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Pereira WDS, Lelis DF, Cunha RS, Griep RH, Barreto SM, Molina MDCB, Schmidt MI, Duncan BB, Bensenor I, Lotufo PA, Mill JG, Baldo MP. Fasting Glucose, Glycated Hemoglobin, and 2h Post-load Blood Glucose Are Independently Associated With Arterial Stiffness in Diabetes: The ELSA-Brasil Study. Angiology 2024; 75:635-644. [PMID: 36951393 DOI: 10.1177/00033197231166180] [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: 03/24/2023]
Abstract
The association of diabetes with increased large artery stiffness is not definitively established. We aimed to describe the carotid-femoral pulse wave velocity (cf-PWV) in participants with and without diabetes and whether the cf-PWV could vary among the different laboratory-based criteria used. A cross-sectional analysis using baseline data from 13,912 adults was used. cf-PWV as well as anthropometric, biochemical, and clinical data were measured. Diabetes was defined by previous medical diagnosis, medication use, fasting glucose, an oral glucose tolerance test (GTT), or glycated hemoglobin (HbA1c). The prevalence of diabetes was 18.7%, higher in men than in women. After adjustment, participants with diabetes showed higher cf-PWV (men: 9.7 ± 1.7 vs 9.4 ± 1.7 m/s, P < .05; women: 9.4 ± 1.6 vs 9.1 ± 1.7 m/s, P < .05). We observed a progressive increase in cf-PWV as >1 laboratory-based criterion for diabetes diagnosis was reached. Also, participants with diabetes with alterations in any laboratory-based criteria had higher cf-PWV than participants without diabetes, regardless of sex. In summary, diabetes is associated with higher cf-PWV as is each laboratory-based parameter used for its diagnosis. These results support the strong consequences of glucose dysregulation on the vascular system and provide evidence to screen all parameters involved in glycemic metabolism to improve vascular health.
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Affiliation(s)
- Wille D S Pereira
- Department of Pathophysiology, Montes Claros State University (UNIMONTES), Montes Claros, Brazil
| | - Deborah F Lelis
- Department of Pathophysiology, Montes Claros State University (UNIMONTES), Montes Claros, Brazil
| | - Roberto S Cunha
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, Brazil
| | - Rosane H Griep
- Laboratory of Health and Environment Education, Oswaldo Cruz Institute, Rio de Janeiro, Brazil
| | - Sandhi M Barreto
- School of Medicine and Clinical Hospital/EBSERH, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | - Maria Inês Schmidt
- School of Medicine and Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Bruce B Duncan
- School of Medicine and Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Isabela Bensenor
- Center for Clinical and Epidemiologic Research, University of São Paulo, São Paulo, Brazil
| | - Paulo A Lotufo
- Center for Clinical and Epidemiologic Research, University of São Paulo, São Paulo, Brazil
| | - José Geraldo Mill
- Department of Physiological Sciences, Federal University of Espírito Santo, Vitória, Brazil
| | - Marcelo P Baldo
- Department of Pathophysiology, Montes Claros State University (UNIMONTES), Montes Claros, Brazil
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Barry AR, Helisaz H, Safari A, Loewen P. Effect of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers After Coronary Artery Bypass Graft Surgery: A Population-Based Cohort Study. J Am Heart Assoc 2024; 13:e035215. [PMID: 38842283 DOI: 10.1161/jaha.124.035215] [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: 02/27/2024] [Accepted: 05/02/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The effect of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) on major adverse cardiovascular events (MACE) in patients who undergo coronary artery bypass graft surgery is equivocal. This retrospective, population-based cohort study evaluated effect of exposure to an ACEI/ARB on MACE using linked administrative databases that included all cardiac revascularization procedures, hospitalizations, and prescriptions for the population of British Columbia, Canada. METHODS AND RESULTS All adults who underwent coronary artery bypass graft surgery between 2002 and 2020 were eligible. The primary outcome was time to MACE, defined as a composite of all-cause death, myocardial infarction, and ischemic stroke using Cox proportional hazards models with inverse probability treatment weighting. Included were 15 439 patients and 6191 (40%) were prescribed an ACEI/ARB. Mean age was 66 years, 83% were men, and 16% had heart failure (HF). Median exposure time was 40 months. Over the 5-year follow-up, 1623 MACE occurred. Impact of exposure was different for patients with and without HF (P <0.0001 for interaction). After probability-weighting and adjustment for relevant covariates, exposure to ACEI/ARBs was associated with a lower hazard of MACE in patients with HF at 1 year (hazard ratio, 0.13 [95% CI, 0.09-0.19]) and 5 years (hazard ratio, 0.36 [95% CI, 0.30-0.44]). In patients without HF, ACEI/ARBs had a lower hazard of MACE at 1 year (hazard ratio, 0.35 [95% CI, 0.27-0.46]) and 5 years (hazard ratio, 0.66 [95% CI, 0.58-0.76]). CONCLUSIONS In this population-based study, ACEI/ARBs were associated with a lower hazard of MACE in a cohort of patients post-coronary artery bypass graft surgery irrespective of HF status.
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Affiliation(s)
- Arden R Barry
- Faculty of Pharmaceutical Sciences The University of British Columbia Vancouver British Columbia Canada
- Jim Pattison Outpatient Care and Surgery Centre Lower Mainland Pharmacy Services Surrey British Columbia Canada
| | - Hamed Helisaz
- GranTAZ Consulting Vancouver British Columbia Canada
- Faculty of Applied Science The University of British Columbia Vancouver British Columbia Canada
| | - Abdollah Safari
- GranTAZ Consulting Vancouver British Columbia Canada
- School of Mathematics, Statistics and Computer Science, College of Science University of Tehran Tehran Iran
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences The University of British Columbia Vancouver British Columbia Canada
- Centre for Cardiovascular Innovation The University of British Columbia Vancouver British Columbia Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences The University of British Columbia Vancouver British Columbia Canada
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3
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Samuel S, Craver K, Miller C, Pelsue B, Gonzalez C, Allison TA, Gulbis B, Choi HA, Kim S. Reviving Decades-Old Wisdom: Longitudinal Analysis of Renin-Angiotensin System Inhibitors and Its Effects on Acute Ischemic Stroke to Improve Outcomes. Am J Hypertens 2024; 37:531-539. [PMID: 38501167 DOI: 10.1093/ajh/hpae033] [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: 01/29/2024] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND While renin-angiotensin system (RAS) inhibitors have a longstanding history in blood pressure control, their suitability as first-line in-patient treatment may be limited due to prolonged half-life and kidney failure concerns. METHODS Using a cohort design, we assessed the impact of RAS inhibitors, either alone or in combination with beta-blockers, on mortality, while exploring interactions, including those related to end-stage renal disease and serum creatinine levels. Eligible subjects were Acute Ischemic Stroke (AIS) patients aged 18 or older with specific subtypes who received in-patient antihypertensive treatment. The primary outcome was mortality rates. Statistical analyses included cross-sectional and longitudinal approaches, employing generalized linear models, G-computation, and discrete-time survival analysis over a 20-day follow-up period. RESULTS In our study of 3,058 AIS patients, those using RAS inhibitors had significantly lower in-hospital mortality (2.2%) compared to non-users (12.1%), resulting in a relative risk (RR) of 0.18 (95% CI: 0.12-0.26). Further analysis using G-computation revealed a marked reduction in mortality risk associated with RAS inhibitors (0.0281 vs. 0.0913, risk difference [RD] of 6.31% or 0.0631, 95% CI: 0.046-0.079). Subgroup analysis demonstrated notable benefits, with individuals having creatinine levels below and above 1.3 mg/dl exhibiting statistically significant RD (RD -0.0510 vs. -0.0895), and a significant difference in paired comparison (-0.0385 or 3.85%, CI 0.023-0.054). Additionally, longitudinal analysis confirmed a consistent daily reduction of 0.93% in mortality risk associated with the intake of RAS inhibitors. CONCLUSIONS RAS inhibitors are associated with a significant reduction in in-hospital mortality in AIS patients, suggesting potential clinical benefits in improving patient outcomes.
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Affiliation(s)
- Sophie Samuel
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Kyndol Craver
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Charles Miller
- Institute of Clinical Research and Learning Health Care, UT Health Houston, Houston, Texas, USA
| | - Brittany Pelsue
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Catherine Gonzalez
- Department of Neurology, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Teresa A Allison
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Brian Gulbis
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Huimahn Alex Choi
- Department of Neurosurgery, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Seokhun Kim
- Institute of Clinical Research and Learning Health Care, UT Health Houston, Houston, Texas, USA
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Jain P, Guha S, Kumar S, Sawhney JPS, Sharma K, Sureshkumar KP, Mehta A, Dhediya R, Gaurav K, Mittal R, Kotak B. Management of Heart Failure in a Resource-Limited Setting: Expert Opinion from India. Cardiol Ther 2024; 13:243-266. [PMID: 38687432 PMCID: PMC11093928 DOI: 10.1007/s40119-024-00367-4] [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: 10/12/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024] Open
Abstract
Heart failure poses a global health challenge affecting millions of individuals, and access to guideline-directed medical therapy is often limited. This limitation is frequently attributed to factors such as drug availability, slow adoption, clinical inertia, and delayed diagnosis. Despite international recommendations promoting the use of guideline-directed medical therapy for heart failure management, personalized approaches are essential in settings with resource constraints. In India, crucial treatments like angiotensin II receptor blocker neprilysin inhibitors and sodium-glucose co-transporter 2 inhibitors are not fully utilized despite their established safety and efficacy. To address this issue, an expert consensus involving 150 specialists, including cardiologists, nephrologists, and endocrinologists, was convened. They deliberated on patient profiles, monitoring, and adverse side effects and provided tailored recommendations for guideline-directed medical therapy in heart failure management. Stressing the significance of early initiation of guideline-directed medical therapy in patients with heart failure, especially with sodium-glucose co-transporter 2 inhibitors, the consensus also explored innovative therapies like vericiguat. To improve heart failure outcomes in resource-limited settings, the experts proposed several measures, including enhanced patient education, cardiac rehabilitation, improved drug access, and reforms in healthcare policies.
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Affiliation(s)
- Peeyush Jain
- Fortis Escorts Heart Institute, New Delhi, India
| | | | | | | | - Kamal Sharma
- Apollo Hospitals, U N Mehta Institute of Cardiology, Ahmedabad, India
| | | | | | | | - Kumar Gaurav
- Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India
| | - Rajan Mittal
- Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India
| | - Bhavesh Kotak
- Dr Reddy's Laboratories Ltd, Hyderabad, Telangana, India
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5
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Rosano GMC, Stolfo D, Anderson L, Abdelhamid M, Adamo M, Bauersachs J, Bayes-Genis A, Böhm M, Chioncel O, Filippatos G, Hill L, Lainscak M, Lambrinou E, Maas AHEM, Massouh AR, Moura B, Petrie MC, Rakisheva A, Ray R, Savarese G, Skouri H, Van Linthout S, Vitale C, Volterrani M, Metra M, Coats AJS. Differences in presentation, diagnosis and management of heart failure in women. A scientific statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024. [PMID: 38783694 DOI: 10.1002/ejhf.3284] [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: 02/05/2024] [Revised: 04/11/2024] [Accepted: 04/29/2024] [Indexed: 05/25/2024] Open
Abstract
Despite the progress in the care of individuals with heart failure (HF), important sex disparities in knowledge and management remain, covering all the aspects of the syndrome, from aetiology and pathophysiology to treatment. Important distinctions in phenotypic presentation are widely known, but the mechanisms behind these differences are only partially defined. The impact of sex-specific conditions in the predisposition to HF has gained progressive interest in the HF community. Under-recruitment of women in large randomized clinical trials has continued in the more recent studies despite epidemiological data no longer reporting any substantial difference in the lifetime risk and prognosis between sexes. Target dose of medications and criteria for device eligibility are derived from studies with a large predominance of men, whereas specific information in women is lacking. The present scientific statement encompasses the whole scenario of available evidence on sex-disparities in HF and aims to define the most challenging and urgent residual gaps in the evidence for the scientific and clinical HF communities.
