Kvantifisering av hjertets muskelfunksjon med tøyning og tøyningshastighet målt med ultralyd for vurdering av koronar sykdom. Automatisert metode versus manuell ved akutt hjerteinfarkt og ultralyd stress test. Vanligvis måles hjertets muskelfunksjon med ultralyd, en mye brukt metode for å diagnostisere hjertesykdommer. Vurderingen av muskelfunksjonen baserer seg i dag på en subjektiv visuell gradering av bevegelsen av hjertemuskelen, og dette krever erfaring. En ny automatisert diagnostisk ultralydsmetode basert på måling av hastigheten i hjertemuskelen gir et kvantitativt mål på muskelens tøyning og sammentrekning. Den nye metoden gir ny og mer detaljert informasjon om hjertets funksjon og om pasientens prognose enn vanlig ultralydsvurdering. Den nye metoden er mer presis ved oppfølgning etter hjerteinfarkt. Et hjerteinfarkt gir nedsatt bevegelse av muskelen og måles med den nye metoden som nedsatt hastighet som muskelen forkortes med. Små forandringer i den skadde hjertemuskelen, ikke alltid synlige for øyet, kan mer nøyaktig følges over tid med den nye metoden. Utbredelsen av hjerteinfarktet kan også vurderes mer nøyaktig. Det samme gjelder når angina vurderes under belastning. Når en pasient ikke kan sykle eller gå på tredemølle brukes en medisinsk belastningstest. Ved å belaste hjertet med et medikament som øker hjertemuskelens arbeid samtidig med en ultralydundersøkelse, kan vi oppdage redusert blodforsyningsreserve i hjertet. Stresstesten hjelper til med å vurdere om en trang blodåre bør åpnes etter et hjerteinfarkt, og til å vurdere pasienters risiko for hjertekomplikasjoner før en større operasjon. Den nye metoden gir i tillegg mer informasjon om den langsiktige prognosen sammenlignet med den gamle metoden. Vi har funnet at den nye ultralydsmetoden er mer presis (gir større diagnostisk treffsikkerhet i diagnostikk av koronarsykdom) sammenlignet med den gamle. Måling av sammentrekningshastigheter i hjertemuskelen ble utviklet og testet på Institutt for sirkulasjon og bildediagnostikk ved NTNU av Andreas Heimdal og Asbjørn Støylen i 1998. Metoden trengte teknisk videreutvikling og testing i et større pasientmateriale. Metoden har ikke fått stor utbredelse på sykehusene pga støyfylte kurver og tidskrevende analyser, men med denne automatiserte metoden blir brukervennligheten større som muliggjør klinisk bruk. / Paper I and II preprinted with kind permission of Elsevier, sciencedirect.com

Uppsatsens syfte är att undersöka vilka ekonomiska effekter införandet av distansuppföljning för ICD-patienter har ur ett samhällsperspektiv. Delsyftet är att identifiera ekonomiska argument och kvalitativa aspekter för och emot införandet av tjänsten distansuppföljning. Författarna har kommit fram till ett antal slutsatser. Att införa distansuppföljning som uppföljningsmetod för ICD-patienter istället för konventionella återbesök på sjukhus innebär stora kostnadsbesparingar. Nettonuvärdet uppgår till drygt 268 miljoner kronor efter femton år. Vid tidsperiodens slut erhålls en kostnadsbesparing på cirka 35,6 procent. De ekonomiska fördelarna överstiger kostnaderna redan efter ett år, och hela investeringskostnaden återfås efter sju år. Kvalitativa argument som talar för distansuppföljning är tidsbesparingar, förenklad uppföljning, bättre övervakning och att patienterna upplever en större trygghet.

Diss. (sammanfattning) Linköping : Univ., 2002. / Härtill 4 uppsatser.

