Tiia Ainla

PurposeLarge-scale, population-based biobanks integrating health records and genomic profiles may provide a platform to identify individuals with disease-predisposing genetic variants. Here, we recall probands carrying familial hypercholesterolemia (FH)-associated variants, perform cascade screening of family members, and describe health outcomes affected by such a strategy.MethodsThe Estonian Biobank of Estonian Genome Center, University of Tartu, comprises 52,274 individuals. Among 4776 participants with exome or genome sequences, we identified 27 individuals who carried FH-associated variants in the LDLR, APOB, or PCSK9 genes. Cascade screening of 64 family members identified an additional 20 carriers of FH-associated variants.ResultsVia genetic counseling and clinical management of carriers, we were able to reclassify 51% of the study participants from having previously established nonspecific hypercholesterolemia to having FH and identify 32% who were completely unaware of harboring a high-risk disease-associated genetic variant. Imaging-based risk stratification targeted 86% of the variant carriers for statin treatment recommendations.ConclusionGenotype-guided recall of probands and subsequent cascade screening for familial hypercholesterolemia is feasible within a population-based biobank and may facilitate more appropriate clinical management.

To evaluate the association between hyperglycaemia on admission, previously known diabetes and 180-day mortality in acute myocardial infarction (AMI) patients.The study population consisted of 779 consecutive AMI patients from the Myocardial Infarction Registry in Estonia who had an admission venous plasma glucose level recorded and who were admitted to the Tartu University Clinics within a period of 2 years. Logistic regression analysis was used to estimate crude and adjusted odds ratios (OR) with 95% confidence interval (95% CI).In patients without a history of diabetes, glucose level was < or = 11.0 mmol/l in 556 patients (group 1) and > 11.0 mmol/l in 109 patients (group 2). Of those with diabetes, glucose level was < or = 11.0 mmol/l in 30 patients (group 3) and > 11.0 mmol/l in 84 patients (group 4). Non-diabetic hyperglycaemic patients underwent more resuscitations outside of hospital (group 2, 31.2% vs. group 1, 2.0% vs. group 3, 6.7% vs. group 4, 6.0%, P < 0.0001) and had a higher 180-day mortality compared with other groups (group 2, 47.7% vs. group 1, 14.1% vs. group 3, 26. 7% vs. group 4, 29.8%, P < 0.0001). After adjustment for potentially confounding factors, hyperglycaemic non-diabetic (OR 4.35, 95% CI 1.79-10.59), but not diabetic (OR 1.79, 95% CI 0.62-5.15) status, remained an independent predictor of 180-day mortality.AMI patients with hyperglycaemia on admission, independent of a history of diabetes, represent a high-risk population for 180-day mortality. The worst outcome occurs in non-diabetic hyperglycaemic patients. Further studies are warranted to clarify the questions of hyperglycaemia treatment in AMI patients.

Data on how differences in risk factors, treatments, and outcomes differ between sexes in European countries are scarce. We aimed to study sex-related differences regarding baseline characteristics, in-hospital managements, and mortality of ST-elevation myocardial infarction (STEMI) patients in different European countries.Patients over the age of 18 with STEMI who were treated in hospitals in 2014-17 and registered in one of the national myocardial infarction registers in Estonia (n = 5817), Hungary (n = 30 787), Norway (n = 33 054), and Sweden (n = 49 533) were included. Cardiovascular risk factors, hospital treatment, and recommendation of discharge medications were obtained from the infarction registries. The primary outcome was mortality, in-hospital, after 30 days and after 1 year. Logistic and cox regression models were used to study the associations of sex and outcomes in the respective countries. Women were older than men (70-78 and 62-68 years, respectively) and received coronary angiography, percutaneous coronary intervention, left ventricular ejection fraction assessment, and evidence-based drugs to a lesser extent than men, in all countries. The crude mortality in-hospital rates (10.9-15.9 and 6.5-8.9%, respectively) at 30 days (13.0-19.9 and 8.2-10.9%, respectively) and at 1 year (20.3-28.1 and 12.4-17.2%, respectively) after hospitalization were higher in women than in men. In all countries, the sex-specific differences in mortality were attenuated in the adjusted analysis for 1-year mortality.Despite improved awareness of the sex-specific inequalities on managing patients with acute myocardial infarction in Europe, country-level data from this study show that women still receive less guideline-recommended management.

Describe the characteristics, management and outcomes of hospitalized ST-segment elevation myocardial infarction (STEMI) patients according to national ongoing myocardial infarction registries in Estonia, Hungary, Norway, and Sweden.Country-level aggregated data was used to study baseline characteristics, use of in-hospital procedures, medications at discharge, in-hospital complications, 30-day and 1-year mortality for all patients admitted with STEMI during 2014-2017 using data from EMIR (Estonia; n = 4584), HUMIR (Hungary; n = 23 685), NORMI (Norway; n = 12 414, data for 2013-2016), and SWEDEHEART (Sweden; n = 23 342). Estonia and Hungary had a higher proportion of women, patients with hypertension, diabetes, and peripheral artery disease compared to Norway and Sweden. Rates of reperfusion varied from 75.7% in Estonia to 84.0% in Sweden. Rates of recommendation of discharge medications were generally high and similar. However, Estonia demonstrated the lowest rates of dual antiplatelet therapy (78.1%) and statins (86.5%). Norway had the lowest rates of beta-blockers (80.5%) and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (61.5%). The 30-day mortality rates ranged between 9.9% and 13.4% remaining lowest in Sweden. One-year mortality rates ranged from 14.8% in Sweden and 16.0% in Norway to 20.6% in Hungary and 21.1% in Estonia. Age-adjusted lethality rates were highest for Hungary and lowest for Sweden.This inter-country comparison of data from four national ongoing European registries provides new insights into the risk factors, management and outcomes of patients with STEMI. There are several possible reasons for the findings, including coverage of the registries and variability of baseline-characteristics' definitions that need to be further explored.

