Incidence of stroke and mortality due to stroke after acute coronary syndrome

Objectives: Stroke is a known complication after myocardial infarction (MI) and it is associated with increased mortality. We aimed to establish the true cumulative incidence of stroke and its subtypes and the associated mortality in a contemporary setting among patients treated for acute coronary syndrome (ACS). Materials and methods: A retrospective registry study based on the data of 8,049 consecutive patients treated for ACS in a sole provider of specialized cardiac and neurologic care for a catchment area of over 0.5 million residents between 2007 and 2018. Incident strokes and their subtypes were identified by in-depth review of written hospital records, hospital discharge registry data and causes of death registry data maintained by Statistics Finland up until December 31st 2020. Results: During a median follow-up of 5.8 years (IQR 3.2-9.0) 570 ACS patients suffered a stroke. The cumulative incidences of stroke for first week, first month, first year and at thirteen years were: 0.8 %, 1.1 %, 2.2 % and 10.3 %. In long-term, patients with different ACS subtypes had similar cumulative incidence of strokes, although the incidence of in-hospital strokes was highest among myocardial infarction patients. Stroke mortality rate was 32.5 % (n=185/570). The majority (88.8 %) of strokes were ischemic with the proportion being most substantial for in-hospital strokes (95.6 %). Conclusions: The risk of stroke among patients treated for ACS and the related mortality are still notable in a contemporary setting. A distinctive majority of strokes following ACS were ischemic especially early on after ACS.publishedVersionPeer reviewe

Incidence of sudden cardiac arrest and sudden cardiac death after unstable angina pectoris and myocardial infarction

BACKGROUND: Sudden cardiac arrests (SCA) and sudden cardiac deaths (SCD) are believed to account for a large proportion of deaths due to cardiovascular causes. The purpose of this study is to provide comprehensive information on the epidemiology of SCAs and SCDs after acute coronary syndrome. METHODS: The incidence of SCA (including SCDs) was studied retrospectively among 10,316 consecutive patients undergoing invasive evaluation for acute coronary syndrome (ACS) between 2007 and 2018 at Tays Heart Hospital (sole provider of specialized cardiac care for a catchment area of over 0.5 million residents). Baseline and follow-up information was collected by combining information from the hospital's electronic health records, death certificate data, and a full-disclosure review of written patient records and accounts of the circumstances leading to death. RESULTS: During twelve years of follow-up, the cumulative incidence of SCAs (including SCDs) was 9.8% (0.8% annually) and that of SCDs 5.4% (0.5% annually). Cumulative incidence of SCAs in patients with ST-elevation myocardial infarction, non-ST-elevation myocardial infarction and unstable angina pectoris were: 11.9%,10.2% and 5.7% at twelve years. SCAs accounted for 30.5% (n = 528/1,732) of all deaths due to cardiovascular causes. The vast majority of SCAs (95.6%) occurred in patients without implantable cardioverter defibrillator (ICD) devices or among patients with no recurrent hospitalizations for coronary artery disease (89.1%). CONCLUSIONS: SCAs accounted for less than a third of all deaths due to cardiovascular causes among patients with previous ACS. Incidence of SCA is highest among STEMI and NSTEMI patients. After the hospital discharge, most of SCAs happen to NSTEMI patients.publishedVersionPeer reviewe

Incidence of Postoperative Hematomas Requiring Surgical Treatment in Neurosurgery : A Retrospective Observational Study

OBJECTIVE: We aimed to characterize the occurrence of postoperative hematoma (POH) after neurosurgery overall and according to procedure type and describe the prevalence of possible confounders. METHODS: Patient data between 2010 and 2012 at the Department of Neurosurgery in Helsinki University Hospital were retrospectively analyzed. A data search was performed according to the type of surgery including craniotomies; shunt procedures, spine surgery, and spinal cord stimulator implantation. We analyzed basic preoperative characteristics, as well as data about the initial intervention, perioperative period, revision operation and neurologic recovery (after craniotomy only). RESULTS: The overall incidence of POH requiring reoperation was 0.6% (n = 56/8783) to 0.6% (n = 26/4726) after craniotomy, 0% (n = 0/928) after shunting procedure, 1.1% (n = 30/2870) after spine surgery, and 0% (n = 0/259) after implantation of a spinal cord stimulator. Craniotomy types with higher POH incidence were decompressive craniectomy (7.9%, n = 7/89), cranioplasty (3.6%, n = 4/112), bypass surgery (1.7%, n = 1/60), and epidural hematoma evacuation (1.6%, n = 1/64). After spinal surgery, POH was observed in 1.1% of cervical and 2.1% of thoracolumbar operations, whereas 46.7% were multilevel procedures. 64.3% of patients with POH and 84.6% of patients undergoing craniotomy had postoperative hypertension (systolic blood pressure >160 mm Hg or lower if indicated). Poor outcome (Glasgow Outcome Scale score 1-3), whereas death at 6 months after craniotomy was detected in 40.9% and 21.7%. respectively, of patients with POH who underwent craniotomy. CONCLUSIONS: POH after neurosurgery was rare in this series but was associated with poor outcome. Identification of risk factors of bleeding, and avoiding them, if possible, might decrease the incidence of POH.Peer reviewe

