Comparison of the effects of different statins and doses on lipid levels in patients with diabetes: results from VOYAGER.

BACKGROUND AND AIMS: Diabetes mellitus is a well-known risk factor for cardiovascular disease, and brings an increased risk of vascular events and a higher mortality rate. Treatment guidelines recommend statins in patients with diabetes, with low-density lipoprotein cholesterol (LDL-C) targets of 100 mg dl(-1) (∼2.5 mmol l(-1)), and 80 (∼2.0 mmol l(-1)) or 70 mg dl(-1) (∼1.8 mmol l(-1)) in especially high-risk patients. The current study used the VOYAGER (an indiVidual patient data-meta-analysis Of statin therapY in At risk Groups: Effects of Rosuvastatin, atorvastatin, and simvastatin) database to characterise effects of rosuvastatin, atorvastatin and simvastatin in different doses on lipid levels in diabetes patients. METHODS AND RESULTS: The VOYAGER database included individual patient data from 37 studies involving comparisons of rosuvastatin with either atorvastatin or simvastatin. Of the 32 258 patients included, 8859 (27.5%) had diabetes. Rosuvastatin appeared to be the most efficacious of the three statins, both for lowering LDL-C and for reaching a target level of <70 mg dl(-1) for LDL-C. It was also more effective than atorvastatin at raising high-density lipoprotein cholesterol in the diabetes population. These results are consistent with the overall VOYAGER results. CONCLUSIONS: This meta-analysis of 8859 patients with diabetes mellitus shows favourable effects on lipids with the three statins studied, in line with results for the overall VOYAGER population. The importance of using an effective statin at an effective dose to reach treatment goals for such high-risk patients is evident.

Pharmacokinetic interaction study with fixed high dose combinations of candesartan cilexetil and hydrochlorothiazide.

OBJECTIVE: Combination treatment with candesartan and hydrochlorothiazide (HCT) has been shown to provide the full additive antihypertensive effect of the components. A clinical program has been undertaken to study the efficacy and safety of the fixed dose combinations of candesartan 32 mg and HCT 12.5 or 25 mg in patients with mild to moderate hypertension. This study evaluated the drug-drug interaction potential of the highest dose combination of candesartan 32 mg and HCT 25 mg. SUBJECTS AND METHODS: 53 healthy male and female subjects were randomized to sequential treatment with single doses of one candesartan/ HCT 32/25 mg tablet, two 16/12.5 mg tablets, one candesartan 32 mg tablet and one HCT 25 mg tablet using an open 4-way cross-over design. RESULTS: There was no pharmacokinetic interaction between candesartan 32 mg and HCT 25 mg during concomitant administration. AUC and Cmax were within the accepted confidence limits of 0.8 - 1.25 compared to the monocomponents, and tmax and t1/2 were similar to those of the monocomponents. There were no unexpected safety findings, and no subject discontinued study treatment due to an adverse event. CONCLUSION: There was no pharmacokinetic interaction found between the high doses of candesartan 32 mg and HCT 25 mg.

Factors associated with development of stroke long-term after myocardial infarction: experiences from the LoWASA trial.

OBJECTIVE: To describe factors associated with the development of stroke during long-term follow-up after acute myocardial infarction (AMI) in the LoWASA trial. PATIENTS: Patients who had been hospitalized for AMI were randomized within 42 days to receive either warfarin 1.25 mg plus aspirin 75 mg daily or aspirin 75 mg alone. DESIGN: The study was performed according to the probe design, that is open treatment and blinded end-point evaluation. SETTING: The study was performed in 31 hospitals in Sweden. The mean follow-up time was 5.0 years with a range of 1.7-6.7 years. RESULTS: In all, 3300 patients were randomized in the trial, of which 194 (5.9%) developed stroke (4.2% nonhaemorrhagic, 0.5% haemorrhagic and 1.3% uncertain. The following factors appeared as independent predictors for an increased risk of stroke: age, hazard ratio and 95% confidence interval (1.07; 1.05-1.08), a history of diabetes mellitus (2.4; 1.8-3.4), a history of stroke (2.3; 1.5-3.5), a history of hypertension (2.0; 1.5-2.7) and a history of smoking (1.5;1.1-2.0). Most of these factors were also predictors of a nonhaemorrhagic stroke whereas no predictor of haemorrhagic stroke was found. CONCLUSION: Risk indicators for stroke long-term after AMI were increasing age, a history of either diabetes mellitus, stroke, hypertension or smoking.

