Long-term mortality, cardiovascular events, and bleeding in stable patients 1 year after myocardial infarction: a Danish nationwide study.

AIMS: Outcomes after myocardial infarction (MI) improved during recent decades alongside better risk factor management and implementation of guideline-recommended treatments. However, it is unknown whether this applies to stable patients who are event-free 1 year after MI. METHODS AND RESULTS: Using nationwide Danish registries, we included all patients with first-time MI during 2000-17 who survived 1 year free from bleeding and cardiovascular events (n = 82 108, median age 64 years, 68.2% male). Follow-up started 1 year after MI and continued through January 2022. Crude risks of mortality, cardiovascular events, and bleeding were estimated in consecutive 3-year periods. Standardized risks were calculated with respect to the distribution of age, sex, comorbidities, and treatments in the latter period. Guideline-recommended treatment use increased during the study period: e.g. statins (68.6-92.5%) and percutaneous coronary intervention (23.9-68.2%). The crude 5-year risks of outcomes decreased (all P-trend <0.001): Mortality, 18.6% (95% confidence interval [CI]: 17.9-19.2) to 12.5% (CI: 11.9-13.1); Recurrent MI, 7.5% (CI: 7.1-8.0) to 5.5% (CI: 5.1-6.0); Bleeding, 3.9% (CI: 3.6-4.3) to 2.7% (CI: 2.4-3.0). Crude 5-year risk of mortality in 2015-17 was as low as 2.6% for patients aged <60 years. Use of guideline-recommended treatments was associated with improved outcomes: After standardization for changes in treatments, 5-year risk of mortality in 2000-02 was 15.5% (CI: 14.9-16.2). CONCLUSIONS: For patients who were event-free 1 year after MI, the long-term risks of mortality, cardiovascular events, and bleeding decreased significantly, along with an improved use of guideline-recommended treatments between 2000 and 2017. In the most recent period, 1 year after MI, the risk of additional events was lower than previously reported.

Increased short-term risk of thrombo-embolism or death after interruption of warfarin treatment in patients with atrial fibrillation.

AIMS: It is presently unknown whether patients with atrial fibrillation (AF) are at increased risk of thrombo-embolic adverse events after interruption of warfarin treatment. The purpose of this study was to assess the risk and timing of thrombo-embolism after warfarin treatment interruption. METHODS AND RESULTS: A retrospective, nationwide cohort study of all patients in Denmark treated with warfarin after a first hospitalization with AF in the period 1997-2008. Incidence rate ratios (IRRs) of thrombo-embolic events and all-cause mortality were calculated using the Poisson regression analyses. In total, 48 989 AF patients receiving warfarin treatment were included. Of these, 35 396 patients had at least one episode of warfarin treatment interruption. In all, 8255 deaths or thrombo-embolic events occurred during treatment interruption showing an initial clustering of events with 2717, 835, 500, and 427 events occurring during 0-90, 91-180, 181-270, and 271-360 days after treatment interruption, respectively. Correspondingly, the crude incidence rates were 31.6, 17.7, 12.3, and 11.4 events per 100 patient-years. In a multivariable analysis, the first 90-day interval of treatment interruption was associated with a markedly higher risk of death or thrombo-embolism (IRR 2.5; 95% confidence interval 2.3-2.8) vs. the interval of 271-360 days. CONCLUSION: In patients with AF, an interruption of warfarin treatment is associated with a significantly increased short-term risk of death or thrombo-embolic events within the first 90 days of treatment interruption.

Bleeding risk and P2Y12 inhibitors in all-comer patients with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention: a single-centre cohort study.

AIMS: To characterize and follow patients with ST-segment elevation myocardial infarction (STEMI) at high bleeding risk (HBR) according to the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score, and to examine the use of P2Y12 inhibitors and the subsequent risk of major adverse cardiovascular events (MACE) and bleeding. METHODS AND RESULTS: This single-centre cohort study included 6179 consecutive STEMI patients who underwent percutaneous coronary intervention (PCI) at Copenhagen University Hospital, Rigshospitalet, between 2009 and 2016. Individual linkage to nationwide registries was conducted to obtain information on diagnoses, claimed drugs, and vital status. Of the 5532 (89.5%) patients with available PRECISE-DAPT scores, 33.0% were at HBR and more often elderly and female with more comorbidities than non-HBR patients. One-year cumulative incidence rates per 100 person-years were 8.7 and 2.1 for major bleeding and 36.8 and 8.3 for MACE in HBR and non-HBR patients, respectively. Among the 4749 (85.8%) patients who survived and collected a P2Y12 inhibitor ≤7 days from discharge, 68.2% of HBR patients were treated with ticagrelor or prasugrel and 31.8% with clopidogrel, while 18.2% non-HBR patients were treated with clopidogrel. Adherence was high for all (>75% days coverage). The risk of MACE was lower in ticagrelor- and prasugrel-treated patients than in clopidogrel-treated patients without differences in major bleeding. CONCLUSION: One-third of PCI-treated all-comer patients with STEMI were at HBR according to the PRECISE-DAPT score and were more often treated with potent P2Y12 inhibitors instead of clopidogrel. Thus, ischaemic risk may be weighted over bleeding risk in STEMI patients at HBR.

