Abstract
Background
Safety data for different anticoagulant medications in venous thromboembolism (VTE) are scarce, in particular for extended treatment.
Objectives
To compare major bleeding rates ...depending on the choice of anticoagulation during initial (first 6 months) and extended treatment (6 months up to 5 years).
Methods
A nationwide register‐based study including cancer‐free patients with a first‐time VTE between 2014 and 2020. Cox proportional hazards models were used to compare bleeding rates.
Results
We included 6558 patients on warfarin, 18,196 on rivaroxaban, and 19,498 on apixaban. At 6 months, 4750 (72.4%) remained on warfarin, 11,366 (62.5%) on rivaroxaban, and 11,940 (61.2%) on apixaban. During initial treatment, major bleeding rates were 3.86 (95% CI 3.14–4.58), 2.93 (2.55–3.31), and 1.95 (1.65–2.25) per 100 patient‐years for warfarin, rivaroxaban, and apixaban, respectively, yielding adjusted hazard ratios (aHRs) of 0.89 (95% CI 0.71–1.12) for rivaroxaban versus warfarin, 0.55 (0.43–0.71) for apixaban versus warfarin, and 0.62 (0.50–0.76) for apixaban versus rivaroxaban. During extended treatment, major bleeding rates were 1.55 (1.19–1.91), 1.05 (0.85–1.26), and 0.96 (0.78–1.15) per 100 patient‐years for warfarin, rivaroxaban, and apixaban, respectively, with aHRs of 0.72 (0.53–0.99) for rivaroxaban versus warfarin, 0.60 (0.44–0.82) for apixaban versus warfarin, and 0.85 (0.64–1.12) for apixaban versus rivaroxaban. Previous bleeding and increasing age were risk factors for bleeding both during initial and extended treatment.
Conclusion
Apixaban had a lower bleeding risk than warfarin or rivaroxaban during initial treatment. During extended treatment, bleeding risk was similar for apixaban and rivaroxaban, and higher with warfarin.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
We aimed to identify determinants in acute stroke that are associated with falls during the stroke unit stay. In order to enable individualized preventive actions, this knowledge is fundamental. ...Based on local and national quality register data on an unselected sample of 5065 stroke patients admitted to a stroke unit at a Swedish university hospital, univariable and multivariable logistic regression analyses were performed. The dependent variable was any fall during stroke unit stay. The independent variables related to function, activity, personal factors, time to assessment, comorbidities and treatments. Determinants of falls were: being male (odds ratio (OR) 2.25, 95% confidence interval (95% CI) 1.79-2.84), haemorrhagic stroke (OR 1.39, 95% CI 1.05-1.86), moderate stroke symptoms according to the National Institutes of Health Stroke Scale (NIHSS score 2-5 vs. NIHSS score 0-1) (OR 1.43, 95% CI 1.08-1.90), smoking (OR 1.70, 95% CI 1.29-2.25), impaired postural control in walking (OR 4.61, 95% CI 3.29-6.46), impaired postural control in standing (OR 1.60, 95% CI 1.25-2.05), stroke-related arm- and hand problems, OR 1.45, 95% CI 1.11-1.91), impaired cognition (OR 1.43, 95% CI 1.04-1.95), and urinary tract infection (OR 1.91, 95% CI 1.43-2.56). The findings from this study are useful in clinical practice and might help to improve patient safety after stroke.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Objectives
The prevalence of dementia is growing rapidly worldwide. The early identification and treatment of cognitive decline could reduce the burden on the health care system. Our objective was to ...investigate whether factors measured at an examination at age 50 predict cognitive impairment (CI) 23 years later.
Materials & Methods
In 1993 we enrolled a randomly selected sample of 798 men, 50 years of age, from the general population. They all underwent a physical examination, provided blood samples and filled out questionnaires addressing lifestyle and psychosocial factors. Cognitive testing was offered to all participants still alive in 2016, at age 73.
Results
A total of 333 men participated in the cognitive study, of which 80 (24.0%) performed at a level corresponding to mild cognitive impairment, and four (1.2%) at a level consistent with severe cognitive impairment. After the first step in the multivariable analysis, hypertension, heavy smoking, high intake of alcohol, financial stress, difficulty falling asleep, and cogwheel rigidity were associated with cognitive impairment. After further adjustment, only wide waist circumference measured in cm (OR 1.04, 95% CI 1.00–1.08, p = .04), leg pendulousness (OR 41.97, 95% CI 3.27–538.62, p = .004) and self‐assessed hidden irritability (OR 2.18, 95% CI 1.10–4.32, p = .03) at baseline, remained as being associated with cognitive impairment 23 years later.
