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Sharma A, Coles A, Sekaran NK, Pagidipati NJ, Lu MT, Mark DB, Lee KL, Al-Khalidi HR, Hoffmann U, Douglas PS. Stress Testing Versus CT Angiography in Patients With Diabetes and Suspected Coronary Artery Disease. J Am Coll Cardiol 2019; 73:893-902. [PMID: 30819356 DOI: 10.1016/j.jacc.2018.11.056] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 11/07/2018] [Accepted: 11/26/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The optimal noninvasive test (NIT) for patients with diabetes and stable symptoms of coronary artery disease (CAD) is unknown. OBJECTIVES The purpose of this study was to assess whether a diagnostic strategy based on coronary computed tomographic angiography (CTA) is superior to functional stress testing in reducing adverse cardiovascular (CV) outcomes (CV death or myocardial infarction [MI]) among symptomatic patients with diabetes. METHODS PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) was a randomized trial evaluating an initial strategy of CTA versus functional testing in stable outpatients with symptoms suggestive of CAD. The study compared CV outcomes in patients with diabetes (n = 1,908 [21%]) and without diabetes (n = 7,058 [79%]) based on their randomization to CTA or functional testing. RESULTS Patients with diabetes (vs. without) were similar in age (median 61 years vs. 60 years) and sex (female 54% vs. 52%) but had a greater burden of CV comorbidities. Patients with diabetes who underwent CTA had a lower risk of CV death/MI compared with functional stress testing (CTA: 1.1% [10 of 936] vs. stress testing: 2.6% [25 of 972]; adjusted hazard ratio: 0.38; 95% confidence interval: 0.18 to 0.79; p = 0.01). There was no significant difference in nondiabetic patients (CTA: 1.4% [50 of 3,564] vs. stress testing: 1.3% [45 of 3,494]; adjusted hazard ratio: 1.03; 95% confidence interval: 0.69 to 1.54; p = 0.887; interaction term for diabetes p value = 0.02). CONCLUSIONS In diabetic patients presenting with stable chest pain, a CTA strategy resulted in fewer adverse CV outcomes than a functional testing strategy. CTA may be considered as the initial diagnostic strategy in this subgroup. (PROspective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550).
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202
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Canaud B, Kooman J, Selby NM, Taal M, Francis S, Kopperschmidt P, Maierhofer A, Kotanko P, Titze J. Sodium and water handling during hemodialysis: new pathophysiologic insights and management approaches for improving outcomes in end-stage kidney disease. Kidney Int 2020; 95:296-309. [PMID: 30665570 DOI: 10.1016/j.kint.2018.09.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/22/2018] [Accepted: 09/24/2018] [Indexed: 02/07/2023]
Abstract
Space medicine and new technology such as magnetic resonance imaging of tissue sodium stores (23NaMRI) have changed our understanding of human sodium homeostasis and pathophysiology. It has become evident that body sodium comprises 3 main components. Two compartments have been traditionally recognized, namely one that is circulating and systemically active via its osmotic action, and one slowly exchangeable pool located in the bones. The third, recently described pool represents sodium stored in skin and muscle interstitium, and it is implicated in cell and biologic activities via local hypertonicity and sodium clearance mechanisms. This in-depth review provides a comprehensive view on the pathophysiology and existing knowledge gaps of systemic hemodynamic and tissue sodium accumulation in dialysis patients. Furthermore, we discuss how the combination of novel technologies to quantitate tissue salt accumulation (e.g., 23NaMRI) with devices to facilitate the precise attainment of a prescribed hemodialytic sodium mass balance (e.g., sodium and water balancing modules) will improve our therapeutic approach to sodium management in dialysis patients. While prospective studies are required, we think that these new diagnostic and sodium balancing tools will enhance our ability to pursue more personalized therapeutic interventions on sodium and water management, with the eventual goal of improving dialysis patient outcomes.
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Affiliation(s)
- Bernard Canaud
- Centre for Medical Excellence, Fresenius Medical Care Deutschland, Bad Homburg, Germany; Montpellier University, Montpellier, France.
| | - Jeroen Kooman
- Maastricht Universitair Medisch Centrum - Maastricht, Netherlands
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, University of Nottingham, Royal Derby Hospital Campus, Derby, UK
| | - Maarten Taal
- Centre for Kidney Research and Innovation, University of Nottingham, Royal Derby Hospital Campus, Derby, UK
| | - Susan Francis
- Sir Peter Mansfield Imaging Centre, University of Nottingham, UK
| | | | | | - Peter Kotanko
- Renal Research Institute, New York, New York, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jens Titze
- Division of Cardiovascular and Metabolic Disease, Duke-NUS, Singapore; Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA; Division of Nephrology and Hypertension, University Clinic Erlangen, Germany
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203
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James SK, Erlinge D, Herlitz J, Alfredsson J, Koul S, Fröbert O, Kellerth T, Ravn-Fischer A, Alström P, Östlund O, Jernberg T, Lindahl B, Hofmann R. Effect of Oxygen Therapy on Cardiovascular Outcomes in Relation to Baseline Oxygen Saturation. JACC Cardiovasc Interv 2019; 13:502-513. [PMID: 31838113 DOI: 10.1016/j.jcin.2019.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/13/2019] [Accepted: 09/04/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the effect of supplemental oxygen in patients with myocardial infarction (MI) on the composite of all-cause death, rehospitalization with MI, or heart failure related to baseline oxygen saturation. A secondary objective was to investigate outcomes in patients developing hypoxemia. BACKGROUND In the DETO2X-AMI (Determination of the Role of Oxygen in Suspected Acute Myocardial Infarction) trial, 6,629 normoxemic patients with suspected MI were randomized to oxygen at 6 l/min for 6 to 12 h or ambient air. METHODS The study population of 5,010 patients with confirmed MI was divided by baseline oxygen saturation into a low-normal (90% to 94%) and a high-normal (95% to 100%) cohort. Outcomes are reported within 1 year. To increase power, all follow-up time (between 1 and 4 years) was included post hoc, and interaction analyses were performed with oxygen saturation as a continuous covariate. RESULTS The composite endpoint of all-cause death, rehospitalization with MI, or heart failure occurred significantly more often in patients in the low-normal cohort (17.3%) compared with those in the high-normal cohort (9.5%) (p < 0.001), and most often in patients developing hypoxemia (23.6%). Oxygen therapy compared with ambient air was not associated with improved outcomes regardless of baseline oxygen saturation (interaction p values: composite endpoint, p = 0.79; all-cause death, p = 0.33; rehospitalization with MI, p = 0.86; hospitalization for heart failure, p = 0.35). CONCLUSIONS Irrespective of oxygen saturation at baseline, we found no clinically relevant beneficial effect of routine oxygen therapy in normoxemic patients with MI regarding cardiovascular outcomes. Low-normal baseline oxygen saturation or development of hypoxemia was identified as an independent marker of poor prognosis. (An Efficacy and Outcome Study of Supplemental Oxygen Treatment in Patients With Suspected Myocardial Infarction; NCT01787110).
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Affiliation(s)
- Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Johan Herlitz
- Department of Health Sciences, University of Borås, Borås, Sweden
| | - Joakim Alfredsson
- Department of Medical and Health Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Sasha Koul
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Ole Fröbert
- Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Thomas Kellerth
- Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine and Sahlgrenska University Hospital, Department of Cardiology, University of Gothenburg, Gothenburg, Sweden
| | - Patrik Alström
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Ollie Östlund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden.
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Abstract
BACKGROUND Optimal glycemic control is required to restrain the increase of cardiovascular events in patients with type 2 diabetes. The effects of sodium-glucose cotransporter-2 (SGLT-2) inhibitors on cardiovascular events and mortality in those patients are not well established. This meta-analysis was conducted to assess the effects of SGLT2 inhibitors on cardiovascular events and mortality in patients with type 2 diabetes. METHODS We conducted a systematic literature search of Medline, Embase and Cochrane Library and included randomized controlled trials (RCTs) of 3 different SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin) that evaluated the effects on cardiovascular outcomes and mortality in the final meta-analysis. The intervention arm was defined either as SGLT2 inhibitor monotherapy or as SGLT2 inhibitor add-on to other non-SGLT2 inhibitor antidiabetic agents (ADAs). RESULTS Forty-two trials with a total of 61,076 patients with type 2 diabetes were included in the meta-analysis. Compared with the control, SGLT2 inhibitor treatment was associated with a reduction in the incidence of major adverse cardiovascular events (MACEs) (OR = 0.86, 95% CI 0.80-0.93, P < .0001), myocardial infarction (OR = 0.86, 95% CI 0.79-0.94, P = .001), cardiovascular mortality (OR = 0.74, 95% CI 0.67-0.81, P < .0001) and all cause mortality (OR = 0.85, 95% CI 0.79-0.92, P < .0001). However, the risk of ischemic stroke was not reduced after SGLT2 inhibitor treatment in patients with type 2 diabetes (OR = 0.95, 95% CI 0.85-1.07, P = .42). CONCLUSION These data suggest a decreased risk of harm with SGLT2 inhibitor as a class with respect to cardiovascular events and mortality.
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Affiliation(s)
- Cai-Yan Zou
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University; Affiliated to Medical School of Southeast University
| | - Xue-Kui Liu
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University; Affiliated to Medical School of Southeast University
| | - Yi-Quan Sang
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University; Affiliated to Medical School of Southeast University
| | - Ben Wang
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University; Affiliated to Medical School of Southeast University
| | - Jun Liang
- Department of Endocrinology, Xuzhou Central Hospital, Xuzhou Clinical School of Xuzhou Medical University; Affiliated to Medical School of Southeast University
- Xuzhou Institute of Medical Science, Xuzhou Institute of Diabetes, Xuzhou, Jiangsu, China
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205
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Wu L, Gunton JE. The Changing Landscape of Pharmacotherapy for Diabetes Mellitus: A Review of Cardiovascular Outcomes. Int J Mol Sci 2019; 20:E5853. [PMID: 31766545 DOI: 10.3390/ijms20235853] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/16/2019] [Accepted: 11/18/2019] [Indexed: 12/16/2022] Open
Abstract
The prevention of cardiovascular morbidity and mortality has always been a primary concern in patients with type 2 diabetes. Modern trials of glucose-lowering therapies now assess major adverse cardiac events as an endpoint in addition to the effects on glycaemic control. Whilst the data on the efficacy of intensive glucose lowering on reducing cardiovascular risk are limited, there are now increasing numbers of glucose-lowering therapies that have proven cardiovascular benefit independent of glucose lowering. This review will summarise the available literature on cardiovascular outcomes in relation to metformin, sulphonylureas, di-peptidyl peptidase-4 inhibitors, glucagon-like peptide receptor agonists, sodium-glucose co-transporter 2 inhibitors, thiazolidinediones, acarbose and insulin. In addition, new paradigms in diabetes management and the importance of treatment selection based on considerations including but not limited to glycaemic control will be discussed.
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206
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Rumana U, Kones R, Taheer MO, Elsayed M, Johnson CW. Trends in Guideline-Driven Revascularization in Diabetic Patients with Multivessel Coronary Heart Disease. J Cardiovasc Dev Dis 2019; 6:E41. [PMID: 31752091 DOI: 10.3390/jcdd6040041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/10/2019] [Accepted: 11/16/2019] [Indexed: 02/07/2023] Open
Abstract
In diabetes patients with chronic ≥3 vessel disease, coronary artery bypass grafting (CABG) holds a class I recommendation in the American College of Cardiology and American Heart Association (ACC/AHA) 2011 guidelines, and this classification has not changed to date. Much of the literature has focused upon whether CABG or percutaneous coronary intervention (PCI) produces better outcomes; there is a paucity of data comparing the odds of receiving these procedures. A secondary analysis was conducted in a de-identified database comprised of 30,482 patients satisfying the entry criteria. Odds of occurrence (CABG, PCI) were determined as the binary dependent variable in period 1, (17 October 2009 through 31 December 2011), and period 2 (1 January 2013 through 16 March 2015), before and after the 2011 guidelines, while controlling for gender, ethnicity/race, and ischemic heart disease as covariates. The odds of performing CABG rather than PCI in period 2 were not statistically significantly different than in period 1 (p = 0.400). The logistic regression model chi-square statistic was statistically significant, with χ2 (7) = 308.850, p < 0.0001. The Wald statistic showed that ethnicity/race (African American, Caucasian, Hispanic and Other), gender, and heart disease contributed significantly to the prediction model with p < 0.05, but ethnicity ‘Unknown’ did not. The odds of CABG versus PCI in period 2 were 0.98 times those in period 1 95% confidence interval (CI) = (0.925, 1.032), statistically controlling for covariates. There was no significant rise in the odds of undergoing a CABG among this dataset of high-risk patients with diabetes and multivessel coronary heart disease. Modern practice has evolved regarding patient choice and additional variables that impact the final revascularization method employed. The degree to which odds of occurrence of procedures are a reliable surrogate for provider compliance with guidelines remains uncertain.
