Þegar slembirannsóknum sleppir: Áhrif fjölveikinda, aldurs og kyns á meðferð kransæðasjúkdóma

Aims: The purpose of this doctoral research is to investigate the treatment of coronary artery disease in groups that are underrepresented in randomized clinical trials using the SWEDEHEART registry. The more specific aims are: i) to compare the outcomes of coronary angiographies (CA) and percutaneous coronary interventions (PCI) in Iceland, with the outcomes in Sweden; ii) to compare the revascularization rate and complication rate in women and men with acute coronary syndromes (ACS); iii) to compare the outcomes of an invasive strategy to that of a non-invasive strategy in older people with multi-morbidity, complex health needs and ACS; and finally, iv) to study catheterizations in nonagenarians. Methods: Data originated from SWEDEHEART, a collection of cardiology registries used in Iceland and Sweden. i) In Paper I, all CA and PCI performed in Iceland and Sweden in 2007 were compared. ii) Paper II analyzed all consecutive CA between 2007-2011 due to ACS to explore gender differences in revascularization, in-hospital complications and 30-day mortality. iii) Paper III and unpublished data compared one-year outcome following invasive strategy in patients ≥ 70 years with multi-morbidity and complex health needs that were admitted in 2006-2013, due to ACS, to the outcome of a non-invasive strategy. iv) Paper IV enrolled all consecutive nonagenarians undergoing CA or PCI during 2006-2014 and examined indications, treatment decisions and outcomes. Results: i) More CA were performed per capita in Iceland in 2007 than in Sweden, but the overall PCI rate was similar. Stable coronary artery disease was more common as an indication for both CA and PCI in Iceland than in Sweden. The practice of PCI was largely similar in the two countries. One of the differences was the use of radial access; it was used in 1% of catheterizations in Iceland compared to 33% in Sweden. After PCI, the complication rate in the coronary care unit was 8% and 5%, in Iceland and Sweden respectively. ii) In total 34,120 CAs ±PCIs were performed in women and 72,761 in men during the study period. No significant stenosis was found in 27% of women and 12% of men. Women with one-vessel disease were less likely to undergo PCI compared to men, 94% and 97% for those with ST-elevation myocardial infarction (STEMI) and 82 and 86% respectively for those with non-ST elevation ACS (NSTE-ACS). Amongst patients with three-vessel disease or left main stem disease and NSTE-ACS, women were more likely to undergo PCI, (adjusted OR 1.12 ([1.05-1.20]) but less likely to undergo coronary artery bypass graft (adjusted OR 0.83 [0.77-0.90]). There was no gender difference in 30-day mortality (3% vs. 2%, adjusted OR 0.97 [0.84-1.05]), with similar results in those with one-vessel disease and those with three-vessel diseases and/or left main stem stenosis. iii) Multi-morbid patients with complex health needs and ACS registered in SWEDEHEART were 10,825 (2,004 with STEMI and 8,821 with NSTE-ACS). After STEMI, patients in the invasive group had a significantly lower risk of one-year primary event (death, ACS, stroke or transient ischemic attack [TIA]), compared to those who were in the non-invasive group, 31% and 55%, (risk-adjusted hazards ratio [HR] 0.73 [95% CI 0.63-0.80]). The risk of readmissions due to bleeding events was not increased. Patients with NSTE-ACS could not be matched with propensity scores. iv) A total of 1,692 nonagenarians underwent catheterizations, of whom 87% had at least one significant stenosis and 62% had multi-vessel disease. The indication for PCI vas ACS in 94%. Both in-hospital complication rate after PCI and in-hospital mortality were 8%. Conclusion: Groups that are underrepresented in randomized clinical trials can be studied using SWEDEHEART. Women are less often treated invasively compared to men, but this does not affect their mortality. Multi-morbid older people with complex health needs and STEMI have a high risk of new ischemic events and, in concordance with randomized studies in younger healthier patients, benefit from an invasive strategy. Most nonagenarians undergoing CAs have multi-vessel disease and a high level of lesion complexity, which, along with multi-morbidity and mainly acute indications, might partly explain both the in-hospital mortality and complication rate.Tilgangur: Konur og fjölveikir aldraðir með kransæðasjúkdóma bera oft skarðan hlut frá borði við framkvæmd slembirannsókna. Tilgangur þessarar doktorsrannsóknar er að rannsaka þessa hópa með gögnum úr gæðaskránni SWEDEHEART. Nánari markmið eru: i) að bera saman árangur kransæða– þræðinga (KÞ) og kransæðavíkkana (KV) á Íslandi og í Svíþjóð; ii) að bera saman líkur kvenna og karla með brátt kransæðaheilkenni (BKH) á að fara í KV og skoða hvort munur er á fylgikvillum og dánartíðni eftir kyni; iii) að bera saman afdrif fjölveikra aldraðra sem fengu ífarandi meðferð við BKH við afdrif þeirra sem fengu eingöngu lyfjameðferð og iv) að skoða árangur og fylgikvilla KÞ og KV hjá einstaklingum á tíræðisaldri. Aðferðir: Öll gögn komu úr SWEDEHEART sem er safn nokkurra gæðaskráa yfir hjartasjúkdóma. i) Í grein eitt var gerður samanburður á öllum KÞ og KV sem voru framkvæmdar á Íslandi og í Svíþjóð árið 2007. ii) Í grein tvö voru skoðaðar allar KÞ á Íslandi og í Svíþjóð framkvæmdar á árunum 2007-2011. Tilvísanir kvenna í KV og opna kransæðaaðgerð voru bornar saman við tilvísanir karla. Fylgikvillar og 30 daga dánartíðni kynjanna voru borin saman. iii) Í grein þrjú og óbirtu efni var ífarandi meðferð borin saman við lyfjameðferð hjá fjölveikum einstaklingum sem voru sjötugir eða eldri og fengu BKH á árunum 2006-2013 í Svíþjóð og voru skráðir í SWEDEHEART. iv) Í grein fjögur var metinn fjöldi, ábendingar, árangur og fylgikvillar eftir KÞ og KV hjá öllum einstaklingum á tíræðisaldri sem fóru í slíkar aðgerðir á árunum 2006-2014 í Svíþjóð. Niðurstöður: i) Fjöldi KÞ á mann var hærri á Íslandi en í Svíþjóð en fjöldi KV var sá sami. Stöðug hjartaöng var algengari sem ábending á Íslandi en í Svíþjóð. Munur var á áhættuþáttum og ábendingum sjúklinga á Íslandi og í Svíþjóð. KV voru framkvæmdar á nokkuð svipaðan hátt. Einn munur var að þrætt var í gegnum úlnliðsslagæð í 1% tilvika á Íslandi en í 33% tilvika í Svíþjóð (p<0.001). Fylgikvillar eftir kransæðavíkkanir KV voru 6% á móti 3% á þræðingarstofu og 8% á móti 5% á hjartadeild, á Íslandi borið saman við Svíþjóð (bæði p