Background: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. There is a need for new pharmacological treatment strategies since the current antiarrhythmic drugs have a modest efficacy and may have severe side effects. Cardioversion (CV) of AF offers an opportunity to study related conditions in sinus rhythm (SR) and during AF. Since catheter ablation of AF is a symptomatic treatment, it is important to have tools for measurement of arrhythmia-related symptoms. Aims: To evaluate the effect of atorvastatin on maintaining SR after CV of persistent AF. To assess if highsensitivity C-reactive protein (hsCRP) predicts the recurrence of AF after CV in a population randomized to treatment with either atorvastatin or placebo. To quantify the symptomatic effect of left atrial catheter ablation of AF. To assess if the restoration of SR by CV, in a population with persistent AF, affects sleep apnea. Methods: Paper I: A total of 234 patients were randomized to treatment with either high dose atorvastatin or placebo prior to CV. Paper II: In a pre-specified substudy which included 128 of the patients in study I, hsCRP was analyzed before and after CV. Paper III: Umea 22 Arrhythmia Questions (U22) is a questionnaire that quantifies paroxysmal tachycardia symptoms. A total of 105 patients underwent first-time pulmonary vein isolation and answered U22 forms at baseline and follow-up 304 (SD 121) days after ablation. Paper IV: Polysomnography was performed before and after CV in 23 patients with persistent AF scheduled for elective CV. Results: Paper I: An intention-to-treat analysis with the available data, by randomization group, showed that 57 (51%) in the atorvastatin group and 47 (42%) in the placebo group were in SR 30 days after CV (OR 1.44, 95%CI 0.85–2.44, P=0.18). Paper II: HsCRP did not significantly predict recurrence of AF at 30 days. However, after adjusting for treatment with atorvastatin, hsCRP predicted the recurrence of AF (OR 1.14, 95% CI 1.01–1.27). Six months after CV, hsCRP at randomization predicted recurrence of AF in both univariate analysis (OR 1.30, 95% CI 1.06–1.60) and in multivariate logistic regression analysis (OR 1.33, 95% CI 1.06– 1.67). Paper III: The U22 scores for well-being, arrhythmia as cause for impaired well-being, derived timeaspect score for arrhythmia, and discomfort during attack detected relevant improvements of symptoms after the ablation. U22 showed larger improvement in patients undergoing only one procedure than in patients who later underwent repeated interventions. Paper IV: Obstructive sleep apnea occurred in 17/23 patients (74%), and central sleep apnea in 6/23 patients (26%). Five patients had both obstructive and central sleep apnea. SR at follow-up was achieved in 16 patients. The obstructive apnea-hypopnea index, central apneahypopnea index, and the number of patients with obstructive or central sleep apnea did not differ before and after restoration of SR. Conclusions: Atorvastatin is not a treatment option with regards to maintaining SR after CV in patients with persistent AF. HsCRP was associated with AF recurrence 1 and 6 months after successful CV of persistent AF. U22 quantifies the symptomatic improvement after AF ablation with adequate internal consistency and construct validity. Both obstructive and central sleep apneas are highly prevalent in patients with persistent AF. Obstructive sleep apneas are unaffected by the CV of AF to SR.

Background Chronic Obstructive Pulmonary disease (COPD) is an under-diagnosed disease with a prevalence of approximately 10%, highly dependent on age and smoking habits. Comorbidities are common in COPD and of these, cardiovascular diseases (CVD) are the most common. COPD is the fourth leading cause of death globally, and CVD probably contribute to the high mortality. Within CVD, Ischemic Heart Disease (IHD) is the most common. It is highly clinically relevant to identify signs of ischemic heart disease, other cardiac conditions, and risk factors for CVD in COPD. Electrocardiogram (ECG) is a simple but still major diagnostic tool in clinical cardiology, including disturbances in the electric conduction system and ischemia. Due to the under-diagnosis of COPD, there is limited knowledge regarding the prevalence and prognostic impact of ECG abnormalities in COPD. Arterial stiffness is a risk factor for CVD, which has raised an increased interest, however not evaluated in population based studies of COPD. Aim The overall aim was to describe cardiovascular aspects on COPD, with a specific focus on arterial stiffness, prevalence and prognostic impact of ischemic ECG abnormalities and prolonged QT interval, by comparing subjects with and without obstructive lung function impairment in a population-based cohort. Methods