A left ventricular thrombus develops in approximately 40% of patients following an anterior myocardial infarction. Embolization from these thrombi has been regarded as the most important cause of stroke following a myocardial infarction. The occurrence and characteristics of left ventricular thrombi and stroke after anterior myocardial infarction may, however, have changed after the introduction of aspirin and thrombolytics as standard therapy. The occurrence of left ventricular thrombi was examined in 99 patients with an acute anterior myocardial infarction, 74 of whom were treated with streptokinase. Thrombi were equally common in the thrombolysis group (46%, 95% confidence interval [Cl], 35-57%) as in the non-thrombolysis group (40%, 95% Cl, 21-59%). The risk of thrombus formation was related to the degree of left ventricular segmental dysfunction. Using serial echocardiographic examinations, the formation and resolution of thrombi was found to be highly dynamic. The majority of thrombi diagnosed during the hospital stay had resolved at follow-up one month later, irrespective of treatment with streptokinase or anticoagulants. The development of new thrombi was, however, observed at every follow-up examination interval. One-hundred-and-twenty-four patients suffering a stroke within 28 days of an acute myocardial infarction were identified in the northern Sweden MONICA stroke registry between 1985 and 1994. The overall event rate of ischemic myocardial infarction-related stroke was 1.07%. The risk of a stroke was highest duringt he first 5 days after the infarction. Only approximately half the strokes were preceded by an anterior myocardial infarction. In a case-control analysis, atrial fibrillation (chronic or new onset), ST elevation and a history of a previous stroke were found to be independent predictors of stroke. There was a long-term trend towards a lower incidence and event rate for myocardial infarction-related stroke. Clinical stroke characteristics were examined in 103 patients with a first-ever stroke within 28 days of a myocardial infarction and compared with stroke characteristics in 206 control subjects without a recent myocardial infarction. The sudden onset of neurological symptoms, an impairment of consciousness, a progression in neurological deficits and a stroke of the total anterior circulation infarction subclass were more common in cases than in controls. The risk of a recurrent stroke during one year of follow-up was not influenced by a recent myocardial infarction, but patients who had suffered a myocardial infarction had markedly higher mortality. To conclude, thrombolytic treatment does not reduce the occurrence of left ventricular thrombi after a myocardial infarction. The risk of thrombus formation is related to the extent of the myocardial injury. The development and resolution of thrombi is a highly dynamic process. There is a long-term trend towards a lower incidence and event rate of ischemic stroke after a myocardial infarction. Although the clinical stroke characteristics differ, they are not specific enough to differentiate between patients with and without a recent myocardial infarction. / <p>S. 1-84: sammanfattning, s. 85-136: 5 uppsatser</p> / digitalisering@umu

ABSTRACT The non-steroidal anti-inflammatory drug (NSAID), diclofenac, has been associated with a high risk for cardiovascular events in observational studies. However, majority of studies identifying this association were conducted when diclofenac was the only NSAID that could be obtained as a combination product (i.e., formulated with misoprostol). As a result, channelling bias might have resulted if prescribers selected the combination of diclofenac/misoprostol (Diclo-Miso) in patients with poor health status frequently than other NSAID products. The main purpose of this study was to identify evidence for channelling bias in a cohort of patients with coronary heart disease (CHD) prescribed NSAIDs. Three independent, retrospective analyses were carried out using Saskatchewan’s health administrative databases. Patients were eligible if they were hospitalized with CHD event between January 1, 1994 and December 31, 2008. In the first analysis, a time series was conducted to examine trends in the use of NSAIDs following discharge from original hospitalization. In the second analysis, multivariate logistic regression models were constructed to identify characteristics of patients prescribed with Diclo-Miso in comparison to single-entity diclofenac. Finally, a nested case-control study was conducted to examine the risk for recurrent myocardial infarction (MI)/ Unstable Angina (UA) or death among patients prescribed with Diclo-Miso versus single-entity diclofenac. For each case, up to five controls were matched by age and sex. Between 1994 and 2008, NSAIDs were used by 20.1% (3,099/15,393) of patients in the year following discharge from their original MI/UA hospitalization. Use of these agents was relatively stable until 2004 when the COX-2 selective agent rofecoxib was withdrawn from the market. Following this date (i.e., September 30, 2004), the use of Diclo-Miso and single-entity diclofenac appeared to follow different trends. However, available patient and disease specific factors could not explain diverging utilization trends. Further, no differences were observed in the risk of experiencing recurrent MI/UA between patients receiving Diclo-Miso (OR 0.88, 95% CI 0.72-1.08, p=0.22) or single-entity diclofenac (OR 0.78, 95% CI 0.60-1.00, p=0.06) versus patients not exposed to NSAIDs. Based on the study’s result, channelling bias does not appear to be a major threat to the analysis of cardiovascular toxicity of diclofenac products.

