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Ljung, L., Lindahl, B., Eggers, K. M., Frick, M., Linder, R., Löfmark, H. B., . . . Jernberg, T. (2019). A Rule-Out Strategy Based on High-Sensitivity Troponin and HEART Score Reduces Hospital Admissions. Annals of Emergency Medicine, 73(5), 491-499
Open this publication in new window or tab >>A Rule-Out Strategy Based on High-Sensitivity Troponin and HEART Score Reduces Hospital Admissions
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2019 (English)In: Annals of Emergency Medicine, ISSN 0196-0644, E-ISSN 1097-6760, Vol. 73, no 5, p. 491-499Article in journal (Refereed) Published
Abstract [en]

Study objective: We evaluate whether a combination of a 1-hour high-sensitivity cardiac troponin algorithm and History, ECG, Age, Risk Factors, and Troponin (HEART) score reduces admission rate (primary outcome) and affects time to discharge, health care-related costs, and 30-day outcome (secondary outcomes) in patients with symptoms suggestive of an acute coronary syndrome.

Methods: This prospective observational multicenter study was conducted before (2013 to 2014) and after (2015 to 2016) implementation of a strategy including level of high-sensitivity cardiac troponin T or I at 0 and 1 hour, combined with the HEART score. Patients with a nonelevated baseline high-sensitivity cardiac troponin level, a 1-hour change in high-sensitivity cardiac troponin T level less than 3 ng/L, or high-sensitivity cardiac troponin I level less than 6 ng/L and a HEART score less than or equal to 3 were considered to be ruled out of having acute coronary syndrome. A logistic regression analysis was performed to adjust for differences in baseline characteristics.

Results: A total of 1,233 patients were included at 6 centers. There were no differences in regard to median age (64 versus 63 years) and proportion of men (57% versus 54%) between the periods. After introduction of the new strategy, the admission rate decreased from 59% to 33% (risk ratio 0.55 [95% confidence interval {CI} 0.48 to 0.63]; odds ratio 0.33 [95% CI 0.26 to 0.42]; adjusted odds ratio 0.33 [95% CI 0.25 to 0.42]). The median hospital stay was reduced from 23.2 to 4.7 hours (95% CI of difference -20.4 to -11.4); median health care-related costs, from $1,748 to $1,079 (95% CI of difference -$953 to -$391). The number of clinical events was very low.

Conclusion: In this before-after study, clinical implementation of a 1-hour high-sensitivity cardiac troponin algorithm combined with the HEART score was associated with a reduction in admission rate and health care burden, with very low rates of adverse clinical events.

Place, publisher, year, edition, pages
MOSBY-ELSEVIER, 2019
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-383149 (URN)10.1016/j.annemergmed.2018.11.039 (DOI)000465551700019 ()30661856 (PubMedID)
Funder
EU, FP7, Seventh Framework ProgrammeSwedish Heart Lung FoundationStockholm County Council
Available from: 2019-05-10 Created: 2019-05-10 Last updated: 2019-05-10Bibliographically approved
Batra, G., Ahlsson, A., Lindahl, B., Lindhagen, L., Wickbom, A. & Oldgren, J. (2019). Atrial fibrillation in patients undergoing coronary artery surgery is associated with adverse outcome. Upsala Journal of Medical Sciences, 124(1), 70-77
Open this publication in new window or tab >>Atrial fibrillation in patients undergoing coronary artery surgery is associated with adverse outcome
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2019 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 124, no 1, p. 70-77Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The aim was to determine the association between atrial fibrillation (AF) and outcome in patients undergoing coronary artery bypass grafting (CABG).

METHODS: All patients undergoing CABG between January 2010 and June 2013 were identified in the Swedish Heart Surgery Registry. Outcomes studied were all-cause mortality, cardiovascular mortality, myocardial infarction, congestive heart failure, ischemic stroke, and recurrent AF. Patients with history of AF prior to surgery (preoperative AF) and patients without history of AF but with AF episodes post-surgery (postoperative AF) were compared to patients with no AF using adjusted Cox regression models.

