Self-care Management Intervention in Heart Failure (SMART-HF): A Multicenter Randomized Controlled Trial.

BACKGROUND: Self-care behavior is important in avoiding hospitalization for patients with heart failure (HF) and refers to those activities performed with the intention of improving or restoring health and well-being, as well as treating or preventing disease. The purpose was to study the effects of a home-based mobile device on self-care behavior and hospitalizations in a representative HF-population. METHODS AND RESULTS: SMART-HF is a randomized controlled multicenter clinical trial, where patients were randomized 1:1 to receive standard care (control group [CG]) or intervention with a home-based tool designed to enhance self-care behavior (intervention group [IG]) and followed for 240 days. The tool educates the patient about HF, monitors objective and subjective symptoms and adjusts loop diuretics. The primary outcome is self-care as measured by the European Heart Failure Self-care behavior scale and the secondary outcome is HF related in-hospital days.A total of 124 patients were recruited and 118 were included in the analyses (CG: n = 60, IG: n = 58). The mean age was 79 years, 39% were female, and 45% had an ejection fraction of less than 40%. Self-care was significantly improved in the IG compared to the CG (median (interquartile range) (21.5 [13.25; 28] vs 26 [18; 29.75], p = 0.014). Patients in the IG spent significantly less time in the hospital admitted for HF (2.2 days less, relative risk 0.48, 95% confidence interval 0.32-0.74, P = .001). CONCLUSIONS: The device significantly improved self-care behavior and reduced in-hospital days in a relevant HF population.

Low risk patients with acute atrial fibrillation and elevated high-sensitivity troponin do not have increased incidence of pathological stress tests.

OBJECTIVES: Many patients with atrial fibrillation (AF) or atrial flutter (AFL) and rapid ventricular response (RVR) have elevated high-sensitivity troponin T (hsTnT) values. Elevated hsTnT is an independent risk marker for cardiovascular events and mortality. The aim was to examine if AF/AFL patients with RVR and elevated hsTnT have an increased incidence of pathological cardiac stress tests, indicating need of further evaluation for coronary artery disease (CAD). Design: We prospectively included 90 AF/AFL patients without known heart failure and CAD presenting with AF/AFL and RVR. Half of the patients had elevated hsTnT (cases) and half had levels below the 99th percentile (controls). All patients were discharged in sinus rhythm. After approximately one week in sinus rhythm a new hsTnT was analysed and the patients performed a bicycle exercise stress test within the 30 day follow-up. The primary endpoint was a pathological stress test confirmed by a pathological SPECT myocardial perfusion imaging or a coronary angiography. Results: None of the controls reached the primary endpoint. Two patients (4%) out of the 45 cases reached the primary endpoint (p = .49 vs controls), but only one was found to have significant CAD at subsequent coronary angiography. Conclusion: Patients with paroxysmal AF/AFL, without a history of CAD and heart failure, who present with a RVR and minor hsTnT elevations were not found to have an increased incidence of pathological stress tests compared to patients with hsTnT values below the 99th percentile.

'Having to learn this so late in our lives ' Swedish elderly patients' beliefs, experiences, attitudes and expectations of e-health in primary health care.

OBJECTIVE: The elderly are an increasing group and large consumers of care in Sweden. Development of mobile information technology shows promising results of interventions for prevention and treatment of chronic diseases. Exploring the elderly patients' beliefs, attitudes, experiences and expectations of e-health services helps us understand the factors that influence adherence to such tools in primary care. MATERIAL AND METHODS: We conducted focus group interviews with 15 patients from three primary health care centers (PHCCs) in Southern Sweden. Data were analysed with thematic content analysis with codes and categories emerged from data during analysis. RESULTS: We found one comprehensive theme: 'The elderly's ambivalence towards e-health:  reluctant curiosity, a wish to join and need for information and learning support'. Eight categories emerged from the text during analysis: 'E-health - a solution for a non-existing problem?', 'The elderly's experiences of e-health', 'Lack of will, skills, self-trust or mistrust in the new technology', 'Organizational barriers', 'Wanting and needing to move forward', 'Concerns to be addressed for making e-health a good solution', 'Potential advantages with e-health versus ordinary health care' and 'Need for speed, access and correct comprehensive information'. CONCLUSIONS: Elderly patients in Sweden described feelings of ambivalence towards e-health, raising concerns as accessibility to health care, mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly. Key points Exploring the elderly patients' beliefs, experiences, attitudes and expectations of the fast developing e-health services helps us understand the factors that influence adherence to such tools in primary care. Elderly patients in Sweden reported ambivalence and different experiences and attitudes towards e-health, raising concerns as accessibility to health care, costs and mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.