Hjärtinfarkt är en av de främsta dödsorsakerna bland män och kvinnor i världens idag. Kardiovaskulär död minskar bland män, men inte bland kvinnor. Att drabbas av en hjärtinfarkt, innebär ett hot mot livet för personen som drabbas, och påverkar personen och dennes familj under lång tid. Kvinnor som insjuknar är i genomsnitt 75 år och har en sjukdomshistoria med andra sjukdomar i bakgrunden när de drabbas av en hjärtinfarkt. Män är i genomsnitt sett 10 år yngre än kvinnor och har oftare varit med om en tidigare hjärtinfarkt, när de återinsjuknar. När kvinnor drabbas av en hjärtinfarkt tenderar de att uppvisa mer atypiska symptom, vilket leder till att de väntar med att söka sjukvård. Kvinnor drabbas av fler biverkningar än män, eftersom det har forskats mer på män av läkemedelsindustrin och inom kardiovaskulär hälsa. För att besvara syftet med denna studie att beskriva på vilket sätt kvinnors livskvalitet skiljer sig från mäns efter en hjärtinfarkt, gjordes en litteraturstudie. Resultatet visade att livskvaliteten efter en hjärtinfarkt skiljer sig åt mellan kvinnor och män. Inom dimensionerna fysisk funktion, fysisk rollfunktion, kroppslig smärta, social funktion och emotionell rollfunktion, vilka ingår i mätinstrumentet SF-36, skattade kvinnor sin livskvalitet sämre än män. / Myocardial infarction is one of the main causes of death among men and women in the world today. Cardiovascular deaths are declining among men but not among women. Suffering from a heart attack, is a threat to the lives of people affected, and continues to affects him and his family for a long time. Women who are diagnosed are on average 75 years and has a history of other diseases in the background when they suffer a heart attack. Men are on average seen 10 years younger than women and have more often experienced a previous heart attack, when they suffer a recurrence. When women suffer a heart attack, they tend to exhibit more atypical symptoms, which means that they delay seeking medical care. Women suffer more side effects than men, as it has been researched more on men of the pharmaceutical industry and cardiovascular health. To answer the purpose of this study was to describe the way women's quality of life differs from men after a heart attack, a literature review was done. The results showed: that the quality of life after a heart attack differs between men and women. Within the dimensions of physical function, role physical functioning, bodilypain, social function and emotional role function, which is part of the instrument SF-36, women rated their quality of life worse than men.

The overall aim of this thesis was to explore and describe women’s recovery after a first myocardial infarction (MI) from an organisational, a relational and an individual perspective. In this thesis a longitudinal, explorative and descriptive design combining both quantitative (papers I-II) and qualitative (papers III-IV) methods has been used. Data was collected from healthcare professionals at 18 acute hospitals (paper I), which on two occasions answered a questionnaire dealing with cardiac rehabilitation efforts. From these 18 hospitals, 240 women who had suffereda first MI (paper II) were consecutively chosen to answer a questionnaire on three occasions on the subject of social support and social network. Descriptive and inferential statistics were used to analyse data over time. Paper III and IV had an exploratory and descriptive design based on an inductive, qualitative content analysis approach. Interviews were conducted with 20 cardiac rehabilitation nurses (CRN) (paper III) and with 26 women suffering a first MI (paper IV). The results showed that patients with MI, and their next of kin, were offered a well-functioning cardiac rehabilitation on both measurement occasions. None of the hospitals offered a CRP that was specifically designed for women (paper I). The women perceived that the extent of general support, support from relatives, and professional support changed positively over time (paper II). The CRNs experienced that women’s recovery was influenced by their ability to cope with the stresses of life, if they wanted to be involved in their own personal care and how they related to themselves, and their opportunities to receive support (paper III). Women experienced that ability to approach the new perspective of life depended on how they embraced the three dimensions; behaviour, i.e. women’s acting and engaging in various activities, social i.e. how women receive and give support in their social environment, and psychological i.e. their way of thinking, reflect and appreciate life (paper IV). In conclusion, the four studies show that women’s recovery after a first MI is depending on factors emerging from an organisational, a relational and an individual perspective. Using knowledge from these three perspectives the possibility of a holistic approach to women’s recovery process to health will increase and the risk of a reductionist thinking will decrease.

