Trends in Clinical Practice and Outcomes After Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery.

Background The use of percutaneous coronary intervention (PCI) to treat unprotected left main coronary artery disease has expanded rapidly in the past decade. We aimed to describe nationwide trends in clinical practice and outcomes after PCI for left main coronary artery disease. Methods and Results Patients (n=4085) enrolled in the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) as undergoing PCI for left main coronary artery disease from 2005 to 2017 were included. A count regression model was used to analyze time-related differences in procedural characteristics. The 3-year major adverse cardiovascular and cerebrovascular event rate defined as death, myocardial infarction, stroke, and repeat revascularization was calculated with the Kaplan-Meier estimator and Cox proportional hazard model. The number of annual PCI procedures grew from 121 in 2005 to 589 in 2017 (389%). The increase was greater for men (479%) and individuals with diabetes (500%). Periprocedural complications occurred in 7.9%, decreasing from 10% to 6% during the study period. A major adverse cardiovascular and cerebrovascular event occurred in 35.7% of patients, falling from 45.6% to 23.9% (hazard ratio, 0.56; 95% CI, 0.41-0.78; P=0.001). Radial artery access rose from 21.5% to 74.2% and intracoronary diagnostic procedures from 14.0% to 53.3%. Use of bare-metal stents and first-generation drug-eluting stents fell from 19.0% and 71.9%, respectively, to 0, with use of new-generation drug-eluting stents increasing to 95.2%. Conclusions Recent changes in clinical practice relating to PCI for left main coronary artery disease are characterized by a 4-fold rise in procedures conducted, increased use of evidence-based adjunctive treatment strategies, intracoronary diagnostics, newer stents, and more favorable outcomes.

Low adherence to statin treatment during the 1st year after an acute myocardial infarction is associated with increased 2nd-year mortality risk-an inverse probability of treatment weighted study on 54 872 patients.

AIMS: Experiencing an acute myocardial infarction (AMI) is a life-threatening event and use of statins can reduce the probability of recurrence and improve long-term survival. However, the effectiveness of statins in the real-world setting may be lower than the reported efficacy in randomized clinical trials. Therefore, we aimed to investigate whether low statin treatment adherence during the year following an AMI episode is associated with increased 2nd-year mortality. METHODS AND RESULTS: We analysed all 54 872 AMI patients aged ≥45 years, admitted to Swedish hospitals between 2010 and 2012, and who survive at least 1 year after the AMI episode. We defined low adherence as a medication possession ratio <50% or non-use of statins. Applying inverse probability of treatment weighting (IPTW), we investigated the association between low adherence and all-cause, cardiovascular disease (CVD), and non-CVD mortality during the 2nd year. Overall, 20% of the patients had low adherence during the 1st year and 8% died during the 2nd year. In the IPTW analysis, low adherence was associated with an increased risk of all-cause [absolute risk difference (ARD) = 0.048, number needed to harm (NNH) = 21, relative risk (RR) = 1.71], CVD (ARD = 0.035, NNH = 29, RR = 1.62), and non-CVD mortality (ARD = 0.013, NNH = 77, RR = 2.17). CONCLUSION: In the real-world setting, low statin adherence during the 1st year after an AMI episode is associated with increased mortality during the 2nd year. Our results reaffirm the importance of achieving a high adherence to statin treatment after suffering from an AMI.

Incidence and outcome of myocardial infarction treated with percutaneous coronary intervention during COVID-19 pandemic.

OBJECTIVE: Most reports on the declining incidence of myocardial infarction (MI) during the COVID-19 have either been anecdotal, survey results or geographically limited to areas with lockdowns. We examined the incidence of MI during the COVID-19 pandemic in Sweden, which has remained an open society with a different public health approach fighting COVID-19. METHODS: We assessed the incidence rate (IR) as well as the incidence rate ratios (IRRs) of all MI referred for coronary angiography in Sweden using the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR), during the COVID-19 pandemic in Sweden (1 March 2020-7 May 2020) in relation to the same days 2015-2019. RESULTS: A total of 2443 MIs were referred for coronary angiography during the COVID-19 pandemic resulting in an IR 36 MIs/day (204 MIs/100 000 per year) compared with 15 213 MIs during the reference period with an IR of 45 MIs/day (254 MIs/100 000 per year) resulting in IRR of 0.80, 95% CI (0.74 to 0.86), p<0.001. Results were consistent in all investigated patient subgroups, indicating no change in patient category seeking cardiac care. Kaplan-Meier event rates for 7-day case fatality were 439 (2.3%) compared with 37 (2.9%) (HR: 0.81, 95% CI (0.58 to 1.13), p=0.21). Time to percutaneous coronary intervention (PCI) was shorter during the pandemic and PCI was equally performed, indicating no change in quality of care during the pandemic. CONCLUSION: The COVID-19 pandemic has significantly reduced the incidence of MI referred for invasive treatment strategy. No differences in overall short-term case fatality or quality of care indicators were observed.

