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Yuan Y, Liu M, Zhang S, Lin Y, Huang Y, Zhou H, Xu X, Zhuang X, Liao X. Effect of blood pressure index on clinical outcomes in patients with heart failure and chronic kidney disease. ESC Heart Fail 2023; 10:3330-3339. [PMID: 37667525 PMCID: PMC10682879 DOI: 10.1002/ehf2.14437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 04/05/2023] [Accepted: 05/23/2023] [Indexed: 09/06/2023] Open
Abstract
AIMS This study aimed to assess the effect of blood pressure (BP) index, in terms of level and variability, on the progression of cardiovascular and renal diseases in patients with both heart failure (HF) and chronic kidney disease (CKD). METHODS AND RESULTS The study involved patients with HF and CKD from the database of the Chronic Renal Insufficiency Cohort (CRIC) study. The study endpoint includes the following: (i) primary endpoint, including cardiovascular disease (CVD) events, renal events, and all-cause death; (ii) CVD events; (iii) renal events; and (iv) all-cause death. Among 3939 participants in the CRIC study, a total of 382 patients were included. The duration of the follow-up was 6.3 ± 2.7 years, the age was 60.2 ± 8.9 years, and 57.6% were male. BP index included 20 indicators in relation to BP level and variability, 4 of which were analysed including baseline systolic BP (SBP), standard deviation of SBP, coefficient of variation of diastolic BP (DBP CV), and average real variability of pulse pressure. In the Cox regression analysis after adjustment, baseline SBP was significant for the risk of primary endpoint [hazard ratio (HR) 1.22, 95% confidence interval (CI) 1.03-1.44, P = 0.02] and renal events (HR 1.54, 95% CI 1.22-1.95, P < 0.001), and DBP CV was significant for the risk of primary endpoint (HR 1.03, 95% CI 1.01-1.06, P = 0.02) and CVD events (HR 1.04, 95% CI 1.02-1.07, P < 0.01). The result of the forest plot depicted that baseline SBP had a linear association with the risk of CVD and renal events (P = 0.04 and 0.001, respectively) and DBP CV with CVD events (P = 0.02). As the restricted cubic spline models displayed, DBP CV featured a J- or L-curved association with the primary endpoint, renal events, and all-cause death (P for nonlinearity = 0.01, <0.001, and 0.01, respectively). CONCLUSIONS The baseline SBP and DBP CV may remain significant for clinical outcomes in patients with both HF and CKD. The increase in baseline SBP is associated with a higher risk of primary endpoint, CVD events, and renal events, and the increase in DBP CV with a higher risk of CVD events. Concerning nonlinear association, DBP CV features a J- or L-curved relationship with the primary endpoint, renal events, and all-cause death, with a higher risk at both low and high values. TRIAL REGISTRATION https://www. CLINICALTRIALS gov; unique identifier: NCT00304148.
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Affiliation(s)
- Ying Yuan
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Menghui Liu
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Shaozhao Zhang
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yifen Lin
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yiquan Huang
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Huimin Zhou
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xingfeng Xu
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xiaodong Zhuang
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xinxue Liao
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
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Farag SM, Rabea HM, Abdelrahim ME, Mahmoud HB. Target Blood Pressure and Combination Therapy: Focus on Angiotensin Receptor Blockers Combination with Either Calcium Channel Blockers or Beta Blockers. Curr Hypertens Rev 2022; 18:138-144. [PMID: 36508272 DOI: 10.2174/1573402118666220627120254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/08/2022] [Accepted: 05/12/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND The target blood pressure has changed many times in the guidelines in past years. However, there is always a question; is it good to lower blood pressure below 120/80 or not? Control of blood pressure in hypertension is very important in reducing hypertension-modified organ damage. So, the guidelines recommend combining more than one antihypertensive drug to reach the target blood pressure goal. RESULTS Combination therapy is recommended by guidelines to reach the blood pressure goal. The guidelines recommend many combinations, such as the combination of angiotensin receptor blockers with either calcium channel blockers (CCB) or beta-blocker (BB). Angiotensin receptor blocker (ARB) combination with CCB has gained superiority over other antihypertension drug combinations because it reduces blood pressure and decreases the incidence of CV events and organ damage. BB combinations are recommended by guidelines in patients with ischemic events but not all hypertensive patients. Unfortunately, the new generation BB, for example, nebivolol, has a vasodilator effect, making it new hope for BB. CONCLUSION Combination therapy is a must in treating the hypertensive patient. The new generation BBs may change the recommendations of guidelines because they have an effect that is similar to CCBs.
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Affiliation(s)
- Selvia M Farag
- Cardiovascular Department, Beni-Suef University Hospital, Egypt
| | - Hoda M Rabea
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed Ea Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hesham B Mahmoud
- Department of Cardiology, Beni-Suef University Hospital, Beni-Suef, Egypt
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Du XL, Simpson LM, Tandy BC, Bettencourt J, Davis BR. Effects of Posttrial Antihypertensive Drugs on Morbidity and Mortality: Findings from 15-Year Passive Follow-Up after ALLHAT Ended. Int J Hypertens 2021; 2021:2261144. [PMID: 34925915 PMCID: PMC8677412 DOI: 10.1155/2021/2261144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/17/2021] [Accepted: 11/25/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) ended in 2002, but it is important to study its long-term outcomes during the posttrial period by incorporating posttrial antihypertensive medication uses in the analysis. PURPOSES The primary aim is to explore the patterns of antihypertensive medication use during the posttrial period from Medicare Part-D data over the 11-year period from 2007 to 2017. The secondary aim is to examine the potential effects of these posttrial antihypertensive medications on the observed mortality and morbidity benefits. METHODS This is a posttrial passive follow-up study of ALLHAT participants in 567 US centers in 1994-1998 with the last date of active in-trial follow-up on March 31, 2002, by linking with their Medicare and National Death Index data through 2017 among 8,007 subjects receiving antihypertensive drugs (3,637 for chlorthalidone, 2,189 for amlodipine, and 2,181 for lisinopril). Outcomes included posttrial antihypertensive drug use, all-cause mortality, and cardiovascular disease (CVD) mortality. RESULTS Of 8007 subjects, 3,637 participants were initially randomized to diuretic (chlorthalidone). The majority (67.9%) of them still received diuretics in 2007, and 52.7%, 47.2%, and 44.0% received β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers (CCBs), respectively. Compared to participants who received diuretic-based antihypertensives, those who received CCB had a nonsignificantly higher risk of all-cause mortality (1.17, 0.99-1.37), whereas those who received ACE/ARB (angiotensin receptor blockers) had a significantly higher risk of all-cause mortality (1.26, 1.09-1.45). For the combined fatal or nonfatal hospitalized events, the risk of CVD was significantly higher in patients receiving CCB (1.30, 1.04-1.61) and ACE/ARB (1.49, 1.22-1.81) as compared to patients receiving diuretics. CONCLUSION After the conclusion of the ALLHAT, almost all patients switched to combination antihypertensive therapies, independently by the original drug class, and the combination therapies (mostly based on diuretics) reduced the incidence of major cardiovascular outcomes and mortality.
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Affiliation(s)
- Xianglin L. Du
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Lara M. Simpson
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Brian C. Tandy
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Judy Bettencourt
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Barry R. Davis
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
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Qi M, Cahan O, Foreman MA, Gruen DM, Das AK, Bennett KP. Quantifying representativeness in randomized clinical trials using machine learning fairness metrics. JAMIA Open 2021; 4:ooab077. [PMID: 34568771 PMCID: PMC8460438 DOI: 10.1093/jamiaopen/ooab077] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/19/2021] [Accepted: 09/03/2021] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE We help identify subpopulations underrepresented in randomized clinical trials (RCTs) cohorts with respect to national, community-based or health system target populations by formulating population representativeness of RCTs as a machine learning (ML) fairness problem, deriving new representation metrics, and deploying them in easy-to-understand interactive visualization tools. MATERIALS AND METHODS We represent RCT cohort enrollment as random binary classification fairness problems, and then show how ML fairness metrics based on enrollment fraction can be efficiently calculated using easily computed rates of subpopulations in RCT cohorts and target populations. We propose standardized versions of these metrics and deploy them in an interactive tool to analyze 3 RCTs with respect to type 2 diabetes and hypertension target populations in the National Health and Nutrition Examination Survey. RESULTS We demonstrate how the proposed metrics and associated statistics enable users to rapidly examine representativeness of all subpopulations in the RCT defined by a set of categorical traits (eg, gender, race, ethnicity, smoking status, and blood pressure) with respect to target populations. DISCUSSION The normalized metrics provide an intuitive standardized scale for evaluating representation across subgroups, which may have vastly different enrollment fractions and rates in RCT study cohorts. The metrics are beneficial complements to other approaches (eg, enrollment fractions) used to identify generalizability and health equity of RCTs. CONCLUSION By quantifying the gaps between RCT and target populations, the proposed methods can support generalizability evaluation of existing RCT cohorts. The interactive visualization tool can be readily applied to identified underrepresented subgroups with respect to any desired source or target populations.
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Affiliation(s)
- Miao Qi
- Department of Computer Science, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Owen Cahan
- Department of Mathematical Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Morgan A Foreman
- Center for Computational Health, IBM Research, Cambridge, Massachusetts, USA
| | - Daniel M Gruen
- Department of Mathematical Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA
| | - Amar K Das
- Center for Computational Health, IBM Research, Cambridge, Massachusetts, USA
| | - Kristin P Bennett
- Department of Computer Science, Rensselaer Polytechnic Institute, Troy, New York, USA
- Department of Mathematical Sciences, Rensselaer Polytechnic Institute, Troy, New York, USA
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Chen Y, Zelnick LR, Huber MP, Wang K, Bansal N, Hoofnagle AN, Paranji RK, Heckbert SR, Weiss NS, Go AS, Hsu CY, Feldman HI, Waikar SS, Mehta RC, Srivastava A, Seliger SL, Lash JP, Porter AC, Raj DS, Kestenbaum BR. Association Between Kidney Clearance of Secretory Solutes and Cardiovascular Events: The Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2021; 78:226-235.e1. [PMID: 33421453 PMCID: PMC8260620 DOI: 10.1053/j.ajkd.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/11/2020] [Indexed: 01/11/2023]
Abstract
RATIONALE & OBJECTIVE The clearance of protein-bound solutes by the proximal tubules is an innate kidney mechanism for removing putative uremic toxins that could exert cardiovascular toxicity in humans. However, potential associations between impaired kidney clearances of secretory solutes and cardiovascular events among patients with chronic kidney disease (CKD) remains uncertain. STUDY DESIGN A multicenter, prospective, cohort study. SETTING & PARTICIPANTS We evaluated 3,407 participants from the Chronic Renal Insufficiency Cohort (CRIC) study. EXPOSURES Baseline kidney clearances of 8 secretory solutes. We measured concentrations of secretory solutes in plasma and paired 24-hour urine specimens using liquid chromatography-tandem mass spectrometry (LC-MS/MS). OUTCOMES Incident heart failure, myocardial infarction, and stroke events. ANALYTICAL APPROACH We used Cox regression to evaluate associations of baseline secretory solute clearances with incident study outcomes adjusting for estimated GFR (eGFR) and other confounders. RESULTS Participants had a mean age of 56 years; 45% were women; 41% were Black; and the median estimated glomerular filtration rate (eGFR) was 43 mL/min/1.73 m2. Lower 24-hour kidney clearance of secretory solutes were associated with incident heart failure and myocardial infarction but not incident stroke over long-term follow-up after controlling for demographics and traditional risk factors. However, these associations were attenuated and not statistically significant after adjustment for eGFR. LIMITATIONS Exclusion of patients with severely reduced eGFR at baseline; measurement variability in secretory solutes clearances. CONCLUSIONS In a national cohort study of CKD, no clinically or statistically relevant associations were observed between the kidney clearances of endogenous secretory solutes and incident heart failure, myocardial infarction, or stroke after adjustment for eGFR. These findings suggest that tubular secretory clearance provides little additional information about the development of cardiovascular disease events beyond glomerular measures of GFR and albuminuria among patients with mild-to-moderate CKD.
