Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients

Risk-directed management of chronic kidney disease

The timely and rational institution of therapy is a key step towards reducing the global burden of chronic kidney disease (CKD). CKD is a heterogeneous entity with varied aetiologies and diverse trajectories, which include risk of kidney failure but also cardiovascular events and death. Developments in the past decade include substantial progress in CKD risk prediction, driven in part by the accumulation of electronic health records data. In addition, large randomized clinical trials have demonstrated the effectiveness of sodium-glucose co-transporter 2 inhibitors, glucagon-like peptide 1 receptor agonists and mineralocorticoid receptor antagonists in reducing adverse events in CKD, greatly expanding the options for effective therapy. Alongside angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, these classes of medication have been proposed to be the four pillars of CKD pharmacotherapy. However, all of these drug classes are underutilized, even in individuals at high risk. Leveraging prognostic estimates to guide therapy could help clinicians to prescribe CKD-related therapies to those who are most likely to benefit from their use. Risk-based CKD management thus aligns patient risk and care, allowing the prioritization of absolute benefit in determining therapeutic selection and timing. Here, we discuss CKD prognosis tools, evidence-based management and prognosis-guided therapies.

Controversies in hypertension therapy: bedtime dosing or daytime dosing?

Hypertension management strategies have evolved from solely controlling office blood pressure (BP) to comprehensive 24-h BP regulation. This review synthesizes current evidence on the timing of antihypertensive medication, with a focus on circadian BP rhythms and patients with specific BP patterns or comorbidities. Bedtime dosing may benefit individuals with nocturnal hypertension and nondipper BP patterns, but large trials, such as the TIME study, have shown no significant cardiovascular outcome differences between morning and bedtime dosing. However, the optimal timing of antihypertensive medication for patients with distinct BP rhythms or comorbidities remains uncertain. Future research should investigate the potential benefits of personalized medication timing tailored to BP patterns and clinical conditions. Additionally, treatment strategies should consider BP rhythms, comorbidities, and adherence to optimize outcomes, paving the way for more effective management of hypertensive patients with complex clinical profiles.

Risk-Based Primary Prevention of Heart Failure: A Scientific Statement From the American Heart Association

The growing morbidity, mortality, and health care costs related to heart failure (HF) underscore the urgent need to prioritize its primary prevention. Whereas a risk-based approach for HF prevention remains in its infancy, several key opportunities exist to actualize this paradigm in clinical practice. First, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guidelines provided recommendations, for the first time, on the clinical utility of multivariable risk equations to estimate risk of incident HF. Second, the American Heart Association recently developed the PREVENT (Predicting Risk of Cardiovascular Disease Events) equations, which not only enable prediction of incident HF separately, but also include HF in the prediction of total cardiovascular disease. Third, the predominant phenotype of HF risk has emerged as the cardiovascular-kidney-metabolic syndrome. Fourth, the emergence of novel therapies that prevent incident HF (eg, sodium-glucose cotransporter-2 inhibitors) and target multiple cardiovascular-kidney-metabolic axes demonstrate growing potential for risk-based interventions. Whereas the concept of risk-based prevention has been established for decades, it has only been operationalized for atherosclerotic cardiovascular disease prevention to date. Translating these opportunities into a conceptual framework of risk-based primary prevention of HF requires implementation of PREVENT-HF (Predicting Risk of Cardiovascular Disease Events-Heart Failure) equations, targeted use of cardiac biomarkers (eg, natriuretic peptides) and echocardiography for risk reclassification and earlier detection of pre-HF, and definition of therapy-specific risk thresholds that incorporate net benefit and cost-effectiveness. This scientific statement reviews the current evidence for accurate risk prediction, defines strategies for equitable prevention, and proposes potential strategies for the successful implementation of risk-based primary prevention of HF.

Impact of COPD on cardiovascular risk factors and outcomes in people with established cardiovascular disease

BACKGROUND

Little is known about the association between chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) in people with established CVD. Knowing if COPD is associated with a higher risk of cardiovascular events would guide appropriate secondary prevention.

OBJECTIVE

To examine the risk of COPD on major adverse cardiac events (MACEs, acute myocardial infarction, stroke and cardiovascular death) in a complete real-world population of a large province, with known CVD.

METHODS

We conducted a retrospective population cohort study using health administration, medication, laboratory, electronic medical record and other data from Ontario, Canada. All people with a history of CVD with and without physician-diagnosed COPD as of 2008 were followed until 2016 and cardiac risk factors, sociodemographic factors, comorbidities and other factors were compared. Sequential cause-specific hazard models adjusting for these factors determined the risk of MACE in people with COPD.

RESULTS

Of 496 056 individuals with CVD in Ontario on 1 January 2008, 69 161 (13.9%) had COPD. MACE occurred more frequently among those with CVD (45.3 per 1000 person-years) and COPD compared with those with CVD alone (28.6 per 1000 person-years) (HR 1.24, 95% CI 1.21-1.26) after adjustment for cardiac risk factors, comorbidities, socioeconomic status and other factors. People with COPD were less likely to receive preventive CVD medications or see a cardiologist.

CONCLUSION

In a large, real-world population of people with established CVD, COPD was associated with a higher rate of cardiovascular events but a lower rate of preventive therapy. Strategies are needed to improve secondary CVD prevention in the COPD population.

Cost-effectiveness of stress echocardiography and exercise tolerance tests as screening in asymptomatic adults before starting physical activity

AIMS

Previous studies on exercise tolerance screening in asymptomatic individuals before starting physical activity were not cost-effective due to low specificity. However, given progress in diagnosing and treating coronary artery disease (CAD), a reevaluation of this approach is justified. We aimed to examine whether stress echocardiography (SE) would be cost-effective.

METHODS AND RESULTS

The study was conducted on asymptomatic individuals with no known coronary disease. The decision tree had two arms: in one arm, the subjects underwent stress echocardiography (SE) as a screening test before starting physical activity, and in the other, they did not. The probabilities and utilities of variables in the decision tree were taken from medical literature, and the costs of treatments were obtained from the Israeli Ministry of Health Tarif (HealthCare in Israel is universal, participation in one of four official health insurance organizations is compulsory, and "supplementary insurance" is optional). A 5-year Markov model and Monte Carlo simulation with 1000 iterations were used to assess cost-effectiveness from the insurer's perspective. The variables that had the most significant impact on cost-effectiveness were the prior risk of coronary disease and the frequency of physical activity in the population under study. When cost-effectiveness assessment of SE was conducted in subjects receiving optimal medical therapy (OMT) and revascularization either transcutaneously or with bypass surgery, both groups had almost identical benefits, with a slight advantage for those who did not undergo SE. However, the cost was higher for subjects who underwent SE, and the Incremental Cost-Effectiveness Ratio (ICER) favored the No-SE group. On the other hand, when subjects only received OMT without therapeutic catheterization or bypass surgery, a cost-effectiveness assessment of SE demonstrated a lower cost and higher benefit in the group that underwent SE. In fact, SE was found to be absolutely dominant, with a negative ICER of $(-)27,644, which means that performing SE not only adds effectiveness but also saves expenses. Finally, a cost-effectiveness evaluation was conducted to compare the benefits of performing exercise tolerance testing (ETT) without stress echocardiography in subjects receiving OMT without therapeutic catheterization or bypass surgery. The results showed that the group that underwent ETT had a slightly higher benefit at a higher cost, with an ICER of $1804. This value is much lower than a WTP (willingness-to-pay) of $50,000 per year.

CONCLUSIONS

Performing SE as a screening test before starting physical activity in asymptomatic individuals is not cost-effective when the therapeutic options include revascularization. However, when the therapeutic policy is medical therapy without revascularization - as recommended in current guidelines - performing SE screening tests improves subjects' utility and results in financial savings. Carrying out ETT also results in improved utility that is inferior to SE as a screening test. At the same time, the ICER for ETT is still much smaller than the WTP, so performing ETT is worthwhile in cases where SE is unavailable.

Optimizing renin-angiotensin-aldosterone inhibition in advanced chronic kidney disease: balancing benefits and risks

PURPOSE OF REVIEW

Renin-angiotensin-aldosterone system inhibitors (RAASi), including angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs), are fundamental in chronic kidney disease (CKD) management, particularly in proteinuric conditions. However, their use in advanced CKD (eGFR <30 ml/min/1.73 m 2 ) remains debated because of risks of hyperkalaemia, acute kidney injury (AKI), and hypotension. This review evaluates the latest evidence, including the STOP-ACEi trial, to inform the risks and benefits of RAASi in advanced CKD.

RECENT FINDINGS

The STOP-ACEi trial, a multicentre randomized controlled trial (RCT), investigated RAASi discontinuation in 411 patients with advanced CKD. After 3 years, discontinuation did not slow eGFR decline or reduce mortality, while continuation was associated with a numerical trend towards lower end-stage kidney disease (ESKD) rates. Meta-analyses also indicate that ACEi may offer superior kidney protection compared to ARBs, though both lower cardiovascular risk and this difference may not be clinically significant. Combination ACEi/ARB therapy provides no additional benefits and increases adverse events, such as hyperkalaemia and hypotension. Adjunct therapies like potassium binders and sodium-glucose cotransporter-2 (SGLT2) inhibitors may enable safer RAASi use in high-risk patients.

