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Coronary artery disease and prognosis in relation to cardiovascular risk factors, interventional techniques and systemic atherosclerosis
Örebro University, School of Medical Sciences.ORCID iD: 0000-0002-9821-0510
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Aim: To evaluate the prognosis associated with location and severity of coronary and systemic atherosclerosis in patients with coronary artery disease (CAD) in relation to risk factors and interventional techniques.

Methods: The thesis comprised six longitudinal studies based on three patient cohorts: The Swedish Coronary Angiography and Angioplasty Registry, the Västmanland Myocardial Infarction Survey, and the Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia study, to evaluate clinical outcome relative to coronary lesion location and severity, extracoronary artery disease (ECAD), intervention techniques, and leisuretime physical inactivity (LTPI).

Results: Stent placement in the proximal left anterior descending artery (LAD) was more often associated with restenosis than was stenting in the other coronary arteries. The use of drug-eluting stents in the LAD was associated with a lower risk of restenosis and death compared to baremetal stents. Thrombus aspiration in in the LAD during acute ST elevation myocardial infarction (MI) did not improve clinical outcome, irrespective of adjunct intervention technique. Clinical, but not subclinical, ECAD was associated with poor prognosis in patients with MI. Longitudinal extent of CAD at the time of MI was a predictor of ECAD, and coexistence of extensive CAD and ECAD was associated with particularly poor prognosis following MI. Self-reported LTPI was associated with MI and all-cause mortality independent of ECAD.

Conclusions: Drug-eluting stents, but not thrombus aspiration, improved prognosis following percutaneous coronary intervention in the proximal LAD. Self- reported LTPI, clinical ECAD, and systemic atherosclerosis defined groups with poor prognosis after MI.

Place, publisher, year, edition, pages
Örebro: Örebro University , 2018. , p. 78
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 173
Keywords [en]
Atherosclerosis, Myocardial infarction, Coronary artery disease, Extra-cardiac artery disease, Coronary stent, Thrombus aspiration, physical inactivity, Prognosis
National Category
General Practice Cardiac and Cardiovascular Systems
Identifiers
URN: urn:nbn:se:oru:diva-64410ISBN: 978-91-7529-232-8 (print)OAI: oai:DiVA.org:oru-64410DiVA, id: diva2:1175847
Public defence
2018-03-23, Örebro universitet, Campus USÖ, hörsal C3, Södra Grev Rosengatan 32, Örebro, 09:00 (English)
Opponent
Supervisors
Available from: 2018-01-19 Created: 2018-01-19 Last updated: 2018-03-02Bibliographically approved
List of papers
1. Proximal coronary artery intervention: Stent thrombosis, restenosis and death
Open this publication in new window or tab >>Proximal coronary artery intervention: Stent thrombosis, restenosis and death
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2013 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 170, no 2, p. 227-232Article in journal (Refereed) Published
Abstract [en]

Background: Percutaneous coronary intervention (PCI) of lesions in the proximal left anterior descending coronary artery (LAD) may confer a worse prognosis compared with the proximal right coronary artery (RCA) and left circumflex coronary artery (LCX). Methods: From May 2005, to May 2011 we identified all PCIs for proximal, one-vessel coronary artery disease in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). We evaluated restenosis, stent thrombosis (ST) and mortality in the LAD as compared to the RCA and LCX according to stent type, bare metal (BMS) or drug-eluting stents (DES). Results: 7840 single vessel proximal PCI procedures were identified. Mean follow-up time was 792 days. No differences in restenosis or ST were seen between the LAD and the RCA. The frequency of restenosis and ST was higher in the proximal LAD compared to the proximal LCX (restenosis: hazard ratio (HR) 2.28, confidence interval (CI) 1.56-3.34 p < 0.001; ST: HR 2.32, CI 1.11-4.85 p = 0.024). We found no difference in mortality related to coronary artery. In the proximal LAD, DES implantation was associated with a lower restenosis rate (HR 0.39, CI 0.27-0.55 < 0.001) and mortality (HR 0.58, CI 0.41-0.82 p = 0.002) compared with BMS. In the proximal RCA and LCX, DES use was not associated with lower frequency of clinical restenosis or mortality. Conclusions: Following proximal coronary artery intervention restenosis was more frequent in the LAD than in the LCX. Solely in the proximal LAD we found DES use to be associated with a lower risk of restenosis and death weighted against BMS. (C) 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords
Angioplasty, Coronary artery disease, Drug-eluting stents
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:oru:diva-56452 (URN)10.1016/j.ijcard.2013.10.060 (DOI)000327889200032 ()24211065 (PubMedID)
Available from: 2017-03-16 Created: 2017-03-16 Last updated: 2018-05-28Bibliographically approved
2. Leisure-time physical inactivity and risk of myocardial infarction and all-cause mortality: A case-control study
Open this publication in new window or tab >>Leisure-time physical inactivity and risk of myocardial infarction and all-cause mortality: A case-control study
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2014 (English)In: International Journal of Cardiology, ISSN 0167-5273, E-ISSN 1874-1754, Vol. 177, no 2, p. 599-600Article in journal (Refereed) Published
Place, publisher, year, edition, pages
Elsevier, 2014
Keywords
Exercise, Cardiovascular diseases, Myocardial infarction, Peripheral artery disease
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:oru:diva-56360 (URN)10.1016/j.ijcard.2014.08.137 (DOI)000345232200087 ()25223818 (PubMedID)2-s2.0-84913582534 (Scopus ID)
Available from: 2017-03-15 Created: 2017-03-15 Last updated: 2018-06-19Bibliographically approved
3. ST-Elevation Myocardial Infarction, Thrombus Aspiration, and Different Invasive Strategies: A TASTE Trial Substudy
Open this publication in new window or tab >>ST-Elevation Myocardial Infarction, Thrombus Aspiration, and Different Invasive Strategies: A TASTE Trial Substudy
2015 (English)In: Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease, ISSN 2047-9980, E-ISSN 2047-9980, Vol. 4, no 6, article id e001755Article in journal (Refereed) Published
Abstract [en]

