Pharmacodynamic effects of the oral glucokinase activator AZD6370 after single doses in healthy volunteers assessed with euglycaemic clamp.

AIMS: This study evaluated the safety, tolerability, pharmacokinetics and pharmacodynamic effects of the glucokinase activator (GKA) AZD6370 in non-diabetic subjects, using the euglycaemic clamp to avoid the risk of hypoglycaemia. METHODS: Oral single ascending doses of AZD6370 10-650 mg or subcutaneous short-acting insulin 4 or 12 U were given to healthy fasting subjects. AZD6370 safety, tolerability and pharmacokinetics were assessed. Pharmacodynamic effects on serum (S)-insulin and glucose infusion rate (GIR) were investigated with euglycaemic clamp. AZD6370 10-20 mg was also assessed when taken with food without euglycaemic clamp. RESULTS: AZD6370 was well tolerated and no safety concerns were raised. AZD6370 was rapidly absorbed and eliminated, and plasma concentration was proportional to dose. Both S-insulin and GIR increased following AZD6370 administration. The observed increase in GIR correlated with increasing AZD6370 area under the plasma concentration vs. time curve, demonstrating a dose-concentration-dependent pharmacodynamic effect. AZD6370 at doses of 50 and 80 mg had similar effects to short-acting insulin 4 U on peripheral S-insulin levels but greater effects on GIR, suggesting an effect beyond the increase of peripheral S-insulin levels at lower doses. In the food interaction part of the study, performed without euglycaemic clamp, dose escalation was stopped at a low dose (20 mg) because of hypoglycaemia. CONCLUSION: The euglycaemic clamp was successfully used to avoid hypoglycaemia and to demonstrate pharmacodynamic effects, that is, markedly increased insulin secretion and glucose utilisation, following administration of AZD6370 in healthy fasting subjects. In addition to the effect on pancreatic insulin secretion, the data support an extra-pancreatic (hepatic) component of GKA action.

Community-based gender perspectives of triage and treatment in suspected myocardial infarction.

BACKGROUND: The gender perspectives of the triage of acute coronary syndromes (ACS) in a community are insufficiently explored. METHODS: Patients (n=3224) with symptoms of ACS, in whom ECG was sent by the ambulance crew to a coronary care unit (CCU)/ cath lab, were investigated in the municipality of Göteborg in 2004-2007. Background, triage priority, investigations and treatment were analysed (p-values age adjusted) in relation to gender. Data were compared with three published studies (1995-2002: Surveys 1-3). RESULTS: Women were directly admitted to the CCU significantly less frequently than men (23 versus 35%, p<0.0001). Adjusted for ECG findings, age, symptoms and medical history, odds ratio and 95% confidence limits (for direct admission; men versus women) were 0.61; 0.46-0.82. SURVEY 1: Patients with ACS, aged <80, in CCU at a university hospital (n=1744). Only minor differences between women and men, with regard to investigations and treatment, were found. SURVEY 2: Patients discharged from hospital (dead or alive) with AMI, regardless of type of ward (n=1423). Fewer women than men were admitted to CCU and fewer women underwent coronary angiography (21% versus 40%; p=0.02) and coronary revascularisation (12% versus 27%; p=0.004). SURVEY 3: Patients with symptoms of AMI (n=930) and patients with a confirmed AMI (n=130) from a pre-hospital perspective. Women tended to be given lower priority than men both by the ambulance dispatchers and by the ambulance crew. CONCLUSION: In our practice setting, men are given priority over women in admission to CCU, but no gender differences are seen thereafter.

C-reactive protein, interleukin-6, secretory phospholipase A2 group IIA and intercellular adhesion molecule-1 in the prediction of late outcome events after acute coronary syndromes.