SUMMARY

Current evidence supports RAASi continuation in most CKD patients, including those with advanced disease, unless contraindicated. Future studies should refine patient selection criteria and optimize adjunctive strategies to mitigate adverse effects.

Key Concepts in Cardiovascular Secondary Prevention: A Case-Based Review

Atherosclerotic cardiovascular disease (ASCVD) continues to be a growing global health concern with ischemic heart disease and stroke as leading causes of years of life lost. While aging is a major ASCVD risk factor, recent trends show a concerning rise in its incidence among younger adults driven, in part, by increased rates of risk factors such as hypertension and diabetes. These individuals with ASCVD are at elevated risk of recurrence years following their initial event, further underscoring the need for aggressive implementation of secondary prevention strategies to reduce morbidity and mortality. This case-based review discusses evidence-based pharmacological approaches to ASCVD secondary prevention-focusing on the roles of antiplatelets, lipid lowering therapies, antihypertensive medications, and glucose lowering treatments, in practical clinical settings.

Pragmatic monitoring of emerging efficacy data in randomized controlled trials

Monitoring the conduct of phase III randomized controlled trials is driven by ethical reasons to protect the study integrity and the safety of trial participants. We propose a group sequential, pragmatic approach for monitoring the accumulating efficacy information in randomized controlled trials. The "Population Health Research Institute boundary" is simple to implement and sensible, as it considers the reduction in uncertainty with increasing information as the study progresses. It is also pragmatic, since it takes into consideration the typical monitoring behavior of monitoring committees of large multicenter trials and is relatively easily implemented. It not only controls the overall Lan-DeMets type I error probability (alpha) spent, but performs better than other group sequential boundaries for the total nominal study alpha. We illustrate the use of our monitoring approach in the early termination of two past completed trials.

Impact of Guideline-Directed Medical Therapy on 2-Year Mortality in Japanese Patients Undergoing Endovascular Therapy for Femoropopliteal Lesions - Results of the Multicenter GEMINI-FP Study

BACKGROUND

The effect of guideline-directed medical therapy (GDMT) on mid-term mortality in Asian patients, including Japanese patients, who have undergone endovascular therapy (EVT) for lower extremity artery disease remains still unclear. This study evaluated the effects of GDMT, defined as the combined prescription of antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, on 2-year mortality in Japanese patients undergoing EVT for femoropopliteal (FP) lesions.

METHODS AND RESULTS

In this multicenter retrospective study, 1,756 registered patients were divided into 2 groups: those who received all 3 medications that comprised GDMT (full GDMT group) and those who received ≤2 medications (non-GDMT group). After propensity score matching, the baseline characteristics did not differ significantly between the 413 pairs of participants in the full GDMT and non-GDMT groups. All-cause mortality within 2 years was significantly lower in the full GDMT than non-GDMT group (14.3% vs. 20.8%; log-rank P=0.030). Mortalities from cardiovascular and cardiocerebrovascular diseases within 2 years were also significantly lower in the GDMT group (4.2% vs. 9.5% [log-rank P=0.021] and 4.2% vs. 10.5% [log-rank P=0.007], respectively).

CONCLUSIONS

In Japanese patients undergoing EVT for FP lesions, GDMT may improve all-cause, cardiovascular, and cardiocerebrovascular mortality within 2 years.

Heart Failure in Older Patients: An Update

Heart failure (HF) is a clinical syndrome with high incidence and prevalence and high morbidity and death rate, even in the short term, representing a serious public health issue, mainly in older people. It is a growing cause for hospital admission in this age group, being frequently associated with several comorbidities, further aggravating the disease's course. Moreover, older HF patients are usually affected by clinical conditions, like frailty, malnutrition, and cachexia, which significantly impact the overall management of HF and need to be properly identified and treated. Diagnosing and managing HF in older patients may be very complicated and challenging. Although specific data on treatment of both acute and chronic HF in older subjects are limited and mainly extrapolated from large-scale clinical trials, the standard pharmacological management may be considered well-tolerated and generally safe. In any case, a personalized and tailored approach is mandatory and is based on severity of comorbidities, overall status, and prognosis, above all in frailer and more comorbid subjects, due to the higher rate of drug interactions, side effects, and therapy discontinuation in this population. In this scenario, palliative care has become a fundamental part of HF management in the elderly in order to improve their care and the quality of life. Moreover, an increasing number of promising pharmacological options deserve further investigation in order to support clinicians in optimizing management of comorbid and frailer patients. In this work, we provide detailed and updated insight into clinical, therapeutic, and prognostic features of both acute and chronic HF in the older population.

Non-Anticoagulation Strategies Aimed at Primary Stroke Prevention in Nascent Atrial Fibrillation

At its earliest appearance, atrial fibrillation (AF) is often unnoticed, asymptomatic, and/or merely device-detected. Widespread use of heart-rate monitoring technologies has facilitated such "nascent atrial fibrillation (nAF)" recognition. Consequently, clinicians face a growing number of patients affected by new-onset AF in the absence of a definite indication for anticoagulation due to several counterarguments: (1) a CHA2DS2-VA score ≤ 1 in otherwise apparently healthy subjects; (2) an uncertain embolic/hemorrhagic benefit/risk ratio with anticoagulation; (3) EKG demonstration and confirmation of AF; and (4) existence of a pathogenic mechanism other than atrial hypercoagulability. In this frustrating limitation of pharmacological options, cardiologists may miss a complete comprehension of drugs with proven anti-ictal potential, whose administration may serve both as a bridge strategy toward future anticoagulation and as a consolidative strategy paralleling anticoagulation. This review aims to summarize and elucidate such therapeutic strategies and their preventative mechanisms.

Treatment of prehypertension among adults with HIV

OBJECTIVE

Elevated blood pressure (BP), even at prehypertensive levels, increases cardiovascular disease risk among people with HIV (PWH); yet international guidelines in low-income countries recommend treatment initiation at BP at least 140/90 mmHg. We determined the efficacy, feasibility, and acceptability of treating prehypertension in PWH in Haiti.

DESIGN

An unblinded randomized clinical trial (enrolled April 2021-March 2022) with 12-month follow-up.

SETTING

GHESKIO Centres, Port-au-Prince, Haiti.

PARTICIPANTS

Two hundred fifty adults with HIV with prehypertension (SBP 120-138 or DBP 80-89) not on medication, aged 18-65 years, virally suppressed, and without pregnancy, diabetes, or kidney disease.

INTERVENTION

Participants were randomized to treatment (amlodipine 5 mg) or control (no amlodipine unless two BP ≥140/90 mmHg).

MAIN OUTCOME MEASURE

Primary outcome was mean change in SBP between intervention versus control groups from enrollment to 12 months.

RESULTS

Among 250 adults, median age was 49 years, 40.8% were women. Baseline median BP was 129/78 mmHg intervention versus 128/77 mmHg control. After 12 months, the difference in mean change between study groups for SBP was -5.9 mmHg [95% confidence interval (95% CI) -8.8 to -3.0] and for DBP was -5.5 mmHg (95% CI -7.9 to -3.2). At 12 months, 5.6% intervention and 23.0% control participants developed incident hypertension (hazard ratio 0.18; 95% CI 0.07-0.47). There were no differences in viral load suppression at 12 months or drug-related serious adverse events. Intervention acceptability was high among providers and participants in qualitative interviews.

CONCLUSION

In PWH in a resource-poor setting, prehypertension treatment was feasible, acceptable, and effective in reducing mean SBP and incident hypertension.

REGISTRATION

Clinicaltrials.gov NCT04692467.

Benefits of aldosterone receptor antagonism in chronic kidney disease: the BARACK-D RCT

Background

Chronic kidney disease affects around 10% of the global population and is associated with significant risk of progression to end-stage renal disease and vascular events. Aldosterone receptor antagonists such as spironolactone have shown prognostic benefits in patients with heart failure, but effects on patients with chronic kidney disease are uncertain.

Objectives

To determine the effect of low-dose spironolactone on mortality and cardiovascular outcomes in people with chronic kidney disease stage 3b.

Design

Prospective randomised open blinded end-point trial.

Settings

Three hundred and twenty-nine general practitioner practices throughout the United Kingdom.

Participants

Patients meeting the criteria for chronic kidney disease stage 3b (estimated glomerular filtration rate 30-44 ml/minute/1.73 m2) according to National Institute for Health and Care Excellence guidelines were recruited. Due to the higher than anticipated measurement error/fluctuations, the eligible range was extended to 30-50 ml/minute/1.73 m2 following the initial recruitment period.

Intervention

Participants were randomised 1 : 1 to receive either spironolactone 25 mg once daily in addition to standard care, or standard care only.

Outcome measures

Primary outcome was the first occurring of all-cause mortality, first hospitalisation for heart disease (coronary heart disease, arrhythmia, atrial fibrillation, sudden death, failed sudden death), stroke, heart failure, transient ischaemic attack or peripheral arterial disease, or first occurrence of any condition not listed at baseline. Secondary outcome measures included changes in blood pressure, renal function, B-type natriuretic peptide, incidence of hyperkalaemia and treatment costs and benefits.

Results

One thousand four hundred and thirty-four participants were randomised of the 3022 planned. We found no evidence of differences between the intervention and control groups in terms of effectiveness with the primary combined vascular end points, nor with the secondary clinical outcomes, including progression in renal decline. These results were similar for the total treatment periods or a 3-year follow-up period as originally planned. More adverse events were experienced and more participants discontinued treatment in the intervention group. Two-thirds of participants randomised to spironolactone stopped treatment within six months because they met pre-specified safety stop criteria. The addition of low-dose spironolactone was estimated to have a cost per quality-adjusted life-year gained value above the National Institute for Health and Care Excellence's threshold of £30,000.