Cardiorespiratory fitness and heart rate recovery predict sudden cardiac death independent of ejection fraction

Objective To evaluate whether cardiorespiratory fitness (CRF) and heart rate recovery (HRR) associate with the risk of sudden cardiac death (SCD) independently of left ventricular ejection fraction (LVEF). Methods The Finnish Cardiovascular Study is a prospective clinical study of patients referred to clinical exercise testing in 2001-2008 and follow-up until December 2013. Patients without pacemakers undergoing first maximal or submaximal exercise testing with cycle ergometer were included (n=3776). CRF in metabolic equivalents (METs) was estimated by achieving maximal work level. HRR was defined as the reduction in heart rate 1 min after maximal exertion. Adjudication of SCD was based on death certificates. LVEF was measured for clinical indications in 71.4% of the patients (n=2697). Results Population mean age was 55.7 years (SD 13.1; 61% men). 98 SCDs were recorded during a median follow-up of 9.1 years (6.9-10.7). Mean CRF and HRR were 7.7 (SD 2.9) METs and 25 (SD 12) beats/min/min. Both CRF and HRR were associated with the risk of SCD in the entire study population (HR(CRF)0.47 (0.37-0.59), p Conclusions CRF and HRR are significantly associated with the risk of SCD regardless of LVEF.Peer reviewe

Wrist-worn device combining PPG and ECG can be reliably used for atrial fibrillation detection in an outpatient setting

Aims: The aim was to validate the performance of a monitoring system consisting of a wrist-worn device and a data management cloud service intended to be used by medical professionals in detecting atrial fibrillation (AF). Methods: Thirty adult patients diagnosed with AF alone or AF with concomitant flutter were recruited. Continuous photoplethysmogram (PPG) and intermittent 30 s Lead I electrocardiogram (ECG) recordings were collected over 48 h. The ECG was measured four times a day at prescheduled times, when notified due to irregular rhythm detected by PPG, and when self-initiated based on symptoms. Three-channel Holter ECG was used as the reference. Results: The subjects recorded a total of 1,415 h of continuous PPG data and 3.8 h of intermittent ECG data over the study period. The PPG data were analyzed by the system’s algorithm in 5-min segments. The segments containing adequate amounts, at least ~30 s, of adequate quality PPG data for rhythm assessment algorithm, were included. After rejecting 46% of the 5-min segments, the remaining data were compared with annotated Holter ECG yielding AF detection sensitivity and specificity of 95.6 and 99.2%, respectively. The ECG analysis algorithm labeled 10% of the 30-s ECG records as inadequate quality and these were excluded from the analysis. The ECG AF detection sensitivity and specificity were 97.7 and 89.8%, respectively. The usability of the system was found to be good by both the study subjects and the participating cardiologists. Conclusion: The system comprising of a wrist device and a data management service was validated to be suitable for use in patient monitoring and in the detection of AF in an ambulatory setting. Clinical Trial Registration: ClinicalTrials.gov/, NCT05008601.publishedVersionPeer reviewe

Long-term prognostic significance of the ST level and ST slope in the 12-lead ECG in the general population

Background: Even minor ST depression in the electrocardiogram (ECG) is associated with cardiovascular disease and increased mortality. There is limited data on the prognostic significance of ST-level changes in the general population. Subjects and methods: A random sample of Finnish subjects (n = 6354) aged over 30 years (56.1% women) underwent a health examination including a 12-lead ECG in the Health 2000 survey. The effects of relative ST level as a continuous variable and ST slope (upsloping, horizontal, downsloping) in three different lead groups were analyzed using a multi-adjusted Cox proportional hazard model separately for men and women with total mortality as endpoint. Results: The follow-up lasted for 13.7 (SD 3.3) years for men and 13.9 (SD 3.1) years for women. Lower lateral ST levels were associated with all-cause mortality in multi-adjusted models in both genders (at.) + 80 ms hazard ratio [HR] 0.64 for a change of 1.0 mm [95% confidence interval 0.49-0.84, p = 0.002] for men and HR 0.61 [0.48-0.78, p <0.001] for women). Associated coronary heart disease had no major influence on the results. Exclusion of subjects with ECG signs of left ventricular hypertrophy from the analyses increased the mortality risk of lower lateral ST levels in men but decreased it in women. For the anterior and inferior lead groups, no statistically significant difference was seen after multivariate adjustment. ST slope was not an independent predictor of mortality after multivariate adjustment Conclusion: Lower ST level in the lateral ECG leads is an independent prognostic factor to predict all-cause mortality in the general population. (C) 2019 Elsevier Inc. All rights reserved.Peer reviewe

