1
|
Kastrati L, Raeisi-Dehkordi H, Llanaj E, Quezada-Pinedo HG, Khatami F, Ahanchi NS, Llane A, Meçani R, Muka T, Ioannidis JPA. Agreement Between Mega-Trials and Smaller Trials: A Systematic Review and Meta-Research Analysis. JAMA Netw Open 2024; 7:e2432296. [PMID: 39240561 PMCID: PMC11380108 DOI: 10.1001/jamanetworkopen.2024.32296] [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: 09/07/2024] Open
Abstract
Importance Mega-trials can provide large-scale evidence on important questions. Objective To explore how the results of mega-trials compare with the meta-analysis results of trials with smaller sample sizes. Data Sources ClinicalTrials.gov was searched for mega-trials until January 2023. PubMed was searched until June 2023 for meta-analyses incorporating the results of the eligible mega-trials. Study Selection Mega-trials were eligible if they were noncluster nonvaccine randomized clinical trials, had a sample size over 10 000, and had a peer-reviewed meta-analysis publication presenting results for the primary outcome of the mega-trials and/or all-cause mortality. Data Extraction and Synthesis For each selected meta-analysis, we extracted results of smaller trials and mega-trials included in the summary effect estimate and combined them separately using random effects. These estimates were used to calculate the ratio of odds ratios (ROR) between mega-trials and smaller trials in each meta-analysis. Next, the RORs were combined using random effects. Risk of bias was extracted for each trial included in our analyses (or when not available, assessed only for mega-trials). Data analysis was conducted from January to June 2024. Main Outcomes and Measures The main outcomes were the summary ROR for the primary outcome and all-cause mortality between mega-trials and smaller trials. Sensitivity analyses were performed with respect to the year of publication, masking, weight, type of intervention, and specialty. Results Of 120 mega-trials identified, 41 showed a significant result for the primary outcome and 22 showed a significant result for all-cause mortality. In 35 comparisons of primary outcomes (including 85 point estimates from 69 unique mega-trials and 272 point estimates from smaller trials) and 26 comparisons of all-cause mortality (including 70 point estimates from 65 unique mega-trials and 267 point estimates from smaller trials), no difference existed between the outcomes of the mega-trials and smaller trials for primary outcome (ROR, 1.00; 95% CI, 0.97-1.04) nor for all-cause mortality (ROR, 1.00; 95% CI, 0.97-1.04). For the primary outcomes, smaller trials published before the mega-trials had more favorable results than the mega-trials (ROR, 1.05; 95% CI, 1.01-1.10) and subsequent smaller trials published after the mega-trials (ROR, 1.10; 95% CI, 1.04-1.18). Conclusions and Relevance In this meta-research analysis, meta-analyses of smaller studies showed overall comparable results with mega-trials, but smaller trials published before the mega-trials gave more favorable results than mega-trials. These findings suggest that mega-trials need to be performed more often given the relative low number of mega-trials found, their low significant rates, and the fact that smaller trials published prior to mega-trial report more beneficial results than mega-trials and subsequent smaller trials.
Collapse
Affiliation(s)
- Lum Kastrati
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hamidreza Raeisi-Dehkordi
- Department of Global Public Health and Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Erand Llanaj
- Epistudia, Bern, Switzerland
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany
- German Centre for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Hugo G Quezada-Pinedo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Farnaz Khatami
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Community Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Noushin Sadat Ahanchi
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | | | - Renald Meçani
- Epistudia, Bern, Switzerland
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Taulant Muka
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
- Epistudia, Bern, Switzerland
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California
- Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California
| |
Collapse
|
2
|
McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, Christodorescu RM, Daskalopoulou SS, Ferro CJ, Gerdts E, Hanssen H, Harris J, Lauder L, McManus RJ, Molloy GJ, Rahimi K, Regitz-Zagrosek V, Rossi GP, Sandset EC, Scheenaerts B, Staessen JA, Uchmanowicz I, Volterrani M, Touyz RM. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J 2024:ehae178. [PMID: 39210715 DOI: 10.1093/eurheartj/ehae178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
|
3
|
de Havenon A, Viscoli C, Kleindorfer D, Sucharew H, Delic A, Becker C, Robinson D, Yaghi S, Li V, Lansberg MG, Cramer SC, Mistry EA, Sarpong DF, Kasner SE, Kernan W, Sheth KN. Disability and Recurrent Stroke Among Participants in Stroke Prevention Trials. JAMA Netw Open 2024; 7:e2423677. [PMID: 39028666 PMCID: PMC11259901 DOI: 10.1001/jamanetworkopen.2024.23677] [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: 02/23/2024] [Accepted: 05/24/2024] [Indexed: 07/21/2024] Open
Abstract
Importance Stroke secondary prevention trials have disproportionately enrolled participants with mild or no disability. The impact of this bias remains unclear. Objective To investigate the association between poststroke disability and the rate of recurrent stroke during long-term follow up. Design, Setting, and Participants This cohort study is a post hoc analysis of the Prevention Regimen For Effectively Avoiding Second Strokes (PRoFESS) and Insulin Resistance Intervention After Stroke (IRIS) secondary prevention clinical trial datasets. PRoFESS enrolled patients from 2003 to 2008, and IRIS enrolled patients from 2005 to 2015. Data were analyzed from September 23, 2023, to May 16, 2024. Exposure The exposure was poststroke functional status at study baseline, defined as modified Rankin Scale (mRS; range, 0-5; higher score indicates more disability) score of 0 vs 1 to 2 vs 3 or greater. Main Outcomes and Measures The primary outcome was recurrent stroke. The secondary outcome was major cardiovascular events (MACE), defined as recurrent stroke, myocardial infarction, new or worsening heart failure, or vascular death. Results A total of 20 183 PRoFESS participants (mean [SD] age, 66.1 [8.5] years; 12 931 [64.1%] male) and 3265 IRIS participants (mean [SD] age, 62.7 [10.6] years; 2151 [65.9%] male) were included. The median (IQR) follow-up was 2.4 (1.9-3.0) years in PRoFESS and 4.7 (3.2-5.0) years in IRIS. In PRoFESS, the recurrent stroke rate was 7.2%, among patients with an mRS of 0, 8.7% among patients with an mRS of 1 or 2, and 10.6% among patients with an mRS of 3 or greater (χ22 = 27.1; P < .001); in IRIS the recurrent stroke rate was 6.4% among patients with an mRS of 0, 9.0% among patients with an mRS of 1 or 2, and 11.7% among patients with an mRS of 3 or greater (χ22 = 11.1; P < .001). The MACE rate was 10.1% among patients with an mRS of 0, 12.2% among patients with an mRS of 1 or 2, and 17.2% among patients with an mRS of 3 or greater (χ22 = 103.4; P < .001) in PRoFESS and 10.9% among patients with an mRS of 0, 13.3% among patients with an mRS of 1 or 2, and 15.3% among patients with an mRS of 3 or greater (χ22 = 5.8; P = .06) in IRIS. Compared with patients with an mRS of 0, patients with an mRS of 3 or greater had increased hazard for recurrent stroke in PRoFESS (hazard ratio [HR], 1.63; 95% CI, 1.38-1.92; P < .001) and in IRIS (HR, 1.91; 95% CI, 1.28-2.86; P = .002). There was also increased hazard for MACE in PRoFESS (HR, 1.90; 95% CI, 1.66-2.18; P < .001) and in IRIS (HR, 1.45; 95% CI, 1.03-2.03; P = .03). Conclusions and Relevance This cohort study found that higher baseline poststroke disability was associated with increased rates of recurrent stroke and MACE. Including more patients with greater baseline disability in stroke prevention trials may improve the statistical power and generalizability of these studies.