Limitations

Main limitations were difficulties in recruiting eligible participants resulting in an underpowered trial with poor ethnic diversity taking twice as long as planned to complete. We have explored the data in secondary analyses that indicate that, despite these difficulties, the findings were reliable.

Conclusions

The benefits of aldosterone receptor antagonism in chronic kidney disease trial found no evidence to support adding low-dose spironolactone (25 mg daily) in patients with chronic kidney disease stage 3b: there were no changes to cardiovascular events during the trial follow-up, either for the combined primary or individual components. There was also no evidence of benefit observed in rates of renal function decline over the trial, but much higher initial creatinine rise and estimated glomerular filtration rate decline, and to a higher percentage rate, in the intervention arm in the first few weeks of spironolactone treatment, which resulted in a high proportion of participants discontinuing spironolactone treatment at an early stage. These higher rates of negative renal change reduced in scale over the study but did not equalise between arms. The addition of 25 mg of spironolactone therefore provided no reno- or cardio-protection and was associated with an increase in adverse events.

Future work

These findings might not be applicable to different mineralocorticoid receptor antagonists.

Study registration

Current Controlled Trials ISRCTN44522369.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/01/52) and is published in full in Health Technology Assessment; Vol. 29, No. 5. See the NIHR Funding and Awards website for further award information.

Inside the Mind of the DMC: A Review of Principles and Issues with Case Studies

A data monitoring committee (DMC) can have an extremely challenging job. Stop a trial too soon, and results are inconclusive and the trial fails to obtain answers to important questions that could inform future clinical practice. Stop a trial too late, and trial participants are exposed to potentially harmful or ineffective interventions longer than necessary. Securing convincing and conclusive evidence and the ethical responsibility to current and future patients are weighed carefully during DMC deliberations. The ability to interpret complex information, and appreciation of issues affecting scientific integrity, are critical for the DMC to protect trial participants and public trust. Challenges faced by and issues of prudence faced by DMCs are discussed including interim analysis issues, assessing the totality of information with statistical boundaries as guidelines, interpretation of composite and surrogate outcomes, reactions to early trends, benefit:risk assessment, landscape changes, subgroup analyses, composing information for a comprehensive understanding of patient-centric effects, and evaluating the value of additional data. Case studies illustrate how DMCs addressed the challenges.

Association between body mass index and clinical outcomes in patients with acute myocardial infarction and reduced systolic function: Analysis of PARADISE-MI trial data

AIMS

The relationship between body mass index (BMI) and clinical outcomes in patients with cardiovascular disease, including acute heart failure (AHF) and acute myocardial infarction (AMI), remains debated. This study investigates the association between BMI and clinical outcomes within the PARADISE-MI cohort, while also evaluating the impact of angiotensin receptor-neprilysin inhibitor (ARNI) versus angiotensin-converting enzyme inhibitor (ACE-I) treatment on this relationship.

METHODS AND RESULTS

The analysis included 5589 patients from the PARADISE-MI study with available baseline BMI data. The cohort comprised patients with AMI and pulmonary congestion and/or left ventricular ejection fraction ≤40%. Patients were categorized into six World Health Organization BMI subgroups. The primary outcome of interest was the composite endpoint of cardiovascular death, heart failure (HF)-associated hospitalization, and outpatient symptomatic HF episodes. The mean baseline BMI of the cohort was 28.1 ± 5.0 kg/m2. The lowest rate of the primary composite endpoint (6.2/100 patient-years) was observed in overweight patients (BMI 25-29.9 kg/m2), while the highest rates were found in the lowest and highest BMI subgroups (8.4/100 patient-years for BMI <18.5 kg/m2 and 9.7/100 patient-years for BMI >40 kg/m2). There was no significant interaction between BMI and the treatment effect of ARNI versus ACE-I on the primary composite outcome (p = 0.73). Additionally, no significant differences in the incidence of adverse events or serious adverse events were noted across the BMI subgroups.

CONCLUSIONS

In AMI with AHF patients, the relationship between BMI and the primary composite outcome is non-linear, with the lowest event rates observed in overweight individuals. Outcomes and safety profiles for ARNI and ACE-I treatments were similar across BMI subgroups.

15-Year trends, predictors, and outcomes of heart failure hospitalization complicating first acute myocardial infarction in the modern percutaneous coronary intervention era

Aims

Heart failure (HF) following acute myocardial infarction (AMI) is a global health concern, but data on risk factors associated with HF hospitalization post-AMI are limited.

Methods and results

We analysed data from the Myocardial Ischaemia National Audit Project, including patients admitted with AMI from 1 January 2006 to 31 March 2019. Data linkage with Hospital Episode Statistics Admitted Patient Care and the Office for National Statistics facilitated a longitudinal analysis. High-risk patients were identified using dapagliflozin in patients without diabetes mellitus with acute myocardial infarction (DAPA-MI) and EMPAgliflozin on Hospitalization for Heart Failure and Mortality in Patients With aCuTe Myocardial Infarction (EMPACT-MI) criteria. We assessed clinical outcomes, adherence to European Society of Cardiology quality indicators, and predictors of HF-related hospitalizations. Out of 1 046 480 AMI patients, 9.1% overall, 17.2% in the DAPA-MI cohort, and 16.6% in the EMPACT-MI cohort experienced HF hospitalization within a year post-AMI. High-risk patients, defined by the presence of five risk factors, had nearly one in four hospitalizations with HF at 1-year follow-up. The predicted adjusted incidence rate for heart failure within 1 year almost doubled from 64.5 cases per 1000 person-years [95% confidence interval (CI): 51.1 to 78.0] in 2005, to 118.2 cases per 1000 person-years in 2019 (95% CI: 115.0 to 121.5). Heart failure hospitalization was associated with a three-fold increase in 1-year mortality (hazard ratio 3.01, 95% CI 2.95-3.13).

Conclusion

One in 10 AMI patients experienced HF hospitalization within the first-year post-AMI, with rising trends in high-risk subgroups. These findings highlight the need for targeted post-AMI care strategies to improve outcomes and address the increasing burden of HF in the modern percutaneous coronary intervention era.

Hypertension increases sympathetic neuron activity by enhancing intraganglionic cholinergic collateral connections

Autonomic dysregulation, including sympathetic hyperactivity, is a common feature of hypertension (HT) and other cardiovascular diseases. The CNS plays a role in driving chronic sympathetic activation in disease, but several lines of evidence suggest that neuroplasticity in the periphery may also contribute. The potential contribution of postganglionic sympathetic neurons to sustained sympathetic hyperactivity is not well understood. We recently discovered that noradrenergic sympathetic neurons in the stellate ganglion (SG) have excitatory cholinergic collateral connections to other neurons within the ganglion. We hypothesize that remodelling of these neurons and increased cholinergic collateral transmission contributes to sustained sympathetic hyperactivity in cardiovascular diseases, including HT. To test that hypothesis, we examined the activity of sympathetic neurons in isolated SG under control conditions and after 1 week of HT induced by peripheral angiotensin II infusion, using whole-cell patch clamp recordings. Despite the absence of central inputs, we observed elevated spontaneous activity and synaptic transmission in sympathetic SG neurons from hypertensive mice that required generation of action potentials. Genetically disrupting cholinergic transmission in noradrenergic neurons decreased basal neuronal activity and prevented angiotensin II-mediated enhancement of activity. Similar changes in activity, driven by increased collateral transmission, were identified in cardiac projecting neurons and neurons projecting to brown adipose tissue. These changes were not driven by altered A-type K+ currents. This suggests that HT stimulates increased activity throughout the intraganglionic network of collateral connections, contributing to the sustained sympathetic hyperactivity characteristic in cardiovascular disease. KEY POINTS: Sympathetic neurons in ganglia isolated from angiotensin II-treated hypertensive mice are more active than neurons from control mice despite the absence of central activation. The enhanced activity is the result of a ganglionic network of cholinergic collaterals, rather than altered intrinsic excitability. Increased neuronal activity was observed in both cardiac neurons and brown adipose tissue-projecting neurons, which are not involved in cardiovascular homeostasis.

Comparative efficacy of different antihypertensive drug classes for stroke prevention: A network meta-analysis of randomized controlled trials

OBJECTIVE

The study aimed to compare the effectiveness of various antihypertensive drugs in preventing strokes in hypertensive patients.

METHODS

We conducted a comprehensive search of PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov to identify randomized controlled trials (RCTs) investigating the efficacy of antihypertensive drugs in stroke prevention from inception until April 2023. A network meta-analysis in a Bayesian framework was performed using the random-effects model.