Quality assurance with regard to outcome and use of medical resources for patients hospitalized with acute chest pain: a comparison between a city university hospital and a county hospital.

This study aimed to test the hypothesis that there is a difference in mortality between patients hospitalized with acute chest pain in a university hospital and those hospitalized in a county hospital, and to describe differences in characteristics and use of medical resources in these two settings. All patients hospitalized at Sahlgrenska University Hospital in Göteborg (with a catchment population of 706 inhabitants/km(2)) and Uddevalla County Hospital (with a catchment population of 34 inhabitants/km(2)) with symptoms of acute chest pain during a registration period of 6 months were included in the study. A total of 1592 patients in the city hospital and 822 in the county hospital fulfilled the given criteria for inclusion. Patients in the urban area differed from those in the rural area in that they had a lower prevalence of previous angina pectoris and hypertension and a higher prevalence of previous cancer, previous percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) and current smoking. On admission to hospital, patients in the urban area less frequently showed clinical signs of congestive heart failure and acute ischaemia on the electrocardiogram (ECG) but more frequently had a pathological ECG without signs of ischaemia and more frequently had a heart rate >100 beats/min. The use of medical resources differed between the two hospitals. Revascularization was more frequent in the city hospital and the use of -blockers in the county hospital. The overall 30 day mortality was 4.7% in the urban area and 4.3% in the rural area (P=0.74). When correcting for differences at baseline, the risk ratio for death in the county hospital versus the city hospital was 0.84 (95% confidence interval 0.51-1.40, P=0.53). In conclusion, among patients hospitalized with acute chest pain in a city university and a county hospital the mortality during the subsequent 30 days did not differ. However, there were differences in terms of the use of medical resources and in previous history, chronic medication prior to hospital admission and status on admission between the two cohorts.

Factors associated with survival to hospital discharge among patients hospitalised alive after out of hospital cardiac arrest: change in outcome over 20 years in the community of Göteborg, Sweden.

OBJECTIVE: To describe the change in survival and factors associated with survival during a 20 year period among patients suffering from out of hospital cardiac arrest and being hospitalised alive. PATIENTS: All patients hospitalised alive in the community of Göteborg after out of hospital cardiac arrest between 1 October 1980 and 1 October 2000 were included. METHODS: Patient data were prospectively computerised with regard to factors at resuscitation. Data on medical history and hospitalisation were retrospectively recorded. Patients were divided into two groups (the first and second 10 year periods). SETTING: Community of Göteborg, Sweden. RESULTS: 5505 patients suffered from cardiac arrest during the time of the survey. Among them 1310 patients (24%) were hospitalised alive. Survival (discharged alive) was 37.5% during the first part and 35.1% during the second part (NS). The following were independent predictors of an increased chance of survival: ventricular fibrillation/tachycardia as the first recorded rhythm (odds ratio (OR) 3.46, 95% confidence interval (CI) 2.36 to 5.07); witnessed arrest (OR 2.50, 95% CI 1.52 to 4.10); bystander initiated cardiopulmonary resuscitation (OR 2.00, 95% CI 1.42 to 2.80); the patient being conscious on admission to hospital (OR 6.43, 95% CI 3.61 to 11.45); sinus rhythm on admission to hospital (OR 1.53, 95% CI 1.12 to 2.10); and treatment with lidocaine in the emergency department (OR 1.64, 95% CI 1.16 to 2.31). The following were independent predictors of a low chance of survival: age > 70 years (median) (OR 0.65, 95% CI 0.47 to 0.88); atropine required in the emergency department (OR 0.35, 95% CI 0.16 to 0.75); and chronic treatment with diuretics before hospital admission (OR 0.59, 95% CI 0.43 to 0.81). CONCLUSION: There was no improvement in survival over time among initial survivors of out of hospital cardiac arrest during a 20 year period. Major indicators for an increased chance of survival were initial ventricular fibrillation/tachycardia, bystander cardiopulmonary resuscitation, arrest being witnessed, and the patient being conscious on admission. Major indicators for a lower chance were high age, requirement for atropine in the emergency department, and chronic treatment with diuretics before cardiac arrest.