Background The purpose was to describe the treatment and outcomes of non-ST-elevation myocardial infarction (NSTEMI) in Estonia according to patients' estimated mortality risk by the Global Registry of Acute Coronary Events (GRACE) score and investigate if inequalities in treatment had an impact on prognosis. Methods We performed a linkage between Estonian Myocardial Infarction Registry, Population Registry and Estonian Health Insurance Fund. All NSTEMI patients 2012–2014 were stratified into low (<4%), intermediate (4–12%), or high (>12%) mortality risk according to GRACE. All-cause mortality and composite endpoint of death, recurrent myocardial infarction, stroke or unplanned revascularization were compared between optimally – defined as concomitant in-hospital use of medicines from recommended groups and coronary angiography – and suboptimally managed patients, using the Cox regression. Results Out of 3803 NSTEMI patients (median age 73 years, 44% women) 20% were classified into low, 35% into intermediate and 45% into high risk category. In these groups, respectively, 62%, 46% and 23% of patients received optimal in-hospital management. Over the mean follow-up of 2.4 years the association between suboptimal in-hospital management and outcomes was the following: in the low risk group mortality hazard ratio (HR) 1.6 (95% confidence interval 0.8–3.2), composite endpoint HR 1.2 (0.8–1.8); in the intermediate risk group mortality HR 2.4 (1.7–3.3), composite endpoint HR 1.8 (1.4–2.3); and in the high risk group mortality HR 2.2 (1.8–2.8), composite endpoint HR 1.6 (1.3–2.0). Conclusions Higher risk NSTEMI patients received less guideline-recommended in-hospital management, which was associated with a worse prognosis.

The presence of diabetes mellitus poses a challenge in the treatment of patients with acute myocardial infarction (AMI). We aimed to evaluate the sex-specific outcomes of diabetic and non-diabetic patients with AMI who have undergone percutaneous coronary intervention (PCI). Data of the Estonian Myocardial Infarction Registry for years 2006–2009 were linked with the Health Insurance Fund database and the Population Registry. Hazard ratios (HRs) with the 95% confidence intervals (CIs) for the primary composite outcome (non-fatal AMI, revascularization, or death whichever occurred first) and for the secondary outcome (all cause mortality) were calculated comparing diabetic with non-diabetic patients by sex. In the final study population (n = 1652), 14.6% of the men and 24.0% of the women had diabetes. Overall, the diabetics had higher rates of cardiovascular risk factors, co-morbidities, and 3–4 vessel disease among both men and women (p < 0.01). Among women, the diabetic patients were younger, they presented later and less often with typical symptoms of chest pain than the non-diabetics (p < 0.01). Women with diabetes received aspirin and reperfusion for ST-segment elevation AMI less often than those without diabetes (p < 0.01). During a follow-up of over two years, in multivariate analysis, diabetes was associated with worse outcomes only in women: the adjusted HR for the primary outcome 1.44 (95% CI 1.05 − 1.96) and for the secondary outcome 1.83 (95% CI 1.17 − 2.89). These results were largely driven by a high (12.0%) mortality during hospitalization of diabetic women. Diabetic women with AMI who have undergone PCI are a high-risk group warranting special attention in treatment strategies, especially during hospitalization. There is a need to improve the expertise to detect AMI earlier, decrease disparities in management, and find targeted PCI strategies with adjunctive antithrombotic regimes in women with diabetes.

To study baseline characteristics, in-hospital managements and mortality of non-ST-elevation myocardial infarction (NSTEMI) patients in different European countries.NSTEMI patients enrolled in the national myocardial infarction (MI) registries [EMIR; n = 5817 (Estonia), HUMIR; n = 30 787 (Hungary), NORMI; n = 33 054 (Norway), and SWEDEHEART; n = 49 533 (Sweden)] from 2014 to 2017 were included and presented as aggregated data. The median age at admission ranged from 70 to 75 years. Current smoking status was numerically higher in Norway (24%), Estonia (22%), and Hungary (19%), as compared to Sweden (17%). Patients in Hungary had a high rate of diabetes mellitus (37%) and hypertension (84%). The proportion of performed coronary angiographies (58% vs. 75%) and percutaneous coronary interventions (38% vs. 56%), differed most between Norway and Hungary. Prescription of dual antiplatelet therapy at hospital discharge ranged from 60% (Estonia) to 81% (Hungary). In-hospital death ranged from 3.5% (Sweden) to 9% (Estonia). The crude mortality rate at 1 month was 12% in Norway and 5% in Sweden (5%), whereas the 1-year mortality rates were similar (20-23%) in Hungary, Estonia, and Norway and 15% in Sweden.Cross-comparisons of four national European MI registries provide important data on differences in risk factors and treatment regiments that may explain some of the observed differences in death rates. A unified European continuous MI registry could be an option to better understand how implementation of guideline-recommended therapy can be used to reduce the burden of cardiovascular disease.

