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In cardiovascular disease, prevention strategies targeting standard modifiable cardiovascular risk factors (SMuRFs; hypertension, diabetes, hypercholesterolaemia, and smoking) are crucial; however, myocardial infarction in the absence of SMuRFs is not infrequent. The outcomes of individuals without SMuRFs are not well known. We retrospectively analysed adult patients with first-presentation ST-elevation myocardial infarction (STEMI) using data from the Swedish myocardial infarction registry SWEDEHEART. Clinical characteristics and outcomes of adult patients (age ≥18 years) with and without SMuRFs were examined overall and by sex. Patients with a known history of coronary artery disease were excluded. The primary outcome was all-cause mortality at 30 days after STEMI presentation. Secondary outcomes included cardiovascular mortality, heart failure, and myocardial infarction at30 days. Endpoints were also examined up to discharge, and to the end of a 12-year follow-up. Multivariable logistic regression models were used to compare in-hospital mortality, and Cox-proportional hazard models and Kaplan-Meier analysis for long-term outcomes. Between Jan 1, 2005, and May 25, 2018, 9228 (14·9%) of 62 048 patients with STEMI had no SMuRFs reaching diagnostic thresholds. Median age was similar between patients with SMuRFs and patients without SMuRFs (68 years [IQR 59–78]) vs 69 years [60–78], p<0·0001). SMuRF-less patients had a similar rate of percutaneous coronary intervention to those with at least one modifiable risk factor, but were significantly less likely to receive statins, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockade (ARB), or β-blockers at discharge. By 30 days after presentation, all-cause mortality was significantly higher in SMuRF-less patients (hazard ratio 1·47 [95% CI 1·37–1·57], p<0·0001). SMuRF-less women had the highest 30-day mortality (381 [17·6%] of 2164), followed by women with SMuRFs (2032 [11·1%] of 18 220), SMuRF-less men (660 [9·3%] of 7064), and men with SMuRFs (2117 [6·1%] of 34 600). The increased risk of 30-day all-cause mortality in SMuRF-less patients remained significant after adjusting for age, sex, left ventricular ejection fraction, creatinine, and blood pressure, but was attenuated on inclusion of pharmacotherapy prescription (ACEI or ARB, β-blocker, or statin) at discharge. Additionally, SMuRF-less patients had a significantly higher rate of in-hospital all-cause mortality than patients with one or more SMuRF (883 [9·6%] vs 3411 [6·5%], p<0·0001). Myocardial infarction and heart failure at 30 days were lower in SMuRF-less patients. All-cause mortality remained increased in the SMuRF-less group for more than 8 years in men and up to the 12-year endpoint in women. Individuals who present with STEMI in the absence of SMuRFs have a significantly increased risk of all-cause mortality, compared with those with at least one SMuRF, which was particularly evident in women. The increased early mortality rates are attenuated after adjustment for use of guideline-indicated treatments, highlighting the need for evidence-based pharmacotherapy during the immediate post-infarct period irrespective of perceived low risk. Swedish Heart and Lung Foundation, National Health and Medical Research Council (Australia).

Patients with myocardial infarction (MI) seldom reach recommended targets for secondary prevention. This study evaluated a smartphone application (“app”) aimed at improving treatment adherence and cardiovascular lifestyle in MI patients. Multicenter, randomized trial. A total of 174 ticagrelor-treated MI patients were randomized to either an interactive patient support tool (active group) or a simplified tool (control group) in addition to usual post-MI care. Primary end point was a composite nonadherence score measuring patient-registered ticagrelor adherence, defined as a combination of adherence failure events (2 missed doses registered in 7-day cycles) and treatment gaps (4 consecutive missed doses). Secondary end points included change in cardiovascular risk factors, quality of life (European Quality of Life–5 Dimensions), and patient device satisfaction (System Usability Scale). Patient mean age was 58 years, 81% were men, and 21% were current smokers. At 6 months, greater patient-registered drug adherence was achieved in the active vs the control group (nonadherence score: 16.6 vs 22.8 [P = .025]). Numerically, the active group was associated with higher degree of smoking cessation, increased physical activity, and change in quality of life; however, this did not reach statistical significance. Patient satisfaction was significantly higher in the active vs the control group (system usability score: 87.3 vs 78.1 [P = .001]). In MI patients, use of an interactive patient support tool improved patient self-reported drug adherence and may be associated with a trend toward improved cardiovascular lifestyle changes and quality of life. Use of a disease-specific interactive patient support tool may be an appreciated, simple, and promising complement to standard secondary prevention.