Conclusions
Extrapyramidal symptoms such as leg pendulousness, at the age of 50, may be an indicator for very early identification of future cognitive decline.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Patients with congenital heart disease (CHD) may be at increased risk of ischemic stroke due to residual shunts, arrhythmias, and other cardiovascular abnormalities. We studied the ...relative risk and potential factors for developing ischemic stroke in children and young adults with CHD in Sweden.
Methods and Results
All patients in the Swedish Patient Register with a diagnosis of CHD, born between 1970 and 1993, were identified and compared with 10 controls for each patient, matched for age, sex, and county and randomly selected from the general population. Follow‐up data through 2011 were collected for both groups. Of 25 985 children and young adults with CHD (51.5% male, 48.5% female), 140 (0.5%) developed ischemic stroke. The hazard ratio for CHD patients developing ischemic stroke was 10.8 (95% CI, 8.5–13.6) versus controls. All major Marelli groups had significantly increased risk, but because of small CHD‐group sizes, only atrial septal defect/patent foramen ovale, double‐inlet ventricle, and aortic coarctation displayed significantly increased risk. In multivariate analysis of CHD patients, congestive heart failure carried the highest risk for developing ischemic stroke (hazard ratio 6.9 95% CI, 4.7–10.3), followed by hypertension and atrial fibrillation, which were also significantly associated with increased risk of ischemic stroke.
Conclusions
The risk of developing ischemic stroke was almost 11 times higher in young patients with CHD than in the general population, although absolute risk is low. Cardiovascular comorbidities were strongly associated with the development of ischemic stroke in young CHD patients.
Abstract
The early identification of individuals at risk of fear of falling after stroke is crucial in order to individualise preventive actions and interventions. The aim of this study was to ...identify the incidence of, and baseline factors in acute stroke that are associated with fear of falling at 6 months after stroke. Fear of falling was assessed by one question, which was answered by 279 of 452 eligible individuals. Univariable and multivariable logistic regression analyses were performed to determine the factors that were associated with fear of falling. The dependent variable was fear of falling at 6 months after stroke. The independent variables were related to function, activity and participation, including personal and environmental factors. Fear of falling was reported by 117 (41.9%) individuals. Poor postural control in acute stroke, measured using the modified version of the Postural Assessment Scale for Stroke Patients (odds ratio OR: 2.60, 95% confidence interval CI: 1.26–5.36), and being physically inactive prior to the stroke, measured using the Saltin-Grimby Physical Activity Scale (OR: 2.04, 95% CI: 1.01–4.12), were found to be associated with fear of falling at 6 months after stroke. The findings in this study are useful in clinical practice to optimise rehabilitation after stroke.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Objective
Among patients assessed by the emergency medical service (EMS) and hospitalized with a final diagnosis of stroke, to describe delays, patient characteristics, actions taken and outcome in ...relation to the early recognition of stroke by the EMS clinician.
Methods
Patients admitted to any of six stroke units in Region Västra Götaland, Sweden, with a final diagnosis of stroke from 1 January 2013 to 31 December 2015 were included. Data on follow‐up were retrieved from the Swedish Stroke Register.
Results
In all, 5467 patients were included. Stroke was recognized by the EMS clinician in 4396 cases (80.4%). The mean difference in the time from dialling 112 until arrival at the stroke unit was 556 min shorter when stroke was recognized, while the mean difference in the time from dialling 112 until a preliminary report from a computed tomography (CT) scan was 219 min shorter as compared with the patients in whom stroke was not recognized. After adjustment for age, sex, neurological deficits and coma, a lack of suspicion of stroke on EMS arrival was associated with an increased risk of death during three months of follow‐up (odds ratio 1.66; 95% confidence interval 1.19–2.32; p = .003).
Conclusion
Among patients with a stroke, more than 80% were recognized by the EMS clinician. Early recognition of stroke was associated with a markedly shorter time until arrival at the stroke unit and until the preliminary report of a CT scan. A lack of early stroke recognition was associated with an increased risk of death.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
Objective:
To identify the incidence of falls and factors present shortly after stroke, which are associated with the occurrence of falls over the first 12 months after stroke onset, following ...discharge from inpatient rehabilitation.
Design:
Prospective follow-up study.
Setting:
Stroke unit and outpatient department.
Subjects:
A total of 490 individuals with acute stroke.
Methods:
Postural control was assessed using the Swedish modified version of the Postural Assessment Scale for Stroke Patients. Data on self-reported falls were collected using a standardized questionnaire at three months after discharge and six and 12 months after stroke onset. Associations between characteristics during the acute phase after a stroke and falls after six and 12 months were investigated using univariable and multivariable regression analyses.
Main measures:
The endpoint was a self-reported fall.
Results:
Within three months after discharge, 38 of 165 respondents (23%) had experienced at least one fall. Within six and 12 months after stroke onset, respectively, 108 of 376 (29%) and 140 of 348 (40%) of the respondents had experienced at least one fall. Poor postural control (odds ratio 3.92, 95% confidence interval 2.07–7.45, P < 0.0001) and using a walking aid (odds ratio 2.84, 95% confidence interval 1.71–4.72, P < 0.0001) were predictors of falls after discharge within 12 months after stroke onset. The same variables were independent predictors of falls within six months.
