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1.
Can J Cardiol ; 35(10): 1419.e13-1419.e15, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31521417

RESUMO

We present a case of a 62-year-old man who was in cardiogenic shock. He had a history of coronary artery bypass grafting 4 years previously, with left internal mammary radial artery Y-grafting to a left dominant coronary circulation. Critical stenoses of the left main coronary and left subclavian arteries were seen at angiography. An occluded abdominal aorta precluded the use of mechanical circulatory support. The patient underwent high-risk stenting of the left subclavian artery with a successful outcome. The case highlights the unresolved issue of screening for subclavian stenoses in patients being considered for revascularization with arterial Y-grafting.

3.
Circ Cardiovasc Interv ; 11(9): e006842, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30354595

RESUMO

BACKGROUND: Guidelines recommend primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI) presenting ≥12 hours of symptom onset in the presence of ongoing ischemia. However, data supporting this recommendation are limited. We evaluated the effect of primary PCI on reperfusion success, using cardiac magnetic resonance, in STEMI patients with signs of ongoing ischemia presenting 12 to 72 hours after symptom onset compared with STEMI patients presenting <12 hours. METHODS AND RESULTS: We included 865 STEMI patients who underwent cardiac magnetic resonance just after index PCI and 3 months later. Despite equal area at risk (34±12% versus 33±12%; P=0.370), patients presenting late (n=58) had larger final infarct size (13% [interquartile range, 9-24] versus 11% [interquartile range, 4-19]; P=0.037) and smaller myocardial salvage index (0.58 [interquartile range, 0.39-0.71] versus 0.65 [interquartile range, 0.49-0.84]; P=0.021) compared with patients presenting <12 hours after symptom onset (n=807). However, 65% of late-presenting patients achieved substantial myocardial salvage ≥0.50, and area under the curve for symptom onset to PCI as predictor of a myocardial salvage index ≥0.50 was poor (0.58 [95% CI, 0.53-0.63]; P<0.001). In addition, final infarct size, salvage index and left ventricular function correlated weakly with duration from symptom onset to primary PCI ( R2 values <0.05). CONCLUSIONS: STEMI patients with signs of ongoing ischemia treated with primary PCI 12 to 72 hours after symptom onset had less myocardial salvage and developed larger infarcts. However, a large proportion achieved substantial myocardial salvage indicating a benefit from primary PCI in late-presenting patients. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01435408 and NCT01960933.

5.
Nat Genet ; 50(5): 766-767, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29549330

RESUMO

In the version of this article originally published, one of the two authors with the name Wei Zhao was omitted from the author list and the affiliations for both authors were assigned to the single Wei Zhao in the author list. In addition, the ORCID for Wei Zhao (Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA) was incorrectly assigned to author Wei Zhou. The errors have been corrected in the HTML and PDF versions of the article.

6.
Fam Pract ; 35(4): 433-439, 2018 Jul 23.
Artigo em Inglês | MEDLINE | ID: mdl-29351658

RESUMO

Objective: To compare the effect of a conventional to an intensive blood pressure monitoring regimen on blood pressure in hypertensive patients in the general practice setting. Design: Randomized controlled parallel group trial with 12-month follow-up. Setting: One hundred and ten general practices in all regions of Denmark. Participants: One thousand forty-eight patients with essential hypertension. Intervention: Conventional blood pressure monitoring ('usual group') continued usual ad hoc blood pressure monitoring by office blood pressure measurements, while intensive blood pressure monitoring ('intensive group') supplemented this with frequent home blood pressure monitoring and 24-hour ambulatory blood pressure monitoring. Primary outcome measures: Mean day- and night-time systolic and diastolic 24-hour ambulatory blood pressure. Secondary outcome measures: Change in systolic and diastolic office blood pressure and change in cardiovascular risk profile. Results: Of the patients, 515 (49%) were allocated to the usual group, and 533 (51%) to the intensive group. The reductions in day- and night-time 24-hour ambulatory blood pressure were similar (usual group: 4.6 ± 13.5/2.8 ± 82 mmHg; intensive group: 5.6 ± 13.0/3.5 ± 8.2 mmHg; P = 0.27/P = 0.20). Cardiovascular risk scores were reduced in both groups at follow-up, but more so in the intensive than in the usual group (P = 0.02). Conclusion: An intensive blood pressure monitoring strategy led to a similar blood pressure reduction to conventional monitoring. However, the intensive strategy appeared to improve patients' cardiovascular risk profile through other effects than a reduction of blood pressure. Trial registration: Clinical Trials NCT00244660.