RESULTS: Among 9,107 identified patients, 8.1% (n = 737) had preoperative AF, and 25.1% (n = 2,290) had postoperative AF. Median follow-up was 2.2 years. Compared to no AF, preoperative AF was associated with higher risk of all-cause mortality, adjusted hazard ratio with 95% confidence interval (HR) 1.76 (1.33-2.33); cardiovascular mortality, HR 2.43 (1.68-3.50); and congestive heart failure, HR 2.21 (1.72-2.84). Postoperative AF was associated with risk of all-cause mortality, HR 1.27 (1.01-1.60); cardiovascular mortality, HR 1.52 (1.10-2.11); congestive heart failure, HR 1.47 (1.18-1.83); and recurrent AF, HR 4.38 (2.46-7.78). No significant association was observed between pre- or postoperative AF and risk for myocardial infarction and ischemic stroke.

CONCLUSIONS: Approximately 1 in 3 patients undergoing CABG had pre- or postoperative AF. Patients with pre- or postoperative AF were at higher risk of all-cause mortality, cardiovascular mortality, and congestive heart failure, but not of myocardial infarction or ischemic stroke. Postoperative AF was associated with higher risk of recurrent AF.

Keywords
Atrial fibrillation, cardiovascular disease, coronary artery bypass grafting
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-374222 (URN)10.1080/03009734.2018.1504148 (DOI)000461811100015 ()30265179 (PubMedID)
Funder
Swedish Foundation for Strategic Research , KF10-0024
Available from: 2019-01-18 Created: 2019-01-18 Last updated: 2019-04-10Bibliographically approved
Baron, T., Beskow, A. H., James, S. K. & Lindahl, B. (2019). Biobank linked to SWEDEHEART quality registry-routine blood sample collection opens new opportunities for cardiovascular research. Upsala Journal of Medical Sciences, 124(1), 12-15
Open this publication in new window or tab >>Biobank linked to SWEDEHEART quality registry-routine blood sample collection opens new opportunities for cardiovascular research
2019 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 124, no 1, p. 12-15Article in journal (Refereed) Published
Abstract [en]

High-quality biobanking within routine health services, through the use of existing health-care practices and infrastructure, with respect to safety and integrity of patients in line with the Swedish Biobank Act, enables large-scale collection of biological material at reasonable costs. Complementing the extensive information on myocardial infarction patients from a national registry gives unique opportunities for research focusing on better understanding of cardiovascular disease occurrence and prognosis, developing of new diagnostic methods, and personalized treatments with greater efficacy and fewer side effects.

Keywords
Biobank, SWEDEHEART, cardiovascular research, quality registry
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-374224 (URN)10.1080/03009734.2018.1498957 (DOI)000461811100004 ()30251587 (PubMedID)
Available from: 2019-01-18 Created: 2019-01-18 Last updated: 2019-04-17Bibliographically approved
Eggers, K. M., Jernberg, T. & Lindahl, B. (2019). Cardiac Troponin Elevation in Patients Without a Specific Diagnosis. Journal of the American College of Cardiology, 73(1), 1-9
Open this publication in new window or tab >>Cardiac Troponin Elevation in Patients Without a Specific Diagnosis
2019 (English)In: Journal of the American College of Cardiology, ISSN 0735-1097, E-ISSN 1558-3597, Vol. 73, no 1, p. 1-9Article in journal (Refereed) Published
Abstract [en]

BACKGROUND Cardiac troponin (cTn) elevation is a common finding in acutely admitted patients, even in the absence of acute coronary syndrome. In some of these patients, no etiology of cTn elevation can be identified. The term troponinemia is sometimes used to describe this scenario.

OBJECTIVES This study aimed to investigate the associations of cTn levels with clinical findings and long-term outcome in acutely admitted patients with suspected acute coronary syndrome who had been discharged without a specified diagnosis.

