Outcomes after STEMI in old multimorbid patients with complex health needs and the effect of invasive management.

BACKGROUND: The aim of this study was to assess one-year outcomes of invasive and non-invasive strategies in ST-elevation myocardial infarction (STEMI) among multimorbid older people with complex health needs. METHODS: We included patients, registered between 2006 and 2013 in the SWEDEHEART registry, who were 70 years old or older with STEMI, had multimorbidity and complex health needs and were discharged alive. The one-year outcomes of patients who underwent invasive strategy (examined with coronary angiography ≤14 days) were compared to those who did not. The primary event was a composite of all-cause death, admission due to new acute coronary syndrome, stroke or transient ischemic attack. RESULTS: We identified patients, and 1089 were managed invasively and 570 non-invasively. The mean age was 79 years and 83 years in the 2 groups, respectively. After multivariable adjustment for baseline differences between the groups, including propensity scores, the primary event occurred in 31% of patients in the invasive group and 55% in the non-invasive group, adjusted hazard ratio (95% confidence intervals): 0.67 (0.54-0.83). One-year mortality was 18% in the invasive group and 45% in the non-invasive group, adjusted hazard ratio 0.51 (0.39-0.65). CONCLUSIONS: Multimorbid older people with complex health needs and STEMI had high rates of new ischemic events and death. In this cohort of older, high risk STEMI patients, an invasive strategy was associated with lower event rates. Randomized studies are needed to clarify whether these high risk patients who might benefit from invasive care are being managed too conservatively.

Cardiac rehabilitation availability and delivery in Europe: How does it differ by region and compare with other high-income countries?: Endorsed by the European Association of Preventive Cardiology.

AIMS: The aims of this study were to establish cardiac rehabilitation availability and density, as well as the nature of programmes, and to compare these by European region (geoscheme) and with other high-income countries. METHODS: A survey was administered to cardiac rehabilitation programmes globally. Cardiac associations were engaged to facilitate programme identification. Density was computed using global burden of disease study ischaemic heart disease incidence estimates. Four high-income countries were selected for comparison (N = 790 programmes) to European data, and multilevel analyses were performed. RESULTS: Cardiac rehabilitation was available in 40/44 (90.9%) European countries. Data were collected in 37 (94.8% country response rate). A total of 455/1538 (29.6% response rate) programme respondents initiated the survey. Programme volumes (median 300) were greatest in western European countries, but overall were higher than in other high-income countries (P < 0.001). Across all Europe, there was on average only 1 CR spot per 7 IHD patients, with an unmet regional need of 3,449,460 spots annually. Most programmes were funded by social security (n = 25, 59.5%; with significant regional variation, P < 0.001), but in 72 (16.0%) patients paid some or all of the programme costs (or ∼18.5% of the ∼€150.0/programme) out of pocket. Guideline-indicated conditions were accepted in 70% or more of programmes (lower for stable coronary disease), with no regional variation. Programmes had a multidisciplinary team of 6.5 ± 3.0 staff (number and type varied regionally; and European programmes had more staff than other high-income countries), offering 8.5 ± 1.5/10 core components (consistent with other high-income countries) over 24.8 ± 26.0 hours (regional differences, P < 0.05). CONCLUSION: European cardiac rehabilitation capacity must be augmented. Where available, services were consistent with guidelines, but varied regionally.

[Non-cardiac chest pain and its association with persistent chest pain and poor mental well-being].

INTRODUCTION: An estimated 50-75% of visits to cardiac emergency departments are due to chest pain which is non-cardiac in nature (non-cardiac chest pain (NCCP). This study evaluates the prevalence of NCCP in the emergency departments at Landspitali, and assesses its association with continued chest-pain post discharge, mental well--being and the information-provision provided to NCCP patients during hospitalization. MATERIAL AND METHODS: Participants were 390 patients (18-65 years) presenting with chest pain to the cardiac emergency or the general emergency department at Landspitali from October 2015-May 2016. Measurements included questionnaires assessing somatic symptoms, mental well-being and quality of life, and questions regarding continued chest-pain and information-provision during hospitalization. RESULTS: In total 72% of participants (282) were considered having NCCP while 24% (92) had cardiac disease. NCCP patients experienced a similar burden of somatic and depressive symptoms, but slightly more anxiety and mental distress than cardiac patients. Equal proportions (60%) of NCCP and cardiac patients reported having experienced chestpain post discharge. Continued chest-pain was, however, associated with greater anxiety (ß=0.18, p<0.001) and depression (ß=0.18, p<0.003) among NCCP patients. Thirty percent of NCCP patients lacked instructions of how to respond to continued chest-pain and only 40% received information regarding other possible causes of chest pain. CONCLUSION: NCCP was prevalent among patients presenting to emergency departments at Landspitali. The majority of NCCP patients experienced continued chest-pain after discharge, and such pain experience was associated with mental distress. A third of NCCP patients lacked information about possible causes for the pain and advice about coping with symptoms.