7.
J Nucl Cardiol ; 25(3): 970-981, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27743299

RESUMO

BACKGROUND: Determining infarct size and myocardial salvage in patients with ST-segment elevation myocardial infarction (STEMI) is important when assessing the efficacy of new reperfusion strategies. We investigated whether rest 82Rb-PET myocardial perfusion imaging can estimate area at risk, final infarct size, and myocardial salvage index when compared to cardiac SPECT and magnetic resonance (CMR). METHODS: Twelve STEMI patients were injected with 99mTc-Sestamibi intravenously immediate prior to reperfusion. SPECT, 82Rb-PET, and CMR imaging were performed post-reperfusion and at a 3-month follow-up. An automated algorithm determined area at risk, final infarct size, and hence myocardial salvage index. RESULTS: SPECT, CMR, and PET were performed 2.2 ± 0.5, 34 ± 8.5, and 32 ± 24.4 h after reperfusion, respectively. Mean (± SD) area at risk were 35.2 ± 16.6%, 34.7 ± 11.3%, and 28.1 ± 16.1% of the left ventricle (LV) in SPECT, CMR, and PET, respectively, P = 0.04 for difference. Mean final infarct size estimates were 12.3 ± 15.4%, 13.7 ± 10.4%, and 11.9 ± 14.6% of the LV in SPECT, CMR, and PET imaging, respectively, P = .72. Myocardial salvage indices were 0.64 ± 0.33 (SPECT), 0.65 ± 0.20 (CMR), and 0.63 ± 0.28 (PET), (P = .78). CONCLUSIONS: 82Rb-PET underestimates area at risk in patients with STEMI when compared to SPECT and CMR. However, our findings suggest that PET imaging seems feasible when assessing the clinical important parameters of final infarct size and myocardial salvage index, although with great variability, in a selected STEMI population with large infarcts. These findings should be confirmed in a larger population.

8.
Nat Genet ; 50(1): 26-41, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29273807

RESUMO

Genome-wide association studies (GWAS) have identified >250 loci for body mass index (BMI), implicating pathways related to neuronal biology. Most GWAS loci represent clusters of common, noncoding variants from which pinpointing causal genes remains challenging. Here we combined data from 718,734 individuals to discover rare and low-frequency (minor allele frequency (MAF) < 5%) coding variants associated with BMI. We identified 14 coding variants in 13 genes, of which 8 variants were in genes (ZBTB7B, ACHE, RAPGEF3, RAB21, ZFHX3, ENTPD6, ZFR2 and ZNF169) newly implicated in human obesity, 2 variants were in genes (MC4R and KSR2) previously observed to be mutated in extreme obesity and 2 variants were in GIPR. The effect sizes of rare variants are ~10 times larger than those of common variants, with the largest effect observed in carriers of an MC4R mutation introducing a stop codon (p.Tyr35Ter, MAF = 0.01%), who weighed ~7 kg more than non-carriers. Pathway analyses based on the variants associated with BMI confirm enrichment of neuronal genes and provide new evidence for adipocyte and energy expenditure biology, widening the potential of genetically supported therapeutic targets in obesity.

