Disability Pension at the Time of Coronary Revascularisation Is Associated with Higher Five-Year Mortality; A Swedish Nationwide, Register-Based Prospective Cohort Study.

BACKGROUND: Although coronary revascularisation by coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are common procedures, little is known regarding disability pension (DP) at the time of coronary revascularisation and its association with mortality. The aim was to investigate the five-year mortality following a first coronary revascularisation among women and men on DP, compared with those not on DP at the time of intervention, accounting for socio-demographic and medical factors. MATERIAL AND METHODS: A nationwide prospective population-based cohort study was conducted, using national registers including 70,040 patients (80% men), aged 30-64 years, with a first CABG (n = 24,987; 36%) or PCI (n = 45,053; 64%) during 1994-2006 in Sweden, who were alive 30 days after the intervention. The main outcome was all-cause and cause-specific mortality within five years or through 31 December 2006, following CABG and PCI, and the exposure was DP at the time of a first coronary revascularisation. Information on DP, patient characteristics, date and cause of death was obtained from nationwide registers. Hazard ratios (HR) with 95% confidence intervals (CI) for the outcome were estimated, using Cox proportional hazard regression analyses. All analyses were stratified by type of intervention and gender. FINDINGS: Four percent died following coronary revascularisation. Cardiovascular disease was the most common cause of death (54%), followed by neoplasms (25%). Regardless of type of intervention, gender and after multivariable adjustments, patients on DP had a higher HR for five-year mortality compared with those not on DP at time of revascularisation (CABG: women HR 2.14; 95% CI 1.59-2.89, men HR 2.09; 1.84-2.38, PCI: women HR 2.25; 1.78-2.83, men HR 1.95; 1.72-2.21). Young women on DP at the time of PCI had a substantially higher HR (HR 4.10; 95% CI: 2.25-7.48). CONCLUSION: Patients on DP at the time of first coronary revascularisation had a higher five-year risk of mortality compared with those not on DP.

Prevalence of all-cause and diagnosis-specific disability pension at the time of first coronary revascularisation: a population-based Swedish cross-sectional study.

BACKGROUND: Although coronary revascularisation by coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) is well documented, scientific knowledge on disability pension (DP) at the time of revascularisation is lacking. The aim was to investigate the prevalence of all-cause and diagnosis-specific DP at the time of a first coronary revascularisation, accounting for socio-demographic and medical factors. MATERIALS AND METHODS: A population-based cross-sectional study using Swedish registers was conducted including all 65,676 patients (80% men) who when aged 30-63 years, within 1994-2006, had a first CABG (n = 22,959) or PCI (n = 42,717) and did not have old-age pension. Associations between socio-demographic and medical factors and the probability of DP were estimated by odds ratios (OR) with 95% confidence intervals (CI) using logistic regression analyses. FINDINGS: The prevalence of DP at time of revascularisation was 24%, mainly due to musculoskeletal diagnoses. Sixty-two percent had had DP for at least four years before the revascularisation. In the multivariable analyses, DP was more common in women (OR: 2.40; 95% CI: 2.29-2.50), older patients (50-63 years); especially men aged 60-63 years with CABG (OR: 4.91; 95% CI: 4.27-5.66), lower educational level; especially men with PCI (OR: 2.96; 95% CI: 2.69-3.26), patients born outside Sweden; especially men with PCI (OR: 2.11; 95% CI: 1.96-2.27), and in women with an indication of other diagnoses than acute coronary syndrome (ACS) or stable angina pectoris for PCI (OR: 1.72; 95% CI: 1.31-2.24). CONCLUSION: About a quarter had DP at the time of revascularisation, often due to musculoskeletal diagnoses. More than half had had DP for at least four years before the intervention. DP was associated with female gender, older age, lower educational level, and being born outside Sweden.

Disability pension after coronary revascularization: a prospective nationwide register-based Swedish cohort study.