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207
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White WB, Jalil F, Cushman WC, Bakris GL, Bergenstal R, Heller SR, Liu Y, Mehta C, Zannad F, Cannon CP. Average Clinician-Measured Blood Pressures and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus and Ischemic Heart Disease in the EXAMINE Trial. J Am Heart Assoc 2019; 7:e009114. [PMID: 30371278 PMCID: PMC6474950 DOI: 10.1161/jaha.118.009114] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Blood pressure (BP) treatment goals in patients with diabetes mellitus and increased cardiovascular risk remain controversial. Our study objective was to determine cardiovascular outcomes according to achieved BPs over the average follow‐up period in the EXAMINE (Examination of Cardiovascular Outcomes With Alogliptin Versus Standard of Care) trial. Methods and Results EXAMINE was a cardiovascular outcomes trial in 5380 patients with type 2 diabetes mellitus and recent acute coronary syndromes. Risks of major adverse cardiac events and cardiovascular death or heart failure were analyzed using a Cox proportional hazards model with adjustment for baseline covariates in 10‐mm Hg increments of clinician‐measured systolic BP from ≤100 to >160 mm Hg and diastolic BP from ≤60 to >100 mm Hg averaged during the 24 months after randomization. Based on 2015 guidelines from the American College of Cardiology, the American Heart Association and the American Society of Hypertension and 2017 American Diabetes Association guidelines, systolic BPs of 131 to 140 mm Hg and diastolic BPs of 81 to 90 mm Hg were the reference groups. A U‐shaped relationship between cardiovascular outcomes and BPs was observed. Importantly, compared with the systolic BP reference group, adjusted hazard ratios for major adverse cardiac events and cardiovascular death or heart failure were significantly higher in patients with systolic BPs <130 mm Hg. Similarly, compared with the diastolic BP reference group, adjusted hazard ratios for major adverse cardiac events and for cardiovascular death or heart failure were significantly higher for diastolic BPs <80 mm Hg. Conclusions In patients with type 2 diabetes mellitus and recent acute coronary syndrome, average BPs <130/80 mm Hg were associated with worsened cardiovascular outcomes. These data suggest that intensive control of BP in patients with type 2 diabetes mellitus and ischemic heart disease should be evaluated in a prospective randomized trial. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00968708. See Editorial by https://doi.org/10.1161/JAHA.118.010752
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Affiliation(s)
| | - Fatima Jalil
- University of Connecticut School of MedicineFarmingtonCT
| | - William C. Cushman
- Memphis Veterans Affairs Medical CenterUniversity of Tennessee Health Science CenterMemphisTN
| | | | | | | | - Yuyin Liu
- Baim Clinical Research InstituteBostonMA
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208
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Hammer Y, Iakobishvili Z, Hasdai D, Goldenberg I, Shlomo N, Einhorn M, Bental T, Witberg G, Kornowski R, Eisen A. Guideline-Recommended Therapies and Clinical Outcomes According to the Risk for Recurrent Cardiovascular Events After an Acute Coronary Syndrome. J Am Heart Assoc 2019; 7:e009885. [PMID: 30371188 PMCID: PMC6222928 DOI: 10.1161/jaha.118.009885] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Patients who have had an acute coronary syndrome (ACS) are at increased risk of recurrent cardiovascular events; however, paradoxically, high‐risk patients who may derive the greatest benefit from guideline‐recommended therapies are often undertreated. The aim of our study was to examine the management, clinical outcomes, and temporal trends of patients after ACS stratified by the Thrombolysis in Myocardial Infarction (TIMI) risk score for secondary prevention, a recently validated clinical tool that incorporates 9 clinical risk factors. Methods and Results Included were patients with ACS enrolled in the biennial Acute Coronary Syndrome Israeli Surveys (ACSIS) between 2008 and 2016. Patients were stratified by the TIMI risk score for secondary prevention to low (score 0–1), intermediate (2), or high (≥3) risk. Clinical outcomes included 30‐day major adverse cardiac events (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1‐year mortality. Of 6827 ACS patients enrolled, 35% were low risk, 27% were intermediate risk, and 38% were high risk. Compared with the other risk groups, high‐risk patients were older, were more commonly female, and had more renal dysfunction and heart failure (P<0.001 for each). High‐risk patients were treated less commonly with guideline‐recommended therapies during hospitalization (percutaneous coronary intervention) and at discharge (statins, dual‐antiplatelet therapy, cardiac rehabilitation). Overall, high‐risk patients had higher rates of 30‐day major adverse cardiac events (7.2% low, 8.2% intermediate, and 15.1% high risk; P<0.001) and 1‐year mortality (1.9%, 4.6%, and 15.8%, respectively; P<0.001). Over the past decade, utilization of guideline‐recommended therapies has increased among all risk groups; however, the rate of 30‐day major adverse cardiac events has significantly decreased among patients at high risk but not among patients at low and intermediate risk. Similarly, the 1‐year mortality rate has decreased numerically only among high‐risk patients. Conclusions Despite an improvement in the management of high‐risk ACS patients, they are still undertreated with guideline‐recommended therapies. Nevertheless, the outcome of high‐risk patients after ACS has significantly improved in the past decade, thus they should not be denied these therapies.
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Affiliation(s)
- Yoav Hammer
- 1 Department of Cardiology Rabin Medical Center Petah Tikva Israel.,3 Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Zaza Iakobishvili
- 1 Department of Cardiology Rabin Medical Center Petah Tikva Israel.,3 Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - David Hasdai
- 1 Department of Cardiology Rabin Medical Center Petah Tikva Israel.,3 Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Ilan Goldenberg
- 2 The Leviev Heart Center Sheba Medical Center Tel Hashomer Israel.,3 Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel.,4 Israeli Association for Cardiovascular Trials Sheba Medical Center Tel Hashomer Israel
| | - Nir Shlomo
- 4 Israeli Association for Cardiovascular Trials Sheba Medical Center Tel Hashomer Israel
| | - Michal Einhorn
- 4 Israeli Association for Cardiovascular Trials Sheba Medical Center Tel Hashomer Israel
| | - Tamir Bental
- 1 Department of Cardiology Rabin Medical Center Petah Tikva Israel.,3 Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Guy Witberg
- 1 Department of Cardiology Rabin Medical Center Petah Tikva Israel.,3 Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Ran Kornowski
- 1 Department of Cardiology Rabin Medical Center Petah Tikva Israel.,3 Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Alon Eisen
- 1 Department of Cardiology Rabin Medical Center Petah Tikva Israel.,3 Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
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209
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Beddhu S, Chertow GM, Greene T, Whelton PK, Ambrosius WT, Cheung AK, Cutler J, Fine L, Boucher R, Wei G, Zhang C, Kramer H, Bress AP, Kimmel PL, Oparil S, Lewis CE, Rahman M, Cushman WC. Effects of Intensive Systolic Blood Pressure Lowering on Cardiovascular Events and Mortality in Patients With Type 2 Diabetes Mellitus on Standard Glycemic Control and in Those Without Diabetes Mellitus: Reconciling Results From ACCORD BP and SPRINT. J Am Heart Assoc 2019; 7:e009326. [PMID: 30371182 PMCID: PMC6222943 DOI: 10.1161/jaha.118.009326] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Intensive systolic blood pressure (SBP) lowering significantly reduced cardiovascular disease (CVD) events in SPRINT (Systolic Blood Pressure Intervention Trial) but not in ACCORD BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure). Methods and Results SPRINT tested the effects of intensive (<120 mm Hg) versus standard (<140 mm Hg) SBP goals on CVD events and all‐cause mortality. Using 2×2 factorial design, ACCORD BP tested the same SBP intervention in addition to an intensive versus standard glycemia intervention. We compared the effects of intensive SBP lowering on the composite CVD end point and all‐cause mortality in SPRINT with its effects within each of the glycemia arms in ACCORD BP. Intensive SBP lowering decreased the hazard of the composite CVD end point similarly in SPRINT (hazard ratio: 0.75; 95% confidence interval, 0.64–0.89) and in the ACCORD BP standard glycemia arm (hazard ratio: 0.77; 95% confidence interval, 0.63–0.95; interaction P=0.87). However, the effect of intensive SBP lowering on the composite CVD end point in the ACCORD BP intensive glycemia arm (hazard ratio: 1.04; 95% confidence interval, 0.83–1.29) was significantly different from SPRINT (interaction P=0.023). Patterns were similar for all‐cause mortality. Conclusions The effects of intensive SBP control on CVD events and all‐cause mortality were similar in patients without diabetes mellitus and in those with diabetes mellitus on standard glycemic control. An interaction between intensive SBP lowering and intensive glycemic control may have masked beneficial effects of intensive SBP lowering in ACCORD BP. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01206062, NCT00000620.
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Affiliation(s)
- Srinivasan Beddhu
- 1 Medical Service Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,2 Division of Nephrology & Hypertension University of Utah School of Medicine Salt Lake City UT
| | - Glenn M Chertow
- 5 Division of Nephrology Stanford University School of Medicine Palo Alto CA
| | - Tom Greene
- 3 Division of Biostatistics University of Utah School of Medicine Salt Lake City UT
| | - Paul K Whelton
- 6 Tulane University School of Public Health and Tropical Medicine New Orleans LA
| | - Walter T Ambrosius
- 7 Department of Biostatistical Sciences Wake Forest School of Medicine Winston-Salem NC
| | - Alfred K Cheung
- 1 Medical Service Veterans Affairs Salt Lake City Health Care System Salt Lake City UT.,2 Division of Nephrology & Hypertension University of Utah School of Medicine Salt Lake City UT
| | | | - Lawrence Fine
- 8 National Heart, Lung and Blood Institute Bethesda MD
| | - Robert Boucher
- 2 Division of Nephrology & Hypertension University of Utah School of Medicine Salt Lake City UT
| | - Guo Wei
- 2 Division of Nephrology & Hypertension University of Utah School of Medicine Salt Lake City UT.,3 Division of Biostatistics University of Utah School of Medicine Salt Lake City UT
| | - Chong Zhang
- 3 Division of Biostatistics University of Utah School of Medicine Salt Lake City UT
| | - Holly Kramer
- 9 Division of Nephrology and Hypertension Departments of Public Health Sciences and Medicine Loyola University Chicago Maywood IL.,10 Hines Veteran's Affairs Medical Center Hines IL
| | - Adam P Bress
- 4 Division of Health System Innovation and Research Department of Population Health Sciences University of Utah School of Medicine Salt Lake City UT
| | - Paul L Kimmel
- 11 National Institute of Diabetes, Digestive and Kidney Diseases Bethesda MD
| | - Suzanne Oparil
- 12 Division of Cardiovascular Disease Department of Medicine University of Alabama at Birmingham AL
| | - Cora E Lewis
- 13 Department of Epidemiology, School of Public Health University of Alabama at Birmingham AL
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210
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Shen JI, Norris KC. Are Cardiac Biomarkers to Predict Cardiovascular Outcomes in Patients with Chronic Kidney Disease Ready for Prime Time? Mayo Clin Proc 2019; 94:2158-2160. [PMID: 31685144 PMCID: PMC6944278 DOI: 10.1016/j.mayocp.2019.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/23/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA; Division of Nephrology, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Keith C Norris
- Division of Nephrology, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
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211
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Abstract
Introduction: Dyslipidemia, particularly elevated low-density lipoprotein cholesterol (LDL-C), is a key risk factor for atherosclerotic cardiovascular disease (ASCVD), and lipid-lowering drugs are beneficial for the primary and secondary prevention of cardiovascular (CV) disease. While statins are clear first-line drugs, new drug developments such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to improve cardiovascular outcomes when added to statins. Evolocumab reduced the risk of cardiovascular events in patients with ASCVD when added to maximally tolerated statin therapy (± ezetimibe), and recent data from the ODYSSEY OUTCOMES trial indicate that alirocumab added to maximally tolerated statin therapy (± other lipid-lowering drugs) reduces the risk of cardiovascular events in patients with a recent acute coronary syndrome. In this article the authors review the available data on the effect of PCSK9 inhibitors on cardiovascular outcomes.Areas covered: This article reviews the available data on the effect of PCSK9 inhibitors on CV outcomes. Relevant papers were identified from a search of PubMed/Medline and the Cochrane Central Register of Controlled Trials (CENTRAL).Expert opinion: The authors conclude that PCSK9 inhibitors provide substantial and durable reductions in LDL-C levels and improve cardiovascular outcomes.
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Affiliation(s)
- Daniel Steffens
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Céline Scheeff
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Mario Kasner
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Adel Hassanein
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Julian Friebel
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
| | - Ursula Rauch-Kröhnert
- Department of Internal Medicine/Cardiology, Campus Benjamin Franklin, Charité- Universitätsmedizin Berlin, Berlin, Germany
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Arora S, Qamar A, Gupta P, Vaduganathan M, Chauhan I, Tripathi AK, Sharma VY, Bansal A, Fatima A, Jain G, Batra V, Tyagi S, Khandelwal L, Kaul P, Rao SV, Girish MP, Bhatt DL, Gupta MD. Design and rationale of the North Indian ST-Segment Elevation Myocardial Infarction Registry: A prospective cohort study. Clin Cardiol 2019; 42:1140-1146. [PMID: 31593344 PMCID: PMC6906983 DOI: 10.1002/clc.23278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/16/2019] [Accepted: 09/18/2019] [Indexed: 12/17/2022] Open
Abstract
ST‐segment elevation myocardial infarction (STEMI) is associated with increased mortality and morbidity. Although remarkable progress has been made in the management of STEMI in high‐income countries, contemporary data to evaluate processes and outcomes of STEMI care in India is limited. The North Indian ST‐segment elevation myocardial infarction (NORIN STEMI) registry is a prospective cohort study based at government funded and largely free of cost tertiary medical centers in New Delhi, India. These hospitals serve a large proportion of the patients with lower socioeconomic status presenting from multiple states in India, as many centers in these states lack adequate specialized cardiovascular care. The study has been approved by the Institutional Review Boards of each institution and informed consent has been obtained from study participants. The NORIN STEMI registry aims to provide important insights regarding contemporary risk factors profiles, practice patterns, and prognosis in patients with STEMI in an underserved population in North India. These findings may identify opportunities to improve the outcomes of patients with STEMI in India.
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Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina.,Preventive Medicine Residency, Department of Family Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Arman Qamar
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Puneet Gupta
- Department of Cardiology, Janakpuri Superspeciality Hospital, New Delhi, India
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Ishit Chauhan
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ashutosh K Tripathi
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Vinamra Y Sharma
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Ankit Bansal
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Amber Fatima
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Gagan Jain
- Department of Cardiology, Janakpuri Superspeciality Hospital, New Delhi, India
| | - Vishal Batra
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Sanjay Tyagi
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Lokesh Khandelwal
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Prashant Kaul
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina.,Piedmont Heart Institute, Atlanta, Georgia
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, North Carolina
| | - Meenahalli Palleda Girish
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Mohit D Gupta
- Department of Cardiology, Gobind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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213
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Mann JFE, Fonseca V, Mosenzon O, Raz I, Goldman B, Idorn T, von Scholten BJ, Poulter NR. Effects of Liraglutide Versus Placebo on Cardiovascular Events in Patients With Type 2 Diabetes Mellitus and Chronic Kidney Disease. Circulation 2019; 138:2908-2918. [PMID: 30566006 PMCID: PMC6296845 DOI: 10.1161/circulationaha.118.036418] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND LEADER trial (Liraglutide Effect and Action in Diabetes: Evaluation of CV Outcome Results) results demonstrated cardiovascular benefits for patients with type 2 diabetes mellitus at high cardiovascular risk on standard of care randomized to liraglutide versus placebo. The effect of glucagon-like peptide-1 receptor agonist liraglutide on cardiovascular events and all-cause mortality in patients with type 2 diabetes mellitus and chronic kidney disease is unknown. Liraglutide's treatment effects in patients with and without kidney disease were analyzed post hoc. METHODS Patients were randomized (1:1) to liraglutide or placebo, both in addition to standard of care. These analyses assessed outcomes stratified by baseline estimated glomerular filtration rate (eGFR; <60 versus ≥60 mL/min/1.73 m2) and baseline albuminuria. The primary outcome (composite of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) and secondary outcomes, including all-cause mortality and individual components of the primary composite outcome, were analyzed using Cox regression. RESULTS Overall, 2158 and 7182 patients had baseline eGFR <60 or ≥60 mL/min/1.73 m2, respectively. In patients with eGFR <60 mL/min/1.73 m2, risk reduction for the primary composite cardiovascular outcome with liraglutide was greater (hazard ratio [HR], 0.69; 95% CI, 0.57-0.85) versus those with eGFR ≥60 mL/min/1.73 m2 (HR, 0.94; 95% CI, 0.83-1.07; interaction P=0.01). There was no consistent effect modification with liraglutide across finer eGFR subgroups (interaction P=0.13) and when analyzing eGFR as a continuous variable (interaction P=0.61). Risk reductions in those with eGFR <60 versus ≥60 mL/min/1.73 m2 were as follows: for nonfatal myocardial infarction, HR, 0.74; 95% CI, 0.55-0.99 versus HR, 0.93; 95% CI, 0.77-1.13; for nonfatal stroke, HR, 0.51; 95% CI, 0.33-0.80 versus HR, 1.07; 95% CI, 0.84-1.37; for cardiovascular death, HR, 0.67; 95% CI, 0.50-0.90 versus HR, 0.84; 95% CI, 0.67-1.05; for all-cause mortality, HR, 0.74; 95% CI, 0.60-0.92 versus HR, 0.90; 95% CI, 0.75-1.07. Risk reduction for the primary composite cardiovascular outcome was not different for those with versus without baseline albuminuria (HR, 0.83; 95% CI, 0.71-0.97; and HR, 0.92; 95% CI, 0.79-1.07, respectively; interaction P=0.36). CONCLUSIONS Liraglutide added to standard of care reduced the risk for major cardiovascular events and all-cause mortality in patients with type 2 diabetes mellitus and chronic kidney disease. These results appear to apply across the chronic kidney disease spectrum enrolled. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/ . Unique identifier: NCT01179048.