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Affiliation(s)
- Giuseppe M C Rosano
- Chair of Pharmacology, Department of Human Sciences and Promotion of Quality of Life, San Raffaele University of Rome, Rome, Italy
- Cardiology, San Raffaele Cassino Hospital, Cassino, Italy
| | - Davide Stolfo
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lisa Anderson
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St. George's University of London and St George's University Hospitals NHS Foundation Trust, London, UK
| | - Magdy Abdelhamid
- Department of Cardiovascular Medicine, Faculty of Medicine, Kasr Al Ainy, Cairo University, Giza, Egypt
| | - Marianna Adamo
- ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Poujol, CIBERCV, Badalona, Spain
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest, Romania
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
| | - Gerasimos Filippatos
- National & Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Chaidari, Greece
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Rakičan, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Angela H E M Maas
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Angela R Massouh
- Hariri School of Nursing, American University of Beirut, Beirut, Lebanon
| | - Brenda Moura
- Armed Forces Hospital, Porto, Portugal
- Faculty of Medicine of University of Porto, Porto, Portugal
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Amina Rakisheva
- City Cardiological Center, Almaty Kazakhstan Qonaev city hospital, Almaty Region, Kazakhstan
| | - Robin Ray
- Department of Cardiology, St George's Hospital, London, UK
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Hadi Skouri
- Division of Cardiology, Sheikh Shakhbout Medical city, Abu Dhabi, UAE
| | - Sophie Van Linthout
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
| | | | - Maurizio Volterrani
- Department of Human Science and Promotion of Quality of Life, San Raffaele Open University, Rome, Italy
- Cardio-Pulmonary Department, IRCCS San Raffaele, Rome, Italy
| | - Marco Metra
- ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Zhang C, Shi Y, Liu C, Sudesh SM, Hu Z, Li P, Liu Q, Ma Y, Shi A, Cai H. Therapeutic strategies targeting mechanisms of macrophages in diabetic heart disease. Cardiovasc Diabetol 2024; 23:169. [PMID: 38750502 PMCID: PMC11097480 DOI: 10.1186/s12933-024-02273-4] [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: 10/12/2023] [Accepted: 05/08/2024] [Indexed: 05/18/2024] Open
Abstract
Diabetic heart disease (DHD) is a serious complication in patients with diabetes. Despite numerous studies on the pathogenic mechanisms and therapeutic targets of DHD, effective means of prevention and treatment are still lacking. The pathogenic mechanisms of DHD include cardiac inflammation, insulin resistance, myocardial fibrosis, and oxidative stress. Macrophages, the primary cells of the human innate immune system, contribute significantly to these pathological processes, playing an important role in human disease and health. Therefore, drugs targeting macrophages hold great promise for the treatment of DHD. In this review, we examine how macrophages contribute to the development of DHD and which drugs could potentially be used to target macrophages in the treatment of DHD.
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Affiliation(s)
- Chaoyue Zhang
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yunke Shi
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Changzhi Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shivon Mirza Sudesh
- Faculty of Medicine, St. George University of London, London, UK
- University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | - Zhao Hu
- Department of Geriatric Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Pengyang Li
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Qi Liu
- Wafic Said Molecular Cardiology Research Laboratory, The Texas Heart Institute, Houston, TX, USA
| | - Yiming Ma
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ao Shi
- Faculty of Medicine, St. George University of London, London, UK.
- University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus.
| | - Hongyan Cai
- Cardiovascular Clinical Medical Center, The First Affiliated Hospital of Kunming Medical University, Kunming, China.
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7
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Gutierrez Del Arroyo A, Patel A, Abbott TEF, Begum S, Dias P, Somanath S, Middleditch A, Cleland S, Brealey D, Pearse RM, Ackland GL. Preoperative N-terminal pro-B-type natriuretic peptide and myocardial injury after stopping or continuing renin-angiotensin system inhibitors in noncardiac surgery: a prespecified analysis of a phase 2 randomised controlled multicentre trial. Br J Anaesth 2024; 132:857-866. [PMID: 38341283 PMCID: PMC11103084 DOI: 10.1016/j.bja.2024.01.010] [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: 11/13/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Patients with elevated preoperative plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP >100 pg ml-1) experience more complications after noncardiac surgery. Individuals prescribed renin-angiotensin system (RAS) inhibitors for cardiometabolic disease are at particular risk of perioperative myocardial injury and complications. We hypothesised that stopping RAS inhibitors before surgery increases the risk of perioperative myocardial injury, depending on preoperative risk stratified by plasma NT-proBNP concentrations. METHODS In a preplanned analysis of a phase 2a trial in six UK centres, patients ≥60 yr old undergoing elective noncardiac surgery were randomly assigned either to stop or continue RAS inhibitors before surgery. The pharmacokinetic profile of individual RAS inhibitors determined for how long they were stopped before surgery. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury (plasma high-sensitivity troponin-T ≥15 ng L-1 or a ≥5 ng L-1 increase, when preoperative high-sensitivity troponin-T ≥15 ng L-1) within 48 h after surgery. The co-exposures of interest were preoperative plasma NT-proBNP (< or >100 pg ml -1) and stopping or continuing RAS inhibitors. RESULTS Of 241 participants, 101 (41.9%; mean age 71 [7] yr; 48% females) had preoperative NT-proBNP >100 pg ml -1 (median 339 [160-833] pg ml-1), of whom 9/101 (8.9%) had a formal diagnosis of cardiac failure. Myocardial injury occurred in 63/101 (62.4%) subjects with NT-proBNP >100 pg ml-1, compared with 45/140 (32.1%) subjects with NT-proBNP <100 pg ml -1 {odds ratio (OR) 3.50 (95% confidence interval [CI] 2.05-5.99); P<0.0001}. For subjects with preoperative NT-proBNP <100 pg ml-1, 30/75 (40%) who stopped RAS inhibitors had myocardial injury, compared with 15/65 (23.1%) who continued RAS inhibitors (OR for stopping 2.22 [95% CI 1.06-4.65]; P=0.03). For preoperative NT-proBNP >100 pg ml-1, myocardial injury rates were similar regardless of stopping (62.2%) or continuing (62.5%) RAS inhibitors (OR for stopping 0.98 [95% CI 0.44-2.22]). CONCLUSIONS Stopping renin-angiotensin system inhibitors in lower-risk patients (preoperative NT-proBNP <100 pg ml -1) increased the likelihood of myocardial injury before noncardiac surgery.
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Affiliation(s)
- Ana Gutierrez Del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Durham, UK
| | | | | | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK; UCL Hospitals NHS Foundation Trust, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
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8
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Leatham SJ, Winckel KR, De Guzman KR. Management and Pharmacological Treatment of Peripheral Arterial Disease. J Pharm Pract 2024:8971900241250084. [PMID: 38693597 DOI: 10.1177/08971900241250084] [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: 05/03/2024]
Abstract
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.
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Affiliation(s)
- Samantha J Leatham
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Karl R Winckel
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, QLD, Australia
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Keshia R De Guzman
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, QLD, Australia
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
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9
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Carnwath TP, Demel SL, Prestigiacomo CJ. Genetics of ischemic stroke functional outcome. J Neurol 2024; 271:2345-2369. [PMID: 38502340 PMCID: PMC11055934 DOI: 10.1007/s00415-024-12263-x] [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: 11/20/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/21/2024]
Abstract
Ischemic stroke, which accounts for 87% of cerebrovascular accidents, is responsible for massive global burden both in terms of economic cost and personal hardship. Many stroke survivors face long-term disability-a phenotype associated with an increasing number of genetic variants. While clinical variables such as stroke severity greatly impact recovery, genetic polymorphisms linked to functional outcome may offer physicians a unique opportunity to deliver personalized care based on their patient's genetic makeup, leading to improved outcomes. A comprehensive catalogue of the variants at play is required for such an approach. In this review, we compile and describe the polymorphisms associated with outcome scores such as modified Rankin Scale and Barthel Index. Our search identified 74 known genetic polymorphisms spread across 48 features associated with various poststroke disability metrics. The known variants span diverse biological systems and are related to inflammation, vascular homeostasis, growth factors, metabolism, the p53 regulatory pathway, and mitochondrial variation. Understanding how these variants influence functional outcome may be helpful in maximizing poststroke recovery.
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Affiliation(s)
- Troy P Carnwath
- University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA.
| | - Stacie L Demel
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Charles J Prestigiacomo
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
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10
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Daugherty A, Sawada H, Sheppard MB, Lu HS. Angiotensinogen as a Therapeutic Target for Cardiovascular and Metabolic Diseases. Arterioscler Thromb Vasc Biol 2024; 44:1021-1030. [PMID: 38572647 DOI: 10.1161/atvbaha.124.318374] [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] [Indexed: 04/05/2024]
Abstract
AGT (angiotensinogen) is the unique precursor for the generation of all the peptides of the renin-angiotensin system, but it has received relatively scant attention compared to many other renin-angiotensin system components. Focus on AGT has increased recently, particularly with the evolution of drugs to target the synthesis of the protein. AGT is a noninhibitory serpin that has several conserved domains in addition to the angiotensin II sequences at the N terminus. Increased study is needed on the structure-function relationship to resolve many unknowns regarding AGT metabolism. Constitutive whole-body genetic deletion of Agt in mice leads to multiple developmental defects creating a challenge to use these mice for mechanistic studies. This has been overcome by creating Agt-floxed mice to enable the development of cell-specific deficiencies that have provided considerable insight into a range of cardiovascular and associated diseases. This has been augmented by the recent development of pharmacological approaches targeting hepatocytes in humans to promote protracted inhibition of AGT synthesis. Genetic deletion or pharmacological inhibition of Agt has been demonstrated to be beneficial in a spectrum of diseases experimentally, including hypertension, atherosclerosis, aortic and superior mesenteric artery aneurysms, myocardial dysfunction, and hepatic steatosis. This review summarizes the findings of recent studies utilizing AGT manipulation as a therapeutic approach.
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Affiliation(s)
- Alan Daugherty
- Saha Cardiovascular Research Center (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
- Saha Aortic Center (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
- Department of Physiology (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
| | - Hisashi Sawada
- Saha Cardiovascular Research Center (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
- Saha Aortic Center (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
- Department of Physiology (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
| | - Mary B Sheppard
- Saha Cardiovascular Research Center (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
- Saha Aortic Center (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
- Department of Physiology (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
- Department of Family and Community Medicine (M.B.S.), University of Kentucky, Lexington
- Department of Surgery (M.B.S.), University of Kentucky, Lexington
| | - Hong S Lu
- Saha Cardiovascular Research Center (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
- Saha Aortic Center (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
- Department of Physiology (A.D., H.S., M.B.S., H.S.L.), University of Kentucky, Lexington
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11
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Egbe AC, Miranda WR, Jain CC, Burchill LJ, Abozied O, Ahmed MH, Jokhadar M, Karnakoti S, Connolly HM. Sex Differences in Outcomes of Adults With Isolated Coarctation of the Aorta. CJC Open 2024; 6:759-767. [PMID: 38846445 PMCID: PMC11150945 DOI: 10.1016/j.cjco.2024.01.008] [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: 12/16/2023] [Accepted: 01/25/2024] [Indexed: 06/09/2024] Open
Abstract
Background Data are limited about the effect (or lack thereof) of sex on clinical outcomes in adults with coarctation of the aorta (COA). The purpose of this study was to compare atherosclerotic cardiovascular disease (ASCVD) risk profile, blood pressure (BP) data, echocardiographic indices, and mortality between men and women with COA. Methods Retrospective study of adults with COA, and no associated left-sided obstructive lesions, who received care at Mayo Clinic (2003-2022). ASCVD risk profile was assessed as the prevalence of hypertension, hyperlipidemia, type 2 diabetes, obesity, smoking history, and coronary artery disease. A 24-hour BP monitor was used to assess daytime and nighttime BP and calculate nocturnal dipping. Results Of 621 patients with isolated COA, 375 (60%) were men, and 246 (40%) were women. Women had similar ASCVD risk profile and daytime BP as men. However, women had less nocturnal dipping (7 ± 5 mm Hg vs 16 ± 7 mm Hg, P < 0.001), higher pulmonary artery mean pressure (23 mm Hg [interquartile range: 16-31] vs 20 mm Hg [interquartile range: 15-28], P = 0.04), and higher pulmonary vascular resistance index (3.41 ± 1.14 WU · m2 vs 3.02 ± 0.76 WU · m2, P = 0.006). Female sex was associated with all-cause mortality (adjusted hazard ratio 1.26, 95% confidence interval 1.04-1.94) and cardiovascular mortality (adjusted hazard ratio 1.38, 95% confidence interval 1.09-2.18). Conclusions Women had a higher risk of both cardiovascular mortality and all-cause mortality compared to the risks in men. This difference may be related to the higher-than-expected ASCVD risk factors, abnormal nocturnal blood pressure, and pulmonary hypertension observed in women in this cohort. Further studies are required to identify optimal measures to address these risk factors.
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Affiliation(s)
- Alexander C. Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R. Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - C. Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Luke J. Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Marwan H. Ahmed
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Maan Jokhadar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Snigdha Karnakoti
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M. Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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12
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Abumoawad A, Okazaki RA, Behrooz L, Eberhardt RT. Medical Optimization of Patients with Symptomatic Peripheral Arterial Disease. Ann Vasc Surg 2024:S0890-5096(24)00160-2. [PMID: 38582206 DOI: 10.1016/j.avsg.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 04/08/2024]
Abstract
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.