METHODS Retrospective registry-based cohort study investigating 48,872 patients (SWEDEHEART [Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies] registry). Patients were stratified into cohorts with cTn levels less than or equal to the assay-specific 99th percentile and separated by assay-specific cTn tertiles in case of higher levels.

RESULTS A cTn level >99th percentile was noted in 9,800 (20.1%) patients. The prevalence of cardiovascular risk factors as well as cardiovascular and noncardiovascular comorbidities increased across higher cTn strata. In total, 7,529 (15.4%) patients had a major adverse event (MAE), defined as the composite of all-cause mortality, myocardial infarction, readmission for heart failure, or stroke (median follow-up 4.9 years). MAE risk was associated with higher cTn strata (hazard ratio for highest assay-specific cTn tertile: 2.59; 95% confidence interval: 2.39 to 2.80; hazard ratio in patients without cardiovascular comorbidities, renal dysfunction, left ventricular dysfunction, or significant coronary stenosis: 3.57; 95% confidence interval: 2.30 to 5.54).

CONCLUSIONS cTn elevation is associated with cardiovascular and noncardiovascular comorbidities and predicts major adverse events in acutely admitted patients, in whom no definite diagnosis could have been established. The term troponinemia is trivializing and should be avoided. Instead, careful work-up is required in these patients.

Keywords
cardiac troponin, chest pain, risk prediction, troponinemia
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-374424 (URN)10.1016/j.jacc.2018.09.082 (DOI)000455014900001 ()30621937 (PubMedID)
Funder
Swedish Foundation for Strategic Research
Available from: 2019-01-29 Created: 2019-01-29 Last updated: 2019-01-29Bibliographically approved
Nordenskjöld, A. M., Eggers, K. M., Jernberg, T., Mohammad, M. A., Erlinge, D. & Lindahl, B. (2019). Circadian onset and prognosis of myocardial infarction with non-obstructive coronary arteries (MINOCA). PLoS ONE, 14(4), Article ID e0216073.
Open this publication in new window or tab >>Circadian onset and prognosis of myocardial infarction with non-obstructive coronary arteries (MINOCA)
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2019 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 4, article id e0216073Article in journal (Refereed) Published
Abstract [en]

Background: Many acute cardiovascular events such as myocardial infarction (MI) follow circadian rhythms. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a newly noticed entity with limited data on onset pattern and its impact on prognosis.

Material and methods: In this observational study of Swedish MINOCA patients registered in the SWEDEHEART registry between 2003-2013 and followed until December 2013 we identified 9,092 unique patients with MINOCA out of 199,163 MI admissions in total. Incidence rate ratios (IRR) were calculated for whole hours, parts of the day, weekdays, months, seasons and major holidays.

Results: The mean age was 65.5 years, 62.0% were women and 16.6% presented with STEMI. The risk for MINOCA proved to be most common in the morning (IRR = 1.70, 95% CI [1.63-1.84]) with a peak at 08.00 AM (IRR = 2.25, 95% CI [1.96-2.59]) and on Mondays (IRR = 1.28, 95% CI [1.18-1.38]). No altered risk was detected during the different seasons, the Christmas and New Year holidays or the Swedish Midsummer festivities. There was no association between time of onset of MINOCA and short-or long-term prognosis.

Conclusion: The onset of MINOCA shows a circadian and circaseptan variation with increased risk at early mornings and Mondays, similar to previous studies on all MI, suggesting stress related triggering. However, during holidays were traditional MI increase, we did not see any increase for MINOCA. No association was detected between time of onset and prognosis, indicating that the underlying pathological mechanisms of MINOCA and the quality of care are similar at different times of onset but triggering mechanism may be more active early mornings and Mondays.

