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Zoccali C, Mallamaci F, Halimi JM, Rossignol P, Sarafidis P, De Caterina R, Giugliano R, Zannad F. From Cardiorenal Syndrome to Chronic Cardiovascular and Kidney Disorder: A Conceptual Transition. Clin J Am Soc Nephrol 2024; 19:813-820. [PMID: 37902772 PMCID: PMC11168830 DOI: 10.2215/cjn.0000000000000361] [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: 08/20/2023] [Accepted: 10/23/2023] [Indexed: 10/31/2023]
Abstract
The association between cardiac and kidney dysfunction has received attention over the past two decades. A putatively unique syndrome, the cardiorenal syndrome, distinguishing five subtypes on the basis of the chronology of cardiac and kidney events, has been widely adopted. This review discusses the methodologic and practical problems inherent to the current classification of cardiorenal syndrome. The term "disorder" is more appropriate than the term "syndrome" to describe concomitant cardiovascular and kidney dysfunction and/or damage. Indeed, the term disorder designates a disruption induced by disease states to the normal function of organs or organ systems. We apply Occam's razor to the chronology-based construct to arrive at a simple definition on the basis of the coexistence of cardiovascular disease and CKD, the chronic cardiovascular-kidney disorder (CCKD). This conceptual framework builds upon the fact that cardiovascular and CKD share common risk factors and pathophysiologic mechanisms. Biological changes set in motion by kidney dysfunction accelerate cardiovascular disease progression and vice versa . Depending on various combinations of risk factors and precipitating conditions, patients with CCKD may present initially with cardiovascular disease or with hallmarks of CKD. Treatment targeting cardiovascular or kidney dysfunction may improve the outcomes of both. The portfolio of interventions targeting the kidney-cardiovascular continuum is in an expanding phase. In the medium term, applying the new omics sciences may unravel new therapeutic targets and further improve the therapy of CCKD. Trials based on cardiovascular and kidney composite end points are an attractive and growing area. Targeting pathways common to cardiovascular and kidney diseases will help prevent the adverse health effects of CCKD.
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Affiliation(s)
- Carmine Zoccali
- Renal Research Institute, New York and Institute of Molecular Biology and Genetics (Biogem), Ariano Irpino, Italy
- Associazione Ipertensione Nefrologia Trapianto Renal (IPNET), c/o Nefrologia, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | - Francesca Mallamaci
- Nefrologia and CNR Unit, Grande Ospedale Metropolitano, Reggio Calabria, Italy
| | | | - Patrick Rossignol
- Inserm, Centre d'Investigations Cliniques-1433, Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
- Department of Medical Specialties-Nephrology Hemodialysis, Princess Grace Hospital, Monaco Private Hemodialysis Centre, Monaco, Monaco
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Raffaele De Caterina
- University of Pisa and Cardiology Division, Pisa University Hospital, Pisa, Italy
| | | | - Faiez Zannad
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Graczyk P, Dach A, Dyrka K, Pawlik A. Pathophysiology and Advances in the Therapy of Cardiomyopathy in Patients with Diabetes Mellitus. Int J Mol Sci 2024; 25:5027. [PMID: 38732253 PMCID: PMC11084712 DOI: 10.3390/ijms25095027] [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: 03/12/2024] [Revised: 04/19/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
Diabetes mellitus (DM) is known as the first non-communicable global epidemic. It is estimated that 537 million people have DM, but the condition has been properly diagnosed in less than half of these patients. Despite numerous preventive measures, the number of DM cases is steadily increasing. The state of chronic hyperglycaemia in the body leads to numerous complications, including diabetic cardiomyopathy (DCM). A number of pathophysiological mechanisms are behind the development and progression of cardiomyopathy, including increased oxidative stress, chronic inflammation, increased synthesis of advanced glycation products and overexpression of the biosynthetic pathway of certain compounds, such as hexosamine. There is extensive research on the treatment of DCM, and there are a number of therapies that can stop the development of this complication. Among the compounds used to treat DCM are antiglycaemic drugs, hypoglycaemic drugs and drugs used to treat myocardial failure. An important element in combating DCM that should be kept in mind is a healthy lifestyle-a well-balanced diet and physical activity. There is also a group of compounds-including coenzyme Q10, antioxidants and modulators of signalling pathways and inflammatory processes, among others-that are being researched continuously, and their introduction into routine therapies is likely to result in greater control and more effective treatment of DM in the future. This paper summarises the latest recommendations for lifestyle and pharmacological treatment of cardiomyopathy in patients with DM.
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Affiliation(s)
- Patryk Graczyk
- Department of Physiology, Pomeranian Medical University, 70-111 Szczecin, Poland; (P.G.); (A.D.)
| | - Aleksandra Dach
- Department of Physiology, Pomeranian Medical University, 70-111 Szczecin, Poland; (P.G.); (A.D.)
| | - Kamil Dyrka
- Department of Pediatric Endocrinology and Rheumatology, Institute of Pediatrics, Poznan University of Medical Sciences, 60-572 Poznan, Poland;
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University, 70-111 Szczecin, Poland; (P.G.); (A.D.)
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Saito Y, Ito H, Fukagawa M, Akizawa T, Kagimura T, Yamamoto M, Kato M, Ogata H. Effect of renin-angiotensin system inhibitors on cardiovascular events in hemodialysis patients with hyperphosphatemia: A post hoc analysis of the LANDMARK trial. Ther Apher Dial 2024; 28:192-205. [PMID: 37921027 DOI: 10.1111/1744-9987.14080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/27/2023] [Accepted: 10/14/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION The clinical benefits of renin-angiotensin system inhibitors (RASi) in patients undergoing hemodialysis remain obscure. METHODS This is a post hoc cohort analysis of the LANDMARK trial investigate whether RASi use was associated with cardiovascular events (CVEs) and all-cause mortality. A total of 2135 patients at risk for vascular calcification were analyzed using a Cox proportional hazards model with propensity-score matching. RESULTS The risk of CVEs was similar between participants with RASi use at baseline and those without RASi use at baseline and between participants with RASi use during the study period and those without RASi use during the study period. No clinical benefits of RASi use on all-cause mortality were observed. Serum phosphate levels were significantly associated with the effect of RASi on CVEs. CONCLUSIONS RASi use was not significantly associated with a lower risk of CVEs or all-cause mortality in hemodialysis patients at risk of vascular calcification.
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Affiliation(s)
- Yoshinori Saito
- Division of Nephrology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Hidetoshi Ito
- Division of Nephrology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Masafumi Fukagawa
- Division of Nephrology, Endocrinology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Tadao Akizawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tatsuo Kagimura
- The Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Kobe, Hyogo, Japan
| | - Masahiro Yamamoto
- Division of Nephrology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Masanori Kato
- Division of Nephrology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
| | - Hiroaki Ogata
- Division of Nephrology, Department of Internal Medicine, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan
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Zaher W, Della Rocca DG, Pannone L, Boveda S, de Asmundis C, Chierchia GB, Sorgente A. Anti-Arrhythmic Effects of Heart Failure Guideline-Directed Medical Therapy and Their Role in the Prevention of Sudden Cardiac Death: From Beta-Blockers to Sodium-Glucose Cotransporter 2 Inhibitors and Beyond. J Clin Med 2024; 13:1316. [PMID: 38592135 PMCID: PMC10931968 DOI: 10.3390/jcm13051316] [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: 01/10/2024] [Revised: 02/14/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Sudden cardiac death (SCD) accounts for a substantial proportion of mortality in heart failure with reduced ejection fraction (HFrEF), frequently triggered by ventricular arrhythmias (VA). This review aims to analyze the pathophysiological mechanisms underlying VA and SCD in HFrEF and evaluate the effectiveness of guideline-directed medical therapy (GDMT) in reducing SCD. Beta-blockers, angiotensin receptor-neprilysin inhibitors, and mineralocorticoid receptor antagonists have shown significant efficacy in reducing SCD risk. While angiotensin-converting enzyme inhibitors and angiotensin receptor blockers exert beneficial impacts on the renin-angiotensin-aldosterone system, their direct role in SCD prevention remains less clear. Emerging treatments like sodium-glucose cotransporter 2 inhibitors show promise but necessitate further research for conclusive evidence. The favorable outcomes of those molecules on VA are notably attributable to sympathetic nervous system modulation, structural remodeling attenuation, and ion channel stabilization. A multidimensional pharmacological approach targeting those pathophysiological mechanisms offers a complete and synergy approach to reducing SCD risk, thereby highlighting the importance of optimizing GDMT for HFrEF. The current landscape of HFrEF pharmacotherapy is evolving, with ongoing research needed to clarify the full extent of the anti-arrhythmic benefits offered by both existing and new treatments.
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Affiliation(s)
- Wael Zaher
- Department of Cardiology, Centre Hospitalier EpiCURA, Route de Mons 63, 7301 Hornu, Belgium;
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, 31076 Toulouse, France;
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
| | - Antonio Sorgente
- Department of Cardiology, Centre Hospitalier EpiCURA, Route de Mons 63, 7301 Hornu, Belgium;
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Laarbeeklan 101, Jette, 1090 Brussels, Belgium; (D.G.D.R.); (L.P.); (C.d.A.); (G.-B.C.)
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Gholami SK, Heydarpour M, Williams JS, Pojoga LH, Adler GK, Williams GH, Romero JR. Striatin Gene Variants Are Associated With Salt Sensitivity of Blood Pressure by Mechanisms That Differ in Women and Men. Hypertension 2024; 81:330-339. [PMID: 38018471 PMCID: PMC10843568 DOI: 10.1161/hypertensionaha.123.21955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/06/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Salt sensitivity of blood pressure (SSBP) is a substantial risk factor for cardiovascular morbidity and mortality. Striatin (STRN) is critical for estrogen and aldosterone nongenomic signaling. However, the role of biological sex on the SSBP phenotype associated with STRN gene variants remains unexplored. METHOD Data from 1306 subjects participating in the Hypertensive Pathotype (HyperPATH) Consortium were used to identify STRN gene single-nucleotide variants associated with SSBP. Haploblock analysis revealed a novel diplotype in the upstream regulatory region of STRN (rs888083 and rs6744560), with 31% of subjects being homozygous for the risk diplotype. RESULTS Individuals homozygous for the risk diplotype had significantly greater SSBP than nonrisk diplotypes (P<0.009). While a significant genotype/SSBP association was present in both sexes, their potential mechanisms differed. Women, but not men homozygous risk diplotypes, had significantly greater aldosterone levels than nonrisk diplotypes (5.8±0.4 versus 3.2±0.7 ng/dl; P=0.01; liberal Na+ diet, adjusted). Men, but not women, homozygous risk diplotypes, had significantly reduced renal plasma flow response to Angiotensin II than nonrisk diplotypes (delta 95.2±5.2 versus 122.9±10.2 mL/min per 1.73 m2; P=0.01; liberal Na+ diet, adjusted). The single-nucleotide variants composing the risk diplotype were associated with lower STRN mRNA expression in human tissues (in silico). CONCLUSION In women, the primary driver of SSBP is increased aldosterone, while in men, it is reduced renal plasma flow responses. Thus, despite a common hypertensive phenotype (SSBP) in both sexes, the specific treatment approaches might differ to increase therapeutic gain and mitigate adverse effects. These genetic- and sex-based observational results require confirmation in a prospective clinical study.
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Affiliation(s)
- Shadi K Gholami
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| | - Mahyar Heydarpour
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| | - Jonathan S Williams
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| | - Luminita H Pojoga
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| | - Gail K Adler
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| | - Gordon H Williams
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
| | - Jose R Romero
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA
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6
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Akhtar KH, Khan MS, Baron SJ, Zieroth S, Estep J, Burkhoff D, Butler J, Fudim M. The spectrum of post-myocardial infarction care: From acute ischemia to heart failure. Prog Cardiovasc Dis 2024; 82:15-25. [PMID: 38242191 DOI: 10.1016/j.pcad.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 01/21/2024]
Abstract
Heart failure (HF) is the leading cause of mortality in patients with acute myocardial infarction (AMI), with incidence ranging from 14% to 36% in patients admitted due to AMI. HF post-MI develops due to complex inter-play between macrovascular obstruction, microvascular dysfunction, myocardial stunning and remodeling, inflammation, and neuro-hormonal activation. Cardiogenic shock is an extreme presentation of HF post-MI and is associated with a high mortality. Early revascularization is the only therapy shown to improve survival in patients with cardiogenic shock. Treatment of HF post-MI requires prompt recognition and timely introduction of guideline-directed therapies to improve mortality and morbidity. This article aims to provide an up-to-date review on the incidence and pathogenesis of HF post-MI, current strategies to prevent and treat onset of HF post-MI, promising therapeutic strategies, and knowledge gaps in the field.
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Affiliation(s)
- Khawaja Hassan Akhtar
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Suzanne J Baron
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jerry Estep
- Section of Heart Failure & Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, Columbia University Medical Center, New York City, NY, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA; Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.
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Fatima N, Ashique S, Upadhyay A, Kumar S, Kumar H, Kumar N, Kumar P. Current Landscape of Therapeutics for the Management of Hypertension - A Review. Curr Drug Deliv 2024; 21:662-682. [PMID: 37357524 DOI: 10.2174/1567201820666230623121433] [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: 09/11/2022] [Revised: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 06/27/2023]
Abstract
Hypertension is a critical health problem. It is also the primary reason for coronary heart disease, stroke, and renal vascular disease. The use of herbal drugs in the management of any disease is increasing. They are considered the best immune booster to fight against several types of diseases. To date, the demand for herbal drugs has been increasing because of their excellent properties. This review highlights antihypertensive drugs, polyphenols, and synbiotics for managing hypertension. Evidence is mounting in favour of more aggressive blood pressure control with reduced adverse effects, especially for specific patient populations. This review aimed to present contemporary viewpoints and novel treatment options, including cutting-edge technological applications and emerging interventional and pharmaceutical therapies, as well as key concerns arising from several years of research and epidemiological observations related to the management of hypertension.