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Affiliation(s)
| | - Ross A Okazaki
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Leili Behrooz
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Robert T Eberhardt
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
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13
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Al-Jarallah A, Babiker FA. High-Density Lipoprotein Signaling via Sphingosine-1-Phosphate Receptors Safeguards Spontaneously Hypertensive Rats against Myocardial Ischemia/Reperfusion Injury. Pharmaceutics 2024; 16:497. [PMID: 38675158 PMCID: PMC11054943 DOI: 10.3390/pharmaceutics16040497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/28/2024] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND High-density lipoprotein (HDL) protects against ischemia/reperfusion (I/R) injury via signaling through scavenger-receptor class B type-I (SR-BI) and sphingosine-1-phosphate receptors (S1PRs). We recently reported that HDL protects the hearts of spontaneously hypertensive rats (SHRs) against I/R injury in an SR-BI-dependent manner. OBJECTIVE In this study, we examined the role of S1PRs in HDL-induced protection against myocardial I/R injury in hypertensive rats. METHODS Hearts from Wistar Kyoto rats (WKYs) and SHRs were subjected to I/R injury using a modified Langendorff system. The hearts were treated with or without HDL in the presence or absence of a receptor- or kinase-specific antagonist. Cardiac hemodynamics and infarct size were measured. Target proteins were analyzed by immunoblotting and ELISA, and nitrite levels were measured using Greis reagent. RESULTS HDL protected the hearts of WKYs and SHRs against I/R injury. HDL, however, was more protective in WKYs. HDL protection in SHRs required lipid uptake via SR-BI and S1PR1 and S1PR3 but not S1PR2. The hearts from SHRs expressed significantly lower levels of S1PR3 than the hearts from WKYs. HDL differentially activated mediators of the SAFE and RISK pathways in WKYs and SHRs and resulted in nitric oxide generation. Blockage of these pathways abrogated HDL effects. CONCLUSIONS HDL protects against myocardial I/R injury in normotensive and hypertensive rats, albeit to varying degrees. HDL protection in hearts from hypertensive rodents involved SR-BI-mediated lipid uptake coupled with signaling through S1PR1 and S1PR3. The extent of HDL-induced cardiac protection is directly proportional to S1PR3 expression levels. Mechanistically, the safeguarding effects of HDL involved activation of the SAFE and RISK pathways and the generation of nitric oxide.
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Affiliation(s)
- Aishah Al-Jarallah
- Department of Biochemistry, College of Medicine, Kuwait University, Safat 13060, Kuwait
| | - Fawzi A. Babiker
- Department of Physiology, College of Medicine, Kuwait University, Safat 13060, Kuwait;
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14
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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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15
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García-Prieto AM, Verdalles Ú, de José AP, Arroyo D, Aragoncillo I, Barbieri D, Camacho RE, Goicoechea M. Renin-angiotensin-aldosterone system blockers effect in chronic kidney disease progression in hypertensive elderly patients without proteinuria: PROERCAN trial. HIPERTENSION Y RIESGO VASCULAR 2024; 41:95-103. [PMID: 38508877 DOI: 10.1016/j.hipert.2023.11.005] [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: 09/20/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Evidence about nefroprotective effect with RAAS blockers in elderly patients with chronic kidney disease (CKD) without proteinuria is lacking. The primary outcome of our study is to evaluate the impact of RAAS blockers in CKD progression in elderly patients without proteinuria. MATERIALS AND METHODS Multicenter open-label, randomized controlled clinical trial including patients over 65 year-old with hypertension and CKD stages 3-4 without proteinuria. Patients were randomized in a 1:1 ratio to either receive RAAS blockers or other antihypertensive drugs and were followed up for three years. Primary outcome is estimated glomerular filtration rate (eGFR) decline at 3 years. Secondary outcome measures include BP control, renal and cardiovascular events and mortality. RESULTS 88 patients were included with a mean age of 77.9±6.1 years and a follow up period of 3 years: 40 were randomized to RAAS group and 48 to standard treatment. Ethiology of CKD was: 53 vascular, 16 interstitial and 19 of unknown ethiology. In the RAAS group eGFR slope during follow up was -4.3±1.1ml/min, whereas in the standard treatment group an increase on eGFR was observed after 3 years (+4.6±0.4ml/min), p=0.024. We found no differences in blood pressure control, number of antihypertensive drugs, albuminuria, potassium serum levels, incidence of cardiovascular events nor mortality during the follow up period. CONCLUSIONS In elderly patients without diabetes nor cardiopathy and with non proteinuric CKD the use of RAAS blockers does not show a reduction in CKD progression. The PROERCAN (PROgresión de Enfermedad Renal Crónica en ANcianos) trial (trial registration: NCT03195023).
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Affiliation(s)
- A M García-Prieto
- RICORS 2040, Instituto de Salud Carlos III, Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Ú Verdalles
- RICORS 2040, Instituto de Salud Carlos III, Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - A P de José
- RICORS 2040, Instituto de Salud Carlos III, Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - D Arroyo
- RICORS 2040, Instituto de Salud Carlos III, Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - I Aragoncillo
- RICORS 2040, Instituto de Salud Carlos III, Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - D Barbieri
- RICORS 2040, Instituto de Salud Carlos III, Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R E Camacho
- Servicio de Nefrología, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - M Goicoechea
- RICORS 2040, Instituto de Salud Carlos III, Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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16
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Smolderen KG, Romain G, Cleman J, Scierka L, Mena-Hurtado C. Variability in guideline-directed medical therapy across sites and operators and long-term mortality and amputation outcomes risk in patients undergoing peripheral vascular interventions. Am Heart J 2024; 270:75-85. [PMID: 38307364 DOI: 10.1016/j.ahj.2024.01.008] [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: 10/06/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND The use of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) decreases the risk of death and amputation and may decrease hospital readmissions. The variability of GDMT prescription across sites and operators and the proportionality of risk is not well understood. We aimed to study the association between variability of GDMT prescription at the site and operator level and outcomes (including 90-day readmissions and 24-month all-cause mortality and major amputation). METHODS We examined GDMT discharge rates in PVIs performed between 2017 and 2018 using Medicare-linked Vascular Quality Initiative registry. GDMT included a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-i/ARB) if hypertensive. Quartiles (Q1-4) of GDMT rates were documented by operators and sites and variability was quantified using median odds ratios (MOR) and intraclass correlation (ICC). The association between lower GDMT rates (per 10%) by sites and operators with 90-day readmission were calculated using logistic regression, and with 24-month mortality and major amputation using parametric survival model. Models were adjusted for patient-level factors and included sites and operators nested within sites as 2 random effects. RESULTS GDMT rates for 17,147 patients across 223 sites and 1,263 operators ranged from 0% to 38% (Q1, MOR 1.43, 95%CI 1.39-1.47, P ≤ .001) to 57%-100% (Q4, MOR 1.48, 95%CI 1.44-1.51, P ≤ .001). Four percent of variance in GDMT use was explained by sites (ICC 3.9, 95%CI 2.9-5.3) and operators (ICC 4.1, 95%CI 3.1-5.4). A dose-response relationship was noted between lower GDMT rates and increased risk of 90-day readmission risk by sites (P = .021) and operators (P < .001). Lower GDMT prescription by site was associated with higher risk of 24-month mortality (HR = 1.07, 95%CI 1.02-1.13) and major amputation (HR = 1.08, 95%CI 1.01-1.15). Similar associations were found for GDMT use by provider (mortality HR = 1.05, 95%CI 1.02-1.08 and amputation HR = 1.04, 95%CI 1.00-1.08). CONCLUSION Both at the operator and health system level, there was significant variability in GDMT prescription following PVI, proportionally translating into risk for readmission, mortality, and major amputation. Targeted quality efforts should prioritize both operator and site levels to improve GDMT use and outcomes for patients undergoing PVI.
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Affiliation(s)
- Kim G Smolderen
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Department of Psychiatry, Psychology Section, Yale University School of Medicine, New Haven, CT.
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Jacob Cleman
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Lindsey Scierka
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
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17
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Ackland GL, Patel A, Abbott TEF, Begum S, Dias P, Crane DR, Somanath S, Middleditch A, Cleland S, Gutierrez del Arroyo A, Brealey D, Pearse RM. Discontinuation vs. continuation of renin-angiotensin system inhibition before non-cardiac surgery: the SPACE trial. Eur Heart J 2024; 45:1146-1155. [PMID: 37935833 PMCID: PMC10984566 DOI: 10.1093/eurheartj/ehad716] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/07/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND AND AIMS Haemodynamic instability is associated with peri-operative myocardial injury, particularly in patients receiving renin-angiotensin system (RAS) inhibitors (angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers). Whether stopping RAS inhibitors to minimise hypotension, or continuing RAS inhibitors to avoid hypertension, reduces peri-operative myocardial injury remains unclear. METHODS From 31 July 2017 to 1 October 2021, patients aged ≥60 years undergoing elective non-cardiac surgery were randomly assigned to either discontinue or continue RAS inhibitors prescribed for existing medical conditions in six UK centres. Renin-angiotensin system inhibitors were withheld for different durations (2-3 days) before surgery, according to their pharmacokinetic profile. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury [plasma high-sensitivity troponin-T (hs-TnT) ≥ 15 ng/L within 48 h after surgery, or ≥5 ng/L increase when pre-operative hs-TnT ≥15 ng/L]. Pre-specified adverse haemodynamic events occurring within 48 h of surgery included acute hypertension (>180 mmHg) and hypotension requiring vasoactive therapy. RESULTS Two hundred and sixty-two participants were randomized to continue (n = 132) or stop (n = 130) RAS inhibitors. Myocardial injury occurred in 58 (48.3%) patients randomized to discontinue, compared with 50 (41.3%) patients who continued, RAS inhibitors [odds ratio (for continuing): 0.77; 95% confidence interval (CI) 0.45-1.31]. Hypertensive adverse events were more frequent when RAS inhibitors were stopped [16 (12.4%)], compared with 7 (5.3%) who continued RAS inhibitors [odds ratio (for continuing): 0.4; 95% CI 0.16-1.00]. Hypotension rates were similar when RAS inhibitors were stopped [12 (9.3%)] or continued [11 (8.4%)]. CONCLUSIONS Discontinuing RAS inhibitors before non-cardiac surgery did not reduce myocardial injury, and could increase the risk of clinically significant acute hypertension. These findings require confirmation in future studies.
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Affiliation(s)
- Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David R Crane
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Darlington, UK
| | | | | | - Ana Gutierrez del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
- UCL Hospitals NHS Foundation Trust, London, UK
- NIHR University College London Hospitals Biomedical Research Centre, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
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18
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Barcellos PAM, Dall'Agnol A, Sandi GM, Remonti LR, Silveiro SP. Dietary approach for the treatment of arterial hypertension in patients with diabetes mellitus. J Hypertens 2024; 42:583-593. [PMID: 38441180 DOI: 10.1097/hjh.0000000000003674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
The association of hypertension and diabetes mellitus is extremely common, increasing the mortality risk of patients, mainly by cardiovascular causes. Regarding the blood pressure (BP) targets to be achieved, most guidelines suggest levels of 130 mmHg for SBP and of 80 mmHg for DBP. Dietary modifications are quite effective, and many studies suggest that decreasing sodium intake and increasing potassium ingestion are both valuable practices for reducing BP. This can be achieved by stimulating the ingestion of lacteous products, vegetables, and nuts. As for the ideal pharmacologic treatment for hypertension, either calcium channel blockers, diuretics or angiotensin-system blockers can be the first class of drug to be used. In this review, we summarize the evaluation of patients with diabetes mellitus and hypertension, and discuss the available therapeutic approaches, with emphasis on evidence-based dietary recommendations.
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Affiliation(s)
| | - Angélica Dall'Agnol
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul
| | - Giovanna M Sandi
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul
| | | | - Sandra P Silveiro
- Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul
- Endocrine Unit, Hospital de Clínicas de Porto Alegre, RS, Brazil
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19
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Eckle T, Bertazzo J, Khatua TN, Tabatabaei SRF, Bakhtiari NM, Walker LA, Martino TA. Circadian Influences on Myocardial Ischemia-Reperfusion Injury and Heart Failure. Circ Res 2024; 134:675-694. [PMID: 38484024 PMCID: PMC10947118 DOI: 10.1161/circresaha.123.323522] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 02/08/2024] [Indexed: 03/19/2024]
Abstract
The impact of circadian rhythms on cardiovascular function and disease development is well established, with numerous studies in genetically modified animals emphasizing the circadian molecular clock's significance in the pathogenesis and pathophysiology of myocardial ischemia and heart failure progression. However, translational preclinical studies targeting the heart's circadian biology are just now emerging and are leading to the development of a novel field of medicine termed circadian medicine. In this review, we explore circadian molecular mechanisms and novel therapies, including (1) intense light, (2) small molecules modulating the circadian mechanism, and (3) chronotherapies such as cardiovascular drugs and meal timings. These promise significant clinical translation in circadian medicine for cardiovascular disease. (4) Additionally, we address the differential functioning of the circadian mechanism in males versus females, emphasizing the consideration of biological sex, gender, and aging in circadian therapies for cardiovascular disease.