Subclinical atherosclerosis and risk factors in relation to autonomic indices in the general population.

OBJECTIVE: Orthostatic hypotension and resting heart rate (RHR) are associated with cardiovascular disease (CVD). However, it is unknown how these factors relate to subclinical CVD. We examined the relationship between orthostatic blood pressure (BP) response, RHR and cardiovascular risk factors, including coronary artery calcification score (CACS) and arterial stiffness, in the general population. METHODS: We included 5493 individuals (age 50-64 years; 46.6% men) from The Swedish CArdioPulmonary-bio-Image Study (SCAPIS). Anthropometric and haemodynamic data, biochemistry, CACS and carotid-femoral pulse wave velocity (PWV) were retrieved. Individuals were categorized into binary variables that manifest orthostatic hypotension and in quartiles of orthostatic BP responses and RHR, respectively. Differences across the various characteristics were tested using χ 2 for categorical variables and analysis of variance and Kruskal-Wallis test for continuous variables. RESULTS: The mean (SD) SBP and DBP decrease upon standing was -3.8 (10.2) and -9.5 (6.4) mmHg, respectively. Manifest orthostatic hypotension (1.7% of the population) associated with age ( P  = 0.021), systolic, diastolic and pulse pressure ( P  < 0.001), CACS (<0.001), PWV ( P  = 0.004), HbA1c ( P  < 0.001) and glucose levels ( P  = 0.035). Age ( P  < 0.001), CACS ( P  = 0.045) and PWV ( P  < 0.001) differed according to systolic orthostatic BP, with the highest values seen in those with highest and lowest systolic orthostatic BP-responses. RHR was associated with PWV ( P  < 0.001), SBP and DBP ( P  < 0.001) as well as anthropometric parameters ( P  < 0.001) but not CACS ( P  = 0.137). CONCLUSION: Subclinical abnormalities in cardiovascular autonomic function, such as impaired and exaggerated orthostatic BP response and increased resting heart rate, are associated with markers of increased cardiovascular risk in the general population.

The relationships between the plasma metabolome and orthostatic blood pressure responses.

Whereas autonomic dysfunction and the metabolic syndrome are clinically associated, the relationships with the plasma metabolome is unknown. We explored the association between orthostatic blood pressure responses and 818 plasma metabolites in middle-aged subjects from the general population. We included 3803 out of 6251 subjects (mean age, 57 years; 52% women) from the Malmö sub-cohort of The Swedish CardioPulmonary bioImage Study with information on smoking habits, diabetes, antihypertensive drug treatment, anthropometrics, hemodynamic measurements and 818 plasma metabolites (mass-spectrometry). The associations between each metabolite and orthostatic systolic blood pressure responses were determined using multivariable linear regression analysis and p values were corrected using the Bonferroni method. Six amino acids, five vitamins, co-factors and carbohydrates, nine lipids and two xenobiotics were associated with orthostatic blood pressure after adjusting for age, gender and systolic blood pressure. After additional adjustments for BMI, diabetes, smoking and antihypertensive treatment, the association remained significant for six lipids, four amino acids and one xenobiotic. Twenty-two out of 818 plasma metabolites were associated with orthostatic blood pressure responses. Eleven metabolites, including lipids in the dihydrosphingomyelin and sphingosine pathways, were independently associated with orthostatic systolic blood pressure responses after additional adjustment for markers of cardio-metabolic disease.

Fast-Acting Insulin Aspart in Patients with Type 1 Diabetes in Real-World Clinical Practice: A Noninterventional, Retrospective Chart and Database Study.

