[Show abstract][Hide abstract] ABSTRACT: Guidelines recommend an early invasive strategy for patients with diabetes with acute coronary syndromes (ACS). We investigated if patients with diabetes with ACS are offered coronary angiography (CAG) and revascularisation to the same extent as patients without diabetes.
The study is a nationwide cohort study linking Danish national registries containing information on healthcare. The study population comprises all patients hospitalised with first-time ACS in Denmark during 2005-2007 (N=24 952). Diabetes was defined as claiming of a prescription for insulin and/or oral hypoglycaemic agents within 6 months prior to the ACS event. Diabetes was present in 2813 (11%) patients. Compared with patients without diabetes, patients with diabetes were older (mean 69 vs 67 years, p<0.0001), less often males (60% vs 64%, p=0.0001) and had more comorbidity. Fewer patients with diabetes underwent CAG: cumulative incidence 64% vs 74% for patients without diabetes, HR=0.72 (95% CI 0.69 to 0.76, p<0.0001); adjusted for age, sex, previous revascularisation and comorbidity HR=0.78 (95% CI 0.74 to 0.82, p<0.0001). More patients with diabetes had CAG showing two-vessel or three-vessel disease (53% vs 38%, p<0.0001). However, revascularisation after CAG revealing multivessel disease was less likely in patients with diabetes (multivariable adjusted HR=0.76, 95% CI 0.68 to 0.85, p<0.0001).
In this nationwide cohort of patients with incident ACS, patients with diabetes were found to be less aggressively managed by an invasive treatment strategy. The factors underlying the decision to defer an invasive strategy in patients with diabetes are unclear and merit further investigation.
[Show abstract][Hide abstract] ABSTRACT: The aim of the present study was to evaluate clopidogrel treatment after incident myocardial infarction (MI) in patients with and without chronic kidney disease (CKD).
Journal of the American Heart Association 06/2014; 3(4).
[Show abstract][Hide abstract] ABSTRACT: Background: From the mid-1980s to mid-1990s, the WHO MONICA Project monitored coronary events and classic risk factors for coronary heart disease (CHD) in 38 populations from 21 countries. We assessed the extent to which changes in these risk factors explain the variation in the trends in coronary-event rates across the populations.
Methods: In men and women aged 35—64 years, non-fatal myocardial infarction and coronary deaths were registered continuously to assess trends in rates of coronary events. We carried out population surveys to estimate trends in risk factors. Trends in event rates were regressed on trends in risk score and in individual risk factors.
Findings: Smoking rates decreased in most male populations but trends were mixed in women; mean blood pressures and cholesterol concentrations decreased, bodymass index increased, and overall risk scores and coronary-event rates decreased. The model of trends in 10-year coronary-event rates against risk scores and single risk factors showed a poor fit, but this was improved with a 4-year time lag for coronary events. The explanatory power of the analyses was limited by imprecision of the estimates and homogeneity of trends in the study populations.
Interpretation: Changes in the classic risk factors seem to partly explain the variation in population trends in CHD. Residual variance is attributable to difficulties in measurement and analysis, including time lag, and to factors that were not included, such as medical interventions. The results support prevention policies based on the classic risk factors but suggest potential for prevention beyond these.
[Show abstract][Hide abstract] ABSTRACT: SUMMARY: The WHO MONICA Project is designed to measure the trends in mortality and morbidity from coronary heart disease (CHD) and stroke, and to assess the extent to which they are related to changes in known risk factors in different populations in 27 countries. Risk-factor data are collected from population samples examined in at least two population surveys (one at the beginning of the study and the other at the end). The results of the baseline population surveys are presented. In populations studied, the proportion of smokers varied between 34-62% among men and 3-52% among women. The population median of systolic blood pressure varied between 121-146 mmHg in men. In women the figures were 118 mmHg and 141 mmHg respectively. In diastolic blood pressure, the variation of median was from 74 mmHg to over 91 mmHg among men and from 72-89 mmHg among women. The third major risk factor considered was total cholesterol, with the population median ranging between 4.1-6.4 mmol/l among men and 4.2-6.3 mmol/l among women. Caution is required when making cross-sectional comparisons between the risk-factor levels as the MONICA Project was not designed for this purpose. Nevertheless, these data demonstrate clearly the large variety of baseline risk-factor patterns in populations studied in the MONICA Project.
