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From Stenting to Preventing: Invasive and Long-term Treatment for Coronary Artery Disease in Sweden
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences. (Kardiologi)ORCID iD: Kristina Hambraeus
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Coronary artery disease (CAD) is the leading cause of death worldwide. Treatment with coronary interventions, long-term treatment and life style changes can reduce symptoms and improve prognosis. The aim of this thesis was to investigate aspects of invasive treatment for multivessel coronary artery disease, and to investigate adherence to prevention guidelines one year after myocardial infarction.

 We used the national quality registry SWEDEHEART to collect data on long term treatment one year after myocardial infarction for 51 620 patients < 75 years of age. For 17 236 of the patients, we collected LDL-cholesterol measurements from SWEDEHEART and defined use of lipid lowering drugs from the Prescribed Drug Register. We developed a questionnaire for post-PCI-patients to investigate patients’ understanding of cause and treatment of coronary artery disease. For 23 342 PCI-patients with multivessel coronary artery disease, SWEDEHEART-data was linked to Swedish health data registries to determine one year outcome for patients undergoing incomplete vs. complete revascularization.

  Lipid control (LDL-cholesterol < 1.8 mmol/L) was attained by one in four patients one year after myocardial infarction, whereas blood pressure control (< 140 mmHg) was attained by two thirds of patients. Lipid and blood pressure control was lower for women but there was no gender difference in smoking cessation rate: 56 %. Over 90 % of patients were treated with a statin after myocardial infarction but treatment was intensified for only one in five patients with LDL-cholesterol above target.

The questionnaire study revealed that non-modifiable factors such as age and heredity were more often seen as cause of coronary artery disease than modifiable life style factors. Only one in five patients perceived CAD as a chronic illness, requiring life style changes.

Two thirds of PCI-patients with multivessel disease underwent incomplete revascularisation, and this was associated with a twofold risk for the combination of death, myocardial infarction and repeat revascularization up to one year, compared to patients who underwent complete revascularization.

We conclude that  long term treatment after myocardial infarction is suboptimal in relation to guideline recommendations. Assessment of patients’ views on CAD and better health education post PCI may facilitate life style changes. Further studies need to investigate whether complete revascularization will improve outcome for PCI-patients with multivessel disease.

 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. , 76 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1033
Keyword [en]
Coronary artery disease, guideline adherence, prevention, cholesterol treatment, lifestyle, percutaneous coronary intervention
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
URN: urn:nbn:se:uu:diva-233167ISBN: 978-91-554-9051-5 (print)OAI: oai:DiVA.org:uu-233167DiVA: diva2:750743
Public defence
2014-11-13, Museum Gustavianum, Akademigatan 3, Uppsala, 13:00 (English)
Opponent
Supervisors
Available from: 2014-10-23 Created: 2014-09-29 Last updated: 2015-01-23
List of papers
1. Time Trends and Gender Differences in Prevention Guideline Adherence and Outcome after Myocardial Infarction: Data from the SWEDEHEART-registry
Open this publication in new window or tab >>Time Trends and Gender Differences in Prevention Guideline Adherence and Outcome after Myocardial Infarction: Data from the SWEDEHEART-registry
2016 (English)In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 23, no 4, 340-348 p.Article in journal (Refereed) Published
Abstract [en]