9.
Nat Genet ; 49(12): 1758-1766, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29083408

RESUMO

We screened variants on an exome-focused genotyping array in >300,000 participants (replication in >280,000 participants) and identified 444 independent variants in 250 loci significantly associated with total cholesterol (TC), high-density-lipoprotein cholesterol (HDL-C), low-density-lipoprotein cholesterol (LDL-C), and/or triglycerides (TG). At two loci (JAK2 and A1CF), experimental analysis in mice showed lipid changes consistent with the human data. We also found that: (i) beta-thalassemia trait carriers displayed lower TC and were protected from coronary artery disease (CAD); (ii) excluding the CETP locus, there was not a predictable relationship between plasma HDL-C and risk for age-related macular degeneration; (iii) only some mechanisms of lowering LDL-C appeared to increase risk for type 2 diabetes (T2D); and (iv) TG-lowering alleles involved in hepatic production of TG-rich lipoproteins (TM6SF2 and PNPLA3) tracked with higher liver fat, higher risk for T2D, and lower risk for CAD, whereas TG-lowering alleles involved in peripheral lipolysis (LPL and ANGPTL4) had no effect on liver fat but decreased risks for both T2D and CAD.


Assuntos
Exoma/genética , Estudos de Associação Genética/métodos , Variação Genética , Lipídeos/sangue , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/genética , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/genética , Predisposição Genética para Doença/genética , Genótipo , Humanos , Degeneração Macular/sangue , Degeneração Macular/genética , Fenótipo , Fatores de Risco
10.
Nature ; 542(7640): 186-190, 2017 02 09.
Artigo em Inglês | MEDLINE | ID: mdl-28146470

RESUMO

Height is a highly heritable, classic polygenic trait with approximately 700 common associated variants identified through genome-wide association studies so far. Here, we report 83 height-associated coding variants with lower minor-allele frequencies (in the range of 0.1-4.8%) and effects of up to 2 centimetres per allele (such as those in IHH, STC2, AR and CRISPLD2), greater than ten times the average effect of common variants. In functional follow-up studies, rare height-increasing alleles of STC2 (giving an increase of 1-2 centimetres per allele) compromised proteolytic inhibition of PAPP-A and increased cleavage of IGFBP-4 in vitro, resulting in higher bioavailability of insulin-like growth factors. These 83 height-associated variants overlap genes that are mutated in monogenic growth disorders and highlight new biological candidates (such as ADAMTS3, IL11RA and NOX4) and pathways (such as proteoglycan and glycosaminoglycan synthesis) involved in growth. Our results demonstrate that sufficiently large sample sizes can uncover rare and low-frequency variants of moderate-to-large effect associated with polygenic human phenotypes, and that these variants implicate relevant genes and pathways.


Assuntos
Estatura/genética , Frequência do Gene/genética , Variação Genética/genética , Proteínas ADAMTS/genética , Adulto , Alelos , Moléculas de Adesão Celular/genética , Feminino , Genoma Humano/genética , Glicoproteínas/genética , Glicoproteínas/metabolismo , Glicosaminoglicanos/biossíntese , Proteínas Hedgehog/genética , Humanos , Peptídeos e Proteínas de Sinalização Intercelular/genética , Peptídeos e Proteínas de Sinalização Intercelular/metabolismo , Fatores Reguladores de Interferon/genética , Subunidade alfa de Receptor de Interleucina-11/genética , Masculino , Herança Multifatorial/genética , NADPH Oxidase 4 , NADPH Oxidases/genética , Fenótipo , Proteína Plasmática A Associada à Gravidez/metabolismo , Pró-Colágeno N-Endopeptidase/genética , Proteoglicanas/biossíntese , Proteólise , Receptores Androgênicos/genética , Somatomedinas/metabolismo
11.
Scand J Clin Lab Invest ; 77(1): 19-26, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27724023