OBJECTIVE: We investigated whether levels of C-reactive protein (CRP), interleukin-6 (IL-6), secretory phospholipase A(2) group IIA (sPLA(2)-IIA) and intercellular adhesion molecule-1 (ICAM-I) predict late outcomes in patients with acute coronary syndromes (ACS). DESIGN: Prospective longitudinal study. CRP (mg L(-1)), IL-6 (pg mL(-1)), sPLA(2)-IIA (ng mL(-1)) and ICAM-1 (ng mL(-1)) were measured at days 1 (n = 757) and 4 (n = 533) after hospital admission for ACS. Their relations to mortality and rehospitalization for myocardial infarction (MI) and congestive heart failure (CHF) were determined. SETTING: Coronary Care Unit at Sahlgrenska University Hospital, Gothenburg, Sweden. SUBJECTS: Patients with ACS alive at day 30; median follow-up 75 months. RESULTS: Survival was related to day 1 levels of all markers. After adjustment for confounders, CRP, IL-6 and ICAM-1, but not sPLA(2)-IIA, independently predicted mortality and rehospitalization for CHF. For CRP, the hazard ratio (HR) was 1.3 for mortality (95% confidence interval (CI): 1.1-1.5, P = 0.003) and 1.4 for CHF (95% CI: 1.1-1.9, P = 0.006). For IL-6, HR was 1.3 for mortality (95% CI: 1.1-1.6, P < 0.001) and 1.4 for CHF (95% CI: 1.1-1.8, P = 0.02). For ICAM-1, HR was 1.2 for mortality (95% CI: 1.0-1.4, P = 0.04) and 1.3 for CHF (95% CI: 1.0-1.7, P = 0.03). No marker predicted MI. Marker levels on day 4 provided no additional predictive value. CONCLUSIONS: In patients with ACS, CRP, IL-6, sPLA(2)-IIA and ICAM-1 are associated with long-term mortality and CHF, but not reinfarction. CRP, IL-6 and ICAM-1 provide prognostic information beyond that obtained by clinical variables.

Admission glycaemia and outcome after acute coronary syndrome.

BACKGROUND: Acute phase hyperglycaemia has been associated with increased mortality in patients with acute coronary syndrome. We investigated whether the predictive value of admission hyperglycaemia for mortality differs between diabetics and non-diabetics with acute coronary syndrome. METHODS: Patients with acute coronary syndrome (n=1957) were followed up prospectively for 45 months. Patients were stratified into quartile groups defined by admission plasma glucose and hyperglycaemia was defined as plasma glucose of >9.4 mmol/l, which was the cut-off value for the 4th quartile. The relationship between admission hyperglycaemia and short-term (< or =30 day) and late (>30 day) mortality was analysed. RESULTS: Of 1957 patients, 22% had a history of diabetes. Among patients without diabetes, those with hyperglycaemia had both a higher 30-day mortality rate (20.2% vs. 3.5%, p<0.0001) and late mortality rate (19.1% vs. 11.7%, p=0.007). Hyperglycaemic patients with diabetes had a higher late mortality rate than diabetic patients with plasma glucose of < or =9.4 mmol/l (29.3% vs. 14.9%, p=0.001). Of patients with hyperglycaemia at admission, those without diabetes had a higher 30-day mortality rate compared with those with diabetes (p=0.002). CONCLUSION: Admission hyperglycaemia is a strong risk factor for mortality in patients with acute coronary syndrome and may be even stronger than a previous history of diabetes. Hyperglycaemic patients without recognised diabetes have a higher short-term mortality risk than hyperglycaemic patients with known diabetes.

Association between glycometabolic status in the acute phase and 21/2 years after an acute coronary syndrome.

OBJECTIVES: To evaluate the association between glycometabolic status in the acute phase and 21/2 years later in patients with acute coronary syndrome (ACS). METHODS: Non-diabetic patients (n = 762) presenting with ACS were prospectively followed up for 21/2 years. Patients were stratified by admission plasma glucose (<6.1 mmol/l, 6.1 - 6.9 mmol/l and >or=7.0 mmol/l) and HbA1c (or=5.5%). The predictive value of glucose levels >or= 7.0 mmol/l and HbA1c >or= 5.5% for glycometabolic disturbance (i.e. diabetes or impaired fasting glycaemia (IFG)) was analysed. RESULTS: Of 762 patients, 13% had a diagnosis of diabetes and 16% had IFG at follow-up. The prevalence of glycometabolic disturbance at follow-up increased with increasing plasma glucose at admission, from 19% in patients with < 6.1 mmol/l to 42% in patients with >or= 7.0 mmol/l. Sixty-one percent of patients with HbA1c >or= 5.5% had glycometabolic disturbance after 21/2 years compared to only 25% of those with HbA1c < 5.5%. CONCLUSION: Non-diabetic patients with ACS and hyperglycaemia are at high risk for developing glycometabolic disturbance. HbA1c may be an even stronger predictor of glycometabolic disturbance than plasma glucose.