Transvenous interventional implantation of CRT-D in a critically ill Mustard patient waiting for heart transplant.

Cardiac resynchronization therapy may stabilize patients with severe heart failure awaiting heart transplant. Transvenous interventional implantation aided by intracardiac echocardiography is feasible in patients with adult congenital heart disease.

Blood lactate is a predictor of short-term mortality in patients with myocardial infarction complicated by heart failure but without cardiogenic shock.

BACKGROUND: Mortality in patients with acute myocardial infarction (AMI) has improved substantially with modern therapy including percutaneous coronary interventions (PCI) but remains high in certain subgroups such as patients presenting with overt cardiogenic shock. However, the risk for AMI in patients presenting acutely with signs of heart failure but without cardiogenic shock is less well described. We aimed to identify risk factors for mortality in AMI patients with heart failure without overt cardiogenic shock. METHODS: Using data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR), we identified patients with operator-registered heart failure (Killip class II-IV), and evaluated predictors of mortality based on clinical factors from review of patient records. RESULTS: A total of 1260 unique patients with acute myocardial infarction underwent PCI in 2014, of which 77 patients (7%) showed signs of heart failure (Killip II-IV) Overall 30-day mortality in patients with Killip class II-IV was 20% (N = 15). In patients classified Killip IV (1%), 30-day mortality was 50% (N = 6). In patients presenting with mild to moderate heart failure (Killlip class II-III), 30-day mortality was 14% (N = 9). In patients with Killip class II-III, lactate ≥2.5 mmol/L was associated with 30-day mortality, whereas systolic blood pressure < 90 mmHg, age, sex and BMI were not. In patients with lactate < 2.5 mmol/L 30-day mortality was 5% (N = 2) whereas mortality was 28% (N = 7) with lactate ≥2.5 mmol/L. This cut-off provided discriminative information on 30-day mortality (area under ROC curve 0.74). CONCLUSIONS: In patients with AMI and signs of mild to moderate heart failure, lactate ≥2.5 mmol/L provides additional prognostic information. Interventions to reduce risk may be targeted to these patients.

Personality factors and depression as predictors of hospital-based health care utilization following acute myocardial infarction.

BACKGROUND: Whether personality factors and depressive traits affect patients' utilization of health care following an acute myocardial infarction is relatively unknown. The aim of this study was to examine whether hospital-based health care utilization after a myocardial infarction was correlated with patients' personality factors and depressive symptoms. METHODS: We studied 366 myocardial infarction patients admitted to Malmö University Hospital between 2002 and 2005 who subsequently participated in a cardiac rehabilitation programme. The patients were followed for two years after their index event. We investigated whether personality factors and depressive traits were correlated with the participants' health care utilization, defined as a) out-patient Cardiology visits and phone calls to a physician, nurse or a social worker, and b) acute visits or admissions to the Emergency or Cardiology Departments, using negative binominal regression analysis. RESULTS: In unadjusted comparisons neuroticism predicted more out-patient contacts. This significance remained after adjusting for age, sex, smoking, alcohol consumption and size of the myocardial infarction (measured as max level on troponin-I and left ventricular ejection fraction). There were no significant correlations between other personality factors or depression and out-patient contacts. None of the personality factors or depression predicted acute admissions. CONCLUSION: Apart from neuroticism, personality factors did not explain utilization of health care in terms of Cardiology out-patient contacts or acute admissions in myocardial infarction patients participating in a cardiac rehabilitation programme. Neither did depressive symptoms predict more health care utilization. This might indicate a robust cardiac rehabilitation programme offered to the study subjects, minimizing the need for additional health care contacts.

A 1-h Combination Algorithm Allows Fast Rule-Out and Rule-In of Major Adverse Cardiac Events.