RESUMO

Whole blood coagulation and markers of endothelial damage were studied in patients with acute pulmonary embolism (PE), and evaluated in relation to PE severity. Twenty-five patients were enrolled prospectively each having viscoelastical analysis of whole blood done using thrombelastography (TEG) and Multiplate aggregometry. Fourteen of these patients were investigated for endothelial damage by ELISA measurements of Syndecan-1 (endothelial glycocalyx degradation), soluble endothelial Selectin (endothelial cell activation), soluble Thrombomodulin (endothelial cell injury) and Histone Complexed DNA fragments (endothelial cytotoxic histones). The mean values of TEG and Multiplate parameters were all within the reference levels, but a significant difference between patients with high and intermediate risk PE was observed for Ly30 (lytic activity) 1.5% [0-10] vs. 0.2% [0-2.2] p = .04, and ADP (platelet reactivity) 92 U [20-145] vs. 59 U [20-111] p = .03. A similar difference was indicated for functional fibrinogen 21 mm [17-29] vs. 18 mm [3-23] p = .05. Analysis of endothelial markers identified a significant difference in circulating levels between high and intermediate risk PE patients for Syndecan-1 118.6 ng/mL [76-133] vs. 36.3 ng/mL [11.8-102.9] p = .008. In conclusion, patients with acute PE had normal whole blood coagulation, but high risk PE patients had signs of increased activity of the haemostatic system and significantly increased level of endothelial glycocalyx degradation.


Assuntos
Plaquetas/patologia , Endotélio Vascular/patologia , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico , Sindecana-1/sangue , Trombomodulina/sangue , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Coagulação Sanguínea , Plaquetas/metabolismo , Selectina E/sangue , Endotélio Vascular/química , Feminino , Fibrinogênio/metabolismo , Glicocálix/química , Glicocálix/patologia , Histonas/sangue , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Agregação Plaquetária , Embolia Pulmonar/patologia , Índice de Gravidade de Doença , Tromboelastografia
12.
J Electrocardiol ; 50(1): 11-15, 2017 Jan - Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27890283

RESUMO

The 4th Report provides a brief review of publications focused on the electrocardiographic diagnosis of left ventricular hypertrophy published during the period of 2010 to 2016 by the members of the Working Group on ECG diagnosis of Left Ventricular Hypertrophy. The Working Group recommended that ECG research and clinical attention be redirected from the estimation of LVM to the identification of electrical remodeling, to better understanding the sequence of events connecting electrical remodeling to outcomes. The need for a re-definition of terms and for a new paradigm is also stressed.


Assuntos
Cardiologia/normas , Eletrocardiografia/métodos , Eletrocardiografia/normas , Hipertrofia Ventricular Esquerda/diagnóstico , Guias de Prática Clínica como Assunto , Diagnóstico Diferencial , Humanos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Estados Unidos
13.
Am Heart J ; 181: 35-42, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27823691

RESUMO

AIMS: Familial hypercholesterolemia (FH) is a common genetic disorder causing accelerated atherosclerosis and premature cardiovascular disease. The aim of this study was to examine the prevalence and prognostic significance of possible FH in patients with myocardial infarction (MI). METHODS AND RESULTS: By individual-level linkage of data from the Eastern Danish Heart Registry and national administrative registries, a study population of patients referred for coronary angiography due to MI was selected. The study population was divided into "unlikely FH" and "possible FH" based on the Dutch Lipid Clinic Network criteria, which included a plasma low-density lipoprotein cholesterol (LDL-C) and age for onset of cardiac disease. A score of ≥3 points was used as the cutpoint between the 2 groups. Among the study population of 13,174 MI patients, 1,281 (9.7%) had possible FH. These patients were younger (59.1 vs 65.7 years, P ≤ .0001), had similar levels of comorbidities, and were treated more aggressively with cholesterol-lowering drugs compared with patients with unlikely FH. During a median of 3.3 years of follow-up, the unadjusted and adjusted event rates of recurrent MI were higher in patients with possible FH compared with unlikely FH (16% vs 11%, adjusted hazard ratio 1.28, 95% CI 1.09-1.51, P = .003.). Differences in adjusted all-cause mortality were not statistically significant (17% vs 23%, adjusted hazard ratio 0.89 [0.74-1.04], P = .1). CONCLUSION: We found that MI patients with possible FH have higher risk of recurrent MI but similar risk of mortality compared with unlikely FH patients. Further studies on secondary prevention are warranted.


