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  • 1.
    Bergström, L.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Ögren, Joachim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Laurell, Katarina
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Recurrent ischemic stroke in patients with diabetes mellitus - incidence, trend over time and predictors2015In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 39, p. 14-14Article in journal (Other academic)
  • 2.
    Bergström, Lisa
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Soderstrom, Lars
    Ögren, Joachim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Laurell, Katarina
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    One-Year Incidence, Time Trends, and Predictors of Recurrent Ischemic Stroke in Sweden From 1998 to 2010 An Observational Study2017In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 48, no 8, p. 2046-Article in journal (Refereed)
    Abstract [en]

    Background and Purpose-Recent data on the incidence, time trends, and predictors of recurrent ischemic stroke are limited for unselected patient populations. Methods-Data for ischemic stroke patients were obtained from The Swedish Stroke Register (Riksstroke) between 1998 and 2009 and merged with The Swedish National Inpatient Register. A reference group of patients was created by Statistics Sweden. The ischemic stroke patient cohort was divided into 4 time periods. Recurrent ischemic stroke within 1 year was recorded until 2010. Kaplan-Meier and Cox regression analyses were performed to study time trends and predictors of ischemic stroke recurrence. Results-Of 196 765 patients with ischemic stroke, 11.3% had a recurrent ischemic stroke within 1 year. The Kaplan-Meier estimates of the 1-year cumulative incidence of recurrent ischemic stroke decreased from 15.0% in 1998 to 2001 to 12.0% in 2007 to 2010 in the stroke patient cohort while the cumulative incidence of ischemic stroke decreased from 0.7% to 0.4% in the reference population. Age > 75 years, prior ischemic stroke or myocardial infarction, atrial fibrillation without warfarin treatment, diabetes mellitus, and treatment with beta-blockers or diuretics were associated with a higher risk while warfarin treatment for atrial fibrillation, lipid-lowering medication, and antithrombotic treatment (acetylsalicylic acid, dipyridamole) were associated with a reduced risk of recurrent ischemic stroke. Conclusions-The risk of recurrent ischemic stroke decreased from 1998 to 2010. Well-known risk factors for stroke were associated with a higher risk of ischemic stroke recurrence; whereas, secondary preventive medication was associated with a reduced risk, emphasizing the importance of secondary preventive treatment.

  • 3.
    Bergström, Lisa
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderström, Lars
    Ögren, Joachim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Laurell, Katarina
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    One-year incidence, time trends, and predictors of recurrent ischemic stroke in Sweden from 1998-2010: An observational studyManuscript (preprint) (Other academic)
  • 4.
    Binsell-Gerdin, Emil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Graipe, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Internal Medicine, Section of Cardiology, Östersund Hospital, Sweden and Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden.
    Ögren, Joachim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Internal Medicine, Section of Cerebrovascular Diseases, Östersund Hospital, Sweden and Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden.
    Jernberg, Tomas
    Department of Medicine, Section of Cardiology, Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Östersund Research Unit, Umeå University.
    Hemorrhagic stroke the first 30 days after an acute myocardial infarction: incidence, time trends and predictors of risk2014In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 176, no 1, p. 133-138Article in journal (Refereed)
    Abstract [en]

    Background/objectives: Hemorrhagic stroke is a rare but serious complication after an acute myocardial infarction (AMI). The aims of our study were to establish the incidence, time trends and predictors of risk for hemorrhagic stroke within 30 days after an AMI in 1998-2008. Methods: We collected data from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA). All patients with a myocardial infarction 1998-2008 were included, n = 173,233. The data was merged with the National Patient Register in order to identify patients suffering a hemorrhagic stroke. To identify predictors of risk we used Cox models. Results: Overall the incidence decreased from 0.2% (n = 94) in 1998-2000 to 0.1% (n = 41) in 2007-2008. In patients with ST-elevation myocardial infarction the corresponding incidences were 0.4% (n = 76) in 1998-2000 and 0.2% (n = 21) in 2007-2008, and after fibrin specific thrombolytic treatment 0.6% and 1.1%, respectively, with a peak of 1.4% during 2003-2004. In total 375 patients (0.22%) suffered a hemorrhagic stroke within 30 days of the AMI. The preferred method of reperfusion changed from thrombolysis to percutaneous coronary intervention (PCI). Older age (hazard ratio (HR) >65- <= 75 vs <= 65 years 1.84, 95% confidence interval (CI) 1.38-2.45), thrombolysis (HR 6.84, 95% CI 5.51-8.48), history of hemorrhagic stroke (HR 12.52, CI 8.36-18.78) and prior hypertension (HR 1.52, CI 1.23-1.86) independently predicted hemorrhagic stroke within 30 days. Conclusions: The rate of hemorrhagic stroke within 30 days of an AMI has decreased by 50% between 1998 and 2008. The main reason is the shift in reperfusion method from thrombolysis to PCI. 

  • 5.
    Björklund, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Modica, Angelo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Prognostic impact of admisson level and dynamic change of cystatin C during an acute myocardial infarctionManuscript (preprint) (Other academic)
    Abstract [en]

    Introduction: Impaired kidney function has emerged as an important risk factor for developing cardiovascular disease. The level of kidney function is also associated with outcome following an acute coronary syndrome. Acute kidney injury during hospitalisation for an acute coronary syndrome has been associated with worsened prognosis. The aim of this study was to investigate the prognostic impact of kidney function on admission and sign of worsening kidney function during hospitalisation as measured by levels of cystatin C.

    Materials and methods: Five hundred and thirty-four patients admitted for an acute myocardial infarction were included. Cystatin C and other biochemical markers were obtained on day 1, 2, 3 and 5 depending on length of hospital stay.

    Results:  At a median follow-up of 2.9 years, the endpoint (death) had occurred in 176 (33%) patients. High admission level of cystatin C was independently associated with increased risk of death, at a hazard ratio of 1.62 (95% CI 1.28-2.03). The maximum recorded difference between levels of cystatin C in-hospital, were independently associated with outcome in patients with estimated glomerular filtration rate on admission>60 ml/(min*1.73m²). Hazard ratio for death at follow-up were 10.14 (95% CI 3.44-29.92) in this patient group.

    Conclusion: Level of kidney function on admission, as estimated by serum level of cystatin C, is independently associated with death at long-term follow up. In patients without chronic kidney disease, changing levels of cystatin C during admission for an AMI, have a strong impact on long-term prognosis. We found no additional information provided by dynamic changes in cystatin C, besides established predictors, in patients with chronic kidney disease.

  • 6.
    Brammås, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jakobsson, Stina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Ulvenstam, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Internal Medicine, Section of Cardiology, Östersund Hospital, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mortality After Ischemic Stroke in Patients With Acute Myocardial Infarction Predictors and Trends Over Time in Sweden2013In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 44, no 11, p. 3050-3055Article in journal (Refereed)
    Abstract [en]

    Background and Purpose Acute myocardial infarction (AMI) increases the risk of ischemic stroke, and mortality among these patients is high. Here, we aimed to estimate the 1-year mortality reliably after AMI complicated by ischemic stroke. We also aimed to identify trends over time for mortality during 1998-2008, as well as factors that predicted increased or decreased mortality. Methods Data for 173 233 unselected patients with AMI were collected from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions registry for 1998-2008. Specifically, we analyzed 1-year follow-up and mortality data for patients with AMI with and without ischemic stroke. Kaplan-Meyer analysis was used to analyze mortality trends over time, and Cox regression analysis was used to identify uni- and multivariate predictors of mortality. Results The 1-year mortality was 36.5% for AMI complicated by ischemic stroke and 18.3% for AMI without stroke. Mortality decreased over time in patients with and without ischemic stroke. The absolute decreases in mortality were 9.4% and 7.5%, respectively. Reperfusion and secondary preventive therapies were associated with a decreased mortality rate. Conclusions Mortality after AMI complicated by an ischemic stroke is very high but decreased from 1998 to 2008. The increased use of evidence-based therapies explains the improved prognosis.

  • 7.
    Graipe, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Section of Cardiology, Department of Internal Medicine, Östersund Hospital, Östersund, Sweden.
    Binsell-Gerdin, Emil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Internal Medicine, Östersund Hospital, Östersund, Sweden .
    Söderström, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Incidence, Time Trends, and Predictors of Intracranial Hemorrhage During Long-Term Follow-up After Acute Myocardial Infarction2015In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, ISSN 2047-9980, E-ISSN 2047-9980, Vol. 4, no 12, article id e002290Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: To address the lack of knowledge regarding the long-term risk of intracranial hemorrhage (ICH) after acute myocardial infarction (AMI), the aims of this study were to: (1) investigate the incidence, time trends, and predictors of ICH in a large population within 1 year of discharge after AMI; (2) investigate the comparative 1-year risk of ICH in AMI patients and a reference group; and (3) study the impact of previous ischemic stroke on ICH risk in patients treated with various antithrombotic therapies.

    METHODS AND RESULTS: Data about patients whose first AMI occurred between 1998 and 2010 were collected from the Swedish Register of Information and Knowledge about Swedish Heart-Intensive-Care Admissions (RIKS-HIA). Patients with an ICH after discharge were identified in the National Patient Register. Risk was compared against a matched reference population. Of 187 386 patients, 590 had an ICH within 1 year. The 1-year cumulative incidence (0.35%) was approximately twice that of the reference group, and it did not change significantly over time. Advanced age, previous ischemic or hemorrhagic stroke, and reduced glomerular filtration rate were associated with increased ICH risk, whereas female sex was associated with a decreased risk. Previous ischemic stroke did not increase risk of ICH associated with single or dual antiplatelet therapy, but increased risk with anticoagulant therapy.

    CONCLUSION: The 1-year incidence of ICH after AMI remained stable, at ≈0.35%, over the study period. Advanced age, decreased renal function, and previous ischemic or hemorrhagic stroke are predictive of increased ICH risk.

  • 8.
    Graipe, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Söderström, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Increased Use of Ticagrelor After Myocardial Infarction Is Not Associated With Intracranial Hemorrhage: Results From a Nationwide Swedish Registry2018In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 49, no 12, p. 2877-2882Article in journal (Refereed)
    Abstract [en]

    Background and Purpose: Guidelines recommend dual antiplatelet treatment with ticagrelor instead of clopidogrel after acute myocardial infarction. Ticagrelor increases major and minor noncoronary artery bypass graft bleeding compared with clopidogrel, but whether the risk of intracranial hemorrhage (ICH) increases is unknown. We aimed to examine any association between ticagrelor and ICH and to identify predictors of ICH among unselected patients after acute myocardial infarction.