Mortality from cardiovascular disease in Estonia is among the highest in Europe. The reasons for this have not been clearly explained. Also, there are no studies available examining outpatient drug utilization patterns in patients who suffered from acute myocardial infarction (AMI) in Estonia. The objective of the present study was to examine drug utilization in different age and gender groups following AMI in Estonia. Patients admitted to hospital with AMI (ICD code I21-I22) during the period of 01.01.2004-31.12.2005 and who survived more than 30 days were followed 365 days from the index episode. Data about reimbursed prescriptions of beta-blockers (BBs), angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARBs) and statins for these patients was obtained from the database of the Estonian Health Insurance Fund. Data were mainly analysed using frequency tables and, where appropriate, the Pearson's χ2 test, the Mann-Whitney U-test and the t-test were used. A logistic regression method was used to investigate the relationship between drug allocation and age and gender. We presented drug utilization data as defined daily dosages (DDD) per life day in four age groups and described proportions of different combinations used in men and women. Four thousand nine hundred patients were hospitalized due to AMI and 3854 of them (78.7%) were treated by BBs, ACE/ARBs and/or statins. Of the 4025 inpatients who survived more than 30 days, 3799 (94.4%) were treated at least by the one of drug groups studied. Median daily dosages differed significantly between men and women in the age group 60-79 years for BBs and ACE/ARBs, respectively. Various combinations of the drugs studied were not allocated in equal proportions for men and women, although the same combinations were the most frequently used for both genders. The logistic regression analysis adjusted to gender and age revealed that some combinations of drugs were not allocated similarly in different age and gender groups. Most of the patients were prescribed at least one of commonly recommended drugs. Only 40% of them were treated by combinations of beta-blockers, ACE inhibitors/angiotensin II receptor blockers and statins, which is inconsistent with guideline recommendations in Estonia. Standards of training and quality programs in Estonia should be reviewed and updated aiming to improve an adherence to guidelines of management of acute myocardial infarction in all age and gender groups.

The aim of the study was to explore trends in short- and long-term mortality after hospitalization for acute myocardial infarction (AMI) over the period 2001─2011 in Estonian secondary and tertiary care hospitals while adjusting for changes in baseline characteristics.In this nationwide cross-sectional study random samples of patients hospitalized due to AMI in years 2001, 2007 and 2011 were identified and followed for 1 year. Trends in 30-day and 1-year all-cause mortality were analysed using Cox proportional hazards regression model.The final analysis included 423, 687 and 665 patients in years 2001, 2007 and 2011 respectively. During the study period, the prevalence of most comorbidities remained unchanged while the in-hospital and outpatient treatment improved significantly. For example, the proportion of tertiary care hospital AMI patients who underwent revascularization was almost three times higher in 2011 compared to 2001. The proportion of secondary care patients who were referred to a tertiary care centre for more advanced care increased from 5.8 to 40.1 % (p for trend <0.001). Meanwhile, the 1-year mortality rates decreased from 29.5 to 20.2 % (adjusted p = 0.004) in the tertiary and from 32.4 to 23.1 % (adjusted p = 0.006) in the secondary care. The decrease in the 30-day mortality rates was statistically significant only in the secondary care hospitals.The use of evidence-based treatments in Estonian AMI patients improved between 2001 and 2011. At the same time, we observed a significant reduction in the long-term mortality rates, both for patients primarily hospitalized into secondary as well as into tertiary care hospitals.

Background We aim to investigate the predictive ability of PCE (Pooled Cohort Equations), QRISK2 and SCORE (Systematic COronary Risk Estimation) scoring systems for atherosclerotic cardiovascular disease (ASCVD) risk prediction in Estonia, a country with one of the highest ASCVD event rates in Europe. Methods Seven-year risk estimates were calculated in risk score–specific subsets of the Estonian Biobank cohort. Calibration was assessed by standardised incidence ratios (SIRs) and discrimination by Harrell’s C-statistics. In addition, a head-to-head comparison of the scores was performed in the intersection of the three score-specific subcohorts. Results PCE, QRISK2 and SCORE risk estimates were calculated for 4356, 7191 and 3987 eligible individuals, respectively. During the 7-year follow-up, 220 hard ASCVD events (PCE outcome), 671 ASCVD events (QRISK2 outcome) and 94 ASCVD deaths (SCORE outcome) occurred among the score-specific subsets of the cohort. While PCE (SIR 1.03, 95% CI 0.90 to 1.18) and SCORE (SIR 0.99, 95% CI 0.81 to 1.21) were calibrated well for the cohort, QRISK2 underestimated the risk by 48% (SIR 0.52, 95% CI 0.48 to 0.56). In terms of discrimination, PCE (C-statistic 0.778) was inferior to QRISK2 (C-statistic 0.812) and SCORE (C-statistic 0.865). All three risk scores performed at similar level in the head-to-head comparison. Conclusion Of three widely used ASCVD risk scores, PCE and SCORE performed at acceptable level, while QRISK2 underestimated ASCVD risk markedly. These results highlight the need for evaluating the accuracy of ASCVD risk scores prior to use in high-risk populations.