[Primary PTCA or thrombolysis in acute myocardial infarction?]. / Primär PTCA eller trombolys vid akut hjärtinfarkt?

In acute ST-elevation infarction two different reperfusion strategies--thrombolytic medication and acute coronary angiography--have proved to improve the prognosis. The clinical course for patients with ST-elevation infarction is described in relation to whether they received thrombolytic medication or underwent acute coronary angiography with the aim of mechanical revascularization. The one-year mortality was high (20 percent) regardless of treatment strategy. In terms of morbidity there were no clear differences between the two treatment groups.

Relief of symptoms and improvement of health-related quality of life five years after coronary artery bypass graft in women and men.

BACKGROUND: Severe coronary artery disease can be successfully treated with coronary artery bypass graft (CABG), with considerable improvement in the symptoms of angina pectoris. Approximately three of four patients are free of ischemic events for 5 years; however, increased survival is demonstrated only in selected subgroups with advanced coronary artery disease, and this effect has not been established in elderly patients. HYPOTHESIS: The study was undertaken to determine the relief of symptoms and improvement in other aspects of health-related quality of life (QoL) during 5 years after CABG in women and men. METHODS: Patients who underwent CABG in western Sweden were approached prior to and 5 years after surgery. Health-related QoL was estimated with Physical Activity Score (PAS), Nottingham Health Profile, and Psychological General Well-Being Index. RESULTS: Women (n = 381) had a 5-year mortality of 17% compared with 13% for men (n = 1,619; NS). After 5 years, 1,719 patients (survivors) were available for the survey; of these, 876 (51%) answered the inquiry both prior to and after 5 years. Both women and men improved markedly and highly significantly, both with respect to symptoms and other aspects of health-related QoL. Women suffered more than men in terms of limitation of physical activity, dyspnea, chest pain, and others aspects of health-related QoL. There was a significant interaction between time and gender, with more improvement in men with regard to chest pain when walking uphill or quickly on level ground, when walking on level ground at the speed of other persons their own age, when under stress, and in windy and cold weather. For those parameters as well as for PAS, improvement was more marked in men than in women. In the other aspects of health-related QoL, there was no interaction between time and gender. CONCLUSION: Five years after CABG, limitation of physical activity, symptoms of dyspnea, and chest pain were reduced, and various aspects of health-related QoL had improved in both women and men. In general, women suffered more than men both prior to and after CABG; however, in some aspects the improvement was more pronounced in men. Because of the limited response rate, the results may not be applicable to a nonselected population who had undergone CABG.

Physical activity, symptoms of chest pain and dyspnea in patients with ischemic heart disease in relation to age before and two years after coronary artery bypass grafting.

BACKGROUND: To describe limitation of physical activity, cause of limitation of physical activity and symptoms of dyspnea and chest pain in relation to age before and 2 years after coronary artery bypass grafting (CABG). METHODS: All patients from Western Sweden who underwent CABG without concomitant procedures during 3 years in 1989-1991 answered questionnaires before, and 2 years after the operation. Patients were divided into 3 age groups of equal size i.e. 32-59 years, 60-67 years and > or = 68 years. RESULTS: In total, 2121 patients participated in the evaluation. The overall 2 year mortality in the 3 age groups was 3.8%, 6.8% and 12.2% (p<0.001). Limitation of physical activity was significantly associated with age prior to surgery but not thereafter. Improvement in physical activity, following CABG, was significant in all age groups. The proportion of patients being free of dyspnea increased markedly regardless of age. The number of chest pain attacks was associated with age after CABG, i.e. fewer attacks in the elderly, but such an association was not found prior to surgery. Improvement in number of chest pain attacks was more marked in the elderly. CONCLUSIONS: Physical activity improved similarly in all age groups after CABG. Attacks of chest pain, although significantly reduced in all age groups, seemed more effectively reduced in the elderly.

