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Mokhtari, A., Lindahl, B., Schiopu, A., Yndigegn, T., Khoshnood, A., Gilje, P. & Ekelund, U. (2017). A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients. Academic Emergency Medicine, 24(8), 983-992.
Open this publication in new window or tab >>A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients
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2017 (English)In: Academic Emergency Medicine, ISSN 1069-6563, E-ISSN 1553-2712, Vol. 24, no 8, 983-992 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: Guidelines recommend a 0-hour/1-hour high-sensitivity cardiac troponin T (hs-cTnT) diagnostic strategy in acute chest pain patients. There are, however, little data on the performance of this strategy when combined with clinical risk stratification. We aimed to evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP) using the 0-hour/1-hour hs-cTnT strategy together with an adapted Thrombolysis In Myocardial Infarction (TIMI) score and electrocardiogram (ECG) for ruling out major adverse cardiac events (MACE) within 30 days.

Methods: This prospective observational study enrolled consecutive emergency department (ED) chest pain patients. TIMI score variables, ED physicians' assessments of the ECG, and 0-and 1-hour hs-cTnT were collected. Thirty-day MACE was defined as acute myocardial infarction (AMI), unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause.

Results: A total of 1,020 patients were included in the final analysis. The combination of an adapted TIMI score <= 1, a nonischemic ECG, and either a 0-hour hs-cTnT < 5 ng/L or a 0-hour hs-cTnT < 12 ng/L combined with a 1-hour increase < 3 ng/L identified 432 (42.4%) patients as very low risk with a negative predictive value of 99.5% (95% confidence interval [CI] = 98.3%-99.9%) and a negative likelihood ratio of 0.04 (95% CI = 0.01-0.14) for 30-day MACE. The ADP missed only two patients with UA and no patients with AMI or other forms of MACE.

Conclusion: An ADP using the guideline recommended 0-hour/1-hour hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients.

Place, publisher, year, edition, pages
WILEY, 2017
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-335719 (URN)10.1111/acem.13224 (DOI)000409257000010 ()28500753 (PubMedID)
Available from: 2017-12-11 Created: 2017-12-11 Last updated: 2017-12-11Bibliographically approved
Lindahl, B., Jernberg, T., Badertscher, P., Boeddinghaus, J., Eggers, K. M., Frick, M., . . . Mueller, C. (2017). An algorithm for rule-in and rule-out of acute myocardial infarction using a novel troponin I assay. Heart, 103(2), 125-131.
Open this publication in new window or tab >>An algorithm for rule-in and rule-out of acute myocardial infarction using a novel troponin I assay
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2017 (English)In: Heart, ISSN 1355-6037, E-ISSN 1468-201X, Vol. 103, no 2, 125-131 p.Article in journal (Refereed) Published
Abstract [en]

Objective To derive and validate a hybrid algorithm for rule-out and rule-in of acute myocardial infarction based on measurements at presentation and after 2 hours with a novel cardiac troponin I (cTnI) assay. Methods The algorithm was derived and validated in two cohorts (605 and 592 patients) from multicentre studies enrolling chest pain patients presenting to the emergency department (ED) with onset of last episode within 12 hours. The index diagnosis and cardiovascular events up to 30 days were adjudicated by independent reviewers. Results In the validation cohort, 32.6% of the patients were ruled out on ED presentation, 6.1% were ruled in and 61.3% remained undetermined. A further 22% could be ruled out and 9.8% ruled in, after 2 hours. In total, 54.6% of the patients were ruled out with a negative predictive value (NPV) of 99.4% (95% CI 97.8% to 99.9%) and a sensitivity of 97.7% (95% CI 91.9% to 99.7%); 15.8% were ruled in with a positive predictive value (PPV) of 74.5% (95% CI 64.8% to 82.2%) and a specificity of 95.2% (95% CI 93.0% to 96.9%); and 29.6% remained undetermined after 2 hours. No patient in the rule-out group died during the 30-day follow-up in the two cohorts. Conclusions This novel two-step algorithm based on cTnI measurements enabled just over a third of the patients with acute chest pain to be ruled in or ruled out already at presentation and an additional third after 2 hours. This strategy maximises the speed of rule-out and rule-in while maintaining a high NPV and PPV, respectively.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-316032 (URN)10.1136/heartjnl-2016-309951 (DOI)000392214500010 ()27486143 (PubMedID)
Funder
EU, FP7, Seventh Framework ProgrammeAstraZeneca
Available from: 2017-02-24 Created: 2017-02-24 Last updated: 2017-11-29Bibliographically approved
Eggers, K. M. & Lindahl, B. (2017). Application of Cardiac Troponin in Cardiovascular Diseases Other Than Acute Coronary Syndrome. Clinical Chemistry, 63(1), 223-235.
Open this publication in new window or tab >>Application of Cardiac Troponin in Cardiovascular Diseases Other Than Acute Coronary Syndrome
2017 (English)In: Clinical Chemistry, ISSN 0009-9147, E-ISSN 1530-8561, Vol. 63, no 1, 223-235 p.Article, review/survey (Refereed) Published
Abstract [en]