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Affiliation(s)
- Tobias Eckle
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Júlia Bertazzo
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Tarak Nath Khatua
- Centre for Cardiovascular Investigations, Department of Biomedical Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Seyed Reza Fatemi Tabatabaei
- Centre for Cardiovascular Investigations, Department of Biomedical Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Naghmeh Moori Bakhtiari
- Centre for Cardiovascular Investigations, Department of Biomedical Sciences, University of Guelph, Guelph, Ontario, Canada
| | - Lori A Walker
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Tami A. Martino
- Centre for Cardiovascular Investigations, Department of Biomedical Sciences, University of Guelph, Guelph, Ontario, Canada
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20
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Festus ID, Spilberg J, Young ME, Cain S, Khoshnevis S, Smolensky MH, Zaheer F, Descalzi G, Martino TA. Pioneering new frontiers in circadian medicine chronotherapies for cardiovascular health. Trends Endocrinol Metab 2024:S1043-2760(24)00040-7. [PMID: 38458859 DOI: 10.1016/j.tem.2024.02.011] [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: 12/21/2023] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 03/10/2024]
Abstract
Cardiovascular disease (CVD) is a global health concern. Circadian medicine improves cardiovascular care by aligning treatments with our body's daily rhythms and their underlying cellular circadian mechanisms. Time-based therapies, or chronotherapies, show special promise in clinical cardiology. They optimize treatment schedules for better outcomes with fewer side effects by recognizing the profound influence of rhythmic body cycles. In this review, we focus on three chronotherapy areas (medication, light, and meal timing) with potential to enhance cardiovascular care. We also highlight pioneering research in the new field of rest, the gut microbiome, novel chronotherapies for hypertension, pain management, and small molecules that targeting the circadian mechanism.
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Affiliation(s)
- Ifene David Festus
- Centre for Cardiovascular Investigations, University of Guelph; Guelph, Ontario, Canada; Department of Biomedical Sciences, University of Guelph; Guelph, Ontario, Canada
| | - Jeri Spilberg
- Centre for Cardiovascular Investigations, University of Guelph; Guelph, Ontario, Canada; Department of Biomedical Sciences, University of Guelph; Guelph, Ontario, Canada
| | - Martin E Young
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sean Cain
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
| | - Sepideh Khoshnevis
- Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Michael H Smolensky
- Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, USA; Department of Internal Medicine, Division of Cardiology, McGovern School of Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Fariya Zaheer
- Department of Biomedical Sciences, University of Guelph; Guelph, Ontario, Canada
| | - Giannina Descalzi
- Department of Biomedical Sciences, University of Guelph; Guelph, Ontario, Canada
| | - Tami A Martino
- Centre for Cardiovascular Investigations, University of Guelph; Guelph, Ontario, Canada; Department of Biomedical Sciences, University of Guelph; Guelph, Ontario, Canada.
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21
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Wardlaw JM, Chabriat H, de Leeuw FE, Debette S, Dichgans M, Doubal F, Jokinen H, Katsanos AH, Ornello R, Pantoni L, Pasi M, Pavlovic AM, Rudilosso S, Schmidt R, Staals J, Taylor-Rowan M, Hussain S, Lindgren AG. European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke. Eur Stroke J 2024; 9:5-68. [PMID: 38380638 PMCID: PMC10916806 DOI: 10.1177/23969873231219416] [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: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 02/22/2024] Open
Abstract
A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.
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Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Hugues Chabriat
- CNVT and Department of Neurology, Hopital Lariboisière, Paris, France
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Stéphanie Debette
- Bordeaux Population Health Research Center; University of Bordeaux – Inserm U1219; Bordeaux; Department of Neurology, Institute for Neurodegenerative Diseases, Bordeaux University Hospital, Bordeaux, France
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Medical Center, Munich; Munich Cluster for Systems Neurology (SyNergy), Munich; German Center for Neurodegenerative Diseases (DZNE, Munich), Munich; German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, Edinburgh, UK
| | - Hanna Jokinen
- Neurocenter, Helsinki University Hospital and University of Helsinki, HUS, Helsinki, Finland
| | - Aristeidis H Katsanos
- Neurology, McMaster University & Population Health Research Institute, Hamilton, ON, Canada
| | - Raffaele Ornello
- Neurology/Department of Biotechnological ad Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | | | - Marco Pasi
- Department of Neurology, University of Tours, Tours, France
| | - Aleksandra M Pavlovic
- University of Belgrade, Faculty of Special Education and Rehabilitation, Belgrade, Serbia
| | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neurology, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | - Julie Staals
- Department of Neurology and CARIM School for cardiovascular diseases, MUMC+, Maastricht, The Netherlands
| | - Martin Taylor-Rowan
- School of Health and Wellbeing; General Practice and Primary Care, Clarice Pears Building, University of Glasgow, Glasgow, UK
| | | | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University; Department of Neurology, Skåne University Hospital, Lund, Skånes Universitetssjukhus, Lund, Sweden
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22
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Wu C, Zhao P, Xu P, Wan C, Singh S, Varthya SB, Luo SH. Evening versus morning dosing regimen drug therapy for hypertension. Cochrane Database Syst Rev 2024; 2:CD004184. [PMID: 38353289 PMCID: PMC10865448 DOI: 10.1002/14651858.cd004184.pub3] [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: 02/16/2024]
Abstract
BACKGROUND Variation in blood pressure levels display circadian rhythms. Complete 24-hour blood pressure control is the primary goal of antihypertensive treatment and reducing adverse cardiovascular outcomes is the ultimate aim. This is an update of the review first published in 2011. OBJECTIVES To evaluate the effectiveness of administration-time-related effects of once-daily evening versus conventional morning dosing antihypertensive drug therapy regimens on all-cause mortality, cardiovascular mortality and morbidity, total adverse events, withdrawals from treatment due to adverse effects, and reduction of systolic and diastolic blood pressure in people with primary hypertension. SEARCH METHODS We searched the Cochrane Hypertension Specialised Register via Cochrane Register of Studies (17 June 2022), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2022); MEDLINE, MEDLINE In-Process and MEDLINE Epub Ahead of Print (1 June 2022); Embase (1 June 2022); ClinicalTrials.gov (2 June 2022); Chinese Biomedical Literature Database (CBLD) (1978 to 2009); Chinese VIP (2009 to 7 August 2022); Chinese WANFANG DATA (2009 to 4 August 2022); China Academic Journal Network Publishing Database (CAJD) (2009 to 6 August 2022); Epistemonikos (3 September 2022) and the reference lists of relevant articles. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing the administration-time-related effects of evening with morning dosing monotherapy regimens in people with primary hypertension. We excluded people with known secondary hypertension, shift workers or people with white coat hypertension. DATA COLLECTION AND ANALYSIS Two to four review authors independently extracted data and assessed trial quality. We resolved disagreements by discussion or with another review author. We performed data synthesis and analyses using Review Manager Web for all-cause mortality, cardiovascular mortality and morbidity, serious adverse events, overall adverse events, withdrawals due to adverse events, change in 24-hour blood pressure and change in morning blood pressure. We assessed the certainty of the evidence using GRADE. We conducted random-effects meta-analysis, fixed-effect meta-analysis, subgroup analysis and sensitivity analysis. MAIN RESULTS We included 27 RCTs in this updated review, of which two RCTs were excluded from the meta-analyses for lack of data and number of groups not reported. The quantitative analysis included 25 RCTs with 3016 participants with primary hypertension. RCTs used angiotensin-converting enzyme inhibitors (six trials), calcium channel blockers (nine trials), angiotensin II receptor blockers (seven trials), diuretics (two trials), α-blockers (one trial), and β-blockers (one trial). Fifteen trials were parallel designed, and 10 trials were cross-over designed. Most participants were white, and only two RCTs were conducted in Asia (China) and one in Africa (South Africa). All trials excluded people with risk factors of myocardial infarction and strokes. Most trials had high risk or unclear risk of bias in at least two of several key criteria, which was most prominent in allocation concealment (selection bias) and selective reporting (reporting bias). Meta-analysis showed significant heterogeneity across trials. No RCTs reported on cardiovascular mortality and cardiovascular morbidity. There may be little to no differences in all-cause mortality (after 26 weeks of active treatment: RR 0.49, 95% CI 0.04 to 5.42; RD 0, 95% CI -0.01 to 0.01; very low-certainty evidence), serious adverse events (after 8 to 26 weeks of active treatment: RR 1.17, 95% CI 0.53 to 2.57; RD 0, 95% CI -0.02 to 0.03; very low-certainty evidence), overall adverse events (after 6 to 26 weeks of active treatment: RR 0.89, 95% CI 0.67 to 1.20; I² = 37%; RD -0.02, 95% CI -0.07 to 0.02; I² = 38%; very low-certainty evidence) and withdrawals due to adverse events (after 6 to 26 weeks active treatment: RR 0.76, 95% CI 0.47 to 1.23; I² = 0%; RD -0.01, 95% CI -0.03 to 0; I² = 0%; very low-certainty evidence), but the evidence was very uncertain. AUTHORS' CONCLUSIONS Due to the very limited data and the defects of the trials' designs, this systematic review did not find adequate evidence to determine which time dosing drug therapy regimen has more beneficial effects on cardiovascular outcomes or adverse events. We have very little confidence in the evidence showing that evening dosing of antihypertensive drugs is no more or less effective than morning administration to lower 24-hour blood pressure. The conclusions should not be assumed to apply to people receiving multiple antihypertensive drug regimens.
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Affiliation(s)
- Chuncheng Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Zhao
- Medical Library, Sichuan University, Chengdu, China
| | - Ping Xu
- Medical Library, Sichuan University, Chengdu, China
| | - Chaomin Wan
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Surjit Singh
- Pharmacology Department, All India Institute of Medical Sciences, Jodhpur, India
| | - Shoban Babu Varthya
- Pharmacology Department, All India Institute of Medical Sciences, Jodhpur, India
| | - Shuang-Hong Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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23
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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24
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Karaca G, Ekmekci A, Kimiaei A, Safaei S, Özer N, Tayyareci G. The Impact of the Neutrophil-to-Lymphocyte Ratio on In-Hospital Outcomes in Patients With Acute ST-Segment Elevation Myocardial Infarction. Cureus 2024; 16:e54418. [PMID: 38375058 PMCID: PMC10874904 DOI: 10.7759/cureus.54418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 02/21/2024] Open
Abstract
Introduction The neutrophil-to-lymphocyte ratio (NLR) is a significant predictor of cardiovascular diseases, influencing their progression and prognosis. The exact role of the NLR in acute ST-segment elevation myocardial infarction (STEMI) is unclear. We investigated the possible association between peak NLR values within the first three days after STEMI onset and in-hospital outcomes in patients undergoing primary percutaneous coronary intervention (PCI). Methods This retrospective study included 641 patients who were diagnosed with acute STEMI and treated with primary PCI for 18 months at Dr. Siyami Ersek Hospital. The NLR was calculated using the maximum values obtained during the first three days after admission. The patients were divided into quartiles according to their NLR values for further analysis of potential complications during and after hospitalization, up to a follow-up period of three months. Results Significant differences were found in factors such as age, body mass index (BMI), and length of hospital stay among these groups. Specifically, we found that in-hospital mortality rates were significantly higher in the Q4 group, and there were variations in target vessel revascularization (TVR) rates, major adverse cardiac events (MACE) rates, and other clinical outcomes. Some parameters, such as reinfarction rates and certain procedural outcomes, did not show significant differences among the groups. However, despite the differences, most of the patients achieved successful outcomes after PCI, with the best results in the low NLR group and the worst results in the high NLR group. Conclusion Higher NLR values were associated with a higher risk of unfavorable outcomes during hospitalization.
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Affiliation(s)
| | | | - Ali Kimiaei
- Cardiology, Bahçeşehir University, Istanbul, TUR
| | | | - Nihat Özer
- Cardiology, Okan University, Istanbul, TUR
| | - Gülşah Tayyareci
- Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Educational Research Hospital, Istanbul, TUR
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25
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Kim MJ, Cho YK, Jung CH, Lee WJ. Association between cardiovascular disease risk and incident type 2 diabetes mellitus in individuals with prediabetes: A retrospective cohort study. Diabetes Res Clin Pract 2024; 208:111125. [PMID: 38309535 DOI: 10.1016/j.diabres.2024.111125] [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: 11/14/2023] [Revised: 01/11/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
AIMS In this study, we aimed to evaluate the impact of overall cardiovascular disease (CVD) risk on the development of incident T2DM in patients with prediabetes. METHODS We retrospectively enrolled 5,908 subjects with prediabetes who underwent health check-ups at the Asan Medical Center. CVD risk was estimated using the Framingham Risk Score (FRS). We compared moderate- to high-risk groups with low-risk controls based on the FRS. Cox proportional hazards regressions were conducted to estimate the time-to-develop incident T2DM. RESULTS Among the 5908 subjects with prediabetes, 3031 (51.8 %) were identified to have either moderate or high CVD risk scores. During a median follow-up of 5.2 years, 278 (9.2 %) patients from the moderate- to high-risk group and 171 (5.9 %) from the low-risk group were diagnosed with T2DM. The covariate-adjusted hazard ratio for the incident T2DM was 1.30 (95 % CI, 1.06-1.60, p = 0.011) in the moderate- to high-risk group compared to the low-risk controls. CONCLUSION Among patients with prediabetes, those with high CVD risk were more likely to develop incident T2DM, as determined by the FRS. CVD risk factors should be properly evaluated and managed in individuals with prediabetes to reduce the risk of both incident T2DM and associated cardiovascular complications.