Impact of a history of diabetes on the improvement of symptoms and quality of life during 5 years after coronary artery bypass grafting.

To describe the impact of a history of diabetes mellitus on the improvement of symptoms and various aspects of quality of life (QoL) during 5 years after coronary artery bypass grafting (CABG). Patients who underwent CABG between 1988 and 1991 in western Sweden were approached with an inquiry prior to surgery and 5 years after the operation. QoL was estimated with three different instruments: Physical Activity Score (PAS), Nottingham Health Profile (NHP) and Psychological General Well-Being (PGWB) index. 876 patients participated in the evaluation, of whom 87 (10%) had a history of diabetes. Symptoms of dyspnea and chest pain improved both in diabetic and non-diabetic patients. Diabetic patients scored worse than non-diabetic patients both prior to and 5 years after CABG, but without any major difference in improvement between the two groups with all three measures of QoL. PAS tended to improve more in non-diabetic than in diabetic patients, whereas improvement in NHP and PGWB was similar regardless of a history of diabetes. Diabetic patients differ from non-diabetic patients having an inferior QoL both prior to and 5 years after CABG. Both diabetic and non-diabetic patients improve in symptoms and QoL after the operation. In some aspects improvement tended to be less marked in the diabetic patients but on the whole improvement was similar compared to non-diabetic patients.

Relief of symptoms and improvement of quality of life five years after coronary artery bypass grafting in relation to preoperative ejection fraction.

AIM: To describe the relief of symptoms and improvement in Quality of Life (QoL) 5 years after coronary artery bypass grafting (CABG) in relation to preoperative ejection fraction (EF). METHODS: Patients who underwent CABG between 1988 and 1991 in western Sweden were approached with an inquiry prior to surgery and 5 years after the operation. Quality of Life was estimated with three different instruments: Physical activity score, Nottingham Health Profile and Psychological General Well-being Index. RESULTS: Among all patients who underwent CABG (n = 1904) the 5-year mortality rate was 27% in those with EF < 0.40 and 12% in those with EF > or = 0.40 (p < 0.0001). In all, 849 patients, of whom 58 (7%) had EF < 0.40 participated in the evaluation. Neither physical activity, symptoms of chest pain, dyspnea nor any indices of QoL were significantly associated with preoperative EF. Improvement in physical activity, symptoms of chest pain and dyspnea and various estimates of QoL appeared similar and marked regardless of preoperative EF. CONCLUSION: Among survivors there was no association between preoperative EF and symptoms or various estimates of QoL 5 years after CABG. Improvement in symptoms and QoL were not dependent on preoperative EF.

Mortality, mode of death and risk indicators for death during 5 years after coronary artery bypass grafting among patients with and without a history of diabetes mellitus.

OBJECTIVE: To describe mortality, mode of death, risk indicators for death and symptoms of angina pectoris among survivors during 5 years after coronary artery bypass grafting (CABG) among patients with and without a history of diabetes mellitus. METHODS: All patients in western Sweden who underwent CABG without concomitant valve surgery and who had no previous CABG between June 1988 and June 1991 were entered prospectively in this study. After 5 years, information on deaths that had occurred was obtained for the analysis. RESULTS: In all, 1998 patients were included in the analysis; 242 (12%) had a history of diabetes. Among the non-diabetic patients, 5-year mortality was 12.5%; the corresponding relative risk for diabetic patients was 2.1 (95% confidence interval 1.6 to 2.9). A history of diabetes was an independent risk indicator of death; there was no significant interaction between any other risk indicator and diabetes. Independent risk indicators for death among diabetic patients were: current smoking, renal dysfunction and left ventricular ejection fraction < 0.40. Compared with non-diabetic patients, those with diabetes more frequently died in hospital, died a cardiac death, or had death associated with the development of acute myocardial infarction and with symptoms of congestive heart failure. Among survivors, diabetic patients tended to have more angina pectoris 5 years after CABG than did those without diabetes. CONCLUSION: During a period of 5 years after CABG, diabetic patients had a mortality twice that of non-diabetic patients. The increased risk included death in hospital, cardiac death and death associated with development of acute myocardial infarction and with symptoms of congestive heart failure.