BACKGROUND: A 1-h algorithm based on high-sensitivity cardiac troponin T (hs-cTnT) testing at presentation and again 1 h thereafter has been shown to accurately rule out acute myocardial infarction. OBJECTIVES: The goal of the study was to evaluate the diagnostic accuracy of the 1-h algorithm when supplemented with patient history and an electrocardiogram (ECG) (the extended algorithm) for predicting 30-day major adverse cardiac events (MACE) and to compare it with the algorithm using hs-cTnT alone (the troponin algorithm). METHODS: This prospective observational study enrolled consecutive patients presenting to the emergency department (ED) with chest pain, for whom hs-cTnT testing was ordered at presentation. Hs-cTnT results at 1 h and the ED physician's assessments of patient history and ECG were collected. The primary outcome was an adjudicated diagnosis of 30-day MACE defined as acute myocardial infarction, unstable angina, cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of a cardiac or unknown cause. RESULTS: In the final analysis, 1,038 patients were included. The extended algorithm identified 60% of all patients for rule-out and had a higher sensitivity than the troponin algorithm (97.5% vs. 87.6%; p < 0.001). The negative predictive value was 99.5% and the likelihood ratio was 0.04 with the extended algorithm versus 97.8% and 0.17, respectively, with the troponin algorithm. The extended algorithm ruled-in 14% of patients with a higher sensitivity (75.2% vs. 56.2%; p < 0.001) but a slightly lower specificity (94.0% vs. 96.4%; p < 0.001) than the troponin algorithm. The rule-in arms of both algorithms had a likelihood ratio >10. CONCLUSIONS: A 1-h combination algorithm allowed fast rule-out and rule-in of 30-day MACE in a majority of ED patients with chest pain and performed better than the troponin-alone algorithm.

Time trends and gender differences in prevention guideline adherence and outcome after myocardial infarction: Data from the SWEDEHEART registry.

BACKGROUND: While secondary prevention improves prognosis after acute myocardial infarction (AMI), previous studies have suggested suboptimal guideline adherence, lack of improvement over time and gender differences. This study contributes contemporary data from a large national cohort. METHOD: We identified 51,620 patients <75 years examined at two and/or twelve months post AMI in the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART). Risk factor control and readmissions at one year were compared between the 2005 and 2012 cohorts, and between genders. RESULTS: Lipid control (LDL-cholesterol <2.5 mmol/L) improved from 67.9% to 71.1% (p = 0.016) over time, achieved by 67.9% vs 63.3%, p < 0.001 of men vs women. Blood pressure control (<140 mmHg systolic) increased over time (59.1% vs 69.5%, p < 0.001 in 2005 and 2012 cohorts) and was better in men (66.4% vs 61.9%, p < 0.001). Smoking cessation rate was 55.6% without differences between genders or over time. Cardiac readmissions occurred in 18.2% of women and 15.5% of men, decreasing from 2005 to 2012 (20.8% vs 14.9%). Adjusted odds ratio was 1.22 (95% CI 1.14-1.32) for women vs men and 0.94 (95% CI 0.92-0.96) for the 2012 vs the 2005 cohort. CONCLUSIONS: Although this study compares favourably to previous studies of risk factor control post AMI, improvement over time was mainly seen regarding blood pressure, revealing substantial remaining preventive potential. The reasons for gender differences seen in risk factor control and readmissions require further analysis.

Smoking Cessation After Acute Myocardial Infarction in Relation to Depression and Personality Factors.

BACKGROUND: Smoking is an important cardiovascular risk factor and smoking cessation should be a primary target in secondary prevention after a myocardial infarction (MI). PURPOSE: The purpose of this study was to examine whether personality, coping and depression were related to smoking cessation after an MI. METHOD: MI patients ≤70 years (n = 323, 73 % men, 58.7 ± 8.3 years), participating in the Secondary Prevention and Compliance following Acute Myocardial Infarction study in Malmö, Sweden, between 2002 and 2005, were interviewed by a psychologist to assess coping strategies and completed Beck Depression and NEO Personality Inventories, in close proximity to the acute event. Correlation between smoking status (current, former and never), personality factors, coping and depression was assessed at baseline and 24 months after the MI using logistic regression and in a multivariate analysis, adjusting for age and sex. RESULTS: Of the participating patients, 46 % were current smokers. Two years after the event, 44 % of these were still smoking. At baseline, current smokers scored higher on the depression and neuroticism scales and had lower agreeableness scores. Patients who continued to smoke after 2 years had higher scores on being confrontational (i.e. confrontative coping style) compared to those who had managed to quit. Patients who continued to smoke had significantly lower agreeableness and were more often living alone. CONCLUSION: Personality, coping strategies and psychosocial circumstances are associated with smoking cessation rates in patients with MI. Considering personality factors and coping strategies to better individualise smoking cessation programs in MI patients might be of importance.