Collapse
Affiliation(s)
- Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut
| | - Catherine Viscoli
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Heidi Sucharew
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Alen Delic
- Department of Neurology, University of Utah, Salt Lake City
| | | | - David Robinson
- Department of Neurology, University of Michigan, Ann Arbor
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Vivian Li
- Department of Neurology, Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut
| | | | - Steven C. Cramer
- Department of Neurology, University of California and California Rehabilitation Institute, Los Angeles
| | - Eva A. Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Daniel F. Sarpong
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Scott E. Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Walter Kernan
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Kevin N. Sheth
- Department of Neurology, Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
4
|
Mutimer CA, Yassi N, Wu TY. Blood Pressure Management in Intracerebral Haemorrhage: when, how much, and for how long? Curr Neurol Neurosci Rep 2024; 24:181-189. [PMID: 38780706 PMCID: PMC11199276 DOI: 10.1007/s11910-024-01341-2] [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] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF REVIEW When compared to ischaemic stroke, there have been limited advances in acute management of intracerebral haemorrhage. Blood pressure control in the acute period is an intervention commonly implemented and recommended in guidelines, as elevated systolic blood pressure is common and associated with haematoma expansion, poor functional outcomes, and mortality. This review addresses the uncertainty around the optimal blood pressure intervention, specifically timing and length of intervention, intensity of blood pressure reduction and agent used. RECENT FINDINGS Recent pivotal trials have shown that acute blood pressure intervention, to a systolic target of 140mmHg, does appear to be beneficial in ICH, particularly when bundled with other therapies such as neurosurgery in selected cases, access to critical care units, blood glucose control, temperature management and reversal of coagulopathy. Systolic blood pressure should be lowered acutely in intracerebral haemorrhage to a target of approximately 140mmHg, and that this intervention is generally safe in the ICH population.
Collapse
Affiliation(s)
- Chloe A Mutimer
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, 3050, Australia.
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, 3050, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, 3052, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| |
Collapse
|
5
|
Li Q, Yan Z, Wang Z, Liang C, Wang X, Wu X, Wang W, Yuan Y, Wang K. A simulation study on the antiarrhythmic mechanisms of established agents in myocardial ischemia and infarction. PLoS Comput Biol 2024; 20:e1012244. [PMID: 38917196 PMCID: PMC11230589 DOI: 10.1371/journal.pcbi.1012244] [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: 01/10/2024] [Revised: 07/08/2024] [Accepted: 06/10/2024] [Indexed: 06/27/2024] Open
Abstract
Patients with myocardial ischemia and infarction are at increased risk of arrhythmias, which in turn, can exacerbate the overall risk of mortality. Despite the observed reduction in recurrent arrhythmias through antiarrhythmic drug therapy, the precise mechanisms underlying their effectiveness in treating ischemic heart disease remain unclear. Moreover, there is a lack of specialized drugs designed explicitly for the treatment of myocardial ischemic arrhythmia. This study employs an electrophysiological simulation approach to investigate the potential antiarrhythmic effects and underlying mechanisms of various pharmacological agents in the context of ischemia and myocardial infarction (MI). Based on physiological experimental data, computational models are developed to simulate the effects of a series of pharmacological agents (amiodarone, telmisartan, E-4031, chromanol 293B, and glibenclamide) on cellular electrophysiology and utilized to further evaluate their antiarrhythmic effectiveness during ischemia. On 2D and 3D tissues with multiple pathological conditions, the simulation results indicate that the antiarrhythmic effect of glibenclamide is primarily attributed to the suppression of efflux of potassium ion to facilitate the restitution of [K+]o, as opposed to recovery of IKATP during myocardial ischemia. This discovery implies that, during acute cardiac ischemia, pro-arrhythmogenic alterations in cardiac tissue's excitability and conduction properties are more significantly influenced by electrophysiological changes in the depolarization rate, as opposed to variations in the action potential duration (APD). These findings offer specific insights into potentially effective targets for investigating ischemic arrhythmias, providing significant guidance for clinical interventions in acute coronary syndrome.