    Methods: Patients with acute myocardial infarction were identified using the Register of Information and Knowledge About Swedish Heart Intensive Care Admissions, and the data were combined with the Swedish National Patient Registry to identify ICH occurrence. To avoid obvious selection bias related to the choice of dual antiplatelet treatment, we divided the study cohorts into 2 time periods of similar length using the first prescription of ticagrelor as a cutoff point (December 20, 2011). The risk of ICH during the first period (100% clopidogrel treatment) versus the second period (52.1% ticagrelor and 47.8% clopidogrel treatment) was assessed using Kaplan-Meier analysis. Cox proportional-hazards regression analyses, with assessment of interactions between all significant variables, were used to identify predictors of ICH.

    Results: The analysis included 47 674 patients with acute myocardial infarction. The cumulative incidence of ICH during the first period was 0.59% (91 cases [95% CI, 0.49-0.69]) versus 0.52% (97 cases [95% CI, 0.43-0.61]) during the second period (P=0.83). In multivariable Cox analysis, study period (second versus first period) was not predictive of ICH. Interaction analyses showed that age and prior cardiovascular morbidities were of importance in predicting the risk of ICH.

    Conclusions: The increased use of ticagrelor was not associated with ICH, whereas age and prior cardiovascular morbidities were related to the risk of ICH and interacted significantly.

  • 9.
    Henriksson, Robin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Björklund, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    The introduction of ticagrelor is associated with lower rates of recurrent ischemic stroke after myocardial infarction2019In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 14, no 5, article id e0216404Article in journal (Refereed)
    Abstract [en]

    Background: Previous ischemic stroke is a predictor of recurrent ischemic stroke after an acute myocardial infarction (AMI). Dual antiplatelet therapy, including a P2Y12-inhibitor, is important in secondary prevention after AMI. Ticagrelor, a P2Y12-inhibitor, is more potent than the commonly used clopidogrel. Here, we evaluated the impact of ticagrelor on the risk of ischemic stroke following AMI in patients with previous ischemic stroke.

    Methods: Data for patients with AMI that had a previous ischemic stroke were obtained from the Swedish Registry of Information and Knowledge about Swedish Heart Intensive Care Admissions. Patients were assigned to early and late cohorts, each covering a two-year time period before and after, respectively, the introduction of ticagrelor prescriptions (20 Dec 2011). Patients in the early cohort (n = 1633) were treated with clopidogrel (100%); those in the late cohort (n = 1642) were treated with either clopidogrel (66.3%) or ticagrelor (33.7%). We assessed the risk of ischemic stroke and intracranial bleeding over time with Kaplan-Meier analyses. We identified predictors of ischemic stroke with multivariable Cox regression analyses.

    Results: Of 3275 patients, 311 experienced ischemic stroke after AMI. Cumulative Kaplan-Meier incidence estimates of ischemic stroke within one year after AMI were 12.1% versus 8.6% for the early and late cohorts, respectively (p<0.01). Intracranial bleeding incidences (1.2% versus 1.5%) were similar between the two cohorts.

    Conclusions: Ticagrelor introduction was associated with a lower rate of ischemic stroke, with no increase in intracranial bleeding, in an AMI population with a history of ischemic stroke.

  • 10.
    Henriksson, Robin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Ulvenstam, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Graipe, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Ticagrelor reduces the risk of ischemic stroke after acute myocardial infarction compared with clopidogrel2016In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 37, p. 636-636Article in journal (Other academic)
  • 11.
    Henriksson, Robin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Unit of Research, Education and Development, Region jämtland Härjedalen, Östersund, Sweden.
    Ulvenstam, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Unit of Research, Education and Development, Region jämtland Härjedalen, Östersund, Sweden.
    Soderstrom, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Unit of Research, Education and Development, Region jämtland Härjedalen, Östersund, Sweden.
    Increase in ticagrelor use over time is associated with lower rates of ischemic stroke following myocardial infarction2019In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 19, no 1, p. 1-11, article id 51Article in journal (Refereed)
    Abstract [en]

    ObjectivesTo evaluate the impact of a rapid change in preferred treatment from clopidogrel to ticagrelor on the risk of ischemic stroke following acute myocardial infarction (AMI).MethodsData for AMI patients treated with either clopidogrel or ticagrelor were obtained from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA). Patients were divided into two cohorts, each covering a two-year time period; the initial prescription of ticagrelor (20 Dec 2011) was used as a cut-off point. Patients in the early cohort (n=23,447) were treated with clopidogrel, while those in the later cohort (n=24,227), were treated with either clopidogrel (47.9%) or ticagrelor (52.1%). Kaplan-Meier analyses were used to assess the risk of ischemic stroke over time, with multivariable Cox regression analyses used to identify predictors of ischemic stroke.ResultsOf 47,674 patients, there were 1203 cases of ischemic stroke. Cumulative Kaplan-Meier incidence estimates of ischemic stroke after one year were 2.8% vs. 2.4% for the early and late cohorts, respectively (p=0.001). Older age, hypertension, diabetes, previous stroke, congestive heart failure, atrial fibrillation, and ST-elevation myocardial infarction were associated with an increased risk of ischemic stroke. Percutaneous coronary intervention and statins at discharge were associated with a decreased risk of ischemic stroke, as was higher estimated glomerular filtration rate. Membership of the late cohort correlated with a 13% reduction in the relative risk of ischemic stroke.ConclusionsThe introduction of ticagrelor as well as an improved management of AMI was associated with a lower rate of ischemic stroke in a relatively unselected AMI population.

  • 12.
    Huber, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Henriksson, Robin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jakobsson, Stina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nurse-led telephone-based follow-up of secondary prevention after acute coronary syndrome: One-year results from the randomized controlled NAILED-ACS trial2017In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 12, no 9, article id e0183963Article in journal (Refereed)
    Abstract [en]

    Background. Secondary prevention after acute coronary syndrome (ACS) could reduce morbidity and mortality, but guideline targets are seldom reached. We hypothesized that nurse-led telephone- based intervention would increase adherence.

    Methods. The NAILED ACS trial is a prospective, controlled, randomized trial. Patients admitted for ACS at Ostersund hospital, Sweden, were randomized to usual follow-up by a general practitioner or a nurse-led intervention. The intervention comprised telephone follow-up after 1 month and then yearly with lifestyle counselling and titration of medications until reaching target values for LDL-C (< 2.5 mmol/L) and blood pressure (BP; < 140/90 mmHg) or set targets were deemed unachievable. This is a 12-month exploratory analysis of the intervention.

    Results. A total of 768 patients (396 intervention, 372 control) completed the 12-month follow-up. After titration at the 1-month follow-up, mean LDL-C was 0.38 mmol/L (95% CI 0.28 to 0.48, p< 0.05), mean systolic BP 7 mmHg (95% CI 4.5 to 9.2, p< 0.05), and mean diastolic BP 4 mmHg (95% CI 2.4 to 4.1, p< 0.05) lower in the intervention group. Target values for LDL-C and systolic BP were met by 94.1% and 91.9% of intervention patients and 68.4% and 65.6% of controls (p< 0.05). At 12 months, mean LDL was 0.3 mmol/L (95% CI 0.1 to 0.4, p < 0.05), systolic BP 1.5 mmHg (95% CI -1.0 to 4.1, p = 0.24), and mean diastolic BP 2.1 mmHg (95% CI 0.6 to 3.6, p < 0.05) lower in the intervention group. Target values for LDL-C and systolic BP were met in 77.7% and 68.9% of intervention patients and 63.2% and 63.7% of controls (p< 0.05 and p = 0.125).

    Conclusion. Nurse-led telephone-based secondary prevention was significantly more efficient at improving LDL-C and diastolic BP levels than usual care. The effect of the intervention declined between 1 and 12 months. Further evaluation of the persistence to the intervention is needed.

  • 13.
    Huber, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Henriksson, Robin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Jakobsson, Stina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nurse-led telephone-based follow-up of secondary prevention after acute myocardial infarction: one-year results from the randomized controlled NAILED-ACS trial2016In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 37, p. 337-338Article in journal (Other academic)
  • 14.
    Huber, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Henriksson, Robin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jakobsson, Stina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stenfors, Nikolai
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Implementation of a telephone-based secondary preventive intervention after acute coronary syndrome (ACS): participation rate, reasons for non-participation and 1-year survival2016In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 17, article id 85Article in journal (Refereed)
    Abstract [en]

    Background: Acute coronary syndrome (ACS) is a major cause of death from a non-communicable disease. Secondary prevention is effective for reducing morbidity and mortality, but evidence-based targets are seldom reached and new interventional methods are needed. The present study is a feasibility study of a telephone-based secondary preventive programme in an unselected ACS cohort. Methods: The NAILED (Nurse-based Age-independent Intervention to Limit Evolution of Disease) ACS trial is a prospective randomized controlled trial. All eligible patients admitted for ACS were randomized to usual follow-up by a general practitioner or telephone follow-up by study nurses. The intervention was made by continuous telephone contact, with counseling on healthy living and titration of medicines to reach target values for blood pressure and blood lipids. Exclusion criteria were limited to physical inability to follow the study design or participation in another study. Results: A total of 907 patients were assessed for inclusion. Of these, 661 (72.9 %) were included and randomized, 100 (11 %) declined participation, and 146 (16.1 %) were excluded. The main reasons for exclusion were participation in another trial, dementia, and advanced disease. "Excluded" and "declining" patients were significantly older with more co-morbidity, decreased functional status, and had more seldom received education above compulsory school level than "included" patients. Non-participants had a higher 1-year mortality than participants. Conclusions: Nurse-led telephone-based follow-up after ACS can be applied to a large proportion in an unselected clinical setting. Reasons for non-participation, which were associated with increased mortality, include older age, multiple co-morbidities, decreased functional status and low level of education.

  • 15.
    Huber, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Section of Cardiology, Dept of Internal Medicine, Östersund Hospital, Östersund Sweden, Östersund, Sweden.
    Wiken, C.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Section of Cardiology, Dept of Internal Medicine, Östersund Hospital, Östersund Sweden, Östersund, Sweden.
    Henriksson, Robin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Section of Cardiology, Dept of Internal Medicine, Östersund Hospital, Östersund Sweden, Östersund, Sweden.
    Statin treatment after acute coronary syndrome: long-term persistence and reasons for non-persistence2018In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 39, p. 1102-1103Article in journal (Other academic)
    Abstract [en]

    Background: Secondary prevention after acute coronary syndrome (ACS) is crucial to prevent recurrent events. Multiple studies however show that patients often end treatments and for reasons unknown. Our aims in this study were to perform a prospective follow-up of persistence to statin treatment in a population based patient cohort after ACS, to explore the reasons for discontinuation, and to determine whether a nurse-based follow-up could improve persistence.