Revising the link between proton-pump inhibitors and risk of acute myocardial infarction-a case-crossover analysis.

PURPOSE: The purpose of this study is to investigate if the prescription of proton-pump inhibitors (PPIs) was associated with a sudden risk of acute myocardial infarction (AMI) while controlling for time-invariant confounding by using a case-crossover design. An association might indicate that physicians take prodromal symptoms of myocardial ischaemia for dyspepsia. METHODS: We applied a case-crossover design to investigate all AMI patients admitted to the hospital in the Skåne region, Sweden, between Oct 14, 2005 and Dec 31, 2006 and their PPI prescriptions and dispensations 3 months prior to the AMI onset. We retrieved the information about prescribed medication from the Swedish Drug Register containing individual information on all dispensed drugs prescribed in the outpatient care and dispensed in any of the Swedish pharmacies. Additionally, we stratified the analyses by history of AMI. RESULTS: We identified 3490 AMI cases aged 40 to 90; 61 % were men. The odds ratio for AMI onset in those with a prescription of PPIs during a hazard period of 3 days compared to control periods was 1.36 (95 % confidence interval (CI) 0.82-2.25) in the whole study cohort and 1.66 (95 % CI 1.00-2.76) in those without history of AMI. The corresponding odds ratio (OR) based on the dispensation date (suggesting use of the drug) was 1.26 (95 % CI 0.92-1.72) and 1.29 (95 % CI 0.92-1.83), respectively. CONCLUSIONS: In our opinion, the previously reported increase in risk of adverse cardiac events in patients using PPIs may reflect the fact that an AMI may be misinterpreted as dyspepsia.

Concomitant use of warfarin and ticagrelor as an alternative to triple antithrombotic therapy after an acute coronary syndrome.

INTRODUCTION: Treatment with warfarin in combination with clopidogrel has been shown to reduce the incidence of major bleeding as compared to triple antithrombotic therapy (TT; warfarin, clopidogrel and aspirin). However, there are uncertainties regarding the risk for thrombosis since poor-responsiveness to clopidogrel is common. Ticagrelor is a more potent platelet inhibitor, but data supporting concurrent use of ticagrelor and warfarin (dual antithrombotic therapy, DT) is limited. This study therefore sought to evaluate the risk of bleeding and thrombosis associated with DT after an acute coronary syndrome (ACS). MATERIALS AND METHODS: We identified all ACS patients on DT upon discharge from Helsingborg Hospital and Skåne University Hospital in Malmö and Lund, Sweden, during 2013. Patients on DT were compared with historical controls discharged with TT. Major bleeding was defined in accordance with the HAS-BLED derivation study. Patients were retrospectively followed for three months. RESULTS: In total, 107 DT patients were identified and compared with 159 controls on TT. Mean HAS-BLED bleeding risk score and duration of treatment were similar between the groups (HAS-BLED 2.2+/-0.8 vs 2.2+/-1.0 units, p=NS; duration 2.7+/-0.8 vs 2.5+/-0.9months, p=NS; DT vs TT). The incidence of spontaneous major bleeding was similar between the groups, as was a composite of all thrombotic events, i.e. peripheral embolism, stroke/TIA and acute coronary syndrome (bleeding 8/106 (7.5%) vs 11/157 (7.0%), p=NS; thrombosis 5/106 (4.7%) vs 5/157 (3.2%), p=NS; DT vs TT). CONCLUSIONS: Rates of thrombotic and bleeding events were similar in patients with TT and patients with ticagrelor and warfarin.

Target-attainment rates of low-density lipoprotein cholesterol using lipid-lowering drugs one year after acute myocardial infarction in sweden.