BACKGROUND: Scientific knowledge on disability pension (DP) after revascularization by coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) is scarce. The aim was to study the incidence of and risk factors for being granted DP in the 5 years following a first CABG or PCI, accounting for socio-demographic and medical factors. METHODS: This is a nationwide population-based study using Swedish registers including all patients 30-63 years of age (n = 34,643, 16.4% women) who had a first CABG (n = 14,107) or PCI (n = 20,536) during 1994-2003. All were alive and without reintervention 30 days after the procedure and were not on DP or old-age pension. Multivariable adjusted Cox proportional hazard ratios (HR) for DP were estimated with 95% confidence intervals (CI). RESULTS: In 5 years following revascularization, 32.4% had been granted DP and the hazard ratio (HR) was higher in women (HR 1.55, 95% CI 1.48-1.62), and in CABG patients compared with PCI patients (HR 1.35, 95% CI 1.30-1.40). Long-term sick leave in the year before intervention was the strongest predictor for DP following revascularization. After adjustments for socio-demographic factors and sick-leave days in the 12 months before revascularization, HR remained high in all patients with diabetes mellitus regardless of type of revascularization. CONCLUSIONS: DP after coronary revascularization was common, especially among women and CABG patients. Most studied medical covariates, including mental and musculoskeletal disorders, were risk factors for future DP, especially long-term sickness absence.

Sickness absence following coronary revascularisation. A national study of women and men of working age in Sweden 1994-2006.

BACKGROUND: Evidence based and gender specific knowledge about sickness absence following coronary revascularisation is lacking. The objective was to investigate sickness absence after a first coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) among women and men in a national Swedish study. MATERIALS AND METHODS: All patients 30-63 years of age, who underwent a first CABG (n = 22,985, 16% women) or PCI (40,891, 22% women) in Sweden between 1994 and 2006 were included. Information on sickness absence, co-morbidity, and other patient characteristics was obtained from national registers. Long-term sickness absence (LTSA) was defined as >180 and >90 sick-leave days in the first sick-leave spell following CABG and PCI, respectively. Prevalence ratio (PR) and 95% confidence interval (CI) of LTSA were calculated. FINDINGS: LTSA followed the interventions in 41% and 36% for CABG and PCI patients, respectively. Women had more often LTSA compared with men, (CABG PR = 1.23: 95% CI 1.19-1.28 and PCI PR = 1.19; 95% CI 1.16-1.23). A history of sickness absence the year before the intervention increased the risk for LTSA after the intervention in both genders. Among women, older age, or being self employed or unemployed was associated with a lower risk for LTSA. Among men previous cardiovascular disease, diabetes and low socio-economic position increased the risk. During the observation period, there was no change in sickness absence rates among PCI patients but an increase among CABG patients adjusting for patient characteristics. CONCLUSION: This national study covering a 13-year period shows that long-term sickness absence following coronary revascularisation is common in Sweden, especially among women, and is associated with socio-economic position, co-morbidity, and sickness absence during the year before the intervention. Gender specific scientific knowledge about use and effects of sickness absence following coronary revascularisation is warranted for the patients, the treating physicians, the healthcare sector, and the society.

Country of birth and survival after a first myocardial infarction in Stockholm, Sweden.

AIM: To analyse survival after a first myocardial infarction among immigrants in Stockholm, Sweden. METHODS: All cases of first myocardial infarction among persons 30-74 years of age during 1985-1996 in Stockholm, Sweden were identified using registers of hospital discharges and deaths. Cases surviving 28 days were followed with regard to mortality during one year. Information on country of birth was obtained from national censuses and from a register on immigration. Early mortality was analysed by odds ratios (OR) through logistic regression and 1 year mortality by hazard ratios (HR) through cox proportional hazards regression. RESULTS: Male immigrants had a lower mortality within 28 days after a first myocardial infarction compared to Sweden-born after adjustment for socioeconomic status (OR 0.84; 95% CI 0.76-0.94). Among women there was a weak similar tendency (OR 0.92; 95% CI 0.76-1.10). There were essentially no differences overall between foreign-born and Sweden-born in 1-year-mortality after adjustment for socioeconomic status (men HR 1.13; 95% CI 0.91-1.41; women HR 0.90; 95% CI 0.61-1.34). CONCLUSION: Immigrants in Sweden in general do not seem to have a higher mortality after a first myocardial infarction than Sweden-born, in particular when differences in socioeconomic status are accounted for. A higher CHD mortality in immigrants appears to be primarily due to an elevated disease incidence.