Safety of Same-Day Discharge After Percutaneous Coronary Intervention in Selected Patients With Non-ST Elevation Acute Coronary Syndrome.

OBJECTIVES: We aimed to investigate the safety of same-day discharge (SDD) after percutaneous coronary intervention (PCI) for non-ST segment elevation acute coronary syndrome (NSTEACS), and to investigate the reduction in duration of hospitalization achievable by SDD. BACKGROUND: Previous studies have established the safety of SDD after elective PCI, while the safety of SDD after non-elective PCI for acute coronary syndrome has only been sparsely studied. METHODS: A single-center, observational, retrospective study of 923 consecutive procedures in patients with NSTEACS who had PCI was performed. The procedures were divided into 2 groups based on postprocedural management: SDD (n = 195) and non-SDD (n = 728). RESULTS: No differences were seen in the total number of adverse events at 1 month (1.5% SDD vs 1.4% non-SDD; P=.74), 3 months (2.5% SDD vs 2.3% non-SDD; P=.80), and 6 months (3.5% SDD vs 3.3% non-SDD; P=.84) after discharge, and there were no deaths in the SDD group. No difference was found in unplanned rehospitalizations within 6 months (20.5% SDD vs 25.3% non-SDD; P=.17), while unplanned revascularizations were more frequent in non-SDD patients (5.6% SDD vs 13.4% non-SDD; P<.01). Median duration of hospitalization was 1.3 days shorter for SDD patients than for non-elderly, uncomplicated non-SDD patients. CONCLUSIONS: SDD after PCI in a selected group of NSTEACS patients was associated with low rates of adverse events, unplanned rehospitalizations, and revascularizations. SDD was associated with a shorter hospitalization duration.

Vasopressin and methylprednisolone for in-hospital cardiac arrest - Protocol for a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To describe the clinical trial "Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest" (VAM-IHCA). METHODS: The VAM-IHCA trial is an investigator-initiated, multicenter, randomized, placebo-controlled, parallel group, double-blind, superiority trial of vasopressin and methylprednisolone during adult in-hospital cardiac arrest. The study drugs consist of 40 mg methylprednisolone and 20 IU of vasopressin given as soon as possible after the first dose of adrenaline. Additional doses of vasopressin (20 IU) will be administered after each adrenaline dose for a maximum of four doses (80 IU).The primary outcome is return of spontaneous circulation and key secondary outcomes include survival and survival with a favorable neurological outcome at 30 days. 492 patients will be enrolled. The trial was registered at the EU Clinical Trials Register (EudraCT Number: 2017-004773-13) on Jan. 25, 2018 and ClinicalTrials.gov (Identifier: NCT03640949) on Aug. 21, 2018. RESULTS: The trial started in October 2018 and the last patient is anticipated to be included in January 2021. The primary results will be reported after 3-months follow-up and are, therefore, anticipated in mid-2021. CONCLUSION: The current article describes the design of the VAM-IHCA trial. The results from this trial will help clarify whether the combination of vasopressin and methylprednisolone when administered during in-hospital cardiac arrest improves outcomes.

Temporal trends in acute myocardial infarction presentation and association with use of cardioprotective drugs: a nationwide registry-based study.

Aim: The present study aimed to investigate temporal trends in myocardial infarction (MI) presentation with or without ST-segment elevation and the association with the use of cardioprotective drugs prior to admission. Methods and results: Using individual-level linkage of data from Danish nationwide registries, we identified all patients 30 years or older admitted with a first-time MI in the period 2003-2012, and their use of cardioprotective drugs 6 months prior to admission. We calculated incidence rates per 100 000 person-years (IRs) of ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI). We identified 22 247 patients admitted with STEMI and 50 403 with NSTEMI. IRs for NSTEMI decreased by 35% from 194 in 2003 to 126 in 2012, whereas IRs for STEMI peaked in 2007 and subsequently declined from 71 to 65. Preadmission use of cardioprotective drugs increased in both groups from 2003 to 2012. Patients admitted with STEMI had odds ratio (OR) 0.64 [95% confidence interval (CI) 0.61-0.67] for preadmission use of aspirin compared with patients admitted with NSTEMI. Corresponding ORs were 0.82 (CI 0.78-0.87) for statins, 0.87 (CI 0.82-0.91) for beta-blockers, 0.89 (CI 0.85-0.92) for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 0.52 (CI 0.44-0.61) for thienopyridines. Also, 30-day and 1-year mortality declined in patients both admitted with STEMI and NSTEMI. Conclusion: The IRs of MI declined between 2003 and 2012, primarily driven by a 35% reduction in IRs for NSTEMI whereas IRs for STEMI declined after 2007. Preadmission use of cardioprotective drugs increased markedly and was associated with lower ORs of presenting with STEMI than NSTEMI.

Nursing home admission after myocardial infarction in the elderly: A nationwide cohort study.