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Affiliation(s)
- Yan Chen
- Department of Epidemiology, University of Washington, Seattle, WA; Kidney Research Institute, Seattle, WA
| | - Leila R Zelnick
- Kidney Research Institute, Seattle, WA; Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA
| | - Matthew P Huber
- Department of Medicine, University of Washington, Seattle, WA
| | - Ke Wang
- Kidney Research Institute, Seattle, WA; Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA
| | - Nisha Bansal
- Kidney Research Institute, Seattle, WA; Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA
| | - Andrew N Hoofnagle
- Kidney Research Institute, Seattle, WA; Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Rajan K Paranji
- Department of Chemistry, University of Washington, Seattle, WA
| | - Susan R Heckbert
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Chi-Yuan Hsu
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, CA
| | - Harold I Feldman
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | | | - Rupal C Mehta
- Department of Medicine, Division of Nephrology and Hypertension, Northwestern University, Chicago, IL
| | - Anand Srivastava
- Department of Medicine, Division of Nephrology and Hypertension, Northwestern University, Chicago, IL
| | - Stephen L Seliger
- Division of Nephrology, University of Maryland School of Medicine, Baltimore, MD
| | - James P Lash
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL
| | - Anna C Porter
- Department of Medicine, Division of Nephrology, University of Illinois at Chicago, Chicago, IL
| | - Dominic S Raj
- Department of Medicine, Division of Kidney Disease and Hypertension, George Washington University, Washington, DC
| | - Bryan R Kestenbaum
- Kidney Research Institute, Seattle, WA; Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA.
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Worsening Kidney Function Is the Major Mechanism of Heart Failure in Hypertension: The ALLHAT Study. JACC-HEART FAILURE 2020; 9:100-111. [PMID: 33189627 DOI: 10.1016/j.jchf.2020.09.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/08/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The authors aimed to quantify the extent to which the effect of antihypertensive drugs on incident heart failure (HF) is mediated by their effect on kidney function. BACKGROUND The authors hypothesized that the dynamic change in kidney function is the mechanism behind differences in the rate of incident HF in ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) participants randomized to lisinopril and chlorthalidone, in comparison with those randomized to amlodipine and doxazosin. METHODS Causal mediation analysis of ALLHAT data (1994 to 2002) included participants with available baseline and 24- to 48-month estimated glomerular filtration rate (eGFR) (N = 27,918; mean age 66 ± 7.4 years; 32.4% Black, 56.3% men). Change in eGFR was the mediator. Incident symptomatic HF was the primary outcome. Hospitalized/fatal HF was the secondary outcome. Linear regression (for mediator) and logistic regression (for outcome) analyses were adjusted for demographics, cardiovascular disease, and risk factors. RESULTS There were 1,769 incident HF events, including 1,359 hospitalized/fatal HF events. In fully adjusted causal mediation analysis, the relative change in eGFR mediated 18% of the effect of chlorthalidone, and 33% of lisinopril on incident symptomatic HF, and 25% of the effect of chlorthalidone, and 41% of lisinopril on hospitalized/fatal HF. In participants with diabetes, the relative change in eGFR mediated nearly 50% of the effect of lisinopril on incident symptomatic HF, whereas in diabetes-free participants, only 17%. CONCLUSIONS On the risk difference scale, change in eGFR accounts for up to 50% of the mechanism by which antihypertensive medications affect HF. (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial [ALLHAT]; NCT00000542).
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Johnson K, Oparil S, Davis BR, Tereshchenko LG. Prevention of Heart Failure in Hypertension-Disentangling the Role of Evolving Left Ventricular Hypertrophy and Blood Pressure Lowering: The ALLHAT Study. J Am Heart Assoc 2020; 8:e011961. [PMID: 30943832 PMCID: PMC6507192 DOI: 10.1161/jaha.119.011961] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Hypertension is a known risk factor for heart failure (HF), possibly via the mechanism of cardiac remodeling and left ventricular hypertrophy (LVH). We studied the extent to which blood pressure (BP) change and evolving LVH contribute to the effect that lisinopril, doxazosin, and amlodipine have on HF compared with chlorthalidone. Methods and Results We conducted causal mediation analysis of ALLHAT (Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial) data (1994‐2002; in‐trial follow‐up). ALLHAT participants with available serial ECGs and BP measurements were included (n=29 892; mean age 67±4 years; 32% black; 56% men): 11 008 were randomized to chlorthalidone, 5967 to doxazosin, 6593 to amlodipine, and 6324 to lisinopril. Evolving ECG LVH and BP lowering served as mediators. Incident symptomatic HF was the primary outcome. Linear regression (for mediator) and logistic regression (for outcome) models were adjusted for mediator‐outcome confounders (demographic and clinical characteristics known to be associated both with both LVH/hypertension and HF). A large majority of participants (96%) had ECG LVH status unchanged, but 4% developed evolving ECG LVH. On average, BP decreased by 11/7 mm Hg. In adjusted Cox regression analyses, progressing ECG LVH (hazard ratio [HR] 1.78 [95% CI 1.43‐2.22]), resolving ECG LVH (HR 1.33 [95% CI 1.03‐1.70]), and baseline ECG LVH (1.17 [95% CI 1.04‐1.31]) carried risk of incident HF. After full adjustment, evolving ECG LVH mediated 4% of the effect of doxazosin on HF. Systolic BP lowering mediated 12% of the effect of doxazosin, and diastolic BP lowering mediated 10% of the effect of doxazosin, 7% of the effect of amlodipine, and borderline 9% of the effect of lisinopril on HF. Conclusions Evolving ECG LVH and BP change account for 4% to 13% of the mechanism by which antihypertensive medications prevent HF. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542. See Editorial Ferdinand and Maraboto
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Affiliation(s)
- Kyle Johnson
- The Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
| | - Suzanne Oparil
- Department of MedicineSchool of MedicineUniversity of Alabama at BirminghamAL
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Jafarnejad S, Mirzaei H, Clark CCT, Taghizadeh M, Ebrahimzadeh A. The hypotensive effect of salt substitutes in stage 2 hypertension: a systematic review and meta-analysis. BMC Cardiovasc Disord 2020; 20:98. [PMID: 32106813 PMCID: PMC7047420 DOI: 10.1186/s12872-020-01347-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 01/20/2020] [Indexed: 12/11/2022] Open
Abstract
Background Hypertension (HTN) is a ubiquitous risk factor for numerous non-communicable diseases, including cardiovascular disease and stroke. There are currently no wholly effective pharmacological therapies for subjects with HTN. However, salt substitutes have emerged as a potential therapy for the treatment of HTN. The aim of the present study was to assess the effect of salt substitutes on reducing systolic blood pressure (SBP) and diastolic BP (DBP), following a meta-analysis of randomized controlled trials. Methods Studies were found via systematic searches of the Pubmed/Medline, Scopus, Ovid, Google Scholar and Cochrane library. Ten studies, comprised of 11 trials and 1119 participants, were included in the meta-analysis. Results Pooled weighted mean differences showed significant reductions of SBP (WMD − 8.87 mmHg; 95% CI − 11.19, − 6.55, p < 0.001) and DBP (WMD − 4.04 mmHg; 95% CI − 5.70, − 2.39) with no statistically significant heterogeneity between the 11 included comparisons of SBPs and DBPs. The stratified analysis of trials based on the mean age of participants showed a significant reduction in the mean difference of SBP in both adults (< 65 years old) and elderly (≥65 years old). However, the DBP-lowering effect of salt substitutes was only observed in adult patients (WMD − 4.22 mmHg; 95% CI − 7.85, − 0.58), but not in the elderly subjects. Conclusions These findings suggest that salt-substitution strategies could be used for lowering SBP and DBP in patients with stage 2 HTN; providing a nutritional platform for the treatment, amelioration, and prevention of HTN.
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Affiliation(s)
- Sadegh Jafarnejad
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan, University of Medical Sciences, Kashan, IR, Iran.
| | - Hamed Mirzaei
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan, University of Medical Sciences, Kashan, IR, Iran
| | - Cain C T Clark
- Centre for Sport, Exercise, and Life Sciences, Coventry University, Coventry, UK
| | - Mohsen Taghizadeh
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan, University of Medical Sciences, Kashan, IR, Iran
| | - Armin Ebrahimzadeh
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan, University of Medical Sciences, Kashan, IR, Iran
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Jafarnejad S, Salek M, Clark CCT. Cocoa Consumption and Blood Pressure in Middle-Aged and Elderly Subjects: a Meta-Analysis. Curr Hypertens Rep 2020; 22:1. [DOI: 10.1007/s11906-019-1005-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Segar MW, Vaduganathan M, Patel KV, McGuire DK, Butler J, Fonarow GC, Basit M, Kannan V, Grodin JL, Everett B, Willett D, Berry J, Pandey A. Machine Learning to Predict the Risk of Incident Heart Failure Hospitalization Among Patients With Diabetes: The WATCH-DM Risk Score. Diabetes Care 2019; 42:2298-2306. [PMID: 31519694 PMCID: PMC7364669 DOI: 10.2337/dc19-0587] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/05/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To develop and validate a novel, machine learning-derived model to predict the risk of heart failure (HF) among patients with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS Using data from 8,756 patients free at baseline of HF, with <10% missing data, and enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, we used random survival forest (RSF) methods, a nonparametric decision tree machine learning approach, to identify predictors of incident HF. The RSF model was externally validated in a cohort of individuals with T2DM using the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). RESULTS Over a median follow-up of 4.9 years, 319 patients (3.6%) developed incident HF. The RSF models demonstrated better discrimination than the best performing Cox-based method (C-index 0.77 [95% CI 0.75-0.80] vs. 0.73 [0.70-0.76] respectively) and had acceptable calibration (Hosmer-Lemeshow statistic χ2 = 9.63, P = 0.29) in the internal validation data set. From the identified predictors, an integer-based risk score for 5-year HF incidence was created: the WATCH-DM (Weight [BMI], Age, hyperTension, Creatinine, HDL-C, Diabetes control [fasting plasma glucose], QRS Duration, MI, and CABG) risk score. Each 1-unit increment in the risk score was associated with a 24% higher relative risk of HF within 5 years. The cumulative 5-year incidence of HF increased in a graded fashion from 1.1% in quintile 1 (WATCH-DM score ≤7) to 17.4% in quintile 5 (WATCH-DM score ≥14). In the external validation cohort, the RSF-based risk prediction model and the WATCH-DM risk score performed well with good discrimination (C-index = 0.74 and 0.70, respectively), acceptable calibration (P ≥0.20 for both), and broad risk stratification (5-year HF risk range from 2.5 to 18.7% across quintiles 1-5). CONCLUSIONS We developed and validated a novel, machine learning-derived risk score that integrates readily available clinical, laboratory, and electrocardiographic variables to predict the risk of HF among outpatients with T2DM.