Renal insufficiency and long-term mortality and incidence of myocardial infarction in patients undergoing coronary artery bypass grafting.

AIMS: To evaluate the impact of renal insufficiency (RI) on long-term mortality and incident myocardial infarction (MI) in patients undergoing coronary artery bypass grafting (CABG). METHODS AND RESULTS: All patients (n = 6575) without dialysis-dependent RI undergoing a first isolated CABG during 1980-1995 at the Karolinska hospital who survived 30 days post-operatively were included. Estimated glomerular filtration rate (eGFR) was related to the incidence of MI and all-cause mortality within 5 years. There were 628 deaths and 496 incident MIs during follow-up. After multivariable adjustment, patients with mild (eGFR 60-90 mL/min), moderate (eGFR 30-60 mL/min), and severe (eGFR <30 mL/min) RI had an increased mortality within 5 years post-CABG; hazard ratio (HR) 1.2 [95% confidence interval (CI) 1.0-1.6], HR 1.8 (95% CI 1.3-2.4), and HR 5.2 (95% CI 3.1-8.6), respectively, compared with patients with normal renal function (eGFR >90 mL/min). In patients with moderate and severe RI, there was an increased incidence of MI; HR 1.5 (95% CI 1.1-2.1) and HR 3.5 (95% CI 1.8-6.8), respectively. There were no gender differences. CONCLUSION: Already mild RI predicts late all-cause mortality after coronary artery bypass grafting (CABG), and moderate and severe RI is associated with an increased long-term incidence of MI post-CABG.

Mitral annulus motion as a predictor of mortality in a community-based sample of 75-year-old men and women.

Mitral annulus motion (MAM) is a predictor of mortality in selected patient groups, but its prognostic value in less selected populations is not known. In a community-based random sample of 75-year-old men and women (n = 408), left ventricular function was measured as: (1) maximum amplitude of MAM; and (2) wall-motion index. During a median follow-up of 7.2 years, 83 persons died (26 from cardiac causes). Left ventricular function as measured by MAM predicted the risk of all-cause and cardiac mortality independently of other potential risk factors in this community-based sample. Regarding cardiac mortality, the predictive ability of MAM was also independent of left ventricular systolic function measured as wall-motion index. MAM may prove to be a valuable complement to other echocardiographic methods in the assessment of prognosis in less selected populations.

Creatinine clearance and risk of early mortality in patients undergoing coronary artery bypass grafting.

OBJECTIVES: We sought to evaluate renal function assessed on the basis of calculated creatinine clearance as a predictor of early mortality and postoperative complications in patients undergoing coronary artery bypass grafting and to assess whether calculated creatinine clearance is superior to serum creatinine concentration in predicting early death postoperatively. METHODS: Six thousand seven hundred eleven consecutive patients without dialysis-dependent renal insufficiency undergoing a first isolated coronary artery bypass grafting were included. Preoperative serum creatinine concentrations and creatinine clearance calculated by using the Cockroft-Gault formula were related to mortality within 30 days postoperatively. RESULTS: There were 136 early deaths. After adjustment for age and other confounders in multivariate analyses, moderate (calculated creatinine clearance 30-60 mL/min) and severe (calculated creatinine clearance < 30 mL/min) renal insufficiency predicted early mortality (odds ratio of 2.4 [95% confidence interval, 1.2-4.8] and odds ratio of 4.8 [95% confidence interval], 1.6-13.9, respectively) compared with normal (calculated creatinine clearance > or = 90 mL/min) renal function. The area under the receiver operating characteristic curve for calculated creatinine clearance and serum creatinine concentration was 0.71 and 0.62, respectively, yielding a difference of 0.08 (P = .0004). No increased risk of mediastinitis or bleeding was observed in patients with renal insufficiency. CONCLUSION: Moderate and severe renal insufficiency independently increase the risk of early death after coronary artery bypass grafting. Our results indicate that calculated creatinine clearance is a better predictor of early mortality postoperatively than serum creatinine concentration.

Outcome of ST-elevation myocardial infarction treated with thrombolysis in the unselected population is vastly different from samples of eligible patients in a large-scale clinical trial.