    Methods: We studied patients recruited between 2010–2014 in the ongoing randomised controlled NAILED-ACS trial. All patients admitted with ACS at our County Hospital were eligible and exclusion criteria limited to inability to adhere to the study concept or participation in another trial. We randomised participants either to an intervention group with nurse-based telephone follow-up or to a control group with follow-up by a general practitioner (usual care). All participants were interviewed and screened yearly for blood pressure and blood lipids. The intervention group also got yearly counselling on healthy living and individualised titration of medicines to reach target values for blood pressure and blood lipids. We forwarded the measurements for the control group to the general practitioner for assessment. We collected information on adherence to statin treatment at the yearly interview and by review of medical records. Each reason for treatment discontinuation were recorded and classified as temporary or permanent.

    Results: Out of 963 patients, 89.3% (n=434) in the intervention and 82.0% (n=391) in the control group were persistent to statin treatment after a median of 3.9 years of follow-up (p=0.001). The most prevalent reason for permanent discontinuation in the intervention group was advanced disease (27.5%, n=14) while in the control group it was side effects without a compelling relation to treatment (32.8%, n=22). A total of 27.8% (n=135) of the patients in the intervention group and 20.5% (n=98) in the control group discontinued treatment at some point during the period (p=0.009). The most common reasons for a first discontinuation were in both arms side effects without a compelling relation to treatment and lack of treatment motivation.

    Conclusion: A nurse-based, long-term follow-up by telephone after an ACS with individualised medical adjustments results in a higher persistence to statin treatment than usual care.

  • 16.
    Huber, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wikén, Christian
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Henriksson, Robin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Söderström, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Statin treatment after acute coronary syndrome: Adherence and reasons for non-adherence in a randomized controlled intervention trial2019In: Scientific Reports, ISSN 2045-2322, E-ISSN 2045-2322, Vol. 9, article id 12079Article in journal (Refereed)
    Abstract [en]

    Studies of secondary prevention for cardiovascular disease show low fulfilment of guidelinere-commended targets. This study explored whether nurse-led follow-up could increase adherence to statins over time and reasons for discontinuation. All patients admitted for acute coronary syndrome at Ostersund hospital between 2010-2014 were screened for the randomized controlled NAILED-ACS trial. The trial comprises two groups, one with nurse-led annual follow-up and medical titration by telephone to reach set intervention targets and one with usual care. All discontinuations of statins were recorded prospectively for at least 36 months and categorized as avoidable or unavoidable. Kaplan-Meier estimates were conducted for first and permanent discontinuations. Predictors for discontinuation were analysed using multivariate Cox regression, statin type and mean LDL-C at end of follow-up. Female gender was a predictor for discontinuation. Allocation in the intervention group predicted increased risk for a first but decreased risk for permanent discontinuation. A nurse-led telemedical secondary prevention programme in a relatively unselected ACS cohort leads to increased adherence to statins over time, greater percentage on potent treatment and lower LDL-C compared to usual care. An initially increased tendency toward early discontinuation in the intervention group stresses the importance of a longer duration of structured follow-up.

  • 17.
    Irewall, Anna-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Bergström, Lisa
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Ögren, Joachim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Laurell, Katarina
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Söderström, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Östersund research unit, Umeå University.
    Implementation of telephone-based secondary preventive intervention after stroke and transient ischemic attack - participation rate, reasons for nonparticipation and one-year mortality2014In: Cerebrovascular diseases extra, ISSN 1664-5456, Vol. 4, no 1, p. 28-39Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Patients who experience a stroke or transient ischemic attack (TIA) are known to be at high risk of subsequent vascular events, underscoring the need for secondary preventive intervention. However, previous studies have indicated insufficiency in the implementation of secondary prevention, emphasizing the need to develop effective methods of follow-up. In the present study, we examined the potential of implementing a telephone-based, nurse-led, secondary preventive follow-up in stroke and TIA patients on a population level by analyzing the participation rate, reasons for nonparticipation, and one-year mortality.

    METHODS: Between January 1, 2010 and December 31, 2011, all patients admitted to Östersund hospital, Sweden, and diagnosed with either stroke or TIA were considered for inclusion into the secondary preventive follow-up. Baseline data were collected at the hospital, and reasons for nonparticipation were documented. Multivariate logistic regression was performed to identify predictors of the patient decision not to participate and to explore independent associations between baseline characteristics and exclusion. A one-year follow-up of mortality was also performed; the survival functions of the three groups (included, excluded, declining participation) was calculated using the Kaplan-Meier estimator.

    RESULTS: From a total of 810 identified patients, 430 (53.1%) were included in the secondary preventive follow-up, 289 (35.7%) were excluded mainly due to physical or cognitive disability, and 91 (11.2%) declined participation. Age ≥85 years, ischemic and hemorrhagic stroke, modified Rankin scale score >3, body mass index ≥25, congestive heart failure, and lower education level were independently associated with exclusion, whereas lower education level was the only factor independently associated with the patient decision not to participate. Exclusion was associated with a more than 12 times higher risk of mortality within the first year after discharge.

    CONCLUSION: Population-based implementation of secondary prevention in stroke and TIA patients is limited by the high prevalence of comorbidity and a considerable degree of disability. In our study, a large proportion of patients were unable to participate even in this simple form of secondary preventive follow-up. Exclusion was associated with substantially higher one-year mortality, and education level was independently associated with physical ability as well as the motivation to participate in the secondary preventive follow-up program.

  • 18.
    Irewall, Anna-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Johansson, C.
    Ostersund Hosp, Dept Stroke & Neurol, Ostersund, Sweden.
    Strömvall, A.
    Ostersund Hosp, Dept Cardiol, Ostersund, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Nurse-led, telephone-based secondary preventive intervention after stroke or TIA Improves blood pressure after 12 months of follow-up2014In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 9 3, p. 278-279Article in journal (Other academic)
  • 19.
    Irewall, Anna-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Ögren, Joachim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Public Health and Clinical Medicine, Östersund, Sweden.
    Bergström, Lisa
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Department of Public Health and Clinical Medicine, Östersund, Sweden.
    Laurell, Katarina
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Söderström, Lars
    Unit of Research, Development and Education, Region Jämtland Härjedalen, Östersund Hospital, Östersund, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nurse-Led, Telephone-Based, Secondary Preventive Follow-Up after Stroke or Transient Ischemic Attack Improves Blood Pressure and LDL Cholesterol: Results from the First 12 Months of the Randomized, Controlled NAILED Stroke Risk Factor Trial2015In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 10, article id e0139997Article in journal (Refereed)
    Abstract [en]

    Background: Enhanced secondary preventive follow-up after stroke or transient ischemic attack (TIA) is necessary for improved adherence to recommendations regarding blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) levels. We investigated whether nurse-led, telephone-based follow-up was more efficient than usual care at improving BP and LDL-C levels at 12 months after hospital discharge.

    Methods: We randomized 537 patients to either nurse-led, telephone-based follow-up (intervention) or usual care (control). BP and LDL-C measurements were performed at 1 month (baseline) and 12 months post-discharge. Intervention group patients who did not meet target values at baseline received additional follow-up, including titration of medication and lifestyle counselling, to reach treatment goals (BP < 140/90 mmHg, LDL-C < 2.5 mmol/L).

    Results: At 12 months, mean systolic BP, diastolic BP and LDL-C was 3.3 (95% CI 0.3 to 6.3) mmHg, 2.3 mmHg (95% CI 0.5 to 4.2) and 0.3 mmol/L (95% CI 0.1 to 0.4) lower in the intervention group compared to controls. Among participants with values above the treatment goal at baseline, the difference in systolic BP and LDL-C was more pronounced (8.0 mmHg, 95% CI 4.0 to 12.1, and 0.6 mmol/L, 95% CI 0.4 to 0.9). A larger proportion of the intervention group reached the treatment goal for systolic BP (68.5 vs. 56.8%, p = 0.008) and LDL-C (69.7% vs. 50.4%, p < 0.001).

    Conclusions: Nurse-led, telephone-based secondary preventive follow-up, including medication adjustment, was significantly more efficient than usual care at improving BP and LDL-C levels by 12 months post-discharge.

  • 20.
    Irewall, Anna-Lotta
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Ögren, Joachim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Bergström, Lisa
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Laurell, Katarina
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neuroscience.
    Söderström, Lars
    Unit of Research, Development and Education, Region Jämtland Härjedalen, Östersund Hospital, Östersund, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Nurse-led, telephone-based secondary preventive follow-up benefits stroke/TIA patients with low education: a randomized controlled trial sub-study2019In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 20, article id 52Article in journal (Refereed)
    Abstract [en]

    Background: The objective of this study was to analyze the impact of two forms of secondary preventive followup on the association between education level and levels of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) after stroke/transient ischemic attack (TIA).

    Methods: We included a population-based cohort of 771 stroke and TIA patients randomly assigned (1:1) to secondary preventive follow-up within primary health care (control) or nurse-led, telephone-based follow-up (intervention) between January 1, 2010, and December 31, 2013, as part of the NAILED (nurse-based ageindependent intervention to limit evolution of disease) stroke risk factor trial. We compared BP and LDL-C levels 12 months after hospital discharge in relation to education level (low, ≤10 years; high, >10 years) separately for the intervention and control groups.

    Results: Among controls, systolic BP (SBP) decreased only among the highly educated (−2.5 mm Hg, 95% confidence interval (CI) −0.2 to −4.8), whereas LDL-C increased in the low-education group (0.2 mmol/L, 95% CI 0.1 to 0.3). At 12 months, controls with low education not more than 70 years of age had higher SBP than controls of the same age with high education (5.8 mm Hg, 95% CI 1.0 to 10.6). In contrast, SBP in the intervention group decreased similarly regardless of education level, LDL-C decreased among those with low education (−0.3 mmol/L, 95% CI −0.2 to −0.4) and, in the subgroup not more than 70 years old, low-educated participants had lower LDL-C at 12 months than those with high education (0.3 mmol/L, 95% CI 0.1 to 0.5).

    Conclusions: Nurse-led, telephone-based secondary preventive follow-up led to comparable improvements in BP across education groups, while routine follow-up disfavored those with low education.

    Trial registration: ISRCTN Registry ISRCTN23868518, June 19, 2012 - Retrospectively registered

  • 21.
    Jakobsson, Stina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Bergstrom, L.
    Bjorklund, F.
    Jernberg, T.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The risk of ischemic stroke after an acute myocardial infarction in diabetic subjects2013In: European Heart Journal, ISSN 0195-668X, E-ISSN 1522-9645, Vol. 34, no Supplement: 1, p. 647-647Article in journal (Other academic)
    Abstract [en]

    Purpose: The incidence, any trend over time and predictors ofischemic stroke after an Acute Myocardial Infarction (AMI) inpatients with diabetes mellitus are unknown.