Impact of a history of hypertension on symptoms and quality of life prior to and at five years after coronary artery bypass grafting.

AIM: To describe symptoms and other aspects of health-related quality of life (QoL) prior to and 5 years after coronary artery bypass grafting (CABG) in relation to a history of hypertension. METHODS: Patients who underwent CABG in western Sweden were approached prior to surgery and 5 years after the operation. Health-related QoL was estimated with the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-Being Index. RESULTS: In patients with a history of hypertension (n = 740) the 5-year mortality was 16.9% versus 12.4% among patients with no history (n = 1257; p = 0.004). Of 1717 patients available for the survey, 876 (51%) responded both prior to and 5 years after CABG. Of these, 36% had a history of hypertension. Compared with the situation prior to surgery there was an improvement in both hypertensive and non-hypertensive patients in terms of physical activity, symptoms of dyspnea and chest pain and other estimates of health-related QoL. However, physical activity and dyspnea improved less in hypertensive than in non-hypertensive patients. CONCLUSION: Five years after CABG, a marked and significant improvement in terms of symptoms and other aspects of health-related QoL was observed among both hypertensive and non-hypertensive patients. However, improvement in physical activity was less marked in patients with a history of hypertension. Overall, a history of hypertension seemed to have a minor impact on improved well-being 5 years after coronary surgery. However, because of the limited response rate the results may not be applicable in a non-selected CABG population.

Mortality, risk indicators for death, and mode of death in younger and elderly patients during five years after coronary artery bypass graft.

BACKGROUND: The number of elderly patients who may be candidates for coronary artery bypass graft (CABG) for severe coronary artery disease has increased. Cardiac surgery in the elderly is a high-risk procedure because many of these patients have concomitant systemic disease and other disabilities. HYPOTHESIS: The study was undertaken to evaluate mortality, risk indicators for death, and mode of death in younger and elderly patients during 5 years after CABG. METHODS: The study included all patients in western Sweden who underwent CABG without concomitant valve surgery and without previously performed CABG between June 1988 and June 1991. In all, 2,000 patients, of whom 953 (48%) were > or = 65 years, were divided into two age groups (< 65 years and > or = 65 years). RESULTS: Compared with the younger patients, the elderly had a relative risk of death of 2.3 (95% confidence interval 1.8-3.0). The increased risk of death in the elderly was significantly more marked in men, in patients with more severe angina pectoris, and in patients without a history of cerebrovascular diseases. The mode and place of death appeared similar regardless of age; neither was there marked difference in symptoms of angina pectoris among survivors 5 years after CABG. CONCLUSION: Compared with patients < 65 years, the elderly have more than twice as high a risk of death during the subsequent 5 years, and this risk is higher in men, in patients with severe symptoms of angina pectoris, and in those with no history of cerebrovascular disease.

Serum homocysteine concentration as an indicator of survival in patients with acute coronary syndromes.

BACKGROUND: Circulating homocysteine levels are predictive of survival in patients with stable coronary artery disease. The prognostic value of serum homocysteine levels, obtained in the acute phase in patients with myocardial infarction or unstable angina, is unknown. OBJECTIVES: To test the hypothesis that circulating homocysteine levels, obtained during the first 24 hours following hospital admission in patients with acute coronary syndromes, are predictive of long-term mortality. METHODS: To test this hypothesis we performed a prospective inception cohort study at a teaching hospital in Gothenburg, Sweden. A total of 579 patients (179 women and 400 men; median age, 67 years) were included (Q-wave myocardial infarction in 163 patients, non-Q-wave myocardial infarction in 210 patients, unstable angina pectoris in 206 patients). MAIN OUTCOME MEASURE: All-cause mortality. RESULTS: During a median follow-up of 628 days, 65 patients died. The serum homocysteine level (mean [SD]) was significantly lower in long-term survivors (n = 514) than in nonsurvivors (n=65) (12.3 [7.0] vs 14.3 [5.9] pmol/L; P=.003). The relative risk (all-cause mortality) for patients with homocysteine levels in the upper quartile was 2.4 (95% confidence interval, 1.5-4.0) compared with that of patients in the 3 lower quartiles. After adjustment for relevant confounders, the relative risk estimate remained significant (relative risk= 1.69; 95% confidence interval, 1.02-2.80). In a stepwise model the homocysteine level provided prognostic information additional to that of patient age, diabetes mellitus, and diuretic usage prior to hospital admission (P=.03). CONCLUSION: The serum homocysteine level on hospital admission is an independent predictor of long-term survival in patients with acute coronary syndromes.