Collapse
Affiliation(s)
- Qince Li
- School of Computer Science and Technology, Harbin Institute of Technology (HIT), Harbin, China
| | - Zheng Yan
- School of Computer Science and Technology, Harbin Institute of Technology (HIT), Harbin, China
| | - Zhen Wang
- Zibo Central Hospital, Zibo, Shandong, China
| | - Cuiping Liang
- Beijing Institute of Computer Technology and Applications, Beijing, China
| | - Xiqian Wang
- Zibo Central Hospital, Zibo, Shandong, China
| | - Xianghu Wu
- Zibo Central Hospital, Zibo, Shandong, China
| | - Wei Wang
- School of Computer Science and Technology, Harbin Institute of Technology (HIT), Harbin, China
| | - Yongfeng Yuan
- School of Computer Science and Technology, Harbin Institute of Technology (HIT), Harbin, China
| | - Kuanquan Wang
- School of Computer Science and Technology, Harbin Institute of Technology (HIT), Harbin, China
| |
Collapse
|
6
|
Karagiannaki A, Kakaletsis N, Chouvarda I, Dourliou V, Milionis H, Savopoulos C, Ntaios G. Association between antihypertensive treatment, blood pressure variability, and stroke severity and outcomes in acute ischemic stroke. J Clin Neurosci 2024; 125:51-58. [PMID: 38754240 DOI: 10.1016/j.jocn.2024.05.014] [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: 03/20/2024] [Revised: 04/25/2024] [Accepted: 05/10/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES The management of blood pressure (BP) and the role of antihypertensive medications (AHT) in acute ischemic stroke (AIS) remain uncertain. This study aimed to investigate the impact of pre- and intra-stroke AHT use on systolic (SBP), diastolic (DBP), and blood pressure variability (BPV). MATERIALS AND METHODS A post-hoc analysis was conducted on 228 AIS patients from the PREVISE study. All patients underwent 24-hour ambulatory blood pressure monitoring within 48 h of symptom onset. Clinical and laboratory data, as well as AHT details, were recorded. Mean BP parameters and BPV for SBP and DBP were computed. The study endpoint was 3-month mortality. RESULTS The majority of stroke patients (84.2%) were already taking AHTs. Beta blockers and ACE inhibitors use before and after stroke were linked to higher DBP variability. Prior angiotensin receptor blockers (ARBs) and vasodilators use correlated with increased SBP variability and lower daytime SBP/DBP levels, respectively. The continuation, discontinuation, or change of AHTs after stroke onset did not significantly affect outcomes. Patients under AHTs during AIS exhibited reduced mortality, with those previously using calcium channel blockers experiencing less severe strokes, and those previously using ARBs showing better outcomes at three months. CONCLUSIONS These findings advocate for personalized BP management in AIS, based on a patient's antihypertensive history. These insights could enhance treatment efficacy, guide research, and improve care for acute ischemic stroke patients.
Collapse
Affiliation(s)
- Anastasia Karagiannaki
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Nikolaos Kakaletsis
- First Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - Ioanna Chouvarda
- Laboratory of Computing, Medical Informatics and Biomedical - Imaging Technologies, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Dourliou
- First Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, University Hospital of Ioannina, University of Ioannina, Greece
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| |
Collapse
|
7
|
Chen YT, Lin CC, Huang PH, Li SY. Comparative analysis of hemodialysis and peritoneal dialysis on the risk of new onset diabetes mellitus. J Formos Med Assoc 2024; 123:606-612. [PMID: 38220559 DOI: 10.1016/j.jfma.2024.01.013] [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: 08/28/2023] [Revised: 11/17/2023] [Accepted: 01/05/2024] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Diabetes mellitus is a significant risk factor for cardiovascular events and mortality in dialysis patients. The impact of different dialysis modalities on the risk of new onset diabetes mellitus (NODM) remains a subject of debate. Previous studies did not adequately account for critical confounding factors such as pre-dialysis glycemic status, medication use, and nutritional status, which may influence the association between dialysis modality and NODM risk. METHODS We conducted a retrospective cohort study of 1426 non-diabetic end-stage renal disease (ESRD) patients who underwent either hemodialysis (HD) or peritoneal dialysis (PD) at a single medical center. We used different statistical methods, adjusting for potential confounding factors, and accounted for competing risk of death. RESULTS Over 12 years, 331 patients (23 %) developed NODM. After adjusting for potential confounding factors and mortality, PD patients had a significantly higher risk of NODM compared to HD patients (adjusted HR 1.52, p = 0.001). A propensity-matched cohort sensitivity analysis yielded similar results. Among patients with prediabetes, those receiving PD had a 2.93 times higher risk of developing NODM than those receiving HD (p for interaction <0.001), whereas no significant difference was observed among euglycemic patients. NODM was also associated with a 1.78 times increased risk of major cardiovascular events. CONCLUSION Our study provides evidence that PD treatment may increase the risk of NODM in ESRD patients, particularly among those with preexisting prediabetes. These findings highlight the importance of personalized treatment approaches, and nephrologists should consider prediabetes when choosing the dialysis modality for their patients.
Collapse
Affiliation(s)
- Yung-Tai Chen
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Medicine, Taipei City Hospital Heping Fuyou Branch, Taipei, Taiwan; University of Taipei, Taiwan
| | - Chih-Ching Lin
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Depart of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Hsun Huang
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Szu-Yuan Li
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Depart of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| |
Collapse
|
8
|
Shukla AK, Awasthi K, Usman K, Banerjee M. Role of renin-angiotensin system/angiotensin converting enzyme-2 mechanism and enhanced COVID-19 susceptibility in type 2 diabetes mellitus. World J Diabetes 2024; 15:606-622. [PMID: 38680697 PMCID: PMC11045416 DOI: 10.4239/wjd.v15.i4.606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 01/22/2024] [Accepted: 02/27/2024] [Indexed: 04/11/2024] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a disease that caused a global pandemic and is caused by infection of severe acute respiratory syndrome coronavirus 2 virus. It has affected over 768 million people worldwide, resulting in approximately 6900000 deaths. High-risk groups, identified by the Centers for Disease Control and Prevention, include individuals with conditions like type 2 diabetes mellitus (T2DM), obesity, chronic lung disease, serious heart conditions, and chronic kidney disease. Research indicates that those with T2DM face a heightened susceptibility to COVID-19 and increased mortality compared to non-diabetic individuals. Examining the renin-angiotensin system (RAS), a vital regulator of blood pressure and pulmonary stability, reveals the significance of the angiotensin-converting enzyme (ACE) and ACE2 enzymes. ACE converts angiotensin-I to the vasoconstrictor angiotensin-II, while ACE2 counters this by converting angiotensin-II to angiotensin 1-7, a vasodilator. Reduced ACE2 expression, common in diabetes, intensifies RAS activity, contributing to conditions like inflammation and fibrosis. Although ACE inhibitors and angiotensin receptor blockers can be therapeutically beneficial by increasing ACE2 levels, concerns arise regarding the potential elevation of ACE2 receptors on cell membranes, potentially facilitating COVID-19 entry. This review explored the role of the RAS/ACE2 mechanism in amplifying severe acute respiratory syndrome coronavirus 2 infection and associated complications in T2DM. Potential treatment strategies, including recombinant human ACE2 therapy, broad-spectrum antiviral drugs, and epigenetic signature detection, are discussed as promising avenues in the battle against this pandemic.