BACKGROUND: Increased cardiac troponin concentrations in acute coronary syndrome (ACS) identify patients with ongoing cardiomyocyte necrosis who are at increased risk. However, with the use of more precise assays, cardiac troponin increases are commonly noted in other cardiovascular conditions as well. This has generated interest in the use of cardiac troponin for prognostic assessment and clinical management of these patients. In this review, we have summarized the data from studies investigating the implications of cardiac troponin concentrations in various acute and chronic conditions beyond ACS,, i.e., heart failure, myocarditis, Takotsubo cardiomyopathy, aortic dissection, supraventricular arrhythmias, valve disease, pulmonary arterial hypertension, stroke, and in the perioperative setting. CONTENT: Cardiac troponin concentrations are often detectable and frankly increased in non-ACS conditions, in particular when measured with high-sensitivity (hs) assays. With the exception of myocarditis and Takotsubo cardiomyopathy, cardiac troponin concentrations carry strong prognostic information, mainly with respect to mortality, or incipient and/or worsening heart failure. Studies investigating the prognostic benefit associated with cardiac troponin guided treatments however, are almost lacking and the potential role of cardiac troponin in the management of non-ACS conditions is not defined. SUMMARY: Increased cardiac troponin indicates increased risk for adverse outcome in patients with various cardiovascular conditions beyond ACS. Routine measurement of cardiac troponin concentrations can however, not be generally recommended unless there is a suspicion of ACS. Nonetheless, any finding of an increased cardiac troponin concentration in a patient without ACS should at least prompt the search for possible underlying conditions and these should be managed meticulously according to current guidelines to improve outcome.

Place, publisher, year, edition, pages
AMER ASSOC CLINICAL CHEMISTRY, 2017
National Category
Biomedical Laboratory Science/Technology
Identifiers
urn:nbn:se:uu:diva-321022 (URN)10.1373/clinchem.2016.261495 (DOI)000395048800030 ()28062620 (PubMedID)
Available from: 2017-04-28 Created: 2017-04-28 Last updated: 2017-04-28Bibliographically approved
Dondo, T. B., Hall, M., West, R. M., Jernberg, T., Lindahl, B., Bueno, H., . . . Gale, C. P. (2017). beta-Blockers and Mortality After Acute Myocardial Infarction in Patients Without Heart Failure or Ventricular Dysfunction. Journal of the American College of Cardiology, 69(22), 2710-2720.
Open this publication in new window or tab >>beta-Blockers and Mortality After Acute Myocardial Infarction in Patients Without Heart Failure or Ventricular Dysfunction
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2017 (English)In: Journal of the American College of Cardiology, ISSN 0735-1097, E-ISSN 1558-3597, Vol. 69, no 22, 2710-2720 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: For acute myocardial infarction (AMI) without heart failure (HF), it is unclear if beta-blockers are associated with reduced mortality.

OBJECTIVES: The goal of this study was to determine the association between beta-blocker use and mortality in patients with AMI without HF or left ventricular systolic dysfunction (LVSD).

METHODS: This cohort study used national English and Welsh registry data from the Myocardial Ischaemia National Audit Project. A total of 179,810 survivors of hospitalization with AMI without HF or LVSD, between January 1, 2007, and June 30, 2013 (final follow-up: December 31, 2013), were assessed. Survival-time inverse probability weighting propensity scores and instrumental variable analyses were used to investigate the association between the use of beta-blockers and 1-year mortality.

RESULTS: Of 91,895 patients with ST-segment elevation myocardial infarction and 87,915 patients with non-ST-segment elevation myocardial infarction, 88,542 (96.4%) and 81,933 (93.2%) received beta-blockers, respectively. For the entire cohort, with> 163,772 person-years of observation, there were 9,373 deaths (5.2%). Unadjusted 1-year mortality was lower for patients who received beta-blockers compared with those who did not (4.9% vs. 11.2%; p < 0.001). However, after weighting and adjustment, there was no significant difference in mortality between those with and without beta-blocker use (average treatment effect [ATE] coefficient: 0.07; 95% confidence interval [CI]: -0.60 to 0.75; p = 0.827). Findings were similar for ST-segment elevation myocardial infarction (ATE coefficient: 0.30; 95% CI: -0.98 to 1.58; p = 0.637) and non-ST-segment elevation myocardial infarction (ATE coefficient: -0.07; 95% CI: -0.68 to 0.54; p = 0.819).