The objective of this prospective cohort study was to describe real-life use of lipid-lowering drugs and low-density lipoprotein cholesterol (LDL-C) target-attainment rates 1 year after acute myocardial infarction (AMI). LDL-C was recorded at hospital admission for AMI and at follow-up at 2 and 12 months after AMI in 17,236 patients in the Swedish heart registry, SWEDEHEART, from 2004 through 2009. Lipid-lowering treatments were identified using the Swedish Prescribed Drug Register. More than 90% of patients received statins after AMI. Simvastatin ≤40 mg was used by 80% of patients at discharge and at 2 months and 68% at 1 year after AMI. Intensive statin therapy (LDL-C-lowering capacity >40%) was prescribed for 8.4%, 11.9%, and 12.2% at these time points, and combinations of statin/ezetimibe for 1.1%, 2.8%, and 5.0%, respectively. The LDL-C target of <2.5 mmol/L (97 mg/dl) was achieved in 74.5% of patients at 2 months and 72.3% at 12 months after AMI. Treatment was intensified for only 21.3% of patients with LDL-C above target at 2 months. In multivariate analysis, higher LDL-C levels at admission and at 2 months correlated to increased risk for under treatment at 12 months after AMI. In conclusion, statin treatment after AMI in Sweden has become standard, but titration to reach recommended LDL-C levels is still suboptimal. Strategies to further improve implementation of guidelines are needed.

Behavior in a stressful situation, personality factors, and disease severity in patients with acute myocardial infarction: baseline findings from the prospective cohort study SECAMI (the Secondary Prevention and Compliance following Acute Myocardial Infarction study).

BACKGROUND: Psychosocial stress has been identified as a risk factor in association with cardiovascular disease but less attention has been paid to heterogeneity in vulnerability to stress. The serial Color Word Test (CWT) measures adaptation to a stressful situation and it can be used to identify individuals that are vulnerable to stress. Prospective studies have shown that individuals with a maladaptive behavior in this test are exposed to an increased risk of future cardiovascular events. The aim of the present study was to investigate whether maladaptive behavior in the serial CWT alone or in combination with any specific personality dimension was associated with severity of myocardial infarction (MI). METHODS: MI-patients (n = 147) completed the test and filled in a personality questionnaire in close proximity to the acute event. The results were analyzed in association with four indicators of severity: maximum levels above median of the cardiac biomarkers troponin I and creatine kinase-MB (CKMB), Q-wave infarctions, and a left ventricular ejection fraction (LVEF) ≤ 50%. RESULTS: Maladaptive behavior in the serial CWT together with low scores on extraversion were associated with maximum levels above median of cardiac troponin I (OR 2.97, CI 1.08-8.20, p = 0.04) and CKMB (OR 3.33, CI 1.12-9.93, p = 0.03). No associations were found between the combination maladaptive behavior and low scores on extraversion and Q-wave infarctions or a decreased LVEF. CONCLUSIONS: Maladaptive behavior in combination with low scores on extraversion is associated with higher cardiac biomarker levels following an MI. The serial CWT and personality questionnaires could be used to identify individuals vulnerable to the hazardous effects of stress and thereby are exposed to an increased risk of a more severe infarction.

The impact of personality factors on delay in seeking treatment of acute myocardial infarction.

BACKGROUND: Early hospital arrival and rapid intervention for acute myocardial infarction is essential for a successful outcome. Several studies have been unable to identify explanatory factors that slowed decision time. The present study examines whether personality, psychosocial factors, and coping strategies might explain differences in time delay from onset of symptoms of acute myocardial infarction to arrival at a hospital emergency room. METHODS: Questionnaires on coping strategies, personality dimensions, and depression were completed by 323 patients ages 26 to 70 who had suffered an acute myocardial infarction. Tests measuring stress adaptation were completed by 180 of them. The patients were then categorised into three groups, based on time from onset of symptoms until arrival at hospital, and compared using logistic regression analysis and general linear models. RESULTS: No correlation could be established between personality factors (i.e., extraversion, neuroticism, openness, agreeableness, conscientiousness) or depressive symptoms and time between onset of symptoms and arrival at hospital. Nor was there any significant relationship between self-reported patient coping strategies and time delay. CONCLUSIONS: We found no significant relationship between personality factors, coping strategies, or depression and time delays in seeking hospital after an acute myocardial infraction.

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.

Bileaflet blood cysts on the mitral valve in an adult.

Blood cysts within the heart are very rare entities in adults. The authors present possibly the first ever case in which blood cysts were found on both mitral valve leaflets. A 65-year-old woman was referred for transthoracic echocardiography because of vague chest discomfort. Transthoracic echocardiography displayed echo-free cysts on the tips of both mitral valve leaflets. Subsequent transesophageal echocardiography confirmed this finding. The blood cysts were successfully surgically removed.

Inflammation-sensitive plasma proteins are associated with increased incidence of heart failure: a population-based cohort study.