MeSH Terms: Adult; Australia; Blood Pressure; Body Weight; China; Cholesterol/blood; Coronary Disease/etiology*; Data Interpretation, Statistical; Europe; Female; Humans; Male; Middle Aged; Population Surveillance*; Quality Control; Risk Factors; Smoking/statistics & numerical data; USSR; World Health Organization;
[Show abstract][Hide abstract] ABSTRACT: The aim of this Danish nationwide study was to evaluate the treatment of myocardial infarction (MI) in patients with non-end-stage chronic kidney disease (CKD) and in patients requiring renal replacement therapy (RRT). Upgraded guidelines for the management of MI were implemented around 2004; hence, the treatment of MI in the time periods before and after 2004 was compared in order to evaluate the impact for patients with CKD.
By linking nationwide registries by the personal registration number, we identified patients admitted to Danish hospitals with first time MI in the period 2000-09 (79 585 with no renal disease, 3144 with non-end-stage CKD, and 725 requiring RRT). Cox proportional hazards model was used to estimate the chance of invasive treatment within 60 days after MI and the chance of filling prescriptions on recommended post-MI drugs within 90 days before and after 2004. Significantly less use of relevant MI treatment in patients with non-end-stage CKD and patients requiring RRT compared with patients with no renal disease were seen; however, the absolute frequencies of invasive procedures and filled prescriptions on post-MI drugs increased after 2004 in all patients.
After 2004, invasive and pharmacological treatment of first-time MI improved in patients with non-end-stage CKD and patients requiring RRT; however, all CKD patients were less treated with standard MI care compared with patients with no renal disease.
European Heart Journal 06/2013; · 14.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Less invasive treatment and poorer outcomes have been shown among patients admitted with acute myocardial infarction (AMI) on weekends compared to weekdays. OBJECTIVES: To investigate the 'weekend-effect' on mortality in patients with AMI. METHODS: Using nationwide registers we identified 92,164 patients aged 30-90years who were admitted to a Danish hospital with a first AMI from 1997 to 2009. Patients were stratified according to weekday- or weekend admissions and four time-periods to investigate for temporal changes. All-cause mortality at 2, 7, 30, and 365days was investigated using proportional hazards Cox regression. RESULTS: Mortality rates were higher on weekends within seven days of admission in 1997-99 (absolute difference ranging from 0.8 to 1.1%). Weekend-weekday hazard-ratios were 1.13 (1.03-1.23) at day 2 and 1.10 (1.01-1.18) at day 7. There were no significant differences in 2000-09 and estimates suggested an attenuation of the initial 'weekend-effect'. Overall, the use of coronary angiography (34.9% vs. 72.3%) and percutaneous coronary intervention (6.6% vs. 51.0%) within 30days increased, as did the use of statins (49.9% vs. 80.1%.) and clopidogrel (26.7% vs. 72.7%). The cumulative mortality decreased during the study period from 5.4% to 2.5% at day of admission, from 19.5% to 11.0% at day 30 and from 28.0% to 19.0% at day 365 (all tests for trend p<0.0001). CONCLUSIONS: No persistent 'weekend-effect' on mortality was present in patients with AMI in 1997-2009. Overall, mortality rates have decreased concomitantly with an increased use of current guideline-recommended invasive and medical therapy.
International journal of cardiology 11/2012; · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Many patients with advanced chronic kidney disease are referred late to renal units. This is associated with negative aspects. The purpose of the present study was to characterize late versus early referrals for renal replacement therapy including their renal disease, health care contacts and medical treatment before renal replacement therapy (RRT) and the consequences for RRT modality and mortality.
Nationwide cohort study including 4495 RRT patients identified in the Danish Nephrology Registry 1999-2006. The cohort was followed to end 2007 by linkage to other national registries. Late referral: follow-up ≤16 weeks in renal unit before RRT start. Cox proportional hazards models were used to estimate the relative risk of mortality or waiting list status within 365 days in late referrals versus early referrals.