Conclusion:
Poor postural control and using a walking aid in the acute phase after a stroke are associated with falls after discharge from a stroke unit within 12 months after stroke onset.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Stroke patients not eligible for acute intervention often have low priority and may spend long time at the emergency department (ED) waiting for admission. The aim of this retrospective case-control ...register study was to evaluate outcomes for such "low priority" stroke patients who were transported via Fast Track directly to the stroke unit, according to pre-specified criteria by emergency medical service (EMS). The outcomes of Fast Track patients, transported directly to stroke unit (cases) were compared with the outcomes of patients who fulfilled these critera for Fast Track, but instead were transported to the ED (controls). In all, 557 cases and 509 controls were identified. The latter spent a mean time of 237 min in the ED before admission. The 90-day mortality rate was 12.9% for cases and 14.7% for controls (n.s.). None of the secondary outcome events differed significantly between the groups: 28-day mortality rate; death rate during hospitalisation; proportion of pneumonias, falls or pressure ulcers; or health-related outcomes according to the EQ-5D-5L questionnaire. These findings indicates that the Fast Track to the stroke unit by an EMS is safe for selected stroke patients and could avoid non-valuable time in the ED.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Abstract
The QRS complex has been shown to be a prognostic marker in coronary artery disease. However, the changes in QRS duration over time, and its predictive value for cardiovascular disease in ...the general population is poorly studied. So we aimed to explore if increased QRS duration from the age of 50–60 is associated with increased risk of major cardiovascular events during a further follow-up to age 71. A random population sample of 798 men born in 1943 were examined in 1993 at 50 years of age, and re-examined in 2003 at age 60 and 2014 at age 71. Participants who developed cardiovascular disease before the re-examination in 2003 (n = 86) or missing value of QRS duration in 2003 (n = 127) were excluded. ΔQRS was defined as increase in QRS duration from age 50 to 60. Participants were divided into three groups: group 1: ΔQRS < 4 ms, group 2: 4 ms ≤ ΔQRS < 8 ms, group 3: ΔQRS ≥ 8 ms. Endpoints were major cardiovascular events. And we found compared with men in group 1 (ΔQRS < 4 ms), men with ΔQRS ≥ 8 ms had a 56% increased risk of MACE during follow-up to 71 years of age after adjusted for BMI, systolic blood pressure, smoking, hyperlipidemia, diabetes and heart rate in a multivariable Cox regression analysis (HR 1.56, 95% CI:1.07–2.27, P = 0.022). In conclusion, in this longitudinal follow-up over a decade QRS duration increased in almost two out of three men between age 50 and 60 and the increased QRS duration in middle age is an independent predictor of major cardiovascular events.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Abstract
Reduced left ventricular ejection fraction (LVEF) is associated with increased mortality after acute myocardial infarction (AMI). However, the prognostic impact of elevated systolic ...pulmonary artery pressure (sPAP) in the very elderly patients after AMI is lacking. We aimed to study the impact of elevated sPAP on one- and five-year all-cause mortality after AMI in very elderly patients, 80 years of age and older. Of a total number of 353 patients (≥ 80 years) who were hospitalized with acute coronary syndrome, 162 patients presenting with AMI and with available data of sPAP on echocardiography were included and followed-up for 5 years. The survival analyses were performed using Cox-Regression models adjusted for conventional risk factors including LVEF. Altogether 66 of 162 patients (41%) had ST-segment elevation MI, and 121 (75%) of patients were treated with percutaneous coronary intervention in the acute phase. Echocardiography during the admission revealed that 78 patients (48%) had a LVEF ≤ 45% and 66 patients (41%) had a sPAP ≥ 40 mmHg. After one and five years of follow-up, 23% (n = 33) and 53% (n = 86) of patients died, respectively. A multivariable Cox-Regression analysis showed that the elevated sPAP (≥ 40 mmHg) was an independent predictor of increased mortality in both one and five years after AMI; HR of 2.63 (95%, CI 1.19–5.84,
P
0.017) and HR of 2.08 (95%, CI 1.25–3.44,
P
0.005) respectively, whereas LVEF ≤ 45% did not show any statistically significant impact, neither on one- nor on five-year mortality (HR 1.3, 95% CI 0.6–2.9,
p
= 0.469) and (HR 1.4, 95% CI 0.8–2.4,
p
= 0.158), respectively. Elevated sPAP was an independent risk factor for one- and five-year all-cause mortality after AMI in very elderly patients and sPAP seems to be a better prognostic predictor for all-cause mortality than LVEF. The risk of all-cause mortality after AMI increased with increasing sPAP.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
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