Background: The clinical effect of thrombus aspiration in ST-elevation myocardial infarction may depend on the type of aspiration catheter and stenting technique.

Methods and Results: The multicenter, prospective, randomized, open-label trial Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia (TASTE) did not demonstrate a clinical benefit of thrombus aspiration compared to percutaneous coronary intervention alone. We assessed the effect of type of aspiration device, stent type, direct stenting, and postdilatation on outcomes at 1 year. There was no difference in all-cause mortality, between the 3 most frequently used aspiration catheters (Eliminate [Terumo] 5.4%, Export [Medtronic] 5.0%, Pronto [Vascular Solutions] 4.5%) in patients randomized to thrombus aspiration. There was no difference in mortality between directly stented patients randomized to thrombus aspiration compared to patients randomized to percutaneous coronary intervention only (risk ratio 1.08, 95% CI 0.70 to 1.67, P=0.73). Similarly, there was no difference in mortality between the 2 randomized groups for patients receiving drug-eluting stents (risk ratio 0.89, 95% CI 0.63 to 1.26, P=0.50) or for those treated with postdilation (risk ratio 0.72, 95% CI 0.49 to 1.07, P=0.11). Furthermore, there was no difference in rehospitalization for myocardial infarction or stent thrombosis between the randomized arms in any of the subgroups.

Conclusions: In patients with ST-elevation myocardial infarction randomized to thrombus aspiration, the type of aspiration catheter did not affect outcome. Stent type, direct stenting, or postdilation did not affect outcome irrespective of treatment with thrombus aspiration and percutaneous coronary intervention or percutaneous coronary intervention alone.

Keywords
angioplasty, myocardial infarction, stenting, thrombus aspiration
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
urn:nbn:se:oru:diva-45542 (URN)10.1161/JAHA.114.001755 (DOI)000357025100014 ()26077585 (PubMedID)
Funder
Swedish Research CouncilSwedish Heart Lung Foundation, 20100178 B0010401
Note

Funding Agencies:

Swedish Association of Local Authorities and Regions

Terumo Medical Corporation

Medtronic Solution

Svenska Hjartförbundet

Vascular Solution

Available from: 2015-08-12 Created: 2015-08-12 Last updated: 2018-07-01Bibliographically approved
4. Thrombus aspiration in patients with large anterior myocardial infarction: A Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia trial substudy
Open this publication in new window or tab >>Thrombus aspiration in patients with large anterior myocardial infarction: A Thrombus Aspiration in ST-Elevation myocardial infarction in Scandinavia trial substudy
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2016 (English)In: American Heart Journal, ISSN 0002-8703, E-ISSN 1097-6744, Vol. 172, no 2, p. 129-134Article in journal (Refereed) Published
Abstract [en]

Background: The TASTE trial did not demonstrate clinical benefit of thrombus aspiration (TA). High-risk patients might benefit from TA.

Methods: The TASTE trial was a multicenter, randomized, controlled, open-label trial obtaining end points from national registries. Patients (n = 7,244) with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) were randomly assigned 1: 1 to TA and PCI or to PCI alone. We assessed the 1-year clinical effect of TA in a subgroup with potentially large anterior STEMI: mid or proximal left anterior descending coronary artery infarct lesion, thrombolysis in myocardial infarction 0 to 2 flow, and symptom onset to PCI time = 5 hours. In this substudy, patient eligibility criteria corresponded to that of the INFUSE-AMI study.