High quality care for acute myocardial infarction (AMI) improves patient outcomes. Still, AMI patients are treated in hospitals with unequal access to percutaneous coronary intervention. The study compares changes in treatment and 30-day and 3-year mortality of AMI patients hospitalized into tertiary and secondary care hospitals in Estonia in 2001 and 2007. Final analysis included 423 cases in 2001 (210 from tertiary and 213 from secondary care hospitals) and 687 cases in 2007 (327 from tertiary and 360 from secondary care hospitals). The study sample in 2007 was older and had twice more often diabetes mellitus. The patients in the tertiary care hospitals underwent reperfusion for ST-elevation myocardial infarction, cardiac catheterization and revascularisation up to twice as often in 2007 as in 2001. In the secondary care, patient transfer for further invasive treatment into tertiary care hospitals increased (P < 0.001). Prescription rates of evidence-based medications for in-hospital and for outpatient use were higher in 2007 in both types of hospitals. However, better treatment did not improve significantly the short- and long-term mortality within a hospital type in crude and baseline-adjusted analysis. Still, in 2007 a mortality gap between the two hospital types was observed (P < 0.010). AMI treatment improved in both types of hospitals, while the improvement was more pronounced in tertiary care. Still, better treatment did not result in a significantly lower mortality. Higher age and cardiovascular risk are posing a challenge for AMI treatment.

AbstractObjective – The objective of this study was to compare process of care, in-hospital outcomes, and 1-year mortality of patients with acute myocardial infarction (AMI) first admitted to hospitals with and without percutaneous coronary intervention (PCI) facilities in Estonia in 2007.Methods – We conducted a retrospective cross-sectional study on a random sample of hospitalized AMI patients. Data on process of care and in-hospital outcomes were abstracted from patient records in 16 hospitals according to a standardized study form.Results – Patients first admitted to PCI hospitals (n88=88327) had higher rates of overall use of coronary angiography (78.3% vs. 24.7%; P 88<880.001), revascularization (64.2% vs. 20.6%; P 88<880.001), and echocardiography (85.3% vs. 65.3%, P 88<880.001) than those first admitted to non-PCI hospitals (n88=88360). Among the non-PCI hospital patients those selected for cardiac catheterization were younger, healthier, and had better clinical status on presentation. Patients admitted to PCI hospitals had higher prescription rates of in-hospital and discharge evidence-based medications except for beta-blockers. PCI hospitals’ patients had lower in-hospital mortality (11.3% vs. 19.2%, P 88=880.004) and 1-year mortality (24.5% vs. 34.7%, P 88=880.003), results remained significant after adjustment for baseline characteristics (odds ratio 0.47; 95% confidence interval 0.28-0.78, hazard ratio 0.66; 95% confidence interval 0.48-0.90).Conclusions – There are disparities in process of care, in-hospital and 1-year mortality between patients first admitted to PCI vs. non-PCI hospitals in Estonia. Patients admitted to non-PCI hospitals should undergo more vigorous risk stratification using invasive and non-invasive methods; use of evidence-based medicine should be encouraged even if cardiac revascularization is not done.Key Words: Acute myocardial infarctiontreatmentpercutaneous coronary interventionoutcomesmortality

To compare validity of AMI diagnosis and treatment of AMI patients between tertiary and secondary care hospitals in Estonia.Two tertiary and seven secondary care hospitals responsible for the treatment of most AMI patients in Estonia were included in the analysis. A random sample of 520 patients admitted to these hospitals with AMI in 2001 was taken from the Estonian Health Insurance Fund database. Medical records were reviewed by trained experts using a standardized data collection form.Forty cases were excluded due to selection errors by the Health Insurance Fund. Of the remaining cases, a diagnosis of AMI was confirmed in 93.3% of cases in tertiary care hospitals and in 83.5% of cases in secondary care hospitals (p < 0.001). A total of 210 cases from tertiary and 213 cases from secondary care hospitals with confirmed AMI diagnoses were included in subsequent analysis. Utilization of beta-blockers, aspirin, and reperfusion therapy was similar in both types of hospitals. In tertiary care hospitals, ACE inhibitors and statins were more frequently used during hospital stay and recommended at discharge compared with secondary care hospitals. In-hospital mortality was similar in both types of hospitals both before and after adjustment.Tertiary care physicians adhered more strictly to the current definition and guidelines for the management of AMI than did secondary care physicians. However, there is still a need for further improvement in both hospital settings according to international guidelines.

Relatively high rates of adherence to myocardial infarction (MI) secondary prevention medications have been reported, but register-based, objective real-world data is scarce. We aimed to analyse adherence to guideline-recommended medications for secondary prevention of MI in 2017 to 2018 (period II) and compare the results with data from 2004 to 2005 (period I) in Estonia.Study populations were formed based on data from the Estonian Health Insurance Fund's database and on Estonian Myocardial Infarction Register. By linking to the Estonian Medical Prescription Centre database adherence to guideline-recommended medications for MI secondary prevention was assessed for 1 year follow-up period from the first hospitalization due to MI. Data was analysed using the defined daily dosages methodology.Total of 6694 and 6060 cases of MI were reported in periods I and II, respectively. At least one prescription during the follow up period was found for beta-blockers in 81.0% and 83.5% (p = 0.001), for angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEi/ARB) in 76.9% and 66.0% (p < 0.001), and for statins in 44.0% and 67.0% (p < 0.001) of patients in period I and II, respectively. P2Y12 inhibitors were used by 76.4% of patients in period II. The logistic regression analysis adjusted to gender and age revealed that some drugs and drug combinations were not allocated similarly in different age and gender groups.In Estonia, adherence to MI secondary prevention guideline-recommended medications has improved. But as adherence is still not ideal more attention should be drawn to MI secondary prevention through systematic guideline implementation.

