Aims:Inflammation and hyperlipidaemia play a pivotal role in atherosclerotic cardiovascular disease (ASCVD), and inflammatory risk may outweigh cholesterol risk among statin-treated patients. However, it is unclear how these risks relate to ASCVD outcomes in a real-world population. Methods and results:Observational study of 39 638 ASCVD adults in Stockholm's healthcare (2007-21) who underwent routine testing for high-sensitivity C-reactive protein (hsCRP) and low-density lipoprotein cholesterol (LDL-C). Groups were defined by LDL-C (≥1.8 vs. < 1.8 mmol/L) and hsCRP (≥2 vs. < 2 mg/L): as low risk, high cholesterol risk (CR) alone, high inflammatory risk (IR) alone, and combined high cholesterol and inflammatory risk (CIR). Primary outcome was major adverse cardiovascular (CV) events (MACE); secondary outcomes included all-cause death, CV death, and heart failure (HF) hospitalization. Mean age at baseline was 69 years, 61% were men, 19.4% had chronic kidney disease (CKD), and 61% were receiving lipid-lowering therapy (LLT). Over follow-up (median 4.5 years), 5349 MACE, 7955 deaths (2088 CV deaths) and 4286 HF hospitalizations occurred. Compared with patients with low risk, those with IR or CIR experienced the highest MACE risk (HR 1.39; 95% CI 1.26-1.54 for CIR, HR 1.18; 1.05-1.33 for IR), followed by CR (HR 1.12; 1.01-1.24). Elevated hsCRP, with or without elevated LDL-C, was strongly associated with secondary outcomes, while CR alone was not. Patterns were generally consistent across CKD and LLT subgroups. Conclusion:In routine care high inflammatory risk, alone or with high cholesterol risk, is a stronger predictor of adverse outcomes than high cholesterol alone.

BACKGROUND:Systemic inflammation (SI) contributes to increased cardiovascular risk in patients with atherosclerotic cardiovascular disease (ASCVD) and chronic kidney disease (CKD). We assessed clinical perceptions toward SI and usage of high-sensitivity C-reactive protein (hsCRP) among nephrologists. METHODS:FLAME-ASCVD Nephro was an online survey of nephrologists from 10 countries who treat ≥20 patients with ASCVD and CKD a month and were practicing for ≥3 years. Results were analyzed using descriptive statistics. RESULTS:Of 513 nephrologists who responded, 300 completed and were included in the survey; the mean age was 46 years and the mean time in practice was 16 years. Hypertension (89%), overweight/obesity (81%), and CKD (80%) were the ASCVD risk factors most often discussed with patients (SI was ninth). The most common unmet needs (ranked 1-3) for patients with ASCVD and CKD were "lack of effective SI treatment options" (44%), "limited awareness of the role of SI in ASCVD" (35%), and "higher risk of CV events" (33%). Seventy-four percent of nephrologists wanted to learn more about the role of SI in ASCVD and 71% test for and use SI results when determining management approaches. Seventy percent of nephrologists considered hsCRP testing in patients with ASCVD and CKD (aided), and proven clinical efficacy of hsCRP was the top reason (37%); out-of-pocket cost (30%) was the most common reason for not considering hsCRP testing. CONCLUSION:Lack of effective treatment options for SI remains the most common unmet need for patients with ASCVD and CKD. Further medical education is needed to raise awareness among nephrologists about the role of SI and hsCRP testing.