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Affiliation(s)
- Matthew W Segar
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Kershaw V Patel
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Mujeeb Basit
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Vaishnavi Kannan
- Department of Health System Information Resources (Clinical Informatics), University of Texas Southwestern Medical Center, Dallas, TX
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Brendan Everett
- Brigham and Women's Hospital Heart and Vascular Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Duwayne Willett
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jarett Berry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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11
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Abstract
Hypertension (HTN) is a major modifiable risk factor for cardiovascular disease (CVD) morbidity and mortality. The left ventricle (LV) is a primary target for HTN end-organ damage. In addition to being a marker of HTN, LV geometrical changes: concentric remodeling, concentric or eccentric LV hypertrophy (LVH) are major independent risk factors for not only CVD morbidity and mortality but also for all-cause mortality and neurological pathologies. Blood pressure control with lifestyle changes and antihypertensive agents has been demonstrated to prevent and regress LVH. Herein, we provide a comprehensive review of literature on the relationship between HTN and LV geometry abnormalities with a focus on diagnosis, prognosis, pathophysiological mechanisms, and treatment approaches.
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12
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Bowling CB, Davis BR, Luciano A, Simpson LM, Sloane R, Pieper CF, Einhorn PT, Oparil S, Muntner P. Sustained blood pressure control and coronary heart disease, stroke, heart failure, and mortality: An observational analysis of ALLHAT. J Clin Hypertens (Greenwich) 2019; 21:451-459. [PMID: 30864748 DOI: 10.1111/jch.13515] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 12/31/2022]
Abstract
Achieving blood pressure (BP) control is associated with lower cardiovascular disease (CVD) risk, but less is known about CVD risk associated with sustained BP control over time. This observational analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was restricted to participants with four to seven visits with systolic BP (SBP) measurements during a 22-month period (n = 24 309). The authors categorized participants as having sustained BP control (SBP < 140 mm Hg) at 100%, 75% to <100%, 50% to <75%, and <50% of visits during this period. Outcomes included fatal coronary heart disease (CHD)/nonfatal myocardial infarction (MI), stroke, heart failure (HF), a composite CVD outcome (fatal CHD/nonfatal MI, stroke, or HF), and mortality. Hazard ratios (HRs) for the association of category of sustained BP control for each outcome were obtained using proportional hazards models. SBP control was present among 20.0% of participants at 100%, 16.4% at 75% to less than 100%, 27.0% at 50% to less than 75%, and 36.6% at less than 50% of visits. Compared to those with SBP control at 100% visits, adjusted HR (95% CI) among those with SBP control at <50% of visits was 1.16 (0.93-1.44) for fatal CHD/nonfatal MI, 1.71 (1.26-2.32) for stroke, 1.63 (1.30-2.06) for HF, 1.39 (1.20-1.62) for the composite CVD outcome, and 1.14 (0.99-1.30) for mortality. Sustained SBP control may be beneficial for preventing stroke, HF, and CVD outcomes in adults taking antihypertensive medication.
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Affiliation(s)
- C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, North Carolina.,Department of Medicine, Duke University, Durham, North Carolina
| | - Barry R Davis
- The University of Texas School of Public Health, Houston, Texas
| | - Alison Luciano
- Center for Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Lara M Simpson
- The University of Texas School of Public Health, Houston, Texas
| | - Richard Sloane
- Center for Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Carl F Pieper
- Center for Study of Aging and Human Development, Duke University, Durham, North Carolina.,Deptartment of Biostatistics and BioInformtics, Duke University, Durham, North Carolina
| | - Paula T Einhorn
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
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13
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Aubiniere-Robb L, McKay G. Diltiazem. PRACTICAL DIABETES 2018. [DOI: 10.1002/pdi.2200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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Bansal N, Zelnick LR, Himmelfarb J, Chertow GM. Bioelectrical Impedance Analysis Measures and Clinical Outcomes in CKD. Am J Kidney Dis 2018; 72:662-672. [PMID: 29885923 DOI: 10.1053/j.ajkd.2018.03.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/27/2018] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Bioelectrical impedance analysis (BIA) provides a noninvasive assessment of body composition. BIA measures of cell integrity (phase angle) and hydration (vector length) have been associated with mortality among patients receiving dialysis. Whether these measures are associated with clinical outcomes in patients with chronic kidney disease (CKD) is unknown. STUDY DESIGN Observational study. SETTINGS & PARTICIPANTS We studied 3,751 participants with CKD in the prospective multicenter Chronic Renal Insufficiency Cohort (CRIC) who had baseline single-frequency BIA performed. PREDICTORS Predictors included phase angle and vector length, which were calculated from measurements of resistance and reactance from BIA. We ranked phase angle and vector length into quartiles and compared the 2 narrower quartiles of phase angle and shorter quartiles of vector length with the 2 upper quartiles. OUTCOMES Mortality, heart failure, atherosclerotic cardiovascular disease, and progression of CKD (30% decline in estimated glomerular filtration rate or end-stage kidney disease). ANALYTIC APPROACH We tested associations of phase angle and vector length with risks for mortality and progression of CKD using Cox proportional hazard models and the association with heart failure and atherosclerotic cardiovascular disease using Fine and Gray models. All models were adjusted for demographics, comorbid conditions, and kidney function. RESULTS Mean phase angle and vector length were 6.6°±1.8° and 470 ± 96 Ω/m, respectively. Relative to phase angle ≥ 6.40o, narrower phase angle (<5.59o) was significantly associated with mortality (HR, 1.31; 95% CI, 1.09-1.58). Relative to vector length ≥ 459 Ω/m, shorter vector length (<401 Ω/m) was significantly associated with heart failure (HR, 1.28; 95% CI, 1.01-1.61). Neither measure was associated with atherosclerotic cardiovascular disease or a composite renal end point. LIMITATIONS Observational study. CONCLUSIONS Adjusted for key confounders, BIA-derived measures of cellular integrity and tissue hydration were significantly associated with death and incident heart failure, respectively.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA.
| | - Leila R Zelnick
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Jonathan Himmelfarb
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
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15
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Jackevicius CA, Ghaznavi Z, Lu L, Warner AL. Safety of Alpha-Adrenergic Receptor Antagonists in Heart Failure. JACC-HEART FAILURE 2018; 6:917-925. [PMID: 30316936 DOI: 10.1016/j.jchf.2018.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 06/18/2018] [Accepted: 06/26/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Cynthia A Jackevicius
- Department of Pharmacy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, California; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacy, University Health Network, Toronto, Ontario, Canada.
| | - Zunera Ghaznavi
- Division of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Lingyun Lu
- Department of Pharmacy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Alberta L Warner
- Division of Cardiology, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California
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16
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Bansal N, Xie D, Sha D, Appel LJ, Deo R, Feldman HI, He J, Jamerson K, Kusek JW, Messe S, Navaneethan SD, Rahman M, Ricardo AC, Soliman EZ, Townsend R, Go AS. Cardiovascular Events after New-Onset Atrial Fibrillation in Adults with CKD: Results from the Chronic Renal Insufficiency Cohort (CRIC) Study. J Am Soc Nephrol 2018; 29:2859-2869. [PMID: 30377231 DOI: 10.1681/asn.2018050514] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 09/03/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF), the most common sustained arrhythmia in CKD, is associated with poor clinical outcomes in both patients without CKD and patients with dialysis-treated ESRD. However, less is known about AF-associated outcomes in patients with CKD who do not require dialysis. METHODS To prospectively examine the association of new-onset AF with subsequent risks of cardiovascular disease events and death among adults with CKD, we studied participants enrolled in the Chronic Renal Insufficiency Cohort Study who did not have AF at baseline. Outcomes included heart failure, myocardial infarction, stroke, and death occurring after diagnosis of AF. We used Cox regression models and marginal structural models to examine the association of incident AF with subsequent risk of cardiovascular disease events and death, adjusting for patient characteristics, laboratory values, and medication use. RESULTS Among 3080 participants, 323 (10.5%) developed incident AF during a mean 6.1 years of follow-up. Compared with participants who did not develop AF, those who did had higher adjusted rates of heart failure (hazard ratio [HR], 5.17; 95% confidence interval [95% CI], 3.89 to 6.87), myocardial infarction (HR, 3.64; 95% CI, 2.50 to 5.31), stroke (HR, 2.66; 95% CI, 1.50 to 4.74), and death (HR, 3.30; 95% CI, 2.65 to 4.12). These associations remained robust with additional adjustment for biomarkers of inflammation, cardiac stress, and mineral metabolism; left ventricular mass; ejection fraction; and left atrial diameter. CONCLUSIONS Incident AF is independently associated with two- to five-fold increased rates of developing subsequent heart failure, myocardial infarction, stroke, or death in adults with CKD. These findings have important implications for cardiovascular risk reduction.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington;
| | - Dawei Xie
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daohang Sha
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lawrence J Appel
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Rajat Deo
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Harold I Feldman
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jiang He
- Department of Medicine, Tulane University, New Orleans, Louisiana
| | - Kenneth Jamerson
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - John W Kusek
- National Institutes of Health, Bethesda, Maryland
| | - Steven Messe
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Mahboob Rahman
- Department of Medicine, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | | | - Elsayed Z Soliman
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Raymond Townsend
- Departments of Medicine and Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan S Go
- Kaiser Permanente Northern California, Oakland, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California; and.,Department of Health Research and Policy, Stanford University, Stanford, California
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17
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Tuegel C, Katz R, Alam M, Bhat Z, Bellovich K, de Boer I, Brosius F, Gadegbeku C, Gipson D, Hawkins J, Himmelfarb J, Ju W, Kestenbaum B, Kretzler M, Robinson-Cohen C, Steigerwalt S, Bansal N. GDF-15, Galectin 3, Soluble ST2, and Risk of Mortality and Cardiovascular Events in CKD. Am J Kidney Dis 2018; 72:519-528. [PMID: 29866459 DOI: 10.1053/j.ajkd.2018.03.025] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/20/2018] [Indexed: 12/28/2022]
Abstract
RATIONALE & OBJECTIVE Inflammation, cardiac remodeling, and fibrosis may explain in part the excess risk for cardiovascular disease (CVD) in patients with chronic kidney disease (CKD). Growth differentiation factor 15 (GDF-15), galectin 3 (Gal-3), and soluble ST2 (sST2) are possible biomarkers of these pathways in patients with CKD. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS Individuals with CKD enrolled in either of 2 multicenter CKD cohort studies: the Seattle Kidney Study or C-PROBE (Clinical Phenotyping and Resource Biobank Study). EXPOSURES Circulating GDF-15, Gal-3, and sST2 measured at baseline. OUTCOMES Primary outcome was all-cause mortality. Secondary outcomes included hospitalization for physician-adjudicated heart failure and the atherosclerotic CVD events of myocardial infarction and cerebrovascular accident. ANALYTIC APPROACH Cox proportional hazards models used to test the association of each biomarker with each outcome, adjusting for demographics, CVD risk factors, and kidney function. RESULTS Among 883 participants, mean estimated glomerular filtration rate was 49±19mL/min/1.73m2. Higher GDF-15 (adjusted HR [aHR] per 1-SD higher, 1.87; 95% CI, 1.53-2.29), Gal-3 (aHR per 1-SD higher, 1.51; 95% CI, 1.36-1.78), and sST2 (aHR per 1-SD higher, 1.36; 95% CI, 1.17-1.58) concentrations were significantly associated with mortality. Only GDF-15 level was also associated with heart failure events (HR per 1-SD higher, 1.56; 95% CI, 1.12-2.16). There were no detectable associations between GDF-15, Gal-3, or sST2 concentrations and atherosclerotic CVD events. LIMITATIONS Event rates for heart failure and atherosclerotic CVD were low. CONCLUSIONS Adults with CKD and higher circulating GDF-15, Gal-3, and sST2 concentrations experienced greater mortality. Elevated GDF-15 concentration was also associated with an increased rate of heart failure. Further work is needed to elucidate the mechanisms linking these circulating biomarkers with CVD in patients with CKD.