Collapse
Affiliation(s)
- Ashwin Kumar Shukla
- Molecular and Human Genetics Laboratory, Department of Zoology, University of Lucknow, Lucknow 226007, Uttar Pradesh, India
| | - Komal Awasthi
- Molecular and Human Genetics Laboratory, Department of Zoology, University of Lucknow, Lucknow 226007, Uttar Pradesh, India
| | - Kauser Usman
- Department of Medicine, King Georges’ Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Monisha Banerjee
- Molecular and Human Genetics Laboratory, Department of Zoology, University of Lucknow, Lucknow 226007, Uttar Pradesh, India
- Institute of Advanced Molecular Genetics, and Infectious Diseases (IAMGID), University of Lucknow, Lucknow 226007, Uttar Pradesh, India
| |
Collapse
|
9
|
Blair G, Appleton JP, Mhlanga I, Woodhouse LJ, Doubal F, Bath PM, Wardlaw JM. Design of trials in lacunar stroke and cerebral small vessel disease: review and experience with the LACunar Intervention Trial 2 (LACI-2). Stroke Vasc Neurol 2024:svn-2023-003022. [PMID: 38569894 DOI: 10.1136/svn-2023-003022] [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: 12/05/2023] [Accepted: 03/02/2024] [Indexed: 04/05/2024] Open
Abstract
Cerebral small vessel disease (cSVD) causes lacunar stroke (25% of ischaemic strokes), haemorrhage, dementia, physical frailty, or is 'covert', but has no specific treatment. Uncertainties about the design of clinical trials in cSVD, which patients to include or outcomes to assess, may have delayed progress. Based on experience in recent cSVD trials, we reviewed ways to facilitate future trials in patients with cSVD.We assessed the literature and the LACunar Intervention Trial 2 (LACI-2) for data to inform choice of Participant, Intervention, Comparator, Outcome, including clinical versus intermediary endpoints, potential interventions, effect of outcome on missing data, methods to aid retention and reduce data loss. We modelled risk of missing outcomes by baseline prognostic variables in LACI-2 using binary logistic regression.Imaging versus clinical outcomes led to larger proportions of missing data. We present reasons for and against broad versus narrow entry criteria. We identified numerous repurposable drugs with relevant modes of action to test in various cSVD subtypes. Cognitive impairment is the most common clinical outcome after lacunar ischaemic stroke but was missing more frequently than dependency, quality of life or vascular events in LACI-2. Assessing cognitive status using Diagnostic and Statistical Manual for Mental Disorders Fifth Edition can use cognitive data from multiple sources and may help reduce data losses.Trials in patients with all cSVD subtypes are urgently needed and should use broad entry criteria and clinical outcomes and focus on ways to maximise collection of cognitive outcomes to avoid missing data.
Collapse
Affiliation(s)
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | |
Collapse
|
10
|
Kim JY, Moon YJ, Lee C, Kim JH, Park J, Kim JW. Postoperative alterations in ventriculoarterial coupling are an indicator of cardiovascular outcomes in liver transplant recipients. Korean J Anesthesiol 2024; 77:217-225. [PMID: 37435614 PMCID: PMC10982538 DOI: 10.4097/kja.23266] [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: 04/05/2023] [Revised: 06/23/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Liver transplantation (LT) increases the heart and vessel workload in patients with cirrhotic cardiomyopathy. While the interaction of the left ventricle (LV) with the arterial system (ventriculoarterial coupling, VAC) is a key determinant of cardiovascular performance, little is known about changes in VAC after LT. Therefore, we evaluated the relationship between VAC after LT and cardiovascular outcomes. METHODS 344 consecutive patients underwent echocardiographic assessments before and within 30 days after LT. Non-invasive arterial elastance (Ea), LV end-systolic elastance (Ees), and LV end-diastolic elastance (Eed) were calculated. The postoperative outcomes included the development of major adverse cardiovascular events (MACE) and the length of stay in the intensive care unit and hospital. RESULTS A total of 240 patients were included in the analyses. After LT, Ea increased by 16% (P < 0.001), and Ees and contractility index of systolic velocity (S') increased by 18% (P < 0.001) and 7% (P < 0.001), respectively. The Eed increased by 6% (P < 0.001). The VAC remained unchanged (0.56 to 0.56, P = 0.912). Of these patients, 29 had MACE, and those with MACE had significantly higher postoperative VAC. Additionally, a higher postoperative VAC was an independent risk factor for a longer postoperative hospital stay (P = 0.038). CONCLUSIONS These data suggest that ventriculoarterial decoupling is associated with poor postoperative outcomes after LT.
Collapse
Affiliation(s)
- Ji Yeon Kim
- Department of Anesthesiology and Pain Medicine, CHA Gangnam Medical Center, CHA University School of Medicine, Seoul, Korea
| | - Young-Jin Moon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Changjin Lee
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jin Ho Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Junghyun Park
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jung-Won Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Sagris D, Ntaios G, Milionis H. Beyond antithrombotics: recent advances in pharmacological risk factor management for secondary stroke prevention. J Neurol Neurosurg Psychiatry 2024; 95:264-272. [PMID: 37775267 DOI: 10.1136/jnnp-2022-329149] [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: 02/03/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023]
Abstract
Patients with ischaemic stroke represent a diverse group with several cardiovascular risk factors and comorbidities, which classify them as patients at very high risk of stroke recurrence, cardiovascular adverse events or death. In addition to antithrombotic therapy, which is important for secondary stroke prevention in most patients with stroke, cardiovascular risk factor assessment and treatment also contribute significantly to the reduction of mortality and morbidity. Dyslipidaemia, diabetes mellitus and hypertension represent common and important modifiable cardiovascular risk factors among patients with stroke, while early recognition and treatment may have a significant impact on patients' future risk of major cardiovascular events. In recent years, there have been numerous advancements in pharmacological agents aimed at secondary cardiovascular prevention. These innovations, combined with enhanced awareness and interventions targeting adherence and persistence to treatment, as well as lifestyle modifications, have the potential to substantially alleviate the burden of cardiovascular disease, particularly in patients who have experienced ischaemic strokes. This review summarises the evidence on the contemporary advances on pharmacological treatment and future perspectives of secondary stroke prevention beyond antithrombotic treatment.