    Methods: Data for 173233 unselected AMI patients, including 33503diabetic subjects, was taken from the Swedish Register of Informationand Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) registry during 1998-2008. Ischemic stroke events were recorded during one year of follow-up.

    Results: Diabetic subjects more often had a history of cardiovascular disease, received less reperfusion therapy and were treated with Acetylsalicylic Acid (ASA), P2Y12-inhibitors and statins to a lesser extent than nondiabetic subjects. However, the use of evidence basedtherapies increased markedly in both groups during the study period.The incidence of ischemic stroke during the first year after the AMI decreased from 7.1 to 4.7% and from 4.2 to 3.7% in diabetic and nondiabetic subjects, respectively. The risk reduction was significantly larger in the diabetic subgroup. Reperfusion therapy, ASA, P2Y12-inhibitors and statins were independently associated with the reduced stroke risk.

    Conclusion: Ischemic stroke is not an uncommon complication afteran AMI in diabetic subjects but the risk of stroke has markedly decreased during recent years. The increased use of evidence basedtherapies importantly contributes to this risk reduction, particularly indiabetic subjects, but there is still room for improvement.

  • 22.
    Jakobsson, Stina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Bergström, Lisa
    Björklund, Fredrik
    Jernberg, Tomas
    Söderström, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Risk of ischemic stroke after an acute myocardial infarction in patients with diabetes mellitus2014In: Circulation. Cardiovascular Quality and Outcomes, ISSN 1941-7713, E-ISSN 1941-7705, Vol. 7, no 1, p. 95-101Article in journal (Refereed)
    Abstract [en]

    Background Incidence, any trend over time, and predictors of ischemic stroke after an acute myocardial infarction (AMI) in diabetic patients are unknown.

    Methods and Results Data for 173 233 unselected patients with an AMI, including 33 503 patients with diabetes mellitus, were taken from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) during 1998 to 2008. Ischemic stroke events were recorded during 1 year of follow-up. Patients with diabetes mellitus more often had a history of cardiovascular disease, received less reperfusion therapy, and were treated with acetylsalicylic acid, P2Y12 inhibitors, and statins to a lesser extent compared with patients without diabetes mellitus. However, the use of evidence-based therapies increased markedly in both groups during the study period. The incidence of ischemic stroke during the first year after AMI decreased from 7.1% to 4.7% in patients with diabetes mellitus and from 4.2% to 3.7% in patients without diabetes mellitus. Risk reduction was significantly larger in the diabetic subgroup. Reperfusion therapy, acetylsalicylic acid, P2Y12 inhibitors, and statins were independently associated with the reduced stroke risk.

    Conclusions Ischemic stroke is a fairly common complication after an AMI in patients with diabetes mellitus, but the risk of stroke has decreased during recent years. The increased use of evidence-based therapies contributes importantly to this risk reduction, but there is still room for improvement.

  • 23.
    Jakobsson, Stina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Graipe, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Huber, Daniel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Björklund, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The Risk of Ischemic Stroke after an Acute Myocardial Infarction in Patients with Decreased Renal Function2014In: Cerebrovascular Diseases, ISSN 1015-9770, E-ISSN 1421-9786, Vol. 37, no 6, p. 460-469Article in journal (Refereed)
    Abstract [en]

    Background: Data on the incidence, trends over time and predictors of ischemic stroke after an acute myocardial infarction (AMI) are sparse for patients with chronic kidney disease (CKD). Methods: Data for unselected AMI patients were obtained from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (RIKS-HIA) between 2003 and 2010. Patients with and without CKD were compared. Multiple logistic regression was performed to identify predictors of ischemic stroke during the hospitalization for AMI, Kaplan-Meier analysis was used to analyze the 1-year postdischarge ischemic stroke trends over time and Cox regression analysis was used to identify predictors. Results: Of 118,434 AMI patients, 40,679 had CKD. The CKD patients had more extensive previous cardiovascular disease and received less reperfusion and secondary preventive therapies than the patients without CKD. An inhospital ischemic stroke occurred in 2.3 and 1.2% of CKD and non-CKD patients, respectively. The incidence of ischemic stroke during hospitalization for AMI was stable during the study period. The occurrence of ischemic stroke after hospital discharge decreased between 2003-2004 and 2009-2010 from 4.1 to 2.5% in CKD patients and from 2.0 to 1.3% in non-CKD patients, respectively. Percutaneous coronary intervention (PCI) and statins were independently associated with a reduced risk of stroke after discharge from hospital. Conclusions: Ischemic stroke is a more common complication after an AMI in CKD patients than in non-CKD patients, but the risk has decreased in recent years. The increased use of PCI and statins may have contributed to this reduction.

  • 24.
    Jakobsson, Stina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Huber, Daniel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Björklund, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Implementation of a new guideline in cardiovascular secondary preventive care: subanalysis of a randomized controlled trial2016In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 16, article id 77Article in journal (Refereed)
    Abstract [en]

    Background

    Cardiovascular secondary preventive recommendations are often not reached. We investigated whether a nurse-led telephone-based follow-up could improve the implementation of a new guideline within a year after its release.

    Methods

    In February 2013, a new secondary preventive guideline for diabetic patients was released in the county of Jämtland, Sweden. It included a changed of the low-density lipoprotein cholesterol (LDL-C) target value from <2.5 mmol/L to <1.8 mmol/L. In the Nurse-Based Age-Independent Intervention to Limit Evolution of Disease (NAILED) trial, patients with an acute coronary syndrome, stroke, or transient ischemic attack were randomized to secondary preventive care with nurse-based telephone follow-up (intervention) or usual care (control). Patient data were obtained from the NAILED trial to study the implementation of the new LDL-C guideline by comparing telephone follow-up with usual care. The Mann–Whitney U-test was used for continuous variables, and Person’s χ 2 test was used for categorical variables to assess between-group differences.

    Results

    Out of the 1267 patients that entered the study period, 101 intervention and 100 control patients with diabetes fulfilled the inclusion criteria and completed the study period. Before the guideline change, 96 % of the intervention patients and 70 % of the control patients reached the target LDL-C value (p < 0.001). After the guideline change, the corresponding respective proportions were 65 % and 36 % (p < 0.001). The main reason that intervention patients did not achieve the target LDL-C value was that they received full-dose treatment; for control patients, the main reason was that medication was not adjusted, for an unknown reason.

    Conclusions

    One year after a change in the cardiovascular secondary preventive guideline, nurse-based telephone follow-up performed better than usual care to implement the new recommendation.

  • 25.
    Jakobsson, Stina
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Björklund, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Cardiovascular secondary prevention in high-risk patients: a randomized controlled trial sub-study2015In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 15, article id 125Article in journal (Refereed)
    Abstract [en]

    Background: Enhanced cardiovascular secondary preventive follow-up is needed to improve adherence to recommended low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP) levels. Patients with diabetes mellitus (DM) or chronic kidney disease (CKD) have a high risk of recurrent events. Secondary prevention is therefore essential in these patients.

    Methods: Patients with acute coronary syndrome, stroke, or transient ischemic attack were randomized to nurse-based telephone follow-up (intervention) or usual care (control). LDL-C and BP were measured at 1 month (baseline) and 12 months post-discharge. Intervention patients with above-target values at baseline received medication titration to achieve treatment goals. Values measured for control patients were given to the patient’s general practitioner for assessment.

    Results: The final analyses included 225 intervention and 215 control patients with DM or CKD. Among patients with above-target baseline values, the following 12-month values were recorded for intervention and control patients, respectively: LDL-C, 2.2 versus 3.0 mmol/L (p < 0.001); and median systolic BP (SBP), 140 versus 145 mmHg (p = 0.26). Among patients with above-target values at baseline, 52.3% of intervention patients reached target LDL-C values at 12 months versus 21.3% of control patients (absolute difference of 30.9%, 95% CI 16.1 to 43.8%), and there was a non-significant trend of more intervention patients reaching target SBP (49.4% versus 36.8%; absolute difference of 12.6%, 95% CI -1.7 to 26.2%).

    Conclusions: Cardiovascular secondary prevention with nurse-based telephone follow-up was more effective than usual care in improving LDL-C levels 12 months after discharge for patients with DM or CKD. 

  • 26. Kajermo, Ulf
    et al.
    Ulvenstam, Anders
    Modica, Angelo
    Jernberg, Tomas
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Incidence, Trends, and Predictors of Ischemic Stroke 30 Days After an Acute Myocardial Infarction2014In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 45, no 5, p. 1324-1330Article in journal (Refereed)
    Abstract [en]

    Background and Purpose Ischemic stroke is a known complication of acute myocardial infarction (AMI). Treatment of AMI has undergone great changes in recent years. We aimed to investigate whether changes in treatment corresponded to a lower incidence of ischemic stroke and which factors predicted ischemic stroke after AMI. Methods Data were taken from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions. Patients with their first registered AMI between 1998 and 2008 were included. To identify ischemic strokes, we used the Swedish national patient register. To study a potential trend in the incidence of ischemic stroke after AMI over time, we divided the patient population into 5 time periods. Event-free survival was studied by Kaplan-Meier analysis. Cox proportional hazards regression model was used to identify stroke predictors. Results Of 173 233 patients with AMI, 3571 (2.1%) developed ischemic stroke within 30 days. The incidence of ischemic stroke was significantly lower during the years 2007 to 2008 compared with 1998 to 2000, with respective rates of 2.0% and 2.2% (P=0.02). Independent predictors of an increased risk of stroke were age, female sex, prior stroke, diabetes mellitus, atrial fibrillation, clinical signs of heart failure in hospital, ST-segment-elevation myocardial infarction, coronary artery bypass grafting, and angiotensin-converting enzyme inhibitor treatment at discharge. Percutaneous coronary intervention, fibrinolysis, acetylsalicylic acid, statins, and P2Y12 inhibitors were predictors of reduced risk of stroke. Conclusions The incidence of ischemic stroke within 30 days of an AMI has decreased during the period 1998 to 2008. This decrease is associated with increased use of acetylsalicylic acid, P2Y12 inhibitors, statins, and percutaneous coronary intervention.

  • 27.
    Karlsson, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Modica, Angelo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Association of level of kidney function and platelet aggregation in acute myocardial infarction2009In: American Journal of Kidney Diseases, ISSN 0272-6386, E-ISSN 1523-6838, Vol. 54, no 2, p. 262-269Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Decreased kidney function has been established as an important risk factor in patients presenting with acute coronary syndrome. In acute coronary syndrome, increased platelet aggregation is associated with vascular complications. The aim of this study is to examine whether decreased kidney function is associated with altered platelet function in patients presenting with acute myocardial infarction. STUDY DESIGN: Prospective cohort.

