Measurement of high-sensitivity troponin-I in suspected coronary-related chest pain in Emergency Departments. / Høysensitiv troponin I-måling ved koronarsuspekte brystsmerter i akuttmottak.

BACKGROUND: The study aimed to evaluate a new algorithm based on analyses of high-sensitivity troponin I for rapid diagnostic clarification in cases of suspected cardiac chest pain. MATERIAL AND METHOD: Two time periods - before (01.10.2016-31.12.2016) and after (01.03.2017-28.02.2018) the introduction of a diagnostic algorithm - were studied by reviewing the medical records of patients who arrived at the emergency department with chest pain. The diagnostic algorithm included a high-sensitivity troponin I test on admission (0 hours) and one hour later (the 0 h/1 h algorithm). The primary endpoint was the proportion of patients that were discharged directly from the emergency department. Secondary endpoints were acute cardiac arrest and death within 30 days and within one year. RESULTS: A larger proportion of patients with chest pain were discharged directly from the emergency department when the 0 h/1 h algorithm was used (10/91 (11 %) before versus 118/306 (39 %) after, p <0.001). Deaths and the incidence of acute myocardial infarction one year after the introduction of the 0 h/1 h algorithm were low (≤ 3 %) and not statistically different from the period before the introduction (p≥ 0.20). INTERPRETATION: The implementation of a diagnostic algorithm based on measurements of high-sensitivity troponin I resulted in fewer patients being hospitalised, and we did not register more deaths or deaths from myocardial infarction. The algorithm was suitable for identifying patients with chest pain who could safely be discharged without the need for hospitalisation, which we believe may optimise patient flow in hospitals.

Does pregnancy complication history improve cardiovascular disease risk prediction? Findings from the HUNT study in Norway.

AIM: To evaluate whether history of pregnancy complications [pre-eclampsia, gestational hypertension, preterm delivery, or small for gestational age (SGA)] improves risk prediction for cardiovascular disease (CVD). METHODS AND RESULTS: This population-based, prospective cohort study linked data from the HUNT Study, Medical Birth Registry of Norway, validated hospital records, and Norwegian Cause of Death Registry. Using an established CVD risk prediction model (NORRISK 2), we predicted 10-year risk of CVD (non-fatal myocardial infarction, fatal coronary heart disease, and non-fatal or fatal stroke) based on established risk factors (age, systolic blood pressure, total and HDL-cholesterol, smoking, anti-hypertensives, and family history of myocardial infarction). We evaluated whether adding pregnancy complication history improved model fit, calibration, discrimination, and reclassification. Among 18 231 women who were parous, ≥40 years of age, and CVD-free at start of follow-up, 39% had any pregnancy complication history and 5% experienced a CVD event during a median follow-up of 8.2 years. While pre-eclampsia and SGA were associated with CVD in unadjusted models (HR 1.96, 95% CI 1.44-2.65 for pre-eclampsia and HR 1.46, 95% CI 1.18-1.81 for SGA), only pre-eclampsia remained associated with CVD after adjusting for established risk factors (HR 1.60, 95% CI 1.16-2.17). Adding pregnancy complication history to the established prediction model led to small improvements in discrimination (C-index difference 0.004, 95% CI 0.002-0.006) and reclassification (net reclassification improvement 0.02, 95% CI 0.002-0.05). CONCLUSION: Pre-eclampsia independently predicted CVD after controlling for established risk factors; however, adding pre-eclampsia, gestational hypertension, preterm delivery, and SGA made only small improvements to CVD prediction among this representative sample of parous Norwegian women.

Association of Conventional Cardiovascular Risk Factors With Cardiovascular Disease After Hypertensive Disorders of Pregnancy: Analysis of the Nord-Trøndelag Health Study.

Importance: Women with a history of hypertensive disorders of pregnancy (HDP) have higher risk of cardiovascular disease (CVD). It is not known how much of the excess CVD risk in women with a history of HDP is associated with conventional cardiovascular risk factors. Objective: To quantify the excess risk of CVD in women with a history of HDP and estimate the proportion associated with conventional cardiovascular risk factors. Design, Setting, and Participants: Prospective cohort study with a median follow-up of 18 years. Population-based cohort of women participating in the Nord-Trøndelag Health Study in Norway. We linked data for 31 364 women from the Nord-Trøndelag Health Study (1984-2008) to validated hospital records (1987-2015), the Cause of Death Registry (1984-2015), and the Medical Birth Registry of Norway (1967-2012). A total of 7399 women were excluded based on selected pregnancy characteristics, incomplete data, or because of emigrating or experiencing the end point before start of follow-up, leaving 23 885 women for study. Data were analyzed between January 1, 2018, and June 6, 2018. Exposures: Experiencing 1 or more pregnancies complicated by HDP before age 40 years vs only experiencing normotensive pregnancies. Main Outcomes and Measures: We used Cox proportional hazards models to estimate the hazard ratios (HRs) for the association between HDP and CVD. The proportion of excess risk associated with conventional cardiovascular risk factors was estimated using an inverse odds ratio weighting approach. Results: Our study population consisted of 23 885 parous women from Nord-Trøndelag County, Norway. A total of 21 766 women had only normotensive pregnancies, while 2199 women experienced ever having an HDP. From age 40 to 70 years, women with history of HDP had an increased risk of CVD compared with women with only normotensive pregnancies (HR, 1.57; 95% CI, 1.32-1.87) but not at older age (ß = 0.98; 95% CI, 0.96-1.00; P for interaction by age = .01). Blood pressure and body mass index were associated with up to 77% of the excess risk of CVD in women with history of HDP, while glucose and lipid levels were associated with smaller proportions. Conclusion and Relevance: In this study, the risk of excess CVD in women with history of HDP was associated with conventional cardiovascular risk factors, indicating that these risk factors are important targets for cardiovascular prevention in these women.

[Takotsubo cardiomyopathy--potential differential diagnosis to myocardial infarction]. / Takotsubokardiomyopati--aktuell differensialdiagnose til hjerteinfarkt.

A new syndrome, first described by the Japanese, presents as acute myocardial infarction. However, by closer examination it shows extensive akinesia in the apical and mid portions of the left ventricle, in the absence of significant coronary artery stenosis. Recently this syndrome has also been recognised outside Japan. The mechanism is unclear, but diffuse impairment of coronary microcirculation may play a role in the pathogenesis. Timely diagnosis of this potential lethal condition is mandatory, as it avoids the unnecessary risk of thrombolysis and allows adequate treatment to be started early. Diagnosis is also important for reassuring the patients that they have a good chance of complete recovery. We present three cases with this syndrome and discuss pathogenesis and clinical implications.