Abstract Background Routine oral anticoagulation (OAC) is recommended for almost all high-risk patients with atrial fibrillation, yet registries show that OACs are still underused. Our aim was to study the lifeday coverage (LDC) of OAC prescriptions and its relationship with one-year mortality rates of AF patients aged ≥ 65 in Estonia for the years 2019 and 2020. Methods Medical data for AF patients aged ≥ 65 years from 2018 and alive as of 01.01.2019 (cohort I) and new AF documentation from 2019 and alive as of 01.01.2020 (cohort II) was obtained from the Health Insurance Fund’s electronic database. The data was linked to the nationwide Estonian Medical Prescription Centre’s database of prescribed OACs. For LDC analysis, daily doses of guideline-recommended OACs were used. The patients were categorized into three LDC groups: 0%, 1–79%, and ≥ 80%. The data was linked to the Estonian Causes of Death Registry to establish the date of death and mortality rate for the whole Estonian population aged ≥ 65. Results There were 34,018 patients in cohort I and 9,175 patients with new AF documentation (cohort II), previously not included in cohort I. Of the patients, 77.7% and 68.6% had at least one prescription of OAC in cohorts I and II respectively. 57.4% in cohort I and 44.5% in cohort II had an LDC of ≥ 80%. The relative survival estimates at 1 year for LDC lifeday coverage groups 0%, 1–79%, and ≥ 80% were 91.2%, 98.2%, and 98.5% (cohort I), and 91.9%, 95.2%, and 97.6% (cohort II), respectively. Conclusions Despite clear indications for OAC use, LDC is still insufficient and anticoagulation is underused for stroke prevention in Estonia. Further education of the medical community and patients is needed to achieve higher lifeday coverage of prescribed OACs.

Abstract Background Prevalence of diabetes (DM) is rapidly increasing. With high rate of concomitant chronic kidney disease (CKD) in the elderly population the risk of cardiovascular (CV) complications is very high. Purpose Aim of our study was to evaluate the effect of DM status and CKD on mortality among elderly patients after acute myocardial infarction (AMI). Methods EMIR is an ongoing nationwide registry recording data from all patients in Estonia diagnosed with AMI (ICD-10 I21-I22). The study included all patients aged &amp;gt; 65 years who were hospitalized with the first AMI from 2012 to 2019. Data on glycated haemoglobin (HbA1c) in the time frame of 30 days prior to 7 days after admission, estimated glomerular filtration (eGFR) and creatinine levels within 24 hours of admission were obtained from the hospitals’ databases. Mortality data was acquired by linking the database to the Estonian population register. Follow up period lasted until the end of 2021. Prediabetes was defined as HbA1c ≥ 5,7 – 6,4 %, new DM as HbA1c ≥ 6,5 % without previous DM diagnosis. Information about previous DM diagnosis was acquired from EMIR. Statistical analysis was done using Cox proportional hazards regression model adjusted for age, sex, DM status and renal function. Results A total of 8902 patients (50.5 % women) were identified. Among female patients there was a larger proportion of diabetics and patients with lower eGFR (Table 1). We found that 30 day, 1-year and long – term (median 5.5 years) mortality was higher for both newly diagnosed (30 days: HR 1.6 (95 % CI 1.14 – 2.23); 1–year: HR 1.57 (95 % CI 1.25 – 1.99); long–term: HR 1.53 (95 % CI 1.29 – 1.81)) and known DM (30 days: HR 1.39 (95 % CI 1.19 – 1.61); 1–year: HR 1.28 (95 % CI 1.15 – 1.42); long–term: HR 1.47 (95 % CI 1.37 – 1.58)) patients. Prediabetes did not increase post MI mortality. In all follow up periods mortality increased progressively in accordance with declining renal function from eGFR below 59 ml/min/1.73m2 (Figure 1). Conclusions Our study suggests that newly diagnosed and known DM status and CKD have a considerable effect on elderly patients’ mortality after AMI, both in short and long term. Timely diagnosis and treatment of DM and CKD and meticulous secondary prevention can add to lowering mortality after AMI. However, our data also indicates that a more lenient medical management of prediabetes and mild CKD would be adequate for the elderly AMI patients in the current polypharmacotherapy era.Table 1.Figure 1.

Recall-by-genotype (RbG) studies conducted with population-based biobank data remain urgently needed, and follow-up RbG studies, which add substance to this research approach, remain solitary. In such studies, potentially disease-related genotypes are identified and individuals with those genotypes are recalled for consultation to gather more detailed clinical phenotypic information and explain to them the meaning of their genetic findings. Familial hypercholesterolemia (FH) is among the most common autosomal-dominant single-gene disorders, with a global prevalence of 1 in 500 (Nordestgaard et al., Eur. Heart J., 2013, 34 (45), 3478-3490). Untreated FH leads to lifelong elevated LDL cholesterol levels, which can cause ischemic heart disease, with potentially fatal consequences at a relatively early age. In most cases, the pathogenesis of FH is based on a defect in one of three LDL receptor-related genes-APOB, LDLR, and PCSK9. We present our first long-term follow-up RbG study of FH, conducted within the Estonian Biobank (34 recalled participants from a pilot RbG study and 291 controls harboring the same APOB, LDLR, and PCSK9 variants that were included in the pilot study). The participants' electronic health record data (FH-related diagnoses, lipid-lowering treatment prescriptions) and pharmacogenomic risk of developing statin-induced myopathy were assessed. A survey was administered to recalled participants to discern the impact of the knowledge of their genetic findings on their lives 4-6 years later. Significant differences in FH diagnoses and lipid-lowering treatment prescriptions were found between the recalled participants and controls (34 and 291 participants respectively). Our study highlights the need for more consistent lipid-lowering treatment adherence checkups and encourage more follow-up RbG studies to be performed.