Ten-year mortality for patients discharged after hospitalization for chest pain or other symptoms raising suspicion of acute myocardial infarction in relation to hospital discharge diagnosis.

AIM: To describe the 10-year prognosis for patients discharged after hospitalization for chest pain or other symptoms giving an initial suspicion of acute myocardial infarction (AMI) in relation to the final hospital diagnosis and furthermore to compare the outcome amongst these patients with the outcome amongst a sex-, age- and community-matched control population. METHODS: All patients who were hospitalized because of chest pain or other symptoms raising a suspicion of AMI and who were discharged alive from hospital. Patients were divided into three groups according to the final diagnosis: (1) confirmed or possible AMI, (2) confirmed or possible myocardial ischaemia and (3) other aetiology. Information on 10-year mortality was available in 3103 patients. A sex-, age- and community-matched control population (n=3221) was compared with the study population in terms of 10-year mortality. TIME OF SURVEY: 15 February 1986 to 9 November 1987. SETTING: Sahlgrenska University Hospital. RESULTS: Patients with confirmed or possible AMI (n=849) had a significantly higher mortality (59.4%) than patients with confirmed or possible myocardial ischaemia (n=1191) who had a mortality of 49.5% (P < 0.0001). The latter group had a higher mortality than patients with 'other aetiology' (n=1063) of whom 40.6% died (P < 0.0001). When comparing the prognosis for patients with AMI and myocardial ischaemia, there was a significant interaction with sex, with a more marked difference in women than in men. Amongst all patients, the 10-year mortality was 49.1 vs. 37.3% in the control group (P < 0.0001). CONCLUSION: The very long term prognosis was strongly associated with diagnosis amongst patients hospitalized and discharged alive because of chest pain or other symptoms raising suspicion of AMI. The absolute mortality difference between patients who were discharged from hospital with confirmed diagnosis of AMI and those whose symptoms were considered to have other aetiology than AMI or ischaemia was nearly 20%. However, the absolute mortality difference between the patients included in the survey and a control population was only 12%.

The epidemiology of out-of-hospital 'sudden' cardiac arrest.

It is difficult to assemble data from an out-of-hospital cardiac arrest since there is often lack of objective information. The true incidence of sudden cardiac death out-of-hospital is not known since far from all of these patients are attended by emergency medical services. The incidence of out-of-hospital cardiac arrest increases with age and is more common among men. Among patients who die, the probability of having a fatal event outside hospital decreases with age; i. e. younger patients tend to more often die unexpectedly and outside hospital. Among the different initial arrhythmias, ventricular fibrillation is the most common among patients with cardiac aetiology. The true distribution of initial arrhythmias is not known since several minutes most often elapse between collapse and rhythm assessment. Most patients with out-of-hospital cardiac arrest have a cardiac aetiology. Out-of-hospital cardiac arrests most frequently occur in the patient's home, but the prognosis is shown to be better when they occur in a public place. Witnessed arrest, ventricular fibrillation as initial arrhythmia and cardiopulmonary resuscitation are important predictors for immediate survival. In the long-term perspective, cardiac arrest in connection with acute myocardial infarction, high left ventricular ejection fraction, moderate age, absence of other heart failure signs and no history of myocardial infarction promotes better prognosis. Still there is much to learn about time trends, the influence of patient characteristics, comorbidity and hospital treatment among patients with prehospital cardiac arrest.

Important factors for the 10-year mortality rate in patients with acute chest pain or other symptoms consistent with acute myocardial infarction with particular emphasis on the influence of age.

