efter godkännande av forskningsetisk kommitté, har kopplats till data på patienternas SES. Syfte: Att analysera skillnader i vårdens insatser och resultat baserat på SES, för patienter som vårdats för akut hjärtinfarkt i Östergötland.

Metod:

Data för patienter vårdade vid sjukhus i Östergötland för akut hjärtinfarkt mellan 2006 och 2016 inhämtandes från kvalitetsregistret SWEDEHEART; delregistren RIKS-HIA (N= 8498) och SEPHIA (N = 4094), SCB databas samt Socialstyrelsens administrativa register. SES mått: Utbildning (högsta uppnådda nivå) och inkomst (disponibel inkomst i tertiler). Bestämningsfaktorer: ålder, kön, civilstånd, tidigare sjukdom, medicinering, riskfaktorer (rökning, BMI, systoliskt blodtryck, lipider), rutin labdata (Hb, njurfunktion, blodsocker), medicinska undersökningar/ingrepp (Ekokardiografisk undersökning, ballongvidgning (PCI) och by-passoperation (CABG), läkemedel vid utskrivning, deltagande i SEPHIA. Utfall: MACE (Major Adverse Cardiovascular Event; hjärtinfarkt, stroke eller död), samt enskilda komponenter av MACE inom 5 år. Skillnader i risk (hazard ratio, HR) mellan inkomstgrupper analyserades via Cox regressionsmodeller med stegvis kontroll för bestämningsfaktorer och möjliga förväxlingsfaktorer.

Resultat:

Risk för MACE efter 5 år var ökad hos patienter med lägst jämfört med högst inkomst, HR 2.88 (CI 2.59-3.20). En stor del av skillnaden i prognos förklarades av skillnad i ålder mellan grupperna. Övriga bestämningsfaktorer förklarade tillsammans en ytterligare del av skillnaden. Efter justering för dessa kvarstod en överrisk på ca 30% för de med lägst inkomst, HR 1.34 (CI 1.12-1.60). Vid analys av patienterna <75 år var risk för MACE på samma sätt förhöjd hos de med lägst inkomst; HR 2.09, (CI 1.77-2.46). Denna påverkades marginellt av kontroll för ålder, kön och civilstånd, men sjönk substantiellt efter kontroll för patienternas riskfaktorer och tidigare sjukdom vid ankomst, HR 1.33 (1.09-1.62). Kontroll, för insatser under vårdtiden påverkade risken marginellt, men efter kontroll också för deltagande i SEPHIA var risken för MACE efter 5 år inte längre statistiskt signifikant HR 1,27 (CI; 0.99–1.63).

Konklusion:

Vi finner i analyser av kvalitetsregisterdata över patienter som vårdats för akut hjärtinfarkt betydligt sämre prognos för patientgruppen med lägst jämfört med högst SES, mätt som disponibel inkomst. Vår analys kan inte peka på orsakssamband och inte avgöra vilka faktorer som är viktigast, utöver ålder. Skillnaden i prognos påverkades dock ganska lite av skillnader i behandling under det akuta vårdtillfället. Däremot påverkades prognosen, för de yngre patienterna (under 75 år), av skillnader i riskfaktorer och tidigare sjukdomar. Efter justering även för deltagande i sekundärpreventivt program var skillnaden i prognos inte längre signifikant. Det är angeläget att identifiera och tillämpa sätt att stödja och hjälpa patienter med lägre SES för att förbättra prognosen vid insjuknande i hjärtinfarkt. Våra data belyser betydelsen av preventiva insatser, både sekundärpreventiva, för att minska återinsjuknande, och primärpreventiva för att minska riskfaktorer i hela befolkningen och särskilt i grupper med lägre socioekonomi. En med individen samproducerad hälso- och sjukvård, kommunikation i en hälsolitterat organisation och vårdmöten som stärker individens resurser, är möjliga vägar till förbättring.

Background: Soluble P-selectin (sP-selectin) and high-sensitivity C-reactive protein (hsCRP) have previously been associated with hypertension, but the relation with out-of-office blood pressure (BP) and coronary artery calcification score is unknown. We aimed to examine the relationship between sP-selectin, hsCRP and home BP, as well as coronary artery calcification score and carotid artery plaques.