Assuntos
Hiperlipoproteinemia Tipo II/epidemiologia , Mortalidade , Infarto do Miocárdio/epidemiologia , Sistema de Registros , Fatores Etários , Idoso , Anticolesterolemiantes/uso terapêutico , Causas de Morte , LDL-Colesterol/sangue , Comorbidade , Dinamarca/epidemiologia , Feminino , Humanos , Hiperlipoproteinemia Tipo II/sangue , Hiperlipoproteinemia Tipo II/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Modelos de Riscos Proporcionais , Recidiva
14.
BMC Cardiovasc Disord ; 16: 118, 2016 05 31.
Artigo em Inglês | MEDLINE | ID: mdl-27246461

RESUMO

BACKGROUND: Takotsubo cardiomypathy (TTC) causes acute reversible heart failure. Prior studies have indicated that the syndrome is associated with traits such as social inhibition, chronic psychological stress, and anxio-depressive disorders. The objective of this study was to further characterize key psychological/psychopathological traits of patients with TTC. METHODS: A survey of three groups was conducted: I) Female post-recovery TTC patients admitted between October 1(st) 2009 and December 10(th) 2014, II) Age, gender and geographically matched ST-elevation myocardial infarction (STEMI) patients, and III) Age, gender and geographically matched individuals from the background population. The following questionnaires were used in the survey: the WHO-5 Well-Being Index, Eysenck's Neuroticism Scale, the Major Depression Inventory, and the anxiety subscale of Symptoms Checklist (SCL-90). RESULTS: In total, 173 of 230 invitees (75 %) participated in the study. In comparison to the background controls, TTC patients reported significantly less well-being, more neuroticism, more depression, and more anxiety. The levels of well-being, depression and neuroticism were comparable between TTC and STEMI patients, but the level of anxiety was higher in the TTC patients. There was a negative correlation between the time since TTC admission and the total scores on the psychopathology rating scales. CONCLUSIONS: Patients with TTC reported significantly higher anxiety levels compared to both STEMI patients and background controls. However, unlike the STEMI patients, the TTC patients appeared to improve psychologically during the post-recovery phase. This may be a consolation for TTC patients in acute psychological distress.


Assuntos
Transtornos de Ansiedade/psicologia , Ansiedade/psicologia , Depressão/psicologia , Infarto do Miocárdio com Supradesnível do Segmento ST/psicologia , Cardiomiopatia de Takotsubo/psicologia , Idoso , Ansiedade/diagnóstico , Transtornos de Ansiedade/diagnóstico , Lista de Checagem , Depressão/diagnóstico , Feminino , Nível de Saúde , Humanos , Saúde Mental , Pessoa de Meia-Idade , Neuroticismo , Escalas de Graduação Psiquiátrica , Psicometria , Qualidade de Vida , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Inquéritos e Questionários , Cardiomiopatia de Takotsubo/diagnóstico , Cardiomiopatia de Takotsubo/fisiopatologia
15.
Ugeskr Laeger ; 178(24)2016 Jun 13.
Artigo em Dinamarquês | MEDLINE | ID: mdl-27292834

RESUMO

Takotsubo cardiomyopathy (TTC) is an acute cardiac syndrome, characterized by transient left ventricular dysfunction often following a stressful event in post-menopausal women. Symptoms are indistinguishable from myocardial infarction. However, TTC patients do not have a culprit lesion on acute angiography, and regional akinesia is not limited to a single vascular territory. As opposed to other cardiomyopathies TTC is completely reversible, albeit with a 5% mortality rate as well as a 10% re-occurrence rate. This article summarizes the current knowledge about aetiology, diagnostics and treatment.