OBJECTIVE: Our purpose was to describe the mortality rate and mode of death over 10 years and factors associated with death among patients admitted to the emergency department with acute chest pain or other symptoms consistent with acute myocardial infarction (AMI). METHODS: All patients who came to the emergency department at Sahlgrenska University Hospital in Göteborg, Sweden, with acute chest pain or other symptoms consistent with AMI during a 21-month period were studied. RESULTS: In all, 5362 patients were registered, for whom information on 10-year mortality was available in 5158 (96.2%). In all, there were 2126 deaths (41.2%). Fifty-two percent of patients were 65 years old. When the above risk indicators were simultaneously considered, development of AMI during the first 3 days after hospital admission was still an independent predictor of death (1.63, 1.43-1.86). CONCLUSION: For patients admitted to the emergency department with acute chest pain or other symptoms consistent with AMI, several predictors based on clinical history and clinical presentation are related to the 10-year prognosis. They are more strongly associated with outcome among patients aged

Ten year mortality in subsets of patients with an acute coronary syndrome.

OBJECTIVE: To describe the mortality during the subsequent 10 years for subsets of patients hospitalised for suspected acute coronary syndrome. PATIENTS AND METHODS: All patients who were admitted to the emergency department in one hospital during 21 months for chest pain or other symptoms raising suspicion of an acute coronary syndrome were registered. From this baseline population three subgroups were defined among those being hospitalised: patients who developed a Q wave acute myocardial infarction (AMI) (n = 306); patients who developed a non-Q wave AMI (n = 527); and patients who developed confirmed or possible myocardial ischaemia (unstable angina pectoris) (n = 1274). These three groups were compared in terms of 10 year mortality. RESULTS: Patients who developed a non-Q wave AMI had the highest 10 year mortality (70.3%), significantly higher than those who developed a Q wave AMI (60.1%; p = 0.004) and those who had confirmed or possible myocardial ischaemia (50.1%; p < 0.0001). There was no difference between patients with confirmed and those with possible myocardial ischaemia (50.0% and 50.1%, respectively). After correction for dissimilarities in age, sex, and history the adjusted risk ratio for death in patients with a non-Q wave AMI compared with Q wave AMI was 1.01 (95% confidence interval (CI) 0.82 to 1.25). The corresponding risk ratio for death in patients with a non-Q wave AMI compared with confirmed or possible myocardial ischaemia was 1.91 (95% CI 1.64 to 2.23). There was also an imbalance in drug regimens among groups. CONCLUSION: This study shows that in a non-selected population of patients hospitalised with a suspected acute coronary syndrome, the highest risk of death is found in those with a non-Q wave AMI and the lowest in those with confirmed or possible myocardial ischaemia. Thus, patients with a Q wave AMI have a long term mortality risk intermediate between the two fractions defined as having unstable coronary artery disease. However, adjusting these results for age and history of cardiovascular disease eliminated the observed difference in mortality between non-Q wave and Q wave AMI. Furthermore, an imbalance in drug regimens might have affected the outcome.

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.

Ten-year mortality rate in relation to observations at a bicycle exercise test in patients with a suspected or confirmed ischemic event but no or only minor myocardial damage: influence of subsequent revascularization.

AIM: Our purpose was to describe symptoms and electrocardiographic findings at a bicycle exercise test 4 weeks after hospitalization for a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis and its relationship to long-term prognosis and subsequent revascularization. METHODS: In all patients a symptom-limited bicycle exercise test was performed 4 weeks after discharge from the hospital. The total mortality rate over 10 years was registered. RESULTS: In all, 770 patients participated in the evaluation. The median age was 63 years, and 34% were women. The most frequent reason for stopping the exercise test was fatigue (69%) followed by dyspnea (33%) and angina pectoris (15%). Angina pectoris was observed in 24% of the patients. ST-segment depression >or=1 mm was observed in 50% and ST-segment depression >or=2 mm was observed in 15% of the patients. The 10-year mortality rate in patients with ST-segment depression >or=2 mm was 24.7%, in patients with ST-segment depression 1.0 to 1.9 mm 33.5%, and in patients with ST-segment depression <1 mm 26.9% (not significant [NS]). Patients with symptoms of angina pectoris had a 10-year mortality rate of 29.4% compared with 27.9% among patients without such symptoms (NS). Patients who had either a drop in systolic blood pressure or failure to raise systolic blood pressure (13%) had a 10-year mortality rate of 36.2% compared with 27.2% among patients without such signs (NS). However, there was a significant association between maximum exercise capacity (in watts) and mortality (P < .0001): 53.8% in the lowest quartile (30-70 W) and 10.2% in the highest (>120 w). When clinical history was considered simultaneously, a low exercise capacity remained as a strong independent predictor of death together with age and a history of either acute myocardial infarction, smoking, or diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted only with angina pectoris and prognosis; thus patients who had angina during the exercise test had a worse prognosis than those without if they were not being revascularized. CONCLUSION: Among patients hospitalized with a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis, we found the maximum working capacity at a symptom-limited bicycle exercise test to be independently associated with the long-term prognosis but not other signs of myocardial ischemia. Further predictors for long-term prognosis were age, a history of acute myocardial infarction, current smoking, and diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted with the influence of symptoms of angina during test and prognosis.