Place, publisher, year, edition, pages
PUBLIC LIBRARY SCIENCE, 2019
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-385566 (URN)10.1371/journal.pone.0216073 (DOI)000465519100087 ()31022242 (PubMedID)
Available from: 2019-06-19 Created: 2019-06-19 Last updated: 2019-06-19Bibliographically approved
Mueller-Hennessen, M., Lindahl, B., Giannitsis, E., Vafaie, M., Biener, M., Haushofer, A. C., . . . Mueller, C. (2019). Combined testing of copeptin and high-sensitivity cardiac troponin T at presentation in comparison to other algorithms for rapid rule-out of acute myocardial infarction. International Journal of Cardiology, 276, 261-267
Open this publication in new window or tab >>Combined testing of copeptin and high-sensitivity cardiac troponin T at presentation in comparison to other algorithms for rapid rule-out of acute myocardial infarction
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2019 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 276, p. 261-267Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: We aimed to directly compare the diagnostic and prognostic performance of a dual maker strategy (DMS) with combined testing of copeptin and high-sensitivity (hs) cardiac troponin T (cTnT) at time of presentation with other algorithms for rapid rule-out of acute myocardial infarction (AMI).

METHODS: 922 patients presenting to the emergency department with suspected AMI and available baseline copeptin measurements qualified for the present TRAPID-AMI substudy. Diagnostic measures using the DMS (copeptin <10, <14 or < 20 pmol/L and hs-cTnT≤14 ng/L), the 1 h-algorithm (hs-cTnT<12 ng/L and change <3 ng/L at 1 h), as well as the hs-cTnT limit-of-blank (LoB, <3 ng/L) and -detection (LoD, <5 ng/L) were compared. Outcomes were assessed as combined end-points of death and myocardial re-infarction.

RESULTS: True-negative rule-out using the DMS could be achieved in 50.9%-62.3% of all patients compared to 35.0%, 45.3% and 64.5% using LoB, LoD or the 1 h-algorithm, respectively. The DMS showed NPVs of 98.1%-98.3% compared to 99.2% for the 1 h-algorithm, 99.4% for the LoB and 99.3% for the LoD. Sensitivities were 93.5%-94.8%, as well as 96.8%, 98.7% and 98.1%, respectively. Addition of clinical low-risk criteria such as a HEART-score ≤ 3 to the DMS resulted in NPVs and sensitivities of 100% with a true-negative rule-out to 33.8%-41.6%. Rates of the combined end-point of death/MI within 30 days ranged between 0.2% and 0.3% for all fast-rule-out protocols.

CONCLUSION: Depending on the applied copeptin cut-off and addition of clinical low-risk criteria, the DMS might be an alternative to the hs-cTn-only-based algorithms for rapid AMI rule-out with comparable diagnostic measures and outcomes.

Keywords
Copeptin, Dual-marker strategy, High-sensitivity cardiac troponin T, Rapid AMI rule-out
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-374217 (URN)10.1016/j.ijcard.2018.10.084 (DOI)000454877900058 ()30404726 (PubMedID)
Available from: 2019-01-18 Created: 2019-01-18 Last updated: 2019-01-30Bibliographically approved
Thygesen, K., Alpert, J. S., Jaffe, A. S., Chaitman, B. R., Bax, J. J., Morrow, D. A. & White, H. D. (2019). Fourth universal definition of myocardial infarction (2018). European Heart Journal, 40(3), 237-269
Open this publication in new window or tab >>Fourth universal definition of myocardial infarction (2018)
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2019 (English)In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 40, no 3, p. 237-269Article in journal (Refereed) Published
Keywords
Expert Consensus Document, Myocardial infarction, Type 1 MI, Type 2 MI, Type 3 MI, Type 4a MI, Type 4b MI, Type 4c MI, Type 5 MI, Cardiac troponin, High sensitivity cardiac troponin, Myocardial injury, Prior myocardial infarction, Silent myocardial infarction, Recurrent myocardial infarction, Re-infarction, Cardiac procedural myocardial injury, Takotsubo syndrome, Myocardial infarction with non-obstructive coronary arteries (MINOCA)
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-374229 (URN)10.1093/eurheartj/ehy462 (DOI)000459338100008 ()30165617 (PubMedID)
Note

This article has been co-published in Kardiologia Polska, 2018, vol.76, issue 10, pages: 1383-1415. DOI: 10.5603/KP.2018.0203