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Affiliation(s)
- Neda Fatima
- Department of Pharmacology, Amity University, Lucknow Campus, Lucknow, Uttar Pradesh 226010, India
| | - Sumel Ashique
- Department of Pharmaceutics, Pandaveswar School of Pharmacy, Pandaveswar, West Bengal 713378, India
| | - Aakash Upadhyay
- Department of Pharmaceutics, Bharat Institute of Technology (BIT), School of Pharmacy, Meerut, Uttar Pradesh, 250103, India
| | - Shubneesh Kumar
- Department of Pharmaceutics, Bharat Institute of Technology (BIT), School of Pharmacy, Meerut, Uttar Pradesh, 250103, India
| | - Himanshu Kumar
- Department of Pharmaceutics, Bharat Institute of Technology (BIT), School of Pharmacy, Meerut, Uttar Pradesh, 250103, India
| | - Nitish Kumar
- SRM Modinagar College of Pharmacy, SRM Institute of Science and Technology (Deemed to be University), Delhi-NCR Campus, Modinagar, Ghaziabad, Uttar Pradesh, 201204, India
| | - Prashant Kumar
- College of Pharmacy, Teerthanker Mahaveer University, Moradabad-244001, UP, India
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Chen W, Ni M, Huang H, Cong H, Fu X, Gao W, Yang Y, Yu M, Song X, Liu M, Yuan Z, Zhang B, Wang Z, Wang Y, Chen Y, Zhang C, Zhang Y. Chinese expert consensus on the diagnosis and treatment of coronary microvascular diseases (2023 Edition). MedComm (Beijing) 2023; 4:e438. [PMID: 38116064 PMCID: PMC10729292 DOI: 10.1002/mco2.438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/11/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
Since the four working groups of the Chinese Society of Cardiology issued first expert consensus on coronary microvascular diseases (CMVD) in 2017, international consensus documents on CMVD have increased rapidly. Although some of these documents made preliminary recommendations for the diagnosis and treatment of CMVD, they did not provide classification of recommendations and levels of evidence. In order to summarize recent progress in the field of CMVD, standardize the methods and procedures of diagnosis and treatment, and identify the scientific questions for future research, the four working groups of the Chinese Society of Cardiology updated the 2017 version of the Chinese expert consensus on CMVD and adopted a series of measures to ensure the quality of this document. The current consensus has raised a new classification of CMVD, summarized new epidemiological findings for different types of CMVD, analyzed key pathological and molecular mechanisms, evaluated classical and novel diagnostic technologies, recommended diagnostic pathways and criteria, and therapeutic strategies and medications, for patients with CMVD. In view of the current progress and knowledge gaps of CMVD, future directions were proposed. It is hoped that this expert consensus will further expedite the research progress of CMVD in both basic and clinical scenarios.
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Affiliation(s)
- Wenqiang Chen
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Mei Ni
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - He Huang
- Department of CardiologySir Run Run Shaw Hospital affiliated with Zhejiang University School of MedicineHangzhouChina
| | - Hongliang Cong
- Department of CardiologyTianjin Chest Hospital, Tianjin UniversityTianjinChina
| | - Xianghua Fu
- Department of CardiologyThe Second Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wei Gao
- Department of CardiologyPeking University Third HospitalBeijingChina
| | - Yuejin Yang
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Mengyue Yu
- Department of CardiologyFuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiantao Song
- Department of CardiologyBeijing Anzhen Hospital, Capital Medical UniversityBeijingChina
| | - Meilin Liu
- Department of GeriatricsPeking University First HospitalBeijingChina
| | - Zuyi Yuan
- Department of CardiologyThe First Affiliated Hospital of Xian Jiaotong UniversityXianChina
| | - Bo Zhang
- Department of CardiologyFirst Affiliated Hospital, Dalian Medical UniversityDalianLiaoningChina
| | - Zhaohui Wang
- Department of CardiologyUnion Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhanChina
| | - Yan Wang
- Department of CardiologyXiamen Cardiovascular Hospital, Xiamen UniversityXiamenChina
| | - Yundai Chen
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China; for the Basic Research Group, Atherosclerosis and Coronary Heart Disease Group, Interventional Cardiology Group, and Women's Heart Health Group of the Chinese Society of Cardiology
| | - Cheng Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
| | - Yun Zhang
- The National Key Laboratory for Innovation and Transformation of Luobing TheoryThe Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical ScienceDepartment of CardiologyQilu Hospital of Shandong UniversityJinanShandongChina
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Akioyamen LE, Abdel-Qadir H, Han L, Sud M, Mistry N, Alter DA, Atzema CL, Austin PC, Bhatia RS, Booth GL, Dhalla I, Ha ACT, Jackevicius CA, Kapral MK, Krumholz HM, Lee DS, McNaughton CD, Roifman I, Schull MJ, Sivaswamy A, Tu K, Udell JA, Wijeysundera HC, Ko DT. Association of Neighborhood-Level Marginalization With Health Care Use and Clinical Outcomes Following Hospital Discharge in Patients Who Underwent Coronary Catheterization for Acute Myocardial Infarction in a Single-Payer Health Care System. Circ Cardiovasc Qual Outcomes 2023; 16:e010063. [PMID: 38050754 DOI: 10.1161/circoutcomes.123.010063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/06/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. METHODS Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. RESULTS Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95-1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03-1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. CONCLUSIONS In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.
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Affiliation(s)
- Leo E Akioyamen
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
| | - Husam Abdel-Qadir
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
- Women's College Hospital, Toronto, ON, Canada (H.A.-Q., J.A.U.)
| | - Lu Han
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
| | - Maneesh Sud
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Nikhil Mistry
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
| | - David A Alter
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Clare L Atzema
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Peter C Austin
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
| | - R Sacha Bhatia
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Gillian L Booth
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada (G.L.B., I.R.,)
| | - Irfan Dhalla
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
| | - Andrew C T Ha
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Cynthia A Jackevicius
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Western University of Health Sciences, Pomona, CA (C.A.J.)
| | - Moira K Kapral
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.)
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Douglas S Lee
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Candace D McNaughton
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Idan Roifman
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada (G.L.B., I.R.,)
| | - Michael J Schull
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Atul Sivaswamy
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
| | - Karen Tu
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Department of Family and Community Medicine, (K.T.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- North York General Hospital, Toronto, ON, Canada (K.T.)
| | - Jacob A Udell
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
- Women's College Hospital, Toronto, ON, Canada (H.A.-Q., J.A.U.)
| | - Harindra C Wijeysundera
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Dennis T Ko
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
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Talha KM, Greene SJ, Butler J, Khan MS. Frailty and Its Implications in Heart Failure with Reduced Ejection Fraction: Impact on Prognosis and Treatment. Cardiol Clin 2023; 41:525-536. [PMID: 37743075 DOI: 10.1016/j.ccl.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Frailty affects half of all patients with heart failure with reduced ejection fraction (HFrEF) and carries a ∼2-fold increased risk of mortality. The relationship between frailty and HFrEF is bidirectional, with one condition exacerbating the other. Paradoxical to their higher clinical risk, frail patients with HFrEF are more often under-treated due to concerns over medication-related adverse clinical events. However, current evidence suggests consistent safety of HF medical therapies among older frail patients with HFrEF. A multidisciplinary effort is necessary for the appropriate management of these high-risk patients which focuses on the optimization of known beneficial therapies with a goal-directed effort toward improving quality of life.
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Affiliation(s)
- Khawaja M Talha
- Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Stephen J Greene
- Division of Cardiology, Department of Medicine, Duke University Hospital, 2301 Erwin Road, Durham, NC 27710, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA; Baylor Scott & White Research Institute, 3434 Live Oak Street Suite 501, Dallas, TX 75204, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Department of Medicine, Duke University Hospital, 2301 Erwin Road, Durham, NC 27710, USA.
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Bhattacharjee P, Khan Z. Sacubitril/Valsartan in the Treatment of Heart Failure With Reduced Ejection Fraction Focusing on the Impact on the Quality of Life: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Cureus 2023; 15:e48674. [PMID: 38090453 PMCID: PMC10714125 DOI: 10.7759/cureus.48674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2023] [Indexed: 04/10/2024] Open
Abstract
There exists a paucity of research data reported by analyses performed on randomized clinical trials (RCTs) that encompass quality of life (QOL) and the aftermath for patients suffering from heart failure with reduced ejection fraction (HFrEF). This systematic review and meta-analysis of randomized clinical trials (RCTs) have been done to evaluate the drug sacubitril/valsartan in the treatment of heart failure (HF) with reduced ejection fraction (HFrEF) with a clear focus on the effect it bestows on measures of physical exercise tolerance and quality of life. A thorough systematic search was done in databases including Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, Embase, and PubMed from 1 January 2010 to 1 January 2023. The search only included published RCTs on adult patients aged 18 and above, with heart failure with reduced ejection fraction (HFrEF). Data analysis was performed by using the software RevMan 5.4 (Cochrane Collaboration, London, United Kingdom). The included studies' bias risk was assessed using the Cochrane Collaboration's Risk of Bias tool. The quality of evidence for the primary outcome was done using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. This systematic review and meta-analysis of RCTs yielded 458 studies, of which eight randomized clinical trials were included and analyzed. The meta-analysis of the included trials shows that the I2 value is 61% (i.e., I2 > 50%), demonstrating a substantial heterogeneity within the studies. The left ventricular ejection fraction (LVEF) expressed in percentage was reported in the five studies, and thereby, a subgroup analysis that yielded a confidence interval (CI) of 95% had the standard mean difference of 0.02 (-0.02, 0.07). The trials had disparity between the reporting of effect on peak oxygen consumption (VO2), measured through cardiopulmonary exercise testing (CPET) methods, six-minute walking test (6MWT), overall physical activity, and exercise capacity. Sacubitril/valsartan did not exponentially improve peak VO2 or 6MWT in these trials; however, the patient-reported data suggested that the quality of life was modestly influenced by the drug. A subgroup analysis was performed using the pooled effect value by the random effects model. The findings showed that the sacubitril/valsartan group significantly was better than the control group in improving HFrEF-associated health-related quality of life (HRQoL). This study is a systematic review and meta-analysis of randomized clinical trials that evaluated the drug sacubitril/valsartan in treating heart failure with reduced ejection fraction (HFrEF) and focused on its tangible effect on the measures of physical exercise tolerance and quality of life. It depicts that the statistical scrutiny due to the lack of significant data and parity across studies did not impart significant improvement of either LVEF, peak VO2, or 6MWT with the use of sacubitril/valsartan; however, the reported exercise tolerance, including daytime physical activity, had a modest impact with the said drug. The pooled values demonstrated that the sacubitril/valsartan group significantly outperformed the control group in improving HFrEF HRQoL.
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Affiliation(s)
| | - Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
- Cardiology, Barts Heart Centre, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
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12
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Abdellatif M, Rainer PP, Sedej S, Kroemer G. Hallmarks of cardiovascular ageing. Nat Rev Cardiol 2023; 20:754-777. [PMID: 37193857 DOI: 10.1038/s41569-023-00881-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2023] [Indexed: 05/18/2023]
Abstract
Normal circulatory function is a key determinant of disease-free life expectancy (healthspan). Indeed, pathologies affecting the cardiovascular system, which are growing in prevalence, are the leading cause of global morbidity, disability and mortality, whereas the maintenance of cardiovascular health is necessary to promote both organismal healthspan and lifespan. Therefore, cardiovascular ageing might precede or even underlie body-wide, age-related health deterioration. In this Review, we posit that eight molecular hallmarks are common denominators in cardiovascular ageing, namely disabled macroautophagy, loss of proteostasis, genomic instability (in particular, clonal haematopoiesis of indeterminate potential), epigenetic alterations, mitochondrial dysfunction, cell senescence, dysregulated neurohormonal signalling and inflammation. We also propose a hierarchical order that distinguishes primary (upstream) from antagonistic and integrative (downstream) hallmarks of cardiovascular ageing. Finally, we discuss how targeting each of the eight hallmarks might be therapeutically exploited to attenuate residual cardiovascular risk in older individuals.
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Affiliation(s)
- Mahmoud Abdellatif
- Department of Cardiology, Medical University of Graz, Graz, Austria.
- Centre de Recherche des Cordeliers, Equipe labellisée par la Ligue contre le cancer, Université de Paris, Sorbonne Université, Inserm U1138, Institut Universitaire de France, Paris, France.
- Metabolomics and Cell Biology Platforms, Institut Gustave Roussy, Villejuif, France.
- BioTechMed Graz, Graz, Austria.
| | - Peter P Rainer
- Department of Cardiology, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
| | - Simon Sedej
- Department of Cardiology, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- Institute of Physiology, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Guido Kroemer
- Centre de Recherche des Cordeliers, Equipe labellisée par la Ligue contre le cancer, Université de Paris, Sorbonne Université, Inserm U1138, Institut Universitaire de France, Paris, France.
- Metabolomics and Cell Biology Platforms, Institut Gustave Roussy, Villejuif, France.
- Institut du Cancer Paris CARPEM, Department of Biology, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.
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13
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Fall M, Grenet G, Le HH, Kassaï B, Lega JC, Boussageon R, Mainbourg S, Marchant I, Gafsi J, Dieye AM, Gueyffier F. [Does aspirin have a place in primary cardiovascular prevention by the polypill ? Simulation study on a realistic virtual population]. Therapie 2023; 78:667-678. [PMID: 36841655 DOI: 10.1016/j.therap.2023.01.011] [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: 11/05/2022] [Revised: 12/19/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The polypill strategy could become widely accepted in cardiovascular prevention due to reduced costs and its simplicity, which promote compliance. Aspirin is often included as a component of the polypill for primary prevention, but three powerful recent trials failed to show any favorable net benefit even in high-risk subgroups. Our objective is to estimate the net benefit associated with aspirin in primary cardiovascular prevention. METHODS We simulated the impact of different polypill compositions combining pravastatin, ramipril, hydrochlorothiazide, with or without aspirin, on a realistic French virtual population between 35 and 65 years old. We assessed how this impact on myocardial infarction and stroke varied according to gender, diabetes, and arterial hypertension. We identified the subgroup of individuals whose specific benefit from aspirin was greater than twice the risk of serious bleeding it induced. RESULTS The absolute benefit associated with aspirin was reduced by co-prescriptions. No subgroup of women benefited from aspirin, and the subgroup of women with a clear net benefit represented 128 women out of 529,421. Men at high risk of cardiovascular death, or with diabetes and hypertension, had a benefit from aspirin exceeding the risk of bleeding induced, but this risk represented more than half of the benefit. No subgroup analyzed did show a benefit greater than twice the risk of bleeding. The proportion of men whose expected benefit from aspirin was greater than twice the risk of bleeding represented 3% of all men. An optimal polypill strategy in primary prevention between the ages of 35 and 65, combining three drugs but not aspirin, can hope to save two out of three strokes and more than one out of two myocardial infarctions. It would prevent a major cardiovascular accident every 16 to 193 individuals treated according to the subgroups considered. CONCLUSION Until proven otherwise, aspirin has only a limited place in individuals between 35 and 65 years without a cardiovascular history. We showed how simulating therapeutic strategies on a realistic virtual population could be used for best applying available evidence.
