Background: Major variations exist in the causes, age at diagnosis, and outcomes of heart failure (HF) in patients from different parts of the world. To try to elucidate whether this is related to differences in healthcare systems, we compared the characteristics and outcomes of immigrants living in Denmark and native Danish patients presenting with new-onset HF with reduced ejection fraction (HFrEF).Methods: By linkage of the Danish Heart Failure Registry, and nationwide administrative registries, we identified patients with new onset HFrEF, from 2005-2021, grouped according to immigration status and, if not native Danish, region of origin, according to the World Bank classification. Outcomes were a composite of HF hospitalization and all-cause death, and up-titration of guidelines-directed medical therapy (GDMT). Cox regression analyses adjusted for age, sex, calendar year, HF severity, socioeconomic status, and major comorbidity were used to compare the primary composite outcome.Findings: Of 33,414 patients included, 31,537 (94.4 %) were native Danish patients (DK), 1029 (3.1%) were originally from Europe/Central Asia (EUR/CA), 436 (1.3%) from Middle East/North Africa (ME/NAF), 224 (0.8%) from South Asia (SA), 62 (0.2%) from East Asia/Pacific (EA/P), 64 (0.2%) from Sub-Saharan Africa (SSA), 34 (0.1%) from North America (NA), and 28 (0.1%) from Latin America (LA). The median time since immigration ranged from 20 to 30 years. Compared to DK, patients originated from SSA, EA/P, ME/NAF, and SA were around 10 years younger (median age 57-64 vs. 71 years), had more diabetes and ischemic heart disease, and less atrial fibrillation (all p < 0.0001). Patients from EUR/CA, NA, and LA were largely alike to DK. The crude 3-year cumulative incidence of the primary composite outcome was 34% (DK), 31% (EUR/CA), 27% (SA), and 23% (ME/NAF). In adjusted analyses with DK as the reference, only ME/NAF was associated with a lower risk; hazard ratio (HR) 0.77 (95% CI 0.62-0.94). No major differences in the up-titration of GDMT were observed across groups.Interpretation: Non-Western immigrants living in Denmark who presented with new-onset HFrEF had a distinct clinical profile, being generally younger but with a greater prevalence of diabetes and ischemic heart disease compared to native Danish patients. In addition, they had lower rates of the primary outcome of HF hospitalization and all-cause death and a similar likelihood of GDMT up-titration. The reasons for these differences deserve more research.Funding: None.Declaration of Interest: J.H.B. reports advisory board honoraria from Bayer outside the submitted work. M.S. reports lecture fees from Novartis, Boehringer-Ingelheim, Astra Zeneca and Novo Nordisk outside the submitted work. E.L.F. has received independent research grants related to valvular heart disease and endocarditis from the Novo Nordisk Foundation and the Danish Heart Association outside the submitted work. P.S.J. reports grant from Boehringer Ingelheim, Analog Devices Inc., AstraZeneca, Roche Diagnostics; his employer, Glasgow University, has been remunerated for work on clinical trials with AstraZeneca, Novartis, Novo Nordisk, Bayer; Speaker fees and/or advisory board fees with AstraZeneca, Novartis, Boehringer Ingelheim; Lecture fees from AstraZeneca Novartis, Inta Pharma, Sun Pharmaceuticals, ProAdwise; Director of Global Clinical Trial Partners Ltd outside the submitted work. L.K. reports speakers' honoraria from Novo Nordisk, Novartis, AstraZeneca, Boehring, and Bayer outside the submitted work. F.G. reports consulting fees from Abbott, Pfizer, Bayer, Ionis, Alnylam, and Boehringer-Ingelheim and speakers fees from Novartis, AstraZeneca, and Orion Pharma outside the submitted work. N.S. reports grants/contracts from Astra Zeneca, Boehringer Ingelheim, Novartis, Roche Diagnostics. Consulting fees from Abbott Laboratories, Afimmune, Amgen, Astra Zeneca, Boehringer Ingelheim, Eli Lilly, Hanmi Pharmaceuticals, Mercks Sharp & Dohme, Novartis, Novo Nordisk, Pfizer, Roche Diagnostics. Lecture fees/manuscript writing for Abbott Laboratories, Astra Zeneca, Boehringer Ingelheim, Eli Lilly, Janssen, Novo Nordisk outside the submitted work. J.J.V. reports payment or honoraria for lectures/ presentations/speaker bureaus/manuscript writing for Abott, Alkem Metabolics, Eris Lifesciences, Hikma, Lupin, Sun Pharmaceuticals, Medscape/Herat.org, ProAdWise, Servier, the Corpus. Other financial or non-financial interests: Cytokinetics, Amgen, Astra Zeneca, Theracos, Ionis Pharmaceuticals, DalCor, Cardurion, Novartis, Glaxo Smith Kline, Bayer, KBP Biosciences, Boehringer- Ingelheim, Bristol-Myers Squibb. S.L.K. reports advisory board honoraria from Bayer and AstraZeneca outside the submitted work. SAA, NEV, JK, JEL, BBL, and IS, declare no competing interests.Ethical Approval: In Denmark, observational studies based in public registries are conducted for the sole purpose of scientific research and do not require ethical approval or informed consent by law. However, the study is approved by the data responsible institute (Capital Region of Denmark in Denmark. P-2019-191).