CONCLUSIONS: Among survivors of hospitalization with AMI who did not have HF or LVSD as recorded in the hospital, the use of beta-blockers was not associated with a lower risk of death at any time point up to 1 year.

Place, publisher, year, edition, pages
ELSEVIER SCIENCE INC, 2017
Keyword
average treatment effect, NSTEMI, preserved left ventricular systolic function, propensity score, STEMI, survival
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-326203 (URN)10.1016/j.jacc.2017.03.578 (DOI)000402134700005 ()28571635 (PubMedID)
Available from: 2017-08-08 Created: 2017-08-08 Last updated: 2017-08-08Bibliographically approved
Eggers, K. M., Lindahl, B., Carrero, J. J., Evans, M., Szummer, K. & Jernberg, T. (2017). Cardiac Troponins and Their Prognostic Importance in Patients with Suspected Acute Coronary Syndrome and Renal Dysfunction. Clinical Chemistry, 63(8), 1409-1417.
Open this publication in new window or tab >>Cardiac Troponins and Their Prognostic Importance in Patients with Suspected Acute Coronary Syndrome and Renal Dysfunction
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2017 (English)In: Clinical Chemistry, ISSN 0009-9147, E-ISSN 1530-8561, Vol. 63, no 8, 1409-1417 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Cardiac troponin (cTn) is important for risk assessment in patients with suspected acute coronary syndrome (ACS). cTn concentrations may, however, be affected by renal dysfunction, and the clinical importance of this interrelation is not well established. We investigated the association between cTnT and cTnI (measured with conventional assays and a more sensitive assay) with the estimated glomerular filtration rate (eGFR) and also assessed the ability of cTn to predict the 1-year all-cause mortality. METHODS: This retrospective registry-based study used data from 309454 admissions to Swedish coronary care units. cTn associations with eGFR and mortality were assessed using different regression models and by calculating multivariable-adjusted c-statistics. RESULTS: cTnT concentrations exhibited stronger associations with eGFR than cTnI concentrations (conventional cTnT assay: beta = -0.113; more sensitive cTnT assay: beta = -0.186; pooled conventional cTnI assays: beta = -0.098). Overall, cTnT provided greater prognostic accuracy than cTnI. This was most evident in non-ACS patients with normal or mildly reduced eGFR when using the more sensitive assay. Despite higher mortality rates, no consistent increases in the c-statistics of cTn were seen with severely reduced eGFR irrespective of the presence of ACS or non-ACS. CONCLUSIONS: cTnT concentrations exhibited stronger associations with reduced eGFR than cTnI concentrations in patients admitted because of suspected ACS. cTnT, particularly when measured using the more sensitive assay, also tended to be a stronger prognosticator. However, the relative significance of the obtained results must be considered in the context of the severity of renal dysfunction and whether ACS is present.

National Category
Clinical Laboratory Medicine
Identifiers
urn:nbn:se:uu:diva-333078 (URN)10.1373/clinchem.2017.271890 (DOI)000406417600015 ()28615229 (PubMedID)
Funder
Swedish Research CouncilSwedish Foundation for Strategic Research Stockholm County CouncilSwedish Heart Lung Foundation
Available from: 2017-11-06 Created: 2017-11-06 Last updated: 2017-11-06Bibliographically approved
Katus, H., Ziegler, A., Ekinci, O., Giannitsis, E., Stough, W. G., Achenbach, S., . . . Semjonow, V. (2017). Early diagnosis of acute coronary syndrome. European Heart Journal, 38(41), 3049-3055.
Open this publication in new window or tab >>Early diagnosis of acute coronary syndrome
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2017 (English)In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 38, no 41, 3049-3055 p.Article, review/survey (Refereed) Published
Abstract [en]