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Affiliation(s)
- Mor Fall
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France; Laboratoire de pharmacologie & de pharmacodynamie, UMRED université Iba Der Thiam, BP A967 Thies, Sénégal; Centre hospitalier universitaire Aristide Le Dantec, pharmacie centrale, BP 3001 Dakar, Sénégal
| | - Guillaume Grenet
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France; Service hospitalo universitaire de pharmaco-toxicologie, 69002 Lyon France
| | - Hai-Ha Le
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Behrouz Kassaï
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France; Service hospitalo universitaire de pharmaco-toxicologie, 69002 Lyon France
| | - Jean-Christophe Lega
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Rémy Boussageon
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Sabine Mainbourg
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Ivanny Marchant
- Laboratorio de Modelamiento en Medicina, Escuela de Medicina, Universidad de Valparaíso, Viña del Mar, Chile
| | - Johanne Gafsi
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France
| | - Amadou Moctar Dieye
- Service hospitalo universitaire de pharmaco-toxicologie, 69002 Lyon France; Laboratoire de pharmacologie & de pharmacodynamie, université Cheikh Anta Diop, BP 5005 Dakar, Sénégal
| | - François Gueyffier
- Laboratoire de biologie et biométrie évolutive - équipe modélisation des effets thérapeutiques, UMR 5558 université Claude Bernard Lyon 1, 69376 Lyon, France; Pôle de santé publique, Hospices civils de Lyon, 69002 Lyon, France.
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14
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Lim B, Jang MJ, Oh SM, No JG, Lee J, Kim SE, Ock SA, Yun IJ, Kim J, Chee HK, Kim WS, Kang HJ, Cho K, Oh KB, Kim JM. Comparative transcriptome analysis between long- and short-term survival after pig-to-monkey cardiac xenotransplantation reveals differential heart failure development. Anim Cells Syst (Seoul) 2023; 27:234-248. [PMID: 37808548 PMCID: PMC10552608 DOI: 10.1080/19768354.2023.2265150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/27/2023] [Indexed: 10/10/2023] Open
Abstract
Cardiac xenotransplantation is the potential treatment for end-stage heart failure, but the allogenic organ supply needs to catch up to clinical demand. Therefore, genetically-modified porcine heart xenotransplantation could be a potential alternative. So far, pig-to-monkey heart xenografts have been studied using multi-transgenic pigs, indicating various survival periods. However, functional mechanisms based on survival period-related gene expression are unclear. This study aimed to identify the differential mechanisms between pig-to-monkey post-xenotransplantation long- and short-term survivals. Heterotopic abdominal transplantation was performed using a donor CD46-expressing GTKO pig and a recipient cynomolgus monkey. RNA-seq was performed using samples from POD60 XH from monkey and NH from age-matched pigs, D35 and D95. Gene-annotated DEGs for POD60 XH were compared with those for POD9 XH (Park et al. 2021). DEGs were identified by comparing gene expression levels in POD60 XH versus either D35 or D95 NH. 1,804 and 1,655 DEGs were identified in POD60 XH versus D35 NH and POD60 XH versus D95 NH, respectively. Overlapped 1,148 DEGs were annotated and compared with 1,348 DEGs for POD9 XH. Transcriptomic features for heart failure and inhibition of T cell activation were observed in both long (POD60)- and short (POD9)-term survived monkeys. Only short-term survived monkey showed heart remodeling and regeneration features, while long-term survived monkey indicated multi-organ failure by neural and hormonal signaling as well as suppression of B cell activation. Our results reveal differential heart failure development and survival at the transcriptome level and suggest candidate genes for specific signals to control adverse cardiac xenotransplantation effects.
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Affiliation(s)
- Byeonghwi Lim
- Department of Animal Science and Technology, Chung-Ang University, Anseong, Republic of Korea
| | - Min-Jae Jang
- Department of Animal Science and Technology, Chung-Ang University, Anseong, Republic of Korea
| | - Seung-Mi Oh
- Department of Animal Science and Technology, Chung-Ang University, Anseong, Republic of Korea
| | - Jin Gu No
- Animal Biotechnology Division, National Institute of Animal Science, RDA, Wanju, Republic of Korea
| | - Jungjae Lee
- Department of Animal Science and Technology, Chung-Ang University, Anseong, Republic of Korea
| | - Sang Eun Kim
- Animal Biotechnology Division, National Institute of Animal Science, RDA, Wanju, Republic of Korea
| | - Sun A. Ock
- Animal Biotechnology Division, National Institute of Animal Science, RDA, Wanju, Republic of Korea
| | - Ik Jin Yun
- Departments of Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Junseok Kim
- Departments of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hyun Keun Chee
- Departments of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Wan Seop Kim
- Departments of Pathology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hee Jung Kang
- Department of Laboratory Medicine, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Kahee Cho
- Primate Organ Transplantation Centre, Genia Inc., Seongnam, Republic of Korea
| | - Keon Bong Oh
- Animal Biotechnology Division, National Institute of Animal Science, RDA, Wanju, Republic of Korea
| | - Jun-Mo Kim
- Department of Animal Science and Technology, Chung-Ang University, Anseong, Republic of Korea
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15
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Xiao J, Liu L, Lin W. Comparison Between Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers in Patients with Unstable Angina with Preserved Left Ventricular Systolic Function. Angiology 2023; 74:840-847. [PMID: 36039598 DOI: 10.1177/00033197221123722] [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] [Indexed: 11/16/2022]
Abstract
The present study evaluated the clinical results of angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) treatment in patients with unstable angina (UA) with preserved left ventricular systolic function who underwent percutaneous coronary intervention (PCI) due to uncertainty regarding the long-term prognosis using ACEI or ARB. A total of 1627 UA patients with preserved left ventricular systolic function after PCI were enrolled. After propensity score matching, there were no differences in major adverse cardiovascular and cerebrovascular events (MACCEs) (hazard ratio (HR) = .860, 95% confidence interval (CI): .465-1.590, P = .630), all-cause death (HR = .334, 95% CI: .090-1.238, P = .101), nonfatal myocardial infarction (HR = 4.929, 95% CI: .576-42.195, P = .145), stroke (HR = 1.049, 95% CI: .208-5.290, P = .954) and target vessel revascularization (TVR) (HR = 1.276, 95% CI: .537-3.031, P = .581) between the ACEI and ARB groups. In conclusion, prognoses were comparable between ACEI or ARB treatment in UA patients who had preserved left ventricular systolic function after PCI.
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Affiliation(s)
- Jiong Xiao
- Department of Cardiology I, Tianjin Economic-Technological Development Area International Cardiovascular Hospital, Tianjin, China
- Department of Cardiology, Taihe Hospital, Hubei University of Medicine, Hubei, China
| | - Linze Liu
- Department of Cardiology I, Tianjin Economic-Technological Development Area International Cardiovascular Hospital, Tianjin, China
| | - Wenhua Lin
- Department of Cardiology I, Tianjin Economic-Technological Development Area International Cardiovascular Hospital, Tianjin, China
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16
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Oh S, Kim JH, Cho KH, Kim MC, Sim DS, Hong YJ, Ahn Y, Jeong MH. Renin-Angiotensin-Aldosterone System Inhibitions and Cardiovascular Outcomes in Acute Myocardial Infarction With Renal Impairment. Mayo Clin Proc 2023; 98:1310-1322. [PMID: 37245133 DOI: 10.1016/j.mayocp.2023.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/04/2023] [Accepted: 02/01/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To compare the clinical outcomes of patients with acute myocardial infarction with renal impairment (AMI-RI) treated with either angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in real-world clinical settings. PATIENTS AND METHODS A total of 4790 consecutive patients with AMI-RI between November 1, 2011, and December 31, 2015, were subdivided into ACEI (n=2845) and ARB (n=1945) treatment groups. The primary end points were major adverse cardiac and cerebrovascular events, including all-cause mortality, nonfatal myocardial infarction, any revascularization, cerebrovascular accident, rehospitalization, and stent thrombosis. Propensity score matching (PSM) was used to adjust for group differences. RESULTS The ARB group had a significantly higher incidence of major adverse cardiac and cerebrovascular events (at 3-year follow-up) than the ACEI group according to the unadjusted analysis (3-year hazard ratio [HR], 1.60; 95% CI, 1.43 to 1.78) and the PSM-adjusted analysis (3-year HR, 1.34; 95% CI, 1.15 to 1.56). However, any revascularization (3-year HR, 1.21; 95% CI, 0.95 to 1.54) and rehospitalization (3-year HR, 1.21; 95% CI, 0.88 to 1.67) were not significantly different between groups in the PSM-adjusted analysis. Compared with the ARB group, the ACEI group had lower rates of all-cause mortality at estimated glomerular filtration rates of at least 15 or less than 90 mL/min/1.73 m2 in the unadjusted data and at least 60 or less than 90 mL/min/1.73 m2 in the PSM-adjusted analysis. CONCLUSION Treatment with ACEIs seemed to be more beneficial than treatment with ARBs for patients with AMI-RI; further prospective studies are required to confirm these results.
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Affiliation(s)
- Seok Oh
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ju Han Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Cardiology, Chonnam National University Medical School, Gwangju, Republic of Korea.
| | - Kyung Hoon Cho
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Cardiology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Doo Sun Sim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Cardiology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Young Joon Hong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Cardiology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Cardiology, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Cardiology, Chonnam National University Medical School, Gwangju, Republic of Korea
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17
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 110] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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18
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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19
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Van der Linden L, Hias J, Walgraeve K, Petrovic M, Tournoy J, Vandenbriele C, Van Aelst L. Guideline-Directed Medical Therapies for Heart Failure with a Reduced Ejection Fraction in Older Adults: A Narrative Review on Efficacy, Safety and Timeliness. Drugs Aging 2023; 40:691-702. [PMID: 37452262 DOI: 10.1007/s40266-023-01046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
Heart failure is a prevalent syndrome among older adults, with a major impact on morbidity and mortality. Higher age is correlated with underuse of guideline-directed medical therapies which, in turn, has been linked to worse clinical outcomes. Importantly, most evidence so far has been collected in adults who were younger, less multi-morbid and polymedicated compared with those who are commonly treated in daily clinical practice. Hence, we aimed to assess and describe the evidence base for pharmacotherapy in older adults with heart failure with a reduced ejection. First, a narrative review was undertaken using Medline, from inception to January 2023. Four foundational therapies were selected based on the latest European Society of Cardiology clinical practice guideline: angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors. Post hoc analyses from landmark heart failure drug trials were searched and included if they contained data on the impact of age on efficacy, safety and/or timeliness of therapies in the management of heart failure with a reduced ejection fraction. Second, a proposal was developed to support and promote the use of evidence-based heart failure pharmacotherapy in complex, older adults. In total, 11 articles were selected: 4 meta-analyses, 6 post hoc analyses and 1 review paper. No attenuation of efficacy for any of the foundational agents was found in older adults. Regarding safety, dedicated analyses showed that beta blockers, mineraloid receptor antagonists, sacubitril-valsartan, dapagliflozin and empagliflozin retained their overall benefit-risk profile regardless of age. Time to benefit was short and occurred generally within 1 month. Consensus was achieved on a five-step proposal to manage complex medication regimens in older adults suffering from heart failure. In conclusion, older adults suffering from heart failure with a reduced ejection fraction should not be denied treatment based on their age.
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Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karolien Walgraeve
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary care, KU Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Adult intensive Care, Royal Brompton Hospital, Guy's & St. Thomas' NHS Foundations Trust, London, UK
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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20
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Abdul-Rahman T, Lizano-Jubert I, Garg N, Talukder S, Lopez PP, Awuah WA, Shah R, Chambergo D, Cantu-Herrera E, Farooqi M, Pyrpyris N, de Andrade H, Mares AC, Gupta R, Aldosoky W, Mir T, Lavie CJ, Abohashem S. The common pathobiology between coronary artery disease and calcific aortic stenosis: Evidence and clinical implications. Prog Cardiovasc Dis 2023; 79:89-99. [PMID: 37302652 DOI: 10.1016/j.pcad.2023.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 06/13/2023]
Abstract
Calcific aortic valve stenosis (CAS), the most prevalent valvular disease worldwide, has been demonstrated to frequently occur in conjunction with coronary artery disease (CAD), the third leading cause of death worldwide. Atherosclerosis has been proven to be the main mechanism involved in CAS and CAD. Evidence also exists that obesity, diabetes, and metabolic syndrome (among others), along with specific genes involved in lipid metabolism, are important risk factors for CAS and CAD, leading to common pathological processes of atherosclerosis in both diseases. Therefore, it has been suggested that CAS could also be used as a marker of CAD. An understanding of the commonalities between the two conditions may improve therapeutic strategies for treating both CAD and CAS. This review explores the common pathogenesis and disparities between CAS and CAD, alongside their etiology. It also discusses clinical implications and provides evidence-based recommendations for the clinical management of both diseases.