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Affiliation(s)
- Courtney Tuegel
- Department of Medicine, University of Washington, Seattle, WA
| | - Ronit Katz
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Mariam Alam
- Department of Medicine, University of Washington, Seattle, WA
| | - Zeenat Bhat
- Nephrology Program, Wayne State University, Detroit, MI
| | | | - Ian de Boer
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Frank Brosius
- Nephrology Program, University of Michigan, Ann Arbor, MI
| | | | - Debbie Gipson
- Nephrology Program, University of Michigan, Ann Arbor, MI
| | | | - Jonathan Himmelfarb
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Wenjun Ju
- Nephrology Program, University of Michigan, Ann Arbor, MI
| | - Bryan Kestenbaum
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | | | | | | | - Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA.
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18
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Bansal N, McCulloch CE, Lin F, Alper A, Anderson AH, Cuevas M, Go AS, Kallem R, Kusek JW, Lora CM, Lustigova E, Ojo A, Rahman M, Robinson-Cohen C, Townsend RR, Wright J, Xie D, Hsu CY. Blood Pressure and Risk of Cardiovascular Events in Patients on Chronic Hemodialysis: The CRIC Study (Chronic Renal Insufficiency Cohort). Hypertension 2017; 70:435-443. [PMID: 28674037 PMCID: PMC5521215 DOI: 10.1161/hypertensionaha.117.09091] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 02/07/2017] [Accepted: 05/02/2017] [Indexed: 12/22/2022]
Abstract
We recently reported a linear association between higher systolic blood pressure (SBP) and risk of mortality in hemodialysis patients when SBP is measured outside of the dialysis unit (out-of-dialysis-unit-SBP), despite there being a U-shaped association between SBP measured at the dialysis unit (dialysis-unit-SBP) with risk of mortality. Here, we explored the relationship between SBP with cardiovascular events, which has important treatment implications but has not been well elucidated. Among 383 hemodialysis participants enrolled in the prospective CRIC study (Chronic Renal Insufficiency Cohort), multivariable splines and Cox models were used to study the association between SBP and adjudicated cardiovascular events (heart failure, myocardial infarction, ischemic stroke, and peripheral artery disease), controlling for differences in demographics, cardiovascular disease risk factors, and dialysis parameters. Dialysis-unit-SBP and out-of-dialysis-unit-SBP were modestly correlated (r=0.34; P<0.001). We noted a U-shaped association of dialysis-unit-SBP and risk of cardiovascular events, with the nadir risk between 140 and 170 mm Hg. In contrast, there was a linear stepwise association between out-of-dialysis-unit-SBP with risk of cardiovascular events. Participants with out-of-dialysis-unit-SBP ≥128 mm Hg (top 2 quartiles) had >2-fold increased risk of cardiovascular events compared with those with out-of-dialysis-unit-SBP ≤112 mm Hg (3rd SBP quartile: adjusted hazard ratio, 2.08 [95% confidence interval, 1.12-3.87] and fourth SBP quartile: adjusted hazard ratio, 2.76 [95% confidence interval, 1.42-5.33]). In conclusion, among hemodialysis patients, although there is a U-shaped (paradoxical) association of dialysis-unit-SBP and risk of cardiovascular disease, there is a linear association of out-of-dialysis-unit-SBP with risk of cardiovascular disease. Out-of-dialysis-unit blood pressure provides key information and may be an important therapeutic target.
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Affiliation(s)
- Nisha Bansal
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.).
| | - Charles E McCulloch
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Feng Lin
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Arnold Alper
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Amanda H Anderson
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Magda Cuevas
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Alan S Go
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Radhakrishna Kallem
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - John W Kusek
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Claudia M Lora
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Eva Lustigova
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Akinlolu Ojo
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Mahboob Rahman
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Cassianne Robinson-Cohen
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Raymond R Townsend
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Jackson Wright
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Dawei Xie
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
| | - Chi-Yuan Hsu
- From the Division of Nephrology, University of Washington (N.B., C.R.-C.); Department of Biostatistics and Epidemiology (C.E.M., F.L.), Division of Nephrology (C.-y.H), University of California, San Francisco; Division of Nephrology, Tulane University (A.A., E.L.); Department of Epidemiology and Biostatistics (A.H.A., M.C., D.X.), Division of Nephrology (R.K., R.R.T.), Perelman School of Medicine, University of Pennsylvania; Kaiser Permanente Northern California Division of Research (A.S.G., C.-y.H.); National Institute of Diabetes and Digestive and Kidney Diseases (J.W.K.); Division of Nephrology, University of Chicago, Illinois (C.M.L.); Division of Nephrology, University of Arizona (A.O.); and Division of Nephrology (M.R.), Division of Cardiology (J.W.), Case Western Reserve University (M.R., J.W.)
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Bozkurt B, Aguilar D, Deswal A, Dunbar SB, Francis GS, Horwich T, Jessup M, Kosiborod M, Pritchett AM, Ramasubbu K, Rosendorff C, Yancy C. Contributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e535-e578. [DOI: 10.1161/cir.0000000000000450] [Citation(s) in RCA: 182] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bansal N, McCulloch CE, Lin F, Robinson-Cohen C, Rahman M, Kusek JW, Anderson AH, Xie D, Townsend RR, Lora CM, Wright J, Go AS, Ojo A, Alper A, Lustigova E, Cuevas M, Kallem R, Hsu CY. Different components of blood pressure are associated with increased risk of atherosclerotic cardiovascular disease versus heart failure in advanced chronic kidney disease. Kidney Int 2016; 90:1348-1356. [PMID: 27717485 DOI: 10.1016/j.kint.2016.08.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 07/25/2016] [Accepted: 08/11/2016] [Indexed: 11/24/2022]
Abstract
Blood pressure is a modifiable risk for cardiovascular disease (CVD). Among hemodialysis patients, there is a U-shaped association between blood pressure and risk of death. However, few studies have examined the association between blood pressure and CVD in patients with stage 4 and 5 chronic kidney disease. Here we studied 1795 Chronic Renal Insufficiency Cohort (CRIC) Study participants with estimated glomerular filtration rate <30 ml/min per 1.73 m2 and not on dialysis. The association of systolic (SBP), diastolic (DBP), and pulse pressure with the risk of physician-adjudicated atherosclerotic CVD (stroke, myocardial infarction, or peripheral arterial disease) and heart failure was tested using Cox regression adjusted for demographics, comorbidity and medications. There was a significant association with higher SBP (adjusted hazard ratio 2.04 [95% confidence interval: 1.46-2.84]) for SBP over 140 vs under 120 mmHg, higher DBP (2.52 [1.54-4.11]) for DBP >90 mm Hg versus <80 mm Hg and higher pulse pressure (2.67 [1.82-3.92]) for pulse pressure >68 mm Hg versus <51 mm Hg with atherosclerotic CVD. For heart failure, there was a significant association with higher pulse pressure only (1.42 [1.05-1.92]) for pulse pressure >68 mm Hg versus <51 mmHg, but not for SBP or DBP. Thus, among participants with stage 4 and 5 chronic kidney disease, there was an independent association between higher SBP, DBP, and pulse pressure with the risk of atherosclerotic CVD, whereas only higher pulse pressure was independently associated with a greater risk of heart failure. Further trials are needed to determine whether aggressive reduction of blood pressure decreases the risk of CVD events in patients with stage 4 and 5 chronic kidney disease.