BACKGROUND: Patients in clinical trials of fibrinolytic agents have been shown to be younger, less often female, and to have lower risk characteristics and a better outcome compared with unselected patients with ST-elevation myocardial infarction. However, a direct comparison of patients treated with fibrinolytic agents and not enrolled versus those enrolled in a trial, including a large number of patients, has not been performed. METHODS: Prospective data from the Swedish Register of Cardiac Intensive Care on patients admitted with acute myocardial infarction treated with thrombolytic agents in 60 Swedish hospitals were linked to data on trial participants in the ASsessment of Safety and Efficacy of a New Thrombolytic (ASSENT)-2 trial of fibrinolytic agents. Baseline characteristics, treatments, and long-term outcome were evaluated in 729 trial participants (A2), 2048 nonparticipants at trial hospitals (non-A2), and 964 nonparticipants at other hospitals (non-A2-Hosp). RESULTS: Nontrial patients compared with A2 patients were older and had higher risk characteristics and more early complications, although the treatments were similar. Patients at highest risk of death were the least likely to be enrolled in the trial. The 1-year mortality rate was 8.8% versus 20.3% and 19.0% (P <.001 for both) among A2 compared with non-A2 and non-A2-Hosp patients, respectively. After adjustment for a number of risk factors, the 1-year mortality rate was still twice as high in nontrial compared with A2 patients. CONCLUSIONS: The adjusted 1-year mortality rate was twice as high in patients treated with fibrinolytic agents and not enrolled in a clinical trial compared with those enrolled. One major reason for the difference in outcome appeared to be the selection of less critically ill patients to the trial.

Electrocardiogram and B-type natriuretic peptide as screening tools for left ventricular systolic dysfunction in a population-based sample of 75-year-old men and women.

BACKGROUND: Plasma concentration of B-type natriuretic peptide (BNP) has been suggested as a powerful screening tool for left ventricular systolic dysfunction. However, there are reports indicating that the 12-lead electrocardiogram (ECG) could be just as powerful. We aimed to evaluate the 12-lead ECG and BNP as screening tools for left ventricular systolic dysfunction in an elderly, unselected population. METHODS: In a randomly selected population-based sample of 75-year-old men and women (n = 407), diagnostic characteristics were evaluated for the ECG and plasma concentration of BNP to detect left ventricular systolic dysfunction. RESULTS: Sensitivity, specificity, and negative and positive predictive values for the ECG to detect left ventricular systolic dysfunction were 96%, 79%, 100%, and 26%, respectively. The corresponding values for the BNP (cut-off value 28 pg/mL) were 93%, 55%, 99%, and 13%. In participants without major abnormalities in the ECG, left ventricular systolic dysfunction was found in <1% (1/302), irrespective of BNP concentrations. In participants with abnormal ECGs, systolic dysfunction was more prevalent in persons with abnormal BNP concentrations than in those with normal concentrations (35% vs 3%, difference 32%, 95%CI for the difference 16%-44%) CONCLUSIONS: In 75-year-old subjects both the ECG and the plasma concentration of BNP are highly efficient in excluding left ventricular systolic dysfunction. However, compared with the BNP, the ECG yields a lower number of false positive cases. In screening for left ventricular systolic dysfunction, the BNP has a diagnostic value in addition to the ECG, but only in individuals with abnormal ECGs.

One-year follow-up of the ASSENT-2 trial: a double-blind, randomized comparison of single-bolus tenecteplase and front-loaded alteplase in 16,949 patients with ST-elevation acute myocardial infarction.