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Affiliation(s)
- Myung Jin Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; Asan Diabetes Center, Asan Medical Center, Seoul 05505, Republic of Korea.
| | - Yun Kyung Cho
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; Asan Diabetes Center, Asan Medical Center, Seoul 05505, Republic of Korea.
| | - Chang Hee Jung
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; Asan Diabetes Center, Asan Medical Center, Seoul 05505, Republic of Korea.
| | - Woo Je Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea; Asan Diabetes Center, Asan Medical Center, Seoul 05505, Republic of Korea.
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26
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Gami A, Everitt I, Blumenthal RS, Newby LK, Virani SS, Kohli P. Applying the ABCs of Cardiovascular Disease Prevention to the 2023 AHA/ACC Multisociety Chronic Coronary Disease Guidelines. Am J Med 2024; 137:85-91. [PMID: 37871731 DOI: 10.1016/j.amjmed.2023.10.013] [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: 08/22/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023]
Abstract
The 2023 American Heart Association/American College of Cardiology Multisociety Guideline for the Management of Patients with Chronic Coronary Disease provides updated recommendations for the management of chronic coronary disease. The term "chronic coronary disease" reflects the lifelong nature of the disease and diverse disease etiologies that come under the chronic coronary disease umbrella, beyond the presence of epicardial coronary stenosis, which require targeted lifestyle recommendations, serial optimization of medications, and involvement of multiple care team members. In this review, we highlight several areas where a collaborative approach between cardiologists, primary care clinicians, and internists is essential to optimize the care of patients with chronic coronary disease.
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Affiliation(s)
- Abhishek Gami
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ian Everitt
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roger S Blumenthal
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - L Kristin Newby
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Salim S Virani
- Aga Khan University, Karachi, Pakistan; Texas Heart Institute and Baylor College of Medicine, Houston, TX
| | - Payal Kohli
- Department of Cardiology, University of Colorado Anschutz, Aurora, CO; Department of Cardiology, Veterans Affairs Hospital, Aurora, CO; Cherry Creek Heart, Aurora, CO; Associate Adjunct Professor in the Cardiology Division, Department of Medicine, Duke University, Durham, NC.
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27
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Sun Y, Mao Q, Zhou D, Tian J, Du H, Yu Q, Zhao J, Duan W, Liu C, Duan Y, Zhou J, Zhang T, Xia Z, Yin Y, Liu Y, Zhao X, Xu S. Association of multiple blood metals and systemic atherosclerosis: A cross-sectional study in the CAD population. CHEMOSPHERE 2024; 349:140991. [PMID: 38141683 DOI: 10.1016/j.chemosphere.2023.140991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 12/03/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Coronary atherosclerotic disease (CAD) is often accompanied by peripheral atherosclerosis, resulting in a higher risk of ischemia and cardiovascular death. Exposure to metals is associated with atherosclerotic plaques at specific sites. However, less is known about the effects of mixed metals on systemic atherosclerotic burden in CAD patients. OBJECTIVES To investigate the association of metal mixtures with systemic atherosclerotic burden in a CAD population. METHODS A cross-sectional study including 1562 CAD patients from Southwest China was conducted. The levels of 10 blood metals were measured via inductively coupled plasma spectrometry. More than one vessel with a stenosis ≥50% vessel diameter was defined as CAD. Carotid and lower limb atherosclerosis was assessed by using ultrasound, and coronary atherosclerosis was quantified via arterial angiography. Systemic atherosclerosis was scored according to the presence or absence of lesions at the three sites and the total number of lesions. To investigate the combined impacts and interaction effects of metals, Bayesian kernel machine regression was used. Weighted quantile regression was used to identify the contributions of the metals. RESULTS Significant overall associations of mixed metals with systemic atherosclerotic burden were found. These positive overall associations were mainly driven by Cd, Cu and Pb in systemic atherosclerosis. The main contributing factors were As and Cu for coronary atherosclerosis as well as Cd, Cu and Pb for carotid and lower limb atherosclerosis. Cd and Pb or Cr can interact, and Pb interacts with age, sex and alcohol. CONCLUSIONS In CAD patients, exposure to combinations of metals was highly positively associated with systemic atherosclerotic burden. These significant trends were more pronounced in the peripheral arteries and carotid arteries. Controlling environmental metal exposure can contribute to reducing systemic atherosclerosis in CAD patients.
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Affiliation(s)
- Yapei Sun
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China; School of Public Health, Nanjing Medical University, Nanjing 211166, China
| | - Qi Mao
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Denglu Zhou
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Jiacheng Tian
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China; School of Public Health, Nanjing Medical University, Nanjing 211166, China
| | - Hang Du
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China
| | - Qin Yu
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China
| | - Jianhua Zhao
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Weixia Duan
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China
| | - Cong Liu
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China
| | - Yu Duan
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China
| | - Jie Zhou
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China; School of Public Health, Nanjing Medical University, Nanjing 211166, China
| | - Tian Zhang
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China
| | - Zhiqin Xia
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China; School of Public Health, Nanjing Medical University, Nanjing 211166, China
| | - Yangguang Yin
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China
| | - Yongsheng Liu
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China
| | - Xiaohui Zhao
- Department of Cardiology, Institute of Cardiovascular Research, Xinqiao Hospital, Army Medical University, Chongqing 400037, China.
| | - Shangcheng Xu
- Center of Laboratory Medicine, Chongqing Prevention and Treatment Center for Occupational Diseases, Chongqing 400060, China; Chongqing Key Laboratory of Prevention and Treatment for Occupational Diseases and Poisoning, Chongqing 400060, China; School of Public Health, Nanjing Medical University, Nanjing 211166, China.
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28
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Ahmed W, Dixit P. Effect of chronic lung diseases on angina pectoris among Indian adults: longitudinal ageing study in India. Sci Rep 2024; 14:2372. [PMID: 38287095 PMCID: PMC10825144 DOI: 10.1038/s41598-024-52786-x] [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: 11/06/2023] [Accepted: 01/23/2024] [Indexed: 01/31/2024] Open
Abstract
The study aimed to evaluate the effect of chronic lung diseases, namely chronic obstructive pulmonary diseases (COPD) and asthma, on angina pectoris in individuals aged 45 years and above. Identifying vulnerable subpopulations suffering from COPD and asthma at higher risk of future cardiovascular events using the rose angina questionnaire is imperative for tailored primary and secondary prevention approaches. The present study utilizes the data from the Longitudinal Ageing Study in India, wave 1, conducted during 2017-2018. The sample size included 58,830 individuals aged 45 years and above. Angina was measured based on seven questions from Rose's questionnaires. Descriptive statistics and bivariate analysis were employed to examine the prevalence of angina among individuals with COPD and asthma. Further, multivariable logistic regression and propensity score matching (PSM) methods were used to assess the independent effect of COPD and asthma on angina after controlling the selected background characteristics. We employed PSM in two different models and included various additional factors in model 2, such as smoking, chewing tobacco, alcohol use, ADL, IADL, body mass index, physical activity, high cholesterol, hypertension, diabetes, and chronic heart disease. The current study shows that the prevalence of angina pectoris, COPD and asthma was 6.0%, 2.3% and 4.7%, respectively, among individuals aged 45 years and above in India. The prevalence of angina pectoris was higher among individuals with COPD (9.6% vs. 5.8%) and asthma (9.9% vs. 5.7%) than those without COPD and asthma, respectively. Additionally, angina pectoris was more prevalent among females and rural respondents with COPD (10.8% and 11.0%) and asthma (10.3% and 10.3%) compared to males and urban respondents with COPD (8.0% and 5.7%) and asthma (8.9% and 7.9%). Moreover, in the adjusted model, individuals with COPD (AOR 1.43, 95% CI 1.03 1.98) and asthma (AOR 1.44, 95% CI 1.17 1.77) had nearly 1.5-fold higher odds of having angina pectoris than those without COPD and asthma. The PSM estimates showed that individuals with COPD had 8.4% and 5.0% increased risk of angina pectoris compared to those without COPD in model 1 and model 2, respectively. We observed that, after adjusting to lifestyle, health-related and morbidity factors in model 2, both average treatment effect on untreated (ATU) and average treatment effect (ATE) values decreased by nearly 3.5%. Additionally, the PSM estimates demonstrated that individuals with asthma had a 3.4% and 2.9% increased risk of angina pectoris compared to those without asthma in model 1 and model 2, respectively. The study suggests that COPD and asthma are significantly associated with angina pectoris, and individuals with COPD and asthma have a higher risk of developing angina pectoris. Additionally, angina pectoris was more prevalent among females, rural respondents and adults aged 45-54 with COPD compared to males, urban respondents and those aged 65 and above, respectively, with COPD. Moreover, the findings of our study underscore the targeted primary and secondary interventions and team-based care approach among individuals with COPD and asthma to reduce the risk of CVD events in future.
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Affiliation(s)
- Waquar Ahmed
- School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India.
| | - Priyanka Dixit
- School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
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29
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Laranjo L, Lanas F, Sun MC, Chen DA, Hynes L, Imran TF, Kazi DS, Kengne AP, Komiyama M, Kuwabara M, Lim J, Perel P, Piñeiro DJ, Ponte-Negretti CI, Séverin T, Thompson DR, Tokgözoğlu L, Yan LL, Chow CK. World Heart Federation Roadmap for Secondary Prevention of Cardiovascular Disease: 2023 Update. Glob Heart 2024; 19:8. [PMID: 38273995 PMCID: PMC10809857 DOI: 10.5334/gh.1278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 01/27/2024] Open
Abstract
Background Secondary prevention lifestyle and pharmacological treatment of atherosclerotic cardiovascular disease (ASCVD) reduce a high proportion of recurrent events and mortality. However, significant gaps exist between guideline recommendations and usual clinical practice. Objectives Describe the state of the art, the roadblocks, and successful strategies to overcome them in ASCVD secondary prevention management. Methods A writing group reviewed guidelines and research papers and received inputs from an international committee composed of cardiovascular prevention and health systems experts about the article's structure, content, and draft. Finally, an external expert group reviewed the paper. Results Smoking cessation, physical activity, diet and weight management, antiplatelets, statins, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and cardiac rehabilitation reduce events and mortality. Potential roadblocks may occur at the individual, healthcare provider, and health system levels and include lack of access to healthcare and medicines, clinical inertia, lack of primary care infrastructure or built environments that support preventive cardiovascular health behaviours. Possible solutions include improving health literacy, self-management strategies, national policies to improve lifestyle and access to secondary prevention medication (including fix-dose combination therapy), implementing rehabilitation programs, and incorporating digital health interventions. Digital tools are being examined in a range of settings from enhancing self-management, risk factor control, and cardiac rehab. Conclusions Effective strategies for secondary prevention management exist, but there are barriers to their implementation. WHF roadmaps can facilitate the development of a strategic plan to identify and implement local and national level approaches for improving secondary prevention.
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Affiliation(s)
- Liliana Laranjo
- Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | | | - Marie Chan Sun
- Department of Medicine, University of Mauritius, Réduit, Mauritius
| | | | - Lisa Hynes
- Croí, the West of Ireland Cardiac & Stroke Foundation, Galway, Ireland
| | - Tasnim F. Imran
- Department of Medicine, Division of Cardiology, Warren Alpert Medical School of Brown University, Providence VA Medical Center, Lifespan Cardiovascular Institute, Providence, US
| | - Dhruv S. Kazi
- Department of Medicine (Cardiology), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, US
| | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Maki Komiyama
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Jeremy Lim
- Global Health Dpt, National University of Singapore Saw Swee Hock School of Public Health, Singapore
| | - Pablo Perel
- Non Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine and World Heart Federation, London, UK
| | | | | | | | - David R. Thompson
- School of Nursing and Midwifery, Queen’s University Belfast, United Kingdom
- European Association of Preventive Cardiology, Sophia Antipolis, UK
| | - Lale Tokgözoğlu
- Department of Cardiology, Hacettepe University, Ankara, Turkey
| | - Lijing L. Yan
- Global Health Research Center, Duke Kunshan University, China
| | - Clara K. Chow
- Faculty of Medicina and Health, Westmead Applied Research Centre, University of Sydney, Australia
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Barzilay JI, Farag YMK, Durthaler J. Albuminuria: An Underappreciated Risk Factor for Cardiovascular Disease. J Am Heart Assoc 2024; 13:e030131. [PMID: 38214258 PMCID: PMC10926810 DOI: 10.1161/jaha.123.030131] [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: 01/13/2024]
Abstract
Albuminuria, an established biomarker of the progression of chronic kidney disease, is also recognized as a biomarker for the risk of cardiovascular disease. Elevated urinary albumin excretion indicates kidney damage and systemic vascular disease, including myocardial capillary disease and arterial stiffness. Albuminuria is associated with an increased risk of coronary artery disease, stroke, heart failure, arrhythmias, and microvascular disease. There are now several therapeutic agents that can lead to albuminuria lowering and a reduction in cardiovascular risk. However, screening for albuminuria is still low. Considering the importance of multidisciplinary management of patients with cardiovascular disease, it is crucial that health care professionals managing such patients are aware of the benefits of albuminuria surveillance and management.