Abstract Background The burden and outcomes of inflammation in people with atherosclerotic cardiovascular disease (ASCVD) are poorly defined, particularly beyond the controlled settings of trials and research cohorts. Methods We conducted a longitudinal observational study of adults with ASCVD undergoing C-reactive-protein (CRP) testing in routine healthcare in Stockholm, Sweden. After excluding CRP tests associated with acute illness and patients with medications/conditions that bias CRP interpretation, the systemic inflammation of participants was defined over a 3-month ascertainment window. Baseline determinants of CRP≥2 mg/L were explored with logistic regression, and baseline CRP categories were compared via Poisson and Cox regression for subsequent healthcare resource utilization and occurrence of major adverse cardiovascular events (MACE), heart failure hospitalization, and all-cause death. Result After applying inclusion/exclusion criteria, we identified 84,399 adults with ASCVD with a mean age of 71 years and of which 54% were men. In total, 60% had CRP≥2 mg/L. At baseline, female sex, older age, lower kidney function, albuminuria, diabetes, hypertension, and recent anemia, were associated with CRP≥2 mg/L. Conversely, the use of RASi, antiplatelets, and lipid-lowering therapy were associated with lower odds. Over a median follow-up of 6.4 years and compared to people with CRP <2 mg/L, those with CRP≥2 mg/L had a higher rate of hospitalizations, days spent in hospital, outpatient consultations, and dispensed medications during follow-up (P<0.05 for all). They also had a higher rate of MACE [adjusted hazard ratio (HR), 1.30; 95% CI, 1.27–1.33], heart failure hospitalization [1.24; 1.20–1.39], and all-cause death [1.35; 1.20–1.30]. Results were consistent across subgroups and more granular CRP categories, and robust to the exclusion of extreme CRP values or early events. Conclusions Two in three adults with ASCVD have systemic inflammation. A CRP≥2 mg/L is associated with excess healthcare resource utilization as well as increased rates of MACE, heart failure, and death.

Background and Aims The burden and outcomes of inflammation in patients with atherosclerotic cardiovascular disease (ASCVD) are not well defined beyond the controlled settings of trials and research cohorts. Methods This was an observational study of ASCVD adults undergoing C-reactive protein testing in Stockholm's healthcare (2007-21). After excluding C-reactive protein tests associated with acute illness or medications/conditions that bias C-reactive protein interpretation, systemic inflammation was evaluated over a 3-month ascertainment window. Determinants of C-reactive protein >= 2 mg/L were explored with logistic regression. C-reactive protein categories were compared via negative-binomial/Cox regression for subsequent healthcare resource utilization and occurrence of major adverse cardiovascular events, heart failure hospitalization, and death. Results A total of 84 399 ASCVD adults were included (46% female, mean age 71 years, 59% with C-reactive protein >= 2 mg/L). Female sex, older age, lower kidney function, albuminuria, diabetes, hypertension, and recent anaemia were associated with higher odds of C-reactive protein >= 2 mg/L. The use of renin-angiotensin system inhibitors, antiplatelets, and lipid-lowering therapy was associated with lower odds. Over a median of 6.4 years, compared with C-reactive protein < 2 mg/L, patients with C-reactive protein >= 2 mg/L had higher rates of hospitalizations, days spent in hospital, outpatient consultations, and dispensed medications (P < .05 for all). They also had a higher rate of major adverse cardiovascular events [hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.27-1.33], heart failure (HR 1.24; 95% CI 1.20-1.30), and death (HR 1.35; 95% CI 1.31-1.39). Results were consistent across subgroups and granular C-reactive protein categories and robust to the exclusion of extreme C-reactive protein values or early events. Conclusions Three in five adults with ASCVD have systemic inflammation, which is associated with excess healthcare resource utilization and increased rates of cardiovascular events and death.

Objective:Orthostatic hypotension and resting heart rate (RHR) are associated with cardiovascular disease (CVD). However, it is unknown how these factors relate to subclinical CVD. We examined the relationship between orthostatic blood pressure (BP) response, RHR and cardiovascular risk factors, including coronary artery calcification score (CACS) and arterial stiffness, in the general population.Methods:We included 5493 individuals (age 50-64 years; 46.6% men) from The Swedish CArdioPulmonary-bio-Image Study (SCAPIS). Anthropometric and haemodynamic data, biochemistry, CACS and carotid-femoral pulse wave velocity (PWV) were retrieved. Individuals were categorized into binary variables that manifest orthostatic hypotension and in quartiles of orthostatic BP responses and RHR, respectively. Differences across the various characteristics were tested using chi 2 for categorical variables and analysis of variance and Kruskal-Wallis test for continuous variables.Results:The mean (SD) SBP and DBP decrease upon standing was -3.8 (10.2) and -9.5 (6.4) mmHg, respectively. Manifest orthostatic hypotension (1.7% of the population) associated with age (P = 0.021), systolic, diastolic and pulse pressure (P < 0.001), CACS (<0.001), PWV (P = 0.004), HbA1c (P < 0.001) and glucose levels (P = 0.035). Age (P < 0.001), CACS (P = 0.045) and PWV (P < 0.001) differed according to systolic orthostatic BP, with the highest values seen in those with highest and lowest systolic orthostatic BP-responses. RHR was associated with PWV (P < 0.001), SBP and DBP (P < 0.001) as well as anthropometric parameters (P < 0.001) but not CACS (P = 0.137).Conclusion:Subclinical abnormalities in cardiovascular autonomic function, such as impaired and exaggerated orthostatic BP response and increased resting heart rate, are associated with markers of increased cardiovascular risk in the general population.