Assuntos
Cardiomiopatia de Takotsubo , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Imagem por Ressonância Magnética , Pessoa de Meia-Idade , Imagem de Perfusão do Miocárdio , Tomografia por Emissão de Pósitrons , Pós-Menopausa , Prognóstico , Cintilografia , Estresse Psicológico/complicações , Cardiomiopatia de Takotsubo/diagnóstico , Cardiomiopatia de Takotsubo/diagnóstico por imagem , Cardiomiopatia de Takotsubo/etiologia , Cardiomiopatia de Takotsubo/terapia
16.
Lancet ; 387(10034): 2199-206, 2016 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-27053444

RESUMO

BACKGROUND: Despite successful treatment of the culprit artery lesion by primary percutaneous coronary intervention (PCI) with stent implantation, thrombotic embolisation occurs in some cases, which impairs the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). We aimed to assess the clinical outcomes of deferred stent implantation versus standard PCI in patients with STEMI. METHODS: We did this open-label, randomised controlled trial at four primary PCI centres in Denmark. Eligible patients (aged >18 years) had acute onset symptoms lasting 12 h or less, and ST-segment elevation of 0·1 mV or more in at least two or more contiguous electrocardiographic leads or newly developed left bundle branch block. Patients were randomly assigned (1:1), via an electronic web-based system with permuted block sizes of two to six, to receive either standard primary PCI with immediate stent implantation or deferred stent implantation 48 h after the index procedure if a stabilised flow could be obtained in the infarct-related artery. The primary endpoint was a composite of all-cause mortality, hospital admission for heart failure, recurrent infarction, and any unplanned revascularisation of the target vessel within 2 years' follow-up. Patients, investigators, and treating clinicians were not masked to treatment allocation. We did analysis by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01435408. FINDINGS: Between March 1, 2011, and Feb 28, 2014, we randomly assigned 1215 patients to receive either standard PCI (n=612) or deferred stent implantation (n=603). Median follow-up time was 42 months (IQR 33-49). Events comprising the primary endpoint occurred in 109 (18%) patients who had standard PCI and in 105 (17%) patients who had deferred stent implantation (hazard ratio 0·99, 95% CI 0·76-1·29; p=0·92). Procedure-related myocardial infarction, bleeding requiring transfusion or surgery, contrast-induced nephopathy, or stroke occurred in 28 (5%) patients in the conventional PCI group versus 27 (4%) patients in the deferred stent implantation group, with no significant differences between groups. INTERPRETATION: In patients with STEMI, routine deferred stent implantation did not reduce the occurrence of death, heart failure, myocardial infarction, or repeat revascularisation compared with conventional PCI. Results from ongoing randomised trials might shed further light on the concept of deferred stenting in this patient population. FUNDING: Danish Agency for Science, Technology and Innovation, and Danish Council for Strategic Research.


Assuntos
Stents Farmacológicos , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/métodos , Antagonistas Adrenérgicos beta/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Bloqueadores dos Canais de Cálcio/administração & dosagem , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/administração & dosagem
17.
Clin Chem ; 62(4): 593-604, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26888894