Which factors determine the long-term outcome among patients with a very small or unconfirmed AMI.

AIM: To describe various factors associated with the very long-term prognosis for patients with a very small or an unconfirmed acute myocardial infarction (AMI). METHODS: Patients below 76 years of age, hospitalized due to suspected AMI who either developed a very small AMI (enzyme elevation

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.

Changes in the use of medications after acute myocardial infarction: possible impact on mortality after myocardial infarction and long-term outcome.

OBJECTIVE: To describe the change in the use of medication after acute myocardial infarction (AMI) and discuss its possible impact on risk and risk indicators for death. PATIENTS: All patients discharged alive after hospitalization for AMI at Sahlgrenska Hospital (covering half the community of Göteborg, i.e. 250,000 of 500,000 inhabitants) during 1986-1987 (period I) and at Sahlgrenska Hospital and Ostra Hospital (covering the whole community of Göteborg, 500,000 inhabitants) during 1990-1991 (period II). METHODS: Overall mortality was retrospectively evaluated during 5 years of follow-up. RESULTS: In all, 740 patients were included in the study during period I and 1448 during period II. The 5-year mortalities were 44.1% for period I patients and 39.3% for period II patients (P = 0.036). The relative risk of death for period II patients was 0.78 [95% confidence interval (CI) 0.67-0.89, P = 0.0005] after adjustment for differences at baseline. There was a significant interaction with a history of congestive heart failure; improvement in duration of survival was found only for patients without such a history. During period I, only 3% of patients were administered fibrinolytic agents, compared with 33% of patients during period II (P < 0.0001). During period I, aspirin was prescribed for 13% of patients discharged from hospital compared with 79% during period II. Other changes in treatment on going from period I to period II included increases in prescription of beta-blockers and angiotensin converting enzyme inhibitors. After adjustment for various risk indicators for death, relative risk of death for those administered fibrinolytic agents was 0.60 (95% CI 0.18-2.02) for patients in the period-I cohort and 0.68% (95% CI 0.51-0.91) for those in the period-II cohort. Adjusted relative risk of death for those prescribed aspirin upon discharge from hospital was 0.81 (95% CI 0.52-1.25) for period-I patients and 0.71 (95% CI 0.56-0.91) for period-II patients. The adjusted relative risk of death for those administered beta-blockers was 0.72 (95% CI 0.55-0.96) for period-I patients and 0.70 (95% CI 0.55-0.90) for period-II patients. CONCLUSION: Increased use of fibrinolytic agents and aspirin for AMI as well as a moderate increase in use of beta-blockers and angiotensin converting enzyme inhibitors was associated with a parallel reduction in age-adjusted mortality during the 5 years after discharge from hospital. However, this improvement was seen only for patients without histories of congestive heart failure.

Long-term mortality among patients discharged alive after out-of-hospital cardiac arrest does not differ markedly compared with that of myocardial infarct patients without out-of-hospital cardiac arrest.