    SETTING & PARTICIPANTS: 413 patients presenting with acute myocardial infarction admitted to the cardiac intensive care unit at Ostersund Hospital, Ostersund, Sweden.

    PREDICTORS: Glomerular filtration rate less than 60 mL/min/1.73 m(2) estimated from serum cystatin C level, comorbidity, medications, and markers of inflammation and hemostasis.

    OUTCOMES & MEASUREMENTS: Platelet aggregation was assessed by measuring the formation of small platelet aggregates (SPAs) by using a laser light scattering method. A greater SPA level indicates greater platelet aggregation. Platelet aggregation analysis was performed on days 1, 2, 3, and 5 in-hospital. RESULTS: We observed a significant increase in platelet aggregation during the first 3 days in the hospital regardless of kidney function (P < 0.001). Platelet aggregation was more pronounced in patients with estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) on day 2 (SPA count, 65,000 versus 47,000; P = 0.01) and day 3 (SPA count, 77,000 versus 52,000; P = 0.02). In a multiple linear regression analysis, decreased kidney function was no longer significantly associated with increased platelet aggregation. Older age, greater plasma fibrinogen level, and diabetes mellitus were associated with increased platelet aggregation in the multivariable model.

    LIMITATIONS: During the study period, 78 patients presenting with acute myocardial infarction were not eligible for inclusion. Differences in treatment with antiplatelet medication between the 2 groups might have affected our findings.

    CONCLUSIONS: Platelet aggregation increases during the first days after acute myocardial infarction regardless of kidney function. There is no difference in platelet aggregation in patients according to level of kidney function.

  • 28.
    Karlsson, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Modica, Angelo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Dynamics of platelet activation in diabetic and non-diabetic subjects during the course of an acute myocardial infarction2007In: Thrombosis Research, ISSN 0049-3848, E-ISSN 1879-2472, Vol. 121, no 2, p. 269-273Article in journal (Refereed)
    Abstract [en]

    Introduction

    The dynamics of platelet activation during the course of a myocardial infarction is unknown but of great importance in terms of risk assessment and anti-thrombotic therapy. The aim of the present study was sequentially to analyse platelet activation in diabetic and non-diabetic subjects with an acute myocardial infarction.

    Materials and methods

    We used a sensitive laser light scattering technique to assess platelet aggregation as a measure of activation. Measurements were made on the first, second, third and fifth day in-hospital. Two hundred and forty-three patients with an acute myocardial infarction, of whom 48 had diabetes, were included.

    Results

    Platelet activation increased until the third in-hospital day in both diabetic and non-diabetic subjects, despite intense anti-thrombotic therapy. The activation was more pronounced in diabetic subjects from the time of hospital admission. Platelet activation tended to decrease after the third in-hospital day.

    Conclusions

    We conclude that platelet activation increases rapidly at the onset of a myocardial infarction, despite aggressive anti-thrombotic treatment. The activation is more pronounced in diabetic subjects and tends to decrease within a few days. More targeted and effective anti-platelet therapy has the potential further to reduce cardiac and cerebral ischemic events following myocardial infarction and ongoing clinical trials are addressing this issue.

  • 29.
    Modica, Angelo
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Karlsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Platelet aggregation and aspirin non-responsiveness increase when an acute coronary syndrome is complicated by an infection2007In: Journal of Thrombosis and Haemostasis, ISSN 1538-7933, E-ISSN 1538-7836, Vol. 5, no 3, p. 507-511Article in journal (Refereed)
    Abstract [en]

    Background: Epidemiologic studies have shown that there is an association between acute respiratory infection and acute coronary syndrome. The aim of this study was to analyze the thrombotic risk, assessed by platelet aggregation and aspirin non-responsiveness, in patients with an acute coronary syndrome complicated by an infection.

    Methods: Patients with an acute coronary syndrome who were admitted to the intensive care unit and hospitalized for at least 3 days in 2002 and 2003 were eligible for the study. Three hundred and fifty-eight patients were included, of whom 66 had an infection during their hospital stay. Platelet aggregation was analyzed by an aggregometer using laser light (PA-200, laser light scattering). Aspirin non-responsiveness was defined as a closure time of ≤193 s measured by PFA-100.

    Results: Platelet aggregation was more pronounced during an infectious complication (P < 0.001). The subgroups of patients with persistent fever, urinary tract infection, and pneumonia all had a higher level of aggregates than the group of patients without an infection (P = 0.007, P = 0.04, and P = 0.01, respectively). Aspirin non-responsiveness was more frequent in the group of subjects with pneumonia compared with those without an infection, 90% vs. 46% (P = 0.006). The CRP levels were independently associated with platelet aggregation and aspirin non-responsiveness (P < 0.001, P < 0.001, respectively).

    Conclusion: An infectious complication during the course of an acute coronary syndrome leads to more pronounced platelet aggregation. Aspirin non-responsiveness is more frequent in severe infections, such as pneumonia. CRP is an independent predictor of platelet aggregation and aspirin non-responsiveness in the setting of an acute coronary syndrome.

  • 30.
    Modica, Angelo
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Karlsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Prognosis after acute myocardial infarction as predicted by CRP and clinical variablesManuscript (preprint) (Other academic)
    Abstract [en]

    Objective. Raised concentrations of C-reactive protein (CRP) have been reported to be strongly related to an adverse long term prognosis in patients with acute myocardial infarction (AMI). However, adjustments for possible confounders have often been incomplete. Thus the clinical usefulness of CRP to predict long term survival in absolute figures has not been clarified. The aims of this study were to examine the predictive value of baseline concentrations of CRP for mortality after adjustment for the most important clinical variables and to compare the clinical usefulness of CRP with easily available clinical variables in the prediction of long term survival.

    Design. Five hundred and thirty-one patients with AMI were included. A blood sample for CRP was obtained on admission. All patients were followed for a minimum of two years and death of any cause was recorded as the study end point.

    Results. In logistic regression analysis the interaction term age by Killip class > 1 and the variables glomerular filtration rate, intervention and atrial fibrillation were retained. The resulting model correctly predicted death or not in 82% of the patients. CRP did not contribute to the final model.

    Conclusions. An elevated C-reactive protein concentration is reported to be associated with death in patients with AMI, but the association is absent after adjustment for an important interaction among the variables in the model. CRP has no value beyond clinical variables in predicting death after AMI.

  • 31.
    Modica, Angelo
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Karlsson, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The impact of platelet function or C-reactive protein, on cardiovascular events after an acute myocardial infarction2009In: Thrombosis Journal, ISSN 1477-9560, E-ISSN 1477-9560, Vol. 7, no 12Article in journal (Refereed)
    Abstract [en]

    Background Recurrent cardiovascular events following acute myocardial infarction (AMI) are common. The purpose of this study was to evaluate the impact of platelet aggregation, PFA-100 closure times and peak C-reactive protein (CRP), respectively, on the occurrence of death, myocardial infarction and ischemic cerebral events after an AMI. Furthermore, to examine the relationship between the platelet function tests and peak CRP.

    Methods Three hundred and thirty-four patients with AMI were included in the study. Platelet aggregation was analyzed by an aggregometer using laser light (PA-200). The state of high residual platelet reactivity was defined as normal closure times (PFA-100) during treatment with antiplatelet and antithrombotic drugs.

    Results The fourth quartile of peak CRP was associated with poorer outcome as compared to the first quartile in a multivariate Cox-regression analysis, with a hazard ratio of 2.0 (95% CI 1.1-3.7) for the occurrence of death, myocardial infarction and ischemic cerebral events. The fourth quartile of peak CRP (>64.6 mg/l) was associated with platelet aggregation (p < 0.001, adjusted R² = 0.13) and high residual platelet reactivity, in a multivariable model, with an odds ratio of 2.9 (CI 95% 1.3-6.8), as compared to the first quartile. Neither the highest quartile of platelet aggregation nor the state of high residual platelet reactivity predicted new cardiovascular events.

    Conclusions In patients with myocardial infarction, measured peak CRP is associated with new cardiovascular events. Despite an association with peak CRP neither more pronounced platelet aggregation nor PFA-100 closure times independently predict new cardiovascular events.

  • 32.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Left ventricular thrombus and stroke after acute myocardial infarction1997Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    A left ventricular thrombus develops in approximately 40% of patients following an anterior myocardial infarction. Embolization from these thrombi has been regarded as the most important cause of stroke following a myocardial infarction. The occurrence and characteristics of left ventricular thrombi and stroke after anterior myocardial infarction may, however, have changed after the introduction of aspirin and thrombolytics as standard therapy.

    The occurrence of left ventricular thrombi was examined in 99 patients with an acute anterior myocardial infarction, 74 of whom were treated with streptokinase. Thrombi were equally common in the thrombolysis group (46%, 95% confidence interval [Cl], 35-57%) as in the non-thrombolysis group (40%, 95% Cl, 21-59%). The risk of thrombus formation was related to the degree of left ventricular segmental dysfunction.

    Using serial echocardiographic examinations, the formation and resolution of thrombi was found to be highly dynamic. The majority of thrombi diagnosed during the hospital stay had resolved at follow-up one month later, irrespective of treatment with streptokinase or anticoagulants. The development of new thrombi was, however, observed at every follow-up examination interval.

    One-hundred-and-twenty-four patients suffering a stroke within 28 days of an acute myocardial infarction were identified in the northern Sweden MONICA stroke registry between 1985 and 1994. The overall event rate of ischemic myocardial infarction-related stroke was 1.07%. The risk of a stroke was highest duringt he first 5 days after the infarction. Only approximately half the strokes were preceded by an anterior myocardial infarction. In a case-control analysis, atrial fibrillation (chronic or new onset), ST elevation and a history of a previous stroke were found to be independent predictors of stroke. There was a long-term trend towards a lower incidence and event rate for myocardial infarction-related stroke.

    Clinical stroke characteristics were examined in 103 patients with a first-ever stroke within 28 days of a myocardial infarction and compared with stroke characteristics in 206 control subjects without a recent myocardial infarction. The sudden onset of neurological symptoms, an impairment of consciousness, a progression in neurological deficits and a stroke of the total anterior circulation infarction subclass were more common in cases than in controls. The risk of a recurrent stroke during one year of follow-up was not influenced by a recent myocardial infarction, but patients who had suffered a myocardial infarction had markedly higher mortality.

    To conclude, thrombolytic treatment does not reduce the occurrence of left ventricular thrombi after a myocardial infarction. The risk of thrombus formation is related to the extent of the myocardial injury. The development and resolution of thrombi is a highly dynamic process. There is a long-term trend towards a lower incidence and event rate of ischemic stroke after a myocardial infarction. Although the clinical stroke characteristics differ, they are not specific enough to differentiate between patients with and without a recent myocardial infarction.