Available from: 2019-01-18 Created: 2019-01-18 Last updated: 2019-05-27Bibliographically approved
Jönelid, B., Kragsterman, B., Berglund, L., Andrén, B., Johnston, N., Lindahl, B., . . . Christersson, C. (2019). Low Walking Impairment Questionnaire score after a recent myocardial infarction identifies patients with polyvascular disease. JRSM Cardiovascular Disease, 8, 1-9
Open this publication in new window or tab >>Low Walking Impairment Questionnaire score after a recent myocardial infarction identifies patients with polyvascular disease
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2019 (English)In: JRSM Cardiovascular Disease, ISSN 2048-0040, Vol. 8, p. 1-9Article in journal (Refereed) Published
Abstract [en]

Objectives: To evaluate whether the Walking Impairment Questionnaire score could identify patients with polyvascular disease in a population with recent myocardial infarction and their association with cardiovascular events during two-year follow-up.

Design: A prospective observational study.

Setting: Patients admitted to the acute coronary care unit, the Department of Cardiology, Uppsala University Hospital.

Participants: Patients admitted with acute Non-STEMI- or STEMI-elevation myocardial infarction.

Main outcome measures: The Walking Impairment Questionnaire, developed as a self-administered instrument to assess walking distance, speed, and stair climbing in patients with peripheral artery disease, predicts future cardiovascular events and mortality. Two hundred and sixty-three patients with recent myocardial infarction answered Walking Impairment Questionnaire. Polyvascular disease was defined as abnormal findings in the coronary- and carotid arteries and an abnormal ankle-brachial index. The calculated score for each of all three categories were divided into quartiles with the lowest score in first quartile.

Results: The lowest (worst) quartile in all three Walking Impairment Questionnaire categories was associated with polyvascular disease, fully adjusted; distance, odds ratio (OR) 5.4 (95% confidence interval (CI) 1.8-16.1); speed, OR 7.4 (95% CI 1.5-36.5); stair climbing, OR 8.4 (95% CI 1.0-73.6). In stair climbing score, patients with the lowest (worst) score had a higher risk for the composite cardiovascular endpoint compared to the highest (best) score; hazard ratio 5.3 (95% CI 1.5-19.0). The adherence to medical treatment was high (between 81.7% and 99.2%).

Conclusions: The Walking Impairment Questionnaire is a simple tool to identify myocardial infarction patients with more widespread atherosclerotic disease and although well treated medically, stair climbing predicts cardiovascular events.

Keywords
Peripheral vascular disease, cardiovascular disease, coronary artery disease, polyvascular disease
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-382843 (URN)10.1177/2048004019841971 (DOI)000464951000001 ()31019682 (PubMedID)
Available from: 2019-05-24 Created: 2019-05-24 Last updated: 2019-05-24Bibliographically approved
Eggers, K. M., Hjort, M., Baron, T., Jernberg, T., Nordenskjold, A. M., Tornvall, P. & Lindahl, B. (2019). Morbidity and cause-specific mortality in first-time myocardial infarction with nonobstructive coronary arteries. Journal of Internal Medicine, 285(4), 419-428
Open this publication in new window or tab >>Morbidity and cause-specific mortality in first-time myocardial infarction with nonobstructive coronary arteries
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2019 (English)In: Journal of Internal Medicine, ISSN 0954-6820, E-ISSN 1365-2796, Vol. 285, no 4, p. 419-428Article in journal (Refereed) Published
Abstract [en]

Background

Myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is receiving increasing interest as a prognostically adverse entity distinct from myocardial infarction with significant coronary artery disease (MI-CAD). However, data are still limited regarding long-term cardiovascular morbidity and cause-specific mortality in MINOCA.

Methods

This is a registry-based cohort study using data from patients admitted to Swedish coronary care units. We investigated various nonfatal outcomes (recurrent MI, hospitalization for heart failure or stroke) and fatal outcomes (cardiovascular, respiratory or cancer-related mortality) in 4069 patients without apparent acute cardiovascular disease, used as non-MI controls, 7266 patients with first-time MINOCA and 69267 patients with first-time MI-CAD.