Has interest in secondary prevention increased among physicians after the 4S study?

This study evaluates the occurrence of various risk indicators, with particular emphasis on serum lipids one year after a coronary event (development of acute mycoardial infarction (AMI); exposure to either coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA), prior to and after presentation of the main results from the 4S study. Patients under 70 years of age either hospitalized for AMI or undergoing CABG or PTCA at Sahlgrenska University Hospital in Göteborg were evaluated one year after the event. Patients who had an event during the period January 1, 1993 until December 31, 1993 were evaluated one year later (Period I) and those who had an event during the period September 1, 1995 until August 31, 1996 were evaluated one year thereafter (Period II). In total, 293 patients were evaluated during Period I and 284 during Period II. Mean total serum cholesterol levels fell from 6.2 mmol/l during Period I to 5.3 mmol/l during Period II (p < 0.001). The proportion of patients with serum cholesterol < or =5.0 mmol/l increased from 15% during Period I to 40% during Period II (p < 0.001). The mean low-density lipoprotein (LDL) levels fell from 4.0 mmol/l during Period I to 3.2 mmol/l during Period II (p < 0.001). The proportion of patients with LDL < or =3.5 mmol/l increased from 32% during Period I to 68% during Period II (p < 0.001). The proportion of patients using lipid-lowering drugs increased from 25% during Period I to 57% during Period II (p < 0.001). Among patients with coronary artery disease who had either developed AMI or undergone CABG or PTCA, a marked increase in the use of lipid-lowering drugs has been observed in a university hospital in Sweden after presentation of the results of the 4S study. Parallel to the increased use of lipid-lowering drugs, we observed a substantial lowering of serum lipids.

Mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in men and women.

AIM: To describe mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in women and men. SAMPLE: All patients in western Sweden who underwent coronary artery bypass grafting without concomitant valve surgery and without previously performed coronary artery bypass grafting between June 1988 and June 1991. RESULTS: In all, 2000 patients participated in the evaluation, 381 (19%) of whom were women. Compared to men, who had a 5-year mortality of 13.3%, women had a relative risk of death of 1.4 (95% CI 1.0-1.8; P = 0.03). Renal dysfunction interacted significantly (P = 0.048) with gender, in that the differences were more marked in patients without renal dysfunction. When adjusting for differences at baseline, the relative risk of death amongst women was 1.0 (95% CL 0.7-1.3). Compared to men, women had an increased risk of in-hospital death and death associated with stroke. However, amongst the patients who died, the place and mode of death appeared to be similar in women and men. Amongst survivors after 5 years, women had more symptoms of angina pectoris than men. CONCLUSION: During 5 years after coronary artery bypass grafting, women had an increased mortality compared to men; renal dysfunction seemed to interact with female gender regarding mortality. Women had a higher risk of in-hospital death and death associated with stroke. However, the adjusted relative risk of death during 5 years was equal in women and men. Amongst survivors, women suffered more from angina pectoris than men.

Limitation of physical activity, dyspnoea and chest pain before and two years after coronary artery bypass grafting in relation to preoperative ejection fraction.

To investigate the relationships between limitation of physical activity and dyspnoea and chest pain before and 2 years after coronary artery bypass grafting (CABG) and preoperative left ventricular ejection fraction (LVEF), questionnaires were issued to all patients from Western Sweden who underwent CABG during 1988-1991. The analysis comprised 985 patients. Physical activity improved significantly after CABG regardless of the preoperative LVEF. No significant association was found between LVEF and degree of limitation of physical activity before or after surgery. Dyspnoea and chest pain improved markedly, irrespective of LVEF. There was significant association between freedom from dyspnoea and LVEF preoperatively (less dyspnoea with higher LVEF), but not after CABG. The frequency of chest-pain attacks was not related to LVEF, before or after the operation. Thus physical activity, dyspnoea and chest pain improved in the 2 years after CABG irrespective of preoperative LVEF. Absence of dyspnoea was related to LVEF before, but not after surgery, and there was no association between preoperative LVEF and frequency of anginal attacks before or after CABG.