ObjectivesThere is a paucity of data on the risk of nursing home admission or domiciliary care initiation according to time to intravenous thrombolysis for ischemic stroke. We investigated the association between time to intravenous thrombolysis and the composite of nursing home admission or domiciliary care initiation in patients with acute ischemic stroke.Materials and MethodsIn this nationwide cohort study, all stroke patients treated with intravenous thrombolysis (2011–2015) and alive at discharge were identified from the Danish Stroke Registry and other nationwide registries. The composite of nursing home admission or domiciliary care initiation one year post-discharge according to time to thrombolysis was examined with multivariable Cox regression.ResultsThe study population comprised 4,349 patients (median age 67 years [25th-75th percentile 57–75], 65.2% men). The median National Institutes of Health Stroke Scale score at presentation was 5, and the median time from symptom-onset to initiation of thrombolysis was 143 min. The absolute 1-year risk of the composite endpoint was 14.0% (95%CI, 11.5–16.8%) in the ≤90 min group, 16.6% (15.1–18.1%) in the 91–180min group, and 16.0% (14.0–18.2%) in the 181–270 min group. Compared with thrombolysis ≤90 min, time to thrombolysis between 91–180 min and 181–270 min was associated with a significantly higher risk of the composite endpoint (hazard ratio 1.31 [1.04–1.65] and 1.47 [1.14–1.91], respectively).ConclusionsIn patients admitted with ischemic stroke, increasing time to thrombolysis was associated with a greater risk of the composite of nursing home admission or domiciliary care initiation. Continued efforts to shorten the time delay from symptom-onset to initiation of thrombolysis are warranted.
To investigate the admission rates of cardiovascular diseases, overall and according to subgroups, and subsequent mortality rates during the coronavirus disease 2019 societal lockdown (12 March 2020) and reopening phase (15 April 2020) in Denmark. Using Danish nationwide registries, we identified patients with a first-time acute cardiovascular admission in two periods: (i) 2 January-16 October 2019 and (ii) 2 January-15 October 2020. Weekly incidence rates of a first-time cardiovascular admission, overall and according to subtypes, in the two periods were calculated. The incidence rate of first-time cardiovascular admissions overall was significantly lower during the first weeks of lockdown in 2020 compared with a similar period in 2019 but increased after the gradual reopening of the Danish society. A similar trend was observed for all subgroups of cardiovascular diseases. The mortality rate among patients admitted after March 12 was not significantly different in 2020 compared with 2019 [mortality rate ratio 0.98; 95% confidence interval (CI) 0.91-1.06)]. In Denmark, we observed a substantial decrease in the rate of acute cardiovascular admissions, overall and according to subtypes, during the first weeks of lockdown. However, after the gradual reopening of the Danish society, the admission rates for acute cardiovascular diseases increased and returned to rates similar to those observed in 2019. The mortality rate in patients admitted with cardiovascular diseases during lockdown was similar to that of patients during the same period in 2019.
Since 2007, transcatheter aortic valve implantation (TAVI) has emerged as another treatment strategy for severe symptomatic aortic stenosis (AS) compared with surgical aortic valve replacement (SAVR). The objectives were to compare annual rates of aortic valve replacement (AVR) procedures performed in Denmark in the era of TAVI and to assess proportion of AVRs stratified by age with use of age recommendations presented in current guidelines.Using Danish nationwide registries, we identified first-time AVRs between 2008 and 2020. Patients who were not diagnosed with AS prior to AVR were excluded RESULTS: The rate of AVRs increased by 39% per million inhabitants from 2008 to 2020. TAVI has steadily increased since 2008, accounting for 64.2% of all AVRs and 72.5% of isolated AVRs by 2020. Number of isolated SAVRs decreased from 2014 and onwards. The proportion of TAVI increased significantly across age groups (<75 and ≥75 years of age, ptrend<0.001), and TAVI accounted for 91.5% of isolated AVR procedures in elderly patients (aged ≥75 years). Length of hospital stay were significantly reduced for all AVRs during the study period (ptrend all<0.001).The number of AVRs increased from 2008 to 2020 due to adaptation of TAVI, which represented 2/3 of AVRs and more than 70% of isolated AVRs. In elderly patients, the increased use of AVR procedures was driven by TAVI, in agreement with the age recommendations in current guidelines; however, TAVI was used more frequently in patients aged <75 years, accompanied by a flattening use of SAVR.