Syftet med studien var att beskriva patienters upplevelser och erfarenheter av fysisk aktivitet i grupp efter hjärtinfarkt. Studien genomfördes som en kvalitativ intervjustudie och hade en beskrivande design. Genom ett ändamålsurval intervjuades tio patienter som deltog i hjärtgymnastikgrupp på ett sjukhus i Mellansverige. Data samlades in genom semistrukturerade intervjuer. Insamlad data analyserades med hjälp av kvalitativ innehållsanalys. Resultatet redovisas utifrån två teman; välbefinnande genom en känsla av trygghet och kontroll samt ökad motivation till en aktiv livsstil. Patienterna beskrev att fysisk aktivitet i grupp varit en trygghet efter hjärtinfarkten. Att få testa gränser under säkra förhållanden, ha ett utbyte mellan individer, känna samhörighet i gruppen och uppleva psykisk och fysisk hälsa. Vidare upplevde patienterna det viktigt att ha en meningsfull aktivitet, att de kände ett behov av att komma på träningarna och att den organiserade träningen var varierad och gav en chans till att prova nya saker. Att uppmuntra och förmå patienter som haft hjärtinfarkt att delta i fysisk aktivitet i grupp bör därför vara av stor vikt för både sjukvårdspersonal och patienterna själva. / The aim of the study was to describe patients' experiences and perceptions of physical activity in a group after myocardial infarction. The study was conducted as a qualitative interview and had a descriptive design. By a purposive sampling ten patients were interviewed who participated in cardiac exercise team at a hospital in central Sweden. Data were collected through semi-structured interviews. The collected data were analyzed using qualitative content analysis. The results are reported based on two themes; well-being through a sense of security and control, and increased motivation for an active lifestyle. Patients described that physical activity in the group has been a security after the myocardial infarction. To be able to test the limits in safe conditions, have an exchange between individuals, a sense of belonging in the group and experience the mental and physical health. Furthermore, patients experienced important to have a meaningful activity, that they felt a need to come to the training sessions and the organized training was varied and gave a chance to try new things. To encourage and persuade patients who had a myocardial infarction to participate in physical activity in a group should be of great importance to both healthcare professionals and patients themselves.

I bakgrunden förklaras att årligen drabbas ett stort antal människor av hjärtinfarkt. Sjukdomen inträffar ofta plötsligt och påverkar stora delar av patientens liv. Det är viktigt att som sjuksköterska ha kunskap kring hur patienten upplever sjukdomen för att kunna ge vård utifrån ett patientperspektiv. Syftet med studien var därmed att beskriva hur patienter upplever att ha drabbats av hjärtinfarkt. Metoden är en litteraturbaserad studie där kvalitativ forskning analyserats. Resultatet sammanställdes i fyra olika teman: Ett förändrat och hotat liv, rädslan för en ny hjärtinfarkt, Livsstilsförändringars påverkan på stress och välbefinnande samt känslan av sårbarhet och brist på individanpassad vård. Livet efter en hjärtinfarkt upplevdes som förändrat. Patienterna såg inte på sig själv och sin kropp på samma sätt som tidigare. Betydelsen av stöd ansågs som viktigt i återhämtningsprocessen, dock sågs sjukvårdens stöd stundtals som bristande. Vissa patienter upplevde förändringarna i livet som positiva och som vägen till ett förbättrat liv. Slutsatsen är att upplevelserna tiden efter hjärtinfarkten är individuella, därmed bör vården vara individanpassad för att uppnå så bra vård som möjligt. Vården bör fokusera på att hjälpa patienterna att hantera vardagliga situationer. / In the background it is explained that every year a large number of people suffer from a heart attack. The disease often occurs very sudden and affects the patients life in many ways. As a nurse it’s very important to have knowledge about how the patient experiences the disease and to be able to give the right treatment from a patient perspective. The purpose with this study was by that to describe how patients experience to have suffered a heart attack. The method is a literature based study where qualitative research has been analyzed. The result was then complied into four different themes, A changed and threatened life, the fear of another heart attack, lifestyle changes impact on stress and well-being and the sense of vulnerability and lack of individualized care The life after a heart attack was seen as altered. Patients did not look at themself and there body in the same way as before. The importance of support was considered significant in the recovery process, though the support provided by health care was sometimes vied as insufficient. Some patients experienced the changes in life as positive and as the road to a new improved life. The conclusion is that the experiences from the time after a heart attack is individual and thereby should the healthcare be adapted for individuals to achieve as good healthcare as possible. The healthcare should focus on helping the patients dealing with everyday situations.