Abstract Introduction Inflammation is a pathophysiological process associated with increased cardiovascular (CV) risk, with high-sensitivity C-reactive protein (hsCRP) used as a biomarker to predict CV risk. However, the prevalence of systemic inflammation (defined as hsCRP ≥ 2 mg/L) in contemporary cohorts with high CV risk, including CV disease (CVD), chronic kidney disease (CKD), obesity and/or type 2 diabetes (T2D), is not well characterized. Purpose To evaluate the proportion of individuals with systemic inflammation and the characteristics of individuals with and without systemic inflammation among groups at high risk of CV events, using baseline data from three ongoing randomized, placebo-controlled, phase 3 trials investigating the efficacy of semaglutide versus placebo in high CV risk populations (SELECT, SOUL and FLOW). Methods SELECT (NCT03574597) recruited adults ≥ 45 years old with a body mass index (BMI) ≥ 27 kg/m² and established CVD (previous myocardial infarction, ischaemic or haemorrhagic stroke, or symptomatic peripheral artery disease [PAD]), without diabetes. SOUL (NCT03914326) recruited adults ≥ 50 years old with T2D and at least one of coronary heart disease, cerebrovascular disease, symptomatic PAD or CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m²). FLOW (NCT03819153) recruited adults ≥ 18 years old with T2D and CKD (eGFR ≥ 25–≤ 75 mL/min/1.73 m² and urinary albumin-to-creatinine ratio > 100–< 5000 mg/g) treated with renin-angiotensin-aldosterone system-blocking agents. Baseline hsCRP levels were measured in the three trials. Descriptive statistics were used to analyse the baseline characteristics of participants; p values were calculated with chi-squared tests using Yates’s correction for continuity. Results Baseline characteristics were available for 17 487 individuals from SELECT, 9577 from SOUL and 3519 from FLOW (Table), with systemic inflammation present in 47.2%, 49.5% and 56.8% of the trial populations, respectively. Across trials, PAD and heart failure were significantly more prevalent in individuals with hsCRP ≥ 2 mg/L than in those with hsCRP < 2 mg/L; in addition, CKD stage 3–5 and stroke were more prevalent in groups with hsCRP ≥ 2 mg/L in SELECT and SOUL. The following factors were characteristic of the groups with systemic inflammation in the three trials: female sex, younger age, higher BMI, lower levels of high-density lipoprotein cholesterol, and higher levels of glycated haemoglobin (HbA1c), total cholesterol, low-density lipoprotein cholesterol and triglycerides. Conclusion In these large phase 3 trials, systemic inflammation was present at baseline in approximately 50% of individuals and was associated with several CV and kidney risk characteristics. The large proportion of participants with systemic inflammation in the groups with high CV risk shown here supports systemic inflammation as a plausible therapeutic target for the prevention of recurrent CV events.

