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IMPORTANCE: Risk stratification strategies in primary prevention of coronary events lack precision.

OBJECTIVE: To determine whether prediction of first coronary events is improved by adding information on coronary atherosclerosis from coronary computed tomography angiography (CCTA) to a model using the pooled cohort equation (PCE) risk score tool and the coronary artery calcification score (CACS).

DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study including individuals aged 50 to 64 years randomly recruited from the general population and examined at 6 university hospitals in Sweden from 2013 to 2018, with a median follow-up of 7.8 years. A sample of 30 154 individuals underwent cardiopulmonary imaging, physical examinations, routine laboratory tests, questionnaires, and/or functional tests. This study included 24 791 individuals without previous cardiovascular disease for whom high-quality CCTA images were available. Events were followed up via registers until September 2024.

EXPOSURES: The information used from the CCTA images was the extent of coronary atherosclerosis (segment involvement score), presence of noncalcified atherosclerosis, and presence of coronary obstructive disease (stenosis ≥50%).

MAIN OUTCOMES AND MEASURES: The outcome was a composite of first occurrence of nonfatal myocardial infarction or death from coronary heart disease.

RESULTS: During follow-up, 304 coronary events occurred. Segment involvement scores of 3 to 4 and greater than 4 and presence of noncalcified atherosclerosis were associated with hazard ratios of 2.71 (95% CI, 1.34-5.44), 5.27 (95% CI, 2.50-11.07), and 1.66 (95% CI, 1.23-2.22), respectively. In a model based on the PCE and CACS, CCTA-derived data improved risk discrimination (C statistic improved from 0.764 to 0.779; P = .004) and risk reclassification (net reclassification improvement of 0.133 [95% CI, 0.031-0.165]), conferred a net correct upward reclassification of 14.2% in those with events and incorrectly classified 1.6% of participants not experiencing an event into a higher-risk category. Because of the low event rate in the cohort, reclassification mainly occurred in the group classified as at low risk (<5%) according to the PCE.

CONCLUSIONS AND RELEVANCE: Information on coronary atherosclerosis from CCTA modestly improved risk prediction beyond traditional risk factors and CACS in identifying individuals at risk of coronary events and in need of primary prevention.

Aims: To evaluate the effects of a nurse-led, person-centred outpatient clinic on patient-reported outcomes in patients with atrial fibrillation (AF).

Methods and results: In this open-label, parallel randomized controlled trial, 140 patients with AF were randomly assigned. The intervention group met experienced cardiac nurses, trained in person-centred care and AF. The control group met a physician in accordance with usual care. At baseline, and after 6 months, patients completed questionnaires: The EuroQol five-dimension three-level questionnaire (EQ-5D-3L), the EuroQol Visual Analogue Scale, the Arrhythmia-Specific questionnaire in Tachycardia and Arrhythmia (ASTA), the Brief Illness Perception Questionnaire (B-IPQ), and the Hospital Anxiety and Depression Scale. Over time, health-related quality of life (HRQoL), as measured by the EQ-5D index and the ASTA mental subscale, improved in the intervention group (P = 0.035 and P  = 0.014, respectively) and the control group (P = 0.031 and P = 0.026, respectively). Illness coherence (B-IPQ) also improved in both groups (P < 0.001 and P = 0.012, respectively). In the nurse-led group, HRQoL as measured by the ASTA total scale (P = 0.035) and personal control (B-IPQ) (P = 0.005) improved, while illness-related concerns (P = 0.008) and emotional representations (B-IPQ) (P = 0.001) decreased. There were no significant between-group differences on any of the analysed measurement instruments.

Conclusion: No significant differences were observed between groups. However, improvements in HRQoL and illness coherence in both groups suggest that receiving support from nurses and physicians may improve these outcomes. Furthermore, the results suggest that a nurse-led, person-centred outpatient clinic may reduce patients’ emotional responses and concerns related to the illness, while strengthening their sense of personal control.

Objectives: To describe the rationale, design and data collection procedures of the Swedish CArdioPulmonary bioImage Study (SCAPIS) re-examination, which, in its further scope, aims to quantify and explain the development of atherosclerosis, pathological cardiovascular ageing, longitudinal decline in lung function and the malignant transformation of pulmonary nodules among middle-aged Swedes in the longitudinal SCAPIS.

Methods: SCAPIS re-examination is a prospective observational study reassessing approximately 15,000 participants (50% of the original SCAPIS cohort) from six university hospitals. Participants were aged 55–75 years at follow-up, occurring a median of 8.1 years after the baseline investigation. Standardized protocols replicated baseline imaging and functional assessments, including questionnaires, clinical assessments and extensive computer tomography imaging.