A total of 1727 (38%) incident RRT patients were referred late. Among these, 72% were treated in non-nephrology hospital departments and 91% in general practice 2 years to 16 weeks before RRT start. Fewer late referrals received recommended pre-RRT treatment as judged by renin-angiotensin-system blockade: 32% versus 57% or the D-vitamin analogue alfacalcidol: 5% versus 30% (P < .001). Primary RRT modality was peritoneal dialysis: 18% in late versus 32% in early referrals (P < .001), 7% versus 30%, respectively, had an arteriovenous dialysis-fistula (P < .001) and 0.2% versus 6% were on the waiting-list for renal transplantation (P < .001) before RRT start. One-year-mortality was higher in late referrals: hazard ratio 1.55 (CI 95% 1.35-1.78). In a subgroup, 30% (CI 95% 25-35%) late and 9% (CI 95% 6-12%) early referrals had plasma creatinine ≤150% of upper reference limit within 1 to 2 years before RRT start (P < .001).
Late nephrology referrals were well-known to the healthcare system before referral for RRT start and more often had near normal plasma creatinine levels within 2 years before RRT start. They infrequently received available treatment or optimal first RRT modality. An increased effort to identify these patients in the healthcare system in time for proper pre-dialysis care including preparation for RRT is needed.
[Show abstract][Hide abstract] ABSTRACT: Reperfusion delay in ST-segment elevation myocardial infarction (STEMI) predicts adverse outcome. We evaluated time from alarm call (system delay) and time from first medical contact (PCI-related delay), where fibrinolysis could be initiated, to balloon inflation in a pre-hospital organization with tele-transmitted electrocardiograms, field triage and direct transfer to a 24/7 primary percutaneous coronary intervention (PPCI) center.
This was a single center cohort study with long-term follow-up in 472 patients. The PPCI center registry was linked by person identification number to emergency medical services (EMS) and National Board of Health databases in the period of 2005-2008. Patients were stratified according to transfer distances to PPCI into zone 1 (0-25 km), zone 2 (65-100 km) and zone 3 (101-185 km) and according to referral by pre-hospital triage. System delay was 86 minutes (interquartile range (IQR) 72-113) in zone 1, 133 (116-180) in zone 2 and 173 (145-215) in zone 3 (p<0.001). PCI-related delay in directly referred patients was 109 (92-121) minutes in zone 2, but exceeded recommendations in zone 3 (139 (121-160)) and for patients admitted via the local hospital (219 (171-250)). System delay was an independent predictor of mortality (p<0.001).
Pre-hospital triage is feasible in 73% of patients. PCI-related delay exceeded European Society of Cardiology (ESC) guidelines for patients living >100 km away and for non-directly referred patients. Sorting the PPCI centers catchment area into geographical zones identifies patients with long reperfusion delays. Possible solutions are pharmaco-invasive regiments, research in early ischemia detection, airborne transfer and EMS personnel education that ensures pre-hospital triage.
European heart journal. Acute cardiovascular care. 09/2012; 1(3):200-9.
[Show abstract][Hide abstract] ABSTRACT: To describe gender-specific long-term outcome and initiation of secondary preventive medication among patients with acute myocardial infarction (AMI).
Observational cohort study.
We included 18,279 patients: 6364 women (35%) and 11,915 men (65%), admitted with AMI (median age, 67 years; range, 30-90 years) surviving for at least 2 months.
According to sex, patients were stratified by invasive treatment strategy: (1) revascularized; (2) examined with coronary angiography (CAG) but not revascularized; and (3) not examined with CAG.
All-cause mortality and readmission with AMI. Initiation of secondary preventive medication.
Of 18,279 patients with a first AMI who survived 2 months, 1857 women (29%) and 1756 men (15%) were not examined with CAG (P<.001), 1295 women (20%) and 1563 men (13%) were examined but not revascularized (P<.001), and 3212 women (51%) and 8596 men (72%) were revascularized (P<.001). Not being examined with CAG after AMI was associated with a three-fold increase in risk of death and, importantly, a 50% increase in the risk of a recurrent AMI compared with patients who were revascularized. Among patients who were revascularized, 85-92% initiated recommended secondary preventive medication compared to 46-71% in patients not examined with CAG (P<.001). Initiation of secondary preventive medication was higher in men (81-84%) than in women (73-79%; P<.001), which could be ascribed to the differences in invasive strategy.