Background While secondary prevention improves prognosis after acute myocardial infarction (AMI), previous studies have suggested suboptimal guideline adherence, lack of improvement over time and gender differences. This study contributes contemporary data from a large national cohort. Method We identified 51,620 patients <75 years examined at two and/or twelve months post AMI in the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART). Risk factor control and readmissions at one year were compared between the 2005 and 2012 cohorts, and between genders. Results Lipid control (LDL-cholesterol <2.5mmol/L) improved from 67.9% to 71.1% (p=0.016) over time, achieved by 67.9% vs 63.3%, p<0.001 of men vs women. Blood pressure control (<140mmHg systolic) increased over time (59.1% vs 69.5%, p<0.001 in 2005 and 2012 cohorts) and was better in men (66.4% vs 61.9%, p<0.001). Smoking cessation rate was 55.6% without differences between genders or over time. Cardiac readmissions occurred in 18.2% of women and 15.5% of men, decreasing from 2005 to 2012 (20.8% vs 14.9%). Adjusted odds ratio was 1.22 (95% CI 1.14-1.32) for women vs men and 0.94 (95% CI 0.92-0.96) for the 2012 vs the 2005 cohort. Conclusions Although this study compares favourably to previous studies of risk factor control post AMI, improvement over time was mainly seen regarding blood pressure, revealing substantial remaining preventive potential. The reasons for gender differences seen in risk factor control and readmissions require further analysis.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-233160 (URN)10.1177/2047487315585293 (DOI)000370071300001 ()25986497 (PubMedID)
Funder
Swedish Association of Local Authorities and Regions
Available from: 2014-09-29 Created: 2014-09-29 Last updated: 2017-12-05Bibliographically approved
2. Target-Attainment Rates of Low-Density Lipoprotein Cholesterol Using Lipid-Lowering Drugs One Year After Acute Myocardial Infarction in Sweden
Open this publication in new window or tab >>Target-Attainment Rates of Low-Density Lipoprotein Cholesterol Using Lipid-Lowering Drugs One Year After Acute Myocardial Infarction in Sweden
Show others...
2014 (English)In: American Journal of Cardiology, ISSN 0002-9149, E-ISSN 1879-1913, Vol. 113, no 1, 17-22 p.Article in journal (Refereed) Published
Abstract [en]

The objective of this prospective cohort study was to describe real-life use of lipid-lowering drugs and low-density lipoprotein cholesterol (LDL-C) target-attainment rates 1 year after acute myocardial infarction (AMI). LDL-C was recorded at hospital admission for AMI and at follow-up at 2 and 12 months after AMI in 17,236 patients in the Swedish heart registry, SWEDEHEART, from 2004 through 2009. Lipid-lowering treatments were identified using the Swedish Prescribed Drug Register. More than 90% of patients received statins after ANT. Simvastatin <= 40 mg was used by 80% of patients at discharge and at 2 months and 68% at 1 year after AMI. Intensive statin therapy (LDL-C-lowering capacity >40%) was prescribed for 8.4%, 11.9%, and 12.2% at these time points, and combinations of statin/ezetimibe for 1.1%, 2.8%, and 5.0%, respectively. The LDL-C target of <2.5 mmol/L (97 mg/dl) was achieved in 74.5% of patients at 2 months and 72.3% at 12 months after AMI. Treatment was intensified for only 21.3% of patients with LDL-C above target at 2 months. In multivariate analysis, higher LDL-C levels at admission and at 2 months correlated to increased risk for under treatment at 12 months after AMI. In conclusion, statin treatment after AMI in Sweden has become standard, but titration to reach recommended LDL-C levels is still suboptimal. Strategies to further improve implementation of guidelines are needed.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-217657 (URN)10.1016/j.amjcard.2013.09.007 (DOI)000329333800004 ()
Available from: 2014-02-12 Created: 2014-02-04 Last updated: 2017-12-06Bibliographically approved
3. Study of Patient Information after Percutaneous Coronary Intervention (SPCI): should prevention programmes become more effective?
Open this publication in new window or tab >>Study of Patient Information after Percutaneous Coronary Intervention (SPCI): should prevention programmes become more effective?
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2015 (English)In: EuroIntervention, ISSN 1774-024X, E-ISSN 1969-6213, Vol. 10, no 11, e1-e7 p.Article in journal (Refereed) Published
Abstract [en]

Aims:

This cross-sectional observational study was designed to evaluate the uptake and outcome of patient education after percutaneous coronary intervention (PCI).