Population assessment of future trajectories in coronary heart disease mortality.

BACKGROUND: Coronary heart disease (CHD) mortality rates have been decreasing in Iceland since the 1980s, largely reflecting improvements in cardiovascular risk factors. The purpose of this study was to predict future CHD mortality in Iceland based on potential risk factor trends. METHODS AND FINDINGS: The previously validated IMPACT model was used to predict changes in CHD mortality between 2010 and 2040 among the projected population of Iceland aged 25-74. Calculations were based on combining: i) data on population numbers and projections (Statistics Iceland), ii) population risk factor levels and projections (Refine Reykjavik study), and iii) effectiveness of specific risk factor reductions (published meta-analyses). Projections for three contrasting scenarios were compared: (1) If the historical risk factor trends of past 30 years were to continue, the declining death rates of past decades would level off, reflecting population ageing. (2) If recent trends in risk factors (past 5 years) continue, this would result in a death rate increasing from 49 to 70 per 100,000. This would reflect a recent plateau in previously falling cholesterol levels and recent rapid increases in obesity and diabetes prevalence. 3) Assuming that in 2040 the entire population enjoys optimal risk factor levels observed in low risk cohorts, this would prevent almost all premature CHD deaths before 2040. CONCLUSIONS: The potential increase in CHD deaths with recent trends in risk factor levels is alarming both for Iceland and probably for comparable Western populations. However, our results show considerable room for reducing CHD mortality. Achieving the best case scenario could eradicate premature CHD deaths by 2040. Public health policy interventions based on these predictions may provide a cost effective means of reducing CHD mortality in the future.

[Health policy interventions: the pathway to public health]. / Stefnumörkun í heilbrigdismálum: leidin til lýdheilsu.

Chronic non-communicable diseases (NCDs) are currently the main cause of premature death and disability in the world. Most of these NCDs are due to unhealthy lifestyle choices i.e. tobacco, unhealthy diet, lack of physical exercise and alcohol consumption. Studies have shown that health policy interventions aiming at improving diet and physical activity and reducing tobacco consumption are inexpensive, effective and cost saving. In this paper we address the political health policy interventions that have been shown to improve public health. We discuss some of the theories of behavioral economics which explain the processes involved in our every-day choices regarding lifestyle and diet.

[Chronic non-communicable diseases: a global epidemic of the 21st century]. / Langvinnir sjukdomar: heimsfaraldur 21. aldar.

Chronic non-communicable diseases (NCDs) are the cause of 86% of all deaths in the EU and 65% of deaths worldwide. A third of these deaths occur before the age of sixty years. The NCDs affect 40% of the adult population of the EU and two thirds of the population reaching retirement age suffers from two or more NCDs. The NCDs are a global epidemic challenging economic growth in most countries. According to the WHO, NCDs are one of the major threats to worldwide social and economic development in the 21st century. The problem is of great concern to the international community and was discussed at a High level meeting at the UN General Assembly in September 2011. In this paper we review the epidemic of NCDs both from a national and international perspective. We discuss the causes and consequences. In a second review paper we reflect on the political health policy issues raised by the international community in order to respond to the problem. These issues will become a major challenge for social and economic development in most countries of the world in the coming decades.

Clinical consequences following regulatory changes in respect to reimbursement of statins cost by the Icelandic Social Insurance Administration.

INTRODUCTION: On 1 March 2009, a new reimbursement system was introduced by the Ministry of Health of Iceland regarding drugs to treat hyperlipidaemia. The Social Insurance Administration was only authorised to reimburse 10 and 20 mg simvastatin unless patients were eligible to receive a medical card from the Social Insurance Administration. The purpose of this study was to evaluate the influence of this reimbursement regulation on the clinical outcome. MATERIALS AND METHODS: Patients that received hyperlipidaemia treatment and were admitted to the cardiac ward were enrolled. The criteria were that the patients had been admitted 1 year prior to the regulation change and were using other statins than simvastatin. RESULTS: Out of 233 eligible patients 170 (73%) reached the treatment goal before the switch. After the switch, only 126 (54%) reached their goal (p<0.05). Total cholesterol was found to be increased after the switch by a mean of 0.48 mmol/l (range 3.90-5.53 mmol/l, p<0.001). Low-density lipoprotein cholesterol increased by a mean of 0.48 mmol/l (range 1.62-3.11, p<0.001). The level of triglycerides did not change significantly. Before the introduction of the new regulations, 73% of subjects were well controlled, but after 1 March 2009, this figure dropped to 46% (37% decrease). CONCLUSIONS: In order to lower costs for subsidising drugs, a switch to simvastatin from other cholesterol-lowering drugs was implemented (by the Ministry of Health of Iceland). The result was a significant and unwanted increase in cholesterol levels among patients with heart disease. The reason seems to be inaccurate prescriptions due to lack of competence among physicians and pharmacists. The use of "one drug fits all" does not comply here.