ObjectivesTo evaluate an artificial intelligence (AI)–based, automatic coronary artery calcium (CAC) scoring software, using a semi-automatic software as a reference.MethodsThis observational study included 315 consecutive, non-contrast-enhanced calcium scoring computed tomography (CSCT) scans. A semi-automatic and an automatic software obtained the Agatston score (AS), the volume score (VS), the mass score (MS), and the number of calcified coronary lesions. Semi-automatic and automatic analysis time were registered, including a manual double-check of the automatic results. Statistical analyses were Spearman’s rank correlation coefficient (⍴), intra-class correlation (ICC), Bland Altman plots, weighted kappa analysis (κ), and Wilcoxon signed-rank test.ResultsThe correlation and agreement for the AS, VS, and MS were ⍴ = 0.935, 0.932, 0.934 (p < 0.001), and ICC = 0.996, 0.996, 0.991, respectively (p < 0.001). The correlation and agreement for the number of calcified lesions were ⍴ = 0.903 and ICC = 0.977 (p < 0.001), respectively. The Bland Altman mean difference and 1.96 SD upper and lower limits of agreements for the AS, VS, and MS were − 8.2 (− 115.1 to 98.2), − 7.4 (− 93.9 to 79.1), and − 3.8 (− 33.6 to 25.9), respectively. Agreement in risk category assignment was 89.5% and κ = 0.919 (p < 0.001). The median time for the semi-automatic and automatic method was 59 s (IQR 35–100) and 36 s (IQR 29–49), respectively (p < 0.001).ConclusionsThere was an excellent correlation and agreement between the automatic software and the semi-automatic software for three CAC scores and the number of calcified lesions. Risk category classification was accurate but showing an overestimation bias tendency. Also, the automatic method was less time-demanding.Key Points• Coronary artery calcium (CAC) scoring is an excellent candidate for artificial intelligence (AI) development in a clinical setting.• An AI-based, automatic software obtained CAC scores with excellent correlation and agreement compared with a conventional method but was less time-consuming.

In a registry-based randomized clinical trial, 6629 patients with suspected acute myocardial infarction who did not have hypoxemia were assigned to either supplemental oxygen or ambient air. Supplemental oxygen did not reduce all-cause mortality at 1 year.

Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill. To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients >65 years in acute clinical settings. Systematic review with narrative synthesis. Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020. Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review. A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients' quality of life is warranted.

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

BackgroundAtrial fibrillation is a common arrhythmia in patients with ischaemic heart disease. New-onset atrial fibrillation after coronary revascularisation is associated with adverse cardiovascular outcomes. This study aimed to determine the long-term cumulative incidence of new-onset atrial fibrillation after percutaneous coronary intervention or coronary artery bypass grafting surgery.MethodsA prospective observational cohort study in a real-world population setting, conducted at three tertiary centres, on new-onset atrial fibrillation incidence after percutaneous coronary intervention (N=123) or coronary artery bypass grafting (N=123). Heart rhythm was monitored the first 30 days in hospital by telemetry and on discharge using a handheld thumb ECG device three times a day, and thereafter for 2-week periods at 3, 12 and 24 months. The primary endpoint was the cumulative incidence of new-onset atrial fibrillation 24 months after the index procedure. Secondary objectives were to describe the incidence of cerebral ischaemic stroke and bleeding, myocardial infarction and major bleeding events during 24 months follow-up.ResultsMean age was 67 years, and male sex was more prevalent. At 30 days, the cumulative incidence of atrial fibrillation was 56% (69/123) in the coronary artery bypass graft group and 2% (3/123) in the percutaneous coronary intervention group. At 24 months, the cumulative incidence of atrial fibrillation was 58% (71/123) in the coronary artery bypass graft group and 6% (7/123) in the percutaneous coronary intervention group. Stroke, myocardial infarction and major bleeding were infrequent during follow-up.ConclusionOver 24 months of follow-up, incident new-onset atrial fibrillation mainly occurred during the first 30 days after coronary artery bypass grafting but was more evenly distributed during 24 months after percutaneous coronary intervention.Trial registration numberNCT04307225.