Evidence indicates that regular physical activity (e.g., aerobic physical activity for 30 minutes most days of the week) reduces recurrent cardiac events and death rates in women with coronary heart disease (CHD). However, study findings consistently report higher rates of physical inactivity among rural versus urban women. In addition, rural women experience significant geographic disparities, health inequities, and limited access to health care services and providers, creating further self-care challenges such as engaging in recommended physical activity behaviors post-MI. To understand how rural Nova Scotia (NS) women engage in physical activity behaviors post MI, and factors that affect their physical activity in the post-MI period, constructivist grounded theory (CGT) and photovoice methodologies and methods were used in this research. Eighteen NS women from rural settings participated in two interviews and in the taking of personal photographs using provided disposable cameras. Findings from the narrative and visual data culminated in a substantive theory, “Seeking-Self Worth: A Theory of How Rural Women Engage in Physical Activity Behavior Post-MI.” What was most problematic for study participants was questioning self-worth as a rural woman post-MI. To manage this problem, study participants engaged in the process of seeking self-worth as a rural woman post-MI. The theory of seeking self-worth also involved the processes of assessing MI damage and physical activity, testing physical activity limits, and choosing physical activity priorities. All of these processes played out within a rural context where gender and contextual factors encouraged or hindered study participants’ seeking of self-worth post-MI and, subsequently, their engagement in physical activity behavior post-MI. This substantive theory has implications for nursing, particularly rural public health nurses and nurse practitioners, in the areas of practice, education, research, and policy development.

Central mechanisms involving aldosterone - mineralocorticoid receptor (MR) activation mediate the increase in sympathetic tone after myocardial infarction (MI). We hypothesized that an increase in cardiac sympathetic activity (CSA) post MI facilitates cardiac sympathetic axonal sprouting, and that central MR blockade attenuates CSA and reduces cardiac sympathetic hyperinnervation post MI. Western blotting and qRT-PCR were used to assess protein and gene expression, and fluorescent immunohistochemistry was used to study changes in sympathetic innervation. Tyrosine hydroxylase (TH) and Norepinephrine transporter protein content in the non-infarcted base of the heart remained unaltered. In contrast, protein gene product (PGP 9.5) protein was significantly increased 2 fold in the base of the heart, and 6 fold in the peri-infarct area at 1 wk post MI, and associated with increased ubiquitin expression. Cardiac myocytes rather than sympathetic axons were identified as the main source of elevated PGP 9.5 expression. At the infarct border sympathetic hyperinnervation was observed with a 4 fold increase in growth associated protein 43 (GAP 43), a 2 fold increase in TH and a 50% increase in PGP 9.5 positive fibers when compared to the epicardial side of the left ventricle in sham rats. Central infusion of the MR blocker eplerenone at 5 ug/day for 9 days post MI markedly attenuated the increase in TH, GAP 43 and PGP 9.5 nerve densities at the infarct border. Central MR blockade may attenuate sympathetic hyperinnervation by several mechanisms, including decreasing CSA post MI, or affecting expression or function of nerve growth factor protein. Marked PGP 9.5 expression occurs in cardiomyocytes early post MI, which may contribute to the increase in ubiquitin and the early cardiac remodeling post MI.