  • 33.
    Mooe, Thomas
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Bergstrom, Lisa
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Ögren, Joachim
    The NAILED stroke risk factor trial (Nurse based Age independent Intervention to Limit Evolution of Disease after stroke): study protocol for a randomized controlled trial2013In: Trials, ISSN 1745-6215, E-ISSN 1745-6215, Vol. 14, p. 5-Article in journal (Refereed)
    Abstract [en]

    Background: Secondary prevention after stroke and transient ischemic attack (TIA) is essential in order to reduce morbidity and mortality. Secondary stroke prevention studies have, however, been fairly small, or performed as clinical trials with non-representative patient selection. Long-term follow-up data is also limited. A nurse-led follow-up for risk factor improvement may be effective but the evidence is limited. The aims of this study are to perform an adequately sized, nurse-led, long-term secondary preventive follow-up with a population-based inclusion of stroke and TIA patients. The focus will be on blood pressure and lipid control as well as tobacco use and physical activity. Methods: A randomized, controlled, long-term, population-based trial with two parallel groups. The patients will be included during the initial hospital stay. Important outcome variables are sitting systolic and diastolic blood pressure, LDL cholesterol and total cholesterol. Outcomes will be measured after 12, 24 and 36 months of follow-up. Trained nurses will manage the intervention group with a focus on reaching set treatment goals as soon as possible. The control group will receive usual care. At least 200 patients will be included in each group, in order to reliably detect a difference in mean systolic blood pressure of 5 mmHg. This sample size is also adequate for detection of clinically meaningful group differences in the other outcomes. Discussion: This study will test the hypothesis that a nurse-led, long-term follow-up after stroke with a focus on reaching set treatment goals as soon as possible, is an effective secondary preventive method. If proven effective, this method could be implemented in general practice at a low cost.

  • 34.
    Mooe, Thomas
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Björklund, Fredrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Graipe, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Huber, Daniel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jakobsson, Stina
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Kajermo, Ulf
    Strömvall, Anna
    Ulvenstam, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The Nurse-Based Age Independent Intervention to Limit Evolution of Disease After Acute Coronary Syndrome (NAILED ACS) Risk Factor Trial: Protocol for a Randomized Controlled Trial2014In: JMIR Research Protocols, ISSN 1929-0748, E-ISSN 1929-0748, Vol. 3, no 3, article id e42.Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Secondary prevention after acute coronary syndrome (ACS) is essential to reduce morbidity and mortality, but related studies have been fairly small or performed as clinical trials with non-representative patient selection. Long-term follow-up data are also minimal. A nurse-led follow-up for risk factor improvement may be effective, but the evidence is limited.

    OBJECTIVE: The aims of this study are to perform an adequately sized, nurse-led, long-term secondary preventive follow-up with inclusion of an unselected population of ACS patients. The focus will be on lipid and blood pressure control as well as tobacco use and physical activity.

    METHODS: The study will consist of a randomized, controlled, long-term, population-based trial with two parallel groups. Patients will be included during the initial hospital stay. Important outcome variables are total cholesterol, low-density lipoprotein (LDL) cholesterol, and sitting systolic and diastolic blood pressure. Outcomes will be measured after 12, 24, and 36 months of follow-up. Trained nurses will manage the intervention group with the aim of achieving set treatment goals as soon as possible. The control group will receive usual care. At least 250 patients will be included in each group to reliably detect a difference in mean LDL of 0.5 mmol/L and in mean systolic blood pressure of 5 mmHg.

    RESULTS: The study is ongoing and recruitment of participants will continue until December 31, 2014.

    CONCLUSIONS: This study will test the hypothesis that a nurse-led, long-term follow-up after an ACS with a focus on achieving treatment goals as soon as possible is an effective secondary preventive method. If proven effective, this method could be implemented in general practice at a low cost.

    TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 96595458; http://www.controlled-trials.com/ISRCTN96595458 (Archived by WebCite at http://www.webcitation.org/6RlyhYTYK).

  • 35.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Unit Clin Res Ctr Östersund, Umeå, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Diagnostic characteristics and prognoses of primary-care patients referred for clinical exercise testing: a prospective observational study2014In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 15, article id 71Article in journal (Refereed)
    Abstract [en]

    Background: Evaluation of angina symptoms in primary care often includes clinical exercise testing. We sought to identify clinical characteristics that predicted the outcome of exercise testing and to describe the occurrence of cardiovascular events during follow-up. Methods: This study followed patients referred to exercise testing for suspected coronary disease by general practitioners in the County of Jamtland, Sweden (enrolment, 25 months from February 2010). Patient characteristics were registered by pre-test questionnaire. Exercise tests were performed with a bicycle ergometer, a 12-lead electrocardiogram, and validated scales for scoring angina symptoms. Exercise tests were classified as positive (ST-segment depression > 1 mm and chest pain indicative of angina), non-conclusive (ST depression or chest pain), or negative. Odds ratios (ORs) for exercise-test outcome were calculated with a bivariate logistic model adjusted for age, sex, systolic blood pressure, and previous cardiovascular events. Cardiovascular events (unstable angina, myocardial infarctions, decisions on revascularization, cardiovascular death, and recurrent angina in primary care) were recorded within six months. A probability cut-off of 10% was used to detect cardiovascular events in relation to the predicted test outcome. Results: We enrolled 865 patients (mean age 63.5 years, 50.6% men); 6.4% of patients had a positive test, 75.5% were negative, 16.4% were non-conclusive, and 1.7% were not assessable. Positive or non-conclusive test results were predicted by exertional chest pain (OR 2.46, 95% confidence interval (Cl) 1.69-3.59), a pathologic ST-T segment on resting electrocardiogram (OR 2.29, 95% Cl 1.44-3.63), angina according to the patient (OR 1.70, 95% Cl 1.13-2.55), and medication for dyslipidaemia (OR 1.51, 95% CI 1.02-2.23). During follow-up, cardiovascular events occurred in 8% of all patients and 4% were referred to revascularization. Cardiovascular events occurred in 52.7%, 18.3%, and 2% of patients with positive, non-conclusive, or negative tests, respectively. The model predicted 67/69 patients with a cardiovascular event. Conclusions: Clinical characteristics can be used to predict exercise test outcome. Primary care patients with a negative exercise test have a very low risk of cardiovascular events, within six months. A predictive model based on clinical characteristics can be used to refine the identification of low-risk patients.

  • 36.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderström, Lars
    Region Jämtland Härjedalen.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Pre-hospital delay in patients with first time myocardial infarction: an observational study in a northern Swedish population2016In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 16, no 1, article id 93Article in journal (Refereed)
    Abstract [en]

    Background: In myocardial infarction (MI), pre-hospital delay is associated with increased mortality and decreased possibility of revascularisation. We assessed pre-hospital delay in patients with first time MI in a northern Swedish population and identified determinants of a pre-hospital delay ≥2 h.

    Methods: A total of 89 women (mean age 72.6 years) and 176 men (mean age 65.8 years) from a secondary prevention study were enrolled in an observational study after first time MI between November 2009 and March 2012. Total pre-hospital delay was defined as the time from the onset of symptoms suggestive of MI to admission to the hospital. Decision time was defined as the time from the onset of symptoms until the call to Emergency Medical Services (EMS). The time of symptom onset was assessed during the episode of care, and the time of call to EMS and admission to the hospital was based on recorded data. The first medical contact was determined from a mailed questionnaire. Determinants associated with pre-hospital delay ≥ 2 h were identified by multivariable logistic regression.

    Results: The median total pre-hospital delay was 5.1 h (IQR 18.1), decision time 3.1 h (IQR 10.4), and transport time 1.2 h (IQR 1.0). The first medical contact was to primary care in 52.3 % of cases (22.3 % as a visit to a general practitioner and 30 % by telephone counselling), 37.3 % called the EMS, and 10.4 % self-referred to the hospital. Determinants of a pre-hospital delay ≥ 2 h were a visit to a general practitioner (OR 10.77, 95 % CI 2.39–48.59), call to primary care telephone counselling (OR 3.82, 95 % CI 1.68–8.68), chest pain as the predominant presenting symptom (OR 0.24, 95 % CI 0.08–0.77), and distance from the hospital (OR 1.03, 95 % CI 1.02–1.04). Among patients with primary care as the first medical contact, 67.0 % had a decision time ≥ 2 h, compared to 44.7 % of patients who called EMS or self-referred (p = 0.002).

    Conclusions: Pre-hospital delay in patients with first time MI is prolonged considerably, particularly when primary care is the first medical contact. Actions to shorten decision time and increase the use of EMS are still necessary.

  • 37.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine. Unit of Research, Education and Development, Östersund Hospital, Östersund, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderström, Lars
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Use of exercise tests in primary care: importance for referral decisions and possible bias in the decision process; a prospective observational study2014In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 15, article id 182Article in journal (Refereed)
    Abstract [en]

    Background: The utility of clinical exercise tests depends on their support of treatment decisions. We sought to assess the utility of exercise tests for the selection of primary-care patients for referral to cardiologic care, and to determine whether referral decisions were biased by gender or socioeconomic status. We also evaluated referral rates and cardiovascular events in patients with positive exercise tests. 

    Methods: We designed a prospective observational study of 438 men and 427 women from 28 Swedish primary-care clinics who were examined with exercise testing for suspected coronary disease. All participants were followed-up with respect to cardiologist referrals and cardiovascular events (hospitalisation for unstable angina, myocardial infarction, and cardiovascular death) within six months and revascularisation within 250 days. Variables associated with referral were identified by multivariable logistic regression. Socioeconomic status was determined by educational level and employment. 

    Results: Positive/inconclusive exercise tests and exertional chest pain predicted referral in men and women. Of 865 participants, patients with positive, inconclusive, or negative exercise tests were referred to cardiologists in 67.3%, 26.1%, and 3.5% of cases, respectively. Overall, there was no significant difference in referral rates related to gender or socioeconomic level. Self-employed women were referred more frequently compared to other women (odds ratio (OR) 3.62, 95% confidence interval (CI) 1.19-10.99). Among non-manual employees, women were referred to cardiologic examination less frequently than men (OR 0.40, 95% CI 0.16-1.00; p = 0.049; ORs adjusted for age, exertional chest pain, and exercise test result). In patients with positive exercise tests, the referral rate decreased continuously with age (OR 0.48, 95% CI 0.23-0.97; adjusted for cardiovascular co-morbidity). Cardiovascular events occurred in 22.2% (4/18) of non-referred patients with positive exercise tests; 56% (10/18) of these patients were not considered for cardiologic care, with continuity problems in primary care as one possible contributing cause. 

    Conclusions: Exercise tests are important for selecting patients for referral to cardiologic care. Interactions related to gender and socioeconomic status affected referral rates. In patients with positive exercise tests, referral rates decreased with age. An increased awareness of possible bias regarding age, gender, and socioeconomic status, which may influence medical decisions, is therefore necessary.