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31
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Martinsson A, Törngren C, Nielsen SJ, Pan E, Hansson EC, Taha A, Jeppsson A. Renin-angiotensin system inhibition after surgical aortic valve replacement for aortic stenosis. Heart 2024; 110:202-208. [PMID: 37460192 PMCID: PMC10850732 DOI: 10.1136/heartjnl-2023-322922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/28/2023] [Indexed: 01/12/2024] Open
Abstract
OBJECTIVE The optimal medical therapy after surgical aortic valve replacement (SAVR) for aortic stenosis remains unknown. Renin-angiotensin system (RAS) inhibitors could potentially improve cardiac remodelling and clinical outcomes after SAVR. METHODS All patients undergoing SAVR due to aortic stenosis in Sweden 2006-2020 and surviving 6 months after surgery were included. The primary outcome was major adverse cardiovascular events (MACEs; all-cause mortality, stroke or myocardial infarction). Secondary endpoints included the individual components of MACE and cardiovascular mortality. Time-updated adjusted Cox regression models were used to compare patients with and without RAS inhibitors. Subgroup analyses were performed, as well as a comparison between angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). RESULTS A total of 11 894 patients (mean age, 69.5 years, 40.4% women) were included. Median follow-up time was 5.4 (2.7-8.5) years. At baseline, 53.6% of patients were dispensed RAS inhibitors, this proportion remained stable during follow-up. RAS inhibition was associated with a lower risk of MACE (adjusted hazard ratio (aHR) 0.87 (95% CI 0.81 to 0.93), p<0.001), mainly driven by a lower risk of all-cause death (aHR 0.79 (0.73 to 0.86), p<0.001). The lower MACE risk was consistent in all subgroups except for those with mechanical prostheses (aHR 1.07 (0.84 to 1.37), p for interaction=0.040). Both treatment with ACE inhibitors (aHR 0.89 (95% CI 0.82 to 0.97)) and ARBs (0.87 (0.81 to 0.93)) were associated with lower risk of MACE. CONCLUSION The results of this study suggest that medical therapy with an RAS inhibitor after SAVR is associated with a 13% lower risk of MACE and a 21% lower risk of all-cause death.
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Affiliation(s)
- Andreas Martinsson
- Department of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
| | - Charlotta Törngren
- Department of Molecular and Clinical Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Susanne J Nielsen
- Department of Molecular and Clinical Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Emily Pan
- Department of Cardiovascular Medicine, Harvard Medical School, Boston, Massachusetts, USA
- University of Turku, Turku, Finland
| | - Emma C Hansson
- Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Amar Taha
- Department of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, University of Gothenburg Sahlgrenska Academy, Goteborg, Sweden
- Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Jia G, Bai H, Mather B, Hill MA, Jia G, Sowers JR. Diabetic Vasculopathy: Molecular Mechanisms and Clinical Insights. Int J Mol Sci 2024; 25:804. [PMID: 38255878 PMCID: PMC10815704 DOI: 10.3390/ijms25020804] [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: 11/27/2023] [Revised: 12/26/2023] [Accepted: 01/07/2024] [Indexed: 01/24/2024] Open
Abstract
Clinical and basic studies have documented that both hyperglycemia and insulin-resistance/hyperinsulinemia not only constitute metabolic disorders contributing to cardiometabolic syndrome, but also predispose to diabetic vasculopathy, which refers to diabetes-mellitus-induced microvascular and macrovascular complications, including retinopathy, neuropathy, atherosclerosis, coronary artery disease, hypertension, and peripheral artery disease. The underlying molecular and cellular mechanisms include inappropriate activation of the renin angiotensin-aldosterone system, mitochondrial dysfunction, excessive oxidative stress, inflammation, dyslipidemia, and thrombosis. These abnormalities collectively promote metabolic disorders and further promote diabetic vasculopathy. Recent evidence has revealed that endothelial progenitor cell dysfunction, gut dysbiosis, and the abnormal release of extracellular vesicles and their carried microRNAs also contribute to the development and progression of diabetic vasculopathy. Therefore, clinical control and treatment of diabetes mellitus, as well as the development of novel therapeutic strategies are crucial in preventing cardiometabolic syndrome and related diabetic vasculopathy. The present review focuses on the relationship between insulin resistance and diabetes mellitus in diabetic vasculopathy and related cardiovascular disease, highlighting epidemiology and clinical characteristics, pathophysiology, and molecular mechanisms, as well as management strategies.
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Affiliation(s)
- George Jia
- Department of Medicine—Endocrinology and Metabolism, University of Missouri School of Medicine, Columbia, MO 65212, USA; (G.J.); (H.B.); (B.M.)
- Department of Biology, Washington University in St Louis, St. Louis, MO 63130, USA
| | - Hetty Bai
- Department of Medicine—Endocrinology and Metabolism, University of Missouri School of Medicine, Columbia, MO 65212, USA; (G.J.); (H.B.); (B.M.)
| | - Bethany Mather
- Department of Medicine—Endocrinology and Metabolism, University of Missouri School of Medicine, Columbia, MO 65212, USA; (G.J.); (H.B.); (B.M.)
| | - Michael A. Hill
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO 65212, USA;
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO 65212, USA
| | - Guanghong Jia
- Department of Medicine—Endocrinology and Metabolism, University of Missouri School of Medicine, Columbia, MO 65212, USA; (G.J.); (H.B.); (B.M.)
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO 65212, USA
| | - James R. Sowers
- Department of Medicine—Endocrinology and Metabolism, University of Missouri School of Medicine, Columbia, MO 65212, USA; (G.J.); (H.B.); (B.M.)
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO 65212, USA;
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO 65212, USA
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Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W, Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A, Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg 2024; 67:9-96. [PMID: 37949800 DOI: 10.1016/j.ejvs.2023.08.067] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Das SR, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Kosiborod MN, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S179-S218. [PMID: 38078592 PMCID: PMC10725811 DOI: 10.2337/dc24-s010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
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.
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Košuta D, Hvala U, Fras Z, Jug B. Prognostic impact of optimal lifestyle advice and medical therapy in patients with peripheral arterial disease. VASA 2024; 53:39-44. [PMID: 38079164 DOI: 10.1024/0301-1526/a001106] [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: 01/09/2024]
Abstract
Background: Secondary prevention remains under-implemented in patients with peripheral arterial disease (PAD). In the present study, we sought to assess the extent, the predictors and the prognostic impact of optimal lifestyle advice (OLA) and optimal medical therapy (OMT) given at discharge to patients with PAD undergoing invasive peripheral procedures. Patients and methods: We included consecutive patients with PAD undergoing invasive peripheral procedures, between 2012 and 2013. Data were obtained from a mandatory fill-in clinical pathway. The primary outcome was all-cause mortality, verified using the National Mortality Registry. Results: A total of 2014 participants were included (mean age 70±11 years, 38.1% women). OLA was given to 279 (14%), OMT to 1186 (59%) participants. Male gender and absence of chronic limb-threatening ischaemia were significant predictors of OLA and OMT. During the median follow-up of 729 days (interquartile range 645) 392 (19.5%) participants died giving an overall mortality rate of 97/1000 patient years. On multivariate analysis both OLA and OMT emerged as independent predictors of survival (HR for all-cause mortality: 0.59; 95% CI: 0.42-0.82, p 0.005 and HR: 0.41; 95% CI: 0.22-0.76, p 0.002). Conclusions: OLA and OMT are associated with better long-term prognosis in patients with PAD, however they are still under-implemented, suggesting a considerable potential for improvement, especially in women.
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Affiliation(s)
- Daniel Košuta
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Slovenia
| | - Urška Hvala
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Zlatko Fras
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Slovenia
| | - Borut Jug
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Slovenia
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Hermida RC, Smolensky MH, Mojón A, Fernández JR. Clinical trial design for assessing hypertension medications: are critical circadian chronopharmacological principles being taking into account? Expert Rev Clin Pharmacol 2024; 17:119-130. [PMID: 38197151 DOI: 10.1080/17512433.2024.2304015] [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: 08/12/2023] [Accepted: 01/08/2024] [Indexed: 01/11/2024]
Abstract
INTRODUCTION Clinical hypertension trials typically rely on homeostatic principles, including single time-of-day office blood pressure (BP) measurements (OBPM), rather than circadian chronopharmacological principles, including ambulatory monitoring (ABPM) done around-the-clock to derive the asleep systolic BP (SBP) mean and sleep-time relative SBP decline - jointly the strongest prognosticators of cardiovascular disease (CVD) risk and true definition of hypertension - to qualify participants and assess outcomes. AREAS COVERED Eight chronopharmacological elements are indispensable for design and conduct of hypertension medication trials, mainly those on ingestion-time differences in effects, and also a means of rating quality of investigations. Accordingly, we highlight the findings and shortcomings of: (i) 155 such ingestion-time trials, 83.9% finding at-bedtime/evening treatment more beneficial than conventional upon-awakening/morning treatment; (ii) HOPE and ONTARGET CVD outcomes investigations assessing in the former add-on ramipril at-bedtime and in the latter telmisartan, ramipril, or both in combination in the morning; and (iii) pragmatic TIME CVD outcomes trial. EXPERT OPINION Failure to incorporate chronopharmacological principals - including ABPM to derive asleep SBP and SBP dipping to qualify subjects as hypertensive and assess CVD risk - results in deficient study design, dubious findings, and unnecessary medical controversy at the expense of advances in patient care.
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Affiliation(s)
- Ramón C Hermida
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Telecommunication Technologies (atlanTTic), Universidade de Vigo, Vigo, Spain
- Bioengineering & Chronobiology Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
- Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Michael H Smolensky
- Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, USA
- Department of Internal Medicine, McGovern School of Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Artemio Mojón
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Telecommunication Technologies (atlanTTic), Universidade de Vigo, Vigo, Spain
- Bioengineering & Chronobiology Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
| | - José R Fernández
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Telecommunication Technologies (atlanTTic), Universidade de Vigo, Vigo, Spain
- Bioengineering & Chronobiology Research Group, Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Vigo, Spain
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Kharawala A, Nagraj S, Pargaonkar S, Seo J, Kokkinidis DG, Altin SE. Hypertension Management in Peripheral Artery Disease: A Mini Review. Curr Hypertens Rev 2024; 20:1-9. [PMID: 38083897 DOI: 10.2174/0115734021267004231122061712] [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: 08/09/2023] [Revised: 09/26/2023] [Accepted: 10/25/2023] [Indexed: 06/01/2024]
Abstract
Lower extremity peripheral artery disease (PAD) affects over 230 million adults globally, with hypertension being one of the major risk factors for the development of PAD. Despite the high prevalence, patients with hypertension who have concomitant PAD are less likely to receive adequate therapy. Through this review, we present the current evidence underlying hypertension management in PAD, guideline-directed therapies, and areas pending further investigation. Multiple studies have shown that both high and relatively lower blood pressure levels are associated with worse health outcomes, including increased morbidity and mortality. Hence, guideline-directed recommendation involves cautious management of hypertensive patients with PAD while ensuring hypotension does not occur. Although any antihypertensive medication can be used to treat these patients, the 2017 American Heart Association/American College of Cardiology (AHA/ACC), 2017 European Society of Cardiology (ESC), and 2022 Canadian guidelines favor the use of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) as the initial choice. Importantly, data on blood pressure targets and treatment of hypertension in PAD are limited and largely stem from sub-group studies and post-hoc analysis. Large randomized trials in patients with PAD are required in the future to delineate hypertension management in this complex patient population.
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Affiliation(s)
- A Kharawala
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - S Nagraj
- Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Cardiology, Montefiore Medical Center, Bronx, NY, USA
| | - S Pargaonkar
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - J Seo
- Department of Medicine, New York City Health+Hospitals/Jacobi, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - D G Kokkinidis
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - S E Altin
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
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Wongcharoen W, Osataphan N, Gunaparn S, Srimahachota S, Porapakkham P, Dutsadeevettakul S, Phrommintikul A. Effect of renin angiotensin system inhibitors on long-term major cardiovascular outcomes in patients with high atherosclerotic cardiovascular risk. Sci Rep 2023; 13:23066. [PMID: 38155206 PMCID: PMC10754885 DOI: 10.1038/s41598-023-50430-8] [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: 06/20/2023] [Accepted: 12/19/2023] [Indexed: 12/30/2023] Open
Abstract
The advantage of angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) in patients with preserved LV systolic function is uncertain. We aimed to investigate the effects of ACEI/ARB in high atherosclerotic risk patients without overt heart failure (HF) on long-term major cardiovascular outcomes (MACEs). The Cohort Of patients with high Risk for cardiovascular Events (CORE-Thailand) registry is a prospective, multicenter, observational, longitudinal study of Thai patients with high atherosclerotic risk. The patients with ejection fraction < 50% were excluded. Among 8513 recruited patients, there were 4246 patients included into final analysis after propensity score matching. At 5-years follow-up, Cox regression analysis showed that ACEI/ARB was significantly associated with reduced risk of all-cause mortality or non-fatal myocardial infarction, non-fatal stroke and HF hospitalization (HR 0.82, 95% CI 0.70-0.96, P = 0.011). The benefit was driven by the reduced all-cause mortality and HF. Subgroup analysis demonstrated that ACEI/ARB decreased risk of long-term MACEs in patients with diabetes (HR 0.77, 95% CI 0.63-0.94, P = 0.011) and patients not taking statin (HR 0.57, 95% CI 0.40-0.82, P = 0.002). We demonstrated that the use of ACEI/ARB was associated with reduced risk of long-term MACEs in a large cohort of high atherosclerotic risk patients. Reduction of all-cause mortality and HF were likely the main contributors to the benefit of ACEI/ARB.