Results

Almost all event rates (median follow-up 3.8years) increased in a stepwise fashion across the three cohorts [rates of major adverse events (MAE; composite of all-cause mortality, recurrent MI, hospitalization for heart failure or stroke): n=268 (6.6%), n=1563 (21.5%), n=17777 (25.7%), respectively]. Compared to non-MI controls, MINOCA patients had an adjusted hazard ratio (HR) of 2.12 (95% confidence interval 1.84-2.43) regarding MAE. MINOCA patients had a substantial risk of cardiovascular mortality and the highest numerical risks of respiratory and cancer-related mortality. Male sex, previous heart failure and chronic obstructive pulmonary disease had a stronger prognostic impact in MINOCA than in MI-CAD. Female MINOCA patients with atrial fibrillation were at particular risk.

Conclusions

Patients with first-time MINOCA have a considerable risk of adverse events. This stresses the need for a comprehensive search of the cause of MINOCA, thorough treatment of underlying disease triggers and close follow-up.

Keywords
MINOCA, myocardial infarction, prognosis, risk prediction
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-382254 (URN)10.1111/joim.12857 (DOI)000462607700007 ()30474313 (PubMedID)
Funder
Swedish Foundation for Strategic Research
Available from: 2019-05-03 Created: 2019-05-03 Last updated: 2019-05-03Bibliographically approved
Nordenskjöld, A. M., Lagerqvist, B., Baron, T., Jernberg, T., Hadziosmanovic, N., Reynolds, H. R., . . . Lindahl, B. (2019). Reinfarction in Patients with Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): Coronary Findings and Prognosis.. American Journal of Medicine, 132(3), 335-346
Open this publication in new window or tab >>Reinfarction in Patients with Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): Coronary Findings and Prognosis.
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2019 (English)In: American Journal of Medicine, ISSN 0002-9343, E-ISSN 1555-7162, Vol. 132, no 3, p. 335-346Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is common. There are limited data on the mechanisms and prognosis for reinfarction in MINOCA patients.

METHODS: In this observational study of MINOCA patients hospitalized in Sweden and registered in the SWEDEHEART registry between July 2003 and June 2013 and followed until December 2013, we identified 9092 unique patients with MINOCA of 199,163 MI admissions in total. The 570 (6.3%) MINOCA patients who were hospitalized due to a recurrent MI constituted the study group.

RESULTS: The mean age was 69.1 years and 59.1% were women. The median time to readmission was 17 months. A total of 340 patients underwent a new coronary angiography and 180 (53%) had no obstructive coronary artery disease (CAD) and 160 (47%) had obstructive CAD; 123 had 1-vessel, 26 had 2-vessel, 9 had 3-vessel disease, and 2 had left main together with 1-vessel disease. Male sex, diabetes, peripheral vascular disease, higher levels of creatinine, and ST elevation at presentation were more common in patients with MI with obstructive CAD than in patients with a recurrent MINOCA. Mortality during a median follow-up of 38 months was similar whether the reinfarction event was MINOCA or MI with obstructive CAD 13.9% vs 11.9% (P = .54).

CONCLUSIONS: About half of patients with reinfarction after MINOCA who underwent coronary angiography had progression of coronary stenosis. Angiography should be strongly considered in patients with MI after MINOCA. Mortality associated with recurrent events was substantial, though there was no difference in mortality between those with or without significant CAD.

Keywords
Coronary angiography, Coronary artery disease, Predictors, SWEDEHEART
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-374218 (URN)10.1016/j.amjmed.2018.10.007 (DOI)000459911500030 ()30367850 (PubMedID)
Funder
Swedish Foundation for Strategic Research Swedish Association of Local Authorities and Regions
Available from: 2019-01-18 Created: 2019-01-18 Last updated: 2019-04-17Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-5795-0061

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