The prognostic significance of T-wave inversion according to ECG lead group during long-term follow-up in the general population

Background Inverted T waves in the electrocardiogram (ECG) have been associated with coronary heart disease (CHD) and mortality. The pathophysiology and prognostic significance of T-wave inversion may differ between different anatomical lead groups, but scientific data related to this issue is scarce. Methods A representative sample of Finnish subjects (n = 6,354) aged over 30 years underwent a health examination including a 12-lead ECG in the Health 2000 survey. ECGs with T-wave inversions were divided into three anatomical lead groups (anterior, lateral, and inferior) and were compared to ECGs with no pathological T-wave inversions in multivariable-adjusted Fine-Gray and Cox regression hazard models using CHD and mortality as endpoints. Results The follow-up for both CHD and mortality lasted approximately fifteen years (median value with interquartile ranges between 14.9 and 15.3). In multivariate-adjusted models, anterior and lateral (but not inferior) T-wave inversions associated with increased risk of CHD (HR: 2.37 [95% confidence interval 1.20-4.68] and 1.65 [1.27-2.15], respectively). In multivariable analyses, only lateral T-wave inversions associated with increased risk of mortality in the entire study population (HR 1.51 [1.26-1.81]) as well as among individuals with no CHD at baseline (HR 1.59 [1.29-1.96]). Conclusions The prognostic information of inverted T waves differs between anatomical lead groups. T-wave inversion in the anterior and lateral lead groups is independently associated with the risk of CHD, and lateral T-wave inversion is also associated with increased risk of mortality. Inverted T wave in the inferior lead group proved to be a benign phenomenon.Peer reviewe

Transformers for cardiac patient mortality risk prediction from heterogeneous electronic health records

With over 17 million annual deaths, cardiovascular diseases (CVDs) dominate the cause of death statistics. CVDs can deteriorate the quality of life drastically and even cause sudden death, all the while inducing massive healthcare costs. This work studied state-of-the-art deep learning techniques to predict increased risk of death in CVD patients, building on the electronic health records (EHR) of over 23,000 cardiac patients. Taking into account the usefulness of the prediction for chronic disease patients, a prediction period of six months was selected. Two major transformer models that rely on learning bidirectional dependencies in sequential data, BERT and XLNet, were trained and compared. To our knowledge, the presented work is the first to apply XLNet on EHR data to predict mortality. The patient histories were formulated as time series consisting of varying types of clinical events, thus enabling the model to learn increasingly complex temporal dependencies. BERT and XLNet achieved an average area under the receiver operating characteristic curve (AUC) of 75.5% and 76.0%, respectively. XLNet surpassed BERT in recall by 9.8%, suggesting that it captures more positive cases than BERT, which is the main focus of recent research on EHRs and transformers.publishedVersionPeer reviewe

Prevalence and long-term prognostic implications of prolonged QRS duration in left ventricular hypertrophy : a population-based observational cohort study

Objectives ECG left ventricular hypertrophy (ECG-LVH) has been associated with left ventricular dysfunction and adverse prognosis, but little is known about the prevalence and prognostic significance of different levels of QRS duration in the presence of ECG-LVH in a general population. Design Population-based observational prospective cohort study. Participants Nationally representative random cluster of Finnish adult population. Methods We assessed the prevalence and long-term (median 15.9 years) prognostic significance of QRS duration in ECG-LVH, and compared the risk to individuals without ECG-LVH in a predominantly middle-aged random sample of 6033 Finnish subjects aged over 30 years (mean age 52.2, SD 14.6 years), who participated in a health examination including a 12-lead ECG. Main outcome measures Cardiovascular and all-cause mortality, incidence of heart failure (HF). Results ECG-LVH was present in 1337 (22.2%) subjects; 403 of these (30.1%) had QRS duration >= 100 ms and 100 (7.5%) had >= 110 ms. The increased risk of mortality in ECG-LVH became evident after a QRS threshold of >= 100 ms. After controlling for known clinical risk factors, QRS 100-109 ms was associated with increased cardiovascular (HR 1.38, 95% CI 1.01 to 1.88, p=0.045) and QRS >= 110 ms with cardiovascular (1.74, 95% CI 1.07 to 2.82, p=0.025) and all-cause mortality (1.52, 95% CI 1.02 to 2.25, p=0.039) in ECG-LVH. The risk of new-onset HF was two-fold in subjects with QRS 100-109 ms and threefold in subjects with QRS >= 110 ms, even after adjustment for incident myocardial infarction within the follow-up. When the prognosis was compared with subjects without ECG-LVH, subjects with ECG-LVH but QRS duration Conclusions In ECG-LVH, the risk of excess mortality and new-onset HF markedly increases with longer QRS duration, but even QRS duration within normal limits in ECG-LVH carried a risk of HF compared with the risk in individuals without ECG-LVH.Peer reviewe