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Affiliation(s)
- Nisha Bansal
- Department of Medicine, University of Washington, Seattle, Washington, USA.
| | - Charles E McCulloch
- Department of Biostatistics and Epidemiology, University of California, San Francisco, San Francisco, California, USA
| | - Feng Lin
- Department of Biostatistics and Epidemiology, University of California, San Francisco, San Francisco, California, USA
| | | | - Mahboob Rahman
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - John W Kusek
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Amanda H Anderson
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dawei Xie
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raymond R Townsend
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Claudia M Lora
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Jackson Wright
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Division of Research, Oakland, California, USA
| | - Akinlolu Ojo
- Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Arnold Alper
- Department of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Eva Lustigova
- School of Public Health, Tulane University, New Orleans, Louisiana, USA
| | - Magda Cuevas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Radhakrishna Kallem
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chi-Yuan Hsu
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA; Department of Medicine, Kaiser Permanente Division of Research, Oakland, California, USA
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21
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Alderman MH, Davis BR, Piller LB, Ford CE, Baraniuk MS, Pressel SL, Assadi MA, Einhorn PT, Haywood LJ, Ilamathi E, Oparil S, Retta TM. Should Antihypertensive Treatment Recommendations Differ in Patients With and Without Coronary Heart Disease? (from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial [ALLHAT]). Am J Cardiol 2016; 117:105-15. [PMID: 26589819 PMCID: PMC4690772 DOI: 10.1016/j.amjcard.2015.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 10/09/2015] [Accepted: 10/09/2015] [Indexed: 01/13/2023]
Abstract
Thiazide-type diuretics have been recommended for initial treatment of hypertension in most patients, but should this recommendation differ for patients with and without coronary heart disease (CHD)? The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized, double-blind hypertension treatment trial in 42,418 participants with high risk of combined cardiovascular disease (CVD) (25% with preexisting CHD). This post hoc analysis compares long-term major clinical outcomes in those assigned amlodipine (n = 9048) or lisinopril (n = 9,054) with those assigned chlorthalidone (n = 15,255), stratified by CHD status. After 4 to 8 years, randomized treatment was discontinued. Total follow-up (active treatment + passive surveillance using national databases for deaths and hospitalizations) was 8 to 13 years. For most CVD outcomes, end-stage renal disease, and total mortality, there were no differences across randomized treatment arms regardless of baseline CHD status. In-trial rates of CVD were significantly higher for lisinopril compared with chlorthalidone, and rates of heart failure were significantly higher for amlodipine compared with chlorthalidone in those with and without CHD (overall hazard ratios [HRs] 1.10, p <0.001, and 1.38, p <0.001, respectively). During extended follow-up, significant outcomes according to CHD status interactions (p = 0.012) were noted in amlodipine versus chlorthalidone comparison for CVD and CHD mortality (HR 0.88, p = 0.04, and 0.84, p = 0.04, respectively) in those with CHD at baseline (HR 1.06, p = 0.15, and 1.08, p = 0.17) and in those without. The results of the overall increased stroke mortality in lisinopril compared with chlorthalidone (HR 1.2; p = 0.03) and hospitalized heart failure in amlodipine compared with chlorthalidone (HR 1.12; p = 0.01) during extended follow-up did not differ by baseline CHD status. In conclusion, these results provide no reason to alter our previous recommendation to include a properly dosed diuretic (such as chlorthalidone 12.5 to 25 mg/day) in the initial antihypertensive regimen for most hypertensive patients.
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Affiliation(s)
- Michael H Alderman
- Department of Epidemiology & Population Health, Department of Medicine (General Internal Medicine), Albert Einstein College of Medicine, Bronx, New York
| | - Barry R Davis
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas
| | - Linda B Piller
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas.
| | - Charles E Ford
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas
| | - M Sarah Baraniuk
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas
| | - Sara L Pressel
- The University of Texas School of Public Health, Coordinating Center for Clinical Trials, Houston, Texas
| | - Mahshid A Assadi
- State University of New York Health Sciences Center at Brooklyn, Brooklyn, New York
| | - Paula T Einhorn
- Division of Prevention and Population Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - L Julian Haywood
- LAC + USC Medical Center, Keck School of Medicine, Los Angeles, California
| | | | - Suzanne Oparil
- Department of Medicine and Physiology & Biophysics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tamrat M Retta
- Department of Medicine, Howard University College of Medicine, Washington, District of Columbia
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Patanè S. Is there a role for quinazoline-based α (1)-adrenoceptor antagonists in cardio-oncology? Cardiovasc Drugs Ther 2015; 28:587-8. [PMID: 25230599 DOI: 10.1007/s10557-014-6552-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Salvatore Patanè
- Cardiologia Ospedale San Vincenzo - Taormina (Me) Azienda Sanitaria Provinciale di Messina, Contrada Sirina, 98039, Taormina, ME, Italy, patane-@libero.it
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23
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Blood pressure control and cardiovascular outcomes in normal-weight, overweight, and obese hypertensive patients treated with three different antihypertensives in ALLHAT. J Hypertens 2015; 32:1503-13; discussion 1513. [PMID: 24842697 DOI: 10.1097/hjh.0000000000000204] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Epidemiologically, there is a strong relationship between BMI and blood pressure (BP) levels. We prospectively examined randomization to first-step chlorthalidone, a thiazide-type diuretic; amlodipine, a calcium-channel blocker; and lisinopril, an angiotensin-converting enzyme inhibitor, on BP control and cardiovascular outcomes in a hypertensive cohort stratified by baseline BMI [kg/m(2); normal weight (BMI <25), overweight (BMI = 25-29.9), and obese (BMI >30)]. METHODS In a randomized, double-blind, practice-based Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, 33,357 hypertensive participants, aged at least 55 years, were followed for an average of 4.9 years, for a primary outcome of fatal coronary heart disease or nonfatal myocardial infarction, and secondary outcomes of stroke, heart failure, combined cardiovascular disease, mortality, and renal failure. RESULTS Of participants, 37.9% were overweight and 42.1% were obese at randomization. For each medication, BP control (<140/90 mmHg) was equivalent in each BMI stratum. At the fifth year, 66.1, 66.5, and 65.1% of normal-weight, overweight, and obese participants, respectively, were controlled. Those randomized to chlorthalidone had highest BP control (67.2, 68.3, and 68.4%, respectively) and to lisinopril the lowest (60.4, 63.2, and 59.6%, respectively) in each BMI stratum. A significant interaction (P = 0.004) suggests a lower coronary heart disease risk in the obese for lisinopril versus chlorthalidone (hazard ratio 0.85, 95% confidence interval 0.74-0.98) and a significant interaction (P = 0.011) suggests a higher risk of end-stage renal disease for amlodipine versus chlorthalidone in obese participants (hazard ratio 1.49, 95% confidence interval 1.06-2.08). However, these results were not consistent among other outcomes. CONCLUSION BMI status does not modify the effects of antihypertensive medications on BP control or cardiovascular disease outcomes.
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Liu KD, Yang W, Go AS, Anderson AH, Feldman HI, Fischer MJ, He J, Kallem RR, Kusek JW, Master SR, Miller ER, Rosas SE, Steigerwalt S, Tao K, Weir MR, Hsu CY. Urine neutrophil gelatinase-associated lipocalin and risk of cardiovascular disease and death in CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis 2015; 65:267-74. [PMID: 25311702 PMCID: PMC4353671 DOI: 10.1053/j.ajkd.2014.07.025] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 07/28/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic kidney disease is common and is associated with increased cardiovascular disease risk. Currently, markers of renal tubular injury are not used routinely to describe kidney health and little is known about the risk of cardiovascular events and death associated with these biomarkers independent of glomerular filtration-based markers (such as serum creatinine or albuminuria). STUDY DESIGN Cohort study, CRIC (Chronic Renal Insufficiency Cohort) Study. SETTING & PARTICIPANTS 3,386 participants with estimated glomerular filtration rate of 20 to 70mL/min/1.73m(2) enrolled from June 2003 through August 2008. PREDICTOR Urine neutrophil gelatinase-associated lipocalin (NGAL) concentration. OUTCOMES Adjudicated heart failure event, ischemic atherosclerotic event (myocardial infarction, ischemic stroke, or peripheral artery disease), and death through March 2011. MEASUREMENTS Urine NGAL measured at baseline with a 2-step assay using chemiluminescent microparticle immunoassay technology on an ARCHITECT i2000SR (Abbott Laboratories). RESULTS There were 428 heart failure events (during 16,383 person-years of follow-up), 361 ischemic atherosclerotic events (during 16,584 person-years of follow-up), and 522 deaths (during 18,214 person-years of follow-up). In Cox regression models adjusted for estimated glomerular filtration rate, albuminuria, demographics, traditional cardiovascular disease risk factors, and cardiac medications, higher urine NGAL levels remained associated independently with ischemic atherosclerotic events (adjusted HR for the highest [>49.5ng/mL] vs lowest [≤6.9ng/mL] quintile, 1.83 [95% CI, 1.20-2.81]; HR per 0.1-unit increase in log urine NGAL, 1.012 [95% CI, 1.001-1.023]), but not heart failure events or deaths. LIMITATIONS Urine NGAL was measured only once. CONCLUSIONS Among patients with chronic kidney disease, urine levels of NGAL, a marker of renal tubular injury, were associated independently with future ischemic atherosclerotic events, but not with heart failure events or deaths.
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Affiliation(s)
- Kathleen D Liu
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Wei Yang
- Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Amanda H Anderson
- Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Harold I Feldman
- Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Michael J Fischer
- Department of Medicine, Jesse Brown VAMC and University of Illinois Hospital and Health Sciences System, Chicago, IL
| | - Jiang He
- Department of Epidemiology, Tulane University, New Orleans, LA
| | - Radhakrishna R Kallem
- Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - John W Kusek
- The National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Stephen R Master
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - Edgar R Miller
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Sylvia E Rosas
- Department of Medicine, Joslin Diabetes Center & Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Susan Steigerwalt
- St. Claire Specialty Physicians, St. John Hospital & Medical Center, Detroit, MI
| | - Kaixiang Tao
- Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Matthew R Weir
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Chi-Yuan Hsu
- Department of Medicine, University of California, San Francisco, San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA.
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Kwon BJ, Kim DB, Jang SW, Yoo KD, Moon KW, Shim BJ, Ahn SH, Cho EJ, Rho TH, Kim JH. Prognosis of heart failure patients with reduced and preserved ejection fraction and coexistent chronic obstructive pulmonary disease. Eur J Heart Fail 2014; 12:1339-44. [DOI: 10.1093/eurjhf/hfq157] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Beom-June Kwon
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
| | - Dong-Bin Kim
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
| | - Sung-Won Jang
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
| | - Ki-Dong Yoo
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
| | - Keun-Woong Moon
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
| | - Byung Ju Shim
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
| | - Seo-Hee Ahn
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
| | - Eun-Ju Cho
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
| | - Tae-Ho Rho
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
| | - Jae-Hyung Kim
- Division of Cardiology, Department of Internal Medicine, College of Medicine; The Catholic University of Korea; Seoul 130-709 Republic of Korea
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Genetic and Adverse Health Outcome Associations with Treatment Resistant Hypertension in GenHAT. Int J Hypertens 2013; 2013:578578. [PMID: 24288596 PMCID: PMC3833110 DOI: 10.1155/2013/578578] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 09/18/2013] [Indexed: 12/16/2022] Open
Abstract
Treatment resistant hypertension (TRH) is defined as uncontrolled hypertension (HTN) despite the use of ≥3 antihypertensive medication classes or controlled HTN while treated with ≥4 antihypertensive medication classes. Risk factors for TRH include increasing age, diminished kidney function, higher body mass index, diabetes, and African American (AA) race. Importantly, previous studies suggest a genetic role in TRH, although the genetics of TRH are largely understudied. With 2203 treatment resistant cases and 2354 treatment responsive controls (36% AA) from the Genetics of Hypertension Associated Treatment Study (GenHAT), we assessed the association of 78 candidate gene polymorphisms with TRH status using logistic regression. After stratifying by race and adjusting for potential confounders, there were 2 genetic variants in the AGT gene (rs699, rs5051) statistically significantly associated with TRH among white participants. The Met allele of rs699 and the G allele of rs5051 were positively associated with TRH: OR = 1.27 (1.12-1.44), P = 0.0001, and OR = 1.36 (1.20-1.53), P < 0.0001, respectively. There was no similar association among AA participants (race interaction P = 0.0004 for rs699 and P = 0.0001 for rs5051). This research contributes to our understanding of the genetic basis of TRH, and further genetic studies of TRH may help reach the goal of better clinical outcomes for hypertensive patients.