Collapse
Affiliation(s)
- Dimitrios Sagris
- Department of Internal Medicine, University of Thessaly, Faculty of Medicine, Larissa, Greece
| | - George Ntaios
- Department of Internal Medicine, University of Thessaly, Faculty of Medicine, Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| |
Collapse
|
13
|
Imenshahidi M, Roohbakhsh A, Hosseinzadeh H. Effects of telmisartan on metabolic syndrome components: a comprehensive review. Biomed Pharmacother 2024; 171:116169. [PMID: 38228033 DOI: 10.1016/j.biopha.2024.116169] [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: 11/19/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/18/2024] Open
Abstract
Telmisartan is an antagonist of the angiotensin II receptor used in the management of hypertension (alone or in combination with other antihypertensive agents. It belongs to the drug class of angiotensin II receptor blockers (ARBs). Among drugs of this class, telmisartan shows particular pharmacologic properties, including a longer half-life than any other angiotensin II receptor blockers that bring higher and persistent antihypertensive activity. In hypertensive patients, telmisartan has superior efficacy than other antihypertensive drugs (losartan, valsartan, ramipril, atenolol, and perindopril) in controlling blood pressure, especially towards the end of the dosing interval. Telmisartan has a partial PPARγ-agonistic effect whilst does not have the safety concerns of full agonists of PPARγ receptors (thiazolidinediones). Moreover, telmisartan has an agonist activity on PPARα and PPARδ receptors and modulates the adipokine levels. Thus, telmisartan could be considered as a suitable alternative option, with multi-benefit for all components of metabolic syndrome including hypertension, diabetes mellitus, obesity, and hyperlipidemia. This review will highlight the role of telmisartan in metabolic syndrome and the main mechanisms of action of telmisartan are discussed and summarized. Many studies have demonstrated the useful properties of telmisartan in the prevention and improving of metabolic syndrome and this well-tolerated drug can be greatly proposed in the treatment of different components of metabolic syndrome. However, larger and long-duration studies are needed to confirm these findings in long-term observational studies and prospective trials and to determine the optimum dose of telmisartan in metabolic syndrome.
Collapse
Affiliation(s)
- Mohsen Imenshahidi
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Roohbakhsh
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Hosseinzadeh
- Pharmaceutical Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Pharmacodynamics and Toxicology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
| |
Collapse
|
14
|
Hilkens NA, de Leeuw FE, Klijn CJM, Richard E. Blood pressure variability and white matter hyperintensities after ischemic stroke. CEREBRAL CIRCULATION - COGNITION AND BEHAVIOR 2024; 6:100205. [PMID: 38292015 PMCID: PMC10827490 DOI: 10.1016/j.cccb.2024.100205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 12/19/2023] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
Background High blood pressure variability (BPV) may be a risk factor for stroke and dementia in patients with ischemic stroke, but the underlying mechanism is unknown. We aimed to investigate whether high BPV is associated with presence and progression of white matter hyperintensities (WMH). Methods We performed a post-hoc analysis on the MRI substudy of the PRoFESS trial, including 771 patients with ischemic stroke who underwent MRI at baseline and after a median of 2.1 years. WMH were rated with a semi-quantitative scale. Visit-to-visit BPV was expressed as the coefficient of variation (interval 3-6 months, median number of visits 7). The association of BPV with WMH burden and progression was assessed with linear and logistic regression analyses adjusted for confounders. Results BPV was associated with burden of periventricular WMH (β 0.36 95%CI 0.19-0.53, per one SD increase in BPV) and subcortical (log-transformed) WMH (β 0.25, 95%CI 0.08-0.42). BPV was not associated with periventricular (OR 1.09, 95%CI 0.94-1.27) and subcortical WMH progression (OR 1.15, 95%CI 0.99-1.35). Associations were independent of mean BP. Conclusion High visit-to-visit BPV was associated with both subcortical and periventricular WMH burden in patients with ischemic stroke, but not with WMH progression in this study.
Collapse
Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Catharina JM Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
15
|
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: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
Scheuermann BC, Parr SK, Schulze KM, Kunkel ON, Turpin VG, Liang J, Ade CJ. Associations of Cerebrovascular Regulation and Arterial Stiffness With Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2023; 12:e032616. [PMID: 37930079 PMCID: PMC10727345 DOI: 10.1161/jaha.123.032616] [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: 09/12/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Cerebral small vessel disease (cSVD) is a major contributing factor to ischemic stroke and dementia. However, the vascular pathologies of cSVD remain inconclusive. The aim of this systematic review and meta-analysis was to characterize the associations between cSVD and cerebrovascular reactivity (CVR), cerebral autoregulation, and arterial stiffness (AS). METHODS AND RESULTS MEDLINE, Web of Science, and Embase were searched from inception to September 2023 for studies reporting CVR, cerebral autoregulation, or AS in relation to radiological markers of cSVD. Data were extracted in predefined tables, reviewed, and meta-analyses performed using inverse-variance random effects models to determine pooled odds ratios (ORs). A total of 1611 studies were identified; 142 were included in the systematic review, of which 60 had data available for meta-analyses. Systematic review revealed that CVR, cerebral autoregulation, and AS were consistently associated with cSVD (80.4%, 78.6%, and 85.4% of studies, respectively). Meta-analysis in 7 studies (536 participants, 32.9% women) revealed a borderline association between impaired CVR and cSVD (OR, 2.26 [95% CI, 0.99-5.14]; P=0.05). In 37 studies (27 952 participants, 53.0% women) increased AS, per SD, was associated with cSVD (OR, 1.24 [95% CI, 1.15-1.33]; P<0.01). Meta-regression adjusted for comorbidities accounted for one-third of the AS model variance (R2=29.4%, Pmoderators=0.02). Subgroup analysis of AS studies demonstrated an association with white matter hyperintensities (OR, 1.42 [95% CI, 1.18-1.70]; P<0.01). CONCLUSIONS The collective findings of the present systematic review and meta-analyses suggest an association between cSVD and impaired CVR and elevated AS. However, longitudinal investigations into vascular stiffness and regulatory function as possible risk factors for cSVD remain warranted.