Impact of age on improvement in health-related quality of life 5 years after coronary artery bypass grafting.

The aim of this study was to describe the relief of symptoms and improvement in other aspects of health-related quality of life 5 years after coronary artery by-pass grafting in relation to age. Patients in western Sweden were approached with an inquiry prior to surgery and 5 years after the operation. Health-related quality of life was estimated with 3 different instruments: Physical Activity Score (PAS), Nottingham Health Profile (NHP), Psychological General Well-Being Index (PGWB). Prior to surgery patients were approached either in the ward or by post and 5 years after surgery they were approached by post. A total of 1719 patients were available for the survey, of whom 876 (51%) responded to the survey both prior to and after 5 years. Among the 876 respondents 287 were <60 years, 331 were 60-67 years and 258 were >67 years. In terms of physical activity, chest pain and dyspnoea, a similar improvement was observed regardless of age. In terms of health-related quality of life questionnaires, there was an inverse association between age and improvement when using PAS and a similar trend was observed with NHP and PGWB. In conclusion, 5 years after coronary artery bypass grafting relief of symptoms and improvement in physical activity was not associated with age, whereas improvement in other aspects of health-related quality of life tended to be less marked in elderly people. Overall age seemed to have a small impact on the improved well-being 5 years after coronary surgery. However, due to the limited response rate the results may not be applicable to a non-selected coronary artery bypass grafting population.

[Cholesterol embolism--a serious systemic disease]. / Kolesterolembolisering--allvarlig systemsjukdom.

The syndrome of cholesterol embolism is a multiorgan disorder caused by peripheral embolization of cholesterol crystals from an ulcerated aorta plaque. The kidney is the organ most often affected (approx 50%). Prognosis is poor, with a mortality of about 70%. We describe two of four cases of cholesterol embolism diagnosed during the autumn of 1997. All were elderly men with advanced generalized atherosclerosis. Positive diagnosis upon renal biopsy required demonstrating cholesterol crystals in renal interlobar and arcuate arteries. Workups for progressive renal failure were performed due to suspected vasculitis in three cases and radiologically induced renal damage subsequent to coronary angiography in another. None of the patients showed renal vasculitis upon biopsy, but one who was ANCA positive developed vasculitis after a few months. Three patients died within a couple of months of onset. The patient with renal vasculitis was treated with cyclophosphamide and steroids, and survives one and a half years after onset. It is vital to consider the diagnosis cholesterol embolism whenever an elderly patient with pronounced atherosclerosis develops progressive renal failure and multi-organ failure. Angiography, aorto-iliaco-femoral surgery and thrombolytic therapy increase the risk of cholesterol embolism in this group. There is no effective therapy. The key is prophylaxis, which means identifying patients at risk prior to invasive vascular procedures.

Improvement in quality of life differs between women and men after coronary artery bypass surgery.

OBJECTIVE: To study improvement in quality of life (QoL) after coronary artery bypass grafting (CABG) in relation to gender. BACKGROUND: Women generally report worse QoL after CABG than men. However, women are older and more symptomatic prior to surgery, which should be considered in comparative analyses. METHODS: We studied consecutive patients who underwent CABG between 1988 and 1991 [n = 2121] with a QoL questionnaire containing the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index prior to, 3 months, 1 year and 2 years after surgery. RESULTS: Females were older than men with more concomitant diseases preoperatively. QoL was improved on all postoperative occasions for both sexes. Improvement in the Physical Activity Score was somewhat, although not significantly, greater in males. Improvement in the Nottingham Health Profile was greater in females. General well-being showed no consistent pattern for improvement. CONCLUSIONS: QoL is significantly improved after CABG in both sexes throughout follow-up. There is a complex association between improvement in various aspects of QoL and gender.