  • 38.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderstrom, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Low use of statins for secondary prevention in primary care: a survey in a northern Swedish population2016In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 17, article id 110Article in journal (Refereed)
    Abstract [en]

    Background: Cholesterol-lowering therapy with statins is recommended in established cardiovascular disease (CVD) and should be considered for patients at high cardiovascular risk. We surveyed statin treatment before first-time myocardial infarction in clinical practice compared to current guidelines, in patients with and without known CVD in primary care clinics with general practitioners (GPs) on short-term contracts vs. permanent staff GPs. Methods: A total of 931 patients (345 women) in northern Sweden were enrolled in the study between November 2009 and December 2014 and stratified by prior CVD, comprising angina pectoris, revascularisation, ischaemic stroke or transitory ischaemic attack, or peripheral artery disease. Primary care clinics were classified by the proportion of GP salaries that were paid to GPs working on short-term contracts: low (0-9 %), medium (10-39 %), or high (>= 40 %). We used logistic regression to identify determinants of statin treatment. Results: Among patients with prior CVD, only 34.5 % received statin treatment before myocardial infarction. The probability of statin treatment decreased with age (>= 70 years OR 0.30; 95 % CI 0.13-0.66) and female gender (OR 0.39; 95 % CI 0.20-0.78) but increased in patients with diabetes (OR 3.52; 95 % CI 1.75-7.08). Among patients with prior CVD, the type of primary care clinic was not predictive of statin treatment. In the entire study cohort, 17.3 % of patients were treated with statins; women < 70 years old were more likely to receive statin treatment than women >= 70 years old (OR 3.24; 95 % CI 1.64-6.38), and men >= 70 years old were twice as likely to be treated with statins than women of the same age (OR 2.22; 95 % CI 1.31-3.76) after adjusting for diabetes and CVD. Overall, patients from clinics with predominantly permanent staff GPs received statin therapy less frequently than those with GPs on short-term contracts. Conclusions: In patients with prior CVD we found considerable under-treatment with statins, especially among women and the elderly. Methodologies for case findings, recall, and follow-up need to be improved and implemented to reach the goals for CVD prevention in clinical practice.

  • 39.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Söderström, Lars
    Region Jämtland Härjedalen.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Treatment with statins prior to first time myocardial infarction, with special reference to patients with previously diagnosed cardiovascular disease: a population-based surveyManuscript (preprint) (Other academic)
  • 40.
    Nilsson, Gunnar
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Soderstrom, L.
    Alverlind, K.
    Samuelsson, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Hand-held cardiac ultrasound examinations performed in primary care patients by nonexperts to identify reduced ejection fraction2019In: BMC Medical Education, ISSN 1472-6920, E-ISSN 1472-6920, Vol. 19, article id 282Article in journal (Refereed)
    Abstract [en]

    BackgroundEarly identification of patients with reduced left ventricular ejection fraction (LVEF) could facilitate the care of patients with suspected heart failure (HF). We examined if (1) focused cardiac ultrasound (FCU) performed with a hand-held device (Vscan 1.2) could identify patients with LVEF <50%, and (2) the distribution of HF types among patients with suspected HF seen at primary care clinics.MethodsFCU performed by general practitioners (GPs)/GP registrars after a training programme comprising 20 supervised FCU examinations were compared with the corresponding results from conventional cardiac ultrasound by specialists. The agreement between groups of estimated LVEF <50%, after visual assessment of global left ventricular function, was compared. Types of HF were determined according to the outcomes from the reference examinations and serum levels of natriuretic peptides (NT-proBNP).ResultsOne hundred patients were examined by FCU that was performed by 1-4 independent examiners as well as by the reference method, contributing to 140 examinations (false positive rate, 19.0%; false negative rate, 52.6%; sensitivity, 47.4% [95% confidence interval [CI]: 27.3-68.3]; specificity, 81.0% [95% CI: 73.1-87.0]; Cohen's kappa measure for agreement=0.22 [95% CI: 0.03-0.40]). Among patients with false negative examinations, 1/7 had HF with LVEF <40%, while the others had HF with LVEF 40-49% or did not meet the full criteria for HF. In patients with NT-proBNP >125ng/L and fulfilling the criteria for HF (68/94), HF with preserved LVEF (>= 50%) predominated, followed by mid-range (40-49%) or reduced LVEF (<40%) HF types (53.2, 11.7 and 7.4%, respectively).ConclusionsThere was poor agreement between expert examiners using standard ultrasound equipment and non-experts using a handheld ultrasound device to identify patients with reduced LVEF. Asides from possible shortcomings of the training programme, the poor performance of non-experts could be explained by their limited experience in identifying left ventricular dysfunction because of the low percentage of patients with HF and reduced ejection fraction seen in the primary care setting.Trial registrationThe study was registered at ClinicalTrials.gov (NCT02939157). Registered 19 October 2016.

  • 41.
    Skielta, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Rheumatology.
    Soderstrom, L.
    Rantapää Dahlqvist, Solbritt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Rheumatology.
    Wållberg Jonsson, Solveig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Rheumatology.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Rheumatology.
    Trends in mortality, co-morbidity and treatment after acute myocardial infarction in patients with rheumatoid arthritis 1998-20132017In: Annals of the Rheumatic Diseases, ISSN 0003-4967, E-ISSN 1468-2060, Vol. 76, p. 113-113Article in journal (Other academic)
  • 42.
    Stenfors, Nikolai
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    The Prevalence of COPD in Individuals with Acute Coronary Syndrome: A Spirometry-Based Screening Study2015In: COPD: Journal of Chronic Obstructive Pulmonary Disease, ISSN 1541-2555, E-ISSN 1541-2563, Vol. 12, no 4, p. 453-461Article in journal (Refereed)
    Abstract [en]

    Background: The prevalence of COPD among individuals with acute coronary syndrome (ACS) is estimated at 5% to 18%, and COPD appears to be a predictor of poor outcome. Diagnosis of COPD has mostly been based on medical records without spirometry. As COPD is largely undiagnosed and misdiagnosed, the prevalence and clinical significance of COPD in the ACS population has not been reliably assessed. The present study aimed to estimate the prevalence of COPD in patients with ACS and evaluate the accuracy of medical record-based COPD diagnoses. Methods: This was a single-centre spirometry screening study for COPD in patients admitted for ACS in the county of Jämtland, Sweden. Patient medical records were reviewed to register previous medical history. Spirometry was performed prior to discharge or at the first follow-up outpatient visit after discharge. COPD was defined as a post-bronchodilator FEV1/FVC of <0.7 or below lower limit of normal. Results: Of 743 eligible patients, 407 performed spirometry. Five percent had COPD according to medical records; 11% and 5% fulfilled spirometric criteria of COPD according to FEV1/FVC of < 0.7 (p = 0.002) and below lower limit of normal definitions, respectively. “COPD according to medical history” had a sensitivity of 23%, specificity of 98%, positive predictive value of 53%, and negative predictive value of 91% compared with spirometric COPD FEV1/FVC of < 0.7 Conclusions: In patients with ACS, COPD is underdiagnosed and misdiagnosed. We raise concerns regarding the validity of medical record-based COPD in evaluating the biological and clinical association between COPD and coronary disease. ­Clinical Trial Registration: ISRCTN number 05697808 (www.controlled-trials.com)

  • 43.
    Ulvenstam, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Unit of Research, Education and Development, Östersund Hospital, Sweden.
    Henriksson, Robin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Söderström, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Ischemic stroke rates decrease with increased ticagrelor use after acute myocardial infarction in patients treated with percutaneous coronary intervention2018In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 25, no 11, p. 1219-1230Article in journal (Refereed)
    Abstract [en]

    Aims: It is unknown whether dual antiplatelet therapy with ticagrelor instead of clopidogrel reduces the risk of ischaemic stroke in acute myocardial infarction patients that undergo percutaneous coronary intervention. This study investigated whether the introduction of dual antiplatelet therapy with ticagrelor was associated with reduced ischaemic stroke risk in a real-world population.

    Methods and results: Patients with ischaemic stroke after acute myocardial infarction from 8 December 2009-31 December 2013 were identified using the Register for Information and Knowledge on Swedish Heart Intensive Care Admissions and the Swedish National Patient Register. The study period was divided into two similar periods using the date of the first prescription of ticagrelor as the cut-off. The risk of ischaemic stroke in percutaneous coronary intervention-treated acute myocardial infarction patients during the first period (100% clopidogrel treatment) versus the second period (60.7% ticagrelor treatment) was assessed using Kaplan-Meier analysis. Variables associated with ischaemic stroke were identified using a multivariable Cox proportional hazards model. There were 686 ischaemic stroke events (2.0%) among 34931 percutaneous coronary intervention-treated acute myocardial infarction patients within one year, 366 (2.2%) during the first period and 320 (1.8%) during the second period (p=0.004). The Cox model showed a 21% relative risk reduction in ischaemic stroke in the second period versus the first one (hazard ratio 0.79, 95% confidence interval, 0.68-0.92; p=0.003). The independent predictors of increased stroke risk were older age, hypertension, diabetes mellitus, atrial fibrillation, heart failure during hospitalization, previous ischaemic stroke, and ST-segment elevation myocardial infarction.

    Conclusion: The risk of ischaemic stroke in percutaneous coronary intervention-treated acute myocardial infarction patients decreased after the introduction of ticagrelor in Sweden.

  • 44.
    Ulvenstam, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Kajermo, Ulf
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Skövde, Sweden.
    Modica, Angelo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Jernberg, Tomas
    Solna, Sweden.
    Söderström, Lars
    Frösön, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Incidence, Trends, and Predictors of Ischemic Stroke 1 Year After an Acute Myocardial Infarction2014In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 45, no 11, p. 3263-3268Article in journal (Refereed)
    Abstract [en]

    Background and Purpose Ischemic stroke after acute myocardial infarction is an important complication. It is unknown whether the risk has changed because the treatment of acute myocardial infarction has improved during the past decade. There is also conflicting data about predictors of stroke risk. Methods To obtain the 1-year incidence of stroke after acute myocardial infarction, the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions database for the years 1998 to 2008 was merged with the Swedish National Patient Register (NPR). The time trend was studied by dividing the entire time period into 5 separate periods. Independent predictors were identified using a multivariable Cox proportional hazards regression model. Results Between 1998 and 2008, 7185 of 173 233 patients with acute myocardial infarction had an ischemic stroke within 1 year (4.1%). There was a 20% relative risk reduction during the study period (1998-2000 versus 2007-2008) relative risk 0.80 (95% confidence interval, 0.75-0.86; P<0.001. Independent predictors of stroke were age, female sex, ST-segment-elevation myocardial infarction, previous stroke, previous diabetes mellitus, heart failure at admission, angiotensin-converting enzyme inhibitor treatment and atrial fibrillation. Reperfusion treatment with fibrinolysis and percutaneous coronary intervention and treatment with aspirin, P2Y12-inhibitors, and statins predicted a reduced risk of stroke. Conclusions The risk of ischemic stroke within a year after myocardial infarction is substantial but has clearly been reduced during the studied time period. The major predictive factors found to correlate well with previous investigations. Reperfusion treatment, thrombocyte aggregation inhibition, and lipid lowering are the main contributors to the observed risk reduction.