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Affiliation(s)
- Wanwarang Wongcharoen
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Rd., Sriphoom, Muang Chiang Mai, 50200, Thailand
| | - Nichanan Osataphan
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Rd., Sriphoom, Muang Chiang Mai, 50200, Thailand
| | - Siriluck Gunaparn
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Rd., Sriphoom, Muang Chiang Mai, 50200, Thailand
| | - Suphot Srimahachota
- Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Somchai Dutsadeevettakul
- Department of Medicine, Golden Jubilee Medical Center, Mahidol University, Nakhon Pathom, Thailand
| | - Arintaya Phrommintikul
- Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Rd., Sriphoom, Muang Chiang Mai, 50200, Thailand.
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McDermott MM, Ho KJ, Alabi O, Criqui MH, Goodney P, Hamburg N, McNeal DM, Pollak A, Smolderen KG, Bonaca M. Disparities in Diagnosis, Treatment, and Outcomes of Peripheral Artery Disease: JACC Scientific Statement. J Am Coll Cardiol 2023; 82:2312-2328. [PMID: 38057074 DOI: 10.1016/j.jacc.2023.09.830] [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: 06/21/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 12/08/2023]
Abstract
Disparities by sex, race, socioeconomic status, and geography exist in diagnosis, treatment, and outcomes for people with lower extremity peripheral artery disease (PAD). PAD prevalence is similar in men and women, but women have more atypical symptoms and undergo lower extremity revascularization at older ages compared to men. People who are Black have an approximately 2-fold higher prevalence of PAD, compared to people who are White and have more atypical symptoms, greater mobility loss, less optimal medical care, and higher amputation rates. Although fewer data are available for other races, people with PAD who are Hispanic have higher amputation rates than White people. Rates of amputation also vary by geography in the United States, with the highest rates of amputation in the southeastern United States. To improve PAD outcomes, intentional actions to eliminate disparities are necessary, including clinician education, patient education with culturally appropriate messaging, improved access to high-quality health care, science focused on disparity elimination, and health policy changes.
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Affiliation(s)
- Mary M McDermott
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Karen J Ho
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Olamide Alabi
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael H Criqui
- University of California-San Diego, School of Medicine, La Jolla, California, USA
| | - Philip Goodney
- Dartmouth School of Medicine, Hanover, New Hampshire, USA
| | | | - Demetria M McNeal
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Amy Pollak
- Mayo Clinic Jacksonville, Jacksonville, Florida, USA
| | - Kim G Smolderen
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marc Bonaca
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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Chen TK, Hoenig MP, Nitsch D, Grams ME. Advances in the management of chronic kidney disease. BMJ 2023; 383:e074216. [PMID: 38052474 DOI: 10.1136/bmj-2022-074216] [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] [Indexed: 12/07/2023]
Abstract
Chronic kidney disease (CKD) represents a global public health crisis, but awareness by patients and providers is poor. Defined as persistent abnormalities in kidney structure or function for more than three months, manifested as either low glomerular filtration rate or presence of a marker of kidney damage such as albuminuria, CKD can be identified through readily available blood and urine tests. Early recognition of CKD is crucial for harnessing major advances in staging, prognosis, and treatment. This review discusses the evidence behind the general principles of CKD management, such as blood pressure and glucose control, renin-angiotensin-aldosterone system blockade, statin therapy, and dietary management. It additionally describes individualized approaches to treatment based on risk of kidney failure and cause of CKD. Finally, it reviews novel classes of kidney protective agents including sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists, non-steroidal selective mineralocorticoid receptor antagonists, and endothelin receptor antagonists. Appropriate, widespread implementation of these highly effective therapies should improve the lives of people with CKD and decrease the worldwide incidence of kidney failure.
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Affiliation(s)
- Teresa K Chen
- Kidney Health Research Collaborative and Division of Nephrology, Department of Medicine, University of California San Francisco; and San Francisco VA Health Care System, San Francisco, CA, USA
| | - Melanie P Hoenig
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Morgan E Grams
- Department of Medicine, New York University Langone School of Medicine, New York, NY, USA
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41
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König CS, Mann A, McFarlane R, Marriott J, Price M, Ramachandran S. Age and the Residual Risk of Cardiovascular Disease following Low Density Lipoprotein-Cholesterol Exposure. Biomedicines 2023; 11:3208. [PMID: 38137429 PMCID: PMC10740806 DOI: 10.3390/biomedicines11123208] [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: 10/18/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
We believe that there is sufficient evidence from basic science, longitudinal cohort studies and randomised controlled trials which validates the low-density lipoprotein cholesterol (LDL-C) or lipid hypothesis. It is important that we can communicate details of the cardiovascular disease (CVD) risk reduction that the average patient could expect depending on the scale of LDL-C decrease following lipid lowering therapy. It is also essential that residual risk (ResR) of CVD be highlighted. To achieve this aim by using existing trial evidence, we developed mathematical models initially for relative risk reduction (RRR) and absolute risk (AR) reduction and then showed that despite optimising LDL-C levels, a considerable degree of ResR remains that is dependent on AR. Age is significantly associated with AR (odds ratio: 1.02, 95% confidence intervals: 1.01-1.04) as was previously demonstrated by analysing the Whickham study cohort using a logistic regression model (age remaining significant even when all the other significant risk factors such as sex, smoking, systolic blood pressure, diabetes and family history were included in the regression model). A discussion of a paper by Ference et al. provided detailed evidence of the relationship between age and AR, based on lifetime LDL-C exposure. Finally, we discussed non-traditional CVD risk factors that may contribute to ResR based on randomised controlled trials investigating drugs improving inflammation, thrombosis, metabolic and endothelial status.
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Affiliation(s)
- Carola S. König
- Department of Mechanical and Aerospace Engineering, Brunel University London, London UB8 3PH, UK
| | - Amar Mann
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (A.M.); (R.M.); (J.M.)
| | - Rob McFarlane
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (A.M.); (R.M.); (J.M.)
| | - John Marriott
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (A.M.); (R.M.); (J.M.)
| | - Malcolm Price
- Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK;
| | - Sudarshan Ramachandran
- Department of Mechanical and Aerospace Engineering, Brunel University London, London UB8 3PH, UK
- Department of Clinical Biochemistry, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK
- Department of Clinical Biochemistry, University Hospitals of North Midlands, Staffordshire ST4 6QG, UK
- School of Medicine, Keele University, Staffordshire ST5 5BG, UK
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42
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Liu J, Pan S, Wang X, Liu Z, Zhang Y. Role of advanced glycation end products in diabetic vascular injury: molecular mechanisms and therapeutic perspectives. Eur J Med Res 2023; 28:553. [PMID: 38042909 PMCID: PMC10693038 DOI: 10.1186/s40001-023-01431-w] [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: 07/19/2023] [Accepted: 10/04/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND In diabetic metabolic disorders, advanced glycation end products (AGEs) contribute significantly to the development of cardiovascular diseases (CVD). AIMS This comprehensive review aims to elucidate the molecular mechanisms underlying AGE-mediated vascular injury. CONCLUSIONS We discuss the formation and accumulation of AGEs, their interactions with cellular receptors, and the subsequent activation of signaling pathways leading to oxidative stress, inflammation, endothelial dysfunction, smooth muscle cell proliferation, extracellular matrix remodeling, and impaired angiogenesis. Moreover, we explore potential therapeutic strategies targeting AGEs and related pathways for CVD prevention and treatment in diabetic metabolic disorders. Finally, we address current challenges and future directions in the field, emphasizing the importance of understanding the molecular links between AGEs and vascular injury to improve patient outcomes.
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Affiliation(s)
- Jing Liu
- Department of Cardiology, Shaanxi Provincial People's Hospital, 256 Youyi Xi Rd, Xi'an, 710068, China
| | - Shuo Pan
- Department of Cardiology, Shaanxi Provincial People's Hospital, 256 Youyi Xi Rd, Xi'an, 710068, China
| | - Xiqiang Wang
- Department of Cardiology, Shaanxi Provincial People's Hospital, 256 Youyi Xi Rd, Xi'an, 710068, China
| | - Zhongwei Liu
- Department of Cardiology, Shaanxi Provincial People's Hospital, 256 Youyi Xi Rd, Xi'an, 710068, China.
- Affiliated Shaanxi Provincial People's Hospital, Medical Research Institute, Northwestern Polytechnical University, Xi'an, China.
| | - Yong Zhang
- Department of Cardiology, Shaanxi Provincial People's Hospital, 256 Youyi Xi Rd, Xi'an, 710068, China.
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43
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Chou HH, Chen CC, Tsai CF, Kuo PL, Chiou YY. Associations between maternal chronic diseases and congenital anomalies of the kidney and urinary tract in offspring: a population-based cohort study. Clin Kidney J 2023; 16:2652-2660. [PMID: 38046024 PMCID: PMC10689185 DOI: 10.1093/ckj/sfad217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Indexed: 12/05/2023] Open
Abstract
Background The relationship between maternal chronic diseases and congenital anomalies of the kidneys and urinary tract (CAKUT) in offspring still needs elucidation. This study aimed to comprehensively evaluate the associations between maternal chronic disease and CAKUT in their offspring. Methods Data of mothers and children were extracted from the Taiwan Maternal and Child Health Database and National Health Insurance Research Database. The concept of developmental origins of health and disease (DOHaD) was used to select maternal chronic diseases. Results The study cohort included 1 196 175 mothers and 1 628 706 offspring. Analysis showed that maternal chronic diseases, especially type 1 diabetes, type 2 diabetes, gestational diabetes, connective tissue disorders and CAKUT were highly associated with CAKUT in the offspring. Higher maternal age, abnormal birthweight (>3500 g or <2500 g), gestational age <36 weeks and birth order <2 were all associated with a higher risk of CAKUT. Maternal chronic hypertension and taking angiotensin-related drugs increased the odds ratios of obstructive kidney disease in the offspring. Offspring tended to have the same type of CAKUT as their mothers. Conclusion Maternal chronic diseases, older maternal age and abnormal birthweight are risk factors for CAKUT. Also, a percentage of patients with CAKUT were not full-term newborns. Results support prenatal counselling and health management of pregnant women with chronic diseases and extra care for infants with a high risk of anomalies. It is strongly recommended that prevention of CAKUT in offspring should start with care of the mothers' prenatal chronic diseases.
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Affiliation(s)
- Hsin-Hsu Chou
- Department of Pediatrics, Ditmanson Medical Foundation Chiayi Christian Hospital, Chia-Yi City, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung City, Taiwan
| | - Chih-Chia Chen
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
- Department of Pediatrics, Division of Pediatric Nephrology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Ching-Fang Tsai
- Department of Medical Research, Clinical Data Center, Ditmanson Medical Foundation Chiayi Christian Hospital, Chia-Yi City, Taiwan
| | - Pao-Lin Kuo
- Department of Obstetrics and Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Yuan-Yow Chiou
- Department of Pediatrics, Division of Pediatric Nephrology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
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Costello HM, Sharma RK, McKee AR, Gumz ML. Circadian Disruption and the Molecular Clock in Atherosclerosis and Hypertension. Can J Cardiol 2023; 39:1757-1771. [PMID: 37355229 DOI: 10.1016/j.cjca.2023.06.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/05/2023] [Accepted: 06/18/2023] [Indexed: 06/26/2023] Open
Abstract
Circadian rhythms are crucial for maintaining vascular function and disruption of these rhythms are associated with negative health outcomes including cardiovascular disease and hypertension. Circadian rhythms are regulated by the central clock within the suprachiasmatic nucleus of the hypothalamus and peripheral clocks located in nearly every cell type in the body, including cells within the heart and vasculature. In this review, we summarize the most recent preclinical and clinical research linking circadian disruption, with a focus on molecular circadian clock mechanisms, in atherosclerosis and hypertension. Furthermore, we provide insight into potential future chronotherapeutics for hypertension and vascular disease. A better understanding of the influence of daily rhythms in behaviour, such as sleep/wake cycles, feeding, and physical activity, as well as the endogenous circadian system on cardiovascular risk will help pave the way for targeted approaches in atherosclerosis and hypertension treatment/prevention.