RESUMO

BACKGROUND: Increased concentrations of remnant cholesterol are causally associated with increased risk of ischemic heart disease. We tested the hypothesis that increased remnant cholesterol is a risk factor for all-cause mortality in patients with ischemic heart disease. METHODS: We included 5414 Danish patients diagnosed with ischemic heart disease. Patients on statins were not excluded. Calculated remnant cholesterol was nonfasting total cholesterol minus LDL and HDL cholesterol. During 35836 person-years of follow-up, 1319 patients died. RESULTS: We examined both calculated and directly measured remnant cholesterol; importantly, however, measured remnant cholesterol made up only 9% of calculated remnant cholesterol at nonfasting triglyceride concentrations <1 mmol/L (89 mg/dL) and only 43% at triglycerides >5 mmol/L (443 mg/dL). Multivariable-adjusted hazard ratios for all-cause mortality compared with patients with calculated remnant cholesterol concentrations in the 0 to 60th percentiles were 1.2 (95% CI, 1.1-1.4) for patients in the 61st to 80th percentiles, 1.3 (1.1-1.5) for the 81st to 90th percentiles, 1.5 (1.1-1.8) for the 91st to 95th percentiles, and 1.6 (1.2-2.0) for patients in the 96th to 100th percentiles (trend, P < 0.001). Corresponding values for measured remnant cholesterol were 1.0 (0.8-1.1), 1.2 (1.0-1.4), 1.1 (0.9-1.5), and 1.3 (1.1-1.7) (trend, P = 0.006), and for measured LDL cholesterol 1.0 (0.9-1.1), 1.0 (0.8-1.2), 1.0 (0.8-1.3), and 1.1 (0.8-1.4) (trend, P = 0.88). Cumulative survival was reduced in patients with calculated remnant cholesterol ≥1 mmol/L (39 mg/dL) vs <1 mmol/L [log-rank, P = 9 × 10(-6); hazard ratio 1.3 (1.2-1.5)], but not in patients with measured LDL cholesterol ≥3 mmol/L (116 mg/dL) vs <3 mmol/L [P = 0.76; hazard ratio 1.0 (0.9-1.1)]. CONCLUSIONS: Increased concentrations of both calculated and measured remnant cholesterol were associated with increased all-cause mortality in patients with ischemic heart disease, which was not the case for increased concentrations of measured LDL cholesterol. This suggests that increased concentrations of remnant cholesterol explain part of the residual risk of all-cause mortality in patients with ischemic heart disease.


Assuntos
Causas de Morte , Colesterol/sangue , Isquemia Miocárdica/sangue , Isquemia Miocárdica/mortalidade , Idoso , Causas de Morte/tendências , Dinamarca/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco
18.
Soc Sci Med ; 135: 109-16, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25965891

RESUMO

Initiatives in the name of 'rational pharmacotherapy' have been launched to alter what is seen as 'inappropriate' prescribing practices of physicians. Based on observations and interviews with 20 general practitioners (GPs) in 2009-2011, we explored how attempts to rationalise prescribing interact with chronic care management in Denmark. We demonstrate how attempts to rationalise prescribing by informing GPs about drug effects, adverse effects and price do not satisfy GPs' knowledge needs. We argue that, for GPs, 'rational' prescribing cannot be understood in separation from the processes that enable patients to use medication. Therefore, GPs do much more to obtain knowledge about medications than seek advice on 'rational pharmacotherapy'. For instance, GPs also seek opportunities to acquaint themselves with the material objects of medication and medical devices. We conceptualise the knowledge needs of GPs as a need for practice-relevant knowledge and argue that industry sales representatives are granted opportunity to access general practice because they understand this need of GPs.


Assuntos
Competência Clínica , Medicina Baseada em Evidências , Marketing , Padrões de Prática Médica , Dinamarca , Prescrições de Medicamentos , Uso de Medicamentos , Clínicos Gerais/educação , Teoria Fundamentada , Humanos , Entrevistas como Assunto
19.
J Electrocardiol ; 48(4): 512-9, 2015 Jul-Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25818746