The thesis is based on the Obstructive Lung Disease in Northern Sweden (OLIN) COPD study; a population-based longitudinal cohort study. During the years 2002-2004, all participants in clinical examinations from previously recruited large population-based cohorts were invited to re-examination including spirometry and a structured interview. All subjects with obstructive lung function impairment (n=993) were identified, together with 993 age and sex-matched referents without airway obstruction. The study population (n=1986) has been invited to annual examinations since 2005 including spirometry and structured interview. Papers I-III are based on data from 2005 when electrocardiogram (ECG) was recorded in addition to the basic program. All ECGs were Minnesota coded and QT-time was measured. Paper IV is based data from 2010 when non-invasive measurements of arterial stiffness, assessed as pulse wave velocity (PWV), was added to the program. Spirometric data were classified as normal lung function (NLF), restrictive spirometric pattern (RSP) and airway obstruction (COPD). The following spirometric criteria for COPD were used: post-bronchodilator FEV1/VC<0.70 (papers I-IV, in paper III labelled GOLD-COPD) and lower limit of normal, LLN (LLN-COPD) (paper III). Spirometric classification of COPD severity was based on FEV1 % predicted as a continuous variable or according to the Global Initiative for Obstructive Lung Disease (GOLD), divided into GOLD 1-4. Results The prevalence of ischemic heart disease (IHD), both self-reported and assessed as probable and possible ischemic ECG abnormalities (I-ECG) according to the Whitehall criteria, was similar among subjects with NLF and COPD. The prevalence of both self-reported and probable (I-ECG) according to Whitehall increased by GOLD grade.  Among those with COPD, self-reported IHD was associated with disease severity, assessed as FEV1 % predicted also after adjustment for age and sex (paper I). In both COPD and NLF, those with I-ECG had a higher cumulative mortality over 5 years than those without I-ECG (29.6 vs. 10.6%, p<0.001 and 17.1 vs. 6.3 %, p=0.001). When analysed in a multivariate model, the Mortality Risk Ratio (MRR, 95%CI) was increased for subjects with COPD and I-ECG (2.4, 1.5-3.9), and non-significantly so for NLF with I-ECG (1.65, 0.94-2.90), when compared to NLF without I-ECG.  When analyzed separately among subjects with COPD, the increased risk for death associated with I-ECG persisted independent of age, sex, BMI-class, smoking habits and disease severity assessed as FEV1 % predicted (1.89, 1.20-2.99). The proportion without reported IHD was high among those with I-ECG; 72.4% in NLF and 67.3% in COPD. The pattern was similar also among them; I-ECG was associated with an increased risk for death in COPD and non-significantly so in NLF (paper II). Mean corrected QT-time (QTc) and prevalence of QTc prolongation was higher in RSP than NLF but similar in NLF and GOLD-COPD. The prevalence of borderline as well as prolonged QTc increased by GOLD grade (test for trend p=0.012 for both groups). Of those with GOLD-COPD, 52% fulfilled the LLN-criterion (LLN-COPD). When comparing LLN-COPD and NLF, the pattern was similar as when comparing NLF and GOLD-COPD. The cumulative mortality over 5 years was higher among subjects with borderline and prolonged QTc than those with normal QTc in subjects with GOLD-COPD and LLN-COPD but not in NLF and RSP (paper III). Arterial stiffness, assessed as PWV, was higher in GOLD 3-4 compared to non-COPD (10.52 vs. 9.13 m/s, p=0.042). Reported CVD and age >60 were both associated with significantly higher PWV in COPD as well as in non-COPD. In a multivariate model, GOLD 3-4 remained associated with higher PWV when compared with non-COPD, also when adjusted for sex, age group, smoking habits, blood pressure, reported CVD and pulse rate (paper IV). Conclusion In this population-based study, the prevalence of ischemic ECG abnormalities was similar among subjects with normal lung function and COPD, but increased by disease severity among subjects with COPD. Ischemic ECG abnormalities were associated with an increased mortality among subjects with COPD, independent of common confounders and disease severity, also among those without known heart disease. Whilst the prevalence of QTc prolongation was similar in NLF, COPD and LLN-COPD, it was associated with an increased mortality only in the COPD-groups. ECG is a simple non-invasive method and seems to identify findings of prognostic importance among subjects with COPD. Central arterial stiffness, a known risk factor for cardiovascular disease, was increased among subjects with severe and very severe COPD when compared to subjects without COPD independent of common confounders.