INTRODUCTION: This study utilized continuous glucose monitoring data to analyze the effects of switching to treatment with fast-acting insulin aspart (faster aspart) in adults with type 1 diabetes (T1D) in clinical practice. METHODS: A noninterventional database review was conducted in Sweden among adults with T1D using multiple daily injection (MDI) regimens who had switched to treatment with faster aspart as part of basal-bolus treatment. Glycemic data were retrospectively collected during the 26 weeks before switching (baseline) and up to 32 weeks after switching (follow-up) to assess changes in time in glycemic range (TIR; 70-180 mg/dL), mean sensor glucose, glycated hemoglobin (HbA1c) levels, coefficient of variation, time in hyperglycemia (level 1, > 180 to ≤ 250 mg/dL; level 2, > 250 mg/dL), and time in hypoglycemia (level 1, ≥ 54 to < 70 mg/dL; level 2, < 54 mg/dL) (ClinicalTrials.gov Identifier NCT03895515). RESULTS: Overall, 178 participants were included in the study cohort. The analysis population included 82 individuals (mean age 48.5 years) with adequate glucose sensor data. From baseline to follow-up, statistically significant improvements were reported for TIR (mean increase 3.3%-points [approximately 48 min/day]; p = 0.006) with clinically relevant improvement (≥ 5%) in 43% of participants. Statistically significant improvements from baseline were observed for mean sensor glucose levels, HbA1c levels, and time in hyperglycemia (levels 1 and 2), with no statistically significant changes in time spent in hypoglycemia. CONCLUSIONS: Switching to faster aspart was associated with improvements in glycemic control without increasing hypoglycemia in adults with T1D using MDI in this real-world setting.

Lack of adherence to hypertension treatment guidelines among GPs in southern Sweden-a case report-based survey.

BACKGROUND: General practitioners (GPs) often fail to correctly adhere to guidelines for the treatment of hypertension. The reasons for this are unclear, but could be related to lack of knowledge in assessing individual patients' cardiovascular disease risk. Our aim was to investigate how GPs in southern Sweden adhere to clinical guidelines for the treatment of hypertension when major cardiovascular risk factors are taken into consideration. METHOD: A questionnaire with five genuine cases of hypertension with different cardiovascular risk profiles was sent to a random sample of GPs in southern Sweden (n=109) in order to investigate the attitude towards blood pressure (BP) treatment when major cardiovascular risk factors were present. RESULTS: In general, GPs who responded tended to focus on the absolute target BP rather than assessing the entire cardiovascular risk factor profile. Thus, cases with the highest risk of cardiovascular disease were not treated accordingly. However, there was also a tendency to overtreat the lowest risk individuals. Furthermore, the BP levels for initiating pharmacological treatment varied widely (systolic BP 140-210 mmHg). ACE inhibitors (70%) were the most common first choice of pharmacological treatment. CONCLUSION: In this study, GPs in Southern Sweden were suggesting, for different cases, either under- or overtreatment in relation to current guidelines for treatment of hypertension. On reason may be that they failed to correctly assess individual cardiovascular risk factor profiles.

Cardiovascular risk factors and autonomic indices in relation to fatal and non-fatal coronary events.

OBJECTIVE: Mortality caused by coronary artery disease has markedly decreased in recent years. However, a substantial proportion of patients suffering a coronary event (CE) die within the first day, most of them out of hospital. We aimed to investigate how established cardiovascular (CV) risk factors and CV autonomic indices associate with fatal versus non-fatal CEs in the population. METHODS: 33 057 individuals (mean age; 45.6 years; 10 773 women) free of coronary artery disease at baseline were included. Baseline examination, including assessment of traditional CV risk factors and autonomic indices such as heart rate and orthostatic reaction, was performed during 1974-1992, after which the subjects were monitored for incident CV disease. The Lunn-McNeil competing risks approach with a prespecified multivariable model was used to assess differences in risks for fatal and non-fatal CEs in relation to baseline CV risk factors. RESULTS: During follow-up period of 29.7 years, 5494 subjects (6.10/1000 person-years) had first CE; 1554 of these were fatal. Age, male gender, smoking, body mass index (BMI), blood pressure, pulse pressure and resting heart rate had stronger relationships with fatal CE than with non-fatal events. The effects of diabetes, serum cholesterol, antihypertensive treatment and orthostatic blood pressure responses were similar for fatal and non-fatal CE. CONCLUSIONS: Several cardiovascular risk factors, such as smoking, high BMI, blood pressure and high resting heart rate, were preferentially associated with fatal compared with non-fatal CEs. These observations may require special attention in the overall efforts to further reduce coronary artery disease mortality.

Marital status and occupation in relation to short-term case fatality after a first coronary event--a population based cohort.