Collapse
Affiliation(s)
| | - Shannon K. Parr
- Department of KinesiologyKansas State UniversityManhattanKSUSA
| | | | | | | | - Jia Liang
- Department of Biostatistics, St. Jude Children’s Research HospitalMemphisTNUSA
| | - Carl J. Ade
- Department of KinesiologyKansas State UniversityManhattanKSUSA
- Department of Physician’s Assistant Studies, Kansas State UniversityManhattanKSUSA
- Johnson Cancer Research CenterKansas State UniversityManhattanKSUSA
| |
Collapse
|
18
|
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.
Collapse
Affiliation(s)
- V D Zakiev
- Pirogov Russian National Research Medical University
| | | | - O N Tkacheva
- Pirogov Russian National Research Medical University
| |
Collapse
|
19
|
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.
Collapse
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.
| |
Collapse
|
20
|
Liu L, Xie X, Pan Y, Wang A, Wei Y, Liu J, Nie X, Liu D, Zhao Z, Wang P, Shen S, Zhong C, Xu T, Wang D, Wang GC, Song D, Ma Y, Zhao J, Jiang Y, Jing J, Meng X, Obst K, Chen CS, Wang D, Wang Y, Zhang Y, Wang Y, He J. Early versus delayed antihypertensive treatment in patients with acute ischaemic stroke: multicentre, open label, randomised, controlled trial. BMJ 2023; 383:e076448. [PMID: 37813418 PMCID: PMC10561001 DOI: 10.1136/bmj-2023-076448] [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] [Accepted: 09/01/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVES To compared the effect of early antihypertensive treatment started within 24-48 h of stroke onset versus delaying treatment until day eight on reducing dependency or death. DESIGN Multicentre, randomised, open label trial. SETTING 106 hospitals in China between 13 June 2018 and 10 July 2022. PARTICIPANTS 4810 patients (≥40 years) were enrolled with acute ischaemic stroke within 24-48 h of symptom onset and elevated systolic blood pressure between 140 mm Hg and <220 mm Hg. INTERVENTIONS Patients were randomly assigned to receive antihypertensive treatment immediately after randomisation (aimed at reducing systolic blood pressure by 10%-20% within the first 24 h and a mean blood pressure <140/90 mm Hg within seven days) or to discontinue antihypertensive medications for seven days if they were taking them, and then receive treatment on day 8 (aimed at achieving mean blood pressure <140/90 mm Hg). MAIN OUTCOME MEASURES The primary outcome was the combination of functional dependency or death (modified Rankin scale score ≥3) at 90 days. Intention to treat analyses were conducted. RESULTS 2413 patients were assigned to the early treatment group and 2397 were assigned to the delayed treatment group. Mean systolic blood pressure was reduced by 9.7% (from 162.9 mm Hg to 146.4 mm Hg) in the early treatment group and by 4.9% (from 162.8 mm Hg to 154.3 mm Hg) in the delayed treatment group within 24 h after randomisation (P for group difference <0.001). Mean systolic blood pressure was 139.1 mm Hg in the early treatment group and 150.9 mm Hg in the delayed treatment group on day seven (P for group difference <0.001). Additionally, 54.6% of patients in the early treatment group and 22.4% in the delayed treatment group had blood pressure of less than 140/90 mm Hg (P<0.001 for group difference) on day seven. At day 90, 289 trial participants (12.0%) in the early treatment group, compared with 250 (10.5%) in the delayed treatment group, had died or experienced a dependency (odds ratio 1.18 (95% confidence interval 0.98 to 1.41), P=0.08). No significant differences in recurrent stroke or adverse events were reported between the two groups. CONCLUSIONS Among patients with mild-to-moderate acute ischaemic stroke and systolic blood pressure between 140 mm Hg and <220 mm Hg who did not receive intravenous thrombolytic treatment, early antihypertensive treatment did not reduce the odds of dependency or death at 90 days. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03479554.
Collapse
Affiliation(s)
- Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Aili Wang
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Yufei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dacheng Liu
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zilin Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Penglian Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Suwen Shen
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
- Department of Chronic Non-Communicable Disease Control, The Affiliated Wuxi Center for Disease Control and Prevention of Nanjing Medical University, Wuxi Center for Disease Control and Prevention, Wuxi, China
| | - Chongke Zhong
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Tan Xu
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Dali Wang
- Affiliated Hospital of North China University of Science and Technology, Tang-shan, China
| | | | - Denghua Song
- Sinopharm Tongmei General Hospital, Datong, China
| | - Yunsheng Ma
- The First People's Hospital of Keerqin District, Tongliao, China
| | - Jinguo Zhao
- Weihai Wendeng District People' Hospital, Weihai, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Katherine Obst
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
- Tulane University Translational Science Institute, New Orleans, Louisiana, USA
| | - Chung-Shiuan Chen
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
- Tulane University Translational Science Institute, New Orleans, Louisiana, USA
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yonghong Zhang
- Department of Epidemiology, School of Public Health, Suzhou Medical College of Soochow University, Suzhou, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiang He
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
- Tulane University Translational Science Institute, New Orleans, Louisiana, USA
| |
Collapse
|
21
|
Cutrell S, Alhomoud IS, Mehta A, Talasaz AH, Van Tassell B, Dixon DL. ACE-Inhibitors in Hypertension: A Historical Perspective and Current Insights. Curr Hypertens Rep 2023; 25:243-250. [PMID: 37284934 DOI: 10.1007/s11906-023-01248-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW This review describes the discovery and development of ACE inhibitors as antihypertensive agents, compares their efficacy, tolerability, and safety to ARBs, and highlights the contemporary issues surrounding ACE inhibitor use for HTN. RECENT FINDINGS Angiotensin-converting enzyme (ACE) inhibitors are commonly prescribed medications for the management of hypertension (HTN) and other chronic conditions including heart failure and chronic kidney disease. These agents inhibit ACE, the enzyme that is responsible for converting angiotensin (AT) I to AT II. Inhibiting the synthesis of AT II causes arterial and venous vasodilation, natriuresis, and a decrease in sympathetic activity, resulting in the reduction of blood pressure. ACE inhibitors are first-line therapy in HTN management along with thiazide diuretics, calcium channel blockers, and angiotensin receptor blockers (ARB). Along with inhibiting AT II synthesis, inhibition of ACE causes accumulation of bradykinin, increasing the risk of bradykinin-mediated side effects like angioedema and cough. Since ARBs do not work on ACE in the renin-angiotensin system, the risk of angioedema and cough are lower with ARBs. Recent evidence has also suggested ARBs may have neuroprotective effects compared to other antihypertensives, including ACE inhibitors; however, this warrants further study. Currently, ACE inhibitors and ARBs have an equal class of recommendation for first-line treatment for the management of HTN. Recent evidence has shown ARBs to be just as effective as ACE inhibitors for HTN but with improved tolerability.