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Affiliation(s)
- Johannes F E Mann
- Kuratorium für Dialyse Kidney Center, Munich, Germany (J.F.E.M.).,Department of Nephrology, Friedrich Alexander University of Erlangen, Germany (J.F.E.M.)
| | - Vivian Fonseca
- Division of Endocrinology, Tulane University Health Sciences Center, School of Medicine, New Orleans, LA (V.F.)
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel (O.M., I.R.)
| | - Itamar Raz
- Diabetes Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel (O.M., I.R.)
| | - Bryan Goldman
- Novo Nordisk A/S, Søborg, Denmark (B.G., T.I., B.J.v.S.)
| | - Thomas Idorn
- Novo Nordisk A/S, Søborg, Denmark (B.G., T.I., B.J.v.S.)
| | | | - Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, UK (N.R.P.)
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214
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Zilov AV, Abdelaziz SI, AlShammary A, Al Zahrani A, Amir A, Assaad Khalil SH, Brand K, Elkafrawy N, Hassoun AA, Jahed A, Jarrah N, Mrabeti S, Paruk I. Mechanisms of action of metformin with special reference to cardiovascular protection. Diabetes Metab Res Rev 2019; 35:e3173. [PMID: 31021474 PMCID: PMC6851752 DOI: 10.1002/dmrr.3173] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/01/2019] [Accepted: 04/18/2019] [Indexed: 12/17/2022]
Abstract
Management guidelines continue to identify metformin as initial pharmacologic antidiabetic therapy of choice for people with type 2 diabetes without contraindications, despite recent randomized trials that have demonstrated significant improvements in cardiovascular outcomes with newer classes of antidiabetic therapies. The purpose of this review is to summarize the current state of knowledge of metformin's therapeutic actions on blood glucose and cardiovascular clinical evidence and to consider the mechanisms that underlie them. The effects of metformin on glycaemia occur mainly in the liver, but metformin-stimulated glucose disposal by the gut has emerged as an increasingly import site of action of metformin. Additionally, metformin induces increased secretion of GLP-1 from intestinal L-cells. Clinical cardiovascular protection with metformin is supported by three randomized outcomes trials (in newly diagnosed and late stage insulin-treated type 2 diabetes patients) and a wealth of observational data. Initial evidence suggests that cotreatment with metformin may enhance the impact of newer incretin-based therapies on cardiovascular outcomes, an important observation as metformin can be combined with any other antidiabetic agent. Multiple potential mechanisms support the concept of cardiovascular protection with metformin beyond those provided by reduced blood glucose, including weight loss, improvements in haemostatic function, reduced inflammation, and oxidative stress, and inhibition of key steps in the process of atherosclerosis. Accordingly, metformin remains well placed to support improvements in cardiovascular outcomes, from diagnosis and throughout the course of type 2 diabetes, even in this new age of improved outcomes in type 2 diabetes.
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Affiliation(s)
- Alexey V. Zilov
- Department of EndocrinologySechenov's First Moscow State Medical UniversityMoscowRussia
| | | | - Afaf AlShammary
- Diabetes Center, Department of MedicineKing Abdulaziz Medical CityRiyadhKingdom of Saudi Arabia
| | - Ali Al Zahrani
- Department of Medicine, Molecular Endocrinology Section, Department of Molecular Oncology, Research CenterKing Faisal Specialist Hospital & Research CentreRiyadhKingdom of Saudi Arabia
| | - Ashraf Amir
- Department of Family MedicineInternational Medical CenterJeddahKingdom of Saudi Arabia
| | - Samir Helmy Assaad Khalil
- Department of Internal Medicine, Unit of Diabetology, Lipidology & Metabolism, Alexandria Faculty of MedicineAlexandria UniversityAlexandriaEgypt
| | - Kerstin Brand
- Global Medical AffairsMerck Healthcare KGaADarmstadtGermany
| | - Nabil Elkafrawy
- Diabetes and Endocrinology UnitMenoufia UniversityAl MinufyaEgypt
| | | | - Adel Jahed
- Gabric Diabetes Education Association, Tehran, Iran and Consultant EndocrinologistTehran General HospitalTehranIran
| | - Nadim Jarrah
- Internal Medicine DepartmentThe Specialty HospitalAmmanJordan
| | - Sanaa Mrabeti
- General Medicine and EndocrinologyMedical Affairs EMEA Merck Serono Middle East FZ‐LLCDubaiUnited Arab Emirates
| | - Imran Paruk
- Department of Diabetes and Endocrinology, Nelson R Mandela School of MedicineUniversity of KwaZulu‐NatalDurbanSouth Africa
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215
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Affiliation(s)
- Joshua J Neumiller
- Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, Washington; and
| | - Rita R Kalyani
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
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216
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Du Z, Bian W, Wu S, Gao B, Sun Y, Kang Z, Zhang X. Effects of blood pressure goals on cardiovascular outcomes in hypertensive patients. Arch Med Sci 2019; 15:1381-1387. [PMID: 31749865 PMCID: PMC6855153 DOI: 10.5114/aoms.2018.80013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 11/02/2018] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION The aim of the study was to evaluate the effects of blood pressure (BP) goals on cardiovascular outcomes in hypertensive patients. MATERIAL AND METHODS Primary hypertensive patients were retrospectively enrolled from outpatient clinics. The demographics, comorbidities, laboratory parameters and glomerular filtration rate (GFR) were collected. All participants were followed for 1 year. Cardiovascular outcomes included composite of all-cause mortality, non-fatal myocardial infarction, and non-fatal ischemic stroke/transient ischemic attack. Adverse event was defined as falling down and GFR decrease at follow-up. RESULTS A total of 1226 patients were included. Based on therapeutic BP goals, participants were divided into low (< 130/80 mm Hg) and high (< 140/90 mm Hg) therapeutic goal groups and an uncontrolled hypertension (≥ 140/90 mm Hg) group. Compared to the low therapeutic goal group, patients in the uncontrolled group were older and more likely to be smokers, have longer duration of hypertension, diabetes mellitus, lower GFR and higher prevalent ischemic stroke (p < 0.05). Patients in the uncontrolled hypertension group had higher incidence of composite endpoints than low and high therapeutic goal groups. Two cases of falling down were observed in the low therapeutic goal group and no significant changes in GFR were observed. With adjustment for confounding factors, the uncontrolled hypertension group had higher risk of composite endpoints compared to low and high therapeutic goal groups, and these benefits were more prominent in the low versus high therapeutic goal group. CONCLUSIONS In hypertension patients, when compared to uncontrolled hypertension patients, low therapeutic BP goal is associated with better cardiovascular outcomes than high therapeutic BP goal.
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Affiliation(s)
- Zonglei Du
- Department of Cardiovascular Medicine, Zouchen People’s Hospital, Zouchen, China
| | - Weishi Bian
- Department of Cardiovascular Medicine, The Third People’s Hospital of Linyi, Linyi, China
| | - Shanxia Wu
- Department of Cardiovascular Medicine, The Third People’s Hospital of Linyi, Linyi, China
| | - Bingfeng Gao
- Department of Cardiovascular Medicine, The Third People’s Hospital of Linyi, Linyi, China
| | - Yanfang Sun
- Department of Cardiovascular Medicine, The Third People’s Hospital of Linyi, Linyi, China
| | - Zhenxing Kang
- Department of Cardiovascular Medicine, The Third People’s Hospital of Linyi, Linyi, China
| | - Xianchao Zhang
- Department of Cardiovascular Medicine, Linyi People’s Hospital, Linyi, China
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217
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Zhang M, Solomon DH, Desai RJ, Kang EH, Liu J, Neogi T, Kim SC. Assessment of Cardiovascular Risk in Older Patients With Gout Initiating Febuxostat Versus Allopurinol: Population-Based Cohort Study. Circulation 2019; 138:1116-1126. [PMID: 29899013 DOI: 10.1161/circulationaha.118.033992] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hyperuricemia and gout are associated with an increased risk of cardiovascular disease. Xanthine oxidase inhibitors, allopurinol and febuxostat, are the mainstay of urate-lowering treatment for gout and may have different effects on cardiovascular risk in patients with gout. METHODS Using US Medicare claims data (2008-2013), we conducted a cohort study for comparative cardiovascular safety of initiating febuxostat versus allopurinol among patients with gout ≥65 years of age. The primary outcome was a composite end point of hospitalization for myocardial infarction or stroke. Secondary outcomes were individual end points of hospitalization for myocardial infarction, stroke, coronary revascularization, new and recurrent heart failure, and all-cause mortality. We used propensity score matching with a ratio of 1:3 to control for confounding. We estimated incidence rates and hazard ratios for primary and secondary outcomes in the propensity score-matched cohorts of febuxostat and allopurinol initiators. RESULTS We included 24 936 febuxostat initiators propensity score-matched to 74 808 allopurinol initiators. The median age was 76 years, 52% were male, and 12% had cardiovascular disease at baseline. The incidence rate per 100 person-years for the primary outcome was 3.43 in febuxostat and 3.36 in allopurinol initiators. The hazard ratio for the primary outcome was 1.01 (95% CI, 0.94-1.08) in the febuxostat group compared with the allopurinol group. Risk of secondary outcomes including all-cause mortality was similar in both groups, except for a modestly decreased risk of heart failure exacerbation (hazard ratio, 0.94; 95% CI, 0.91-0.99) in febuxostat initiators. The hazard ratio for all-cause mortality associated with long-term use of febuxostat (>3 years) was 1.25 (95% CI, 0.56-2.80) versus allopurinol. Subgroup and sensitivity analyses consistently showed similar cardiovascular risk in both groups. CONCLUSIONS Among a cohort of 99 744 older Medicare patients with gout, overall there was no difference in the risk of myocardial infarction, stroke, new-onset heart failure, coronary revascularization, or all-cause mortality between patients initiating febuxostat compared with allopurinol. However, there seemed to be a trend toward an increased, albeit not statistically significant, risk for all-cause mortality in patients who used febuxostat for >3 years versus allopurinol for >3 years. The risk of heart failure exacerbation was slightly lower in febuxostat initiators.
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Affiliation(s)
- MaryAnn Zhang
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.Z., D.H.S., R.D., S.C.K.)
| | - Daniel H Solomon
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.Z., D.H.S., R.D., S.C.K.)
| | - Rishi J Desai
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.Z., D.H.S., R.D., S.C.K.)
| | - Eun Ha Kang
- Seoul National University Bundang Hospital, Seongnam, South Korea (E.H.K.)
| | | | - Tuhina Neogi
- Boston Medical Center, Boston University School of Medicine, MA (T.N.)
| | - Seoyoung C Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.Z., D.H.S., R.D., S.C.K.)
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218
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De Viti D, Malvasi A, Busardò F, Beck R, Zaami S, Marinelli E. Cardiovascular Outcomes in Advanced Maternal Age Delivering Women. Clinical Review and Medico-Legal Issues. ACTA ACUST UNITED AC 2019; 55:medicina55100658. [PMID: 31569595 PMCID: PMC6843194 DOI: 10.3390/medicina55100658] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 02/07/2023]
Abstract
Background and objecives: Adverse cardiovascular outcomes during pregnancy have increased over the past few decades, with increased numbers of women delivering later in their reproductive life. Other factors include higher rates of female obesity, diabetes, hypertension, cardiovascular diseases and assisted reproductive technology, which has extended fertility. Those at risk require extensive prenatal maternal screening, constant pregnancy supervising, monitoring during labor, delivery and puerperium and careful anesthetic evaluation during delivery. Materials and Methods: The present review reports the relevant information available on cardiovascular outcomes in advanced maternal age delivering women and related medico-legal issues. The search was performed on Pubmed, Cochrane, Semantic Scholar, Medline and Embase databases, accessed by Ovid, including among others the terms "cardiomyopathy", "ischaemic heart disease", "arrhythmias", "hypertension", "peripartum period", "diabetes", "advanced maternal age" "anesthesia", "maternal morbidity and mortality" and "litigation". Results: To the extent that underestimating risk factors for peripartum cardiomyopathy (PPCM) can adversely impact maternal and fetal outcomes, the legal implications of misdiagnosis or mismanagement can result in high compensatory damages. Substantial indemnity payments drive up costs of insurance coverage. Conclusions: Multidisciplinary approaches are necessary from obstetricians, cardiologists, anesthesiologists and perinatologists for pregnancy monitoring and delivery outcomes.
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Affiliation(s)
- Daniele De Viti
- Department of Cardiology, Santa Maria Hospital, GVM Care & Research, 70124 Bari, Italy.
| | - Antonio Malvasi
- Department of Obstetrics and Gynecology, Santa Maria Hospital, GVM Care & Research, 70124 Bari, Italy.
| | - Francesco Busardò
- Section of Legal Medicine, Università Politecnica delle Marche, 60120 Ancona, Italy.
| | - Renata Beck
- Department of Anesthesia and Analgesia, Santa Maria Hospital, GVM Care & Research, 70124 Bari, Italy.
| | - Simona Zaami
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University, 00161 Rome, Italy.
| | - Enrico Marinelli
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University, 00161 Rome, Italy.