BACKGROUND: Data on nursing home admission after myocardial infarction (MI) in the elderly are scarce. We investigated nursing home admission within 6 months and 2 years after MI including predictors for nursing home admission in a nationwide cohort of elderly patients. METHODS: Using Danish nationwide registries, we identified all subjects 65 years or older residing at home who were discharged following first-time MI in the period 2008-2015. We determined sex- and age-stratified incidence rates per 1000 person years (IRs) and incidence rate ratios (IRRs) of nursing home admissions using Poisson regression models compared to the Danish population 65 years or older with no prior MI. Poisson regression models were also applied to identify predictors of nursing home admission. RESULTS: The 26,539 patients who were discharged after MI had a median age of 76 (quartile 1-quartile 3: 70-83) years. The IRs of nursing home admission after MI increased with increasing age and for 80-84-year-old women IRs after 6 months and 2 years were 113.9 and 62.9, respectively, compared to 29.4 for women of the same age with no prior MI. The IRs for 80-84-year-old men after MI were 56.0 and 36.2, respectively, compared to 24.3 for men of the same age with no prior MI. In adjusted analyses the 6 months and 2 years IRRs for 80-84-year-old subjects were 2.56 (95% CI 2.11-3.10) and 1.41 (95% CI 1.22-1.65) for women and 1.74 (95% CI 1.34-2.25) and 1.05 (95% CI 0.88-1.26) for men, respectively. Predictors were advanced age, dementia, home care, Parkinson's disease, cerebrovascular disease, living alone, depression, and arrhythmia. CONCLUSION: In elderly patients discharged following first-time MI, the risk of subsequent nursing home admission within 6 months was 2-fold higher compared to an age-stratified population with no prior MI. After 2 years this risk remained higher in women.

Moderate overweight is beneficial and severe obesity detrimental for patients with documented atherosclerotic heart disease.

OBJECTIVE: Obesity is paradoxically associated with enhanced survival in patients with established cardiovascular disease. We explored this paradox further by examining the influence of obesity on survival in patients with verified atherosclerotic heart disease. DESIGN AND PATIENTS: This retrospective registry based cohort study included all patients from the Western Denmark Heart Registry with coronary atherosclerosis confirmed by coronary angiography from January 2000 to December 2010. Patients were divided into eight groups according to body mass index (BMI) based on WHO BMI classification. SETTING: Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark. RESULTS: The study included 37 573 patients (70.7% men) with a mean age of (66.3 ± 11.1) years. During the 11 years of follow-up, 5866 (15.6%) patients died. Multivariable analysis confirmed that the risk of death was the lowest among the preobese patients (27.5 ≤ BMI<30 kg/m(2)) with adjusted HR of 0.82 (95% CI 0.71 to 0.95; p=0.008) and increased with both low (BMI<18.50 kg/m(2)) and very high (BMI ≥ 40 kg/m(2)) BMI, HR 2.04 (95% CI 1.63 to 2.57; p<0.001) and HR 1.35 (95% CI 1.05 to 1.72; p<0.01), respectively. Also the normal weight class I (18.5 ≤ BMI<23 kg/m(2)) had a significant risk of mortality HR 1.28 (95% CI 1.13 to 1.45; p<0.001). Obese classes I and II did not differ from the reference group (23 ≤ BMI<25 kg/m(2)). CONCLUSIONS: Overweight atherosclerotic heart disease patients have improved survival compared with normal weight patients. Underweight and severely obese patients have increased mortality. Our results lean more towards an overweight paradox than an obesity paradox.

Psoriasis carries an increased risk of venous thromboembolism: a Danish nationwide cohort study.

BACKGROUND: Psoriasis is an immunoinflammatory disease associated with cardiovascular risk factors, atherothrombotic events, and hypercoagulability. Venous thromboembolism (VTE) is potentially lethal and shares risk factors with psoriasis, but the risk of VTE associated with psoriasis is unknown. The present study investigated the potential association between psoriasis and VTE. METHODS AND FINDINGS: Information from nationwide prospectively recorded registers of hospitalization, drug dispensing from pharmacies, socio-economic data, and causes of death was linked on an individual level. In an unselected nationwide cohort, we used multivariate Poisson regression models controlling for age, gender, comorbidity, concomitant medication, socio-economic data, and calendar year, to assess the risk of VTE associated with psoriasis. A total of 35,138 patients with mild and 3,526 patients with severe psoriasis were identified and compared with 4,126,075 controls. Patients with psoriasis had higher incidence rates per 1000 person-years of VTE than controls (1.29, 1.92, and 3.20 for controls, mild psoriasis, and severe psoriasis, respectively). The rate ratio (RR) of VTE was elevated in all patients with psoriasis with RR 1.35 (95% confidence interval [CI] 1.21-1.49) and RR 2.06 (CI 1.63-2.61) for mild and severe psoriasis, respectively. Exclusion of patients with malignancies, and censoring of patients undergoing surgery did not alter the results. CONCLUSION: This nationwide cohort study indicates that patients with psoriasis are at increased risk of VTE. The risk was highest in young patients with severe psoriasis. Physicians should be aware that patients with psoriasis may be at increased risk of both venous and arterial thromboembolic events.