Abstract Background There is a high need for real-world international comparisons of management of patients with acute myocardial infarction. In Europe Estonia, Hungary, Norway and Sweden are among the few countries with national ongoing acute myocardial infarction registries with a high degree of completeness of data. Purpose To compare the management and outcome of hospitalized ST-segment elevation myocardial infarction (STEMI) patients in four European countries with a national ongoing myocardial infarction registry. Methods We compared patient baseline characteristics, use of in-hospital procedures and medications at discharge as well as 30-day and 1-year mortality for all patients admitted with STEMI during 2014–2017 using EMIR (Estonia; n=4,584), HUMIR (Hungary; n=23,685), NOMIR (Norway; n=12,414; data available for years 2013–2016) and SWEDEHEART (Sweden; n=23,342). Country-level results were compared as aggregated data. Results Mean age ranged from 65 to 69 years (table 1). Estonia and Hungary had compared to Norway and Sweden a higher proportion of women (resp. 39%; 38% vs. 29%; 31%), as well as patients with hypertension (resp. 79%; 72% vs. 39%; 50%), diabetes (resp. 21%; 27% vs. 14%; 19%) and peripheral artery disease (resp. 9% vs. 6%; 4%). Proportion of current smokers was highest in Norway (38%) and lowest in Sweden (27%). Rates of discharge medications were generally high. The results for in-hospital procedures and mortality are shown in table 1. Estonia had the lowest rates of dual antiplatelet treatment (78%) and statins (86%). Norway had the lowest rates of beta-blockers (80%) and angiotensin converting enzyme inhibitors/ angiotensin II receptor blockers (61%). Conclusions This cross-country comparison of four national European registries provide new insights into differences in risk factors, treatment regiments and outcomes of patients with STEMI. There are several possible reasons for the observed differences, including differences in underlying expected mortality in the populations, inclusion-criteria and coverage of the registries and variable definitions, that need to be further explored. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Estonian Research Council

Ageda muokardiinfarktiga (AMI) patsientide hulgas kasvab eakate patsientide osakaal. Nende suremus on suur, vaatamata sellele et viimaste aastakumnete jooksul on AMI-haigete letaalsus oluliselt vahenenud. Selle uheks pohjuseks peetakse seda, et eakatel patsientidel rakendatakse vahem toenduspohist ravi. Uuringus hinnati AMI riskitegureid, AMI-haigete ravi ja haiglasisest letaalsust vanuseruhmades. Uuring naitas selgelt vanuse moju, kusjuures suurim erinevus ravimite kasutamises ja haiglasiseses letaalsuses esines ≥85 a patsientide hulgas. Eesti Arst 2005; 84 (1): 13-17

Sudame isheemiatobi on komplekshaigus, mille avaldumises on roll keskkonnal, eluviisil, parilikkusel ja nende koosmojudel. Haiguse tekkeriski voimalikult varajane ja tapne hindamine on ennetava ravi maaramise nurgakiviks. Kasutusel olevates riskiskoorides ei ole voetud arvesse parilikkust, kuigi selle osakaalu sudame isheemiatove kujunemisel hinnatakse 40–60%-ni. Uute meetodite joudmine geneetiliste uuringute paletti on toonud kaasa enam kui 50 sudame isheemiatove avaldumise riskiga soetud geneetilise markeri tuvastamise. Leitud markerite kombineerimine voimaldab koostada polugeense riskiskoori, mis aitab seni klassikalistel riskiteguritel pohinenud riski hindamist ja ravi maaramist oluliselt tapsemaks muuta. On ootusparane, et lahitulevikus kuulub sudame isheemiatove tervikliku kasitluse hulka lisaks klassikalistele riskiteguritele ka geneetiliste markerite hindamine. Eesti Arst 2015; 94(9):522–529

Eesmark. Vahe on uuringuid, kus on hinnatud ageda muokardiinfarkti (AMI) alatuupide ravitulemusi parast perkutaannset koronaarinterventsiooni (PKI). Uuringu eesmark oli vorrelda ST-elevatsiooniga (STEMI) ja ST-elevatsioonita AMI (NSTEMI) patsientide hilistulemusi parast PKI-d. Metoodika. TU Kliinikumi aastatel 2006−2009 hospitaliseeritud AMI-patsientide andmed muokardiinfarktiregistrist lingiti haigekassa andmebaasi ja rahvastikuregistri andmetega. Esmane liittulem koosnes korduvast mittefataalsest AMI-st, korduvast revaskulariseerimisest voi surmast, mis iganes neist oli esimesena aset leidnud. Teisese tulemina hinnati uuringus suremust. Riskisuhete ja nende 95% usaldusintervallide (CI)arvutamiseks kasutati Coxi regressiooni, mis kohandati pohitunnustele ja kahjustatud koronaararterite arvule. Tulemused. Uuringuperioodil hospitaliseeritud 2330 AMI-patsiendist tehti PKI 1107 (82,9%) STEMI-juhu ja 545 (54,8%) NSTEMI-juhu puhul, mis moodustasid lopliku uuringuvalimi. Ligi 3aastase jalgimisperioodi ajamediaani jooksul oli STEMI-patsientidel esmase tulemi risk 1,30 (95% CI 1,09−1,56) ja teisese tulemi risk 1,57 (95% CI 1,19−2,08) korda suurem kui NSTEMI-patsientidel. Jareldused. Parast PKI-d on STEMI-patsientide ravi hilistulemused oluliselt halvemad kui NSTEMI-patsientidel. Erinevused voivad olla tingitud asjaolust, et PKI-le suunatud NSTEMI-patsientidel on vaiksem kardiovaskulaarne risk kui sel AMI alatuubi patsientidel keskmiselt. Eesti Arst 2012; 91(7):343–348