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Woo VC. Cardiovascular Effects of Sodium-Glucose Cotransporter-2 Inhibitors in Adults With Type 2 Diabetes. Can J Diabetes 2019; 44:61-67. [PMID: 31839265 DOI: 10.1016/j.jcjd.2019.09.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/30/2019] [Accepted: 09/06/2019] [Indexed: 12/19/2022]
Abstract
Adults with type 2 diabetes mellitus can benefit from pharmacotherapies that lower their risk for cardiovascular disease. This review describes the salient findings from sodium-glucose cotransporter-2 (SGLT2) inhibitor cardiovascular outcome trials that serendipitously revealed the cardiorenal benefits of SGLT2 inhibitors in adults with type 2 diabetes mellitus who either have established cardiovascular disease or multiple cardiovascular risk factors. It also summarizes the findings from other phase 3 clinical studies that measured the cardiovascular effects of SGLT2 inhibitors and real-world evidence reports that compared the cardiovascular impact of SGLT2 inhibitors with other antihyperglycemic agents. The collective data indicate that SGLT2 inhibitors are pleiotropic agents that offer important cardiovascular, metabolic and renal benefits beyond glucose lowering with low incidences of hypoglycemia. Specifically, the placebo-controlled SGLT2 inhibitor cardiovascular outcome trials documented either fewer major adverse cardiac events (nonfatal myocardial infarction, nonfatal stroke and cardiovascular death) or a reduction in the composite endpoint of cardiovascular death or hospitalization for heart failure in participants with type 2 diabetes mellitus and established cardiovascular disease. Amongst those with type 2 diabetes mellitus who did not have established cardiovascular disease but did present with multiple risk factors, SGLT2 inhibitors lowered the combined endpoint of cardiovascular death or hospitalization for heart failure but had little impact on the occurrence of major adverse cardiac events. Ongoing clinical trials and subanalyses of the trials that have been reported should shed further light on the clinical benefits and utility of SGLT2 inhibitors.
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Affiliation(s)
- Vincent C Woo
- Section of Endocrinology and Metabolism, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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220
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Affiliation(s)
- William B White
- Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington
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221
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Machado A, Quadflieg K, Oliveira A, Keytsman C, Marques A, Hansen D, Burtin C. Exercise Training in Patients with Chronic Respiratory Diseases: Are Cardiovascular Comorbidities and Outcomes Taken into Account?-A Systematic Review. J Clin Med 2019; 8:E1458. [PMID: 31540240 PMCID: PMC6780679 DOI: 10.3390/jcm8091458] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 12/16/2022] Open
Abstract
Patients with chronic obstructive pulmonary disease (COPD), asthma and interstitial lung diseases (ILD) frequently suffer from cardiovascular comorbidities (CVC). Exercise training is a cornerstone intervention for the management of these conditions, however recommendations on tailoring programmes to patients suffering from respiratory diseases and CVC are scarce. This systematic review aimed to identify the eligibility criteria used to select patients with COPD, asthma or ILD and CVC to exercise programmes; assess the impact of exercise on cardiovascular outcomes; and identify how exercise programmes were tailored to CVC. PubMed, Scopus, Web of Science and Cochrane were searched. Three reviewers extracted the data and two reviewers independently assessed the quality of studies with the Quality Assessment Tool for Quantitative Studies. MetaXL 5.3 was used to calculate the individual and pooled effect sizes (ES). Most studies (58.9%) excluded patients with both stable and unstable CVC. In total, 26/42 studies reported cardiovascular outcomes. Resting heart rate was the most reported outcome measure (n = 13) and a small statistically significant effect (ES = -0.23) of exercise training on resting heart rate of patients with COPD was found. No specific adjustments to exercise prescription were described. Few studies have included patients with CVC. There was a lack of tailoring of exercise programmes and limited effects were found. Future studies should explore the effect of tailored exercise programmes on relevant outcome measures in respiratory patients with CVC.
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Affiliation(s)
- Ana Machado
- REVAL-Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, 3590 Diepenbeek, Belgium
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, 3810 Aveiro, Portugal
| | - Kirsten Quadflieg
- REVAL-Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, 3590 Diepenbeek, Belgium
| | - Ana Oliveira
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, 3810 Aveiro, Portugal
- Respiratory Medicine, West Park Healthcare Centre, Toronto, ON M6M 2J5, Canada
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, ON L8S 4K1, Canada
| | - Charly Keytsman
- REVAL-Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, 3590 Diepenbeek, Belgium
- BIOMED-Biomedical Research Institute, Hasselt University, 3590 Diepenbeek, Belgium
| | - Alda Marques
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, 3810 Aveiro, Portugal
- Institute of Biomedicine (iBiMED), University of Aveiro, 3810 Aveiro, Portugal
| | - Dominique Hansen
- REVAL-Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, 3590 Diepenbeek, Belgium
- BIOMED-Biomedical Research Institute, Hasselt University, 3590 Diepenbeek, Belgium
- Jessa hospital, Heart Centre Hasselt, 3500 Hasselt, Belgium
| | - Chris Burtin
- REVAL-Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, 3590 Diepenbeek, Belgium.
- BIOMED-Biomedical Research Institute, Hasselt University, 3590 Diepenbeek, Belgium.
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Khan SU, Khan MU, Valavoor S, Khan MS, Okunrintemi V, Mamas MA, Leucker TM, Blaha MJ, Michos ED. Association of lowering apolipoprotein B with cardiovascular outcomes across various lipid-lowering therapies: Systematic review and meta-analysis of trials. Eur J Prev Cardiol 2019; 27:1255-1268. [PMID: 31475865 DOI: 10.1177/2047487319871733] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIMS The effect of therapeutic lowering of apolipoprotein B (apoB) on mortality and major adverse cardiovascular events is uncertain. It is also unclear whether these potential effects vary by different lipid-lowering strategies. METHODS A total of 29 randomized controlled trials were selected using PubMed, Cochrane Library and EMBASE through 2018. We selected trials of therapies which ultimately clear apolipoprotein B particles by upregulating low-density lipoprotein receptor (LDL-R) expression (statins, ezetimibe, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, bile acid sequestrants) or therapies which reduce apolipoprotein B independent of LDL-R (cholesteryl ester transfer protein inhibitor, fibrates, niacin, omega-3 fatty acids) with sample size of ≥1000 patients and follow-up of ≥1 year. The meta-regression and meta-analyses were constructed using a random effects model. RESULTS In 332,912 patients, meta-regression analyses showed relative risks of 0.95 for all-cause mortality (95% confidence interval 0.92-0.99) and 0.93 (0.88-0.98) for cardiovascular mortality for every 10 mg/dL decrease in apolipoprotein B by all interventions combined. Reduction in all-cause mortality was limited to statins (0.92 (0.86-0.98)). For MACE, the relative risk per 10 mg/dL reduction in apolipoprotein B was 0.93 (0.90-0.97) for all therapies combined, with both statin (0.88 (0.83-0.93)) and non-statin therapies (0.96 (0.94-0.99)). which clear apolipoprotein B by upregulating LDL-R showing significant reductions; whereas interventions which lower apolipoprotein B independent of LDL-R did not demonstrate this effect (1.02 (0.81-1.30)). CONCLUSION While both statin and established non-statin therapies (PCSK9 inhibitor and ezetimibe) reduced cardiovascular risk per decrease in apolipoprotein B, interventions which reduce apolipoprotein B independently of LDL-R were not associated with cardiovascular benefit.
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Affiliation(s)
- Safi U Khan
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Muhammad U Khan
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Shahul Valavoor
- Department of Medicine, West Virginia University, Morgantown, WV, USA
| | - Muhammad Shahzeb Khan
- Department of Medicine, John H. Stroger J. Hospital of Cook County, Chicago, IL, USA
| | - Victor Okunrintemi
- Department of Internal Medicine, East Carolina University, Greenville, SC, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, Staffordshire, UK.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK
| | - Thorsten M Leucker
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Michael J Blaha
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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223
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Kelli HM, Mehta A, Tahhan AS, Liu C, Kim JH, Dong TA, Dhindsa DS, Ghazzal B, Choudhary MK, Sandesara PB, Hayek SS, Topel ML, Alkhoder AA, Martini MA, Sidoti A, Ko YA, Lewis TT, Vaccarino V, Sperling LS, Quyyumi AA. Low Educational Attainment is a Predictor of Adverse Outcomes in Patients With Coronary Artery Disease. J Am Heart Assoc 2019; 8:e013165. [PMID: 31476920 PMCID: PMC6755831 DOI: 10.1161/jaha.119.013165] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Educational attainment is an indicator of socioeconomic status and is inversely associated with coronary artery disease risk. Whether educational attainment level (EAL) among patients with coronary artery disease influences outcomes remains understudied. Methods and Results Patients undergoing cardiac catheterization had their highest EAL assessed using options of elementary/middle school, high school, college, or graduate education. Primary outcome was all‐cause mortality and secondary outcomes were a composite of cardiovascular death/non‐fatal myocardial infarction and non‐fatal myocardial infarction during follow‐up. Cox models adjusted for clinically relevant confounders were used to analyze the association of EAL with outcomes. Among 6318 patients (63.5 years, 63% men, 23% black) enrolled, 16%, 42%, 38%, and 4% had received graduate or higher, college, high school, and elementary/middle school education, respectively. During 4.2 median years of follow‐up, there were 1066 all‐cause deaths, 812 cardiovascular deaths/non‐fatal myocardial infarction, and 276 non‐fatal myocardial infarction. Compared with patients with graduate education, those in lower EAL categories (elementary/middle school, high school, or college education) had a higher risk of all‐cause mortality (hazard ratios 1.52 [95% CI 1.11–2.09]; 1.43 [95% CI 1.17–1.73]; and 95% CI 1.26 [1.03–1.53], respectively). Similar findings were observed for secondary outcomes. Conclusions Low educational attainment is an independent predictor of adverse outcomes in patients undergoing angiographic coronary artery disease evaluation. The utility of incorporating EAL into risk assessment algorithms and the causal link between low EAL and adverse outcomes in this high‐risk patient population need further investigation.
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Affiliation(s)
- Heval M Kelli
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Anurag Mehta
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Ayman S Tahhan
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Chang Liu
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA.,Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Jeong Hwan Kim
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Tiffany A Dong
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA.,Department of Medicine Emory University School of Medicine Atlanta GA
| | - Devinder S Dhindsa
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Bahjat Ghazzal
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Muaaz K Choudhary
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Pratik B Sandesara
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Salim S Hayek
- Division of Cardiology Department of Internal Medicine University of Michigan Medical School Ann Arbor MI
| | - Matthew L Topel
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Ayman A Alkhoder
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Mohamed A Martini
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Arianna Sidoti
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Yi-An Ko
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA.,Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Tene T Lewis
- Department of Biostatistics and Bioinformatics Rollins School of Public Health Emory University Atlanta GA
| | - Viola Vaccarino
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Laurence S Sperling
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute Division of Cardiology Department of Medicine Emory University School of Medicine Atlanta GA
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Baker WL, Beyer-Westendorf J, Bunz TJ, Eriksson D, Meinecke AK, Sood NA, Coleman CI. Effectiveness and safety of rivaroxaban and warfarin for prevention of major adverse cardiovascular or limb events in patients with non-valvular atrial fibrillation and type 2 diabetes. Diabetes Obes Metab 2019; 21:2107-2114. [PMID: 31099460 DOI: 10.1111/dom.13787] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/06/2019] [Accepted: 05/15/2019] [Indexed: 11/29/2022]
Abstract
AIMS To assess the effectiveness and safety of rivaroxaban versus warfarin for the prevention of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in patients with type 2 diabetes (T2D) and non-valvular atrial fibrillation (NVAF). MATERIALS AND METHODS Using MarketScan data from January 2012 to December 2017, we identified oral anticoagulant-naïve patients with NVAF and comorbid T2D and ≥12 months of insurance coverage prior to rivaroxaban or warfarin initiation. Differences in baseline covariates between cohorts were adjusted for using inverse probability of treatment weights based on propensity scores (absolute standardized differences <0.1 achieved for all covariates after adjustment). Patients were followed until a MACE, MALE or major bleeding event, oral anticoagulant discontinuation/switch, insurance disenrolment or end of data availability. Hazard ratios (HRs) and 95% confidence intervals (CIs) comparing the cohorts were calculated using Cox regression. RESULTS We identified 10 700 rivaroxaban users (24.1% received a reduced dose) and 13 946 warfarin users. The median (25%, 75% range) age was 70 (62, 79) years, CHA2DS2-VASc score was 4 (3, 5) and duration of available follow-up was 1.4 (0.6, 2.7) years. Eleven percent of patients had peripheral artery disease, 5.1% had coronary artery disease, and 5.1% had a prior MALE, at baseline. Rivaroxaban was associated with a 25% (95% CI 4-41) reduced risk of MACE and a 63% (95% CI 35-79) reduced risk of MALE compared to warfarin. Major bleeding risk did not significantly differ between cohorts (HR 0.95). CONCLUSIONS Among patients with NVAF and T2D treated in routine practice, rivaroxaban was associated with lower risks of both MACE and MALE versus warfarin, with no significant difference in major bleeding.
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Affiliation(s)
- William L Baker
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut
- Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut
| | - Jan Beyer-Westendorf
- Department of Medicine, Hematology Division, Dresden University, Dresden, Germany
| | - Thomas J Bunz
- Department of Pharmacoepidemiology, New England Health Analytics, Granby, Connecticut
| | | | | | - Nitesh A Sood
- Department of Cardiac Electrophysiology, Southcoast Health System, Fall River, Massachusetts
| | - Craig I Coleman
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, Connecticut
- Evidence-Based Practice Center, Hartford Hospital, Hartford, Connecticut
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225
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Gastrich MD, Zinonos S, Bachmann G, Cosgrove NM, Cabrera J, Cheng JQ, Kostis JB. Preeclamptic Women Are at Significantly Higher Risk of Future Cardiovascular Outcomes Over a 15-Year Period. J Womens Health (Larchmt) 2019; 29:74-83. [PMID: 31414929 DOI: 10.1089/jwh.2019.7671] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Preeclampsia (PE) may lead to maternal and infant mortality and severe medical complications. Understanding future short- and long-term cardiovascular (CV) outcomes of PE is important to women's health. Materials and Methods: A retrospective matched case-control study assessed the risks of CV outcomes over a 15-year period (1999-2013) in pregnant case women, with gravidity and parity of one, diagnosed with PE, compared to pregnant primiparous control women who were not diagnosed with PE. The New Jersey Electronic Birth Certificate (EBC) database and the Myocardial Infarction Data Acquisition System (MIDAS), a database of all hospital admissions in New Jersey with longitudinal follow-up, were used to conduct the analysis. Participants were 18 years and older with demographics consistent with New Jersey, a state with a range of racial and ethnic diversity. Main outcome measures postpregnancy and over this 15-year period were myocardial infarction (MI), stroke, CV death, and all-cause death. Results: Women with PE (N = 6,360) were more likely to suffer MI, stroke, CV death, and all-cause death than controls (N = 325,347). After matching cases to controls for demographics and comorbidities, hazard ratios of PE cases for the outcomes of MI (p adjusted for comorbidities and demographics = 0.0196), CV death (adjusted p = 0.007), and all-cause death (adjusted p = 0.0026) were significantly higher than 1 compared to matched controls. Women with PE had 3.94 (95% CI: 1.25-12.4) times higher hazard for MI, 4.66 (95% CI: 1.52-14.26) times higher hazard of CV death, and 2.32 (95% CI: 1.34-4.02) times higher hazard for all-cause death than matched controls. Conclusions: This 15-year study indicates that women who have PE with their first pregnancy have a significantly higher risk of adverse CV outcomes compared to controls and suggest a heightened and continued CV monitoring after birth for this population of women.