Methods: In the Swedish CArdioPulmonary bioImage Study (SCAPIS), 5057 randomly selected participants were evaluated with office and home BP using the semi-automatic Omron M10-IT device. For this cross-sectional study, participants with sP-selectin <4 standard deviations above mean and hsCRP <5 mg/l, representing low-grade inflammation, were included. Using generalized linear models, these inflammatory markers were evaluated in relation to BP classifications, as well as coronary artery calcification score and carotid artery plaques.

Results: Of participants, 4548 were included in the analyses. The median age was 57.2 (53.4–61.2) years, and 775 (17.0%) reported taking medication for hypertension. Participants in the highest quartile of sP-selectin [odds ratio (OR) 1.67, 95% confidence interval (CI) 1.40–1.98, P < 0.001] and hsCRP [OR 2.25, (95% CI 1.89–2.60), P < 0.001] were more likely to have sustained hypertension. Participants in the highest quartile of hsCRP were also more likely to have masked hypertension, OR (95% CI) 2.31 (1.72–3.10), P < 0.001 and carotid artery plaques, OR (95% CI) 1.21 (1.05–1.38), P = 0.007.

Conclusion: Increased sP-selectin and hsCRP were independently associated with sustained hypertension. These findings indicate an association between hypertension and platelet activity, as expressed by sP-selectin.

Purpose To study the association between the use of drugs for hypertension or heart failure, particularly diuretics, and risk of death in COVID-19.Methods We conducted a cohort study, based on record linked individual-based data from national registers, of all Swedish inhabitants 50 years and older (n = 3,909,321) at the start of the first SARS-CoV-2 wave in Sweden. The association between use of angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB), thiazides, loop diuretics, aldosterone antagonists, beta blocking agents and calcium channel blockers at the index date 6 March 2020, and death in COVID-19 during 7 March to 31 July 2020, was analysed using Cox-proportional hazards regression, adjusted for a wide range of possible confounders.Results Use of loop diuretics was associated with higher risk [adjusted hazard ratio (HR) 1.26; 95% confidence interval (95% CI) 1.17-1.35] and thiazides with reduced risk (0.78; 0.69-0.88) of death in COVID-19. In addition, lower risk was observed for ACEI and higher risk for beta-blocking agents, although both associations were weak. For ARB, aldosterone antagonists and calcium channel blockers no significant associations were found.Conclusion In this nationwide cohort of nearly 4 million persons 50 years and older, the use of loop diuretics was associated with increased risk of death in COVID-19 during the first SARS-CoV-2 wave in Sweden. This contrasted to the decreased risk observed for thiazides. As treatment with loop diuretics is common, particularly in the elderly, the group most affected by severe COVID-19, this finding merit further investigation.

ObjectiveBeta-blockers (BB) are an established treatment following myocardial infarction (MI). However, there is uncertainty as to whether BB beyond the first year of MI have a role in patients without heart failure or left ventricular systolic dysfunction (LVSD). MethodsA nationwide cohort study was conducted including 43 618 patients with MI between 2005 and 2016 in the Swedish register for coronary heart disease. Follow-up started 1 year after hospitalisation (index date). Patients with heart failure or LVSD up until the index date were excluded. Patients were allocated into two groups according to BB treatment. Primary outcome was a composite of all-cause mortality, MI, unscheduled revascularisation and hospitalisation for heart failure. Outcomes were analysed using Cox and Fine-Grey regression models after inverse propensity score weighting. ResultsOverall, 34 253 (78.5%) patients received BB and 9365 (21.5%) did not at the index date 1 year following MI. The median age was 64 years and 25.5% were female. In the intention-to-treat analysis, the unadjusted rate of primary outcome was lower among patients who received versus not received BB (3.8 vs 4.9 events/100 person-years) (HR 0.76; 95% CI 0.73 to 1.04). Following inverse propensity score weighting and multivariable adjustment, the risk of the primary outcome was not different according to BB treatment (HR 0.99; 95% CI 0.93 to 1.04). Similar findings were observed when censoring for BB discontinuation or treatment switch during follow-up. ConclusionEvidence from this nationwide cohort study suggests that BB treatment beyond 1 year of MI for patients without heart failure or LVSD was not associated with improved cardiovascular outcomes.