RESULTS

This study included 88 RCTs involving 487,076 patients to investigate the effects of antihypertensive drugs in preventing stroke. Among these trials, 58 RCTs specifically focused on comparing the impact of such drugs on hypertensive subjects. In overall population, Angiotensin-converting enzyme inhibitor (ACEIs), Angiotensin receptor blockers (ARBs), Calcium channel blockers (CCBs), and Diuretics (DIs) demonstrated superiority over placebo in in reducing stroke, all-cause mortality, and cardiovascular mortality. CCBs and DIs outperformed β adrenergic receptor blockers (BBs), ACEIs, and ARBs in stroke reduction. However, when focusing on hypertensive patients, ACEIs, CCBs, and DIs proved superior to placebo in reducing stroke, all-cause mortality, and cardiovascular mortality. ARBs reduced stroke and all-cause mortality but lacked efficacy in reducing cardiovascular mortality. Of the various CCB subclasses, only the Dihydropyridines displayed efficacy in preventing stroke, all-cause mortality, and cardiovascular mortality. Among diuretic subclasses, thiazide-type DIs exhibited no efficacy in preventing all-cause mortality. ACEIs+CCBs were more effective than ACEIs or ARBs monotherapy in reducing stroke, more effective than ACEIs, ARBs, CCBs, or DIs monotherapy in reducing all-cause mortality, and more effective than ARBs in reducing cardiovascular mortality.

CONCLUSION

These findings suggest that ACEIs, dihydropyridine CCBs, and thiazide-like diuretics may provide superior prevention against stroke, all-cause mortality, and cardiovascular mortality in hypertensive patients. Combinations of ACEIs and CCBs may provide enhanced protection of stroke than ACEIs or ARBs monotherapy.

Routine Spironolactone in Acute Myocardial Infarction

BACKGROUND

Mineralocorticoid receptor antagonists have been shown to reduce mortality in patients after myocardial infarction with congestive heart failure. Whether routine use of spironolactone is beneficial after myocardial infarction is uncertain.

METHODS

In this multicenter trial with a 2-by-2 factorial design, we randomly assigned patients with myocardial infarction who had undergone percutaneous coronary intervention to receive either spironolactone or placebo and either colchicine or placebo. The results of the spironolactone trial are reported here. The two primary outcomes were a composite of death from cardiovascular causes or new or worsening heart failure, evaluated as the total number of events; and a composite of the first occurrence of myocardial infarction, stroke, new or worsening heart failure, or death from cardiovascular causes. Safety was also assessed.

RESULTS

We enrolled 7062 patients at 104 centers in 14 countries; 3537 patients were assigned to receive spironolactone and 3525 to receive placebo. At the time of our analyses, the vital status was unknown for 45 patients (0.6%). For the first primary outcome, there were 183 events (1.7 per 100 patient-years) in the spironolactone group as compared with 220 events (2.1 per 100 patient-years) in the placebo group over a median follow-up period of 3 years (hazard ratio adjusted for competing risk of death from noncardiovascular causes, 0.91; 95% confidence interval [CI], 0.69 to 1.21; P = 0.51). With respect to the second primary outcome, an event occurred in 280 of 3537 patients (7.9%) in the spironolactone group and 294 of 3525 patients (8.3%) in the placebo group (hazard ratio adjusted for competing risk, 0.96; 95% CI, 0.81 to 1.13; P = 0.60). Serious adverse events were reported in 255 patients (7.2%) in the spironolactone group and 241 (6.8%) in the placebo group.

CONCLUSIONS

Among patients with myocardial infarction, spironolactone did not reduce the incidence of death from cardiovascular causes or new or worsening heart failure or the incidence of a composite of death from cardiovascular causes, myocardial infarction, stroke, or new or worsening heart failure. (Funded by the Canadian Institutes of Health Research and others; CLEAR ClinicalTrials.gov number, NCT03048825.).

The European Society of Cardiology 2024 Guidelines on Chronic Coronary Syndromes: A Critical Appraisal

Background: During the 2024 annual meeting in London, The European Society of Cardiology released new guidelines (GLs) on chronic coronary syndromes (CCSs) and simultaneously published them in the European Heart Journal. Method: A few experts on the topic from Europe, South America, India, and Asia, who attended the presentation and the Question and Answer sections, met virtually to comment on the GLs after carefully reading the 123-page document. Result: There is a consensus that the presented GLs are a comprehensive, up-to-date, clear document of the available data on how to diagnose and treat CCSs and a definite step forward compared to all previous GLs. Of particular value are (a) the efforts to link both diagnosis and treatment to the underlying pathophysiology with the recognition that not all the ischaemic episodes are the same; (b) the decision to adopt the graphic of the so-called "Diamond Approach", although its spirit that no antianginal drug is superior to another is not fully adopted; and (c) the innovative way it condenses and expresses the relevant messages with eye-catching illustrations. Conclusions: The present article summarises and comments on the 123-page GLs, highlighting strengths and weaknesses according to the thoughts of the authors.

Secondary Prevention Medications in 17 Countries Grouped by Income Level (PURE): A Prospective Cohort Study

BACKGROUND

It is unclear whether global use of medications for secondary cardiovascular (CVD) prevention is improving over time.

OBJECTIVES

This study across 17 high-, middle- and low-income countries described variations in secondary CVD prevention medication use over a median follow-up of 12 years.

METHODS

In the multinational PURE (Prospective Urban Rural Epidemiology) cohort study, we conducted a repeated cross-sectional analysis to examine temporal variations in the use of secondary prevention medications in participants with CVD. In participants with coronary artery disease, we focused on antiplatelet agents, statins, renin-angiotensin system (RAS) inhibitors, and β-blockers. In participants with stroke, we focused on antiplatelet agents, statins, RAS inhibitors, and other blood pressure-lowering drugs. Medications were collected at baseline and on 4 subsequent follow-up visits.

RESULTS

The analysis included 7,409 participants with a diagnosis of CVD at the baseline visit, 8,792 at the second visit, 9,236 at the third visit, 11,082 at the fourth visit, and 11,677 at the last visit. The median age at baseline was 58.0 years, and 52.9% of the participants were female. The median follow-up was 12 years, with the median year of the baseline visit in 2007 and the fifth visit in 2019. Over this period, use of 1 or more classes of medications for secondary CVD prevention was 41.3% (95% CI: 40.2%-42.4%) at baseline, peaked at 43.1% (95% CI: 42.0%-44.1%), and then decreased to 31.3% (95% CI: 30.4%-32.1%) by the last study visit. In high-income countries, this use decreased from 88.8% (95% CI: 86.6%-91.0%) to 77.3% (95% CI: 74.9%-79.6%). In upper-middle-income countries, this use increased from 55.0% (95% CI: 52.8%-57.3%) to 61.1% (95% CI: 59.1%-63.1%). In lower-middle-income countries, use of at least 1 class of medications was 29.5% (95% CI: 28.1%-30.9%) at baseline, peaked at 31.7% (95% CI: 30.4%-33.1%), and then decreased to 13.4% (95% CI: 12.5%-14.2%) by the last visit. In low-income countries, use of at least 1 class of medications was 20.8% (95% CI: 18.1%-23.5%) at baseline, peaked at 47.3% (95% CI: 44.8%-49.9%), and then decreased to 27.5% (95% CI: 25.2%-29.9%) by the last study visit.

CONCLUSIONS

Globally and in most country income-level groups, the use of medications for secondary CVD prevention has been low, with little improvement over time.

A Case-Based Approach to the Management of Patients with Chronic Coronary Disease: Updates from the 2023 AHA/ACC Guidelines

The 2023 American Heart Association (AHA)/American College of Cardiology (ACC) Multisociety Guideline for the Management of Patients with Chronic Coronary Disease presents important updates to the care of patients with chronic coronary disease. The recommendations of these guidelines inform the care for patients with 1) asymptomatic coronary artery disease, 2) stable angina or equivalent symptoms (e.g., dyspnea upon exertion), 3) symptomatic nonobstructive coronary disease including coronary microvascular dysfunction and vasospasm, and 4) left ventricular (LV) systolic dysfunction with known coronary artery disease. In this review, we aim to demonstrate key recommendations in the 2023 guideline using the following four hypothetical cases.

Endothelial dysfunction in acute ischemic stroke: a review

BACKGROUND AND PURPOSE

Endothelial dysfunction is considered an emerging therapeutic target to prevent complications during acute stroke and to prevent recurrent stroke. This review aims to provide an overview of the current knowledge on endothelial dysfunction, outline the diagnostic methods used to measure it and highlight the drugs currently being investigated for the treatment of endothelial dysfunction in acute ischemic stroke.

METHODS

 The PubMed® and ClinicalTrials.gov electronic databases were searched for eligible articles/studies dealing with endothelial dysfunction and stroke. The references of the articles were screened to identify additional sources. The data were abstracted and summarized.

FINDINGS AND DISCUSSION

Endothelial dysfunction can be measured by serum biomarkers as well as by ultrasound or plethysmography techniques. Drugs targeting endothelial dysfunction include widely used agents such as angiotensin-converting enzyme inhibitors or isosorbide mononitrate, but also experimental therapies such as endothelial progenitor cells.

CONCLUSION

The role of endothelial dysfunction in acute ischemic stroke has been studied increasingly in recent years. It has been shown that there is a correlation between endothelial dysfunction and parenchymal hematoma after endovascular thrombectomy. Also, early clinical trials are conducted investigating, e.g., endothelial progenitor cells in the treatment of endothelial dysfunction in ischemic stroke. Current research focuses on the integration of novel markers of endothelial dysfunction into routine clinical practice to support decision making in the treatment of acute ischemic stroke.