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Affiliation(s)
- Mary Downes Gastrich
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute of New Jersey, New Brunswick, New Jersey.,Department of Ob/Gyn and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Stavros Zinonos
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute of New Jersey, New Brunswick, New Jersey
| | - Gloria Bachmann
- Department of Ob/Gyn and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Nora M Cosgrove
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute of New Jersey, New Brunswick, New Jersey
| | - Javier Cabrera
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute of New Jersey, New Brunswick, New Jersey.,Department of Statistics and Biostatics, Rutgers University, New Brunswick, New Jersey
| | - Jerry Q Cheng
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute of New Jersey, New Brunswick, New Jersey
| | - John B Kostis
- Rutgers Robert Wood Johnson Medical School, Cardiovascular Institute of New Jersey, New Brunswick, New Jersey
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226
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Desai R, Amraotkar AR, Amraotkar MG, Thakkar S, Fong HK, Varma Y, Damarlapally N, Doshi RP, Gangani K. Outcomes and Predictors of Mortality in Hospitalized Frail Patients Undergoing Percutaneous Coronary Intervention. Cureus 2019; 11:e5399. [PMID: 31482044 PMCID: PMC6701902 DOI: 10.7759/cureus.5399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective To study the impact of frailty on inpatient outcomes among patients undergoing percutaneous coronary intervention (PCI). Methods The National Inpatient Sample data of all PCI-related hospitalizations throughout the United States (US) from 2010 through 2014 was utilized. Patients were divided into two groups: frailty and no-frailty. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to stratify groups and outcomes. In order to address the substantial difference in the total number of valid observations between the two groups, a propensity-matched analysis was performed at a 1:1 ratio and caliper width of 0.01. Results A total of 2,612,661 PCI-related hospitalizations throughout the US from 2010 through 2014 were identified, out of which 16,517 admissions (0.6%) had coexisting frailty. Only 1:1 propensity-matched data was utilized for the study. Propensity-matched frailty group (n=14,717) as compared to no-frailty (n=14,755) was frequently older, white, and Medicare enrollee (p<0.05). The frailty group had significantly higher rates of comorbidities and complications (p<0.05). All-cause in-hospital mortality was higher in the no-frailty group (p<0.05). Age, white race, non-elective admission, urban hospitals, and comorbidities predicted in-hospital mortality in frailty group (p<0.05). Rheumatoid arthritis, depression, hypertension, obesity, dyslipidemia, and history of previous PCI decreased odds of in-hospital mortality in frailty group (p<0.05). Frailty group had prolonged hospital stay and higher hospital charges (p<0.05). Conclusions Frailty has a significant effect on PCI-related outcomes. We present a previously unknown protective effect of cardiovascular disease risk factors and other health risk factors on frail patients undergoing PCI. Frailty's inclusion in risk stratification will help in predicting the post-procedure complications and improve resource utilization.
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Affiliation(s)
- Rupak Desai
- Cardiology, Atlanta Veterans Affairs Medical Center, Decatur, USA
| | - Alok R Amraotkar
- Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, USA
| | - Melissa G Amraotkar
- Nursing Education, University of Louisville School of Nursing, Louisville, USA
| | | | - Hee Kong Fong
- Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, USA
| | - Yash Varma
- Internal Medicine, Government Medical College, Bhavnagar, IND
| | | | - Rajkumar P Doshi
- Internal Medicine, University of Nevada, Reno School of Medicine, Reno, USA
| | - Kishorbhai Gangani
- Internal Medicine, Texas Health Arlington Memorial Hospital, Arlington, USA
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227
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Zhang XL, Lan RF, Zhang XW, Xu W, Wang L, Kang LN, Xu B. Association Between Baseline, Achieved, and Reduction of CRP and Cardiovascular Outcomes After LDL Cholesterol Lowering with Statins or Ezetimibe: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2019; 8:e012428. [PMID: 31411090 PMCID: PMC6759897 DOI: 10.1161/jaha.119.012428] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Several lipid‐lowering therapies reduce CRP (C‐reactive protein) independently of LDL‐C (low‐density lipoprotein cholesterol) reduction, but the association between CRP parameters and benefits from more‐intensive LDL‐C lowering is inconclusive. We aimed to determine whether the benefits of more‐ versus less‐intensive LDL‐C lowering on cardiovascular events related to baseline, achieved, or magnitude of reduction in CRP concentrations. Methods and Results PubMed, EMBASE, and Cochrane were searched through July 2, 2018. We included randomized controlled cardiovascular outcome trials of LDL‐C lowering with statins or ezetimibe. Two reviewers independently extracted study data and rated study quality. Data were analyzed using meta‐analysis and metaregression analysis. Rate ratios of mortality and cardiovascular outcomes associated with baseline, achieved, and magnitude reduction of CRP concentration were calculated. Twenty‐four trials were included, with 171 250 patients randomly assigned to more‐ or less‐intensive LDL‐C–lowering treatments. Median follow‐up duration was 4.2 years. More‐intensive LDL‐C lowering resulted in a significant reduction in incidences of all outcomes. Compared with less‐intensive LDL‐C lowering, more‐intensive LDL‐C lowering was associated with less reductions in myocardial infarction with a higher baseline CRP concentration (change in rate ratios per 1‐mg/L increase in log‐transformed CRP, 1.12 [95% CI, 1.04–1.22; P=0.007]), but not other outcomes. Similar risk reductions occurred for more‐ versus less‐intensive LDL‐C–lowering therapy regardless of the magnitude of CRP reduction or the achieved CRP level for all outcomes. Conclusions Baseline CRP concentrations might be associated with the benefits of LDL‐C lowering on myocardial infarction, but no other outcomes, whereas the achieved and magnitude of reduction in CRP did not seem to have an important association.
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Affiliation(s)
- Xin-Lin Zhang
- Department of Cardiology Affiliated Drum Tower Hospital Nanjing University School of Medicine Nanjing China
| | - Rong-Fang Lan
- Department of Cardiology Affiliated Drum Tower Hospital Nanjing University School of Medicine Nanjing China
| | - Xiao-Wen Zhang
- Department of Endocrinology Affiliated Drum Tower Hospital Nanjing University School of Medicine Nanjing China
| | - Wei Xu
- Department of Cardiology Affiliated Drum Tower Hospital Nanjing University School of Medicine Nanjing China
| | - Lian Wang
- Department of Cardiology Affiliated Drum Tower Hospital Nanjing University School of Medicine Nanjing China
| | - Li-Na Kang
- Department of Cardiology Affiliated Drum Tower Hospital Nanjing University School of Medicine Nanjing China
| | - Biao Xu
- Department of Cardiology Affiliated Drum Tower Hospital Nanjing University School of Medicine Nanjing China
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228
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Jones DR, Chew DP, Horsfall MJ, Chuang AMY, Sinhal AR, Joseph MX, Baker RA, Bennetts JS, Selvanayagam JB, Lehman SJ. Multidisciplinary transcatheter aortic valve replacement heart team programme improves mortality in aortic stenosis. Open Heart 2019; 6:e000983. [PMID: 31413842 PMCID: PMC6667939 DOI: 10.1136/openhrt-2018-000983] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 04/03/2019] [Accepted: 04/14/2019] [Indexed: 12/24/2022] Open
Abstract
Objectives To analyse the effect of the implementation of a transcatheter aortic valve replacement (TAVR) and multidisciplinary heart team programme on mortality in severe aortic stenosis (AS). Methods A retrospective, observational cohort study was performed using the echocardiography, cardiothoracic surgery and TAVR databases between 1 January 2006 and 31 December 2016. Outcomes were compared between the pre- and post-TAVR programme eras in a tertiary referral centre providing transcatheter and surgical interventions for AS. All-cause mortality within 5 years from diagnosis was determined for 3399 patients with echocardiographically defined severe AS. Results Of 3399 patients, there were 210 deaths (6.2%) at 30 days and 1614 deaths (47.5%) at 5 years. Overall, patients diagnosed in the post-TAVR programme era were older, with a lower ejection fraction and more severe AS, but were less comorbid. Among 705 patients undergoing intervention, those in the post-TAVR programme era were older, with a lower ejection fraction and more severe AS but no significant differences in comorbidities. Using an inverse probability weighted cohort and a Cox proportional hazards model, a significant mortality benefit was noted between eras alone (HR=0.86, 95% CI 0.77 to 0.97, p=0.015). When matching for age, comorbidities and valve severity, this benefit was more evident (HR=0.82, 95% CI 0.73 to 0.92, p=0.001). After adjusting for the presence of aortic valve intervention, a significant benefit persisted (HR=0.84, 95% CI 0.75 to 0.95, p=0.005). Conclusion The implementation of a TAVR programme is associated with a mortality benefit in the population with severe AS, independent of the expansion of access to intervention.
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Affiliation(s)
- Dylan R Jones
- Cardiology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Derek P Chew
- Cardiology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Matthew J Horsfall
- Cardiology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Anthony Ming-Yu Chuang
- Cardiology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Ajay R Sinhal
- Cardiology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Majo X Joseph
- Cardiology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Robert A Baker
- Cardiac and Thoracic Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Jayme S Bennetts
- Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia.,Cardiac and Thoracic Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Joseph B Selvanayagam
- Cardiology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Sam J Lehman
- Cardiology, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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229
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Zafrir B, Adawi S, Khalaily M, Jaffe R, Eitan A, Barnett-Griness O, Saliba W. Long-Term Risk Stratification of Patients Undergoing Coronary Angiography According to the Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention. J Am Heart Assoc 2019; 8:e012433. [PMID: 31271083 PMCID: PMC6662136 DOI: 10.1161/jaha.119.012433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background A risk score for secondary prevention after myocardial infarction (Thrombolysis in Myocardial Infarction Risk Score for Secondary Prevention [TRS2P]), based on 9 established clinical factors, was recently developed from the TRA2°P‐TIMI50 (Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events) trial. We aimed to evaluate the performance of TRS2P for predicting long‐term outcomes in real‐world patients presenting for coronary angiography. Methods and Results A retrospective analysis of 13 593 patients referred to angiography for the assessment or treatment of coronary disease was performed. Risk stratification for 10‐year major adverse cardiovascular events was performed using the TRS2P, divided into 6 categories (0 to ≥5 points), and in relation to the presenting coronary syndrome. All clinical variables, except prior coronary artery bypass grafting, were independent risk predictors. The annualized incidence rate of major adverse cardiovascular events increased in a graded manner with increasing TRS2P, ranging from 1.65 to 16.6 per 100 person‐years (Ptrend<0.001). Compared with the lowest‐risk group (risk indicators=0), the hazard ratios (95% CIs) for 10‐year major adverse cardiovascular events were 1.60 (95% CI, 1.36–1.89), 2.58 (95% CI, 2.21–3.02), 4.31 (95% CI, 3.69–5.05), 6.43 (95% CI, 5.47–7.56), and 10.03 (95% CI, 8.52–11.81), in those with 1, 2, 3, 4 and ≥5 risk indicators, respectively. Risk gradation was consistent among individual clinical end points. TRS2P showed reasonable discrimination with C‐statistics of 0.693 for major adverse cardiovascular events and 0.758 for mortality. The graded relationship between the risk score and event rates was observed in both patients presenting with acute and nonacute coronary syndromes. Conclusions The use of TRS2P, a simple risk score based on routinely collected variables, enables risk stratification in patients undergoing coronary angiography. Its predictive value was demonstrated in a real‐world setting with long‐term follow‐up and regardless of the acuity of coronary presentation.
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Affiliation(s)
- Barak Zafrir
- 1 Department of Cardiology Lady Davis Carmel Medical Center Haifa Israel.,4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
| | - Salim Adawi
- 1 Department of Cardiology Lady Davis Carmel Medical Center Haifa Israel.,4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
| | - Marah Khalaily
- 4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
| | - Ronen Jaffe
- 1 Department of Cardiology Lady Davis Carmel Medical Center Haifa Israel.,4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
| | - Amnon Eitan
- 1 Department of Cardiology Lady Davis Carmel Medical Center Haifa Israel
| | - Ofra Barnett-Griness
- 2 Statistical Unit Lady Davis Carmel Medical Center Haifa Israel.,3 Department of Community Medicine and Epidemiology Lady Davis Carmel Medical Center Haifa Israel
| | - Walid Saliba
- 3 Department of Community Medicine and Epidemiology Lady Davis Carmel Medical Center Haifa Israel.,4 Faculty of Medicine Technion Israel Institute of Medicine Haifa Israel
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Bansilal S, Bonaca MP, Cornel JH, Storey RF, Bhatt DL, Steg PG, Im K, Murphy SA, Angiolillo DJ, Kiss RG, Parkhomenko AN, Lopez-Sendon J, Isaza D, Goudev A, Kontny F, Held P, Jensen EC, Braunwald E, Sabatine MS, Oude Ophuis AJ. Ticagrelor for Secondary Prevention of Atherothrombotic Events in Patients With Multivessel Coronary Disease. J Am Coll Cardiol 2019; 71:489-496. [PMID: 29406853 DOI: 10.1016/j.jacc.2017.11.050] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/05/2017] [Accepted: 11/25/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with prior myocardial infarction (MI) and multivessel coronary disease (MVD) are at high risk for recurrent coronary events. OBJECTIVES The authors investigated the efficacy and safety of ticagrelor versus placebo in patients with MVD in the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis In Myocardial Infarction 54) trial. METHODS Patients with a history of MI 1 to 3 years before inclusion in the PEGASUS-TIMI 54 trial were stratified in a pre-specified analysis based on the presence of MVD. The effect of ticagrelor (60 mg and 90 mg) on the composite of cardiovascular death, MI, or stroke (major adverse cardiovascular events [MACE]), as well as the composite of coronary death, MI, or stent thrombosis (coronary events), and on TIMI major bleeding, intracranial hemorrhage (ICH), and fatal bleeding were evaluated over a median of 33 months. RESULTS A total of 12,558 patients (59.4%) had MVD. In the placebo arm, compared with patients without MVD, those with MVD were at higher risk for MACE (9.37% vs. 8.57%, adjusted hazard ratio [HRadj]: 1.24; p = 0.026) and for coronary events (7.67% vs. 5.34%, HRadj: 1.49; p = 0.0005). In patients with MVD, ticagrelor reduced the risk of MACE (7.94% vs. 9.37%, HR: 0.82; p = 0.004) and coronary events (6.02% vs. 7.67%, HR: 0.76; p < 0.0001), including a 36% reduction in coronary death (HR: 0.64; 95% confidence interval: 0.48 to 0.85; p = 0.002). In this subgroup, ticagrelor increased the risk of TIMI major bleeding (2.52% vs. 1.08%, HR: 2.67; p < 0.0001), but not ICH or fatal bleeds. CONCLUSIONS Patients with prior MI and MVD are at increased risk of MACE and coronary events, and experience substantial relative and absolute risk reductions in both outcomes with long-term ticagrelor treatment relative to those without MVD. Ticagrelor increases the risk of TIMI major bleeding, but not ICH or fatal bleeding. For patients with prior MI and MVD, ticagrelor is an effective option for long-term antiplatelet therapy. (Prevention of Cardiovascular Events [e.g., Death From Heart or Vascular Disease, Heart Attack, or Stroke] in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS]; NCT01225562).