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Affiliation(s)
- Toufik Abdul-Rahman
- Medical Institute, Sumy State University; Toufik's World Medical Association, Sumy, Ukraine
| | | | - Neil Garg
- Rowan-Virtua School of Osteopathic Medicine, One Medical Center Drive, Stratford, NJ, United States
| | | | - Pablo Perez Lopez
- Faculty of Medicine, Autonomous University of Madrid (UAM), Madrid, Spain; Puerta de Hierro Majadahonda University Hospital, Majadahonda, Spain
| | - Wireko Andrew Awuah
- Medical Institute, Sumy State University; Toufik's World Medical Association, Sumy, Ukraine
| | | | - Diego Chambergo
- Faculty of Medicine, Anahuac University, Huixquilucan, Mexico
| | - Emiliano Cantu-Herrera
- Department of Clinical Sciences, Division of Health Sciences, University of Monterrey, San Pedro Garza García, Nuevo León, Mexico
| | | | - Nikolaos Pyrpyris
- School of Medicine, National and Kapodistrian University of Athens, Greece
| | | | - Adriana C Mares
- Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Rahul Gupta
- Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA, United States of America.
| | - Wesam Aldosoky
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, United States
| | - Tanveer Mir
- Detroit Medical Center - Cardiology department, Wayne State University, Detroit, United States
| | - Carl J Lavie
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA, United States of America; The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA, United States of America
| | - Shady Abohashem
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School Boston, MA, United States; Epidemiology Department, Harvard T. Chan of Public Health, Boston, MA, United States
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Kim HY, Mok J, Kim JY, Jeon D, Her SH, Park MW, Kim DB, Park CS, Lee JM, Chang K, Jung WS, Ahn Y. Effect of Angiotensin Receptor Blocker Dose in Myocardial Infarction With Preserved Left Ventricular Systolic Function. J Cardiovasc Pharmacol 2023; 82:52-60. [PMID: 37019077 DOI: 10.1097/fjc.0000000000001427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/12/2023] [Indexed: 04/07/2023]
Abstract
ABSTRACT There have been few studies of angiotensin receptor blocker (ARB) dose in myocardial infarction (MI) with preserved left ventricular (LV) systolic function. We evaluated the association of ARB dose with clinical outcomes after MI with preserved LV systolic function. We used MI multicenter registry. Six months after discharge, the ARB dose was indexed to the target ARB doses used in randomized clinical trials and grouped as >0%-25% (n = 2333), >25% of the target dose (n = 1204), and no ARB (n = 1263). The primary outcome was the composite of cardiac death or MI. Univariate analysis showed that mortality of those with any ARB dose was lower than those without ARB therapy. After multivariable adjustment, patients receiving >25% of target dose had a similar risk of cardiac death or MI compared with those receiving ≤25% or no ARB [hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.83-1.33; HR 0.94, 95% CI 0.82-1.08, respectively]. Propensity score analysis also demonstrated that patients with >25% dose had no difference in primary endpoint compared with those ≤25% dose or the no ARB group (HR 1.03, 95% CI 0.79-1.33; HR 0.86, 95% CI 0.64-1.14, respectively). The present study demonstrates that patients treated with >25% of target ARB dose do not have better clinical outcomes than those treated with ≤25% of target ARB dose or those with no ARB dose in MI patients with preserved LV systolic function.
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Affiliation(s)
- Hee-Yeol Kim
- Department of Cardiology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Jisu Mok
- Department of Cardiology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Republic of Korea
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae-Young Kim
- Department of Statistics, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Doosoo Jeon
- Department of Cardiology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, Republic of Korea
| | - Sung-Ho Her
- Department of Cardiology, College of Medicine, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Mahn Won Park
- Department of Cardiology, College of Medicine, Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Dong-Bin Kim
- Department of Cardiology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Chul-Su Park
- Department of Cardiology, College of Medicine, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong-Min Lee
- Department of Cardiology, College of Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Kiyuk Chang
- Department of Cardiology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea; and
| | - Wook Sung Jung
- Department of Cardiology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea; and
| | - Yongkeun Ahn
- Caridiovascular Center, Chonnam National University Hosptial, Kwangju, Republic of Korea
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22
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Bhattarai S, Shrestha A, Skovlund E, Åsvold BO, Mjølstad BP, Sen A. Cluster randomised trial to evaluate comprehensive approach to hypertension management in Nepal: a study protocol. BMJ Open 2023; 13:e069898. [PMID: 37169495 PMCID: PMC10186459 DOI: 10.1136/bmjopen-2022-069898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 04/26/2023] [Indexed: 05/13/2023] Open
Abstract
INTRODUCTION Despite having effective approaches for hypertension management including use of antihypertensive medication, monitoring of blood pressure and lifestyle modification many people with hypertension in Nepal remain undetected and untreated. A comprehensive intervention which provides personalised counselling on lifestyle modification, medication adherence together with support for regular monitoring of blood pressure is expected to achieve well controlled blood pressure. METHODS AND ANALYSIS This is a community-based, non-blinded, parallel group, two-arm cluster randomised controlled trial, with an allocation ratio of 1:1, conducted in Budhanilkantha municipality, Nepal. Ten health facilities and their catchment area are randomly allocated to either of the two arms. 1250 individuals aged 18 years and older with an established diagnosis of hypertension will be recruited. The intervention arm receives a comprehensive hypertension management package that includes blood pressure audit by health workers, home-based patient support by community health workers to engage patient and family members in providing tailored educational counselling on behavioural and lifestyle changes in addition to routine care. The control arm includes routine hypertension care. Trained enumerators will ensure consent and collect data. Outcome data on blood pressure, weight, waist and hip circumference will be measured and self-reported data on diet, lifestyle, medication adherence and hypertension knowledge will be registered at 11 months' follow-up. The change in outcome measures will be compared by intention to treat, using a generalised linear mixed model. A formative assessment will be conducted using semistructured interviews and focus group discussions to explore factors affecting hypertension management. A mix-method approach will be applied for process evaluation to explore acceptability, adoption, fidelity, feasibility and coverage. ETHICS AND DISSEMINATION Ethics approval was obtained from Nepal Health Research Council (682/2021) and Regional Committee for Medical and Health Research Ethics, Norway (399479). The findings will be disseminated in peer-reviewed journal articles and with decision makers in Nepal.
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Affiliation(s)
- Sanju Bhattarai
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Institute for Implementation Science and Health, Kathmandu, Nepal
| | - Archana Shrestha
- Institute for Implementation Science and Health, Kathmandu, Nepal
- Department of Public Health, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
- Department of Chronic Disease Epidemiology, Center of Methods for Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut, USA
| | - Eva Skovlund
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjørn Olav Åsvold
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Endocrinology, Clinic of Medicine, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bente Prytz Mjølstad
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- General Practice Research Unit, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Abhijit Sen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Center for Oral Health Services and Research, Mid-Norway (TkMidt), Norwegian University of Science and Technology, Trondheim, Norway
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23
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Lee K, Han S, Lee M, Kim DW, Kwon J, Park GM, Park MW. Evidence-Based Optimal Medical Therapy and Mortality in Patients With Acute Myocardial Infarction After Percutaneous Coronary Intervention. J Am Heart Assoc 2023; 12:e024370. [PMID: 37158100 DOI: 10.1161/jaha.121.024370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Background The secondary prevention with pharmacologic therapy is essential for preventing recurrent cardiovascular events in patients experiencing acute myocardial infarction. Guideline-based optimal medical therapy (OMT) for patients with acute myocardial infarction consists of antiplatelet therapy, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, β-blockers, and statins. We aimed to determine the prescription rate of OMT use at discharge and to evaluate the impact of OMT on long-term clinical outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention in the drug-eluting stent era using nationwide cohort data. Methods and Results Using the National Health Insurance claims data in South Korea, patients with acute myocardial infarction who had undergone percutaneous coronary intervention with a drug-eluting stent between July 2013 and June 2017 were enrolled. A total of 35 972 patients were classified into the OMT and non-OMT groups according to the post-percutaneous coronary intervention discharge medication. The primary end point was all-cause death, and the 2 groups were compared using a propensity-score matching analysis. Fifty-seven percent of patients were prescribed OMT at discharge. During the follow-up period (median, 2.0 years [interquartile range, 1.1-3.2 years]), OMT was associated with a significant reduction in the all-cause mortality (adjusted hazard ratio [aHR], 0.82 [95% CI, 0.76-0.90]; P<0.001) and composite outcome of death or coronary revascularization (aHR, 0.89 [95% CI, 0.85-0.93]; P<0.001). Conclusions OMT was prescribed at suboptimal rates in South Korea. However, our nationwide cohort study showed that OMT has a benefit for long-term clinical outcomes on all-cause mortality and composite outcome of death or coronary revascularization after percutaneous coronary intervention in the drug-eluting stent era.
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Affiliation(s)
- Kyusup Lee
- Cardiovascular Research Institute for Intractable Disease, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Department of Cardiology, Daejeon St. Mary's Hospital, College of Medicine The Catholic University of Korea Daejeon Republic of Korea
| | - Seungbong Han
- Department of Biostatistics, College of Medicine Korea University Seoul Republic of Korea
| | - Myunhee Lee
- Cardiovascular Research Institute for Intractable Disease, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Department of Cardiology, Daejeon St. Mary's Hospital, College of Medicine The Catholic University of Korea Daejeon Republic of Korea
| | - Dae-Won Kim
- Cardiovascular Research Institute for Intractable Disease, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Department of Cardiology, Daejeon St. Mary's Hospital, College of Medicine The Catholic University of Korea Daejeon Republic of Korea
| | - Jongbum Kwon
- Department of Thoracic and Cardiovascular Surgery, Daejeon St. Mary's Hospital The Catholic University of Korea Daejeon Republic of Korea
| | - Gyung-Min Park
- Department of Cardiology, Ulsan University Hospital University of Ulsan College of Medicine Ulsan Republic of Korea
| | - Mahn-Won Park
- Cardiovascular Research Institute for Intractable Disease, College of Medicine The Catholic University of Korea Seoul Republic of Korea
- Department of Cardiology, Daejeon St. Mary's Hospital, College of Medicine The Catholic University of Korea Daejeon Republic of Korea
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24
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Johnson M, Morrison FJ, McMahon G, Su M, Turchin A. Outcomes in patients with cardiometabolic disease who develop hyperkalemia while treated with a renin-angiotensin-aldosterone system inhibitor. Am Heart J 2023; 258:49-59. [PMID: 36642227 DOI: 10.1016/j.ahj.2023.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/06/2023] [Accepted: 01/07/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Many patients with indications for renin-angiotensin-aldosterone system inhibitor (RAASi) therapy are not receiving these medications. Concern about hyperkalemia is thought to contribute to this lack of evidence-based therapy. METHODS A retrospective cohort study included adult patients in primary care practices affiliated with an integrated health care delivery system treated with RAASi between 2000 and 2019 for any of the following indications: (a) coronary artery disease (CAD); (b) heart failure (HF) with a left ventricle ejection fraction ≤ 40%; (c) diabetes mellitus (DM) with proteinuria; or (d) chronic kidney disease (CKD) with proteinuria. Relationship between hyperkalemia (K > 5.0 mEg/L) over the first 12 months of follow-up and a composite end point of cardiovascular events, renal dysfunction, and all-cause mortality was evaluated. RESULTS Among 82,732 study patients, 7,727 (9.34%) developed hyperkalemia. Patients with hyperkalemia were older (69.0 vs 64.6) and more likely to have CAD (57.8 vs 53.7%), CKD (57.3 vs 51.1%), HF (19.3 vs 9.7%), and DM (45.3 vs 33.3%) (P < .001 for all). Five-year cumulative risk of the primary outcome was higher in patients who did (63.9%; 95% CI: 62.8%-65.1%) versus did not (37.2%; 95% CI: 36.8%-37.6%) develop hyperkalemia. Five-year cumulative risk of ED visit or hospitalization for hyperkalemia was 15.6% (14.7%-16.6%) for patients with versus 2.7% (95% CI: 2.6-2.9) for patients without hyperkalemia, rising to 25.9% (95% CI: 22.4-29.9) for patients with severe (K > 6.0 mEq/dL) hyperkalemia. Patients who experienced hyperkalemia were more likely (34.4%) than patients who did not (29.2%) to deintensify RAASi therapy (P < .001). Five-year cumulative risk of the primary outcome was higher in patients who lowered RAASi dose (50.4%; 95% CI: 48.5%-52.4%) or stopped RAASi therapy completely (49.3%; 95% CI: 48.5%-50.1%), compared to patients who continued RAASi therapy (36.1%; 95% CI: 25.7-36.5). Similar findings were observed in multivariable analyses and for individual components of the primary outcome. CONCLUSIONS Hyperkalemia is a common complication of RAASi therapy and is associated with an increased risk of multiple adverse outcomes. Patients who have their RAASi medications deintensified after a hyperkalemic event have higher incidence of cardiovascular events, renal dysfunction and death.