Background Hereditary transthyretin amyloid (ATTRm) amyloidosis is a systemic disease mainly affecting the peripheral nervous system and the heart. The disease is inherited in an autosomal dominant manner with a varying penetrance. It is caused by mutations in the transthyretin (TTR) gene. Today more than 100 disease causing mutations are known. The V30M mutation that is endemic in northern Sweden is the best studied and comprises the majority of the reported disease cases in the world. In ATTRm amyloidosis caused by the V30M mutation two distinct sub populations are seen, one with disease onset early in life and a mainly neuropathic disease and the other with late onset disease and both neuropathic disease and a progressive cardiomyopathy. These phenotypical findings have in Swedish patients been tied to differences in amyloid fibril composition. Generally, patients with early onset disease have amyloid fibrils containing only full length transthyretin (type B) whereas patients with late onset disease have amyloid containing both full length and fragmented transthyretin (type A). Until recently, the only available treatment for the disease has been liver transplantation. Patients with type A fibrils, especially males, have significantly worse survival after liver transplant due to progressive amyloid cardiomyopathy. Furthermore, it appears that type A fibrils may be the most common finding in other mutations. This thesis work aims to in depth investigate the impact amyloid fibril composition has on cardiac manifestations of the disease and on the outcome of available and novel modalities for cardiac amyloid imaging. Methods The four studies included in the thesis were done as part of the on going clinical research at the Swedish centre for transthyretin amyloidosis in Umeå.  Patients in whom amyloid fibril composition had been determined were included. Available echocardiographic data were analysed to find predictors for left ventricular hypertrophy and systolic function as measured by strain analysis in a large cohort of 105 patients (paper I). Serial 12-lead electrocardiograms from 98 patients were gathered and retrospectively interpreted and analysed to investigate the impact of amyloid fibril composition and disease progression on frequency and development of ECG abnormalities (paper IV).  DPD scintigraphy, cardiac biomarkers, clinical data and echocardiograms were analysed in a cohort of 53 consecutive patients. to assess the impact of amyloid fibril composition on the outcome of DPD scintigraphy and its relationship with cardiac hypertrophy. (paper II). To evaluate the usefulness of positron emission tomography (PET) using the amyloid specific tracer PIB, 10 patients, five with each fibril type, were selected and examined. The patients selected had a similar age of onset and similar echocardiographic findings (paper III). Results Paper I: Type A fibrils, male gender and age were independent factors associated with increased LV thickness. The distribution of amyloid fibril composition did not differ between the sexes, but in patients with type A fibrils, females had lower median cardiac wall thickness (p<0.01and better left ventricular septal strain (p=0.04).The gender differences were not apparent in patients with type B fibrils. Paper II: Ninety-seven per cent of patients with type A fibrils had pathological cardiac DPD uptake compared to none of the patients with type B fibrils. Among patients with normal septal thickness, none of 15 patients with type B fibrils had positive scintigraphy compared with 2 out of 2 with type A fibrils (P<0.01) Cardiac biomarkers, demographic data and cardiac biomarkers were significantly different, but could not differentiate between type A and type B fibrils in individual patients. Paper III: All patients had pathological cardiac PIB retention. In patients with type B fibrils the retention was significantly higher (p<0.01) than in patients with type A fibrils. Based on the selection criteria, no significant differences were seen in various echocardiographic measurements. Paper IV: All patients had a high prevalence of AV-blocks, LAH and anterior infarction pattern. Patients with type A fibrils had significantly more electrocardiographic abnormalities compared to those with type B fibrils, both at an early stage of diseases and at later follow up. Conclusion Type A fibrils are associated with more pronounced cardiac involvement, which appear to be more severe in males than in females. In study II we showed that DPD scintigraphy appears to be a very good tool for non-invasive determination of amyloid fibril composition. Papers III and IV show that patients with type B amyloid have cardiac involvement even without echocardiographic or DPD-scintigraphic evidence of amyloid cardiomyopathy and that ECG abnormalities are common irrespectively of amyloid fibril composition, and increase with time for both groups.