Antihypertensive strategies for the prevention of secondary stroke: a systematic review and meta-analysis

BACKGROUND

Stroke is an important contributor to disability and death globally. Hypertension is a main risk factor for recurrent stroke in patients with ischemic and hemorrhagic stroke or transient ischemic attack. Higher systolic blood pressure, diastolic blood pressure, pulse pressure and mean arterial pressure at admission are independently associated with the risk of stroke recurrence. Therefore, lowering blood pressure is recommended by guidelines to prevent the recurrence of stroke.

METHODS

A systematic search of PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science databases was conducted through January 12, 2024. The search identified randomized controlled trials (RCTs) comparing antihypertensive drugs with control measures (placebo or no treatment) or standard blood pressure control (SBPC) with intensive blood pressure control (IBPC) for recurrent stroke prevention. Primary outcomes included overall and subtype stroke recurrence rates, fatal and non-fatal strokes, cardiovascular deaths, and myocardial infarctions (MIs). Secondary outcomes comprised non-fatal MIs and all-cause mortality. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using random or fixed-effect models in Stata 15.0.

RESULTS

The analysis included 19 RCTs encompassing 72,048 patients. Twelve studies (n = 53,971) evaluated antihypertensive drugs against placebo or no treatment, while seven studies (n = 18,077) compared SBPC with IBPC. Antihypertensive therapy demonstrated significant risk reductions compared to placebo or no treatment for recurrent stroke (RR = 0.86, 95% CI: 0.75-0.97), cardiovascular deaths (RR = 0.92, 95% CI: 0.87-0.97), and MIs (RR = 0.87, 95% CI: 0.79-0.96). IBPC showed superior outcomes compared to SBPC, with significant reductions in recurrent stroke (RR = 0.87, 95% CI: 0.77-0.98), cardiovascular deaths (RR = 0.75, 95% CI: 0.61-0.91), and all-cause mortality (RR = 0.85, 95% CI: 0.73-0.95).

CONCLUSION

In stroke patients, antihypertensive therapy demonstrates significant protective effects against stroke recurrence, cardiovascular deaths, and MIs compared to placebo or no treatment. Additionally, IBPC provides enhanced protection against stroke recurrence, cardiovascular deaths, and all-cause mortality compared to SBPC.

Cardiorenal Syndrome in Heart Failure with Preserved Ejection Fraction: Insights into Pathophysiology and Recent Advances

BACKGROUND

Cardiorenal syndrome (CRS) refers to the bidirectional interactions between the acutely or chronically dysfunctioning heart and kidney that lead to poor outcomes. Due to the evolving literature on renal impairment and heart failure with preserved ejection fraction (HFpEF), this review aimed to highlight the pathophysiological pathways, diagnosis using imaging and biomarkers, and management of CRS in patients with HFpEF.

SUMMARY

The mechanism of CRS in HFpEF can be hypothesized due to the interplay of elevated central venous pressure, renin-angiotensin-aldosterone system (RAAS) activation, oxidative stress, endothelial dysfunction, coronary microvascular dysfunction, and chronotropic incompetence. The correlation between HFpEF and worsening renal function seen in both long-term trials and observational data points to the evidence for these mechanisms. Upcoming biomarkers such as cystatin C, NGAL, NAG, KIM-1, ST-2, and galectin-3, along with conventional ones, are promising for early diagnosis, risk stratification, or response to therapy. Despite the lack of specific treatment for CRS in HFpEF, the management can be discussed with similar medications used in goal-directed medical therapy for heart failure with reduced ejection fraction (HFrEF). Additionally, there is increasing evidence for the role of vasodilators, inotropes, assist devices, and renal denervation, although long-term studies are necessary.

KEY MESSAGE

The management of CRS in HFpEF is an evolving field that currently shows promise for using diagnostic and prognostic biomarkers, conventional heart failure medications, and novel therapies such as renal denervation, interatrial shunt, and renal assist devices. Further studies are needed to understand the pathophysiological pathways, validate the use of novel biomarkers, especially for early diagnosis and prognostication, and institute new management strategies for CRS in patients with HFpEF.

The diabetes annual review in a postal box: A qualitative study exploring the views of people living with diabetes (DiaBox-Qual)

AIM

The diabetes annual review is an important part of clinical care. Non-attendance is increasingly common and associated with poor health outcomes. At-home self-collection of blood tests, urine samples and anthropometric data through a postal box may facilitate engagement. We aimed to explore the views of people living with diabetes on the use of a postal box as an alternative to usual care for self-collecting blood samples, urine samples and anthropometric data and to understand whether the availability of a postal box would facilitate the uptake of the diabetes annual review.

METHODS

We conducted semi-structured interviews and focus groups with adults who have type 1 or type 2 diabetes. Purposive sampling was used to obtain a high representation of infrequent attendees of annual review appointments within the study population. Transcripts were collated and analysed thematically.

RESULTS

Twenty participants took part including eight infrequent attendees. All infrequent attendees and most regular attendees responded positively to a postal box, with convenience being the most prominent value described. Concerns raised related to capability of self-collection and the accuracy of results. Participants were asked for suggestions to improve the postal box. The most common themes related to communication; needing clearer information about each test in the postal box; feedback of results; and utilising the box to communicate priorities for discussion at future consultations.

CONCLUSION

Postal boxes for annual reviews were well-received by those living with diabetes. Designed well, they have the potential to overcome more than just the physical barriers to annual review attendance.

Target Trial Emulation Using Cohort Studies: Estimating the Effect of Antihypertensive Medication Initiation on Incident Dementia

BACKGROUND

Observational studies link high midlife systolic blood pressure to increased dementia risk. However, the synthesis of evidence from randomized controlled trials has not definitively demonstrated that antihypertensive medication use reduces dementia risk. Here, we emulate target trials of antihypertensive medication initiation on incident dementia using three cohort studies, with attention to potential violations of necessary assumptions.

METHODS

We emulated trials of antihypertensive medication initiation on incident dementia using data from the Atherosclerosis Risk in Communities study, Cardiovascular Health Study, and Health and Retirement Study. We used data-driven methods to restrict participants to initiators and noninitiators with overlap in propensity scores and positive control outcomes to look for violations of positivity and exchangeability assumptions.

RESULTS

Analyses were limited by the small number of cohort participants who met eligibility criteria. Associations between antihypertensive medication initiation and incident dementia were inconsistent and imprecise (Atherosclerosis Risk in Communities: HR = 0.30 [0.05, 1.93]; Cardiovascular Health Study: HR = 0.66 [0.27, 1.64]; Health and Retirement Study: HR = 1.09 [0.75, 1.59]). More stringent propensity score restrictions had little effect on findings. Sensitivity analyses using a positive control outcome unexpectedly suggested antihypertensive medication initiation increased the risk of coronary heart disease in all three samples.

CONCLUSIONS

Positive control outcome analyses suggested substantial residual confounding in effect estimates from our target trials, precluding conclusions about the impact of antihypertensive medication initiation on dementia risk through target trial emulation. Formalized processes for identifying violations of necessary assumptions will strengthen confidence in target trial emulation and avoid inappropriate confidence in emulated trial results.

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are associated with improved amputation-free survival in chronic limb-threatening ischemia

BACKGROUND

In the Heart Outcomes Prevention Evaluation study, investigators found that ramipril was associated with improved survival as well as decreased MI and stroke rates in patients with peripheral arterial disease. Nonetheless, their effect on chronic limb-threatening ischemia (CLTI)-specific outcomes is unclear. We aim to assess the effect of ACEIs/ARBs on amputation-free survival in patients with CLTI undergoing peripheral vascular intervention (PVI) in a Medicare-linked database.

METHODS

Patients undergoing PVI in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network database were included. Primary outcomes included amputation-free survival. Kaplan-Meier survival and multivariable Cox regression analyses were used to assess 1-year outcomes.

RESULTS

A total of 34,284 patients were included, 46.3% of whom were discharged on ACEIs/ARBs. Patients discharged on ACEIs/ARBs were more likely to be smokers, have diabetes, and have hypertension. They were also more likely to present with rest pain. The overall 1-year survival rate for patients on ACEIs/ARBs vs those who are not was (79.1% vs 69.4%; P < .001). Freedom from amputation was 87.8% for patients on ACEIs/ARBs vs 84.2% for those who were not (P < .001). Amputation-free survival was 70.5% vs 59.5% for ACEIs/ARBs vs no ACEIs/ARBs (P < .001). After adjusting for potential confounders, ACEIs/ARBs use was associated with lower 1-year mortality (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.7-0.8; P < .001), amputation (HR, 0.89; 95% CI, 0.8-0.9; P < .001), and amputation or death (HR, 0.79; 95% CI, 0.76-0.8; P < .001).

CONCLUSIONS

ACEIs/ARBs were associated independently with lower amputation, improved survival, and amputation-free rates survival at 1 year in patients with CLTI undergoing PVI. The fact that more than one-half the patients were not discharged on these medications presents an area for potential quality improvement.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The chronobiology of human heart failure: clinical implications and therapeutic opportunities

Circadian variation in cardiovascular and metabolic dynamics arises from interactions between intrinsic rhythms and extrinsic cues. By anticipating and accommodating adaptation to awakening and activity, their synthesis maintains homeostasis and maximizes efficiency, flexibility, and resilience. The dyssynchrony of cardiovascular load and energetic capacity arising from attenuation or loss of such rhythms is strongly associated with incident heart failure (HF). Once established, molecular, neurohormonal, and metabolic rhythms are frequently misaligned with each other and with extrinsic cycles, contributing to HF progression and adverse outcomes. Realignment of biological rhythms via lifestyle interventions, chronotherapy, and time-tailored autonomic modulation represents an appealing potential strategy for improving HF-related morbidity and mortality.