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Affiliation(s)
- Matthew Johnson
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA; Columbia University College of Physicians and Surgeons, New York, NY
| | | | - Gearoid McMahon
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Maxwell Su
- Harvard School of Public Health, Boston, MA; Phase V, Wellesley Hills, MA
| | - Alexander Turchin
- Division of Endocrinology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Ward T, Lewis RD, Brown T, Baxter G, de Arellano AR. A cost-effectiveness analysis of patiromer in the UK: evaluation of hyperkalaemia treatment and lifelong RAASi maintenance in chronic kidney disease patients with and without heart failure. BMC Nephrol 2023; 24:47. [PMID: 36890464 PMCID: PMC9995261 DOI: 10.1186/s12882-023-03088-3] [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: 10/20/2022] [Accepted: 02/15/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) patients with and without heart failure (HF) often present with hyperkalaemia (HK) leading to increased risk of hospitalisations, cardiovascular related events and cardiovascular-related mortality. Renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, the mainstay treatment in CKD management, provides significant cardiovascular and renal protection. Nevertheless, its use in the clinic is often suboptimal and treatment is frequently discontinued due to its association with HK. We evaluated the cost-effectiveness of patiromer, a treatment known to reduce potassium levels and increase cardiorenal protection in patients receiving RAASi, in the UK healthcare setting. METHODS A Markov cohort model was generated to assess the pharmacoeconomic impact of patiromer treatment in regulating HK in patients with advanced CKD with and without HF. The model was generated to predict the natural history of both CKD and HF and quantify the costs and clinical benefits associated with the use of patiromer for HK management from a healthcare payer's perspective in the UK. RESULTS Economic evaluation of patiromer use compared to standard of care (SoC) resulted in increased discounted life years (8.93 versus 8.67) and increased discounted quality-adjusted life years (QALYs) (6.36 versus 6.16). Furthermore, patiromer use resulted in incremental discounted cost of £2,973 per patient and an incremental cost-effectiveness ratio (ICER) of £14,816 per QALY gained. On average, patients remained on patiromer therapy for 7.7 months, and treatment associated with a decrease in overall clinical event incidence and delayed CKD progression. Compared to SoC, patiromer use resulted in 218 fewer HK events per 1,000 patients, when evaluating potassium levels at the 5.5-6 mmol/l; 165 fewer RAASi discontinuation episodes; and 64 fewer RAASi down-titration episodes. In the UK, patiromer treatment was predicted to have a 94.5% and 100% chance of cost-effectiveness at willingness-to-pay thresholds (WTP) of £20,000/QALY and £30,000/QALY, respectively. CONCLUSION This study highlights the value of both HK normalisation and RAASi maintenance in CKD patients with and without HF. Results support the guidelines which recommend HK treatment, e.g., patiromer, as a strategy to enable the continuation of RAASi therapy and improve clinical outcomes in CKD patients with and without HF.
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Affiliation(s)
- Thomas Ward
- Health Economics and Outcomes Research Ltd., Rhymney House Unit A Copse Walk Cardiff Gate Business Park, Cardiff, CF23 8RB, UK.,Health Economics Group, College of Medicine and Health, University of Exeter, Exeter, England
| | - Ruth D Lewis
- Health Economics and Outcomes Research Ltd., Rhymney House Unit A Copse Walk Cardiff Gate Business Park, Cardiff, CF23 8RB, UK
| | - Tray Brown
- Health Economics and Outcomes Research Ltd., Rhymney House Unit A Copse Walk Cardiff Gate Business Park, Cardiff, CF23 8RB, UK.
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26
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Recent Developments in the Evaluation and Management of Cardiorenal Syndrome: A Comprehensive Review. Curr Probl Cardiol 2023; 48:101509. [PMID: 36402213 DOI: 10.1016/j.cpcardiol.2022.101509] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Abstract
Cardiorenal syndrome (CRS) is an increasingly recognized diagnostic entity associated with high morbidity and mortality among acutely ill heart failure (HF) patients with acute and/ or chronic kidney diseases (CKD). While traditionally viewed as a state of decline in glomerular filtration rate (GFR) due to decreased renal perfusion, mainly due to therapeutic interventions to relieve congestive in HF, recent insights into the underlying pathophysiologic mechanisms of CRS led to a broader definition and further classification of CRS into 5 distinct types. In this comprehensive review, we discuss the classification of CRS, highlighting the underlying common pathogenetic pathways of heart failure and kidney injury, including increased congestion, neurohormonal dysregulation, oxidative stress as well as inflammation, and cytokine storm that are particularly evident in COVID-19 patients with multiorgan failure and also in those with other disorders including sepsis, systemic lupus erythematosus and amyloidosis. In this review we also present the recent advances in the diagnostic strategies of CRS including cardiac and renal biomarkers as well as advanced cardiac and renal imaging techniques that are available to aid in the diagnosis as well as in the prognostication of this disorder. Finally, we discuss the various therapeutic options available to-date, including fluid optimization, hemofiltration, renal replacement therapy as well as the role of SGLT2 inhibitors in light of recent data from RCTs. It is important to note that, CRS population are either excluded or underrepresented, at best, in major RCTs and therefore, therapeutic recommendations are largely extrapolated from HF and CKD clinical trials.
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Yedlapati SH, Mendu A, Tummala VR, Maganti SS, Nasir K, Khan SU. Vaccines and cardiovascular outcomes: lessons learned from influenza epidemics. Eur Heart J Suppl 2023; 25:A17-A24. [PMID: 36937374 PMCID: PMC10021491 DOI: 10.1093/eurheartjsupp/suac110] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Cardiovascular disease (CVD) is the leading cause of death in the world and is largely preventable. An increasing amount of evidence suggests that annual influenza vaccination reduces CVD-related morbidity and mortality. Despite various clinical guidelines recommending annual influenza vaccination for the general population for influenza-like illness risk reduction, with a particular emphasis on people with CVD, vaccination rates fall consistently below the goal established by the World Health Organization. This review outlines the importance of influenza vaccination, mechanisms of cardiovascular events in influenza, summarizing the available literature on the effects of influenza vaccine in CVD and the benefits of influenza vaccine during the COVID-19 pandemic.
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Affiliation(s)
- Siva H Yedlapati
- Department of Medicine, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
| | - Anuradha Mendu
- Department of Medicine, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
| | - Venkat R Tummala
- Department of Biology, Virginia Commonwealth University, 1000 W Cary St, Richmond, VA 23284, USA
| | - Sowmith S Maganti
- Department of Biology, Virginia Commonwealth University, 1000 W Cary St, Richmond, VA 23284, USA
| | - Khurram Nasir
- Department of Cardiology, DeBakey Heart and Vascular Center, 6565 Fannin St, Houston, TX 77030, USA
| | - Safi U Khan
- Department of Cardiology, DeBakey Heart and Vascular Center, 6565 Fannin St, Houston, TX 77030, USA
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Sosa-Liprandi MI, Zaidel EJ, Sosa-Liprandi Á. A recent experience on the role of influenza vaccination on cardiovascular events. Eur Heart J Suppl 2023; 25:A31-A35. [PMID: 36937369 PMCID: PMC10021488 DOI: 10.1093/eurheartjsupp/suac111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
The purpose of this review is to update the recent information regarding the role of influenza vaccination (IV) as a strategy to reduce cardiovascular (CV) events. During the last 2 years, new meta-analysis, guidelines, and two randomized controlled trials (RCTs) were published. The IAMI trial added information regarding the safety and efficacy of IV right after an acute myocardial infarction hospitalization. A significant reduction in the primary endpoint-including mortality-was observed. More recently, the influenza vaccine to prevent vascular events trial (IVVE) trial did not meet the primary CV endpoint in patients with heart failure (HF). However, a significant reduction was observed during the seasonal peaks of Influenza circulation. COVID-19 pandemic provoked recruitment difficulties in these trials, as well as an altered influenza seasonality and incidence. Further analysis of IVVE trial is needed to clarify the precise role of IV in patients with HF. A recent meta-analysis of RCTs and observational studies indicated that IV was safe and effective to reduce CV events, and it was included in the most updated guideline. Despite these benefits, and the recommendations for its prescription by scientific societies and health regulatory agencies, the vaccination rate remains below than expected globally. The correct understanding of implementation barriers, which involve doctors, patients, and their context, is essential when continuous improvement strategies are planned, in order to improve the IV rate in at-risk subjects.
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Affiliation(s)
| | - Ezequiel José Zaidel
- Department of Cardiology, Sanatorio Güemes, Acuña de Figueroa 1228 C1180AAX, Buenos Aires, Argentina
| | - Álvaro Sosa-Liprandi
- Department of Cardiology, Sanatorio Güemes, Acuña de Figueroa 1228 C1180AAX, Buenos Aires, Argentina
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Kinugawa K, Matsukawa M, Nakamura Y, Aihara M, Sano H. Impact of tolvaptan add-on treatment on patients with heart failure requiring long-term congestion management: A retrospective cohort study using a medical claim database in Japan. J Cardiol 2022:S0914-5087(22)00323-9. [PMID: 36587792 DOI: 10.1016/j.jjcc.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/29/2022] [Accepted: 12/08/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The impact of tolvaptan on the long-term outcomes of patients with heart failure (HF) remains inconclusive. We evaluated patients requiring long-term congestion management for the time to rehospitalization for HF (HF rehospitalization), the time to in-hospital death and explored the factors that may influence the outcomes. METHODS Using data (April 2008 to September 2019) from a medical claims database, patients with HF prescribed tolvaptan (tolvaptan cohort) and those prescribed loop diuretics before tolvaptan was introduced to the hospital (furosemide cohort) were compared. Patients with HF who experienced ≥2 HF hospitalizations and ≥ 1 tolvaptan or loop diuretic prescription during and after HF hospitalization were included. Data of patients with serum creatinine and estimated glomerular filtration rate were analyzed for time to HF rehospitalization and in-hospital death within 1 year after the second discharge and factors that may influence the outcomes. RESULTS Among the 1931 and 631 tolvaptan and furosemide cohort patients, respectively, time to HF rehospitalization was not significantly different (p = 0.0921); time to in-hospital death was significantly longer in the tolvaptan cohort than in the furosemide cohort (p = 0.0005). Age, serum sodium, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were identified as factors for both outcomes (p < 0.05). CONCLUSIONS Tolvaptan did not significantly affect time to HF rehospitalization. However, further worsening of the condition leading to death may be delayed, and time to in-hospital death may be prolonged in patients treated with tolvaptan, indicating its usefulness for long-term congestion management.
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Affiliation(s)
- Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | | | - Yumiko Nakamura
- Medical Affairs, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Miki Aihara
- Medical Affairs, Otsuka Pharmaceutical Co., Ltd., Tokyo, Japan
| | - Hiromi Sano
- Medical Affairs, Otsuka Pharmaceutical Co., Ltd., Osaka, Japan
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30
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Mehran R, Steg PG, Pfeffer MA, Jering K, Claggett B, Lewis EF, Granger C, Køber L, Maggioni A, Mann DL, McMurray JJV, Rouleau JL, Solomon SD, Ducrocq G, Berwanger O, De Pasquale CG, Landmesser U, Petrie M, Leng DSK, van der Meer P, Lefkowitz M, Zhou Y, Braunwald E. The Effects of Angiotensin Receptor-Neprilysin Inhibition on Major Coronary Events in Patients With Acute Myocardial Infarction: Insights From the PARADISE-MI Trial. Circulation 2022; 146:1749-1757. [PMID: 36321459 DOI: 10.1161/circulationaha.122.060841] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In patients who survive an acute myocardial infarction (AMI), angiotensin-converting enzyme inhibitors decrease the risk of subsequent major cardiovascular events. Whether angiotensin-receptor blockade and neprilysin inhibition with sacubitril/valsartan reduce major coronary events more effectively than angiotensin-converting enzyme inhibitors in high-risk patients with recent AMI remains unknown. We aimed to compare the effects of sacubitril/valsartan on coronary outcomes in patients with AMI. METHODS We conducted a prespecified analysis of the PARADISE-MI trial (Prospective ARNI vs ACE Inhibitors Trial to Determine Superiority in Reducing Heart Failure Events After MI), which compared sacubitril/valsartan (97/103 mg twice daily) with ramipril (5 mg twice daily) for reducing heart failure events after myocardial infarction in 5661 patients with AMI complicated by left ventricular systolic dysfunction, pulmonary congestion, or both. In the present analysis, the prespecified composite coronary outcome was the first occurrence of death from coronary heart disease, nonfatal myocardial infarction, hospitalization for angina, or postrandomization coronary revascularization. RESULTS Patients were randomly assigned at a median of 4.4 [3.0-5.8] days after index AMI (ST-segment-elevation myocardial infarction 76%, non-ST-segment-elevation myocardial infarction 24%), by which time 89% of patients had undergone coronary reperfusion. Compared with ramipril, sacubitril/valsartan decreased the risk of coronary outcomes (hazard ratio, 0.86 [95% CI, 0.74-0.99], P=0.04) over a median follow-up of 22 months. Rates of the components of the composite outcomes were lower in patients on sacubitril/valsartan but were not individually significantly different. CONCLUSIONS In survivors of an AMI with left ventricular systolic dysfunction and pulmonary congestion, sacubitril/valsartan-compared with ramipril-reduced the risk of a prespecified major coronary composite outcome. Dedicated studies are necessary to confirm this finding and elucidate its mechanism. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02924727.
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Affiliation(s)
- Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, AP-HP (Assistance Publique-Hôpitaux de Paris), FACT (French Alliance for Cardiovascular Trials) and INSERM U-1148, France (P.G.S.)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Karola Jering
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, CA (E.F.L.)
| | | | - Lars Køber
- Professor of Cardiology, Department of Clinical Medicine, University of Copenhagen, Denmark (L.K.)
| | - Aldo Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy (A.M.)
| | - Douglas L Mann
- Washington University Medical Center, St Louis, MO (D.L.M.)
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Scotland (J.J.V.M., M.P.)
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Gregory Ducrocq
- Département de Cardiologie, Hôpital Bichat Assistance Publique Hôpitaux de Paris. France (G.D.)
| | - Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, São Paulo-SP, Brazil (O.B.)
| | - Carmine G De Pasquale
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia (C.G.D.P.)
| | - Ulf Landmesser
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Germany (U.L.)