Cardiac amyloidosis (CA) has been associated with poor outcomes. Screening studies suggest that CA is overlooked-especially in the elderly. Recent advances in treatment have brought attention to the disease, but data on temporal changes in CA epidemiology are sparse.The aim of this work was to describe all patients with CA in Denmark, examining changes in patient characteristics from 1998 to 2017.All patients with any form of amyloidosis diagnosed from 1998 to 2017, as well as their comorbidities and pharmacotherapy, were identified in Danish nationwide registries. CA was defined as any diagnosis code for amyloidosis combined with a diagnosis code for heart failure, cardiomyopathy, or atrial fibrillation or a procedural code for pacemaker implantation, regardless of the order. The index date was defined as the date of meeting those criteria. Patients were divided into 5-year periods by index date. For comparison, we also included control subjects (1:4 ratio) from the general population.CA criteria were met by 619 patients. Comparing 1998-2002 vs 2013-2017, the median age at baseline increased from 67.4 years (interquartile range [IQR]: 53.9-75.2 years) to 72.3 years (IQR: 66.0-79.3 years). The frequency of male patients increased from 62.1% to 66.2%. The incidence of CA rose from 0.88 to 3.56 per 100,000 person-years in the Danish population aged ≥65 years, and the 2-year mortality decreased from 82.6% (IQR: 69.9%-90.5%) to 50.2% (IQR: 43.1%-56.9%). Compared with control subjects, the mortality among CA patients was significantly higher (log-rank test: P < 0.0001).CA, as defined in this study, was increasingly diagnosed on a national scale. The increasing frequency of male patients and median age suggest that wild-type transthyretin amyloidosis is driving this increase. Greater recognition of earlier, less advanced cases might explain decreasing mortality.
Abstract Background With the global pandemic of coronavirus disease 2019 (Covid-19) there has been disruption to normal clinical activity in response to the increased demand on health services. There are reports of a reduction in non-Covid-19 emergency presentations. Consequentially, there are concerns that deaths from non-Covid-19 causes could increase. We examined recent reported population-based mortality rates, compared with expected rates, and compared any excess in deaths with the number of deaths attributed to Covid-19. Methods National agency and death registration reports were searched for numbers of deaths attributed to Covid-19 and overall mortality that had been publicly reported by 06 May 2020. Data on the number of deaths attributed to Covid-19, the total number of deaths registered in the population and the historical average over at least 3 years were collected. Data were available for 4 European countries (England & Wales, Scotland, Netherlands and Italy) and New York State, United States of America. Results There was an increase in observed, compared with expected, mortality in Scotland (+68%), England and Wales (+74%), the Netherlands (+58%), Italy (+39%) and New York state (+49%). Of these deaths, only 73% in Scotland, 71 % in England and Wales, 53% in the Netherlands, 54% in Italy and 79% in New York state were attributed to Covid-19 leaving a number of excess deaths not attributed to Covid-19. In the 5-week period of study, Scotland, 10% of the excess of deaths were attributed to dementia/Alzheimer’s disease and 7% to cardiovascular causes. Conclusion A substantial proportion of excess deaths observed during the current COVID-19 pandemic are not attributed to COVID-19 and may represent unrecognised deaths due to Covid-19, an excess of deaths due to other causes, or both. The impact of Covid-19 on mortality and morbidity from other causes needs to be quantified and addressed in public health planning.
Abstract Background The short-term incidence of ischemic stroke after a transient ischemic attack (TIA) is high. However, data on the long-term incidence are sparse but relevant in order to guide preventive strategies. Purpose Estimate 5-year incidence of ischemic stroke after TIA. Methods Using the Danish Stroke Registry, patients with first-time TIA during the period September 2014-December 2020 were identified and matched 1:4 with individuals from the background population, and 1:1 with patients with a first-time ischemic stroke, based on age, sex, and calendar year. The cumulative incidences of ischemic stroke and mortality were estimated by the Aalen-Johansen and Kaplan-Meier estimators, respectively, and compared between groups by use of conditional multivariable Cox regression. Results After matching, we included 23,244 patients with TIA, 92,976 patients from the background population, and 23,244 patients with ischemic stroke (median age 70 years [25th-75th percentile 60-78]: 53% men). Patients with TIA had more comorbidities than the background population, yet less than the ischemic stroke population. The five-year incidence of ischemic stroke following TIA (6.5% [95% CI 6.1-7.0]) was higher than for the background population (2.3% [95% CI 2.2-2.4], hazard ratio (HR) 3.31 [95% CI 3.04-3.61]), but lower than for the control stroke population (10.3% [95% CI 9.8-10.8], HR 0.60 [95% CI 0.55-0.66]). Five-year mortality for patients with TIA (18.0% [95% CI 17.8-19.1]) was higher than for the background population (15.0% [95% CI 14.7-15.3], HR 1.20 [95% CI 1.14-1.26]), but lower than for the control stroke population (29.9% [95%CI 29.2-30.6], HR 0.41 [95% CI 0.39-0.44]) (Figure 1). Conclusion Patients with first-time transient ischemic attach had a 5-year incidence of ischemic stroke of 6.5%. After adjustment for potential confounders, the rate of ischemic stroke was approximately three-fold higher than that of the background population, and 40% lower than that of patients with ischemic stroke.Figure 1.Cumulative incidence of stroke
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