Abstract Introduction Elevated levels of high-sensitivity C-reactive protein (hsCRP ≥ 2 mg/L) are a marker of systemic inflammation and a risk factor for atherosclerotic cardiovascular disease (ASCVD). We set out to determine the prevalence of systemic inflammation among individuals with ASCVD participating in the SELECT, SOUL and FLOW trials, three ongoing randomized, placebo-controlled, phase 3 trials investigating the efficacy of semaglutide versus placebo. Purpose To evaluate the prevalence of systemic inflammation among people with ASCVD with or without chronic kidney disease (CKD) who are enrolled in SELECT, SOUL and FLOW, and to characterize populations with ASCVD and CKD with and without systemic inflammation. Methods SELECT (NCT03574597) recruited adults ≥ 45 years old with a body mass index (BMI) ≥ 27 kg/m2 and established CVD (previous myocardial infarction, ischaemic or haemorrhagic stroke, or symptomatic peripheral artery disease [PAD]), without diabetes. SOUL (NCT03914326) recruited adults ≥ 50 years old with type 2 diabetes (T2D) and at least one of coronary heart disease, cerebrovascular disease, symptomatic PAD or CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2). FLOW (NCT03819153) recruited adults ≥ 18 years old with T2D and CKD (eGFR ≥ 25–≤ 75 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio > 100–< 5000 mg/g) treated with renin-angiotensin-aldosterone system-blocking agents. Baseline hsCRP levels were measured in all trials; systemic inflammation was defined as hsCRP ≥ 2 mg/L. Descriptive statistics and chi-squared test with Yates’s correction for continuity were used to analyse the baseline characteristics for individuals with ASCVD (defined as at least one of previous myocardial infarction, stroke or PAD) and CKD stage 3–5 (eGFR < 60 mL/min/1.73 m2). Results A total of 4087 individuals with ASCVD and CKD and 20 331 with ASCVD without CKD were included. Systemic inflammation was present in a significantly larger proportion of individuals with ASCVD and CKD than with ASCVD but without CKD (56.2% vs 46.7%; p < 0.001). In the group with ASCVD, CKD and hsCRP ≥ 2 mg/L, heart failure, PAD and stroke were significantly more prevalent than in the group with hsCRP < 2 mg/L (Table). For individuals with ASCVD and CKD, the following factors were characteristic of systemic inflammation: female sex, smoking, younger age, higher BMI, lower eGFR and high-density lipoprotein cholesterol levels, and higher levels of low-density lipoprotein (LDL) cholesterol, triglycerides and glycated haemoglobin (HbA1c) (Table). Conclusion In these large, ongoing phase 3 trials, systemic inflammation, defined as hsCRP levels ≥ 2 mg/L, was present at baseline in > 55% of individuals with ASCVD and CKD. CV risk factors were more prevalent among individuals with hsCRP ≥ 2 mg/L than in those with hsCRP < 2 mg/L. Interventional studies are warranted to assess to what extent anti-inflammatory agents can address the associated ASCVD risk.Table

Whereas autonomic dysfunction and the metabolic syndrome are clinically associated, the relationships with the plasma metabolome is unknown. We explored the association between orthostatic blood pressure responses and 818 plasma metabolites in middle-aged subjects from the general population. We included 3803 out of 6251 subjects (mean age, 57 years; 52% women) from the Malmö sub-cohort of The Swedish CardioPulmonary bioImage Study with information on smoking habits, diabetes, antihypertensive drug treatment, anthropometrics, hemodynamic measurements and 818 plasma metabolites (mass-spectrometry). The associations between each metabolite and orthostatic systolic blood pressure responses were determined using multivariable linear regression analysis and p values were corrected using the Bonferroni method. Six amino acids, five vitamins, co-factors and carbohydrates, nine lipids and two xenobiotics were associated with orthostatic blood pressure after adjusting for age, gender and systolic blood pressure. After additional adjustments for BMI, diabetes, smoking and antihypertensive treatment, the association remained significant for six lipids, four amino acids and one xenobiotic. Twenty-two out of 818 plasma metabolites were associated with orthostatic blood pressure responses. Eleven metabolites, including lipids in the dihydrosphingomyelin and sphingosine pathways, were independently associated with orthostatic systolic blood pressure responses after additional adjustment for markers of cardio-metabolic disease.

Background: Self-care behavior is important in avoiding hospitalization for patients with heart failure (HF) and refers to those activities performed with the intention of improving or restoring health and well-being, as well as treating or preventing disease. The purpose was to study the effects of a home-based mobile device on self-care behavior and hospitalizations in a representative HF-population. Methods and Results: SMART-HF is a randomized controlled multicenter clinical trial, where patients were randomized 1:1 to receive standard care (control group [CG]) or intervention with a home-based tool designed to enhance self-care behavior (intervention group [IG]) and followed for 240 days. The tool educates the patient about HF, monitors objective and subjective symptoms and adjusts loop diuretics. The primary outcome is self-care as measured by the European Heart Failure Self-care behavior scale and the secondary outcome is HF related in-hospital days. A total of 124 patients were recruited and 118 were included in the analyses (CG: n = 60, IG: n = 58). The mean age was 79 years, 39% were female, and 45% had an ejection fraction of less than 40%. Self-care was significantly improved in the IG compared to the CG (median (interquartile range) (21.5 [13.25; 28] vs 26 [18; 29.75], p = 0.014). Patients in the IG spent significantly less time in the hospital admitted for HF (2.2 days less, relative risk 0.48, 95% confidence interval 0.32-0.74, P = .001). Conclusions: The device significantly improved self-care behavior and reduced in-hospital days in a relevant HF population.