Elektrokardiografi är en medicinsk teknik som används för att registrera hjärtats elektriska aktivitet. QRS-tiden avspeglar hur snabbt kammarmuskulaturen depolariseras. QRS-tiden mäts från början av Q-vågen till slutet av S-vågen och har ett normalt värde som ligger på <120 millisekunder (ms) hos vuxna. Ett breddökat QRS-komplex (>120 ms) kan uppstå på grund av defekta retledningsbanor som vänstersidigt skänkelblock/högersidigt skänkelblock då kammarnas depolarisation sker långsammare. QRS-tiden kan även förlängas vid användning av vissa antiarytmiska läkemedel som Tambocor. Många studier har visat att Tambocor kan medföra en viss QRS-breddökning vid fysisk ansträngning. QRS-breddökning är en avgörande prognostisk markör för Tambocor-utsättning eller dosjustering då en förlängd QRS-tid kan leda till livshotande arytmier såsom ventrikelflimmer. I studien utfördes QRS-mätningar på friska patienter, patienter med Tambocor-behandling och patienter med vänstersidigt/högersidigt skänkelblock. Syftet med studien var att undersöka om QRS-tiden i vila och maxbelastning vid arbetsprov skiljer sig statistiskt och kliniskt åt när mätning sker med två olika metoder. QRS-mätning med båda metoderna utfördes digitalt via ECView program. Metod 1 baserade på att välja ett QRS-komplex som ser bredast ut och har bra teknisk kvalitet för att kunna mäta på. Metod 2 baserade på att mäta på avledningen som har tidigast Q och på avledningen som har senast S. Resultatet visade en stark positiv korrelation mellan metoderna både i vila och vid maxbelastning. One sample T test visade att metod 2 ger signifikant högre värde än metod 1. Bland-Altman diagram visade en god överenstämmelse mellan metoderna. Resultatet visade även att det kliniska beslutet för medicinutsättning/dosjustering hade påverkats hos två patienter med Tambocor-behandling beroende på vilken metod som används. Slutsatsen är att metoderna skiljer sig signifikant åt och fler studier behövs för att bekräfta om skillnaden är klinisk signifikant

Bakgrund: Hjärtsvikt är en vanligt förekommande folksjukdom i Sverige, och egenvård är en central del i patienternas vardag. För att minska risken av försämring i sin sjukdom är det därmed väsentligt för patienterna att få adekvat patientundervisning om hur egenvården främjas. Syfte: Syftet med litteraturöversikten var att beskriva effekter av sjuksköterskans pedagogiska omvårdnad för upprätthållandet av en god egenvård hos patienter med kronisk hjärtsvikt. Metod: En kvantitativ litteraturöversikt innehållande 11 artiklar från Cinahl och Medline genomfördes. Resultat: En strukturerad pedagogisk omvårdnad visade förbättring på patienters symtomuppfattning, egenvårdshantering, egenvårdsbeteenden och minskade återinläggningar. Patienterna visade dessutom förbättrad kunskap om mat- och vätskerestriktioner, läkemedelsföljsamhet och fysisk aktivitet. Slutsats: Sjuksköterskans pedagogiska omvårdnad kan vara fördelaktig i arbetet med att befrämja egenvården hos patienter med kronisk hjärtsvikt.