Results: Interim analyses of the first 5000 participants (50% women; median age 65.5 [61.8–69.1] years) indicated an expected age-related increase in the prevalence and treatment of hypertension (from 22% to 37%) and diabetes (from 4% to 8%), together with a modest rise in central adiposity. Body mass index (median 26.6 kg/m2) and the proportion of obesity (22%) remained largely stable, whereas current smoking decreased from 7.5% to 3.4%. The observed patterns were consistent in men and women.

Conclusion: Here we present the rationale, design, methods and management of incidental findings in the SCAPIS re-examination. By integrating serial imaging, functional testing and biomarker profiling, the re-examination will furnish unprecedented insight into cardiopulmonary disease dynamics in an ageing population. These data will underpin personalized risk prediction and inform preventive strategies, while serving as a benchmark for future population-based imaging cohorts.

AIM: This study aimed to establish general consensus on a systematic needs assessment model to determine eligibility for cardiac rehabilitation (CR) as part of secondary prevention in individuals with atrial fibrillation (AF). Specific objectives included identifying relevant needs assessment criteria and establishing consensus on referral criteria.

METHODS: A Delphi study was conducted following the ACCORD guidelines (ACcurate COnsensus Reporting Document) with participation of an international, multi-disciplinary expert panel including physicians, nurses and other healthcare professionals, across primary and secondary care as well as academic research. The panel also included six people who had AF themselves. The Delphi process involved three iterative rounds of surveys and a video meeting to determine needs assessment criteria and facilitate consensus. Data collection included qualitative feedback and quantitative voting on proposed criteria.

RESULTS: Sixty-nine experts participated. There was high agreement on the importance of the study, which identified 12 needs assessment criteria related to AF symptom burden, health-related quality of life, anxiety, medicine adherence, and various risk factors. Whilst there was agreement on the needs assessment model, experts noted that referral criteria should be flexible and tailored to local healthcare settings, emphasizing that each individual's situation is unique.

CONCLUSION: This Delphi study established a needs assessment model that can be adapted to local contexts for individuals with AF. More research is needed to refine referral criteria and ensure effective implementation of individually tailored CR strategies.

Background and Aims: Covid-19 is a multiorgan disease affecting the kidney. However, the risk of kidney injury after infection remains unknown. Therefore, this study aimed to determine the risk and time of first ever diagnosed kidney injury following Covid-19, and determine the impact of Covid-19 disease severity on this risk.

Research Questions:

• Is the risk of a first ever kidney injury increased following Covid-19 in a nationwide Swedish whole population setting?
• If so, which patients are at higher risk?

Method: The total Swedish adult population were included in the study from January 1, 2020, to July 26, 2022. Nationwide multi-registry data was used and cross-linked with Personal Identification Numbers. Data was retrieved from the Swedish Inpatient, Outpatient, Covid-19 (SmiNet), Vaccination, Intensive Care, Cancer and Cause of Death Registries. Covid-19 date (exposure) was defined as the first SARS-CoV-2 related date registered in SmiNet based on the date of symptom onset, sample date, diagnosis date or date of report. All ICD-codes (IDC9 and ICD10) used for kidney injury registered since 1987 and 2000 respectively were identified to exclude patients with previous kidney injury. Outcome was defined as all first-time events of kidney injury diagnosis (acute, non-specified and chronic) reported with ICD10 codes post Covid-19 date, during the study period. We used the Self-Controlled Case Series (SCCS) method to determine the incidence rate ratio (IRR) of kidney injury during risk periods up to 6 months after infection. In the SCCS analysis, all individuals with reported Covid-19 (exposure) and first time diagnosed kidney injury (outcome) were included. The adjusted SCCS model was used, which considers deaths in the model.

Results: Among the total 2 426 423 Covid-19 cases, there were 10 351 first kidney injury events diagnosed. In a preliminary analysis, the risk of developing kidney injury after Covid-19 was increased up to 90 days post infection with the highest IRR during the first week (day 1–7) of Covid-19 onset being 56.1 (95% CI 52.5–60). The highest risk was day 0 with nearly 200-fold increased risk, however, due to risk of selection bias (Fonseca-Rodriguez O., 2021) when including day 0, this data is excluded from the first week and should be considered with caution. The IRR was elevated for a longer time for men than for women. For women, the IRR was elevated up until 60 days post infection, compared to 90 days for men. Stratified by age groups, the IRRs were highest in the group aged 51–74 years, compared with those ≤50 years and >74 years. Individuals with higher Covid-19 disease severity were also at higher risk than those with mild infection.