Chest Pain at Rest With Unremarkable ECG and Cardiac Enzymes: Case Study Emphasising the Importance of Clinical Suspicion in the Diagnosis of Coronary Artery Disease

BACKGROUND

Coronary artery disease (CAD), primarily caused by atherosclerosis, is a leading cause of death, presenting as angina or myocardial infarction. Advances in cardiac imaging, angiography, and procedures like percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery have improved early detection and management of this condition. This report presents the case of a man who experienced worsening exertional chest pain and discomfort while at rest.

CASE REPORT

A 66-year-old man with a history of neurogenic syncope and asthma presented at the same-day emergency care (SDEC) unit with worsening exertional chest pain and discomfort whilst at rest. Despite normal ECG and cardiac enzyme results, further cardiac computed tomography angiography (CTCA) revealed significant CAD with moderate stenosis in the right coronary artery (RCA) and severe stenosis at the left anterior descending artery (LAD) bifurcation, leading to CABG surgery. Echocardiography showed a left ventricular ejection fraction of 50-54% with mid-inferior and basal to mid-inferoseptal hypokinesia. The cardiology-cardiothoracic multidisciplinary team concluded that CABG surgery would provide the most durable long-term outcome.

CONCLUSION

This case demonstrates the high importance of clinical suspicion of CAD despite normal initial investigations in the early identification and timely investigation as well as the role multidisciplinary teams and CABG can play in the timely management of complex CAD, ultimately leading to improved patient outcomes.

Cardiorenal effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers among people underrepresented in trials: analysis of routinely collected data with emulation of a reference trial (ONTARGET)

Cardiovascular disease is a leading cause of death globally. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB), compared in the ONTARGET trial (Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial), each prevent cardiovascular disease. However, trial results may not be generalizable, and their effectiveness in underrepresented groups is unclear. Using trial emulation methods within routine-care data to validate findings, we explored the generalizability of ONTARGET results. For people prescribed an ACEi/ARB in the UK Clinical Practice Research Datalink GOLD dataset from January 1, 2001, to July 31, 2019, we applied trial criteria and propensity-score methods to create an ONTARGET trial-eligible cohort. Comparing ARB with ACEi, we estimated hazard ratios for the primary composite trial outcome (cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure) and secondary outcomes. Because the prespecified criteria were met, confirming trial emulation, we then explored treatment heterogeneity among 3 trial-underrepresented subgroups: females, persons aged ≥75 years, and those with chronic kidney disease. In the trial-eligible population (n = 137 155), results for the primary outcome demonstrated similar effects of ARB and ACEi (hazard ratio = 0.97; 95% CI, 0.93-1.01), meeting the prespecified validation criteria. When extending this outcome to trial-underrepresented groups, similar treatment effects were observed by sex, age, and chronic kidney disease. This suggests that ONTARGET trial findings are generalizable to trial-underrepresented subgroups. This article is part of a Special Collection on Pharmacoepidemiology.

Association of ACEI/ARB therapy with total and cardiovascular death in coronary artery disease patients with advanced chronic kidney disease: a large multi-center longitudinal study

INTRODUCTION

Advanced chronic kidney disease (CKD) is common among patients with coronary artery disease (CAD), and angiotensin‑converting enzyme inhibitors (ACEI) or angiotensin‑receptor blockers (ARB) can improve cardiac and renal function, but whether ACEI/ARB therapy improves long-term prognosis remains unclear among these high-risk patients. Therefore, this research aimed to investigate the relationship between ACEI/ARB therapy and long-term prognosis among CAD patients with advanced CKD.

METHODS

CAD patients with advanced CKD were included in five hospitals. Advanced CKD was defined as estimated glomerular filtration rate (eGFR)<30 ml/min per 1.73 m2. Cox regression models and competing risk Fine and Gray models were used to examine the relationship between ACEI/ARB therapy and all-cause and cardiovascular death, respectively.

RESULTS

Of 2527 patients, 47.6% population of our cohort was discharged on ACEI/ARB. The overall all-cause and cardiovascular mortality were 38.6% and 24.7%, respectively. Multivariate Cox regression analyses indicated that ACEI/ARB therapy was found to be associated with lower rates of both all-cause mortality (hazard ratio (HR)=0.836, 95% confidence interval (CI): 0.738-0.948, p = 0.005) and cardiovascular mortality (HR = 0.817, 95%CI: 0.699-0.956, p = 0.011). In the propensity-matched cohort, the survival benefit was consistent, and significantly better survival was observed for all-cause mortality (HR = 0.856, 95%CI: 0.752-0.974, p = 0.019) and cardiovascular mortality (HR = 0.830, 95%CI: 0.707-0.974, p = 0.023) among patients treated with ACEI/ARB.

CONCLUSION

ACEI/ARB therapy showed a better survival benefit among high-risk CAD patients with advanced CKD at long-term follow-up, which manifested that strategies to maintain ACEI/ARB treatment may improve clinical outcomes among these high-risk populations.

Routine beta-blocker therapy after acute coronary syndromes: The end of an era?

BACKGROUND

Beta-blocker therapy, a treatment burdened by side effects including fatigue, erectile dysfunction and depression, was shown to reduce mortality and cardiovascular events after acute coronary syndromes (ACS) in the pre-coronary reperfusion era. Potential mechanisms include protection from ventricular arrhythmias, increased ischaemia threshold and prevention of left ventricular (LV) adverse remodelling. With the advent of early mechanical reperfusion and contemporary pharmacologic secondary prevention, the benefit of beta-blockers after ACS in the absence of LV dysfunction has been challenged.

METHODS

The present narrative review discusses the contemporary evidence based on searching the PubMed database and references in identified articles.

RESULTS

Recently, the REDUCE-AMI trial-the first adequately powered randomized trial in the reperfusion era to test beta-blocker therapy after myocardial infarction with preserved left ventricular ejection fraction (LVEF)-showed no benefit on the composite of all-cause death or myocardial infarction over a median 3.5-year follow-up. While the benefit of beta-blockers in patients with reduced LVEF remains undisputed, their value in post-ACS patients with mildly reduced systolic function (LVEF 41%-49%) has not been studied in contemporary randomized trials; in this setting, observational studies have suggested a reduction in cardiovascular events with these agents. The adequate duration of beta-blocker therapy remains unknown, but observational data suggests that any mortality benefit may be lost beyond 1-12 months after ACS in patients with LVEF >40%.

CONCLUSION

We believe that there is sufficient evidence to abandon routine beta-blocker prescription in post-ACS patients with preserved LV systolic function.

Management and Pharmacological Treatment of Peripheral Arterial Disease

Background: Peripheral arterial disease (PAD) is a complex, heterogeneous condition that has become a leading health concern globally. Peripheral arterial disease often co-exists with other vascular disease states, including cerebrovascular and cardiovascular disease. Optimal therapy for managing symptoms and progression of disease employs non-pharmacological, pharmacological, and contemporary revascularisation techniques to improve clinical outcomes and quality of life. However, large well-designed randomised control trials (RCT) and corresponding evidence-based guidelines for management of PAD are lacking, with current practice standards often extrapolated from evidence in coronary artery disease. Purpose: This review article aims to discuss currently accepted best pharmacological practice for PAD. Method: Relevant articles were searched between May 2023 and January 2024 through PubMed, Cochrane Library, Google Scholar and international guidelines, focusing on pharmacological management for PAD. Results: This narrative review discusses holistic pharmacological treatments for PAD.

Alterations in platelet activity and endothelial glycocalyx biomarkers by treatment with an angiotensin converting enzyme inhibitor or an alpha-1 adrenoceptor antagonist in patients with hypertension: results from the DoRa study

Drugs blocking the renin-angiotensin-aldosterone system may offer benefit on endothelial function, inflammation, and hemostasis in addition to the effects of reducing blood pressure. We have shown antithrombin effects by treatment with the angiotensin converting enzyme (ACE) inhibitor ramipril. As thrombin is a key inducer of platelet aggregation, we hypothesized that treatment with ramipril could modulate platelet reactivity and endothelial glycocalyx (eGCX) function. This study assessed platelet activity (CD40 ligand and P-selectin) and eGCX markers (E-selectin, hyaluronan, syndecan-1, and thrombomodulin) in 59 individuals with mild-to-moderate hypertension, randomized double-blind to ramipril 10 mg or doxazosin 8 mg od for 12 weeks. Ramipril and doxazosin similarly reduced blood pressure. Antihypertensive treatment reduced CD40 ligand (p < .001) with no interaction (p = .405) by treatment group (reductions by ramipril and doxazosin were 8.7 ± 30.8 ng/L, p = .044, and 13.4 ± 25.5 ng/L, p = .002, respectively). There were no changes in P-selectin by treatment within (p = .556) or between (p = .256) treatment groups. No changes were observed in E-selectin, hyaluronan, syndecan-1, or thrombomodulin by antihypertensive treatment (p = .091-.991), or between ramipril and doxazosin (p = .223-.999). Our results show a potential reduction of platelet activity by ACE inhibitor treatment. Also, the alpha 1-adrenoceptor antagonist doxazosin may reduce platelet activation. Neither drug influenced eGCX markers.