RESUMO

INTRODUCTION: Several studies have investigated the ability of the twelve-lead electrocardiogram (ECG) to reliably distinguish Takotsubo cardiomyopathy (TC) from an acute anterior ST-segment elevation myocardial infarction (STEMI). In these studies, only ECG changes were required - ST-segment deviation and/or T-wave inversion - in TC whereas in acute anterior STEMI, ECGs had to meet STEMI criteria. In the majority of these studies, patients of both genders were used even though TC predominantly occurs in women. The aim of this study is to see whether TC can be distinguished from acute anterior STEMI in a predominantly female study population where all patients meet STEMI-criteria. METHODS: Retrospective analysis of the ST-segment changes was done on the triage ECGs of 37 patients with TC (34 female) and was compared to the triage ECGs of 103 female patients with acute anterior STEMI. The latter group was divided into the following subgroups: 46 patients with proximal, 47 with mid and 10 with distal LAD occlusion. Three ST-segment based ECG features were investigated: (1) Existing criterion for differentiating anterior STEMI from TC: ST-segment depression >0.5mm in lead aVR+ST-segment elevation ≤1mm in lead V1, (2) frontal plane ST-vector and (3) mean amplitude of ST-segment deviation in each lead. RESULTS: The existing ECG criterion was less accurate (76%) than in the original study (95%), with a large difference in sensitivity (26% vs. 91%). Only a frontal plane ST-vector of 60° could significantly distinguish TC from all acute anterior STEMI subgroups (p<0.01) with an overall diagnostic accuracy of 81%. The mean amplitude in inferior leads II and aVF was significantly higher for patients with TC compared to all patients with acute anterior STEMI (p<0.01 and p<0.05 respectively) and the mean amplitude in the precordial leads V1 and V2 was significantly lower compared to proximal and mid LAD occlusion (p<0.01). CONCLUSIONS: Given the consequences of missing the diagnosis of an acute anterior STEMI the diagnostic accuracy of the ECG criteria investigated in this retrospective study were insufficient to reliably distinguish patients with TC from patients with an acute anterior STEMI. To definitely exclude the diagnosis of an acute anterior STEMI coronary angiography, which remains the gold standard, will need to be performed.


Assuntos
Algoritmos , Diagnóstico por Computador/métodos , Eletrocardiografia/métodos , Infarto do Miocárdio/diagnóstico , Cardiomiopatia de Takotsubo/diagnóstico , Triagem/métodos , Idoso , Diagnóstico Diferencial , Feminino , Humanos , Masculino , Variações Dependentes do Observador , Reprodutibilidade dos Testes , Sensibilidade e Especificidade
20.
J Electrocardiol ; 47(4): 438-47, 2014 Jul-Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24891265

RESUMO

BACKGROUND: Acute myocardial infarction creates regions of altered electrical properties of myocardium resulting in typical QRS patterns (pathological Q waves) and ST segment deviations observed in leads related to the MI location. The aim of this study was to present a graphical method for imaging the changes in the sequence of depolarization and the ST segment deviations in myocardial infarction using the Dipolar ElectroCARdioTOpography (DECARTO) method. MATERIAL AND METHODS: Simulated ECG data corresponding to intramural, electrically inactive areas encircled by transmural areas with slowed impulse propagation velocity in anteroseptal and inferior locations were used for imaging the altered sequence of depolarization and the ST vector. The ECGs were transformed to areas projected on the image surface so as to image the process of ventricular depolarization based on the orientation and magnitude of the instantaneous QRS vectors, and the estimated "myocardium at risk" based on the ST segment deviation. RESULTS: The images are presented as Mercator projections with the texture of anatomical segments of the heart and the corresponding coronary artery distribution. The changes in depolarization sequence were visible as dislocations of activated areas circumventing the affected areas, while the "myocardium at risk" estimated from the ST segment deviation pointed to the affected area. CONCLUSION: The presented method of imaging ECG allows visualizing changes in sequence of depolarization as well as the ST segment deviations in myocardial infarction and they can be visually compared with non-ECG imaging methods.


Assuntos
Algoritmos , Mapeamento Potencial de Superfície Corporal/métodos , Diagnóstico por Computador/métodos , Eletrocardiografia/métodos , Infarto do Miocárdio/diagnóstico , Doença Aguda , Humanos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade
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