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Scotland (J.J.V.M., M.P.)
| | | | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (P.v.d.M.)
| | - Martin Lefkowitz
- Novartis Pharmaceutical Corporation, East Hanover, NJ (M.L., Y.Z.)
| | - Yinong Zhou
- Novartis Pharmaceutical Corporation, East Hanover, NJ (M.L., Y.Z.)
| | - Eugene Braunwald
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
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Renal Safety and Renin-Angiotensin-Aldosterone System Inhibitors in Patients With Contrast Media Exposure: A Multicenter Randomized Controlled Study. J Cardiovasc Pharmacol 2022; 80:718-724. [PMID: 35881908 PMCID: PMC9640273 DOI: 10.1097/fjc.0000000000001325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/19/2022] [Indexed: 02/04/2023]
Abstract
ABSTRACT There is no clear consensus on the safety of renin-angiotensin-aldosterone system inhibitors in patients with contrast media exposure. We aimed to assess the safety of renin-angiotensin-aldosterone system inhibitors in patients exposed to contrast media at 1-year follow-up. Patients treated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) were recruited and randomly divided into 2 groups (1:1 ratio): with ACEI/ARB group (ACEI/ARB continued throughout the study period) and without ACEI/ARB group (ACEI/ARB stopped 24 hours before and continued 48 hours after the procedure). The primary endpoint was contrast-induced acute kidney injury (CI-AKI) and secondary endpoints were major adverse cardiovascular events (MACEs), and the need for renal replacement therapy during hospitalization and at 1-year follow-up. The occurrence rates of CI-AKI were not comparable in the ACEI/ARB group and the without ACEI/ARB group (2.92% and 2.62%, respectively; P = 0.866). No significant between-group differences were found with respect to the frequency of MACEs or renal replacement therapy during hospitalization and at 1-year follow-up. On subgroup analysis, among patients with estimated glomerular filtration rate (eGFR) < 45 mL/min, the incidence of CI-AKI was significantly higher in the ACEI/ARB group [17.95% (14/78) vs. 6.02% (5/83), P = 0.029]. Among patients with eGFR ≥ 45 mL/min, the incidence of CI-AKI was comparable in the 2 groups [0.87% (5/572) vs. 2.12% (12/567), P = 0.094]. The incidence of MACEs and renal replacement therapy was not comparable in the 2 groups, during hospitalization and at 1-year follow-up. ACEI or ARB treatment can safely be continued after exposure to contrast media, but not in patients with eGFR < 45 mL/min.
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Joo SJ, Kim SY, Lee JG, Beom JW, Choi JH, Park HK, Boo KY, Yoon CH, Lee JH, Chae JK, Jeong MH. Association of the medical therapy with beta-blockers or inhibitors of renin-angiotensin system with clinical outcomes in patients with mildly reduced left ventricular ejection fraction after acute myocardial infarction. Medicine (Baltimore) 2022; 101:e30846. [PMID: 36281078 PMCID: PMC9592534 DOI: 10.1097/md.0000000000030846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
In the era of the initial optimal interventional and medical therapy for acute myocardial infarction (AMI), a number of patients with mildly reduced left ventricular ejection fraction (EF) (41%-49%) have been increasing. This observational study aimed to investigate the association between the medical therapy with oral beta-blockers or inhibitors of renin-angiotensin system (RAS) and 2-year clinical outcomes in patients with mildly reduced EF after AMI. Among patients enrolled in the Korea Acute Myocardial Infarction Registry-National Institute of Health, propensity-score matched patients who survived the initial attack and had mildly reduced EF were selected according to beta-blocker or RAS inhibitor therapy at discharge. Beta-blocker therapy at discharge was associated with lower 2-year major adverse cardiac events which was a composite of cardiac death, myocardial infarction, revascularization and re-hospitalization due to heart failure (8.7 vs 12.8/100 patient-years; hazard ratio [HR] 0.68; 95% confidence interval [CI] 0.50-0.93; P = .015), and no significant interaction between EF ≤ 45% and > 45% was observed (Pinteraction = 0.354). This association was mainly driven by lower myocardial infarction in patients with beta-blockers (HR 0.50; 95% CI 0.26-0.95; P = .035). Inhibitors of RAS at discharge were associated with lower re-hospitalization due to heart failure (1.8 vs 3.5/100 patient-years; HR 0.53; 95% CI 0.33-0.86; P = .010) without a significant interaction between EF ≤ 45% and > 45% (Pinteraction = 0.333). In patients with mildly reduced EF after AMI, the medical therapy with beta-blockers or RAS inhibitors at discharge was associated with better 2-year clinical outcomes.
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Affiliation(s)
- Seung-Jae Joo
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Song-Yi Kim
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Jae-Geun Lee
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Jong Wook Beom
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Joon-Hyouk Choi
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Hyeung Keun Park
- Department of Health Policy and Management, Jeju National University College of Medicine, Jeju, Republic of Korea
| | - Ki Yung Boo
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Chang-Hwan Yoon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jung-Hee Lee
- Division of Cardiology, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Jei Keon Chae
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea
| | - Myung Ho Jeong
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
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Iacoviello M, Pugliese R, Correale M, Brunetti ND. Optimization of Drug Therapy for Heart Failure With Reduced Ejection Fraction Based on Gender. Curr Heart Fail Rep 2022; 19:467-475. [PMID: 36197626 DOI: 10.1007/s11897-022-00583-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 10/10/2022]
Abstract
PURPOSE OF REVIEW Over the last decades, several classes of drugs have been introduced for the treatment of patients with heart failure with reduced ejection fraction (HFrEF). Their use has been supported by randomized controlled trials that have demonstrated improved patient outcomes. However, these trials enrolled a small number of female patients and sometimes have reported gender-related differences regarding the efficacy of the treatments. The aim of this review is to revise the available data about the influence of gender on the optimal treatment and drug dose in patients with HFrEF. RECENT FINDINGS Several gender-related differences in terms of pharmacokinetic and pharmacodynamic characteristics of the drugs have been described. These characteristics could be responsible for a different response and tolerability in men and women also when current recommended treatment of HFrEF is considered. Some studies have shown that, in women, lower doses of beta-blockers and inhibitors of renin angiotensin aldosterone system could be equally effective than higher doses in men, whereas sacubitril/valsartan could exert its favorable effect at greater values of left ventricular ejection fraction. Although there is evidence about differences in the response to treatment of HFrEF in men and women, this has not been sufficient for differentiating current recommended therapy. Further studies should better clarify if the treatment of HFrEF should be based also on the patients' gender.
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Affiliation(s)
- Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy. .,Cardiology Unit, University Polyclinic Hospital of Foggia, Foggia, Italy.
| | - Rosanna Pugliese
- Cardiology Unit, University Polyclinic Hospital of Foggia, Foggia, Italy
| | - Michele Correale
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy
| | - Natale Daniele Brunetti
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy.,Cardiology Unit, University Polyclinic Hospital of Foggia, Foggia, Italy
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Reviewing the Modern Therapeutical Options and the Outcomes of Sacubitril/Valsartan in Heart Failure. Int J Mol Sci 2022; 23:ijms231911336. [PMID: 36232632 PMCID: PMC9570001 DOI: 10.3390/ijms231911336] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/22/2022] [Accepted: 09/22/2022] [Indexed: 11/16/2022] Open
Abstract
Sacubitril/valsartan (S/V) is a pharmaceutical strategy that increases natriuretic peptide levels by inhibiting neprilysin and regulating the renin-angiotensin-aldosterone pathway, blocking AT1 receptors. The data for this innovative medication are mainly based on the PARADIGM-HF study, which included heart failure with reduced ejection fraction (HFrEF)-diagnosed patients and indicated a major improvement in morbidity and mortality when S/V is administrated compared to enalapril. A large part of the observed favorable results is related to significant reverse cardiac remodeling confirmed in two prospective trials, PROVE-HF and EVALUATE-HF. Furthermore, according to a subgroup analysis from the PARAGON-HF research, S/V shows benefits in HFrEF and in many subjects having preserved ejection fraction (HFpEF), which indicated a decrease in HF hospitalizations among those with a left ventricular ejection fraction (LVEF) < 57%. This review examines the proven benefits of S/V and highlights continuing research in treating individuals with varied HF characteristics. The article analyses published data regarding both the safeness and efficacy of S/V in patients with HF, including decreases in mortality and hospitalization, increased quality of life, and reversible heart remodeling. These benefits led to the HF guidelines recommendations updating and inclusion of S/V combinations a key component of HFrEF treatment.
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Abdel Rhman M, Owira P. The role of microRNAs in the pathophysiology, diagnosis, and treatment of diabetic cardiomyopathy. J Pharm Pharmacol 2022; 74:1663-1676. [PMID: 36130185 DOI: 10.1093/jpp/rgac066] [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: 01/10/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Diabetic cardiomyopathy (DCM) is an end-point macrovascular complication associated with increased morbidity and mortality in 12% of diabetic patients. MicroRNAs (miRNAs) are small noncoding RNAs that can act as cardioprotective or cardiotoxic agents in DCM. METHODS We used PubMed as a search engine to collect and analyse data in published articles on the role of miRNAs on the pathophysiology, diagnosis and treatment of DCM. RESULTS MiRNAs play an essential role in the pathophysiology, diagnosis and treatment of DCM due to their distinct gene expression patterns in diabetic patients compared to healthy individuals. Advances in gene therapy have led to the discovery of potential circulating miRNAs, which can be used as biomarkers for DCM diagnosis and prognosis. Furthermore, targeted miRNA therapies in preclinical and clinical studies, such as using miRNA mimics and anti-miRNAs, have yielded promising results. Application of miRNA mimics and anti-miRNAs via different nanodrug delivery systems alleviate hypertrophy, fibrosis, oxidative stress and apoptosis of cardiomyocytes. CONCLUSION MiRNAs serve as attractive potential targets for DCM diagnosis, prognosis and treatment due to their distinctive expression profile in DCM development.
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Affiliation(s)
- Mahasin Abdel Rhman
- Department of Pharmacology, Discipline of Pharmaceutical Sciences, Molecular and Clinical Pharmacology Research Laboratory, University of Kwazulu-Natal, P.O. Box X5401, Durban, South Africa
| | - Peter Owira
- Department of Pharmacology, Discipline of Pharmaceutical Sciences, Molecular and Clinical Pharmacology Research Laboratory, University of Kwazulu-Natal, P.O. Box X5401, Durban, South Africa
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Ward T, Brown T, Lewis RD, Kliess MK, de Arellano AR, Quinn CM. The Cost Effectiveness of Patiromer for the Treatment of Hyperkalaemia in Patients with Chronic Kidney Disease with and without Heart Failure in Ireland. PHARMACOECONOMICS - OPEN 2022; 6:757-771. [PMID: 35925491 PMCID: PMC9440184 DOI: 10.1007/s41669-022-00357-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE Hyperkalaemia can be a life-threatening condition, particularly in patients with advanced chronic kidney disease with and without heart failure. Renin-angiotensin-aldosterone system inhibitor therapy offers cardiorenal protection in chronic kidney disease and heart failure; however, it may also cause hyperkalaemia subsequently resulting in down-titration or discontinuation of treatment. Hence, there is an unmet need for hyperkalaemia treatment in patients with chronic kidney disease with and without heart failure to enable renin-angiotensin-aldosterone system inhibitor use in this patient population. In this study, we develop a de novo disease progression and cost-effectiveness model to evaluate the clinical and economic outcomes associated with the use of patiromer for the treatment of hyperkalaemia in patients with chronic kidney disease with and without heart failure. METHODS A Markov model was developed using data from the OPAL-HK trial to assess the health economic impact of patiromer therapy in comparison to standard of care in controlling hyperkalaemia in patients with advanced chronic kidney disease with and without heart failure in the Irish setting. The model was designed to predict the natural history of chronic kidney disease and heart failure and quantify the costs and benefits associated with the use of patiromer for hyperkalaemia management over a lifetime horizon from a payer perspective. RESULTS Treatment with patiromer was associated with an increase in discounted life-years (8.62 vs 8.37) and an increase in discounted quality-adjusted life-years (6.15 vs 5.95). Incremental discounted costs were predicted at €4979 per patient, with an incremental cost-effectiveness ratio of €25,719 per quality-adjusted life-year gained. Patients remained taking patiromer treatment for an average of 7.7 months, with treatment associated with reductions in the overall clinical event incidence and a delay in chronic kidney disease progression. Furthermore, patiromer was associated with lower overall rates of hospitalisation, major adverse cardiovascular events, dialysis, renin-angiotensin-aldosterone system inhibitor discontinuation episodes and renin-angiotensin-aldosterone system inhibitor down-titration episodes. At a willingness-to-pay threshold of €45,000 per quality-adjusted life-year in Ireland, treatment with patiromer was estimated to have a 100% chance of cost effectiveness compared with standard of care. CONCLUSIONS This study has demonstrated an economic case for the reimbursement of patiromer for the treatment of hyperkalaemia in patients with chronic kidney disease with and without heart failure in Ireland. Patiromer was estimated to improve life expectancy and quality-adjusted life expectancy, whilst incurring marginal additional costs when compared with current standard of care. Results are predominantly attributed to the ability of patiromer to enable the continuation of renin-angiotensin-aldosterone system inhibitor treatment whilst also reducing potassium levels.
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Affiliation(s)
- Thomas Ward
- Health Economics and Outcomes Research Ltd., Rhymney House, Unit A, Copse Walk, Cardiff Gate Business Park, Cardiff, CF23 8RB, UK
- Health Economics Group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Tray Brown
- Health Economics and Outcomes Research Ltd., Rhymney House, Unit A, Copse Walk, Cardiff Gate Business Park, Cardiff, CF23 8RB, UK.
| | - Ruth D Lewis
- Health Economics and Outcomes Research Ltd., Rhymney House, Unit A, Copse Walk, Cardiff Gate Business Park, Cardiff, CF23 8RB, UK
| | - Melodi Kosaner Kliess
- Health Economics and Outcomes Research Ltd., Rhymney House, Unit A, Copse Walk, Cardiff Gate Business Park, Cardiff, CF23 8RB, UK
| | | | - Carol M Quinn
- Vifor Pharma Group, Medical Department, Glattbrugg, Switzerland
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Abdelhamid M, Rosano G, Metra M, Adamopoulos S, Böhm M, Chioncel O, Filippatos G, Jankowska EA, Lopatin Y, Lund L, Milicic D, Moura B, Ben Gal T, Ristic A, Rakisheva A, Savarese G, Mullens W, Piepoli M, Bayes-Genis A, Thum T, Anker SD, Seferovic P, Coats AJS. Prevention of sudden death in heart failure with reduced ejection fraction: do we still need an implantable cardioverter-defibrillator for primary prevention? Eur J Heart Fail 2022; 24:1460-1466. [PMID: 35753058 DOI: 10.1002/ejhf.2594] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/13/2022] [Accepted: 06/23/2022] [Indexed: 11/12/2022] Open
Abstract
Sudden death is a devastating complication of heart failure (HF). Current guidelines recommend an implantable cardioverter-defibrillator (ICD) for prevention of sudden death in patients with HF and reduced ejection fraction (HFrEF) specifically those with a left ventricular ejection fraction ≤35% after at least 3 months of optimized HF treatment. The benefit of ICD in patients with symptomatic HFrEF caused by coronary artery disease has been well documented; however, the evidence for a benefit of prophylactic ICD implantation in patients with HFrEF of non-ischaemic aetiology is less strong. Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA) block the deleterious actions of angiotensin II, norepinephrine, and aldosterone, respectively. Neprilysin inhibition potentiates the actions of endogenous natriuretic peptides that mitigate adverse ventricular remodelling. BB, MRA, angiotensin receptor-neprilysin inhibitor (ARNI) have a favourable effect on reduction of sudden cardiac death in HFrEF. Recent data suggest a beneficial effect of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in reducing serious ventricular arrhythmias and sudden cardiac death in patients with HFrEF. So, in the current era of new drugs for HFrEF and with the optimal use of disease-modifying therapies (BB, MRA, ARNI and SGLT2i), we might need to reconsider the need and timing for use of ICD as primary prevention of sudden death, especially in HF of non-ischaemic aetiology.