Ūminis širdies nepakankamumas yra vis dažniau sutinkama patologija, reikalaujanti didelių diagnostikos ir gydymo resursų, o šios patologijos baigčių prognozavimas išlieka mažai tyrinėtas. Tyrimui pasirinktas sergančių ligonių ūminiu miokardo infarktu, komplikuotu ūminiu širdies nepakankamumu, kontingentas. Darbe siekiama nustatyti hemodinamikos rodiklių ir biocheminių žymenų vertę prognozuojant ūminio miokardo infarkto sąlygoto širdies nepakankamumo eigos ypatumus, komplikacijų išsivystymo riziką, gydymo efektyvumą ir baigtis. Keliami uždaviniai nustatyti intervencinio gydymo metodų derinimo vertę ligoniams, sergantiems ūminio miokardo infarkto sąlygotu širdies nepakankamumu. Taip pat šiems ligoniams darbe numatyta įvertinti hemodinaminių oksigenacijos rodiklių pokyčius, jų kitimo dinamiką ir vertę prognozuojant gydymo baigtis; įvertinti invaziniais hemodinamikos tyrimo metodais nustatytų hemodinamikos rodiklių bei biocheminių žymenų pokyčių vertę prognozavimui. Taip pat siekiama nustatyti ligonių, sergančių ūminiu širdies nepakankamumu, sąlygotu ūminio miokardo infarkto, ribines hemodinaminių ir biocheminių žymenų vertes gydymo baigčių prognozavimui ir pagrįsti biocheminių žymenų bei nepertraukiamo hemodinamikos stebėjimo tikslingumą skirtingo lygio pagalbą teikiančiuose gydymo centruose, numatant ligonių tikslingą perkėlimą, savalaikiai numatant diagnozuojant būklės sunkumą, gyvybei grėsmingų komplikacijų kilimą, vertinant gydymo efektyvumą, prognozuojant gydymo baigtis. / Heart failure is a significant issue in the healthcare system, and its prevalence in developed countries tends to increase due to the increasing proportion of the aging population. Acute heart failure as a complication of acute myocardial infarction is explored in the study. The aim of the study was to determine the value of hemodynamic indices and biochemical markers in the prognostication of the peculiarities of the course of acute heart failure, the risk of complications, and the effectiveness and outcomes of its treatment. The main objectives of the study were the following: to evaluate changes in hemodynamic oxygenation markers, and the dynamics and value of these changes in the prognostication of treatment outcomes in patients with acute heart failure depending on complications and therapeutic techniques;. to evaluate the value of the combination of interventional treatment techniques in patients with acute heart failure; to evaluate the prognostic value of hemodynamic markers identified via invasive hemodynamic examination techniques and changes in biochemical indices; to identify marginal values of hemodynamic and biochemical markers in the prognostication of treatment outcomes; to substantiate the expedience of and indications for biochemical markers and continuous monitoring of hemodynamics during the acute period of heart failure for timely detection of life-threatening complications, evaluation of treatment efficiency, and prognostication of outcomes.

Type D personality, or distressed personality, refers to the joint tendency to experience negative emotions and to inhibit self-expression in social interactions. The overall aims of this thesis were to examine the impact of Type D personality on adolescents’ self-perceived health, to examine the factorial and temporal stability of the Type D personality construct DS14, and to clarify whether type D personality is an independent risk factor for recurrent myocardial infarction and all-cause mortality among patients with myocardial infarction. The prevalence of Type D personality in the adolescent population was 10.4% for boys and 14.6% for girls. Boys and girls with Type D personality were approximately twice as likely to report musculoskeletal pain and five times as likely to report psychosomatic symptoms. Adolescents with Type D personality were four times more likely to have sleep disturbances and to sleep fewer hours, especially on school nights. Among patients with myocardial infarction, the Swedish DS14 had stable structural validity. Our measurements confirmed the two-factor model of the DS14. However, the DS14 exhibited low temporal stability, especially when comparing the measurement obtained during hospitalization with the 1- and 12-month follow-up measurements. Among patients with myocardial infarction, the Framingham risk score had a strong predictive value for recurrent myocardial infarction, and a somewhat weaker predictive value for all-cause mortality. However, none of the previously proposed methods for the analysis of the DS14 Type D personality measurement predicted recurrent myocardial infarction or all-cause mortality, either in univariable analyses or in addition to the Framingham risk score. In conclusion, the present thesis found significant associations between the DS14 and psychosomatic symptoms in adolescents. However, the measurement exhibited a low stability over time and no predictive value for recurrent myocardial infarction and mortality among patients with myocardial infarction. Taken together, these results raise the question of whether the Swedish DS14 really is a measure of personality. An alternative explanation for the strong cross-sectional associations observed between the DS14 and psychosomatic symptoms might be that the DS14 functions as a pseudo-measure of ill health, or co-varies with depressive or psychosomatic characteristics.