Eesti Kardioloogide Seltsi ja Eesti Haigekassa koostoos valminud eksperdihinnang ageda muokardiinfarkti ravikasitluse kohta Eesti haiglates 2007. a naitab, et vorreldes 2001. a on toimunud positiivne areng. Paranenud on koronarograafia kattesaadavus ning toenduspohiste ravimite kasutamine, mones haiglas on kasutusele voetud ageda koronaarhaige haigusloo vorme ning koostatud tegevusjuhendeid. Tanapaevast ravikasitlust negatiivselt mojutavatest teguritest on esiplaanil nii sisulised kui ka vormilised haiguslugude taitmise probleemid, esmase EKG teostamise ja interpreteerimise kiirus, samuti varieeruvad reperfusioonravi rakendamise aluseks olevad otsused. Vajakajaamiste korvaldamiseks on oluline luua tingimused ravijuhendite koostamise ja uuendamise ning koolituse kulude katteks riiklikul tasemel. Eesti Arst 2009; 88(9):552−555

Muokardiinfarkt (MI) on uks sagedasemaid surma ja toovoimetuse pohjuseid maailmas ning seega on diagnoosi kriteeriumite tapne maaratlemine ja rahvusvaheline uhtlustamine oluline nii haige kui ka uhiskonna seisukohast. Muokardiinfarkt on epidemioloogiliselt uhe peamise terviseprobleemi indikaator ning laialdaselt kasutusel kliinilistesse uuringutesse kaasamise kriteeriumi ja tulemusnaitajana. Uhtne arusaam diagnoosist voimaldab teadusuuringuid paremini omavahel vorrelda ja teha erinevate uuringute tulemuste analuuse. Eesti Arst 2008; 87(6):411−416

Natriureetilised peptiidid on peptiidhormoonid, mida sunteesitakse sudamelihases vas tu sena sudame seina pinge ja plasmamahu suurenemisele. NT-proBNP on B-tuupi natriureeti lise peptiidi (BNP) N-terminaalne propeptiid, millel ei ole fusioloogilist ak tiiv sust, kuid mille kontsentratsioonid muutuvad sarnaselt fusioloogiliselt aktiivse vormiga. Kirjanduse andmetel on NT-proBNP osutunud muokardiinfarkti (MI) haige tel tugevaks ja soltumatuks sudame puudu lik kuse (SP) tekke ja suremuse prognostiliseks markeriks. Toos uuriti, millised on NT-proBNP vaartused ja nen de dunaamika MI-haigetel ning kuivord on need vaartused seotud pat sientide hilisema SP kujunemisega ja pika ajalise elulemusega. Eesti Arst 2006; 85 (4): 278–284

Statiine ordineeritakse jarjest sagedamini sudame-veresoonkonnahaigustega patsientidel. Nad on efektiivsed nii haiguse primaarseks preventsiooniks kui ka muokardiinfarkti ravis. Uurimuses on hinnatud statiinravi kasutamist muokardiinfarkti podenud haigetel. Eesti Arst 2005; 84 (10): 710–713

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Estonian Research Council Introduction High rates of adherence to myocardial infarction (MI) secondary prevention medications have been reported by several studies in Europe. However, results derived from unselected populations registry based data is scarce. Purpose Aim of our study was to analyse adherence to guideline recommended medications for secondary prevention of MI of unselected patient population in Estonia in 2017-2018 and compare the results with data from 2004-2005. Methods Population studied in 2004-2005 was based on Estonian Health Insurance Fund"s (EHIF) database and in 2017-2018 on Estonian Myocardial Infarction Registry (EMIR). EMIR is an ongoing registry recording data from all patients in Estonia diagnosed with MI (ICD-10 I21 – I22). Patients hospitalised due to MI and survived &amp;gt; 30 days formed the study population. By linking to EHIF"s prescription database medication adherence for angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), statins, beta blockers (BB) and P2Y12 inhibitors clopidogrel and ticagrelor was assessed during one year follow-up period from first hospitalisation during period studied (at least one reimbursed prescription for the drug group during follow-up period). Results 4900 and 5067 index episodes were defined in 2004-2005 and 2017-2018, respectively. Mean age in the study population was 64.7 (+/- 11.5) and 66.5 (+/- 12.1) for men and 72.7 +/- 9.9 and 76.4 +/- 10.9 for women in 2004-2005 and 2017-2018. Rates of medication adherence among patients who survived &amp;gt; 30 days are presented in the Table. Conclusion Adherence to guideline recommended medication for secondary prevention of MI in Estonia has improved considerably over 13 years. Based on our data there is room for advancement, especially among women and the elderly. Rates of medication adherence.2004-20052017-2018p value (comparison between studies)MEN (n = 2365)WOMEN (n = 1660)TOTAL (n = 4025)MEN (n = 2704)WOMEN (n = 1668)TOTAL (n = 4372)BB, No. (%)1907 (80.6)1344 (81.0)3251 (81.0)2265 (84.0)1385 (83.0)3650 (83.5)0.001ACE/ARB, No. (%)1780 (75.3)1317 (79.3)3097 (76.9)1817 (67.2)1070 (64.1)2887 (66.0)&amp;lt; 0.001Statins, No. (%)946 (40.0)826 (50.0)*1772 (44.0)1910 (70.6)1020 (61.2)*2930 (67.0)&amp;lt; 0.001Statin + ACE/ARB + BB, No. (%)999 (42.2)647 (39.0)1646 (40.9)1336 (49.4)686 (41.1)*2022 (46.2)&amp;lt; 0.001None of the above medications, No. (%)130 (5.5)96 (6.0)226 (5.6)214 (7.9)148 (9.0)362 (8.3)&amp;lt; 0.001P2Y12 inhibitorsNANANA2194 (81.1)1147 (69.0)*3341 (76.4)NABB, beta-blockers; ACE/ARB, angiotensin converting enzyme inhibitors/angiotensin II receptor blockers. NA, not available *P &amp;lt; 0.01 for comparison between men and women with Pearson"s χ2 test. Pearson"s χ2 test used for comparison between studies.