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Affiliation(s)
- Magdy Abdelhamid
- Faculty of Medicine, Kasr Al Ainy, Cardiology Department, Cairo University, Cairo, Egypt
| | - Giuseppe Rosano
- St George's Hospitals, NHS Trust, University of London, London, UK
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Stamatis Adamopoulos
- Heart Failure - Transplant - Mechanical Circulatory Support Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Michael Böhm
- Universitatsklinikum des Saarlandes, Klinik fur Innere Medizin III, Saarland University, Kardiologie, Angiologie und Internistische Intensivmedizin, Homburg/Saar, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, University Hospital Attikon, Athens, Greece
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Yury Lopatin
- Volgograd State Medical University, Regional Cardiology Centre, Volgograd, Russian Federation
| | - Lars Lund
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Davor Milicic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Brenda Moura
- Armed Forces Hospital, Porto, & Faculty of Medicine, University of Porto, Porto, Portugal
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel, & Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade University School of Medicine, Belgrade, Serbia
| | - Amina Rakisheva
- Scientific Research Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Wilfried Mullens
- Cardiovascular Physiology, Hasselt University, Belgium, & Heart Failure and Cardiac Rehabilitation Specialist, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Massimo Piepoli
- Cardiac Unit, Guglielmo da Saliceto Hospital, University of Parma, Piacenza, Italy
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona & CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Thomas Thum
- Institute of Molecular and Therapeutic Strategies, Hannover & Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charite Universitatsmedizin, Berlin, Germany
| | - Petar Seferovic
- Department Faculty of Medicine, University of Belgrade, Belgrade & Serbian Academy of Sciences and Arts, Belgrade, Serbia
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Elsayed N, Unkart J, Abdelgawwad M, Naazie I, Lawrence PF, Malas MB. Role of Renin-Angiotensin-Aldosterone System Inhibition in Patients Undergoing Carotid Revascularization. J Am Heart Assoc 2022; 11:e025034. [PMID: 36000412 PMCID: PMC9496413 DOI: 10.1161/jaha.121.025034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Previous data suggest that using renin‐angiotensin‐aldosterone system inhibitors (RAASIs) improves survival in patients with cardiovascular diseases. We sought to investigate the association of different patterns of use of RAASIs on perioperative and 1‐year outcomes following carotid revascularization. Methods and Results We investigated patients undergoing carotid revascularization, either with carotid endarterectomy or transfemoral carotid artery stenting, in the VQI (Vascular Quality Initiative) VISION (Vascular Implant Surveillance and Interventional Outcomes Network) data set between 2003 and 2018. We divided our cohort into 3 groups: (1) no history of RAASI intake, (2) preoperative intake only, and (3) continuous pre‐ and postoperative intake. The final cohort included 73 174 patients; 44.4% had no intake, 50% had continuous intake, and 5.6% had only preoperative intake. Compared with continuous intake, preoperative and no intake were associated with higher odds of postoperative stroke (odds ratio [OR], 1.7 [95% CI, 1.5–1.9]; P<0.001; OR, 1.1 [95% CI, 1.03–1.2]; P=0.010); death (OR, 4.8 [95% CI, 3.8–6.1]; P<0.001; OR, 1.9 [95% CI, 1.6–2.2]; P<0.001); and stroke/death (OR, 2.05 [95% CI, 1.8–2.3]; P<0.001; OR, 1.2 [95% CI, 1.1–1.3]; P<0.001), respectively. At 1 year, preoperative and no intake were associated with higher odds of stroke (hazard ratio [HR], 1.4 [95% CI, 1.3–1.6]; P<0.001; HR, 1.15, [95% CI, 1.08–1.2]; P<0.001); death (HR, 1.7 [95% CI, 1.5–1.9]; P<0.001; HR, 1.3 [95% CI, 1.2–1.4]; P<0.001); and stroke/death (HR, 1.5 [95% CI, 1.4–1.7]; P<0.001; HR, 1.2 [95% CI, 1.17–1.3]; P<0.001), respectively. Conclusions Compared with subjects discontinuing or never starting RAASIs, use of RAASIs before and after carotid revascularization was associated with a short‐term stroke and mortality benefit. Future clinical trials examining prescribing patterns of RAASIs should aim to clarify the timing and potential to maximize the protective effects of RAASIs in high‐risk vascular patients.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
| | - Jonathan Unkart
- Department of Surgery State University New York Downstate University Health Sciences University Brooklyn NY
| | - Mohammad Abdelgawwad
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery David Geffen School of Medicine at UCLA Los Angeles CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
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De Filippo O, Russo C, Manai R, Borzillo I, Savoca F, Gallone G, Bruno F, Ahmad M, De Ferrari GM, D'Ascenzo F. Impact of secondary prevention medical therapies on outcomes of patients suffering from Myocardial Infarction with NonObstructive Coronary Artery disease (MINOCA): A meta-analysis. Int J Cardiol 2022; 368:1-9. [PMID: 35987312 DOI: 10.1016/j.ijcard.2022.08.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/19/2022]
Abstract
AIMS To assess the impact of secondary prevention medical therapies (statins, ACE-inhibitors/Angiotensin Receptor Blockers (ARB), beta-blockers (BB) and Dual Antiplatelet Therapy (DAPT)) on outcomes of patients with myocardial infarction with nonobstructive coronary artery disease (MINOCA). METHODS Five adjusted observational studies encompassing 10,546 were included in this meta-analysis. All-cause death was the primary endpoint, while Major Adverse Cardiovascular Events (MACE) and acute myocardial infarction (AMI) were the secondary endpoints. RESULTS After 24 months of follow up, statins (tested in 8093 patients) were associated with a reduced risk of all-cause death (HR 0.60:0.45-0.81, p 〈0,001), while ACE-inhibitors/ARB (on 9666 patients) were not. Aggregate data from two studies (n = 9720, 7719 on beta-blockers, 6423 on DAPT) indicated that beta-blockers and DAPT (median follow-up 34.1 and 15.7 months, respectively) were both associated with a significant reduction of all-cause death (HR0.81:0.66-0.99, p = 0.04, and HR0.73:0.55-0.98, p = 0.03, for beta-blockers and DAPT, respectively). Among the investigated therapies, only ACE-inhibitors/ARBs entailed a reduced risk of MACE (HR0.65:0.44-0.94, p = 0.02, all CI 95%) over 36.5 months (four studies, n = 10,150). None of the investigated therapies was associated with a reduced risk of AMI. CONCLUSIONS Data from adjusted observational studies suggest that beta-blockers, statins and DAPT are associated with a survival benefit among MINOCA patients. ACE-inhibitors/ARB entail a reduced risk of MACE while none of the investigated secondary prevention therapies is associated with a reduced risk of AMI. Randomized controlled trials are warranted to confirm these findings.
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Affiliation(s)
- Ovidio De Filippo
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy.
| | - Caterina Russo
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Rossella Manai
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Irene Borzillo
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Federica Savoca
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Guglielmo Gallone
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Francesco Bruno
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Mahmood Ahmad
- Department of Cardiology, Royal Free Hospital, London, United Kingdom
| | - Gaetano Maria De Ferrari
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Fabrizio D'Ascenzo
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
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Nutritional Evaluation of Sea Buckthorn “Hippophae rhamnoides” Berries and the Pharmaceutical Potential of the Fermented Juice. FERMENTATION-BASEL 2022. [DOI: 10.3390/fermentation8080391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sea buckthorn is a temperate bush plant native to Asian and European countries, explored across the world in traditional medicine to treat various diseases due to the presence of an exceptionally high content of phenolics, flavonoids and antioxidants. In addition to the evaluation of nutrients and active compounds, the focus of the present work was to assess the optimal levels for L. plantarum RM1 growth by applying response surface methodology (RSM), and to determine the impact of juice fermentation on antioxidant, anti-hypertension and anticancer activity, as well as on organoleptic properties. Sea buckthorn berries were shown to contain good fiber content (6.55%, 25 DV%), high quality of protein (3.12%, 6.24 DV%) containing: histidine, valine, threonine, leucine and lysine (with AAS 24.32, 23.66, 23.09, 23.05 and 21.71%, respectively), and 4.45% sugar that provides only 79 calories. Potassium was shown to be the abundant mineral content (793.43%, 22.66 DV), followed by copper and phosphorus (21.81 and 11.07 DV%, respectively). Sea buckthorn juice exhibited a rich phenolic, flavonoid and carotenoid content (283.58, 118.42 and 6.5 mg/g, respectively), in addition to a high content of vitamin C (322.33 mg/g). The HPLC profile indicated that benzoic acid is the dominant phenolic compound in sea buckthorn berries (3825.90 mg/kg). Antioxidant potentials (DPPH and ABTS) of sea buckthorn showed higher inhibition than ascorbic acid. Antimicrobial potentials were most pronounced against Escherichia coli BA12296 (17.46 mm). The probiotic growth was 8.5 log cfu/mL, with juice concentration, inoculum size and temperature as the main contributors to probiotic growth with a 95% confidence level. Fermentation of sea buckthorn juice with L. plantarum RM1 enhanced the functional phenolic and flavonoid content, as well as antioxidant and antimicrobial activities. The fermentation with L. plantarum RM1 enhanced the anti-hypertension and anticancer properties of the sea buckthorn juice and gained consumers’ sensorial overall acceptance.
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Molaei A, Molaei E, Sadeghnia H, Hayes AW, Karimi G. LKB1: An emerging therapeutic target for cardiovascular diseases. Life Sci 2022; 306:120844. [PMID: 35907495 DOI: 10.1016/j.lfs.2022.120844] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/22/2022] [Accepted: 07/24/2022] [Indexed: 10/16/2022]
Abstract
Cardiovascular diseases (CVDs) are currently the most common cause of morbidity and mortality worldwide. Experimental studies suggest that liver kinase B1 (LKB1) plays an important role in the heart. Several studies have shown that cardiomyocyte-specific LKB1 deletion leads to hypertrophic cardiomyopathy, left ventricular contractile dysfunction, and an increased risk of atrial fibrillation. In addition, the cardioprotective effects of several medicines and natural compounds, including metformin, empagliflozin, bexarotene, and resveratrol, have been reported to be associated with LKB1 activity. LKB1 limits the size of the damaged myocardial area by modifying cellular metabolism, enhancing the antioxidant system, suppressing hypertrophic signals, and inducing mild autophagy, which are all primarily mediated by the AMP-activated protein kinase (AMPK) energy sensor. LKB1 also improves myocardial efficiency by modulating the function of contractile proteins, regulating the expression of electrical channels, and increasing vascular dilatation. Considering these properties, stimulation of LKB1 signaling offers a promising approach in the prevention and treatment of heart diseases.
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Affiliation(s)
- Ali Molaei
- Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Hamidreza Sadeghnia
- Pharmacological Research Center of Medicinal Plants, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmacology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - A Wallace Hayes
- University of South Florida College of Public Health, Tampa, FL, USA
| | - Gholamreza Karimi
- Pharmaceutical Research Center, Institute of Pharmaceutical Technology, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmacodynamics and Toxicology, Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran..
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Influenza Vaccination for Cardiovascular Prevention: Further Insights from the IAMI Trial and an Updated Meta-analysis. Curr Cardiol Rep 2022; 24:1327-1335. [PMID: 35876953 PMCID: PMC9310360 DOI: 10.1007/s11886-022-01748-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 12/04/2022]
Abstract
Purpose of Review Influenza infection is a significant, well-established cause of cardiovascular disease (CVD) and CV mortality. Influenza vaccination has been shown to reduce major adverse cardiovascular events (MACE) and CV mortality. Therefore, major society guidelines have given a strong recommendation for its use in patients with established CVD or high risk for CVD. Nevertheless, influenza vaccination remains underutilized. Historically, influenza vaccination is administered to stable outpatients. Until recently, the safety and efficacy of influenza vaccination among patients with acute myocardial infarction (MI) had not been established. Recent Findings The recently published Influenza Vaccination after Myocardial Infarction (IAMI) trial showed that influenza vaccination within 72 h of hospitalization for MI led to a significant 28% reduction in MACE and a 41% reduction in CV mortality, without any excess in serious adverse events. Additionally, we newly performed an updated meta-analysis of randomized clinical trials (RCTs) including IAMI and the recent Influenza Vaccine to Prevent Adverse Vascular Events (IVVE) trial. In pooled analysis of 8 RCTs with a total of 14,420 patients, influenza vaccine, as compared with control/placebo, was associated with significantly lower risk of MACE at follow-up [RR 0.75 (95%CI 0.57–0.97), I2 56%]. Summary The recent IAMI trial showed that influenza vaccination in patients with recent MI is safe and efficacious at reducing CV morbidity and mortality. Our updated meta-analysis confirms a 25% reduction in MACE. The influenza vaccine should be strongly encouraged in all patients with CVD and incorporated as an essential facet of post-MI care and secondary CVD prevention.