BACKGROUND: Although marital status and low occupation level has been associated with mortality, the relationship with case fatality rates (CFR) after a coronary event (CE) is unclear. This study explored whether incidence of CE and short-term CFR differ between groups defined in terms of marital status and occupation, and if this could be explained by biological and life-style risk factors. METHODS: Population-based cohort study of 33,224 subjects (67% men), aged 27 to 61 years, without history of myocardial infarction, who were enrolled between 1974 and 1992. Incidence of CE, and CFR (death during the first day or within 28 days after CE, including out-of-hospital deaths) was examined over a mean follow-up of 21 years. RESULTS: A total of 3,035 men (6.0 per 1000 person-years) and 507 women (2.4 per 1000) suffered a first CE during follow-up. CFR (during the 1st day) was 29% in men and 23% in women. After risk factor adjustments, unmarried status in men, but not in women, was significantly associated with increased risk of suffering a CE [hazard ratios (HR) 1.10, 95% CI: 0.97-1.24; 1.42: 1.27-1.58 and 1.77: 1.31-2.40 for never married, divorced and widowed, respectively, compared to married]. Unmarried status, in both gender, was also related with an increased CFR (1st day), taking potential confounders into account (odds ratio (OR) 2.14, 95% CI: 1.63-2.81; 1.91: 1.50-2.43 and 1.49: 0.77-2.89 for never married, divorced and widowed, respectively, compared to married men. Corresponding figures for women was 2.32: 0.93-5.81; 1.87: 1.04-3.36 and 2.74: 1.03-7.28. No differences in CFR (1st day) were observed between occupational groups in neither gender. CONCLUSIONS: In this population-based Swedish cohort, short-term CFR was significantly related to unmarried status in men and women. This relationship was not explained by biological-, life-style factors or occupational level.

Income and short-term case fatality after myocardial infarction in the whole middle-aged population of Malmö, Sweden.

BACKGROUND: There are no previous studies investigating when and where those who die pre-hospitally after an AMI paid their last visit to medical care. METHODS AND RESULTS: Incidence of AMI, pre-hospital and 28-day case fatality rates were monitored over 13 years of follow-up, in relation to sex-specific quartiles of annual income in all inhabitants aged 40-64 years in Malmö, Sweden. Both incidence and short-term case fatality were inversely related to income. In all, 60-70% of all deaths within 28 days after the AMI were pre-hospital deaths. As compared with the lowest income group, the highest income group had lower odds of pre-hospital death with an age- and time-to-event-adjusted odds ratio of 0.5 (95% CI 0.4-0.8) for men and 0.3 (95% CI 0.1-0.6) for women. On the other hand, while 72% of those in the lowest two income groups had paid a visit to the medical services during the three months before death, only 59% had done so in the two highest income groups (P < 0.05). CONCLUSIONS: Poor socioeconomic circumstances increase the risk of pre-hospital death after an AMI. Of the pre-hospital deaths, the proportion who had visited the medical services during the 3 months preceding their AMI was higher among those from lower income groups. However, many of those suffering a pre-hospital death had visited clinics that normally do not treat coronary symptoms. If more patients were identified at an earlier stage this might increase the number of patients reaching hospital alive.

Barriers to adherence to hypertension guidelines among GPs in southern Sweden: a survey.

OBJECTIVE: To evaluate barriers to adherence to hypertension guidelines among publicly employed general practitioners (GPs). DESIGN: Questionnaire-based survey distributed to GPs in 24 randomly selected primary care centres in the Region of Skåne in southern Sweden. SUBJECTS: A total of 109 GPs received a self-administered questionnaire and 90 of them responded. MAIN OUTCOME MEASURES: Use of risk assessment programmes. Reasons to postpone or abstain from pharmacological treatment for the management of hypertension. RESULTS: Reported managing of high blood pressure (BP) varied. In all, 53% (95% CI 42-64%) of the GPs used risk assessment programmes and nine out of 10 acknowledged blood pressure target levels. Only one in 10 did not inform the patients about these levels. The range for immediate initiating pharmacological treatment was a systolic BP 140-220 (median 170) mmHg and diastolic BP 90-110 (median 100) mmHg. One-third (32%; 95% CI 22-42%) of the GPs postponed or abstained from pharmacological treatment of hypertension due to a patient's advanced age. No statistically significant associations were observed between GPs' gender, professional experience (i.e. in terms of specialist family medicine and by number of years in practice), and specific reasons to postpone or abstain from pharmacological treatment of hypertension. CONCLUSION: These data suggest that GPs accept higher blood pressure levels than recommended in clinical guidelines. Old age of the patient seems to be an important barrier among GPs when considering pharmacological treatment for the management of hypertension.