Objective Mortality caused by coronary artery disease has markedly decreased in recent years. However, a substantial proportion of patients suffering a coronary event (CE) die within the first day, most of them out of hospital. We aimed to investigate how established cardiovascular (CV) risk factors and CV autonomic indices associate with fatal versus non-fatal CEs in the population.Methods 33 057 individuals (mean age; 45.6 years; 10 773 women) free of coronary artery disease at baseline were included. Baseline examination, including assessment of traditional CV risk factors and autonomic indices such as heart rate and orthostatic reaction, was performed during 1974–1992, after which the subjects were monitored for incident CV disease. The Lunn-McNeil competing risks approach with a prespecified multivariable model was used to assess differences in risks for fatal and non-fatal CEs in relation to baseline CV risk factors.Results During follow-up period of 29.7 years, 5494 subjects (6.10/1000 person-years) had first CE; 1554 of these were fatal. Age, male gender, smoking, body mass index (BMI), blood pressure, pulse pressure and resting heart rate had stronger relationships with fatal CE than with non-fatal events. The effects of diabetes, serum cholesterol, antihypertensive treatment and orthostatic blood pressure responses were similar for fatal and non-fatal CE.Conclusions Several cardiovascular risk factors, such as smoking, high BMI, blood pressure and high resting heart rate, were preferentially associated with fatal compared with non-fatal CEs. These observations may require special attention in the overall efforts to further reduce coronary artery disease mortality.

Background Many patients with atrial fibrillation (AF) or atrial flutter (AFL) and rapid ventricular response (RVR) have elevated high-sensitivity troponin T (hsTnT) values. Elevated hsTnT is an independent risk marker for cardiovascular events and mortality. The aim was to examine if AF/AFL patients with RVR and elevated hsTnT have an increased incidence of pathological cardiac stress tests, indicating need of further evaluation for coronary artery disease (CAD). Methods We prospectively included 90 AF/AFL patients without known heart failure and CAD presenting with AF/AFL and RVR. Half of the patients had elevated hsTnT (cases) and half had levels below the 99th percentile (controls). All patients were discharged in sinus rhythm. After approximately one week in sinus rhythm a new hsTnT was analysed and the patients performed a bicycle exercise stress test within the 30 day follow-up. The primary endpoint was a pathological stress test confirmed by a pathological SPECT myocardial perfusion imaging or a coronary angiography. Results None of the controls reached the primary endpoint. Two patients (4%) out of the 45 cases reached the primary endpoint (p= 0.49 vs controls), but only one was found to have significant CAD at subsequent coronary angiography. Conclusions Patients with paroxysmal AF/AFL, without history of CAD and heart failure, who present with a RVR and minor hsTnT elevations do not have an increased incidence of pathological stress test compared to patients with hsTnT values below the 99th percentile.