The diagnostic evaluation of acute chest pain has been augmented in recent years by advances in the sensitivity and precision of cardiac troponin assays, new biomarkers, improvements in imaging modalities, and release of new clinical decision algorithms. This progress has enabled physicians to diagnose or rule-out acute myocardial infarction earlier after the initial patient presentation, usually in emergency department settings, which may facilitate prompt initiation of evidence-based treatments, investigation of alternative diagnoses for chest pain, or discharge, and permit better utilization of healthcare resources. A non-trivial proportion of patients fall in an indeterminate category according to rule-out algorithms, and minimal evidence-based guidance exists for the optimal evaluation, monitoring, and treatment of these patients. The Cardiovascular Round Table of the ESC proposes approaches for the optimal application of early strategies in clinical practice to improve patient care following the review of recent advances in the early diagnosis of acute coronary syndrome. The following specific 'indeterminate' patient categories were considered: (i) patients with symptoms and high-sensitivity cardiac troponin <99th percentile; (ii) patients with symptoms and high-sensitivity troponin <99th percentile but above the limit of detection; (iii) patients with symptoms and high-sensitivity troponin >99th percentile but without dynamic change; and (iv) patients with symptoms and high-sensitivity troponin >99th percentile and dynamic change but without coronary plaque rupture/erosion/dissection. Definitive evidence is currently lacking to manage these patients whose early diagnosis is 'indeterminate' and these areas of uncertainty should be assigned a high priority for research.

Keyword
Acute coronary syndrome, Troponin
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-333083 (URN)10.1093/eurheartj/ehx492 (DOI)29029109 (PubMedID)
Available from: 2017-11-06 Created: 2017-11-06 Last updated: 2017-11-23Bibliographically approved
Möckel, M., Giannitsis, E., Mueller, C., Huber, K., Jaffe, A. S., Mair, J., . . . Lindahl, B. (2017). Editor's Choice-Rule-in of acute myocardial infarction: Focus on troponin. European heart journal. Acute cardiovascular care., 6(3), 212-217.
Open this publication in new window or tab >>Editor's Choice-Rule-in of acute myocardial infarction: Focus on troponin
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2017 (English)In: European heart journal. Acute cardiovascular care., ISSN 2048-8726, Vol. 6, no 3, 212-217 p.Article in journal (Refereed) Published
Keyword
Acute myocardial infarction, diagnosis, rule-in, troponin
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-322840 (URN)10.1177/2048872616653228 (DOI)000399753200002 ()27257262 (PubMedID)
Available from: 2017-06-08 Created: 2017-06-08 Last updated: 2017-06-08Bibliographically approved
Giannitsis, E., Mair, J., Christersson, C., Siegbahn, A., Huber, K., Jaffe, A. S., . . . Lindahl, B. (2017). How to use D-dimer in acute cardiovascular care. European heart journal. Acute cardiovascular care., 6(1), 69-80.
Open this publication in new window or tab >>How to use D-dimer in acute cardiovascular care
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2017 (English)In: European heart journal. Acute cardiovascular care., ISSN 2048-8726, Vol. 6, no 1, 69-80 p.Article in journal (Refereed) Published
Abstract [en]

D-dimer testing is important to aid in the exclusion of venous thromboembolic events (VTEs), including deep venous thrombosis and pulmonary embolism, and it may be used to evaluate suspected aortic dissection. D-dimer is produced upon activation of the coagulation system with the generation and subsequent degradation of cross-linked fibrin by plasmin. Many different assays for D-dimer testing are currently used in routine care. However, these tests are neither standardized nor harmonized. Consequently, only clinically validated assays and assay specific decision limits should be used for routine testing. For the exclusion of pulmonary embolism/deep vein thrombosis, age-adjusted cut-offs are recommend. Clinicians must be aware of the validated use of their hospital's D-dimer assay to avoid inappropriate use of this biomarker in routine care.