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Carta F, Supuran CT. Diuretics with carbonic anhydrase inhibitory action: a patent and literature review (2005 - 2013). Expert Opin Ther Pat 2013; 23:681-91. [PMID: 23488823 DOI: 10.1517/13543776.2013.780598] [Citation(s) in RCA: 221] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The benzothiadiazines and high ceiling diuretics (hydrochlorothiazide, hydroflumethiazide, quinethazone, metolazone, chlorthalidone, indapamide, furosemide and bumetanide) contain primary sulfamoyl moieties acting as zinc-binding groups in the metalloenzyme carbonic anhydrase (CA, EC 4.2.1.1). These drugs are widely used clinically and were recently shown to weakly inhibit isoforms CA I and II, but to possess stronger activity against isoforms involved in other important pathologies, for example, obesity, cancer, epilepsy and hypertension. AREAS COVERED The class of clinically used diuretics, with CA inhibitory properties, is the main topic of the review. A patent literature review covering the period from 2005 to 2013 is presented. EXPERT OPINION This section presents an overview of the patent literature in the sulfonamide diuretic field. Most of the patents deal with the combination of diuretic sulfonamide CA inhibitors with other agents useful in the management of cardiovascular diseases and obesity. Such combinations exert a better therapeutic activity compared to similar diuretics that do not inhibit CAs, raising the question of the polypharmacological and drug repositioning effects of these old drugs. These effects seem to be due to the potent inhibition of such drugs against CA isoforms present in kidneys and blood vessels, which explain both the blood pressure lowering effects as well as organ-protective activity of the drugs. An explanation of these data is provided by the fact that inhibition of the renal CAs leads to a large increase of the nitrite excretion in urine, suggesting that renal CAs are involved in nitrite reabsorption in humans. Important lessons for the drug design of sulfonamide CA inhibitors (CAIs) can be drawn from these data.
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Affiliation(s)
- Fabrizio Carta
- Università degli Studi di Firenze, Laboratorio di Chimica Bioinorganica, Rm. 188, Via della Lastruccia 3, I-50019 Sesto Fiorentino (Firenze), Italy
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Potentially inappropriate medications in the elderly: a comprehensive protocol. Eur J Clin Pharmacol 2012; 68:1123-38. [PMID: 22362342 DOI: 10.1007/s00228-012-1238-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Accepted: 01/31/2012] [Indexed: 01/04/2023]
Abstract
Elderly patients are at increased risk of drug-related morbidity and mortality. Avoiding the use of potentially inappropriate medications (PIMs) is one of the strategies that has been widely adopted to reduce the harmful consequences of drug use. There are several PIM screening tools available. In this review, we provide an overview of existing screening tools to detect PIMs in the elderly, emphasizing the advantages and disadvantages of each. Combining previously published and adopted tools (adjusted Beers list, French consensus panel, McLeod's list, and Lindblad's list of clinically important drug-disease interactions), we develop a new comprehensive tool that also includes the adjusted Hanlon's and Malone's lists of potentially serious drug-drug interactions in the elderly. In addition to listed PIMs and clinically important drug-drug interactions, alternative therapeutic solutions are suggested. The new protocol differentiates: drugs with an unfavorable benefit/risk ratio (to be avoided regardless of the underlying disease/condition), drugs with a questionable efficacy, and drugs to be avoided with certain diseases/conditions, and provides a list of potentially serious drug-drug interactions. A tool consisting of PIMs and potential drug-drug interactions within the same protocol provides more comprehensive quality assessment of drug-prescribing behavior to the elderly, which in turn may lead to better prescribing practices.
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Fragasso G, Maranta F, Montanaro C, Salerno A, Torlasco C, Margonato A. Pathophysiologic therapeutic targets in hypertension: a cardiological point of view. Expert Opin Ther Targets 2012; 16:179-93. [DOI: 10.1517/14728222.2012.655724] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Piller LB, Baraniuk S, Simpson LM, Cushman WC, Massie BM, Einhorn PT, Oparil S, Ford CE, Graumlich JF, Dart RA, Parish DC, Retta TM, Cuyjet AB, Jafri SZ, Furberg CD, Saklayen MG, Thadani U, Probstfield JL, Davis BR. Long-term follow-up of participants with heart failure in the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). Circulation 2011; 124:1811-8. [PMID: 21969009 DOI: 10.1161/circulationaha.110.012575] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind, practice-based, active-control, comparative effectiveness trial in high-risk hypertensive participants, risk of new-onset heart failure (HF) was higher in the amlodipine (2.5-10 mg/d) and lisinopril (10-40 mg/d) arms compared with the chlorthalidone (12.5-25 mg/d) arm. Similar to other studies, mortality rates following new-onset HF were very high (≥50% at 5 years), and were similar across randomized treatment arms. After the randomized phase of the trial ended in 2002, outcomes were determined from administrative databases. METHODS AND RESULTS With the use of national databases, posttrial follow-up mortality through 2006 was obtained on participants who developed new-onset HF during the randomized (in-trial) phase of ALLHAT. Mean follow-up for the entire period was 8.9 years. Of 1761 participants with incident HF in-trial, 1348 died. Post-HF all-cause mortality was similar across treatment groups, with adjusted hazard ratios (95% confidence intervals) of 0.95 (0.81-1.12) and 1.05 (0.89-1.25), respectively, for amlodipine and lisinopril compared with chlorthalidone, and 10-year adjusted rates of 86%, 87%, and 83%, respectively. All-cause mortality rates were also similar among those with reduced ejection fractions (84%) and preserved ejection fractions (81%), with no significant differences by randomized treatment arm. CONCLUSIONS Once HF develops, risk of death is high and consistent across randomized treatment groups. Measures to prevent the development of HF, especially blood pressure control, must be a priority if mortality associated with the development of HF is to be addressed. Clinical Trial Registration- http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
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Affiliation(s)
- Linda B Piller
- University of Texas School of Public Health, Houston, TX 77030, USA.
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Abstract
KEY POINTS AND PRACTICAL RECOMMENDATIONS: • α Antagonists lower blood pressure by selectively blocking post-synaptic α(1) -adrenoreceptors, which antagonizes catecholamine-induced constriction of the arterial and venous vascular beds. • α(1) -Adrenoreceptor antagonists are not indicated for initial, first-line antihypertensive therapy; however, they can be added to most other antihypertensive drug classes in--preferably diuretic-containing--drug regimens. • When used over time, these agents cause expansion of the extracellular fluid and plasma volumes that typically manifests as weight gain and an attenuation of the blood pressure-lowering efficacy in persons who are consuming usual amounts of dietary sodium. • Utilization of α(1) -adrenoreceptor antagonists with diuretics such as chlorthalidone or hydrochlorothiazide is beneficial because these agents minimize the α antagonist-induced expansion of the extracellular and plasma volumes while providing significant incremental reductions in blood pressure. • α(1) -Adrenoreceptor antagonists are especially useful in men with benign prostatic hypertrophy because they increase mean and peak urinary flow rates as well as reduce lower urinary tract symptoms. • α(1) -Adrenoreceptor antagonists are contraindicated in persons with heart failure because of their aforementioned ability to expand extracellular and plasma volumes.
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Affiliation(s)
- Richard H Grimm
- Cardiolgy and Epidemiology, University of Minnesota, Minneapolis, MN, USA.
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Medicare's Coverage With Evidence Development: A Policy-Making Tool in Evolution. J Oncol Pract 2011; 3:296-301. [PMID: 20859385 DOI: 10.1200/jop.0763501] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
PURPOSE OF REVIEW The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is re-evaluated considering information from recent subgroup and exploratory analyses, other new clinical trials, and meta-analyses. The ALLHAT analyses specifically emphasize heart failure findings, results in Black participants and those with chronic kidney disease, selection and doses of thiazide and similar diuretics, and the association of antihypertensive drug use with new-onset diabetes and its cardiovascular consequences. RECENT FINDINGS The initial ALLHAT conclusion, that thiazide diuretics are superior to angiotensin-converting enzyme inhibitors (ACEIs), calcium antagonists (CCBs) and alpha-blockers in preventing one or more major clinical outcomes, including heart failure and stroke, and unsurpassed in significantly preventing any cardiovascular or renal outcome, has been further validated for patients with diabetes, renal disease, and/or metabolic syndrome. The evidence is even more compelling for Black patients. New-onset diabetes associated with thiazides did not increase cardiovascular outcomes. The diuretic was superior to all in preventing heart failure with preserved left-ventricular ejection fraction (LVEF) and similar to the ACEI in preventing heart failure with impaired LVEF. It was also unsurpassed in preventing atrial fibrillation. SUMMARY The totality of evidence re-affirms the initial ALLHAT conclusion that thiazide and similar diuretics (at evidence-based doses) are the preferred first-step therapy in most patients with hypertension.