BACKGROUND: Single-bolus tenecteplase and accelerated alteplase were shown to be equivalent for 30-day mortality rates in the double-blind Assessment of the Safety of a New Thrombolytic (ASSENT-2) study. The aim of this study is to assess mortality rates after 1-year follow-up. METHODS AND RESULTS: One-year vital status was obtained from 92.8% of the patients initially enrolled in the ASSENT-2 trial. Completeness of follow-up was similar for both groups. At 1 year, mortality rates were 9.1% for alteplase and 9.2% for tenecteplase (risk ratio, 1.01; 95% CI, 0.91-1.12). The mortality rate between 30 and 365 days after enrollment was 2.6% for alteplase and 2.8% for tenecteplase (risk, 1.07; 95% CI, 0.88-1.30). A lower 30-day mortality rate in patients treated with tenecteplase after 4 hours of symptom-onset persisted at 1-year follow-up (10.9% vs 12.6% for alteplase), but was no longer statistically significant. There were also no significant differences in mortality rates between the 2 treatments in other major subgroups. In a Cox regression model, no significant interaction was observed between treatment assignment and age, sex, time-to-treatment, Killip class, body weight, and history of previous myocardial infarction, infarction location, systolic blood pressure, or heart rate. CONCLUSIONS: One year after randomization, mortality rates remain similar in patients with acute myocardial infarction treated with an accelerated infusion of alteplase or a single bolus of tenecteplase.

Mitral annulus motion compared with wall motion scoring index in the assessment of left ventricular ejection fraction.

The biplane disc summation method is the recommended echocardiographic procedure to determine left ventricular (LV) ejection fraction (EF). Assessment of mitral annulus motion (MAM) or wall motion scoring index (WMI) has been reported to be less dependent on image quality compared with the recommended method, and proposed as a surrogate to the disc summation method in calculation of LVEF. We aimed to compare MAM and WMI in the echocardiographic assessment of LVEF. In a randomly selected population-based sample of 75-year-old men and women in sinus rhythm (n = 409) MAM, as measured by M-mode, was compared with WMI, calculated as the mean value of wall motion scoring in 9 LV segments. LVEF, as measured by the biplane disc summation method was used as reference. The limits of agreement (mean difference +/- 1.96 SD) between LVEF and corresponding MAM values were -18 to +13 LVEF%, and between LVEF and corresponding WMI values were -12 to +13 LVEF%. The areas under the receiver operating characteristic curves for MAM and WMI to predict a LVEF < 50% were 0.892 and 0.998, respectively (95% confidence interval of the difference 0.062-0.149). The corresponding areas for MAM and WMI to predict a LVEF < 40% were 0.955 and 0.998, respectively (95% confidence interval of the difference 0.017-0.069). In conclusion, the ability of WMI to estimate LVEF was more favorable than MAM in this population-based sample of 75-year-old participants. The findings suggest that the WMI is preferable to MAM in estimating LVEF.

Low molecular weight heparin (dalteparin) compared to unfractionated heparin as an adjunct to rt-PA (alteplase) for improvement of coronary artery patency in acute myocardial infarction-the ASSENT Plus study.

BACKGROUND: Current thrombolytic-antithrombotic regimens in acute myocardialinfarction (AMI) are limited by incomplete early coronary reperfusion and by reocclusion and reinfarction. We compared the effects of low molecular weight heparin (LMWH) versus unfractionated heparin (UFH) as an adjunct to recombinant tissue-plasminogen activator (alteplase) on coronary artery patency and clinical outcomes in AMI. METHODS: Patients with AMI treated with alteplase (n=439) were randomised to either subcutaneous dalteparin (120 IU/kg every 12h) for 4-7 days or intravenous infusion of UFH for 48 h. Coronary angiography was performed between day 4 and hospital discharge. Clinical events and safety were evaluated until day 30. RESULTS: Overall there were higher thrombolysis in myocardial infarction (TIMI) flows in the infarct related coronary artery in the dalteparin group (p=0.016). The predefined primary end-point, TIMI grade 3 flow, did not reach statistical significance (dalteparin 69.3% versus heparin 62.5%; p=0.163). However, TIMI 0-1 flow (13.4 versus 24.4%; p=0.006) and its combination with intraluminal thrombus (27.9 versus 42.0%; p=0.003) were less common in the dalteparin group. During the period of randomised treatment there were less myocardial reinfarctions in the dalteparin group(p=0.010) but after cessation of dalteparin there were more reinfarctions resulting in no difference in death or MI at 30 days. There were no significant differences in major bleeding or stroke after 30 days. CONCLUSIONS: In alteplase treated AMI adjunctive dalteparin for 4-7 days seems to reduce the risk of early coronary artery occlusion and reinfarction. However, early after cessation of treatment there is a raised risk of events, which might eliminate any long-term gains.