Collapse
Affiliation(s)
- Stacey Cutrell
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA
| | - Ibrahim S Alhomoud
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Buraydah, Saudi Arabia
| | - Anurag Mehta
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Azita H Talasaz
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA
| | - Benjamin Van Tassell
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th St., Smith Building, 6th floor, Room 660, Richmond, VA, USA.
| |
Collapse
|
22
|
Hsu CY, Saver JL, Ovbiagele B, Wu YL, Cheng CY, Lee M. Association Between Magnitude of Differential Blood Pressure Reduction and Secondary Stroke Prevention: A Meta-analysis and Meta-Regression. JAMA Neurol 2023; 80:506-515. [PMID: 36939729 PMCID: PMC10028545 DOI: 10.1001/jamaneurol.2023.0218] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/06/2023] [Indexed: 03/21/2023]
Abstract
Importance The degree to which more intensive blood pressure reduction is better than less intensive for secondary stroke prevention has not been delineated. Objective To perform a standard meta-analysis and a meta-regression of randomized clinical trials to evaluate the association of magnitude of differential blood pressure reduction and recurrent stroke in patients with stroke or transient ischemic attack (TIA). Data Sources PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1, 1980, to June 30, 2022. Study Selection Randomized clinical trials that compared more intensive vs less intensive blood pressure lowering and recorded the outcome of recurrent stroke in patients with stroke or TIA. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used for abstracting data and assessing data quality and validity. Risk ratio (RR) with 95% CI was used as a measure of the association of more intensive vs less intensive blood pressure lowering with primary and secondary outcomes. The univariate meta-regression analyses were conducted to evaluate a possible moderating effect of magnitude of differential systolic blood pressure (SBP) and diastolic blood pressure (DBP) reduction on the recurrent stroke and major cardiovascular events. Main Outcomes and Measures The primary outcome was recurrent stroke and the lead secondary outcome was major cardiovascular events. Results Ten randomized clinical trials comprising 40 710 patients (13 752 women [34%]; mean age, 65 years) with stroke or TIA were included for analysis. The mean duration of follow-up was 2.8 years (range, 1-4 years). Pooled results showed that more intensive treatment compared with less intensive was associated with a reduced risk of recurrent stroke in patients with stroke or TIA (absolute risk, 8.4% vs 10.1%; RR, 0.83; 95% CI, 0.78-0.88). Meta-regression showed that the magnitude of differential SBP and DBP reduction was associated with a lower risk of recurrent stroke in patients with stroke or TIA in a log-linear fashion (SBP: regression slope, -0.06; 95% CI, -0.08 to -0.03; DBP: regression slope, -0.17; 95% CI, -0.26 to -0.08). Similar results were found in the association between differential blood pressure lowering and major cardiovascular events. Conclusions and Relevance More intensive blood pressure-lowering therapy might be associated with a reduced risk of recurrent stroke and major cardiovascular events. These results might support the use of more intensive blood pressure reduction for secondary prevention in patients with stroke or TIA.
Collapse
Affiliation(s)
- Chia-Yu Hsu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - Jeffrey L. Saver
- UCLA Stroke Center, Department of Neurology, University of California, Los Angeles, Los Angeles
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, Los Angeles
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Chun-Yu Cheng
- Department of Neurosurgery, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| |
Collapse
|
23
|
Reddin C, Murphy R, Hanrahan C, Loughlin E, Ferguson J, Judge C, Waters R, Canavan M, Kenny RA, O'Donnell M. Randomised controlled trials of antihypertensive therapy: does exclusion of orthostatic hypotension alter treatment effect? A systematic review and meta-analysis. Age Ageing 2023; 52:afad044. [PMID: 37014001 PMCID: PMC10883139 DOI: 10.1093/ageing/afad044] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Management of antihypertensive therapy is challenging in patients with symptomatic orthostatic hypotension, a population often excluded from randomised controlled trials of antihypertensive therapy. In this systematic review and meta-analysis, we sought to determine whether the association of antihypertensive therapy and adverse events (e.g. falls, syncope), differed among trials that included or excluded patients with orthostatic hypotension. METHODS We performed a systematic review and meta-analysis of randomised controlled trials comparing blood pressure lowering medications to placebo, or different blood pressure targets on falls or syncope outcomes and cardiovascular events. A random-effects meta-analysis was used to estimate a pooled treatment-effect overall in subgroups of trials that excluded patients with orthostatic hypotension and trials that did not exclude patients with orthostatic hypotension, and tested P for interaction. The primary outcome was fall events. RESULTS 46 trials were included, of which 18 trials excluded orthostatic hypotension and 28 trials did not. The incidence of hypotension was significantly lower in trials that excluded participants with orthostatic hypotension (1.3% versus 6.2%, P < 0.001) but not incidences of falls (4.8% versus 8.8%; P = 0.40) or syncope (1.5% versus 1.8%; P = 0.67). Antihypertensive therapy was not associated with an increased risk of falls in trials that excluded (OR 1.00, 95% CI; 0.89-1.13) or included (OR 1.02, 95% CI; 0.88-1.18) participants with orthostatic hypotension (P for interaction = 0.90). CONCLUSIONS The exclusion of patients with orthostatic hypotension does not appear to affect the relative risk estimates for falls and syncope in antihypertensive trials.