Abstract Background A common heart failure (HF) aetiology is hypertension (HTN), second only to ischemic heart disease and with a prevalence in the HF community of between 62% and 84%, depending on sex and ejection-fraction. Undertreated HTN leads to worse prognosis and resistant HTN is defined as blood pressure (BP) exceeding 140/90 mmHg, in spite of pharmacological treatment. Since one constituent of self-care behaviour is treatment adherence, we wished to study whether patients exposed to a digital intervention shown to improve self-care behaviour, would also display improved BP control. Methods SMART-HF was a randomized controlled trial, recruiting patients from seven centres in Region Skåne in southern Sweden, where patients in the intervention group (IG) were equipped with a digital home-based tool, designed to enhance self-care behaviour for HF-patients and the control group (CG) were subject to standard care. BP data was registered at baseline and after eight months of intervention and self-care behaviour was measured using the European Heart Failure Self-care Behaviour Scale (EHFScB). We used a Chi-square test to analyse whether there was an inter-group difference of prevalence of resistant HTN or a mean arterial pressure (MAP) outside the recommended range of 60 mmHg < MAP <100 mmHg. Results Out of the 118 patients included in the original analysis, 92 (78%) had complete BP measurements. At baseline there was no difference in self-care behaviour between the groups, with CG: 25 [17.5; 32] and IG: 24.5 [18; 30], p=0.61, and 28% of the CG patients and 24% of the IG population displayed resistant HTN, p=0.73. After eight months of intervention the IG had 21% (or 4.5 points) better self-care behaviour compared to the CG, p=0.014, and the fraction of patients with resistant HTN was 30% for the CG and 11% for the IG, p=0.027. There was also a significant effect on the fraction of patients having a MAP >100 mmHg, with 22% in the CG versus 16% in the IG having MAP >100 mmHg at baseline (p=0.39) and 19% in the CG versus 0% in the IG at follow-up (p=0.002). Conclusions There was a significant improvement in self-care behaviour and also a significant reduction in the number of patients with resistant hypertension and elevated mean arterial pressure after eight months of intervention. Funding Acknowledgement Type of funding source: None

Clinical studies evaluating home-based interventions for heart failure (HF) patients are performed on patients that are too young, too often male and predominately have reduced ejection-fraction (EF). The Selfcare Management Intervention in Heart Failure (SMART-HF) study was designed to evaluate a digital intervention enhancing self-care behaviour in a more generalizable population. The aim was to see if the intervention could reduce in-hospital care due to HF. SMART-HF was a randomized controlled trial, recruiting patients from seven centres in Region Skåne. Patients were randomized 1:1 to a control group (CG) receiving standard care or an intervention group (IG) who were equipped with the digital intervention. The intervention educates the patient about HF and supports the patient with medication and symptom monitoring, also notifying the patient in case of deterioration. The primary outcome was number of in-hospital days due to HF after 240 days follow-up. A total of 124 patients were randomized and 118 (CG: 60, IG: 58) were included in the analysis. The mean age was 79 years, 39% were women and 45% had EF <40%. The groups were well balanced at randomization. A total of 367 HF in-hospital days were registered among 33 patients, and patients in the IG lost on average 2.2 days fewer to HF-hospitalizations than patients in the CG, a reduction by 52%, p<0.001. An unadjusted Cox-regression to analyse the event-free survival yielded a hazard ratio = 0.50 (CI:0,24–0,96), p=0.046. The self-care behaviour was 21% better in the IG, p=0.014. The median system adherence was 85% after 240 days. The intervention significantly reduced HF-related in-hospital days and improved event-free survival in a representative HF-population. The findings match previous published data from studies evaluating the same intervention. Type of funding source: None

Objective: The elderly are an increasing group and large consumers of care in Sweden. Development of mobile information technology shows promising results of interventions for prevention and treatment of chronic diseases. Exploring the elderly patients' beliefs, attitudes, experiences and expectations of e-health services helps us understand the factors that influence adherence to such tools in primary care. Material and methods: We conducted focus group interviews with 15 patients from three primary health care centers (PHCCs) in Southern Sweden. Data were analysed with thematic content analysis with codes and categories emerged from data during analysis. Results: We found one comprehensive theme: 'The elderly's ambivalence towards e-health: reluctant curiosity, a wish to join and need for information and learning support'. Eight categories emerged from the text during analysis: 'E-health - a solution for a non-existing problem?', 'The elderly's experiences of e-health', 'Lack of will, skills, self-trust or mistrust in the new technology', 'Organizational barriers', 'Wanting and needing to move forward', 'Concerns to be addressed for making e-health a good solution', 'Potential advantages with e-health versus ordinary health care' and 'Need for speed, access and correct comprehensive information'. Conclusions: Elderly patients in Sweden described feelings of ambivalence towards e-health, raising concerns as accessibility to health care, mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.