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Affiliation(s)
- Sameer Bansilal
- Zena and Michael Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marc P Bonaca
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jan H Cornel
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar and Dutch Network for Cardiovascular Research (WCN), the Netherlands
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ph Gabriel Steg
- DHU (Département Hospitalo-Universitaire)-FIRE (Fibrosis, Inflammation, REmodelling), Hôpital Bichat, AP-HP (Assistance Publique-Hôpitaux de Paris), Université Paris-Diderot, Sorbonne-Paris Cité, and FACT (French Alliance for Cardiovascular clinical Trials), an F-CRIN network, INSERM U-1148, Paris, France; National Heart and Lung Institute, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, Imperial College, London, United Kingdom
| | - Kyungah Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Robert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | | | | | - Daniel Isaza
- Fundacion Cardioinfantil, Instituto de Cardiología, Bogotá, Cundinamarca, Colombia
| | - Assen Goudev
- Medical University Sofia, Queen Ioanna Hospital, Sofia, Bulgaria
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway; Drammen Heart Center, Drammen, Norway
| | - Peter Held
- AstraZeneca Research and Development, Mölndal, Sweden
| | - Eva C Jensen
- AstraZeneca Research and Development, Mölndal, Sweden
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - A J Oude Ophuis
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar and Dutch Network for Cardiovascular Research (WCN), the Netherlands; Department of Cardiology, CWZ Hospital, Nijmegen, the Netherland
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Farmer RE, Mathur R, Schmidt AF, Bhaskaran K, Fatemifar G, Eastwood SV, Finan C, Denaxas S, Smeeth L, Chaturvedi N. Associations Between Measures of Sarcopenic Obesity and Risk of Cardiovascular Disease and Mortality: A Cohort Study and Mendelian Randomization Analysis Using the UK Biobank. J Am Heart Assoc 2019; 8:e011638. [PMID: 31221000 PMCID: PMC6662360 DOI: 10.1161/jaha.118.011638] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/23/2019] [Indexed: 12/22/2022]
Abstract
Background The "healthy obese" hypothesis suggests the risks associated with excess adiposity are reduced in those with higher muscle quality (mass/strength). Alternative possibilities include loss of muscle quality as people become unwell (reverse causality) or unmeasured confounding. Methods and Results We conducted a cohort study using the UK Biobank (n=452 931). Baseline body mass index ( BMI) was used to quantify adiposity and handgrip strength ( HGS ) used for muscle quality. Outcomes were fatal and non-fatal cardiovascular disease, and mortality. As a secondary analysis we used waist-hip-ratio or fat mass percentage instead of BMI , and skeletal muscle mass index instead of HGS . In a subsample, we used gene scores for BMI , waist-hip-ratio and HGS in a Mendelian randomization ( MR ). BMI defined obesity was associated with an increased risk of all outcomes (hazard ratio [ HR ] range 1.10-1.82). Low HGS was associated with increased risks of cardiovascular and all-cause mortality ( HR range 1.39-1.72). HR s for the association between low HGS and cardiovascular disease events were smaller ( HR range 1.05-1.09). There was no suggestion of an interaction between HGS and BMI to support the healthy obese hypothesis. Results using other adiposity metrics were similar. There was no evidence of an association between skeletal muscle mass index and any outcome. Factorial Mendelian randomization confirmed no evidence for an interaction. Low genetically predicted HGS was associated with an increased risk of mortality ( HR range 1.08-1.19). Conclusions Our analyses do not support the healthy obese concept, with no evidence that the adverse effect of obesity on outcomes was reduced by improved muscle quality. Lower HGS was associated with increased risks of mortality in both observational and MR analyses, suggesting reverse causality may not be the sole explanation.
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Affiliation(s)
- Ruth E. Farmer
- Department of Non Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Rohini Mathur
- Department of Non Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - A. Floriaan Schmidt
- Institute of Cardiovascular ScienceUniversity College LondonUnited Kingdom
- Division Heart and LungsDepartment of CardiologyUniversity Medical Center UtrechtNetherlands
| | - Krishnan Bhaskaran
- Department of Non Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Ghazaleh Fatemifar
- The Farr Institute of Health InformaticsLondonUnited Kingdom
- The Institute of Health InformaticsUniversity College LondonLondonUnited Kingdom
| | - Sophie V. Eastwood
- Institute of Cardiovascular ScienceUniversity College LondonUnited Kingdom
| | - Chris Finan
- The Institute of Computer ScienceUniversity College LondonUnited Kingdom
- The Farr Institute of Health InformaticsLondonUnited Kingdom
| | - Spiros Denaxas
- The Farr Institute of Health InformaticsLondonUnited Kingdom
- The Institute of Health InformaticsUniversity College LondonLondonUnited Kingdom
| | - Liam Smeeth
- Department of Non Communicable Disease EpidemiologyLondon School of Hygiene & Tropical MedicineLondonUnited Kingdom
| | - Nish Chaturvedi
- Institute of Cardiovascular ScienceUniversity College LondonUnited Kingdom
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232
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Ouellet GM, McAvay G, Murphy TE, Tinetti ME. Treatment of Hypertension in Complex Older Adults: How Many Medications Are Needed? Gerontol Geriatr Med 2019; 5:2333721419856436. [PMID: 31245434 PMCID: PMC6580710 DOI: 10.1177/2333721419856436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Many older adults with hypertension receive multiple
antihypertensives. It is unclear whether treatment with several antihypertensive
classes results in greater cardiovascular benefits than fewer antihypertensive
classes. Objectives: We investigated (a) the longitudinal
associations between treatment with ≥ 3 versus 1-2 classes and death and major
adverse cardiovascular events (MACE) and (b) whether these associations varied
by the presence of mobility disability. Methods: We included 6,011
treated hypertensive adults ≥65 from the Medical Expenditure Panel Survey
(MEPS), a nationally representative community sample. Times to MACE and death
were compared between those receiving ≥3 versus 1-2 classes using multivariable
proportional hazards regression. We used inverse probability of treatment
weighting to account for indication and contraindication bias.
Results: There were no significant differences in the risk of
mortality (hazard ratio [HR] = 0.96, p = .769) or MACE (HR =
1.10, p = .574) between the exposure groups, and there were no
significant exposure × mobility disability interactions.
Discussion: We found no benefit of ≥3 versus 1-2
antihypertensive classes in reducing mortality and cardiovascular events in a
representative cohort of older adults, raising concern about the added benefit
of additional antihypertensives in the real world.
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Affiliation(s)
- Gregory M Ouellet
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Gail McAvay
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Terrence E Murphy
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mary E Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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233
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Kim S, Chang Y, Kang J, Cho A, Cho J, Hong YS, Zhao D, Ahn J, Shin H, Guallar E, Ryu S, Sung KC. Relationship of the Blood Pressure Categories, as Defined by the ACC/AHA 2017 Blood Pressure Guidelines, and the Risk of Development of Cardiovascular Disease in Low-Risk Young Adults: Insights From a Retrospective Cohort of Young Adults. J Am Heart Assoc 2019; 8:e011946. [PMID: 31140347 PMCID: PMC6585354 DOI: 10.1161/jaha.119.011946] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background There are limited outcome studies of hypertension among young adults, especially using the new blood pressure (BP) categories from the American College of Cardiology and the American Heart Association. We examined associations between the new BP categories and the risk of incident cardiovascular disease (CVD) in low‐risk and young adults. Methods and Results A cohort study was performed in 244 837 Korean adults (mean age, 39.0 years; SD, 8.9 years) who underwent a comprehensive health examination at Kangbuk Samsung Hospital from January 1, 2011, to December 31, 2016; they were followed up for incident CVD via linkage to the Health Insurance and Review Agency database until the end of 2016, with a median follow‐up of 4.3 years. BP was categorized according to the new American College of Cardiology/American Heart Association (ACC/AHA) hypertension guidelines. During 924 420.7 person‐years, 1435 participants developed new‐onset CVD (incidence rate of 16.0 per 104 person‐years). The multivariable‐adjusted hazard ratios (95% CIs ) for CVD comparing elevated BP, stage 1 hypertension, stage 2 hypertension, treated and strictly controlled (systolic BP/diastolic BP <130/80 mm Hg with antihypertensive use), treated and controlled (systolic BP 130–139 and diastolic BP 80 to 89 mm Hg with antihypertensive use), treated uncontrolled, and untreated hypertension to normal BP were 1.37 (1.11–1.68), 1.45 (1.26–1.68), 2.12 (1.74–2.58), 1.41 (1.12–1.78), 1.97 (1.52–2.56), 2.29 (1.56–3.37) and 1.93 (1.53–2.45), respectively. Conclusions In this large cohort of low‐risk and young adults, all categories of higher BP were independently associated with an increased risk of CVD compared with normal BP, underscoring the importance of BP management even in these low‐risk populations.
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Affiliation(s)
- Seolhye Kim
- 1 Center for Cohort Studies Total Healthcare Center Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Yoosoo Chang
- 1 Center for Cohort Studies Total Healthcare Center Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea.,2 Department of Occupational and Environmental Medicine Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea.,3 Department of Clinical Research Design and Evaluation Samsung Advanced Institute for Health Sciences and Technology Sungkyunkwan University Seoul Republic of Korea
| | - Jeonggyu Kang
- 1 Center for Cohort Studies Total Healthcare Center Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Ara Cho
- 1 Center for Cohort Studies Total Healthcare Center Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Juhee Cho
- 1 Center for Cohort Studies Total Healthcare Center Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea.,3 Department of Clinical Research Design and Evaluation Samsung Advanced Institute for Health Sciences and Technology Sungkyunkwan University Seoul Republic of Korea.,4 Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Yun Soo Hong
- 4 Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Di Zhao
- 4 Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Jiin Ahn
- 1 Center for Cohort Studies Total Healthcare Center Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Hocheol Shin
- 1 Center for Cohort Studies Total Healthcare Center Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea.,5 Department of Family Medicine Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul South Korea.,6 Division of Cardiology Department of Medicine Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea
| | - Eliseo Guallar
- 3 Department of Clinical Research Design and Evaluation Samsung Advanced Institute for Health Sciences and Technology Sungkyunkwan University Seoul Republic of Korea.,4 Department of Epidemiology Johns Hopkins Bloomberg School of Public Health Baltimore MD
| | - Seungho Ryu
- 1 Center for Cohort Studies Total Healthcare Center Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea.,2 Department of Occupational and Environmental Medicine Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea.,3 Department of Clinical Research Design and Evaluation Samsung Advanced Institute for Health Sciences and Technology Sungkyunkwan University Seoul Republic of Korea
| | - Ki-Chul Sung
- 6 Division of Cardiology Department of Medicine Kangbuk Samsung Hospital Sungkyunkwan University School of Medicine Seoul Republic of Korea
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Abstract
See Article Segal et al
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Affiliation(s)
| | - Alex Sandhu
- 1 Stanford University Palo Alto California.,2 VA Palo Alto Health Care System Palo Alto California
| | - Richard Schofield
- 3 Division of Cardiovascular Medicine University of Florida Gainesville Florida.,4 North Florida/South Georgia Veterans Health System Gainesville Florida
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235
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McGuire DK, Marx N, Johansen OE, Inzucchi SE, Rosenstock J, George JT. FDA guidance on antihyperglyacemic therapies for type 2 diabetes: One decade later. Diabetes Obes Metab 2019; 21:1073-1078. [PMID: 30690856 DOI: 10.1111/dom.13645] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/15/2019] [Accepted: 01/25/2019] [Indexed: 01/08/2023]
Abstract
In 2008, the US Food and Drug Administration (FDA) issued a guidance to industry statement concerning evaluation of the cardiovascular (CV) safety of new antihyperglycaemic therapies for type 2 diabetes. Fifteen CV outcome trials assessing three novel classes of antihyperglycaemic therapies, DPP-4 inhibitors, GLP-1 receptor agonists and SGLT-2 inhibitors, were completed by the end of 2018 and several others are ongoing. In addition, one comparative insulin trial also has been completed. None of these trials reported an increase in risk for major adverse CV events (MACE), and six agents have demonstrated CV benefits. This experience has led to the first FDA-approved indications for antihyperglycaemic medications to reduce the risk of CV death (empagliflozin) and to reduce the risk of MACE (liraglutide, canagliflozin), both indications specific to patients with established atherosclerotic cardiovascular disease (ASCVD). Because of the aggregate results from dedicated CV outcomes trials conducted in response to the FDA guidance statement, the contemporary paradigm for treatment of patients with type 2 diabetes has evolved substantially. However, the guidance has substantially increased the cost of developing new medications to address this important disease that afflicts hundreds of millions of adults worldwide, with reduction in quality of life as well as in life expectancy. The cost burden of drug development of medications proven effective that may directly impact cost to patients and to their insurers might be alleviated by modifications to the present guidance statement. These include areas of trial design, aspects of trial operation, expansion of composite outcomes to include broader component CV outcomes and continued evolution of analytic methodology. The guidance statement will benefit from consideration of a number of modifications to support continued innovation and, of course, the safety of marketed medications for type 2 diabetes. However, the requirement to assess each new antihyperglycaemic medication in at least one large-scale standard randomized clinical outcomes trial should remain, so that clinicians can be reassured about the favourable efficacy/safety profiles of the medications they prescribe.