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Gosch M. [Pharmacological treatment of cardiovascular diseases in old age : Geriatic perspective]. Z Gerontol Geriatr 2022; 55:471-475. [PMID: 35849160 DOI: 10.1007/s00391-022-02084-w] [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] [Accepted: 06/24/2022] [Indexed: 11/25/2022]
Abstract
Cardiovascular diseases have the highest prevalence in advanced age. Nevertheless, older age groups are frequently underrepresented in randomized controlled trials (RCT). Consequently, in many cases the evidence is often insufficient. Therefore, recommendations from guidelines can only be transferred to this age group to a limited extent. Due to the complexity and vulnerability of geriatric patients, individual considerations in pharmacological therapy are often required. In the following article, the pharmacotherapy of some relevant cardiovascular diseases is discussed from the perspective of a geriatric treatment approach.
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Affiliation(s)
- Markus Gosch
- Klinikum Nürnberg, Medizinische Klinik 2 - Schwerpunkt Geriatrie, Paracelsus Medizinische Privatuniversität Nürnberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland.
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Jan RK, Alsheikh-Ali A, Mulla AA, Sulaiman K, Panduranga P, Al-Mahmeed W, Bazargani N, Al-Suwaidi J, Al-Jarallah M, Al-Motarreb A, Salam A, Al-Zakwani I. Outcomes of guideline-based medical therapy in patients with acute heart failure and reduced left ventricular ejection fraction: Observations from the Gulf acute heart failure registry (Gulf CARE). Medicine (Baltimore) 2022; 101:e29452. [PMID: 35687781 PMCID: PMC9276384 DOI: 10.1097/md.0000000000029452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/22/2022] [Indexed: 01/04/2023] Open
Abstract
This study aimed to report on the use, predictors and outcomes of guideline-based medical therapy (GBMT) in patients with acute heart failure (HF) with reduced ejection fraction of <40% (HFrEF), from seven countries in the Arabian Gulf.Patients with acute HFrEF (N = 2680), aged 18 years or older, and hospitalized February-November 2012 were recruited and data were collected post discharge at 3 months (n = 2477) and 1 year (n = 2418). The use and doses of GBMT were evaluated as per European, American and Canadian HF guidelines. Analyses were performed using multivariate logistic regression. This study was registered at clinicaltrials.gov (NCT01467973).The majority of patients were on dual (39%) and triple (39%) GBMT modalities, 14% received one GBMT medication, while 7.2% were not on any GBMT medications. On admission, 80% of patients were on renin-angiotensin system (RAS) blockers, 75% on b-blockers and 56% on mineralocorticoid receptor antagonists (MRAs), with a small proportion of these patients were taking target doses (RAS blockers 13%, b-blockers 7.3%, MRAs 14%). Patients taking triple GBMT were younger (P < .001), less likely to have comorbidities such as diabetes mellitus (P < .001) and CKD/dialysis (P < .001), less likely to receive in-hospital invasive treatments (P < .001), and more likely to be treated by a cardiologist (P < .001), than patients on a single medication. Patients taking triple GBMT showed significantly reduced all-cause mortality both at 3-months (P = .048), and at 12-months (P = .003), compared to patients taking no GBMT.Triple GBMT prescribing and dosing in patients with HFrEF were suboptimal in the Arabian Gulf. Further studies are required to investigate GBMT utilization and dosing in the outpatient setting.
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Affiliation(s)
- Reem K. Jan
- College of Medicine, Mohammed Bin Rashid University of Medicine & Health Sciences, Dubai, UAE
| | - Alawi Alsheikh-Ali
- College of Medicine, Mohammed Bin Rashid University of Medicine & Health Sciences, Dubai, UAE
| | - Arif Al Mulla
- Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, UAE
| | - Kadhim Sulaiman
- Department of Cardiology, Royal Hospital, Muscat, Oman
- Director General of Specialized Medical Care, Ministry of Health, Muscat, Oman
| | | | - Wael Al-Mahmeed
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, UAE
| | | | - Jassim Al-Suwaidi
- Department of Adult Cardiology, Hamad Medical Corporation, Doha, Qatar
- Qatar Cardiovascular Research Centre, Doha, Qatar
| | - Mohammed Al-Jarallah
- Department of Cardiology, Sabah Al Ahmed Cardiac Centre, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Ahmed Al-Motarreb
- Department of Internal Medicine, Faculty of Medicine, Sana’a University, Sana’a, Yemen
| | - Amar Salam
- Department of Adult Cardiology, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, QU Health, Qatar University, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Ibrahim Al-Zakwani
- Department of Pharmacology & Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
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Berrill M, Ashcroft E, Fluck D, John I, Beeton I, Sharma P, Baltabaeva A. Right Ventricular Dysfunction Predicts Outcome in Acute Heart Failure. Front Cardiovasc Med 2022; 9:911053. [PMID: 35665249 PMCID: PMC9157539 DOI: 10.3389/fcvm.2022.911053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/22/2022] [Indexed: 12/02/2022] Open
Abstract
Aim The severity of cardiac impairment in acute heart failure (AHF) predicts outcome, but challenges remain to identify prognostically important non-invasive parameters of cardiac function. Left ventricular ejection fraction (LVEF) is relevant, but only in those with reduced LV systolic function. We aimed to assess the standard and advanced parameters of left and right ventricular (RV) function from echocardiography in predicting long-term outcomes in AHF. Methods A total of 418 consecutive AHF patients presenting over 12 months were prospectively recruited and underwent bedside echocardiography within 24 h of recruitment. We retrospectively assessed 8 RV and 5 LV echo parameters of the cardiac systolic function to predict 2-year mortality, using both guideline-directed and study-specific cutoffs, based on the maximum Youden indices via ROC analysis. For the RV, these were the tricuspid annular plane systolic excursion, RV fractional area change, tissue Doppler imaging (TDI) peak tricuspid annular systolic wave velocity, both peak- and end-systolic RV free wall global longitudinal strain (RV GLS) and strain rate (mean RV GLSR), RV ejection fraction (RVEF) derived from a 2D ellipsoid model and the ratio of the TAPSE to systolic pulmonary artery pressure (SPAP). For the LV, these were the LVEF, mitral regurgitant ΔP/Δt (MR dP/dt), the lateral mitral annular TDI peak systolic wave velocity, LV GLS, and the LV GLSR. Results A total of 7/8 parameters of RV systolic function were predictive of 2-year outcome, with study cutoffs like international guidelines. A cutoff of < −1.8 s–1 mean RV GLSR was associated with worse outcome compared to > −1.8 s–1 [HR 2.13 95% CI 1.33–3.40 (p = 0.002)]. TAPSE:SPAP of > 0.027 cm/mmHg (vs. < 0.027 cm/mmHg) predicted worse outcome [HR 2.12 95% CI 1.53–2.92 (p < 0.001)]. A 3-way comparison of 2-year mortality by LVEF from the European Society of Cardiology (ESC) guideline criteria of LVEF > 50, 41–49, and < 40% was not prognostic [38.6% vs. 30.9 vs. 43.9% (p = 0.10)]. Of the 5 parameters of LV systolic function, only an MR dP/dt cutoff of < 570 mmHg was predictive of adverse outcome [HR 1.63 95% CI 1.01–2.62 (p = 0.047)]. Conclusion With cutoffs broadly like the ESC guidelines, we identified RV dysfunction to be associated with adverse prognosis, whereas LVEF could not identify patients at risk.
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Affiliation(s)
- Max Berrill
- Department of Cardiology, St. Peter’s Hospital, Surrey, United Kingdom
- Department of Research and Development, St. Peter’s Hospital, Surrey, United Kingdom
| | - Eshan Ashcroft
- Department of Cardiology, St. Peter’s Hospital, Surrey, United Kingdom
| | - David Fluck
- Department of Cardiology, St. Peter’s Hospital, Surrey, United Kingdom
- Department of Research and Development, St. Peter’s Hospital, Surrey, United Kingdom
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, United Kingdom
| | - Isaac John
- Department of Research and Development, St. Peter’s Hospital, Surrey, United Kingdom
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, United Kingdom
| | - Ian Beeton
- Department of Cardiology, St. Peter’s Hospital, Surrey, United Kingdom
| | - Pankaj Sharma
- Department of Research and Development, St. Peter’s Hospital, Surrey, United Kingdom
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, United Kingdom
| | - Aigul Baltabaeva
- Department of Cardiology, St. Peter’s Hospital, Surrey, United Kingdom
- Department of Research and Development, St. Peter’s Hospital, Surrey, United Kingdom
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, United Kingdom
- Department of Cardiology, Royal Brompton and Harefield Hospital, London, United Kingdom
- *Correspondence: Aigul Baltabaeva,
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Milinković I, Polovina M, Coats AJS, Rosano GMC, Seferović PM. Medical Treatment of Heart Failure with Reduced Ejection Fraction in the Elderly. Card Fail Rev 2022; 8:e17. [PMID: 35601008 PMCID: PMC9115638 DOI: 10.15420/cfr.2021.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/26/2021] [Indexed: 11/24/2022] Open
Abstract
The aging population, higher burden of predisposing conditions and comorbidities along with improvements in therapy all contribute to the growing prevalence of heart failure (HF). Although the majority of trials have not demonstrated age-dependent heterogeneity in the efficacy or safety of medical treatment for HF, the latest trials demonstrate that older participants are less likely to receive established drug therapies for HF with reduced ejection fraction. There remains reluctance in real-world clinical practice to prescribe and up-titrate these medications in older people, possibly because of (mis)understanding about lower tolerance and greater propensity for developing adverse drug reactions. This is compounded by difficulties in the management of multiple medications, patient preferences and other non-medical considerations. Future research should provide a more granular analysis on how to approach medical and device therapies in elderly patients, with consideration of biological differences, difficulties in care delivery and issues relevant to patients’ values and perspectives. A variety of approaches are needed, with the central principle being to ‘add years to life – and life to years’. These include broader representation of elderly HF patients in clinical trials, improved education of healthcare professionals, wider provision of specialised centres for multidisciplinary HF management and stronger implementation of HF medical treatment in vulnerable patient groups.
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Affiliation(s)
- Ivan Milinković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | | | | | - Petar M Seferović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Serbian Academy of Sciences and Arts, Belgrade, Serbia
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 612] [Impact Index Per Article: 306.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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Stolfo D, Sinagra G, Savarese G. Evidence-based Therapy in Older Patients with Heart Failure with Reduced Ejection Fraction. Card Fail Rev 2022; 8:e16. [PMID: 35541287 PMCID: PMC9069263 DOI: 10.15420/cfr.2021.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/15/2022] [Indexed: 11/06/2022] Open
Abstract
Older patients are becoming prevalent among people with heart failure (HF) as the overall population ages. However, older patients are largely under-represented, or even excluded, from randomised controlled trials on HF with reduced ejection fraction, limiting the generalisability of trial results in the real world and leading to weaker evidence supporting the use and titration of guideline-directed medical therapy (GDMT) in older patients with HF with reduced ejection fraction. This, in combination with other factors limiting the application of guideline recommendations, including a fear of poor tolerability or adverse effects, the heavy burden of comorbidities and the need for multiple therapies, classically leads to lower adherence to GDMT in older patients. Although there are no data supporting the under-use and under-dosing of HF medications in older patients, large registry-based studies have confirmed age as one of the major obstacles to treatment optimisation. In this review, the authors provide an overview of the contemporary state of implementation of GDMT in older groups and the reasons for the lower use of treatments, and discuss some measures that may help improve adherence to evidence-based recommendations in older age groups.
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Affiliation(s)
- Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina and University Hospital of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina and University Hospital of Trieste, Trieste, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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Heart Failure After ST-Elevation Myocardial Infarction: Beyond Left Ventricular Adverse Remodeling. Curr Probl Cardiol 2022:101215. [PMID: 35460680 DOI: 10.1016/j.cpcardiol.2022.101215] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 12/11/2022]
Abstract
ST-segment elevation myocardial infarction (STEMI) remains a significant source of morbidity and mortality worldwide. Despite advances in treatment leading to a significant reduction in the early complications and in-hospital mortality, a significant proportion of STEMI survivors develop heart failure (HF) at follow-up. The classic paradigm of HF after STEMI is one characterized by left ventricular adverse remodeling (LVAR) and encompasses the process of regional and global structural and functional changes that occur in the heart as a consequence of loss of viable myocardium, increased wall stress and neurohormonal activation, and results in HF with reduced ejection fraction (HFrEF). More recently, however, with further improvements in the treatment of STEMI the incidence and entity of LVAR appear to be largely reduced, yet the risk for HF following STEMI is not abolished and remains substantial, identifying a new paradigm by which patients with STEMI present with HF and preserved EF (HFpEF) characterized by reduction of diastolic or systolic reserve independent of LVAR.
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Gaudino M, Di Franco A, Cao D, Giustino G, Bairey Merz CN, Fremes SE, Kirtane AJ, Kunadian V, Lawton JS, Masterson Creber RM, Sandner S, Vogel B, Zwischenberger BA, Dangas GD, Mehran R. Sex-Related Outcomes of Medical, Percutaneous, and Surgical Interventions for Coronary Artery Disease: JACC Focus Seminar 3/7. J Am Coll Cardiol 2022; 79:1407-1425. [PMID: 35393023 DOI: 10.1016/j.jacc.2021.07.066] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/12/2021] [Indexed: 12/15/2022]
Abstract
Biological and sociocultural differences between men and women are complex and likely account for most of the variations in the epidemiology and treatment outcomes of coronary artery disease (CAD) between the 2 sexes. Worse outcomes in women have been described following both conservative and invasive treatments of CAD. For example, increased levels of residual platelet reactivity during treatment with antiplatelet drugs, higher rates of adverse cardiovascular outcomes following percutaneous coronary revascularization, and higher operative and long-term mortality after coronary bypass surgery have been reported in women compared with in men. Despite the growing recognition of sex-specific determinants of outcomes, representation of women in clinical studies remains low and sex-specific management strategies are generally not provided in guidelines. This review summarizes the current evidence on sex-related differences in patients with CAD, focusing on the differential outcomes following medical therapy, percutaneous coronary interventions, and coronary artery bypass surgery.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Stephen E Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ajay J Kirtane
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center and the Cardiovascular Research Foundation, New York, New York, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brittany A Zwischenberger
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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