Methods and results:

A questionnaire containing 41 items was handed out to consecutive patients from randomly selected Swedish hospitals after PCI. Questions concerned the patient's attribution of the cause of the cardiac event, perception of the information provided by physicians and nurses, and a self-assessment of changes in lifestyle post PCI regarding tobacco, physical activity, food habits and stress. Replies were obtained from 1,073 patients (reply rate 67%). Non-modifiable risk factors (age, heredity) were attributed a higher rate as the cause of disease compared to modifiable factors (smoking, physical activity, food habits). Most patients (67%) perceived they were cured, and 38% perceived from the given information that there was no need to change their habits. A mere 27% reported that they still had cardiovascular disease and needed behavioural change. After PCI, 16% continued to use tobacco; half of these were offered smoking cessation support. In spite of an 80% referral rate to cardiac rehabilitation, one out of two patients did not enrol. Fewer than half were regularly physically active. Nutritional counselling was provided to 71%, but only 40% changed food habits. Stress management programmes were rarely provided.

Conclusions:

Current preventive practice scarcely meets the challenge posed by the progress in modern invasive cardiology. The Study of Patient Information after percutaneous Coronary Intervention (SPICI) motivates an in-depth revision and adaptation of cardiac rehabilitation programmes in order to improve patient understanding of the disease, and to support greater compliance with a cardioprotective lifestyle.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-233163 (URN)10.4244/EIJV10I11A223 (DOI)24472705 (PubMedID)
Available from: 2014-09-29 Created: 2014-09-29 Last updated: 2017-12-05Bibliographically approved
4. Long-Term Outcome of Incomplete Revascularization After Percutaneous Coronary Intervention in SCAAR (Swedish Coronary Angiography and Angioplasty Registry)
Open this publication in new window or tab >>Long-Term Outcome of Incomplete Revascularization After Percutaneous Coronary Intervention in SCAAR (Swedish Coronary Angiography and Angioplasty Registry)
Show others...
2016 (English)In: JACC: Cardiovascular Interventions, ISSN 1936-8798, E-ISSN 1876-7605, Vol. 9, no 3, 207-215 p.Article in journal (Other academic) Published
Abstract [en]

OBJECTIVES The aim of this study was to describe current practice regarding completeness of revascularization in patients with multivessel disease undergoing percutaneous coronary intervention (PCI) and to investigate the association of incomplete revascularization (IR) with death, repeat revascularization, and myocardial infarction (MI) in a large nationwide registry. BACKGROUND The benefits of multivessel PCI are controversial. METHODS Between 2006 and 2010 we identified 23,342 patients with multivessel disease in the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) and merged data with official Swedish health data registries. IR was defined as any nontreated significant (60%) stenosis in a coronary artery supplying > 10% of the myocardium. RESULTS Patients with IR (n = 15,165) were older, had more extensive coronary disease, and more often had ST-segment elevation MI at presentation than those with complete revascularization (CR) (n = 8,177). All-cause 1-year mortality, MI, and repeat revascularization were higher in IR than CR: 7.1% versus 3.8%, 10.4% versus 6.0%, and 20.5% versus 8.5%, respectively. Propensity score methodology was used in the adjusted analyses. Adjusted hazard ratio (HR) for the composite of death, MI, or repeat revascularization at 1 year was higher in IR than CR: 2.12 (95% confidence interval [CI]: 1.98 to 2.28; p < 0.0001). Adjusted HR for death and the combination of death/MI were 1.29 (95% CI: 1.12 to 1.49; p = 0.0005) and 1.42 (95% CI: 1.30 to 1.56; p < 0.0001), respectively. CONCLUSIONS Incomplete revascularization at the time of hospital discharge in patients with multivessel disease undergoing PCI is associated with a high risk of recurrent 1-year adverse cardiac events.

Keyword
incomplete revascularization; multivessel disease; PCI; registry study
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-233164 (URN)10.1016/j.jcin.2015.10.034 (DOI)000370272600003 ()26847112 (PubMedID)
Funder
AstraZeneca
Available from: 2014-09-29 Created: 2014-09-29 Last updated: 2017-12-05Bibliographically approved

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