BACKGROUND: Although inflammation has been associated with different cardiovascular diseases, the relationships with future heart failure (HF) are unclear. This population-based study explored whether elevated plasma levels of inflammatory proteins are associated with incidence of HF. METHODS: Five inflammation-sensitive plasma proteins (ISPs, fibrinogen, ceruloplasmin, haptoglobin, orosomucoid, and alpha1-antitrypsin) was measured in 6071 men (mean age 46 years) without history of myocardial infarction (MI) or stroke. Incidence of hospitalizations due to HF (primary diagnosis) was monitored over 22 years of follow-up, in relation to the number of elevated ISPs (i.e., in the 4th quartile). Subjects with myocardial infarction during follow-up were censored. RESULTS: During the follow-up, 159 men were hospitalized due to HF. Baseline levels of all ISPs, except for haptoglobin, were significantly higher in men who developed HF. After adjustments for confounding factors, the hazard ratios (HR) of HF were 1.00 (reference), 1.7 (95% CI: 1.1-2.7), 2.0 (CI: 1.2-3.3) and 2.6 (CI: 1.6-4.1), respectively, in men with none, one, two and three or more ISPs in the 4th quartile (trend: p<0.001). Of the individual ISPs, fibrinogen, ceruloplasmin and alpha1-antitrypsin showed significant relationships with incidence of HF after adjustment for risk factors. CONCLUSION: Plasma levels of inflammatory markers are associated with long-term incidence of hospitalizations due to HF in middle-aged men.

Fatality of future coronary events is related to inflammation-sensitive plasma proteins: a population-based prospective cohort study.

BACKGROUND: Approximately 40% of men suffering a first acute coronary event die the first day; most of them never reach hospital. It is largely unknown whether a low-grade inflammation in healthy men predicts the fatality of future coronary events. METHODS AND RESULTS: Five inflammation-sensitive plasma proteins (ISPs; fibrinogen, orosomucoid, alpha(1)-antitrypsin, haptoglobin, and ceruloplasmin) were measured in 6075 apparently healthy men, 680 of whom had a first coronary event [nonfatal myocardial infarction (MI) or death from coronary heart disease (CHD)] over a mean follow-up of 19 years. Of the 680 men who had a coronary event, 197 died the first day and 228 died within 28 days. Elevated ISPs were significantly associated with both nonfatal MI and CHD death, but the relative risks for CHD death were higher than for nonfatal MI. Among men who subsequently had a coronary event, the proportion of fatal events was related to the number of elevated ISPs at the baseline examination. The proportions who died the first day were 26%, 25%, 29%, and 35%, respectively, among men with 0, 1, 2, and > or =3 elevated ISPs (trend: P=0.01, adjusted for risk factors). The corresponding proportions who died within 28 days were 30%, 31%, 34%, and 38%, respectively (trend: P=0.03). CONCLUSIONS: Men who have been exposed to a low-grade inflammation many years earlier have higher fatality in future coronary events, with a higher proportion of CHD deaths and less nonfatal MI. This relation should be regarded when inflammatory markers are considered for risk assessment in primary prevention.

Prognostic significance of ventricular arrhythmia modified by ability to adapt to stressful situations.

BACKGROUND: Ventricular arrhythmia is a risk factor for myocardial infarction and mortality but many individuals with this abnormality live long and healthy lives. The aim of this study is to analyse the prognostic significance of frequent and complex ventricular arrhythmia in men who differed regarding ability to adapt to a stressful situation. DESIGN: Prospective cohort study. METHODS: The serial Color Word Test is a semi-experimental way to assess how individuals behave in a stressful encounter. This test was included in the prospective cohort study 'Men born in 1914' together with 24-h ambulatory electrocardiographic recordings at a baseline examination in 1982/83. Behaviour in the test was categorized as either adaptive or maladaptive. Behaviour in the test and occurrence of ventricular arrhythmia at baseline were analyzed in relation to incidence of myocardial infarction and mortality during approximately 14 years of follow-up. RESULTS: Multivariate analyses showed that ventricular arrhythmia was not associated with the incidence of myocardial infarction or all-cause mortality in the presence of an adaptive behaviour. Ventricular arrhythmia together with a maladaptive behaviour was associated with the incidence of myocardial infarction [relative risk (RR) 2.43; 95% confidence interval (CI) 1.37 to 4.31] and with all-cause mortality (RR 1.56; 95% CI 1.01 to 2.41) during follow-up. CONCLUSIONS: A maladaptive behaviour in a stressful encounter makes men with electrocardiographically detected ventricular arrhythmias more vulnerable and thereby exposed to an increased risk of a future myocardial infarction and overall mortality.