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Affiliation(s)
- Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Odd Erik Johansen
- Clinical Development, Therapeutic Area Cardiometabolism, Boehringer Ingelheim, Asker, Norway
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Julio Rosenstock
- Dallas Diabetes Research Center at Medical City and University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Jyothis T George
- Clinical Development, Therapeutic Area Cardiometabolism, Boehringer Ingelheim, Ingelheim, Germany
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236
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Ascott A, Mulick A, Yu AM, Prieto-Merino D, Schmidt M, Abuabara K, Smeeth L, Roberts A, Langan SM. Atopic eczema and major cardiovascular outcomes: A systematic review and meta-analysis of population-based studies. J Allergy Clin Immunol 2019; 143:1821-1829. [PMID: 30576754 PMCID: PMC6497108 DOI: 10.1016/j.jaci.2018.11.030] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/17/2018] [Accepted: 11/16/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Atopic eczema is a common inflammatory skin disease. Various inflammatory conditions have been linked to cardiovascular disease, a major cause of global mortality and morbidity. OBJECTIVE We sought to systematically review and meta-analyze population-based studies assessing associations between atopic eczema and specific cardiovascular outcomes. METHODS MEDLINE, Embase, and Global Health were searched from inception to December 2017. We obtained pooled estimates using random-effects meta-analyses. We used a multivariate Bayesian meta-regression model to estimate the slope of effect of increasing atopic eczema severity on cardiovascular outcomes. RESULTS Nineteen relevant studies were included. The effects of atopic eczema reported in cross-sectional studies were heterogeneous, with no evidence for pooled associations with angina, myocardial infarction, heart failure, or stroke. In cohort studies atopic eczema was associated with increased risk of myocardial infarction (n = 4; relative risk [RR], 1.12; 95% CI, 1.00-1.25), stroke (n = 4; RR, 1.10; 95% CI, 1.03-1.17), ischemic stroke n = 4; RR, 1.17; 95% CI, 1.14-1.20), angina (n = 2; RR, 1.18; 95% CI, 1.13-1.24), and heart failure (n = 2; RR, 1.26; 95% CI, 1.05-1.51). Prediction intervals were wide for myocardial infarction and stroke. The risk of cardiovascular outcomes appeared to increase with increasing severity (mean RR increase between severity categories, 1.15; 95% credibility interval, 1.09-1.21; uncertainty interval, 1.04-1.28). CONCLUSION Significant associations with cardiovascular outcomes were more common in cohort studies but with considerable between-study heterogeneity. Increasing atopic eczema severity was associated with increased risk of cardiovascular outcomes. Improved awareness among stakeholders regarding this small but significant association is warranted.
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Affiliation(s)
- Anna Ascott
- Royal Sussex County Hospital, Eastern Road, Brighton, United Kingdom.
| | - Amy Mulick
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ashley M Yu
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David Prieto-Merino
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark Department of Cardiology, Regional Hospital West Jutland, Herning, Denmark
| | - Katrina Abuabara
- Program for Clinical Research, Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, Calif
| | - Liam Smeeth
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amanda Roberts
- Nottingham Support Group for Carers of Children with Eczema, Nottingham, United Kingdom
| | - Sinéad M Langan
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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237
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Lin LY, Hwu CM, Chu CH, Won JG, Chen HS, Chang LH. The ankle brachial index exhibits better association with cardiovascular outcomes than interarm systolic blood pressure difference in patients with type 2 diabetes. Medicine (Baltimore) 2019; 98:e15556. [PMID: 31083218 PMCID: PMC6531172 DOI: 10.1097/md.0000000000015556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Increased interarm systolic blood pressure difference (IASBPD) is associated with cardiovascular prognosis in the general population. This study aimed to evaluate whether IASBPD or ankle brachial index (ABI) is strongly associated with cardiovascular outcomes in patients with type 2 diabetes.Total 446 type 2 diabetes followed up for a mean 5.8 years divided by ABI (<0.9 vs ≥0.9) or IASBPD (<10 vs ≥10 mm Hg). The primary outcome was a composite of all-cause mortality, hospitalization for coronary artery disease, nonfatal stroke, carotid, or peripheral revascularization, amputations, and diabetic foot syndrome. The secondary endpoint was all-cause mortality.Sixty-four composite events and 17 deaths were identified. The primary and secondary outcomes were higher than those in the group with ABI < 0.9 vs ABI ≥ 0.9 (32.8% vs 11.6%, P < .005 for primary outcome; 14.0% vs 2.3%, P < .005 for all-cause mortality) but IASBPD cannot exhibit a prognostic value. ABI < 0.9 was also the dominant risk factor of both endpoints demonstrated by multivariate Cox proportional analysis (composite events: adjusted hazard ratio [HR], 2.39; 95% confidence interval [CI], 1.26-4.53; P = .007; all-cause mortality: adjusted HR, 3.27: 95% CI, 1.91-5.60; P < .001).The ABI was more associated with cardiovascular outcomes in patients with diabetes than IASBPD.
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Affiliation(s)
- Liang-Yu Lin
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital
- Faculty of Medicine, National Yang-Ming University
| | - Chii-Min Hwu
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital
- Faculty of Medicine, National Yang-Ming University
| | - Chia-Huei Chu
- Faculty of Medicine, National Yang-Ming University
- Division of Otology, Department of Otorhinolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei
| | - Justin G.S. Won
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital
- Faculty of Medicine, National Yang-Ming University
| | - Harn-Shen Chen
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital
- Faculty of Medicine, National Yang-Ming University
| | - Li-Hsin Chang
- Faculty of Medicine, National Yang-Ming University
- Division of Endocrinology and Metabolism, Department of Medicine, Tao-Yuan Branch of Taipei Veterans General Hospital, Tao-Yuan, Taiwan
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238
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Masoli JAH, Delgado J, Bowman K, Strain WD, Henley W, Melzer D. Association of blood pressure with clinical outcomes in older adults with chronic kidney disease. Age Ageing 2019; 48:380-387. [PMID: 30824915 PMCID: PMC6504072 DOI: 10.1093/ageing/afz006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 10/30/2018] [Accepted: 01/24/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND in chronic kidney disease (CKD), hypertension is associated with poor outcomes at ages <70 years. At older ages, this association is unclear. We tested 10-year mortality and cardiovascular outcomes by clinical systolic blood pressure (SBP) in older CKD Stages 3 and 4 patients without diabetes or proteinuria. METHODS retrospective cohort in population representative primary care electronic medical records linked to hospital data from the UK. CKD staged by CKD-EPI equation (≥2 creatinine measurements ≥90 days apart). SBPs were 3-year medians before baseline, with mean follow-up 5.7 years. Cox competing models accounted for mortality. RESULTS about 158,713 subjects with CKD3 and 6,611 with CKD4 met inclusion criteria. Mortality increased with increasing CKD stage in all subjects aged >60. In the 70 plus group with SBPs 140-169 mmHg, there was no increase in mortality, versus SBP 130-139. Similarly, SBPs 140-169 mmHg were not associated with increased incident heart failure, stroke or myocardial infarctions. SBPs <120 mmHg were associated with increased mortality and cardiovascular risk. At ages 60-69, there was increased mortality at SBP <120 and SBP >150 mmHg.Results were little altered after excluding those with declining SBPs during 5 years before baseline, or for longer-term outcomes (5-10 years after baseline). CONCLUSIONS in older primary care patients, CKD3 or 4 was the dominant outcome predictor. SBP 140-169 mmHg having little additional predictive value, <120 mmHg was associated with increased mortality. Prospective studies of representative older adults with CKD are required to establish optimum BP targets.
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Affiliation(s)
- Jane A H Masoli
- Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, UK
- Department of Healthcare for Older People, Royal Devon and Exeter Hospital, Barrack Road, Exeter, UK
| | - Joao Delgado
- Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, UK
| | - Kirsty Bowman
- Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, UK
| | - W David Strain
- Department of Healthcare for Older People, Royal Devon and Exeter Hospital, Barrack Road, Exeter, UK
- Diabetes and Vascular Research, University of Exeter Medical School, Exeter, UK
| | - William Henley
- Medical Statistics, University of Exeter Medical School, Exeter, UK
| | - David Melzer
- Epidemiology and Public Health Group, University of Exeter Medical School, RILD Building, Barrack Road, Exeter, UK
- UConn Center on Aging, University of Connecticut Health Center, 263 Farmington Avenue, Farmington CT, USA
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239
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Park J, De Luca A, Dutton H, Malcolm JC, Doyle MA. Cardiovascular Outcomes in Autonomous Cortisol Secretion and Nonfunctioning Adrenal Adenoma: A Systematic Review. J Endocr Soc 2019; 3:996-1008. [PMID: 31065617 PMCID: PMC6497919 DOI: 10.1210/js.2019-00090] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 03/15/2019] [Indexed: 01/06/2023] Open
Abstract
There is growing evidence that autonomous cortisol secretion (ACS), previously known as subclinical Cushing syndrome, is associated with greater prevalence of cardiovascular (CV) risk factors. However, it is unclear whether ACS is associated with greater prevalence of CV outcomes compared with nonfunctioning adrenal adenomas (NFAAs). The objective of this study is to evaluate CV outcomes and CV risk factors in patients with adrenal adenoma with ACS compared with NFAA. A literature review was performed in Embase, Medline, Cochrane Library, and reference lists within selected articles. The study protocol was registered with PROSPERO. A literature search yielded six studies that met the inclusion criteria. Studies varied in their definitions of ACS and CV outcomes. Two retrospective longitudinal studies further demonstrated higher incidence of new CV events (ACS 16.7% vs NFAA 6.7%, P = 0.04) and higher CV mortality in patients with ACS (ACS 22.6% vs 2.5%, P = 0.02). The prevalence of CV outcomes in ACS was more than three times greater than in patients with NFAA. Three of five studies found that ACS was associated with higher prevalence of diabetes and hypertension. There was no difference in dyslipidemia or body mass index demonstrated in any study. There is heterogeneity among the few studies evaluating the association between ACS and CV outcomes. Although these studies suggest a higher risk of CV outcomes in patients with ACS, many did not adjust for known confounders. Larger, high quality, prospective studies are needed to evaluate this association and to identify modifiable risk factors.
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Affiliation(s)
- Jane Park
- Western University, London, Ontario, Canada.,University of Ottawa, Ottawa, Ontario, Canada
| | | | - Heidi Dutton
- University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology and Metabolism, University of Ottawa The Ottawa Hospital, Ottawa, Ontario, Cananda
| | - Janine C Malcolm
- University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology and Metabolism, University of Ottawa The Ottawa Hospital, Ottawa, Ontario, Cananda
| | - Mary-Anne Doyle
- University of Ottawa, Ottawa, Ontario, Canada.,Division of Endocrinology and Metabolism, University of Ottawa The Ottawa Hospital, Ottawa, Ontario, Cananda.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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240
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Abstract
Hypertension and chronic kidney disease (CKD) are closely interlinked pathophysiologic states, such that sustained hypertension can lead to worsening kidney function and progressive decline in kidney function can conversely lead to worsening blood pressure (BP) control. The pathophysiology of hypertension in CKD is complex and is a sequela of multiple factors, including reduced nephron mass, increased sodium retention and extracellular volume expansion, sympathetic nervous system overactivity, activation of hormones including the renin-angiotensin-aldosterone system, and endothelial dysfunction. Currently, the treatment target for patients with CKD is a clinic systolic BP < 130mm Hg. The main approaches to the management of hypertension in CKD include dietary salt restriction, initiation of treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and diuretic therapy. Uncontrolled hypertension can lead to significant cardiovascular morbidity and mortality and accelerate progression to end-stage kidney disease. Although intensive BP control has not been shown in clinical trials to slow the progression of CKD, intensive BP control reduces the risk for adverse cardiovascular outcomes and mortality in the CKD population.
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Affiliation(s)
- Elaine Ku
- Division of Nephrology and Pediatric Nephrology, Departments of Medicine and Pediatrics, University of California San Francisco, San Francisco, CA.
| | - Benjamin J Lee
- Houston Kidney Consultants, Houston Methodist Institute for Academic Medicine, Houston, TX
| | - Jenny Wei
- School of Medicine, University of Southern California, Los Angeles, CA
| | - Matthew R Weir
- Division of Nephrology and Hypertension, Department of Medicine, University of Maryland, Baltimore, MD
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241
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Kamstra R, Durkin M, Cai J, Bookhart B, Lafeuille MH, Pilon D, Tiggelaar S, Manceur AM, Lefebvre P. Economic modelling of costs associated with outcomes reported for type 2 diabetes mellitus (T2DM) patients in the CANVAS and EMPA-REG cardiovascular outcomes trials. J Med Econ 2019; 22:280-287. [PMID: 30575426 DOI: 10.1080/13696998.2018.1562817] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS To model direct medical costs associated with reductions in cardiovascular disease (CVD) events in T2DM patients reported in the CANVAS and EMPA-REG trials, which assessed the cardiovascular safety of canagliflozin and empagliflozin, respectively. MATERIALS AND METHODS Costs were modeled from a US managed care organization (MCO) perspective for the CVD outcomes included in both trials: three-point major adverse cardiovascular event (MACE) and its components (cardiovascular-related death, nonfatal myocardial infarction, nonfatal stroke), as well as heart failure requiring hospitalization. The rate of CVD events averted (difference between study drug and placebo) was projected to the portion of an MCO T2DM population matching the respective trial's inclusion criteria. A targeted literature search for paid amounts directly associated with each CVD event provided the unit costs, which were applied to the projected number of events averted, to calculate costs avoided per member per year (PMPY). One-way sensitivity analyses were performed on events averted, unit costs, and percentages of trial-applicable patients. RESULTS Based on three-point MACE events averted, costs avoided PMPY of $6.17 (range: $1.27-$10.94) for CANVAS and $2.75 ($0.19-$4.83) for EMPA-REG were estimated. Costs avoided for individual components of MACE ranged from $0.77 to $3.84 PMPY for CANVAS and from -$0.97 (additional costs) to $1.54 for EMPA-REG. PMPY costs avoided for heart failure were $2.72 for CANVAS and $1.32 for EMPA-REG. LIMITATIONS AND CONCLUSIONS Models assumed independent, non-recurrent outcomes and were restricted to medical costs directly associated with the trial-reported events. The reductions in CVD events in T2DM patients reported for both CANVAS and EMPA-REG project to a positive cost avoidance for these events in an MCO population. The analysis did not include an assessment of the impact on total cost, as the costs associated with adverse events, drug utilization or other clinical outcomes were not examined.