Conclusion: Covid-19 is associated with an increased risk of kidney injury according to this nationwide preliminary analysis, including more than two million Covid-19 cases in Sweden. The risk of a first ever diagnosed kidney injury is elevated up to 90 days after Covid-19, which is later than previously shown. The risk was higher for men than for women and was highest for age group 51–74 years. These results highlight the importance of vaccination to prevent severe Covid-19, and if diseased by Covid-19, follow up to detect kidney injury post Covid-19.

Aims: Despite increasing prevalence, the general population lacks knowledge regarding diagnosis, implications, and management of cardiac arrhythmias (CA). This study aims to assess public perception of CA and identify knowledge gaps.

Methods and results: The 36-item PULSE survey was disseminated via social media to the general population and conducted under the auspices of and results the European Heart Rhythm Association Scientific Initiatives Committee (EHRA SIC) with EHRA patient committee support. Among 3924 participants (2177 healthy, 1747 with previously diagnosed CA; 59% female, 90% European), 81% reported fear of CA. Females were more likely to be ‘very’ or ‘moderately afraid’ than males [odds ratio (OR) 1.159 (1.005, 1.337), P = 0.046]. While most recognized complications of CA—heart failure (82%), stroke (80%), and death (75%)—43% were unaware that CA can be asymptomatic. Those with cardiopulmonary resuscitation (CPR) training in the past 5 years were 2.6 times and 4.7 times more confident identifying sudden cardiac death and initiating CPR (P < 0.001). Confidence was lower in retired participants [OR 0.574 (0.499, 0.660), P < 0.001] and Southern Europeans [OR 0.703 (0.600, 0.824), P < 0.001]. Without CPR training, only 15% felt confident initiating CPR. Among CA participants, 28% reported severe to disabling daily symptoms. Males were more often asymptomatic (20% vs. 9%, P < 0.001). Treatment rates were comparable between sex categories (81% vs. 79%, P = 0.413). Interdisciplinary shared decision-making processes were reported by 4%. Notably, 1 in 10 CA cases was self-diagnosed using a wearable device, and 30% of CA participants used smartwatches for self-monitoring.

Conclusion: Significant knowledge gaps regarding CA exist in the general population. Targeted educational initiatives could be a viable tool to enhance public knowledge, confidence in detecting and managing arrhythmias, particularly for women, who experience greater fear and symptom severity despite similar treatment rates.

Object: Type 2 diabetes (T2D) is an established risk factor for cardiovascular disease (CVD), with increased risk already observed in the prediabetic state. This study aimed to investigate the association of insulin sensitivity, secretion, and clearance with subclinical atherosclerosis in a randomly selected cohort of Swedish adults aged 50–64 years without known diabetes.

Material and Methods: For this cross-sectional analysis, data from the Umeå site of the Swedish CArdioPulmonary BioImage Study (SCAPIS) were used, which included 2507 individuals aged 50–64 years. After applying exclusion criteria, 2054 participants remained. Insulin sensitivity, secretion, and clearance were calculated using an oral glucose tolerance test (OGTT). Atherosclerosis was assessed by coronary computed tomography angiography (CCTA) and carotid ultrasound, yielding coronary artery calcification scores (CACS), coronary segment involvement scores (SIS), and total carotid plaque counts. Ordinal regression models analyzed associations between insulin measures and atherosclerosis, adjusting for cardiovascular risk factors.

Results: Lower insulin sensitivity, as measured by the GUTT index, was associated with higher CACS and SIS, but not with carotid plaque count. No significant relationship was found between insulin secretion (Insulinogenic Index) and any atherosclerotic marker. Reduced insulin clearance was associated with CACS and SIS in unadjusted analyses; however, these associations did not persist after multivariable adjustment.

Conclusion: In individuals without diabetes, insulin resistance is associated with markers of subclinical coronary atherosclerosis, reinforcing its role in early CVD. Insulin secretion or clearance are not directly associated with measures of subclinical atherosclerosis in this population but may contribute indirectly via effects on circulating insulin levels.

To investigate whether coronary artery disease (CAD) burden is associated with plasma levels of the myocardial biomarkers Troponin I (TropI) and NT-proBNP in a large population-based sample using a cross-sectional design. Coronary computerized tomography (CT) angiography was performed in 25,859 subjects without a history of atherosclerotic disease from SCAPIS study (age 50–65, 52% women). TropI and NT-proBNP were measured in plasma. Segment involvement score (SIS) was the primary exposure and TropI the primary outcome. Both SIS and coronary artery calcium score, were associated with TropI levels following adjustment for age, sex and multiple confounders (p < 0.001), with similar relationships in men and women. Proximal segments from all three coronary arteries were related to TropI levels independently of one another. Adding TropI to traditional risk factors marginally increased discrimination of atherosclerosis as compared to risk factors alone (C-statistics + 0.0005, p = 0.014). SIS was related also to NT-proBNP levels, mainly in men, but with lower estimates than TropI. The burden of CAD was related to TropI levels in both men and women. All three major coronary arteries contributed to this relationship. Adding TropI to traditional risk factors resulted in only marginally improved discrimination of coronary atherosclerosis.

