Clinical implications of high-sensitivity cardiac troponins.

Cardiac troponin assays have become more sensitive over the years leading to the clinical introduction of high-sensitivity cardiac troponin assays in 2010. Their use has revolutionized the assessment of patients with chest pain in the emergency department by allowing earlier rule-in and rule-out of myocardial infarction leading to shorter stays in the emergency department and reduced admissions for chest pain. The incidence of myocardial infarction has increased slightly, and patients with myocardial infarction diagnosed with high-sensitivity cardiac troponins have been found to have a reduced risk of reinfarction, though without an impact on survival. High-sensitivity cardiac troponins are powerful predictors of long-term mortality and cardiovascular disease in the general population as well as in patients with chest pain with or without cardiovascular disease. The increase in risk for death and cardiovascular disease associated with high-sensitivity cardiac troponins is graded and starts already at detectable levels, well below the upper normal level. The aim of this review was to describe the clinical use and consequences of the introduction of high-sensitivity cardiac troponins. In addition, the importance of persistently elevated troponin levels for prognosis and what investigations may be appropriate to perform in patients with stable troponin elevations are discussed.

The use of a Swedish telephone medical advice service by the elderly - a population-based study.

OBJECTIVE: The present study aimed to describe contact made by the elderly to Sweden's nationwide medical helpline, Healthcare Guide 1177 by Phone (HGP). Other objectives were to study potential gender differences and the association between different HGP referral levels and acute visits to hospital-based emergency departments and acute visits to primary care centres. DESIGN: De-identified data from recorded calls to HGP was extracted for analysis (n = 7477 for the oldest age group). Information about acute visits to emergency departments and to primary care reception was extracted from the patient administration system. SETTING: Västerbotten County, Sweden. SUBJECTS: Patients over 80 years. MAIN OUTCOME MEASURES: Calling and visiting frequencies for different age groups as well as reasons for contact and individual recommendations. RESULTS: The utilisation rate of the telephone advice service for the oldest age group was high, with an incidence rate of 533 per 1000 person-years. Women had a 1.17 times higher incidence rate compared with men. The most common reason for contact was drug-related questions (17% of all contacts). Calls that were recommended to care by a medical specialist correlated with total emergency department visits (r = 0.30, p < 0.05) and calls that were given advice correlated with acute primary healthcare visits (r = 0.38, p = 0.005). CONCLUSION: The high utilisation of the telephone advice service by the elderly gives the telephone advice service a unique ability to function as a gatekeeper to further healthcare. Our data suggest that with the telephone advice service's present guidelines, a significant proportion of all calls are being directed to further medical help. The high frequency of drug-related questions raises concerns about the elderly's medication regimens. Key points Patients over 80 years of age had a high utilisation of the telephone medical advice service compared with other age groups. Drug-related questions were the most common reason for contact. A significant proportion of all calls made resulted in further heatlhcare contacts.

Low fructosamine and mortality - A long term follow-up of 215,011 non-diabetic subjects in the Swedish AMORIS study.

BACKGROUND AND AIMS: Both high and low fasting glucose has been associated with an increased mortality among individuals without diabetes. This J-shaped association has also been shown for HbA1c in relation to all-cause mortality. High fructosamine is associated with increased mortality. In this study we aim to evaluate if low fructosamine is also associated with increased mortality in non-diabetic subjects. METHODS AND RESULTS: We included 215,011 subjects from the AMORIS cohort undergoing occupational health screening or primary care in Stockholm, Sweden. Cause specific mortality was obtained from the Swedish Cause-of-Death Register by record linkage. Hazard ratios for the lowest decile of fructosamine were estimated by Cox regression for all-cause (n = 41,388 deaths) and cause-specific mortality during 25 years of follow-up. We observed gradually increased mortality with lower fructosamine in a large segment of the population. In the lowest decile of fructosamine the sex, age, social class and calendar adjusted hazard ratio was 1.20 (95% CI; 1.18-1.27) compared to deciles 2-9. This increased mortality was attenuated after adjustment for six other biomarkers (HR = 1.11 (95% CI; 1.07-1.15)). Haptoglobin, an indicator of chronic inflammation, made the greatest difference in the point estimate. In sensitivity analyses we found an association between low fructosamine and smoking and adjustment for smoking further attenuated the association between low fructosamine and mortality. CONCLUSION: Low levels of fructosamine in individuals without diabetes were found to be associated with increased mortality. Smoking and chronic inflammation seem to at least partially explain this association but an independent contribution by low fructosamine cannot be excluded.

Renal function assessed by two different formulas and incidence of myocardial infarction and death in middle-aged men and women.

BACKGROUND: Chronic kidney disease predicts mortality in the general population, but less is known about the association with incidence of first myocardial infarction. We evaluated glomerular filtration rates (GFR) estimated by the Modification of Diet in Renal Disease study (GFR-MDRD) equation and the Mayo formula (GFR-Mayo) as predictors of myocardial infarction and death. METHODS: In 571 353 Swedish men and women, undergoing health controls, with mean age 45 years, and no previous myocardial infarction, hazard ratios were calculated to assess the association between renal function and incidence of myocardial infarction and all-cause mortality, respectively. Glomerular filtration rate 60-90, 30-60 and <30 mL per minute per 1.73 m(2), was defined as mildly, moderately and severely decreased GFR, respectively. RESULTS: There were 19 510 myocardial infarctions and 56 367 deaths during 11.6 years of follow-up. Hazard ratios (and 95% confidence intervals) for myocardial infarction, using GFR-Mayo were 1.11 (1.06-1.16) for mildly, 1.32 (1.18-1.48) for moderately and 2.54 (1.90-3.40) for severely decreased GFR. The corresponding figures for GFR-MDRD were 1.01 (0.96-1.05), 1.23 (1.14-1.32) and 2.49 (1.85-3.35). Mortality was increased at all levels of reduced GFR-Mayo and at moderately or severely decreased GFR-MDRD. CONCLUSIONS: Already mildly decreased GFR increase the risk of myocardial infarction and death in the general population. The association with adverse outcomes is stronger when GFR-Mayo rather than GFR-MDRD is used to assess renal function.