Abstract Introduction Women receive less evidence-based care than men and have higher mortality after myocardial infarctions than men. But it is not known how the gender difference in risk factors, treatments and outcomes differs between European countries. Purpose In order to investigate the gender differences in European countries with different economic predispositions we aimed to describe and compare baseline characteristics, in-hospital management, medications at discharge and death outcomes of man and woman ST-elevation infarction (STEMI) patients following routine clinical practice in Sweden, Norway, Hungary and Estonia. Methods The study population is patients over the age of 18 with STEMI who were treated in hospital 2014–2017 (for Norway between 2013–2016) and registered in one of the national myocardial infarction registers. Patients with non-ST elevation infarction and unstable angina were excluded. Risk factors, hospital treatment, and prescription medications were obtained from the national myocardial infarction registries from each country. Mortality in-hospital, after 30 days and after 1 year, was obtained from national death registers. Results Women were on average older, had more comorbidities and higher mortality in hospital, after 30 days and one year after hospitalization. Women received coronary angiography, percutaneous coronary intervention, left ventricular ejection fraction assessment and evidence-based drugs to a lesser extent than men. Conclusions The study illustrates that there are differences in characteristics, management, treatments and outcomes between men and women in all of the studied countries no matter economic predispositions. Generally, women are treated with guideline recommended therapy to a lesser extent than men in the studied countries. Funding Acknowledgement Type of funding sources: None.

Abstract Background: Relatively high rates of adherence to myocardial infarction (MI) secondary prevention medications have been reported, but register-based, objective real-world data is scarce.We aimed to analyse adherence to guideline-recommended medications for secondary prevention of MI in 2017-2018 (period II) and compare the results with data from 2004-2005 (period I) in Estonia. Methods: Study populations were formed based on data from the Estonian Health Insurance Fund's database and on Estonian Myocardial Infarction Register. By linking to the Estonian Medical Prescription Centre database adherence to guideline-recommended medications for MI secondary prevention was assessed for one year follow-up period from the first hospitalization due to MI. Data was analysed using the defined daily dosages methodology. Results: Total of 6694 and 6060 cases of MI were reported in periods I and II, respectively. At least one prescription during the follow up period was found for beta-blockers (BB) in 81.0 % and 83.5 % (p = 0.001), for angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEi/ARB) in 76.9 % and 66.0 % (p &lt; 0.001), and for statins in 44.0 % and 67.0 % (p &lt; 0.001) of patients in period I and II, respectively. P2Y12 inhibitors were used by 76.4 % of patients in period II. The logistic regression analysis adjusted to gender and age revealed that some drugs and drug combinations were not allocated similarly in different age and gender groups. Conclusions: In Estonia, adherence to MI secondary prevention guideline-recommended medications has improved. But as adherence is still not ideal more attention should be drawn to MI secondary prevention through systematic guideline implementation.

Abstract Background: Relatively high rates of adherence to myocardial infarction (MI) secondary prevention medications have been reported, but register-based, objective real-world data is scarce.We aimed to analyse adherence to guideline-recommended medications for secondary prevention of MI in 2017-2018 (period II) and compare the results with data from 2004-2005 (period I) in Estonia. Methods: Study populations were formed based on data from the Estonian Health Insurance Fund's database and on Estonian Myocardial Infarction Register. By linking to the Estonian Medical Prescription Centre database adherence to guideline-recommended medications for MI secondary prevention was assessed for one year follow-up period from the first hospitalization due to MI. Data was analysed using the defined daily dosages methodology. Results: Total of 6694 and 6060 cases of MI were reported in periods I and II, respectively. At least one prescription during the follow up period was found for beta-blockers (BB) in 81.0 % and 83.5 % (p = 0.001), for angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEi/ARB) in 76.9 % and 66.0 % (p &lt; 0.001), and for statins in 44.0 % and 67.0 % (p &lt; 0.001) of patients in period I and II, respectively. P2Y12 inhibitors were used by 76.4 % of patients in period II. The logistic regression analysis adjusted to gender and age revealed that some drugs and drug combinations were not allocated similarly in different age and gender groups. Conclusions: In Estonia, adherence to MI secondary prevention guideline-recommended medications has improved. But as adherence is still not ideal more attention should be drawn to MI secondary prevention through systematic guideline implementation.