Background and Aim: COVID-19 is a multiorgan disease and there has been increasing reports of cardiovascular complications. However, previous studies have shown conflicting results and have mainly included hospitalized individuals with severe disease. The aim of this thesis was to estimate the risk of incident cardiovascular disease following COVID-19. 

Material and Methods: This project was based on Swedish national register data from all individuals who tested positive for SARS-CoV-2 between February 1^st, 2020, and May 25^th, 2021. Outcomes were events of incident cardiovascular disease, recorded as ICD-10 codes in the National Patient Register. Self-controlled case series (SCCS) studies and matched cohort studies were performed to determine the relative risks for a new onset cardiovascular event following COVID-19. Moreover, a data-simulation study was performed to investigate features that could introduce bias in the SCCS studies: the "day zero-effect", i.e., a high incidence of events at the COVID-19 date; and the increase in mortality due to cardiovascular events.

Results: In the SCCS studies, the risk of cardiovascular disease was significantly increased compared to the control period as follows: up to 14 days after COVID-19 for acute myocardial infarction; up to 1 month for ischemic stroke; up to 3 months for deep vein thrombosis; up to 6 months for pulmonary embolism; up to 2 months for bleeding and for atrial tachycardias; up to 6 months for paroxysmal supraventricular tachycardias; and up to 14 days for bradyarrhythmias. In the matched cohort studies, COVID-19 was associated with an approximately 3- and 4-fold increase in the risk of acute myocardial infarction and ischemic stroke, respectively, during day 1-14 after the infection. During day 1-30 following the infection, the increase in risk was 5-fold for deep vein thrombosis; 33-fold for pulmonary embolism; 2-fold for bleeding; 12-fold for atrial tachycardias; 5-fold for paroxysmal supraventricular tachycardias; and 3-fold for bradyarrhythmias. The relative risks were higher in older individuals with comorbidities, with more severe COVID-19, and during the first months of the pandemic. Unvaccinated individuals had a higher risk of arrhythmias. In the data-simulation study, bias was introduced by including "day-zero events" in the analyses. Moreover, the extended rather the traditional SCCS model was more appropriate to minimize possible bias introduced by the increase in mortality due to cardiovascular events.

Conclusion: There is an increased risk of cardiovascular complications in individuals with COVID-19, especially in individuals with severe disease. These findings highlight the value of diagnostic and prophylactic strategies in individuals with COVID-19, such as risk factor control or thromboprophylaxis, and the value of vaccination. 

Aims: To identify robust circulating predictors for incident atrial fibrillation (AF) using classical regressions and machine learning (ML) techniques within a broad spectrum of candidate variables.

Methods and results: In pooled European community cohorts (n = 42 280 individuals), 14 routinely available biomarkers mirroring distinct pathophysiological pathways including lipids, inflammation, renal, and myocardium-specific markers (N-terminal pro B-type natriuretic peptide [NT-proBNP], high-sensitivity troponin I [hsTnI]) were examined in relation to incident AF using Cox regressions and distinct ML methods. Of 42 280 individuals (21 843 women [51.7%]; median [interquartile range, IQR] age, 52.2 [42.7, 62.0] years), 1496 (3.5%) developed AF during a median follow-up time of 5.7 years. In multivariable-adjusted Cox-regression analysis, NT-proBNP was the strongest circulating predictor of incident AF [hazard ratio (HR) per standard deviation (SD), 1.93 (95% CI, 1.82-2.04); P < 0.001]. Further, hsTnI [HR per SD, 1.18 (95% CI, 1.13-1.22); P < 0.001], cystatin C [HR per SD, 1.16 (95% CI, 1.10-1.23); P < 0.001], and C-reactive protein [HR per SD, 1.08 (95% CI, 1.02-1.14); P = 0.012] correlated positively with incident AF. Applying various ML techniques, a high inter-method consistency of selected candidate variables was observed. NT-proBNP was identified as the blood-based marker with the highest predictive value for incident AF. Relevant clinical predictors were age, the use of antihypertensive medication, and body mass index.

Conclusion: Using different variable selection procedures including ML methods, NT-proBNP consistently remained the strongest blood-based predictor of incident AF and ranked before classical cardiovascular risk factors. The clinical benefit of these findings for identifying at-risk individuals for targeted AF screening needs to be elucidated and tested prospectively.