  • 45.
    Valham, Fredrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Rabben, Terje
    Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Clinical Neurophysiology.
    Stenlund, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Wiklund, Urban
    Umeå University, Faculty of Science and Technology, Centre for Biomedical Engineering and Physics (CMTF).
    Franklin, Karl A
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Increased risk of stroke in patients with coronary artery disease and sleep apnea: a 10-year follow-up2008In: Circulation, ISSN 0009-7322, E-ISSN 1524-4539, Vol. 118, no 9, p. 955-960Article in journal (Refereed)
    Abstract [en]

    Background The effect of sleep apnea on mortality and cardiovascular morbidity is mainly unknown. We aimed to study whether sleep apnea is related to stroke, death, or myocardial infarction in patients with symptomatic coronary artery disease.

    Methods and Results A total of 392 men and women with coronary artery disease referred for coronary angiography were examined by use of overnight sleep apnea recordings. Sleep apnea, defined as an apnea-hypopnea index ≥5, was recorded in 54% of the patients. All patients were followed up prospectively for 10 years, and no one was lost to follow-up. Stroke occurred in 47 (12%) of 392 patients during follow-up. Sleep apnea was associated with an increased risk of stroke, with an adjusted hazard ratio of 2.89 (95% confidence interval 1.37 to 6.09, P=0.005), independent of age, body mass index, left ventricular function, diabetes mellitus, gender, intervention, hypertension, atrial fibrillation, a previous stroke or transient ischemic attack, and smoking. Patients with an apnea-hypopnea index of 5 to 15 and patients with an apnea-hypopnea index ≥15 had a 2.44 (95% confidence interval 1.08 to 5.52) and 3.56 (95% confidence interval 1.56 to 8.16) times increased risk of stroke, respectively, than patients without sleep apnea, independent of confounders (P for trend=0.011). Death and myocardial infarction were not related to sleep apnea. Intervention in the form of coronary artery bypass grafting or percutaneous coronary intervention was related to a longer survival but did not affect the incidence of stroke.

    Conclusions Sleep apnea is significantly associated with the risk of stroke among patients with coronary artery disease who are being evaluated for coronary intervention.

  • 46.
    Ögren, J.
    et al.
    Hosp Ostersund, Dept Internal Med, Sect Cerebrovasc Dis, Ostersund, Sweden.
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Bergström, L.
    Hosp Ostersund, Dept Internal Med, Neurol Sect, Ostersund, Sweden.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Intracranial hemorrhage after ischemic stroke Incidence, time-trends and predictors in a Swedish nationwide cohort of 196765 patients2014In: International Journal of Stroke, ISSN 1747-4930, E-ISSN 1747-4949, Vol. 9, p. 165-165Article in journal (Other academic)
    Abstract [en]

    BACKGROUND:

    Epidemiological data on the risk of intracranial hemorrhage (ICrH) after ischemic stroke are sparse. The aims of this study were to describe incidence, trends over time, and predictors of ICrH within 1 year after ischemic stroke.

    METHODS AND RESULTS:

    All patients registered in the Swedish stroke register Riksstroke for 1998 to 2009 were included (n=196 765), and data were combined with the National Patient Register to identify ICrH occurrence. A matched reference population was obtained. Incidence rates and cumulative incidences were calculated. Multivariable regression analyses were used to identify predictors. Analyses were performed separately for the first 30 days and days 31 to 365 after ischemic stroke. The incidence rate was 1.97% per year at risk for the first year (0.13% in the reference population) and 0.85% excluding the first 30 days. Over time, the cumulative incidence increased the first 30 days but decreased over days 31 to 365. Thrombolysis, previous ICrH, atrial fibrillation, and male sex were associated with increased risk of ICrH during the first 30 days. Previous ICrH, increasing age, and male sex were associated with increased risk during days 31 to 365. Statins and antithrombotic treatment did not independently predict ICrH occurrence.

    CONCLUSIONS:

    The incidence of ICrH within 1 year after ischemic stroke was ≈2% per year at risk, about 15 times higher compared with the reference population. Over the study period, ICrH risk increased within the first 30 days but decreased thereafter. Previous ICrH, thrombolysis, and male sex affected the risk, whereas an increased use of antithrombotic treatments and statins did not.

  • 47.
    Ögren, Joachim
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Bergström, Lisa
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Intracranial Hemorrhage After Ischemic Stroke Incidence, Time Trends, and Predictors in a Swedish Nationwide Cohort of 196765 Patients2015In: Circulation. Cardiovascular Quality and Outcomes, ISSN 1941-7713, E-ISSN 1941-7705, Vol. 8, no 4, p. 413-420Article in journal (Refereed)
    Abstract [en]

    Background Epidemiological data on the risk of intracranial hemorrhage (ICrH) after ischemic stroke are sparse. The aims of this study were to describe incidence, trends over time, and predictors of ICrH within 1 year after ischemic stroke. Methods and Results All patients registered in the Swedish stroke register Riksstroke for 1998 to 2009 were included (n=196 765), and data were combined with the National Patient Register to identify ICrH occurrence. A matched reference population was obtained. Incidence rates and cumulative incidences were calculated. Multivariable regression analyses were used to identify predictors. Analyses were performed separately for the first 30 days and days 31 to 365 after ischemic stroke. The incidence rate was 1.97% per year at risk for the first year (0.13% in the reference population) and 0.85% excluding the first 30 days. Over time, the cumulative incidence increased the first 30 days but decreased over days 31 to 365. Thrombolysis, previous ICrH, atrial fibrillation, and male sex were associated with increased risk of ICrH during the first 30 days. Previous ICrH, increasing age, and male sex were associated with increased risk during days 31 to 365. Statins and antithrombotic treatment did not independently predict ICrH occurrence. Conclusions The incidence of ICrH within 1 year after ischemic stroke was approximate to 2% per year at risk, about 15 times higher compared with the reference population. Over the study period, ICrH risk increased within the first 30 days but decreased thereafter. Previous ICrH, thrombolysis, and male sex affected the risk, whereas an increased use of antithrombotic treatments and statins did not.

  • 48.
    Ögren, Joachim
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Söderström, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Long-term, telephone-based follow-up after stroke and TIA improves risk factors: 36-month results from the randomized controlled NAILED stroke risk factor trial2018In: BMC Neurology, ISSN 1471-2377, E-ISSN 1471-2377, Vol. 18, article id 153Article in journal (Refereed)
    Abstract [en]

    Background: Strategies are needed to improve adherence to the blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) level recommendations after stroke and transient ischemic attack (TIA). We investigated whether nurse-led, telephone-based follow-up that included medication titration was more efficient than usual care in improving BP and LDL-C levels 36 months after discharge following stroke or TIA.

    Methods: All patients admitted for stroke or TIA at Ostersund hospital that could participate in the telephone-based follow-up were considered eligible. Participants were randomized to either nurse-led, telephone-based follow-up (intervention) or usual care (control). BP and LDL-C were measured one month after discharge and yearly thereafter. Intervention group patients who did not meet the target values received additional follow-up, including lifestyle counselling and medication titration, to reach their treatment goals (BP < 140/90 mmHg, LDL-C < 2.5 mmol/L). The primary outcome was the systolic BP level 36 months after discharge.

    Results: Out of 871 randomized patients, 660 completed the 36-month follow-up. The mean systolic and diastolic BP values in the intervention group were 128.1 mmHg (95% CI 125.8-1305) and 75.3 mmHg (95% CI 73.8-76.9), respectively. This was 6.1 mmHg (95% CI 3.6-8.6, p < 0.001) and 3.4 mmHg (95% CI 1.8-5.1, p < 0.001) lower than in the control group. The mean LDL-C level was 22 mmol/L in the intervention group, which was 03 mmol/L (95% CI 0.2-0.5, p < 0.001) lower than in controls. A larger proportion of the intervention group reached the treatment goal for BP (systolic: 79.4% vs. 55.3%, p < 0.001; diastolic 90.3% vs. 77.9%, p < 0.001) as well as for LDL-C (69.3% vs. 48.9%, p < 0.001).

    Conclusions: Compared with usual care, a nurse-led telephone-based intervention that included medication titration after stroke or TIA improved BP and LDL-C levels and increased the proportion of patients that reached the treatment target 36 months after discharge.

  • 49.
    Ögren, Joachim
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Irewall, Anna-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Söderström, Lars
    Mooe, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Medicine.
    Serious hemorrhages after ischemic stroke or TIA - Incidence, mortality, and predictors2018In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 4, article id e0195324Article in journal (Refereed)
    Abstract [en]

    Background: Data are lacking on the risk and impact of a serious hemorrhage on the prognosis after ischemic stroke (IS) or transient ischemic attack (TIA). We aimed to estimate the incidence of serious hemorrhage, analyze the impact on mortality, and identify predictors of hemorrhage after discharge from IS or TIA.

    Methods and findings: All patients admitted to Östersund Hospital for an IS or TIA in 2010–2013 were included (n = 1528, mean age: 75.1 years). Serious hemorrhages were identified until 31st December 2015. Incidence rates were calculated. The impact on mortality (stratified by functional level) was determined with Kaplan-Meier analysis. Non-parametric estimation under the assumption of competing risk was performed to assess the cumulative incidence and predictors of serious hemorrhages. The incidence rates of serious (n = 113) and intracranial hemorrhages (n = 45) after discharge from IS and TIA were 2.48% and 0.96% per year at risk, respectively. Patients with modified Rankin Scale (mRS) scores of 3–5 exhibited 58.9% mortality during follow-up and those with mRS scores of 0–2 exhibited 18.4% mortality. A serious hemorrhage did not affect mortality in patients with impaired functional status, but it increased the risk of death in patients with mRS scores of 0–2. Hypertension was associated with increased risk of serious hemorrhage.

    Conclusions: We found that, after discharge from an IS or TIA, serious hemorrhages were fairly common. Impairments in function were associated with high mortality, but serious hemorrhages only increased the risk of mortality in patients with no or slight disability. Improved hypertension treatment may decrease the risk of serious hemorrhage, but in patients with low functional status, poor survival makes secondary prevention challenging.

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