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Grossman E, Verdecchia P, Shamiss A, Angeli F, Reboldi G. Diuretic treatment of hypertension. Diabetes Care 2011; 34 Suppl 2:S313-9. [PMID: 21525475 PMCID: PMC3632199 DOI: 10.2337/dc11-s246] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ehud Grossman
- Internal Medicine D and Hypertension Unit, The Chaim Sheba Medical Center, Tel-Hashomer, affiliated with Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Einhorn PT. National heart, lung, and blood institute-initiated program "interventions to improve hypertension control rates in African Americans": background and implementation. Circ Cardiovasc Qual Outcomes 2010; 2:236-40. [PMID: 20031843 DOI: 10.1161/circoutcomes.109.850008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Paula T Einhorn
- Division of Prevention and Population Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
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Weber MA, Black H, Bakris G, Krum H, Linas S, Weiss R, Linseman JV, Wiens BL, Warren MS, Lindholm LH. A selective endothelin-receptor antagonist to reduce blood pressure in patients with treatment-resistant hypertension: a randomised, double-blind, placebo-controlled trial. Lancet 2009; 374:1423-31. [PMID: 19748665 DOI: 10.1016/s0140-6736(09)61500-2] [Citation(s) in RCA: 207] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypertension cannot always be adequately controlled with available drugs. We investigated the blood-pressure-lowering effects of the new vasodilatory, selective endothelin type A antagonist, darusentan, in patients with treatment-resistant hypertension. METHODS This randomised, double-blind study was undertaken in 117 sites in North and South America, Europe, New Zealand, and Australia. 379 patients with systolic blood pressure of 140 mm Hg or more (>/=130 mm Hg if patient had diabetes or chronic kidney disease) who were receiving at least three blood-pressure-lowering drugs, including a diuretic, at full or maximum tolerated doses were randomly assigned to 14 weeks' treatment with placebo (n=132) or darusentan 50 mg (n=81), 100 mg (n=81), or 300 mg (n=85) taken once daily. Randomisation was made centrally via an automated telephone system, and patients and all investigators were masked to treatment assignments. The primary endpoints were changes in sitting systolic and diastolic blood pressures. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number NCT00330369. FINDINGS All randomly assigned participants were analysed. The mean reductions in clinic systolic and diastolic blood pressures were 9/5 mm Hg (SD 14/8) with placebo, 17/10 mm Hg (15/9) with darusentan 50 mg, 18/10 mm Hg (16/9) with darusentan 100 mg, and 18/11 mm Hg (18/10) with darusentan 300 mg (p<0.0001 for all effects). The main adverse effects were related to fluid accumulation. Oedema or fluid retention occurred in 67 (27%) patients given darusentan compared with 19 (14%) given placebo. One patient in the placebo group died (sudden cardiac death), and five patients in the three darusentan dose groups combined had cardiac-related serious adverse events. INTERPRETATION Darusentan provides additional reduction in blood pressure in patients who have not attained their treatment goals with three or more antihypertensive drugs. As with other vasodilatory drugs, fluid management with effective diuretic therapy might be needed. FUNDING Gilead Sciences.
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Affiliation(s)
- Michael A Weber
- State University of New York, Downstate College of Medicine, New York, NY 11203, USA.
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Massie BM. Prevention of Heart Failure With Chlorthalidone in ALLHAT: Placing the Results Into Perspective. J Clin Hypertens (Greenwich) 2009; 11:462-5. [DOI: 10.1111/j.1751-7176.2009.00169.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Barry M. Massie
- From the Department of Medicine, University of California, San Francisco, CA
- Cardiology Division, San Francisco VAMC, San Francisco, CA
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Grimm RH, Davis BR, Piller LB, Cutler JA, Margolis KL, Barzilay J, Dart RA, Graumlich JF, Murden RA, Randall OS. Heart failure in ALLHAT: did blood pressure medication at study entry influence outcome? J Clin Hypertens (Greenwich) 2009; 11:466-74. [PMID: 19751458 PMCID: PMC2788785 DOI: 10.1111/j.1751-7176.2009.00149.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Accepted: 05/28/2009] [Indexed: 01/28/2023]
Abstract
J Clin Hypertens (Greenwich). 2009;11:466-474. (c)2009 Wiley Periodicals, Inc.Lower heart failure (HF) rates in individuals taking chlorthalidone vs amlodipine, lisinopril, or doxazosin were unanticipated in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). HF differences appeared early, leading to questions about the possible influence of pre-enrollment antihypertensive drugs. A post hoc study evaluated hospitalized HF events. During year 1479 individuals had HF, with pre-entry antihypertensive medication data obtained on 301 patients (63%). Case-only analysis examined interactive effects (interaction odds ratio [OR, ratio of ORs]) of previous medication and ALLHAT treatment on HF outcomes, eg, did treatment effect differ by pre-entry antihypertensive class? Among cases, 39%, 37%, 17%, and 47% were taking pre-entry diuretics, angiotensin-converting enzyme inhibitors, beta-blockers, and calcium channel blockers, respectively. Interaction OR for year 1 HF for amlodipine vs chlorthalidone for patients taking vs not taking diuretics pre-entry was 1.08 (95% confidence interval [CI], 0.53-2.21; P=.83); for lisinopril vs chlorthalidone, 1.33 (95% CI, 0.65-2.74; P=.44); and for doxazosin vs chlorthalidone, 1.13 (95% CI, 0.57-2.25; P=.73). Controlling for other pre-entry antihypertensives yielded similar results. There was no significant evidence that pre-entry drug type explained observed hospitalized HF differences by ALLHAT treatment.
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Affiliation(s)
- Richard H. Grimm
- From the Department of Internal Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Barry R. Davis
- The University of Texas School of Public Health, Houston, TX
| | - Linda B. Piller
- The University of Texas School of Public Health, Houston, TX
| | | | | | | | - Richard A. Dart
- the Department of Nephrology and Hypertension, Marshfield Clinic, Marshfield, WI
| | - James F. Graumlich
- the Department of Medicine, University of Illinois College of Medicine, Peoria, IL
| | - Robert A. Murden
- the Department of Internal Medicine, Ohio State University, Columbus, OH
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Abstract
In patients with arterial hypertension and/or high cardiovascular risk, including patients with diabetes, chronic ischemic heart disease and kidney disease, the risk of heart failure decreases with blood pressure reduction and the use of drugs that inhibit the renin-angiotensin system (RAS) [angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)]. The heart failure incidence seen in ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) and Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) is in line with this observation. In ONTARGET, telmisartan and ramipril were equally effective in heart failure prevention and with the same blood pressure reduction. The low event rate, including the low incidence of heart failure in TRANSCEND with the greater use of diuretics in the placebo arm, may help to explain the absence of significant differences between telmisartan and placebo.
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Wright JT, Probstfield JL, Cushman WC, Pressel SL, Cutler JA, Davis BR, Einhorn PT, Rahman M, Whelton PK, Ford CE, Haywood LJ, Margolis KL, Oparil S, Black HR, Alderman MH. ALLHAT findings revisited in the context of subsequent analyses, other trials, and meta-analyses. ACTA ACUST UNITED AC 2009; 169:832-42. [PMID: 19433694 DOI: 10.1001/archinternmed.2009.60] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is reevaluated considering information from new clinical trials, meta-analyses, and recent subgroup and explanatory analyses from ALLHAT, especially those regarding heart failure (HF) and the association of drug treatment with new-onset diabetes mellitus (DM) and its cardiovascular disease (CVD) consequences. Chlorthalidone was superior to (1) doxazosin mesylate in preventing combined CVD (CCVD) (risk ratio [RR], 1.20; 95% confidence interval [CI], 1.13-1.27), especially HF (RR, 1.80; 95% CI, 1.40-2.22) and stroke (RR, 1.26; 95% CI, 1.10-1.46); (2) lisinopril in preventing CCVD (RR, 1.10; 95% CI, 1.05-1.16), including stroke (in black persons only) and HF (RR, 1.20; 95% CI, 1.09-1.34); and (3) amlodipine besylate in preventing HF, overall (by 28%) and in hospitalized or fatal cases (by 26%). Central independent blinded reassessment of HF hospitalizations confirmed each comparison. Results were consistent by age, sex, race (except for stroke and CCVD), DM status, metabolic syndrome status, and renal function level. Neither amlodipine nor lisinopril was superior to chlorthalidone in preventing end-stage renal disease overall, by DM status, or by renal function level. In the chlorthalidone arm, new-onset DM was not significantly associated with CCVD (RR, 0.96; 95% CI, 0.88-2.42). Evidence from subsequent analyses of ALLHAT and other clinical outcome trials confirm that neither alpha-blockers, angiotensin-converting enzyme inhibitors, nor calcium channel blockers surpass thiazide-type diuretics (at appropriate dosage) as initial therapy for reduction of cardiovascular or renal risk. Thiazides are superior in preventing HF, and new-onset DM associated with thiazides does not increase CVD outcomes.
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Affiliation(s)
- Jackson T Wright
- ALLHAT Clinical Trials Center, University of Texas at Houston Health Science Center School of Public Health, 1200 Herman Pressler Street, Houston, TX 77030, USA
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Solun B, Marcoviciu D, Dicker D. Does treatment of hypertension decrease the incidence of atrial fibrillation and cardioembolic stroke? Eur J Intern Med 2009; 20:125-31. [PMID: 19327599 DOI: 10.1016/j.ejim.2008.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 07/08/2008] [Accepted: 07/10/2008] [Indexed: 11/25/2022]
Abstract
Hypertension is the most common disease affecting humans. Statistical surveys indicate that approximately one billion individuals worldwide suffer from this serious condition. The spotlight of the present review is on the cardiac involvement in patients with hypertension and especially on the possibility that treatment of increased blood pressure may abolish the incidence of cardiac arrhythmia and particularly atrial fibrillation. Modern therapeutic approach based on the electrical and structural remodeling process in the hypertensive heart with a consequent administration of ACE inhibitors and AT1 receptor blockers represent new and more efficient option compared to other antihypertensive drugs, such as calcium channel blockers, beta-blockers and thiazide-type diuretics and might be useful in the prevention of atrial fibrillation and incidence of stroke.
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Affiliation(s)
- B Solun
- Department of Internal Medicine A and D, Rabin Medical Center, Hasharon Hospital, Petah Tiqva, Israel
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Protective effects of renin–angiotensin blockade beyond blood pressure control. J Hum Hypertens 2009; 23:570-7. [DOI: 10.1038/jhh.2008.171] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kenchaiah S, Sesso HD, Gaziano JM. Body mass index and vigorous physical activity and the risk of heart failure among men. Circulation 2008; 119:44-52. [PMID: 19103991 DOI: 10.1161/circulationaha.108.807289] [Citation(s) in RCA: 213] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Elevated body mass index (BMI; weight in kilograms divided by height in meters squared) in the obese range (> or =30 kg/m(2)) is associated with an excess risk of heart failure (HF). However, the impact of overweight or preobese (BMI, 25 to 29.9 kg/m(2)) status and physical activity on HF risk is unclear. METHODS AND RESULTS In a prospective cohort of 21,094 men (mean age, 53 years) without known coronary heart disease at baseline in the Physicians' Health Study, we examined the individual and combined effects of BMI and vigorous physical activity (exercise to the point of breaking a sweat) on HF incidence from 1982 to 2007. We evaluated BMI as both a continuous (per 1-kg/m(2) increment) and a categorical (lean, <25 kg/m(2); overweight, 25 to 29.9 kg/m(2); and obese, > or =30 kg/m(2)) variable; we evaluated vigorous physical activity primarily as a dichotomous variable (inactive [rarely/never] versus active [> or =1 to 3 times a month]). During follow-up (mean, 20.5 years), 1109 participants developed new-onset HF. In multivariable analyses, every 1-kg/m(2) increase in BMI was associated with an 11% (95% confidence interval [CI], 9 to 13) increase in HF risk. Compared with lean participants, overweight participants had a 49% (95% CI, 32 to 69) and obese participants had a 180% (95% CI, 124 to 250) increase in HF risk. Vigorous physical activity conferred an 18% (95% CI, 4 to 30) decrease in HF risk. No interaction was found between BMI and vigorous physical activity and HF risk (P=0.96). Lean active men had the lowest and obese inactive men had the highest risk of HF. Compared with lean active men, the hazard ratios were 1.19 (95% CI, 0.94 to 1.51), 1.49 (95% CI, 1.30 to 1.71), 1.78 (95% CI, 1.43 to 2.23), 2.68 (95% CI, 2.08 to 3.45), and 3.93 (95% CI, 2.60 to 5.96) in lean inactive, overweight active, overweight inactive, obese active, and obese inactive men, respectively. CONCLUSIONS In this cohort of men, elevated BMI, even in the preobese range, was associated with an increased risk of HF, and vigorous physical activity was associated with a decreased risk. Public health measures to curtail excess weight, to maintain optimal weight, and to promote physical activity may limit the scourge of HF.