The aim of our research was to study the long-term prognosis among patients discharged alive after an out-of-hospital cardiac arrest (OHCA) in comparison with patients discharged alive after acute myocardial infarction (AMI) without OHCA, and also to study the long-term influence of AMI in connection with OHCA. Our research was conducted in the municipality of Göteborg. We retrospectively studied patients discharged from hospital 1990-91 after an OHCA of cardiac aetiology and patients discharged after an AMI without prehospital cardiac arrest. During 1980-98, we studied all patients discharged alive after OHCA of cardiac aetiology, divided into groups of precipitating AMI and no AMI. The study includes 48 patients discharged alive after an OHCA 1990-91, 30 (62%) of whom had a simultaneous AMI and 1425 patients with an AMI without OHCA. Compared with AMI survivors, survivors of an OHCA of cardiac origin were younger but had more frequently a history of congestive heart failure. Their mortality rate during the subsequent 5 years was 46%, compared with 40% among survivors of an AMI (NS). The 5-year mortality rate among patients with an OHCA precipitated by an AMI was 40%. When correcting for differences at baseline, the adjusted risk ratio for death among patients with an OHCA of cardiac origin was 1.2 (95% CI 0.8-1.8) compared with patients with an uncomplicated AMI. During 1980-98, 215 patients were judged as having an OHCA precipitated by an AMI and 115 patients had an OHCA of cardiac aetiology but no simultaneous AMI. Five-year mortality was 54% and 50% respectively (NS). It is concluded that survivors of an OHCA of cardiac origin differed from survivors of an uncomplicated AMI in that they were younger and more frequently had a history of cardiovascular disease. Their 5-year mortality after discharge was similar to that of survivors of an AMI without a prehospital cardiac arrest, even after adjusting for differences at baseline.

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.

Monotherapy with amlodipine or atenolol versus their combination in stable angina pectoris.

BACKGROUND: The basic cause of angina pectoris is imbalance between the metabolic needs of the myocardium and the capacity of the coronary circulation to deliver sufficient oxygenated blood to satisfy these needs. HYPOTHESIS: The study was undertaken to evaluate whether the effect of combined amlodipine and atenolol therapy on patients with stable angina pectoris and with ST-depression during exercise testing and 48-h ambulatory electrocardiographic monitoring is superior to that of either agent given alone. METHODS: Patients with stable angina pectoris and ST depression during exercise and ambulatory monitoring were randomized to receive amlodipine (n = 116) or atenolol (n = 116), or both (n = 119). All patients were also treated with short- and long-acting nitrates. The design was a double-blind, randomized, triple-arm parallel group study with 10 weeks of administration of the test medication. RESULTS: In terms of time to onset of ST depression > 1 mm, time to onset of angina, total exercise time, maximum achieved workload, and peak intensity of angina, amlodipine and atenolol alone were as effective as their combination. During ambulatory monitoring, atenolol was more effective than amlodipine regarding total time and number of ST-depression episodes, and as effective as the combined drugs. CONCLUSION: For individual patients with stable angina pectoris, combination of a beta blocker with a calcium antagonist is not necessarily more effective than either drug given alone.

Experiences from treatment of out-of-hospital cardiac arrest during 17 years in Göteborg.

AIMS: To describe changes in different factors at resuscitation and survival in a 17-year survey of patients suffering from out-of-hospital cardiac arrest. METHOD: The investigation was carried out in the community of Göteborg with 450 000 inhabitants during 1981-1997 on all patients suffering out-of-hospital cardiac arrest in whom resuscitation was attempted. RESULTS: The number of cases per year, the proportion of witnessed arrests and the proportion of arrests of cardiac aetiology remained similar over time. There was an increase in median age from 68 to 73 years (P<0.0001), in the proportion of females from 27% to 33% (P=0.035) and in the proportion of patients receiving bystander cardiopulmonary resuscitation from 14% to 28% (P<0.0001) with time. There was a shortening of the median interval from collapse until defibrillation from 9 min to 6 min (P<0.0001) over time but a decrease in the occurrence of ventricular fibrillation as the initially recorded arrhythmia from 39% to 32% (P=0.022). There was an increase in the proportion of patients having a bystander witnessed cardiac arrest of cardiac aetiology being hospitalized alive from 32% to 45% (P<0. 0001 for change over time). The proportion of patients discharged alive from hospital increased from 16% to 29% until 1993, but thereafter decreased to 13% in 1997 (P=0.002 for change over time). CONCLUSION: In a survey covering 17 years of resuscitation of out-of-hospital cardiac arrest patients we found that the occurrence of ventricular fibrillation as the initially recorded arrhythmia decreased. There was an increase in age, in the proportion of females and in the use of bystander cardiopulmonary resuscitation. The interval between collapse and defibrillation was shortened. Survival changed over time with an increase until 1993 but with a decrease thereafter.

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.