Impact of first-line antihypertensive drug class and intensity on NT-proBNP improvement and cardiovascular outcomes among hypertensive patients with pre-heart failure: findings from SPRINT trial

Five first-line classes of antihypertensive drugs are recommended for hypertension treatment. However, it is unclear which class should be chosen for hypertensive patients with pre-heart failure (pre-HF). The study aimed to investigate the association between antihypertensive drug classes and intensity with probability of NT-proBNP (N-terminal pro-B-type natriuretic peptide) improvement and risk of cardiovascular events among pre-HF hypertensive patients. Utilizing the data from SPRINT, we included pre-HF hypertensive patients, identified by NT-proBNP ≥125 pg/mL at baseline. NT-proBNP improvement is defined as a reduction of ≥50% to a level below 125 pg/mL. A total of 3293 patients (mean age: 71.9 years; female: 43.8%) were included. NT-proBNP improvement was observed in 415 patients (12.6%) over 1-year follow up. Thiazide-type diuretics users were associated with a higher likelihood of NT-proBNP improvement (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.05-1.70), a lower risk of HF (hazard ratio [HR], 0.54; 95% CI, 0.37-0.78) and primary composite outcome (HR, 0.72; 95% CI, 0.57-0.89). ACEI/ARB users were only associated with a lower risk of primary composite outcome (HR, 0.80; 95% CI, 0.63-0.99). In contrast, beta-blockers users were associated with a lower likelihood of NT-proBNP improvement (OR, 0.43; 95% CI, 0.34-0.55), while a higher risk of HF (HR, 1.79; 95% CI, 1.21-2.64) and primary composite outcome (HR, 1.48; 95% CI, 1.18-1.87). These associations varied across subgroups of different drug intensities. This post hoc analysis supports the use of thiazide-type diuretics and ACEI/ARB for prevention of cardiovascular events. The use of beta-blockers is associated with an increased risk of HF and primary outcomes, which requires further validation. Association between antihypertensive drug classes and intensity with NT-proBNP improvement and long-term clinical outcome.

Diabetes Mellitus and Cardiovascular Disease: Exploring Epidemiology, Pathophysiology, and Treatment Strategies

Diabetes mellitus (DM) affects 537 million people as of 2021, and is projected to rise to 783 million by 2045. This positions DM as the ninth leading cause of death globally. Among DM patients, cardiovascular disease (CVD) is the primary cause of morbidity and mortality. Notably, the prevalence rates of CVD is alarmingly high among diabetic individuals, particularly in North America and the Caribbean (46.0%), and Southeast Asia (42.5%). The predominant form of CVD among diabetic patients is coronary artery disease (CAD), accounting for 29.4% of cases. The pathophysiology of DM is complex, involving insulin resistance, β-cell dysfunction, and associated cardiovascular complications including diabetic cardiomyopathy (DCM) and cardiovascular autonomic neuropathy (CAN). These conditions exacerbate CVD risks underscoring the importance of managing key risk factors including hypertension, dyslipidemia, obesity, and genetic predisposition. Understanding the genetic networks and molecular processes that link diabetes and cardiovascular disease can lead to new diagnostics and therapeutic interventions. Imeglimin, a novel mitochondrial bioenergetic enhancer, represents a promising medication for diabetes with the potential to address both insulin resistance and secretion difficulties. Effective diabetes management through oral hypoglycemic agents (OHAs) can protect the cardiovascular system. Additionally, certain antihypertensive medications can significantly reduce the risk of diabetes-related CVD. Additionally, lifestyle changes, including diet and exercise are vital in managing diabesity and reducing CVD risks. These interventions, along with emerging therapeutic agents and ongoing clinical trials, offer hope for improved patient outcomes and long-term DM remission. This study highlights the urgent need for management strategies to address the overlapping epidemics of DM and CVD. By elucidating the underlying mechanisms and risk factors, this study aims to guide future perspectives and enhance understanding of the pathogenesis of CVD complications in patients with DM, thereby guiding more effective treatment strategies.

ACE Inhibitors and Angiotensin Receptor Blockers for the Primary and Secondary Prevention of Cardiovascular Outcomes: Recommendations from the 2024 Egyptian Cardiology Expert Consensus in Collaboration with the CVREP Foundation

INTRODUCTION

The renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in regulating blood pressure (BP), with dysregulation of RAAS resulting in hypertension and potentially heart failure (HF), myocardial infarction (MI), cardio-renal syndrome, and stroke. RAAS inhibitors, such as angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs), have advantages beyond BP control. However, differences between these two drug classes need to be considered when choosing a therapy for preventing cardiovascular events.

METHODS

A panel of 36 Egyptian cardiologists developed consensus statements on RAAS inhibitors for primary and secondary prevention of cardiovascular outcomes and stroke, using a modified three-step Delphi process.

RESULTS

The consensus statements highlight the importance of effective BP control and the role of RAAS blockade for prevention and management of various cardiovascular diseases. ACEis and ARBs differ in their mode of action and, thus, clinical effects. On the basis of available evidence, the consensus group recommended the following: ACEis should be considered as first choice (in preference to ARBs) to reduce the risk of MI, for primary prevention of HF, and for secondary prevention of stroke. ACEis and ARBs show equivalent efficacy for the primary prevention of stroke. Evidence also favors the preferential use of ACEis in patients with type 2 diabetes, for BP control, for the primary prevention of diabetic kidney disease, and to reduce the risk of major cardiovascular and renal outcomes. Treatment with an ACEi should be started within 24 h of ST segment elevation MI (and continued long term) in patients with HF, left ventricular systolic dysfunction, and/or diabetes. Angiotensin receptor/neprilysin inhibitors (ARNIs) are the first choice for patients with HF and reduced ejection fraction, with ACEis being the second choice in this group. ARBs are indicated as alternatives in patients who cannot tolerate ACEis. ACEis may be associated with cough development, but the incidence tends to be overestimated, and the risk can be reduced by use of a lipophilic ACEi or combining the ACEi with a calcium channel blocker.

CONCLUSION

RAAS blockade is an essential component of hypertension therapy; however, the protective effects provided by ACEis are superior to those of ARBs. Therefore, an ACEi is indicated in almost all cases, unless not tolerated.

Optimal duration of medical therapy for patients with acute myocardial infarction

Optimal medical therapy, including Beta-blockers (BB), inhibitors of the renin-angiotensin system (RAS), and statins, is recommended for patients with acute myocardial infarction (AMI) in the absence of contraindications. However, the optimal duration of these medications has not been clearly established in clinical studies. This observational study aimed to investigate the period during which these medications are associated with improved clinical outcomes. Among patients enrolled in the Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH), in-hospital survivors were selected. In a Cox-proportional hazard analysis of 12,200 patients, BB (hazard ratio [HR] = 0.73; 95% confidence interval [CI] = 0.57-0.95; P = .019), RAS inhibitors (HR 0.70; 95% CI = 0.55-0.89; P = .004), and statins at discharge (HR = 0.65; 95% CI = 0.48-0.87; P = .004) were all associated with lower 1-year cardiac mortality. At 1-year, 10,613 patients without all-cause death, myocardial infarction, revascularization, or re-hospitalization due to heart failure were selected for further analysis. RAS inhibitors (HR = 0.53; 95% CI = 0.37-0.76; P = .001) and statins (HR = 0.30; 95% CI = 0.14-0.61; P = .001) prescribed at 1-year were associated with lower 2-year cardiac mortality, whereas BB were not (HR = 0.79; 95% CI = 0.51-1.23; P = .23). However, none of these medications prescribed at 2-years were associated with reduced 3-year cardiac mortality among the 9232 patients who remained event-free until then. RAS inhibitors and statins were associated with reduced cardiac mortality for up to 2-years, and BB for up to 1-year after the initial attack. The effectiveness of these medications beyond these periods remains questionable.

Angiotensin II Exposure In Vitro Reduces High Salt-Induced Reactive Oxygen Species Production and Modulates Cell Adhesion Molecules' Expression in Human Aortic Endothelial Cell Line

Background/Objectives: Increased sodium chloride (NaCl) intake led to leukocyte activation and impaired vasodilatation via increased oxidative stress in human/animal models. Interestingly, subpressor doses of angiotensin II (AngII) restored endothelium-dependent vascular reactivity, which was impaired in a high-salt (HS) diet in animal models. Therefore, the present study aimed to assess the effects of AngII exposure following high salt (HS) loading on endothelial cells' (ECs') viability, activation, and reactive oxygen species (ROS) production. Methods: The fifth passage of human aortic endothelial cells (HAECs) was cultured for 24, 48, and 72 h with NaCl, namely, the control (270 mOsmol/kg), HS320 (320 mOsmol/kg), and HS350 (350 mOsmol/kg). AngII was administered at the half-time of the NaCl incubation (10-4-10-7 mol/L). Results: The cell viability was significantly reduced after 24 h in the HS350 group and in all groups after longer incubation. AngII partly preserved the viability in the HAECs with shorter exposure and lower concentrations of NaCl. Intracellular hydrogen peroxide (H2O2) and peroxynitrite (ONOO-) significantly increased in the HS320 group following AngII exposure compared to the control, while it decreased in the HS350 group compared to the HS control. A significant decrease in superoxide anion (O2.-) formation was observed following AngII exposure at 10-5, 10-6, and 10-7 mol/L for both HS groups. There was a significant decrease in intracellular adhesion molecule 1 (ICAM-1) and endoglin expression in both groups following treatment with 10-4 and 10-5 mol/L of AngII. Conclusions: The results demonstrated that AngII significantly reduced ROS production at HS350 concentrations and modulated the viability, proliferation, and activation states in ECs.