Despite abundant knowledge about the relationship between inflammation and coronary atherosclerosis, it is still unknown whether systemic inflammation measured as high-sensitivity C-reactive protein (hsCRP) is associated with coronary atherosclerosis in a general population. This study aimed to examine the association between hsCRP and coronary computed tomography angiography (CCTA)-detected coronary atherosclerosis in a population-based cohort. Out of 30,154 randomly invited men and women aged 50 to 64 years in the Swedish Cardiopulmonary Bioimage Study (SCAPIS), 25,408 had a technically acceptable CCTA and analysed hsCRP. Coronary atherosclerosis was defined as presence of plaque of any degree in any of 18 coronary segments. HsCRP values were categorised in four groups. Compared with hsCRP below the detection limit, elevated hsCRP (≥ 2.3 mg/L) was weakly associated with any coronary atherosclerosis (OR 1.15, 95% CI 1.07–1.24), coronary diameter stenosis ≥ 50% (OR 1.27, 95% CI 1.09–1.47), ≥ 4 segments involved (OR 1.13, 95% CI 1.01–1.26 ) and severe atherosclerosis (OR 1.33, 95% CI 1.05–1.69) after adjustment for age, sex and traditional risk factors. The associations were attenuated after further adjustment for body mass index (BMI), although elevated hsCRP still associated with noncalcified plaques (OR 1.16, 95% CI 1.02–1.32), proposed to be more vulnerable. In conclusion, the additional value of hsCRP to traditional risk factors in detection of coronary atherosclerosis is low. The association to high-risk noncalcified plaques, although unlikely through a causal pathway, could explain the relationship between hsCRP and clinical coronary events in numerous studies.

BackgroundOptimal antithrombotic therapy and its duration, whether triple therapy with dual antiplatelets plus oral anticoagulant (OAC), or dual antithrombotic therapy with an antiplatelet plus OAC, is uncertain for patients with myocardial infarction (MI) and atrial fibrillation (AF).MethodsPatients registered in SWEDEHEART (Swedish Web-system for enhancement and development of evidence-based care in heart disease evaluated according to recommended therapies) for their first MI between 2011 and 2021 with a history or new-onset AF were included (n=26 574). Linkage between SWEDEHEART and Swedish administrative health databases was performed, and pseudonymised data analysed.ResultsOver time, OAC use at discharge after MI tripled from 27% in 2011 to 77% in 2021, with direct OACs (DOACs) largely replacing warfarin, predominantly in combination with a single antiplatelet. The strongest factors for initiating OAC therapy were the performance of coronary angiography (OR 1.53 (1.40–1.68)), and percutaneous coronary intervention (OR 1.49 (1.39–1.61)). However, the year of the MI was the most predictive variable associated with OAC initiation, with an OR of 9.31 (7.92–10.95) in 2021 compared with 2011. The clinical factors associated with lower likelihood of OAC initiation were dementia, liver disease, cancer and ST-elevation MI (STEMI) versus non-STEMI.ConclusionsUse of OAC has increased over the years in patients with MI and concurrent AF, primarily driven by the increased adoption of DOACs. Additionally, there has been a shift in antithrombotic combinations, with most patients in recent years receiving DOAC in combination with a single antiplatelet, reflecting the nationwide implementation of recent evidence and guidelines. However, significant variation in antithrombotic therapy strategies remains.

Background When developing a clinical prediction model (CPM), a case-mix shift could occur in the development dataset where the distribution of individual predictors changes, potentially affecting model performance. This study exploits the case-mix shift that is already observed in the development dataset to address the case-mix shift between the development and deployment phase of a CPM. Methods We propose a Membership-based method to correct for case-mix shift in the development phase of CPMs. This method uses a probabilistic similarity metric to re-weight data samples in the source set (before the case-mix shift) to more closely match the target set (after the case-mix shift), assuming the target set reflects the target population. We apply the proposed method in a real-world dataset of myocardial infarction patients with out-of-hospital cardiac arrest within 90 days as the outcome. We design nine scenarios (including case-mix shift and no case-mix shift with a range of target/source sets sample sizes) to explore the impact on predictive performance of CPM developed with the proposed method in comparison to CPMs developed by either using all data samples but ignore the shift, or only using the most recent data. We report calibration and discrimination on development and 200 bootstrap samples. Results and Conclusions The proposed method shows promise in accounting for case-mix shift when developing a CPM, particularly when the target set sample size is insufficient. In a partial case-mix shift scenario with an insufficient target sample size, the Membership-based model achieved an optimism-adjusted calibration slope (c-slope) of 0.98, outperforming other models. Conversely, when the target set sample size is sufficient, the Unweighted model on target data only had an optimism-adjusted c-slope of 0.95, compared to 0.92 for the Membership-based model. In complete case-mix shift cases, the Membership-based and Unweighted on target data only models performed similarly. Both achieved an optimism-adjusted c-slope of 0.77 with insufficient target sample size, and optimism-adjusted c-slope of 0.94 with a sufficient target sample size. Further investigation and testing are needed, as well as accounting for other types of data distribution shift to improve model fit for the latest distribution shift in the development dataset.