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Affiliation(s)
- Hannah M Costello
- Department of Physiology and Aging, University of Florida, Gainesville, Florida, USA; Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA; Center for Integrative Cardiovascular and Metabolic Disease, University of Florida, Gainesville, Florida, USA.
| | - Ravindra K Sharma
- Department of Physiology and Aging, University of Florida, Gainesville, Florida, USA; Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA; Center for Integrative Cardiovascular and Metabolic Disease, University of Florida, Gainesville, Florida, USA
| | - Annalisse R McKee
- Department of Physiology and Aging, University of Florida, Gainesville, Florida, USA; Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Michelle L Gumz
- Department of Physiology and Aging, University of Florida, Gainesville, Florida, USA; Division of Nephrology, Hypertension, and Renal Transplantation, Department of Medicine, University of Florida, Gainesville, Florida, USA; Center for Integrative Cardiovascular and Metabolic Disease, University of Florida, Gainesville, Florida, USA; Department of Biochemistry and Molecular Biology, University of Florida, Gainesville, Florida, USA
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45
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Dagan M, Dinh DT, Stehli J, Nan Tie E, Brennan A, Ajani AE, Clark DJ, Freeman M, Reid CM, Hiew C, Oqueli E, Kaye DM, Duffy SJ. Sex Differences in Pharmacotherapy and Long-Term Outcomes in Patients With Ischaemic Heart Disease and Comorbid Left Ventricular Dysfunction. Heart Lung Circ 2023; 32:1457-1464. [PMID: 37945426 DOI: 10.1016/j.hlc.2023.09.008] [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: 09/24/2022] [Revised: 06/07/2023] [Accepted: 09/02/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Left ventricular (LV) dysfunction and ischaemic heart disease (IHD) are common among women. However, women tend to present later and are less likely to receive guideline-directed medical therapy (GDMT) compared with men. METHODS We analysed prospectively collected data (2005-2018) from a multicentre registry on GDMT 30 days after percutaneous coronary intervention in 13,015 patients with LV ejection fraction <50%. Guideline-directed medical therapy was defined as beta blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker±mineralocorticoid receptor antagonist. Long-term mortality was determined by linkage with the Australian National Death Index. RESULTS Women represented 20% (2,634) of the total cohort. Mean age was 65±12 years. Women were on average >5 years, with higher body mass index and higher rates of hypertension, diabetes, renal dysfunction, prior stroke, and rheumatoid arthritis. Guideline-directed medical therapy was similar between sexes (73% vs 72%; p=0.58), although women were less likely to be on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (80% vs 82%; p=0.02). Women were less likely to be on statin therapy (p<0.001) or a second antiplatelet agent (p=0.007). Women had higher unadjusted long-term mortality (25% vs 19%; p<0.001); however, there were no differences in long-term mortality between sexes on adjusted analysis (hazard ratio 0.99; 95% confidence interval 0.87-1.14; p=0.94). CONCLUSIONS Rates of GDMT for LV dysfunction were high and similar between sexes; however, women were less likely to be on appropriate IHD secondary prevention. The increased unadjusted long-term mortality in women was attenuated in adjusted analysis, which highlights the need for optimisation of baseline risk to improve long-term outcomes of women with IHD and comorbid LV dysfunction.
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Affiliation(s)
- Misha Dagan
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia. http://www.twitter.com/misha_dagan
| | - Diem T Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Julia Stehli
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Emilia Nan Tie
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia
| | - Angela Brennan
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Andrew E Ajani
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David J Clark
- Department of Cardiology, Austin Hospital, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Vic, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; School of Population Health, Curtin University, Perth, WA, Australia
| | - Chin Hiew
- Department of Cardiology, University Hospital Geelong, Geelong, Vic, Australia; School of Medicine, Deakin University, Melbourne, Vic, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Melbourne, Vic, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Vic, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Vic, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Vic, Australia.
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46
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Zhou YF, Deng H, Wang GD, Chen S, Xing A, Wang Y, Zhao H, Gao J, Wu S. Cost-effectiveness of drug treatment for young and middle-aged stage 1 hypertensive patients with high risk. J Glob Health 2023; 13:04147. [PMID: 37997845 PMCID: PMC10668205 DOI: 10.7189/jogh.13.04147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
Background Drug treatment was recommended for stage 1 hypertensive patients (blood pressure of 130-139 / 80-89 millimetres of mercury (mmHg)) with high cardiovascular disease (CVD) risk in the 2017 Hypertension Clinical Practice Guidelines, 2018 Chinese guidelines and 2021 World Health Organization guidelines, but not in other guidelines. However, evidence on the cost-effectiveness of drug treatment among young and middle-aged patients remains scarce. This study aimed to compare the cost-effectiveness of drug treatment vs. non-drug treatment for stage 1 hypertensive patients aged <60 years with high CVD risk. Methods A microsimulation model projected quality-adjusted life years (QALYs), health care costs, and incremental cost-effectiveness ratios for drug treatment from a societal perspective. Transition probabilities were estimated from the Kailuan study with a sample size of 34 093 patients aged <60 years with high CVD risk. Costs and health utilities were obtained from the Kailuan study, national statistics reports and published literature. Results Over a 15-year time horizon, the model predicted that drug treatment generated QALY of 9.36 and was associated with expected costs of 3735 US dollars ($) compared with 9.07 and $3923 produced by non-drug treatment among stage 1 hypertensive patients, resulting in a cost-saving for drug treatment. At a willingness-to-pay threshold of $10439/QALY (one gross domestic product (GDP) per capita in 2020), drug treatment had a 99.99% probability of being cost-effective for 10 000 samples of probabilistic sensitivity analysis. Sensitivity analyses by different values of transition probability, cost, utility and discount rate did not appreciably change the results. Shortening the time horizon to the average follow-up period of eight years resulted in ICER of $189/QALY for drug treatment (<1 × GDP/QALY). Conclusions Our results suggested that drug treatment was a dominant strategy for stage 1 hypertensive patients aged <60 years with high CVD risk in China, which may provide evidence for policymakers and clinicians when weighing the pros and cons of drug treatment for young and middle-aged stage 1 hypertensive patients.
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Affiliation(s)
- Yan-Feng Zhou
- Department of Social Medicine, School of Public Health, Guangxi Medical University, Nanning, China
| | - Hua Deng
- Department of Nephrology, The First People's Hospital of Chenzhou, Chenzhou, China
| | - Guo-Dong Wang
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Shuohua Chen
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Aijun Xing
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Yanxiu Wang
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Haiyan Zhao
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
| | - Jingli Gao
- Department of Intensive Care Unit, Kailuan General Hospital, Tangshan, China
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, Tangshan, China
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Zakiev VD, Kotovskaya YV, Tkacheva ON. [Sartans in the treatment of arterial hypertension: focus on telmisartan and azilsartan. A review]. TERAPEVT ARKH 2023; 95:810-817. [PMID: 38158926 DOI: 10.26442/00403660.2023.09.202423] [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: 11/04/2023] [Accepted: 11/04/2023] [Indexed: 01/03/2024]
Abstract
The activity of the renin-angiotensin-aldosterone system is one of the main pathogenetic mechanisms underlying cardiovascular diseases at all stages of the cardiovascular continuum. This article discusses the role of telmisartan and azilsartan as the most powerful sartans in modern cardiology. Azilsartan and especially telmisartan have a significant organoprotection and are superior to other antihypertensive drugs in terms of lowering blood pressure. However, the effect of azilsartan on hard endpoints has not been studied while the efficacy of telmisartan on hard endpoints has been evaluated in plenty clinical trials including 3 large randomized clinical trials with several thousand patients. The article also presents calculations showing the better cost-effectiveness of telmisartan compared to azilsartan.
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Affiliation(s)
- V D Zakiev
- Pirogov Russian National Research Medical University
| | | | - O N Tkacheva
- Pirogov Russian National Research Medical University
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48
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Alcocer LA, Bryce A, De Padua Brasil D, Lara J, Cortes JM, Quesada D, Rodriguez P. The Pivotal Role of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Hypertension Management and Cardiovascular and Renal Protection: A Critical Appraisal and Comparison of International Guidelines. Am J Cardiovasc Drugs 2023; 23:663-682. [PMID: 37668854 PMCID: PMC10625506 DOI: 10.1007/s40256-023-00605-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2023] [Indexed: 09/06/2023]
Abstract
Arterial hypertension is the main preventable cause of premature mortality worldwide. Across Latin America, hypertension has an estimated prevalence of 25.5-52.5%, although many hypertensive patients remain untreated. Appropriate treatment, started early and continued for the remaining lifespan, significantly reduces the risk of complications and mortality. All international and most regional guidelines emphasize a central role for renin-angiotensin-aldosterone system inhibitors (RAASis) in antihypertensive treatment. The two main RAASi options are angiotensin-converting enzyme inhibitors (ACEis) and angiotensin II receptor blockers (ARBs). Although equivalent in terms of blood pressure reduction, ACEis are preferably recommended by some guidelines to manage other cardiovascular comorbidities, with ARBs considered as an alternative when ACEis are not tolerated. This review summarizes the differences between ACEis and ARBs and their place in the international guidelines. It provides a critical appraisal of the guidelines based on available evidence from randomized controlled trials (RCTs) and meta-analyses, especially considering that hypertensive patients in daily practice often have other comorbidities. The observed differences in cardiovascular and renal outcomes in RCTs may be attributed to the different mechanisms of action of ACEis and ARBs, including increased bradykinin levels, potentiated bradykinin response, and stimulated nitric oxide production with ACEis. It may therefore be appropriate to consider ACEis and ARBs as different antihypertensive drugs classes within the same RAASi group. Although guideline recommendations only differentiate between ACEis and ARBs in patients with cardiovascular comorbidities, clinical evidence suggests that ACEis provide benefits in many hypertensive patients, as well as those with other cardiovascular conditions.
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Affiliation(s)
| | | | - David De Padua Brasil
- Departamento de Medicina, Faculdade de Ciências da Saúde (FCS), Universidade Federal de Lavras (UFLA), Lavras, Minas Gerais, Brazil
| | - Joffre Lara
- Hospital Juan Tanca Marengo, Guayaquil, Ecuador
| | | | | | - Pablo Rodriguez
- Instituto Cardiovascular de Buenos Aires, Sanatorio Dr. Julio Méndez, Av del Libertador 6302, C1428ART, Buenos Aires, Argentina.
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Park CS, Kim B, Rhee TM, Lee HJ, Lee HS, Park JB, Kim YJ, Han KD, Kim HK. Association between renin-angiotensin-aldosterone system blockade and clinical outcomes in patients with hypertension: real-world observation from a nationwide hypertension cohort. Clin Res Cardiol 2023; 112:1577-1586. [PMID: 36867200 DOI: 10.1007/s00392-023-02179-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/23/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE We investigated the association between the use of ACEi, ARB, or non-renin-angiotensin-aldosterone system inhibitors (non-RASi) and incident cardiovascular events in an unselected nationwide hypertension cohort. METHODS The information regarding 2,025,849 patients who underwent general health checkup between 2010 and 2011 and were on antihypertensive medication was collected. Patients were allocated into ACEi, ARB, and non-RASi groups and followed until 2019. The outcomes of interest were myocardial infarction (MI), ischemic stroke (IS), atrial fibrillation (AF), heart failure (HF), and all-cause deaths. RESULTS Patients on ACEi and ARB showed unfavorable baseline characteristics compared to those on non-RASi. After adjusting for covariates, the ACEi group showed lower risks of MI, AF, and all-cause deaths (HR (95% CI): 0.94 (0.89-0.99), 0.96 (0.92-1.00), and 0.93 (0.90-0.96), respectively), but similar risks of IS and HF (0.97 (0.92-1.01) and 1.03 (1.00-1.06), respectively), compared to the non-RASi group. Likewise, the ARB group showed decreased risks of MI, IS, AF, HF, and all-cause deaths (HR (95% CI): 0.93 (0.91-0.95), 0.88 (0.86-0.90), 0.86 (0.85-0.88), 0.94 (0.93-0.96), and 0.84 (0.83-0.85)), compared to the non-RASi group. Sensitivity analysis of patients taking a single antihypertensive medication showed similar results. In the propensity score matching (PSM) cohort, the ARB group showed similar risks of MI and decreased risks of IS, AF, HF, and all-cause deaths compared to the ACEi group. CONCLUSIONS ACEi and ARB users were associated with decreased risks of MI, IS, AF, HF, and all-cause deaths, compared to non-RASi users.
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Affiliation(s)
- Chan Soon Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Bongseong Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Tae-Min Rhee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun Jung Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Sun Lee
- Cardiovascular Center, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Republic of Korea
| | - Jun-Bean Park
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yong-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Hyung-Kwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
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50
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Divakaran S, Krawisz AK, Secemsky EA, Kant S. Sex and Racial Disparities in Peripheral Artery Disease. Arterioscler Thromb Vasc Biol 2023; 43:2099-2114. [PMID: 37706319 PMCID: PMC10615869 DOI: 10.1161/atvbaha.123.319399] [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: 04/05/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023]
Abstract
Several studies have shown that women and racial and ethnic minority patients are at increased risk of developing lower extremity peripheral artery disease and suffering adverse outcomes from it, but a knowledge gap remains regarding the underlying causes of these increased risks. Both groups are more likely to be underdiagnosed, have poorly managed contributory comorbidities, and incur disparities in treatment and management postdiagnosis. Opportunities for improvement in the care of women and racial and ethnic minorities with peripheral artery disease include increased rates of screening, higher rates of clinical suspicion (particularly in the absence of typical symptoms of intermittent claudication), and more aggressive risk factor management before and after the diagnosis of peripheral artery disease.
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Affiliation(s)
- Sanjay Divakaran
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna K Krawisz
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Shashi Kant
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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