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Affiliation(s)
| | - Mike Durkin
- b Janssen Scientific Affairs, LLC , Titusville , NJ , USA
| | - Jennifer Cai
- b Janssen Scientific Affairs, LLC , Titusville , NJ , USA
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242
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McFarlane IM, Leon SYZ, Bhamra MS, Burza A, Waite SA, Rodriguez Alvarez M, Koci K, Taklalsingh N, Kaplan I, Pathiparampil J, Kabani N, Watler E, Sorrento CS, Frefer M, Vaitkus V, Green J, Matthew K, Arroyo-Mercado F, Lyo H, Soliman F, Sanchez RA, Reyes FM, Ozeri DJ, Dronamraju V, Trevisonno M, Grant C, Clerger G, Amin K, Freeman L, Dawkins M, Lenis Lopez D, Smerling J, Gondal I, Dellinger E, Paltoo K, Bhat H, Kolla S. Assessment of Cardiovascular Disease Risk and Therapeutic Patterns among Urban Black Rheumatoid Arthritis Patients. Med Sci (Basel) 2019; 7:E31. [PMID: 30791646 PMCID: PMC6410013 DOI: 10.3390/medsci7020031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 01/27/2019] [Accepted: 01/27/2019] [Indexed: 12/29/2022] Open
Abstract
Rheumatoid arthritis (RA) patients have nearly twice the risk of cardiovascular disease (CVD) compared to the general population. We aimed to assess, in a predominantly Black population, the prevalence of traditional and RA-specific CVD risk factors and therapeutic patterns. Utilizing ICD codes, we identified 503 RA patients ≥18 years old who were seen from 2010 to 2017. Of them, 88.5% were Black, 87.9% were women and 29.4% were smokers. CVD risk factors (obesity, diabetes, hypertension, dyslipidemia) were higher than in previously reported White RA cohorts. Eighty-seven percent of the patients had at least one traditional CVD risk factor, 37% had three or more traditional CVD risk factors and 58% had RA-specific risk factors (seropositive RA, >10 years of disease, joint erosions, elevated inflammatory markers, extra-articular disease, body mass index (BMI) < 20). CV outcomes (coronary artery disease/myocardial infarction, heart failure, atrial fibrillation and stroke) were comparable to published reports. Higher steroid use, which increases CVD risk, and lesser utilization of biologics (decrease CV risk) were also observed. Our Black RA cohort had higher rates of traditional CVD risk factors, in addition to chronic inflammation from aggressive RA, which places our patients at a higher risk for CVD outcomes, calling for revised risk stratification strategies and effective interventions to address comorbidities in this vulnerable population.
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Affiliation(s)
- Isabel M. McFarlane
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Su Yien Zhaz Leon
- Samaritan Medical Center Department of Rheumatology, Watertown, NY 13601, USA;
| | - Manjeet S. Bhamra
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Aaliya Burza
- Department of Medicine, Division of Pulmonary and Critical Care State, SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA;
| | - Stephen Anthony Waite
- Department of Radiology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (S.A.W.); (S.K.)
| | - Milena Rodriguez Alvarez
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Kristaq Koci
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Nicholas Taklalsingh
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Ian Kaplan
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Joshy Pathiparampil
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Naureen Kabani
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Elsie Watler
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Cristina S. Sorrento
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Mosab Frefer
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Vytas Vaitkus
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Jason Green
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Keron Matthew
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Fray Arroyo-Mercado
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Helen Lyo
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Faisal Soliman
- Department of Geriatrics, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY 11201, USA;
| | - Randolph A. Sanchez
- Department of Rheumatology, Hahnemann Hospital, Philadelphia, PA 19019, USA;
| | - Felix M. Reyes
- Department of Family and Social Medicine, Montefiore Medical Center Albert Einstein College of Medicine, Bronx, NY 10468, USA;
| | | | - Veena Dronamraju
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Michael Trevisonno
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Christon Grant
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Guerrier Clerger
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Khabbab Amin
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Latoya Freeman
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Makeda Dawkins
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Diana Lenis Lopez
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Jonathan Smerling
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Irfan Gondal
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Elaine Dellinger
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Karen Paltoo
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Hina Bhat
- Department of Medicine, Division of Rheumatology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (M.S.B.); (M.R.A.); (K.K.); (N.T.); (I.K.); (J.P.); (N.K.); (E.W.); (C.S.S.); (M.F.); (V.V.); (J.G.); (K.M.); (F.A.-M.); (H.L.); (V.D.); (M.T.); (C.G.); (G.C.); (K.A.); (L.F.); (M.D.); (D.L.L.); (J.S.); (I.G.); (E.D.); (K.P.); (H.B.)
| | - Srinivas Kolla
- Department of Radiology SUNY Downstate Medical Center/Health + Hospitals Kings County, Brooklyn, NY 11201, USA; (S.A.W.); (S.K.)
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Abstract
See Article by Raghavan et al.
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Affiliation(s)
- David Aguilar
- 1 Department of Epidemiology, Human Genetics and Environmental Sciences School of Public Health University of Texas Health Science Center at Houston TX.,2 Division of Cardiology UT McGovern Medical School Houston TX
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Magkas N, Tsioufis C, Thomopoulos C, Dilaveris P, Georgiopoulos G, Doumas M, Papadopoulos D, Tousoulis D. Orthostatic hypertension: From pathophysiology to clinical applications and therapeutic considerations. J Clin Hypertens (Greenwich) 2019; 21:426-433. [PMID: 30724451 DOI: 10.1111/jch.13491] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/16/2018] [Accepted: 12/24/2018] [Indexed: 12/12/2022]
Abstract
Orthostatic hypertension (OHT), that is, sustained increase in blood pressure after standing, is an increasingly recognized cardiovascular disorder having been examined in much fewer studies compared with orthostatic hypotension (OH). However, in both OHT and OH, dysfunction of the autonomous nervous system is considered to be the primary pathophysiological disturbance, while significant associations with essential hypertension have been observed. Although in many studies OHT has been related to subclinical or clinical target organ damage, there is also evidence denying such an association. Because OHT is defined variably across different studies, the comparison of relevant outcomes is at least problematic. Since evidence about OHT treatment is exclusively based on limited non-randomized studies, no specific recommendations have been developed. Therefore, both the prognostic role and the clinical significance of OHT remain largely undefined. The aim of the present review is to summarize the available evidence regarding the definition, diagnosis, pathophysiology, prognostic role and treatment of OHT and highlight potential clinical implications of this underestimated condition.
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Affiliation(s)
- Nikolaos Magkas
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Costas Tsioufis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | | | - Polychronis Dilaveris
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Georgios Georgiopoulos
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Michael Doumas
- 2nd Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Dimitris Papadopoulos
- Hypertension Excellence Centre-ESH, Department of Cardiology, LAIKO General Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
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246
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Shunan F, Jiqing Y, Xue D. Effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on cardiovascular events in patients with diabetes and overt nephropathy: a meta-analysis of randomised controlled trials. J Renin Angiotensin Aldosterone Syst 2019; 19:1470320318803495. [PMID: 30296880 PMCID: PMC6178369 DOI: 10.1177/1470320318803495] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The efficacy of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in reducing cardiovascular outcomes in patients with diabetes and overt nephropathy is still a controversial issue. METHODS We systematically searched MEDLINE, Embase and Cochrane Library for randomised controlled trials. RESULTS Thirteen trials containing 4638 patients with diabetes and overt nephropathy were included. Compared with controls, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker treatment did not reduce the risk of cardiovascular events (odds ratio 0.94, 95% confidence interval 0.86 to 1.03, P=0.18; I2=0.0%, P=0.75). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy reduced the odds of heart failure events by 29% (0.71, 0.61 to 0.83, P<0.001; I2=0%, P=0.78). The results indicated no significant differences between the two treatment regimens with regard to the frequency of MI (0.95, 0.76 to 1.19, P=0.64), stroke (1.20, 0.83 to 1.74, P=0.32), cardiovascular death (1.26, 0.96 to 1.65, P=0.09) and all-cause mortality (0.98, 0.86 to 1.12, P=0.73). Among all kinds of adverse effects, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy increased the incidence of hyperkalemia (2.26, 1.42 to 3.61, P=0.001). CONCLUSION This study demonstrated that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers did not reduce cardiovascular events in patients with diabetes and overt nephropathy.
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Affiliation(s)
- Fan Shunan
- 1 Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, China
| | - Yuan Jiqing
- 2 Department of Internal Medicine, Tianjin Medical University General Hospital, China
| | - Dong Xue
- 3 Changchun University of Chinese Medicine, China
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247
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Affiliation(s)
- Faiez Zannad
- From Inserm, Centre d'Investigations Cliniques-1433, and Inserm U1116, CHRU de Nancy, Université de Lorraine, France (F.Z., P.R.); F-CRIN INI-CRCT, Nancy, France (F.Z., P.R.); and Association Lorraine pour le Traitement de l'Insuffisance Rénale, Nancy, France (P.R.).
| | - Patrick Rossignol
- From Inserm, Centre d'Investigations Cliniques-1433, and Inserm U1116, CHRU de Nancy, Université de Lorraine, France (F.Z., P.R.); F-CRIN INI-CRCT, Nancy, France (F.Z., P.R.); and Association Lorraine pour le Traitement de l'Insuffisance Rénale, Nancy, France (P.R.)
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Lin WC, Chen CW, Lu CL, Lai WW, Huang MH, Tsai LM, Li CY, Lai CH. The association between recent hospitalized COPD exacerbations and adverse outcomes after percutaneous coronary intervention: a nationwide cohort study. Int J Chron Obstruct Pulmon Dis 2019; 14:169-179. [PMID: 30655664 PMCID: PMC6322514 DOI: 10.2147/copd.s187345] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose COPD is associated with coronary artery disease, and exacerbations are major events in COPD. However, the impact of recent hospitalized exacerbations on outcomes of percutaneous coronary intervention (PCI) remains underdetermined. Patients and methods Using the National Health Insurance Research Database of Taiwan, we identified 215,275 adult patients who underwent first-time PCI between 2000 and 2012. Among these patients, 15,485 patients had COPD. The risks of hospital mortality, overall mortality, and adverse cardiovascular outcomes after PCI (ie, ischemic events, repeat revascularization, cerebrovascular events, and major adverse cardiac and cerebrovascular events [MACCEs]) in relation to COPD, and the frequency and timing of recent hospitalized exacerbations within 1 year before PCI were estimated. Results COPD was independently associated with increased risks of hospital mortality, overall mortality, ischemic events, cerebrovascular events, and MACCE during follow-up after PCI. Among cerebrovascular events, ischemic rather than hemorrhagic stroke was more likely to occur. In COPD patients, recent hospitalized exacerbations further increased the risks of overall mortality, ischemic events, and MACCE following PCI. Notably, patients with more frequent or more recent hospitalized exacerbations had a trend toward higher risks of these adverse events (all P-values for trend <0.0001), especially those with ≥2 exacerbations within 1 year or any exacerbation within 1 month before PCI. Conclusion Integrated care is urgently needed to alleviate COPD-related morbidity and mortality after PCI, especially for patients with a recent hospitalized exacerbation.
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Affiliation(s)
- Wei-Chieh Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chang-Wen Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Li Lu
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, .,Graduate Institute of Food Safety, College of Agriculture and Nature Resources, National Chung Hsing University, Taichung, Taiwan
| | - Wu-Wei Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,
| | - Min-Hsin Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,
| | - Liang-Miin Tsai
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan, .,Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan,
| | - Chao-Han Lai
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,
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Bailey CJ, Marx N. Cardiovascular protection in type 2 diabetes: Insights from recent outcome trials. Diabetes Obes Metab 2019; 21:3-14. [PMID: 30091169 DOI: 10.1111/dom.13492] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 07/29/2018] [Accepted: 08/04/2018] [Indexed: 02/06/2023]
Abstract
This review examines recent randomized controlled cardiovascular (CV) outcome trials of glucose-lowering therapies in type 2 diabetes and their impact on the treatment of patients with type 2 diabetes. The trials were designed to comply with regulatory requirements to confirm that major adverse cardiac events (MACE) are not detrimentally affected by such therapies. Trials involving dipeptidyl peptidase-4 (DPP-4) inhibitors did not alter a composite MACE outcome comprising CV deaths, non-fatal myocardial infarction and non-fatal stroke; however, the possibility that some members of this class might incur a small increased risk or worsening of heart failure cannot be excluded. Some studies on glucagon-like peptide-1 receptor agonists (liraglutide: LEADER trial; semaglutide: SUSTAIN-6 trial) found significant benefits for MACE, while treatment with sodium-glucose co-transporter-2 inhibitors (empagliflozin: EMPA-REG OUTCOME trial; canagliflozin: CANVAS trial) also significantly reduced MACE and reduced hospitalization for heart failure. Comparisons among trials are complicated by variance in the populations recruited, particularly CV status at randomization, and differences in trial design, data collection and analyses. A large proportion of patients recruited into these trials have previously experienced adverse CV events; thus, the therapies are mostly assessing secondary prevention of a further event. This contrasts with the overall type 2 diabetes population receiving glucose-lowering therapies, of whom the majority will not have had MACE and will be regarded as primary prevention. Overall, the trials provide reassuring evidence that new glucose-lowering medications do not adversely affect CV events and some of these agents may offer CV protection.
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Affiliation(s)
- Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Nikolaus Marx
- Department of Internal Medicine I, RWTH Aachen University, Aachen, Germany
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250
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Abstract
BACKGROUND There is widespread obesity paradox in cardiovascular diseases, the cardiovascular influence from weight management remains controversial. Moreover, previous publications indicating that different weight reduction extent might lead to various results. Thus, it is of importance to reassess the cardiovascular benefits of weight management strategies. OBJECTIVES This review is designed to assess the association between weight loss and cardiovascular outcomes. METHODS Clinical trials including randomized control trials, observational studies reported a weight change before and after weight interventions including lifestyle intervention, as well as pharmacotherapies were included. Three major databases will be searched to retrieve the appropriate studies. Dual selection and abstraction of data will be conducted by 2 authors independently. The population, intervention, comparator, outcomes, study characteristics framework will be used to extract all the necessary data from included studies. The risk of bias assessment will be conducted in duplicate based on the Cochrane risk of bias guideline for randomized controlled trials (RCTs) and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement for observational studies respectively. The primary outcomes will be the cardiovascular mortality, and the secondary outcomes are all-cause mortality and new cardiovascular events. A meta-analysis will be considered if there is sufficient homogeneity among selected studies. Follow the criteria of Grading of Recommendations, Assessment, Development and Evaluation (GRADE), the quality of the cumulative evidence will be evaluated. RESULTS AND CONCLUSIONS The results of this systematic review could provide reliable and concrete evidence for weight loss and its cardiovascular benefits.Prospero registration number: CRD42018108582.
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Affiliation(s)
- Yingke Zhao
- School of Chinese Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
- Cardiovascular diseases center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Branda Yee-Man Yu
- School of Nursing, the Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Yanfei Liu
- Graduate school of Beijing University of Chinese Medicine, Beijing, China
| | - Tiejun Tong
- Department of Mathematics, Hong Kong Baptist University, Kowloon Tong, Hong Kong
| | - Yue Liu
- Cardiovascular diseases center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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