Interaction of proteinuria and diabetes on the risk of cardiovascular events: a prospective cohort CKD-ROUTE study

OBJECTIVE

We evaluated the interaction of urinary protein-to-creatinine ratio (UPCR) with diabetes on the risk of cardiovascular events in a cohort study.

METHODS

The study population consisted of 639 participants with chronic kidney disease (CKD) stages 2-5, enrolled between 2010 and 2011 in Japan. Cox proportional hazards models were used to evaluate the independent and combined effects of the UPCR and diabetes on cardiovascular events.

RESULTS

During a median follow-up of 3 years, 59 participants developed cardiovascular events during follow-up. A notably higher risk of cardiovascular events was found in participants with proteinuria [hazards ratio (HR): 2.16, 95% confidence interval (95% CI): 1.17-3.97] compared to those without proteinuria at UPCR levels. In addition, the participants with diabetes had a higher risk of cardiovascular events (HR: 2.53, 95% CI: 1.49-4.30) than those without diabetes. Moreover, an interaction was found between UPCR and diabetes on cardiovascular events (P for interaction = 0.04). Participants with both proteinuria (UPCR ≥ 0.5 g/gCr) and diabetes had a 4.09 times higher risk of cardiovascular events (HR: 4.09, 95% CI: 1.97-8.47) compared with those without proteinuria (UPCR < 0.5 g/gCr) and diabetes.

CONCLUSIONS

In summary, among participants with CKD stages 2-5, proteinuria and diabetes were found to independently and jointly affect the risk of cardiovascular events. Participants with proteinuria and diabetes had the highest risk of cardiovascular events compared with other groups.

Renin-angiotensin system inhibition and mortality in patients undergoing dialysis with coronary artery disease: insights from a multi-center observational study

BACKGROUND

While the survival benefits of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are firmly established in the general population, their efficacy within patient undergoing dialysis with coronary artery disease (CAD) remains controversial.

METHODS

Between January 2015 and June 2021, 1168 patients undergoing dialysis with CAD were assessed from 30 tertiary medical centers. The primary outcome was all-cause death, and the secondary outcome was cardiovascular death. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) were performed to account for between-group differences.

RESULTS

Overall, ACEI or ARB were prescribed to 518 patients (44.3%) upon discharge. After a median follow-up of 22.2 months, 361 (30.9%) patients died, including 243 cardiovascular deaths. The use of ACEI or ARB was associated with a significantly lower risk of all-cause (25.3% vs 35.4%, hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.52-0.82, p < 0.001) and cardiovascular death (17.0% vs 23.8%; HR 0.64, 95% CI 0.48-0.83, p = 0.001). These findings remained consistent across IPTW and PSM analyses. Sensitivity analyses for ACEI and ARB use separately yielded similar results.

CONCLUSIONS

Our findings suggested that among patients undergoing dialysis with CAD, ACEI or ARB use was associated with a lower risk of all-cause and cardiovascular death.

Angiotensin Receptor Blockers Versus Angiotensin Converting Enzyme Inhibitors in Acute Myocardial Infarction Without Heart Failure

BACKGROUND

Whether angiotensin II receptor blockers (ARBs) can be an alternative to angiotensin-converting enzyme inhibitors (ACEIs) in patients without heart failure (HF) after acute myocardial infarction (MI) remains controversial. The aim of this study was to compare clinical outcomes between initial ARB and ACEI therapy in patients with MI without HF.

METHODS

Between 2010 and 2016, a total of 31,013 patients who underwent coronary revascularization for MI with prescription of ARBs or ACEIs at hospital discharge were enrolled from the Korean nationwide medical insurance data. Patients who had HF at index MI were excluded. The primary outcome was all-cause death. The secondary outcomes included recurrent MI, hospitalization for new heart HF, stroke, and a composite of each outcome.

RESULTS

Of 31,013 patients, ARBs were prescribed in 12,685 (40.9%) and ACEIs in 18,328 (59.1%). Patients receiving ARBs had a lower discontinuation rate compared with those receiving ACEIs (28.2% vs 43.5%, adjusted hazard ratio [HR] 0.34; 95% confidence interval [CI] 0.31-0.37; P < .01). During a median follow-up of 2.2 years, 2480 patients died. The incidence rate of all-cause death in patients receiving ARBs and those receiving ACEIs was 27.7 and 22.9 per 1000 person-years, respectively (adjusted HR 1.04; 95% CI 0.95-1.13; P = .40). There were no significant differences in the secondary outcomes between patients receiving ARBs and those receiving ACEIs, except stroke (19.2 vs 13.6 per 1000 person-years; adjusted HR 1.17; 95% CI 1.04-1.32; P = .01). In a subgroup analysis, a higher mortality was observed with ARBs compared with ACEIs in patients with diabetes.

CONCLUSIONS

In this nationwide cohort, there was no significant difference in the incidence of all-cause death between ARBs and ACEIs as discharge medications in patients with myocardial infarction without heart failure. Angiotensin II receptor blockers would be an alternative to ACEIs for those intolerant to ACEI therapy.

Pharmacotherapy of acute ST-elevation myocardial infarction and the pharmacist's role, part 2: Complications, postrevascularization care, and quality improvement

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Key pharmacotherapeutic modalities and considerations for the patient with ST-elevation myocardial infarction (STEMI) across the later phases of inpatient care are reviewed.

SUMMARY

Published descriptions and validation of clinical pharmacist roles specific to the acute management of STEMI are limited. This high-risk period from presentation through revascularization, stabilization, and hospital discharge involves complex pharmacotherapeutic decision points, many operational medication needs, and multiple layers of quality oversight. A companion article reviewed STEMI pharmacotherapy from emergency department presentation through revascularization. Herein we complete the pharmacotherapy review for the STEMI patient across the inpatient phases of care, including the management of peri-infarction complications with vasoactive and antiarrhythmic agents, considerations for postrevascularization antithrombotics, and assessments of supportive therapies and secondary prevention. Key guideline recommendations and literature developments are summarized from the clinical pharmacist's perspective alongside suggested pharmacist roles and responsibilities. Considerations for successful hospital discharge after STEMI and pharmacist involvement in associated institutional quality improvement efforts are also provided. We aim to support inpatient pharmacy departments in advancing clinical services for this critical patient population and call for further research delineating pharmacists' impact on patient and institutional STEMI outcomes.

Medical Optimization of Patients with Symptomatic Peripheral Arterial Disease

Peripheral artery disease (PAD) is a progressive disease associated with the occurrence of major adverse cardiovascular and limb events and elevated mortality rates. Symptoms of PAD, including claudication and chronic limb-threatening ischemia, impair functional capacity and lead to lower quality of life. The focus of current therapies is to minimize symptoms, improve quality of life, and reduce adverse cardiovascular and limb events. Among the medical therapies are antiplatelets, anticoagulants, antihypertensives, lipid lowering therapies, cilostazol and pentoxifylline, and novel blood sugar-lowering therapies, plus exercise therapy and smoking cessation. In this review, we discuss these evidence-based medical therapies that are available for patients with symptomatic PAD.

Response to retention hypothesis as a source of targets for arterial wall-directed therapies to prevent atherosclerosis: A critical review

The subendothelial retention of circulating lipoproteins on extracellular matrix proteins and proteoglycans is one of the earliest events in the development of atherosclerosis. Multiple factors, including the size, type, composition, surrounding pH, and chemical modifications to lipoproteins, influence the electrostatic interactions between relevant moieties of the apolipoproteins on lipoproteins and the glycosaminoglycans of proteoglycans. The length and chemical composition of glycosaminoglycan chains attached to proteoglycan core proteins determine the extent of initial lipoprotein binding and retention in the artery wall. The phenomena of hyperelongation of glycosaminoglycan chains is associated with initial lipid retention and later atherosclerotic plaque formation. This review includes a summary of the current literature surrounding cellular mechanisms leading to GAG chain modification and lipid retention and discusses potential therapeutic strategies to target lipoprotein:proteoglycan interactions to prevent the development and progression of atherosclerosis.

Practicalities and importance of assessing urine albumin excretion in type 2 diabetes: A cutting-edge update

Type 2 diabetes (T2D) is associated with increased risk for chronic kidney disease (CKD). It is estimated that 40 % of people with diabetes have CKD, which consequently leads to increase in morbidity and mortality from cardiovascular diseases (CVDs). Diabetic kidney disease (DKD) is leading cause of CKD and end-stage renal disease (ESRD) globally. On the other hand, DKD is independent risk factor for CVDs, stroke and overall mortality. According to the guidelines, using spot urine sample and assessing urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) are both mandatory methods for screening of CKD in T2D at diagnosis and at least annually thereafter. Diagnosis of CKD is confirmed by persistent albuminuria followed by a progressive decline in eGFR in two urine samples at an interval of 3 to 6 months. However, many patients with T2D remain underdiagnosed and undertreated, so there is an urgent need to improve the screening by detection of albuminuria at all levels of health care. This review discusses the importance of albuminuria as a marker of CKD and cardiorenal risk and provides insights into the practical aspects of methods for determination of albuminuria in routine clinical care of patients with T2D.