In both sexes, those who were not examined had a highly increased risk of both recurrent AMI and death. Moreover, initiation of secondary preventive medication was closely related to the choice of invasive strategy disfavoring the women.
The Journal of invasive cardiology 01/2012; 24(1):19-24. · 1.57 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate possible gender differences in patients with acute myocardial infarction (AMI) and without significant stenoses on coronary angiography (CAG) regarding prognosis and use of secondary preventive medication.
Nationwide register-based cohort study.
By compiling data from Danish registries, we identified 20,800 patients hospitalized with AMI during 2005-2007. We included the 834 women and 761 men without significant stenoses on CAG who were discharged and alive after 60 days.
All-cause mortality, recurrent AMI, and redeeming a prescription for a lipid-lowering drug, beta-blocker, clopidogrel, or aspirin within 60 days of discharge.
During follow-up, 97 women and 60 men died, resulting in a crude female/male hazard ratio (HR) of 1.51 (95% CI 1.09-2.08). After adjustment for age, time-period, and comorbidity, the gender difference was attenuated (HR 1.22, 95% CI 0.86-1.72). AMI recurrence was experienced by 28 women and 29 men with a female/male HR 0.88 (95% CI 0.52-1.48). After multivariable adjustment results were similar (HR 0.84, 95% CI 0.50-1.43). More women than men redeemed a prescription for lipid-lowering drugs with no differences in other medication. In the adjusted models lipid-lowering drugs, beta-blockers, clopidogrel, and aspirin were all redeemed equally with odds ratio (OR) 1.25 (95% CI 0.99-1.59), OR 1.10 (95% CI 0.88-1.37), OR 1.09 (95% CI 0.88-1.34), and OR 1.13 (95% CI 0.90-1.42), respectively.
Our study shows that in a population of patients with a first admission for AMI and no significant stenoses on CAG, women share the same prospects as men regarding long-term prognosis and the extent of secondary preventive medical treatment.
European journal of preventive cardiology. 07/2011; 19(4):746-54.
[Show abstract][Hide abstract] ABSTRACT: The Danish Heart Register (DHR) is a clinical database of invasive procedures within cardiology.
All providers of these procedures have been obliged to report to DHR since 2000. DHR is used to monitor the activity and quality of the procedures and serves as a data source for research.
The coverage is high (>95%) but some variables have many missing.
The combination of both cardiological and surgical data in this register is internationally unique and makes it possible to follow the patient from the invasive examination to treatment and by linkage to other registers to follow the prognosis.
Scandinavian Journal of Public Health 07/2011; 39(7 Suppl):46-9. · 3.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: The use of the unique personal identification number in the Nordic database systems enables the researchers to link the registers at the individual level. The registers can be used for both defining specific patient populations and to identify later events during follow-up. This review gives three examples within cardiovascular epidemiology to illustrate the use of the national administrative registers available to all researchers upon request. RESEARCH TOPICS: The hospitalisation rate of acute myocardial infarction (AMI) was expected to be increased and case-fatality rate to decrease when the diagnostic criteria were changed in 2000. Linkage of national registers found a relative increase in hospitalisation rate of 14% while the case-fatality rate was unaffected. The pharmacological treatment of AMI patients was evaluated by linkage of administrative data. The use of evidence-based treatment increased significantly over time and adherence to treatment was high. Finally, use of specific nonsteroidal antiinflammatory drugs by healthy subjects was associated with a dose-dependent increase in cardiovascular risk. CONCLUSION: The nationwide registers have proven very useful in monitoring the hospitalisation rate and treatment of cardiovascular disease. The risk of unmeasured factors affecting the results calls for cautious interpretation of the results.
