Initiation and persistence with dual antiplatelet therapy after acute myocardial infarction:a Danish nationwide population-based cohort study

OBJECTIVES: The study investigated dual antiplatelet therapy (DAPT) patterns over time and patient characteristics associated with the various treatments in a myocardial infarction (MI) population. DESIGN: A registry-based observational cohort study was performed using antecedent data. SETTING: This study linked morbidity, mortality and medication data from Danish national registries. PARTICIPANTS: All 28 449 patients admitted to a Danish hospital with a first-time MI and alive at discharge from 2009 through 2012 were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was initiation of DAPT and secondary outcomes comprised persistence in DAPT treatment and switches between DAPT treatments. RESULTS: The overall proportion of patients prescribed DAPT increased from 68% (CL 95% 67–69%) to 73% (CL 95% 72–74%) from 2009 to 2012. For treatment of patients with and without percutaneous coronary intervention (PCI), the corresponding numbers were from 87% (CL 95% 86–88%) to 91% (CL 95% 90–92%) and from 49% (CL 95% 47–50%) to 52% (CL 95% 51–54%), respectively. Non-PCI patients had a higher cardiovascular risk compared with PCI patients. Among PCI patients, age>75 years, atrial fibrillation, diabetes and peripheral arterial disease were associated with a higher risk of treatment breaks for DAPT. Among patients without PCI, ticagrelor treatment was associated with an increased risk of treatment breaks during the first 12 months compared with clopidogrel treatment. CONCLUSIONS: From 2009 to 2012, there was an increase in the proportion of patients with MI receiving DAPT, and a longer duration of DAPT. Still, a large proportion of patients without PCI are discharged either without DAPT or with a short DAPT duration. These findings may indicate the need for more careful attention to DAPT for patients with MI not undergoing PCI in Denmark

Cardiovascular Disease and the Use of Swedish Health Care Registries and Electronic Medical Data From Primary Care: Disease Reality, Risk Factors, Comparative Effectiveness and Outcomes

Data from Swedish health care registries, being nationwide and linkable with other registers by using personal identification number, provides an excellent source for disease insights from various aspects. Paper I showed that among peripheral artery disease (PAD) patients the presence of additional risk factors other than age was the main driver for both CV-related and non-CV-related costs. Although the PAD population has a well-recognized high-CV risk, the major proportion of hospitalization costs for PAD patients are not related to CV disease. Furthermore, the combination of Swedish health care register data and data extracted from primary care medical records can be used to study risk predictors and outcomes. In paper II it was shown that two-thirds of statin-naïve patients initiating statin treatment had a change in their HDL-C level. A paradoxical decrease in HDL-C of (0.1 mmol/L) was associated with a 56% increase in major adverse cardiovascular events compared with unchanged HDL-C levels. No association between increased HDL-C levels and risk of major adverse cardiovascular events was observed. While in paper III was shown that in the management of hypertension, candesartan treatment compared with enalapril treatment was associated with a risk reduction of new-onset diabetes, while no difference was observed between the two treatments in prevention of cardiovascular outcomes

Treatment pattern of contemporary dual antiplatelet therapies after acute coronary syndrome: a Swedish nationwide population based cohort study.

New dual antiplatelet therapies (DAPTs) have been introduced in clinical practice for patients with acute coronary syndrome (ACS). This nationwide study investigated DAPT patterns over time and patient characteristics associated with the various treatments in a population with ACS

Predictors for repeated hyperkalemia and potassium trajectories in high-risk patients - A population-based cohort study.

Understanding predictors and trajectories of increased potassium may inform testing and treatment of hyperkalemia. We examined predictors for repeated hyperkalemia among patients after first-time renin angiotensin system inhibitor (RASi) prescription, chronic kidney disease (CKD), or chronic heart failure (CHF); and we also examined potassium trajectories in these patients after their first hyperkalemia event. We used Danish population-based registries to identify all patients with first-time RASi prescription, incident CKD, or incident CHF (2000-2012). For patients with a first hyperkalemia event, potassium trajectories over the following 6 months were examined. The predictors associated with repeated hyperkalemia were assessed, with repeated hyperkalemia defined as a potassium test >5.0 mmol/L after the first event within 6 months. Overall 262,375 first-time RASi users, 157,283 incident CKD patients, and 14,600 incident CHF patients were included. Of patients with a first hyperkalemia event, repeated hyperkalemia within 6 months occurred in 37% of RASi users, 40% with CKD, and 49% of patients with CHF. Predictors included severe hyperkalemia, low eGFR, diabetes, and spironolactone use. In all cohorts, the median potassium levels declined over 2-4 weeks after a hyperkalemia event for the first time, but reverted to levels higher than before the initial hyperkalemia event in those who had repeated hyperkalemia. Following hyperkalemia, discontinuation of RASi and spironolactone was common in the RASi and CHF cohorts. Repeated hyperkalemia was common among the explored cohorts. The first hyperkalemia event was an indicator of increased median potassium levels. Predictors may identify patients likely to benefit from intensified monitoring and intervention

Association between paradoxical HDL cholesterol decrease and risk of major adverse cardiovascular events in patients initiated on statin treatment in a primary care setting

Background and Objectives Statin-induced changes in high-density lipoprotein cholesterol (HDL-C) and lowdensity lipoprotein cholesterol (LDL-C) are unrelated. Many patients initiated on statins experience a paradoxical decrease in HDL-C. The aim of this study was to evaluate the association between a decrease in HDL-C and risk of major adverse cardiovascular events (MACE). Methods Data from 15,357 primary care patients initiated on statins during 2004–2009 were linked with data from mandatory national hospital, drug-dispensing, and causeof- death registers, and were grouped according to HDL-C change: decreased C0.1 mmol/L, unchanged ±0.1 or C0.1 mmol/L increased. To evaluate the association between decrease in HDL-C and risk of MACE, a sample of propensity score-matched patients from the decreased and unchanged groups was created, using the latter group as reference. MACE was defined as myocardial infarction, unstable angina pectoris, ischaemic stroke, or cardiovascular mortality. Cox proportional hazards models were used to estimate relative risks. Results HDL-C decreased in 20 %, was unchanged in 58%, and increased in 22 % of patients initiated on statin treatment (96 % treated with simvastatin). The propensity score-matched sample comprised 5950 patients with mean baseline HDL-C and LDL-C of 1.69 and 4.53 mmol/L, respectively. HDL-C decrease was associated with 56 % higher MACE risk (hazard ratio 1.56; 95 % confidence interval 1.12–2.16; p\0.01) compared with the unchanged HDL-C group. Conclusions Paradoxical statin-induced reduction in HDL-C was relatively common and was associated with increased risk of MACE