Extracorporeal Membrane Oxygenation (ECMO) is a life-saving therapy usedfor support in critical heart and/or lung failure. Patient’s blood is pumped viaan artificial lung for oxygenation outside of the body. The circuit is composedof a blood pump, cannulae for drainage and reinfusion, a membrane lung,tubing and connectors. Its use is associated with thromboembolic complicationsand hemolytic damage. Detailed numerical studies of two blood pumps anda lighthouse tip drainage cannula were undertaken to characterize the flowstructures in different scenarios and their link to platelet activation. The pumpsimulations were modelled according to manufacturer’s proclaimed use but alsoin off-design conditions with flow rates used in adult and neonatal patients.Lagrangian Particle Tracking (LPT) was used to simulate the injection ofparticles similar in size to platelets to compute platelet activation state (PAS).The results indicated that low flow rates impacted PAS similarly to high flowrates due to increased residence time leading to prolonged exposure to shearstress despite the fact that shear per se was lower at low flow rate. Regardingthe cannula, the results showed that a flow pattern similar to a jet in crossflowdeveloped at the side holes. A parameter study was conducted to quantifydrainage characteristics in terms of flow rate distribution across the holes wheninput variables of flow rate, modelled fluid, and hematocrit were altered. Thefindings showed, across all the cases, that the most proximal hole row drainedthe largest fraction of fluid. The effects due to the non-Newtonian nature ofblood were confined to regions far from the cannula holes and the flow structuresshowed very limited dependence on the hematocrit. A scaling law was found tobridge the global drainage performance of fluid between water and blood. / <p>QC 210906</p>

Sammanfattning   Bakgrund: Hjärtsvikt är en folksjukdom som är utbrett problem över hela världen. I Sverige diagnostiseras två till tre procent per år med hjärtsvikt. För att personer skall få rätt stöd och behandling behövs en individuell plan uppföras i samråd med sjuksköterskan. Sjuksköterskors uppgift är att ge råd till personer med hjärtsvikt och möjligheterna kan öka att följa råden om personerna har en känsla av att ingå i ett sammanhang.    Syfte: var att beskriva hur personer med hjärtsvikt upplever sitt dagliga liv.   Metod: En kvalitativ metod med induktiv ansats har använts. Tolv vetenskapliga artiklar användes till resultatet. Artiklarna hämtades från CINAHL, MEDLINE och PSYCINFO samt kvalitetsgranskas med kvalitetsgranskningsprotokollet från Hälsohögskolan, i Jönköping.   Resultat: Resultatet bestod av två teman och åtta subteman; att anpassa sig till vardagslivets fysiska utmaningar (Orkeslöshet i vardag, Kunskapsbrist om hjärtsvikt, Att anpassa sig till sjukdomen och Att vara i behov av familj och vänner), och Att genomgå emotionella förändringar i vardagen (Osäkerhet om framtid, Social isolering, Frågor om döden och Att acceptera sin sjukdom).    Slutsats: Personer med hjärtsvikt upplever begränsningar i det dagliga livet. Kunskapsbrist ledde till försvårade hantering av hjärtsvikt. Sjuksköterskan inom primärvården bör ge information och kunskapen kring hjärtsvikt på ett förståeligt sätt baserat på individens anpassning och har förutsättningar att hantera sin sjukdom för att kunna förbättra välbefinnandet för personen. / Summary  Daily life changed for people with heart failure Background: Heart failure is a common disease that is a widespread problem worldwide. In Sweden, two to three percent of people per year are diagnosed with heart failure. For someone with heart failure to receive the right support and treatment, an individual plan needs to be drawn in consultation between the nurse and the person with hearts failure. The task of nurses is to give advice a person with heart failure and follow up the individual in order know if person have a feeling of being part of a context.  Aims: The purpose was to describe experiences for people with heart failure in everyday life.  Method: A qualitative method with an inductive approach has been used. Twelve scientific articles were used for the result. The articles were retrieved from CINAHL, MEDLINE and PSYCINFO and quality reviewed with the quality review protocol from the School of Health Sciences, in Jönköping.   Results: The result consisted of two themes; to adapt to the physical challenges of everyday life (lack of energy in everyday life, lack of knowledge about heart failure, adapt to the disease and the need of family and friends), and to undergo emotional changes in everyday life (Uncertainty about the future, Social isolation, Questions about death and accepting their illness).  Conclusion: people with heart failure experience limitations in daily life. Lack of knowledge leads to difficulties in managing heart failure. The nurse in primary care should provide information and knowledge about heart failure in an understandable way based on the individual’s adaptation and have the conditions to manage their illness to improve the well-being of people with heart failure.