Scandinavian Journal of Public Health 07/2011; 39(7 Suppl):165-9. · 3.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The impact of insulin secretagogues (ISs) on long-term major clinical outcomes in type 2 diabetes remains unclear. We examined mortality and cardiovascular risk associated with all available ISs compared with metformin in a nationwide study.
All Danish residents >20 years, initiating single-agent ISs or metformin between 1997 and 2006 were followed for up to 9 years (median 3.3 years) by individual-level linkage of nationwide registers. All-cause mortality, cardiovascular mortality, and the composite of myocardial infarction (MI), stroke, and cardiovascular mortality associated with individual ISs were investigated in patients with or without previous MI by multivariable Cox proportional-hazard analyses including propensity analyses. A total of 107 806 subjects were included, of whom 9607 had previous MI. Compared with metformin, glimepiride (hazard ratios and 95% confidence intervals): 1.32 (1.24-1.40), glibenclamide: 1.19 (1.11-1.28), glipizide: 1.27 (1.17-1.38), and tolbutamide: 1.28 (1.17-1.39) were associated with increased all-cause mortality in patients without previous MI. The corresponding results for patients with previous MI were as follows: glimepiride: 1.30 (1.11-1.44), glibenclamide: 1.47 (1.22-1.76), glipizide: 1.53 (1.23-1.89), and tolbutamide: 1.47 (1.17-1.84). Results for gliclazide [1.05 (0.94-1.16) and 0.90 (0.68-1.20)] and repaglinide and [0.97 (0.81-1.15) and 1.29 (0.86-1.94)] were not statistically different from metformin in both patients without and with previous MI, respectively. Results were similar for cardiovascular mortality and for the composite endpoint.
Monotherapy with the most used ISs, including glimepiride, glibenclamide, glipizide, and tolbutamide, seems to be associated with increased mortality and cardiovascular risk compared with metformin. Gliclazide and repaglinide appear to be associated with a lower risk than other ISs.
European Heart Journal 04/2011; 32(15):1900-8. · 14.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate whether distance from a patient's home to the nearest invasive centre influenced the invasive treatment strategy in acute coronary syndrome (ACS).
This was an observational cohort study using nationwide registries involving 24,910 patients admitted with ACS (median age 67, range 30-90 years). All persons were grouped in tertiles according to the distance from their residence to the invasive centre. Cox proportional hazard models were applied to estimate the differences in coronary angiography and revascularisation rate within 60 days of admission according to the distance to the centre. The end points were coronary angiography and subsequent revascularisation.
Of 24,910 patients with a first ACS, 33% resided <21 km from one of the five invasive centres in Denmark, 33% lived between 21 and 64 km away and 34% lived >64 km away. The incidence of coronary angiography was 68% for long distance versus 77% for short distance (p<0.05), with an HR of 0.78 (95% CI 0.75 to 0.81, p<0.0001). Adjustment for patient characteristics such as age, sex, co-morbidity and socioeconomic status did not attenuate the difference (HR 0.74, 95% CI 0.71 to 0.77, p<0.0001). Furthermore, revascularisation in the subgroup examined with coronary angiography was less likely for those residing a long distance from the invasive centre compared with those living nearer (adjusted HR of 0.82 (95% CI 0.78 to 0.85, p<0.0001).
In patients hospitalised with ACS, invasive examination and treatment were less likely the further away from an invasive centre the patients resided, thus equal and uniform invasive examination and treatment was not found.
[Show abstract][Hide abstract] ABSTRACT: To examine whether treatment with clarithromycin was associated with an increased risk of death in patients with preexisting ischemic heart disease (IHD).
Employing nationwide registers, all patients with IHD events from 1997 to 2007 who subsequently claimed prescriptions for dual antibiotic treatment for eradication treatment were identified. The primary endpoint was all-cause mortality.
The study included 214,330 individuals with IHD; 5,265 (2.5 %) of these claimed prescriptions for dual antibiotics. Compared with IHD patients not undergoing eradication therapy, no increase in the risk of all-cause mortality was demonstrated (HR 1.02; 95% CI 0.84-1.23, p = 0.87) after 5 years.
The use of clarithromycin in the setting of eradication treatment for Helicobacter pylori in patients with IHD was not associated with an increased risk of death.