BACKGROUND:General practitioners (GPs) often fail to correctly adhere to guidelines for the treatment of hypertension. The reasons for this are unclear, but could be related to lack of knowledge in assessing individual patients' cardiovascular disease risk. Our aim was to investigate how GPs in southern Sweden adhere to clinical guidelines for the treatment of hypertension when major cardiovascular risk factors are taken into consideration.METHOD:A questionnaire with five genuine cases of hypertension with different cardiovascular risk profiles was sent to a random sample of GPs in southern Sweden (n=109) in order to investigate the attitude towards blood pressure (BP) treatment when major cardiovascular risk factors were present.RESULTS:In general, GPs who responded tended to focus on the absolute target BP rather than assessing the entire cardiovascular risk factor profile. Thus, cases with the highest risk of cardiovascular disease were not treated accordingly. However, there was also a tendency to overtreat the lowest risk individuals. Furthermore, the BP levels for initiating pharmacological treatment varied widely (systolic BP 140-210 mmHg). ACE inhibitors (70%) were the most common first choice of pharmacological treatment.CONCLUSION:In this study, GPs in Southern Sweden were suggesting, for different cases, either under- or overtreatment in relation to current guidelines for treatment of hypertension. On reason may be that they failed to correctly assess individual cardiovascular risk factor profiles.

Aims: In western countries out-of-hospital ischaemic heart disease (IHD) deaths account for approximately 50–70% of all IHD deaths. The objective was to examine the trends in out-of-hospital IHD deaths in the Region of Skåne in southern Sweden, in different sex- and age-groups. Methods: All 14,347 persons (range 24–110 years) in Skåne who died out-of-hospital between 1992 and 2003 from IHD (I410–I414; I20–I25) as the underlying cause of death. Subjects with previous admission for IHD since 1970 were excluded. Data were retrieved from the Swedish National Cause of Death and Patient Register. Age-standardized IHD mortality rates and trends were calculated using Poisson regression analysis. Results: Age-standardized annual out-of-hospital IHD mortality rates from 1992–2003 decreased in men from 177±13 to 103±9/100,000 inhabitants (−4.7%; p<0.001) and in women from 142±11 to 96±9/100,000 (−2.7%; p<0.001). In men, the annual change in age-standardized IHD mortality rates were −5.3 % (p<0.001), −4.0 % (p<0.001) and −4.7 % (p<0.001), respectively, in the age groups 20–64 years, 65–74 years and ≥75 years. Corresponding figures in women were −4.4 % (p<0.001), −2.4 % (p=0.003) and −2.5 % (p<0.001). The proportion of IHD deaths occurring out-of-hospital was in these age groups 50%, 40% and 35% respectively. Conclusions: In Skåne, out-of-hospital mortality in IHD deaths decreased significantly between 1992 and 2003. The decrease is more pronounced in men than women, and at the end of the study period in 2003, rates were almost equal. The proportion of IHD deaths occurring outside hospital was higher in younger people than in older people.

BACKGROUND:Although marital status and low occupation level has been associated with mortality, the relationship with case fatality rates (CFR) after a coronary event (CE) is unclear. This study explored whether incidence of CE and short-term CFR differ between groups defined in terms of marital status and occupation, and if this could be explained by biological and life-style risk factors.METHODS:Population-based cohort study of 33,224 subjects (67% men), aged 27 to 61 years, without history of myocardial infarction, who were enrolled between 1974 and 1992. Incidence of CE, and CFR (death during the first day or within 28 days after CE, including out-of-hospital deaths) was examined over a mean follow-up of 21 years.RESULTS:A total of 3,035 men (6.0 per 1000 person-years) and 507 women (2.4 per 1000) suffered a first CE during follow-up. CFR (during the 1st day) was 29% in men and 23% in women. After risk factor adjustments, unmarried status in men, but not in women, was significantly associated with increased risk of suffering a CE [hazard ratios (HR) 1.10, 95% CI: 0.97-1.24; 1.42: 1.27-1.58 and 1.77: 1.31-2.40 for never married, divorced and widowed, respectively, compared to married]. Unmarried status, in both gender, was also related with an increased CFR (1st day), taking potential confounders into account (odds ratio (OR) 2.14, 95% CI: 1.63-2.81; 1.91: 1.50-2.43 and 1.49: 0.77-2.89 for never married, divorced and widowed, respectively, compared to married men. Corresponding figures for women was 2.32: 0.93-5.81; 1.87: 1.04-3.36 and 2.74: 1.03-7.28. No differences in CFR (1st day) were observed between occupational groups in neither gender.CONCLUSIONS:In this population-based Swedish cohort, short-term CFR was significantly related to unmarried status in men and women. This relationship was not explained by biological-, life-style factors or occupational level.