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Affiliation(s)
- Satish Kenchaiah
- Physicians' Health Study, Brigham and Women's Hospital, Boston, MA 02215, USA.
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Massie BM, Carson PE, McMurray JJ, Komajda M, McKelvie R, Zile MR, Anderson S, Donovan M, Iverson E, Staiger C, Ptaszynska A. Irbesartan in patients with heart failure and preserved ejection fraction. N Engl J Med 2008; 359:2456-67. [PMID: 19001508 DOI: 10.1056/nejmoa0805450] [Citation(s) in RCA: 1369] [Impact Index Per Article: 85.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Approximately 50% of patients with heart failure have a left ventricular ejection fraction of at least 45%, but no therapies have been shown to improve the outcome of these patients. Therefore, we studied the effects of irbesartan in patients with this syndrome. METHODS We enrolled 4128 patients who were at least 60 years of age and had New York Heart Association class II, III, or IV heart failure and an ejection fraction of at least 45% and randomly assigned them to receive 300 mg of irbesartan or placebo per day. The primary composite outcome was death from any cause or hospitalization for a cardiovascular cause (heart failure, myocardial infarction, unstable angina, arrhythmia, or stroke). Secondary outcomes included death from heart failure or hospitalization for heart failure, death from any cause and from cardiovascular causes, and quality of life. RESULTS During a mean follow-up of 49.5 months, the primary outcome occurred in 742 patients in the irbesartan group and 763 in the placebo group. Primary event rates in the irbesartan and placebo groups were 100.4 and 105.4 per 1000 patient-years, respectively (hazard ratio, 0.95; 95% confidence interval [CI], 0.86 to 1.05; P=0.35). Overall rates of death were 52.6 and 52.3 per 1000 patient-years, respectively (hazard ratio, 1.00; 95% CI, 0.88 to 1.14; P=0.98). Rates of hospitalization for cardiovascular causes that contributed to the primary outcome were 70.6 and 74.3 per 1000 patient-years, respectively (hazard ratio, 0.95; 95% CI, 0.85 to 1.08; P=0.44). There were no significant differences in the other prespecified outcomes. CONCLUSIONS Irbesartan did not improve the outcomes of patients with heart failure and a preserved left ventricular ejection fraction. (ClinicalTrials.gov number, NCT00095238.)
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Affiliation(s)
- Barry M Massie
- University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco 94121, USA.
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Chapman N, Chang CL, Dahlöf B, Sever PS, Wedel H, Poulter NR. Effect of Doxazosin Gastrointestinal Therapeutic System as Third-Line Antihypertensive Therapy on Blood Pressure and Lipids in the Anglo-Scandinavian Cardiac Outcomes Trial. Circulation 2008; 118:42-8. [PMID: 18559700 DOI: 10.1161/circulationaha.107.737957] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The role of doxazosin in treatment of hypertension remains controversial.
Methods and Results—
We evaluated the effects on blood pressure (BP) and biochemical parameters of doxazosin GITS (gastrointestinal therapeutic system) as a third-line antihypertensive agent among 10 069 participants in the Anglo-Scandinavian Cardiac Outcomes Trial–Blood Pressure Lowering Arm (ASCOT-BPLA) whose BP remained above 140/90 mm Hg (130/80 mm Hg in those with diabetes mellitus). Among those who received doxazosin, mean age was 63 years (SD 9 years), 79% were male, and 32% had diabetes. Doxazosin was initiated a median of 8 months (interquartile range 3 to 24 months) after randomization and was added to a mean of 2.0 (SD 0.3) other antihypertensive drugs; the mean starting and final doses were 4.1 (SD 0.6) and 7.0 (SD 3.1) mg, respectively. During a median of 12 months (interquartile range 4 to 31 months) of uninterrupted doxazosin treatment, during which other antihypertensive treatments remained unchanged, mean BP fell 11.7/6.9 mm Hg (SD 18.8/9.6 mm Hg,
P
<0.0001) from 158.7/89.2 mm Hg (SD 18.3/10.6 mm Hg). After the addition of doxazosin, 29.7% of participants achieved target BP. There was no apparent excess of heart failure among doxazosin users. There were associated modest favorable effects on plasma lipid profiles, but a small rise in fasting plasma glucose was observed. Doxazosin was generally well tolerated, with 7.5% of participants discontinuing the drug because of adverse events, most frequently dizziness, fatigue, headache, and edema.
Conclusions—
α-Blockers are no longer recommended as add-on therapy in some hypertension guidelines. However, although they are nonrandomized and were not placebo-controlled, the present findings suggest that doxazosin is a safe and effective third-line antihypertensive agent.
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Affiliation(s)
- Neil Chapman
- From the Imperial College (N.C., C.L.C., P.S.S., N.R.P.), London, United Kingdom; Sahlgrenska University Hospital (B.D.), Göteborg, Sweden; and Nordic School of Public Health (H.W.), Göteborg, Sweden
| | - Choon Lan Chang
- From the Imperial College (N.C., C.L.C., P.S.S., N.R.P.), London, United Kingdom; Sahlgrenska University Hospital (B.D.), Göteborg, Sweden; and Nordic School of Public Health (H.W.), Göteborg, Sweden
| | - Björn Dahlöf
- From the Imperial College (N.C., C.L.C., P.S.S., N.R.P.), London, United Kingdom; Sahlgrenska University Hospital (B.D.), Göteborg, Sweden; and Nordic School of Public Health (H.W.), Göteborg, Sweden
| | - Peter S. Sever
- From the Imperial College (N.C., C.L.C., P.S.S., N.R.P.), London, United Kingdom; Sahlgrenska University Hospital (B.D.), Göteborg, Sweden; and Nordic School of Public Health (H.W.), Göteborg, Sweden
| | - Hans Wedel
- From the Imperial College (N.C., C.L.C., P.S.S., N.R.P.), London, United Kingdom; Sahlgrenska University Hospital (B.D.), Göteborg, Sweden; and Nordic School of Public Health (H.W.), Göteborg, Sweden
| | - Neil R. Poulter
- From the Imperial College (N.C., C.L.C., P.S.S., N.R.P.), London, United Kingdom; Sahlgrenska University Hospital (B.D.), Göteborg, Sweden; and Nordic School of Public Health (H.W.), Göteborg, Sweden
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Cutler JA, Davis BR. Thiazide-type diuretics and beta-adrenergic blockers as first-line drug treatments for hypertension. Circulation 2008; 117:2691-704; discussion 2705. [PMID: 18490537 PMCID: PMC2897820 DOI: 10.1161/circulationaha.107.709931] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Albert NM. Heart failure with preserved systolic function: giving well-deserved attention to the "other" heart failure. Crit Care Nurs Q 2007; 30:287-96; quiz 297-8. [PMID: 17873564 DOI: 10.1097/01.cnq.0000290361.72924.a4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Heart failure with preserved systolic function is common in patients hospitalized with decompensated heart failure and is associated with postdischarge morbidity and costs similar to patients with heart failure and systolic dysfunction. It is common in the older people, and hypertension and cardiac ischemia are often etiological factors. Nurses must be able to recognize left ventricular diastolic abnormalities and understand treatment priorities and treatment options on the basis of structural cardiovascular disease; etiology and risk factors; and signs, symptoms, and hemodynamic parameters. Currently, clinical treatments are on the basis of individual randomized clinical trials; however, there are general principles that should be followed during hospitalization and as part of general practice. As in the treatment of systolic heart failure, nurses have active roles in ensuring accurate assessment; optimal care planning; implementation of clinical, psychosocial; and education interventions; and timely and accurate evaluation so that patients have the best chance for successful hospital and postdischarge outcomes.
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Affiliation(s)
- Nancy M Albert
- Division of Nursing and Kaufman Center for Heart Failure, Cleveland Clinic, Ohio 44195, USA.
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Abstract
Background—
Heart failure (HF) developing in hypertensive patients may occur with preserved or reduced left ventricular ejection fraction (PEF [≥50%] or REF [<50%]). In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), 42 418 high-risk hypertensive patients were randomized to chlorthalidone, amlodipine, lisinopril, or doxazosin, providing an opportunity to compare these treatments with regard to occurrence of hospitalized HFPEF or HFREF.
Methods and Results—
HF diagnostic criteria were prespecified in the ALLHAT protocol. EF estimated by contrast ventriculography, echocardiography, or radionuclide study was available in 910 of 1367 patients (66.6%) with hospitalized events meeting ALLHAT criteria. Cox regression models adjusted for baseline characteristics were used to examine treatment differences for HF (overall and by PEF and REF). HF case fatality rates were examined. Of those with EF data, 44.4% had HFPEF and 55.6% had HFREF. Chlorthalidone reduced the risk of HFPEF compared with amlodipine, lisinopril, or doxazosin; the hazard ratios were 0.69 (95% confidence interval [CI], 0.53 to 0.91;
P
=0.009), 0.74 (95% CI, 0.56 to 0.97;
P
=0.032), and 0.53 (95% CI, 0.38 to 0.73;
P
<0.001), respectively. Chlorthalidone reduced the risk of HFREF compared with amlodipine or doxazosin; the hazard ratios were 0.74 (95% CI, 0.59 to 0.94;
P
=0.013) and 0.61 (95% CI, 0.47 to 0.79;
P
<0.001), respectively. Chlorthalidone was similar to lisinopril with regard to incidence of HFREF (hazard ratio, 1.07; 95% CI, 0.82 to 1.40;
P
=0.596). After HF onset, death occurred in 29.2% of participants (chlorthalidone/amlodipine/lisinopril) with new-onset HFPEF versus 41.9% in those with HFREF (
P
<0.001; median follow-up, 1.74 years); and in the chlorthalidone/doxazosin comparison that was terminated early, 20.0% of HFPEF and 26.0% of HFREF patients died (
P
=0.185; median follow-up, 1.55 years).
Conclusions—
In ALLHAT, with adjudicated outcomes, chlorthalidone significantly reduced the occurrence of new-onset hospitalized HFPEF and HFREF compared with amlodipine and doxazosin. Chlorthalidone also reduced the incidence of new-onset HFPEF compared with lisinopril. Among high-risk hypertensive men and women, HFPEF has a better prognosis than HFREF.
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