Results: In total, 1,826 patients fulfilled inclusion criteria. All-cause mortality at 1 year of patients randomized to TA did not differ from those randomized to PCI only (hazard ratio [HR] 1.05, 95% CI 0.74-1.49, P = .77). Rates of rehospitalization for myocardial infarction, heart failure, and stent thrombosis did not differ between groups (HR 0.87, 95% CI 0.51-1.46, P = .59; HR 1.10 95% CI 0.77-1.58, P = .58; and HR 0.75, 95% CI 0.30-1.86, P = .53, respectively). This was also the case for the combined end point of all-cause mortality and rehospitalization for myocardial infarction, heart failure, or stent thrombosis (HR 1.00, 95% CI 0.79-1.26, P = .99).

Conclusion: In patients with STEMI and large area of myocardium at risk, TA did not affect outcome within 1 year.

Place, publisher, year, edition, pages
Elsevier, 2016
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
urn:nbn:se:oru:diva-48941 (URN)10.1016/j.ahj.2015.11.012 (DOI)000369659400016 ()26856224 (PubMedID)
Note

Funding Agencies:

Medtronic

Vascular solutions

Terumo

Biosensors 

Biotronik

Available from: 2016-03-07 Created: 2016-03-04 Last updated: 2019-02-13Bibliographically approved
5. Prognostic impact of subclinical or manifest extracoronary artery diseases after acute myocardial infarction
Open this publication in new window or tab >>Prognostic impact of subclinical or manifest extracoronary artery diseases after acute myocardial infarction
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2017 (English)In: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 263, p. 53-59Article in journal (Refereed) Published
Abstract [en]

Background and aims: In patients with coronary artery disease (CAD), clinically overt extracoronary artery diseases (ECADs), including claudication or previous strokes, are associated with poor outcomes. Subclinical ECADs detected by screening are common among such patients. We aimed to evaluate the prognostic impact of subclinical versus symptomatic ECADs in patients with acute myocardial infarction (AMI).

Methods: In a prospective observational study, 654 consecutive patients diagnosed with AMI underwent ankle brachial index (ABI) measurements and ultrasonographic screening of the carotid arteries and abdominal aorta. Clinical ECADs were defined as prior strokes, claudication, or extracoronary artery intervention. Subclinical ECADs were defined as the absence of a clinical ECAD in combination with an ABI <= 0.9 or >1.4, carotid artery stenosis, or an abdominal aortic aneurysm.

Results: At baseline, subclinical and clinical ECADs were prevalent in 21.6% and 14.4% of the patients, respectively. Patients with ECADs received evidence-based medication more often at admission but similar medications at discharge compared with patients without ECADs. During a median follow-up of 5.2 years, 166 patients experienced endpoints of hospitalization for AMI, heart failure, stroke, or cardiovascular death. With ECAD-free cases as reference and after adjustment for risk factors, a clinical ECAD (hazard ratio [HR] 2.10, 95% confidence interval [CI] 1.34-3.27, p = 0.001), but not a subclinical ECAD (HR 1.35, 95% CI 0.89-2.05, p = 0.164), was significantly associated with worse outcomes.

Conclusions: Despite receiving similar evidence-based medication at discharge, patients with clinical ECAD, but not patients with a subclinical ECAD, had worse long-term prognosis than patients without an ECAD after AMI. (C) 2017 The Authors. Published by Elsevier Ireland Ltd.

Place, publisher, year, edition, pages
Elsevier, 2017
Keywords
Extracoronary artery disease, Myocardial infarction, Prognosis
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:oru:diva-60724 (URN)10.1016/j.atherosclerosis.2017.05.027 (DOI)000407634000884 ()28599258 (PubMedID)2-s2.0-85020304353 (Scopus ID)
Note

Funding Agencies:

Sparbanksstiftelsen Nya  552  693  0932  2297 

County of Västmanland  

Swedish Medical Association

Available from: 2017-09-11 Created: 2017-09-11 Last updated: 2018-08-06Bibliographically approved
6. Incremental prognostic value of coronary and systemic atherosclerosis aftermyocardial infarction
Open this publication in new window or tab >>Incremental prognostic value of coronary and systemic atherosclerosis aftermyocardial infarction
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(English)Manuscript (preprint) (Other academic)
National Category
General Practice Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:oru:diva-65425 (URN)
Available from: 2018-03-02 Created: 2018-03-02 Last updated: 2018-03-02Bibliographically approved

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