Keyword
D-dimer, acute cardiovascular care, pulmonary embolism, thrombosis
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-265866 (URN)10.1177/2048872615610870 (DOI)000394780400007 ()26450781 (PubMedID)
Available from: 2015-12-04 Created: 2015-11-03 Last updated: 2017-04-25Bibliographically approved
Lindahl, B., Baron, T., Erlinge, D., Hadziosmanovic, N., Nordenskjöld, A., Gard, A. & Jernberg, T. (2017). Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease. Circulation, 135(16), 1481-1489.
Open this publication in new window or tab >>Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease
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2017 (English)In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 135, no 16, 1481-1489 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 5% to 10% of all patients with myocardial infarction. Clinical trials of secondary prevention treatment in MINOCA patients are lacking. Therefore, the aim of this study was to examine the associations between treatment with statins, renin-angiotensin system blockers, beta-blockers, dual antiplatelet therapy, and long-term cardiovascular events. METHODS: This is an observational study of MINOCA patients recorded in the SWEDEHEART registry (the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapy) between July 2003 and June 2013 and followed until December 2013 for outcome events in the Swedish Cause of Death Register and National Patient Register. Of 199 162 myocardial infarction admissions, 9466 consecutive unique patients with MINOCA were identified. Among those, the 9136 patients surviving the first 30 days after discharge constituted the study population. Mean age was 65.3 years, and 61% were women. No patient was lost to follow-up. A stratified propensity score analysis was performed to match treated and untreated groups. The association between treatment and outcome was estimated by comparing between treated and untreated groups by using Cox proportional hazards models. The exposures were treatment at discharge with statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and dual antiplatelet therapy. The primary end point was major adverse cardiac events defined as all-cause mortality, hospitalization for myocardial infarction, ischemic stroke, and heart failure. RESULTS: At discharge, 84.5%, 64.1%, 83.4%, and 66.4% of the patients were on statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and dual antiplatelet therapy, respectively. During the follow-up of a mean of 4.1 years, 2183 (23.9%) patients experienced a major adverse cardiac event. The hazard ratios (95% confidence intervals) for major adverse cardiac events were 0.77 (0.68-0.87), 0.82 (0.73-0.93), and 0.86 (0.74-1.01) in patients on statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and beta-blockers, respectively. For patients on dual antiplatelet therapy followed for 1 year, the hazard ratio was 0.90 (0.74-1.08). CONCLUSIONS: The results indicate long-term beneficial effects of treatment with statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers on outcome in patients with MINOCA, a trend toward a positive effect of beta-blocker treatment, and a neutral effect of dual antiplatelet therapy. Properly powered randomized clinical trials to confirm these results are warranted.

Place, publisher, year, edition, pages
LIPPINCOTT WILLIAMS & WILKINS, 2017
Keyword
adrenergic beta-antagonists, coronary angiography, hydroxymethylglutaryl-CoA reductase inhibitors, myocardial infarction, prognosis, renin-angiotensin system, secondary prevention
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-321802 (URN)10.1161/CIRCULATIONAHA.116.026336 (DOI)000399298700008 ()28179398 (PubMedID)
Funder
Swedish Foundation for Strategic Research Swedish Association of Local Authorities and Regions
Available from: 2017-05-11 Created: 2017-05-11 Last updated: 2017-05-11Bibliographically approved
Hofmann, R., James, S. K., Jernberg, T., Lindahl, B., Erlinge, D., Witt, N., . . . Svensson, L. (2017). Oxygen Therapy in Suspected Acute Myocardial Infarction. New England Journal of Medicine, 377(13), 1240-1249.
Open this publication in new window or tab >>Oxygen Therapy in Suspected Acute Myocardial Infarction
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2017 (English)In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 377, no 13, 1240-1249 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND The clinical effect of routine oxygen therapy in patients with suspected acute myocardial infarction who do not have hypoxemia at baseline is uncertain. METHODS In this registry-based randomized clinical trial, we used nationwide Swedish registries for patient enrollment and data collection. Patients with suspected myocardial infarction and an oxygen saturation of 90% or higher were randomly assigned to receive either supplemental oxygen (6 liters per minute for 6 to 12 hours, delivered through an open face mask) or ambient air. RESULTS A total of 6629 patients were enrolled. The median duration of oxygen therapy was 11.6 hours, and the median oxygen saturation at the end of the treatment period was 99% among patients assigned to oxygen and 97% among patients assigned to ambient air. Hypoxemia developed in 62 patients (1.9%) in the oxygen group, as compared with 254 patients (7.7%) in the ambient-air group. The median of the highest troponin level during hospitalization was 946.5 ng per liter in the oxygen group and 983.0 ng per liter in the ambient-air group. The primary end point of death from any cause within 1 year after randomization occurred in 5.0% of patients (166 of 3311) assigned to oxygen and in 5.1% of patients (168 of 3318) assigned to ambient air (hazard ratio, 0.97; 95% confidence interval [CI], 0.79 to 1.21; P = 0.80). Rehospitalization with myocardial infarction within 1 year occurred in 126 patients (3.8%) assigned to oxygen and in 111 patients (3.3%) assigned to ambient air (hazard ratio, 1.13; 95% CI, 0.88 to 1.46; P = 0.33). The results were consistent across all predefined subgroups. CONCLUSIONS Routine use of supplemental oxygen in patients with suspected myocardial infarction who did not have hypoxemia was not found to reduce 1-year all-cause mortality.

Place, publisher, year, edition, pages
MASSACHUSETTS MEDICAL SOC, 2017
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-337093 (URN)10.1056/NEJMoa1706222 (DOI)000411838100007 ()28844200 (PubMedID)
Funder
Swedish Heart Lung FoundationSwedish Research CouncilSwedish Foundation for Strategic Research AstraZeneca
Available from: 2018-01-08 Created: 2018-01-08 Last updated: 2018-01-08Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-5795-0061

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