Collapse
Affiliation(s)
- Catriona Reddin
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway D02 V583, Ireland
- Galway University Hospital, Newcastle Road, Galway H91 T861, Ireland
- Wellcome Trust-HRB, Irish Clinical Academic Training, London NW1 2BE, UK
| | - Robert Murphy
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway D02 V583, Ireland
- Galway University Hospital, Newcastle Road, Galway H91 T861, Ireland
| | - Caoimhe Hanrahan
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway D02 V583, Ireland
- Galway University Hospital, Newcastle Road, Galway H91 T861, Ireland
| | - Elaine Loughlin
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway D02 V583, Ireland
- Galway University Hospital, Newcastle Road, Galway H91 T861, Ireland
| | - John Ferguson
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway D02 V583, Ireland
| | - Conor Judge
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway D02 V583, Ireland
- Galway University Hospital, Newcastle Road, Galway H91 T861, Ireland
| | - Ruairi Waters
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway D02 V583, Ireland
- Galway University Hospital, Newcastle Road, Galway H91 T861, Ireland
| | - Michelle Canavan
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway D02 V583, Ireland
- Galway University Hospital, Newcastle Road, Galway H91 T861, Ireland
| | - Rose Anne Kenny
- Mercer's Institute for Successful Ageing (MISA), St James's Hospital, Dublin D08 X9HD, UK
- Department of Medical Gerontology, Trinity College Dublin, Dublin 2 D02 PN40, Ireland
| | - Martin O'Donnell
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway D02 V583, Ireland
- Galway University Hospital, Newcastle Road, Galway H91 T861, Ireland
| |
Collapse
|
24
|
Abstract
The health burden of ischemic stroke is high and will continue to increase with an aging population. Recurrent ischemic stroke is increasingly recognized as a major public health concern with potentially debilitating sequelae. Thus, it is imperative to develop and implement effective strategies for stroke prevention. When considering secondary ischemic stroke prevention, it is important to consider the mechanism of the first stroke and the related vascular risk factors. Secondary ischemic stroke prevention typically includes multiple medical and, potentially, surgical treatments, but with the shared goal of reducing the risk of recurrent ischemic stroke. Providers, health care systems, and insurers also need to consider the availability of treatments, their cost and patient burden, methods for improving adherence, and interventions that target lifestyle risk factors such as diet or activity. In this article, we discuss aspects from the 2021 AHA Guideline on Secondary Stroke Prevention as well as highlight additional information relevant to best practices for reducing recurrent stroke risk.
Collapse
Affiliation(s)
- Aaron Bangad
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA
| | - Mehdi Abbasi
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA
| | - Adam de Havenon
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA.
| |
Collapse
|
25
|
Awad K, Lavie CJ, Banach M. In Reply: ACEI and ARB - Each Unique RAAS Inhibitors: The Importance of Impact on Inflammation. Mayo Clin Proc 2023; 98:351-352. [PMID: 36737126 DOI: 10.1016/j.mayocp.2022.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/23/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Kamal Awad
- Faculty of Medicine, Zagazig University, Zagazig, El-Sharkia, Egypt; Zagazig University Hospitals, Zagazig, El-Sharkia, Egypt
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School - the University of Queensland School of Medicine, New Orleans, LA, USA
| | - Maciej Banach
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz (MUL), Lodz, Poland; Cardiovascular Research Centre, University of Zielona Gora, Zielona Gora, Poland
| |
Collapse
|
26
|
Chrysant SG. Superior stroke prevention with angiotensin receptor blockers compared with other antihypertensive drugs. Expert Opin Drug Saf 2023; 22:125-131. [PMID: 36882886 DOI: 10.1080/14740338.2023.2189236] [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: 03/09/2023]
Abstract
INTRODUCTION Stroke is a major cause of death and disability and its incidence is linearly increased with the elevation of blood pressure (BP) and the advancement of age in both men and women, with its incidence being higher in older subjects, the blacks and women. AREAS COVERED The annual worldwide incidence of stroke is 7.6 million for subjects ≥ 20 years of age with the average direct and indirect annual costs of stroke care, is expected to be $94.3 billion between 2014 and 2015. With respect to the cause of stroke, this is multifactorial, due to atherosclerotic heart disease, inflammation, atrial fibrillation, and hypertension with the latter being the most important cause. Therefore, control of BP is the major factor for its prevention. In order to get a better perspective on the current management of stroke, a Medline search of the English literature was conducted between 2014 and 2022 and 26 pertinent papers were selected. EXPERT OPINION Review of data from the selected papers demonstrated that control of SSBP < 130 mmHg was better in stroke prevention than SBP 130-140 mmHg for primary and secondary strokes. Among the drugs used, angiotensin receptor blockers provided superior stroke prevention compared to angiotensin converting enzyme inhibitors and other antihypertensive drugs.
Collapse
Affiliation(s)
- Steven G Chrysant
- Department of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Department of Cardiology, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| |
Collapse
|
27
|
Angiotensin Receptor Blocker Associated with a Decreased Risk of Lung Cancer: An Updated Meta-Analysis. J Pers Med 2023; 13:jpm13020243. [PMID: 36836477 PMCID: PMC9961472 DOI: 10.3390/jpm13020243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION There have been disputes in the association between angiotensin receptor blockers (ARB) and the incidence of lung cancer. Our meta-analysis reevaluated this problem from the perspectives of race, age, drug type, comparison objects and smoking. METHOD We used the following databases to carry out our literature search: Pubmed, Medline, Cochrane Library, and Ovid (From 1 January 2020 to 28 November 2021). The correlation between ARBs and the incidence rate of lung cancer was calculated by risk ratios (RRs). Confidence intervals were selected with 95% confidence intervals. RESULTS A total of 10 randomized controlled trials (RCTs), 18 retrospective studies and 3 case-control studies were found to satisfy the inclusion criteria. The use of ARB drugs reduced the incidence of lung cancer. The pooled results of 10 retrospective studies revealed a decreased lung cancer incidence in patients treated with ARBs, especially in patients using Valsartan. A significantly lower lung cancer incidence was found in the ARB drugs than in calcium channel blockers (CCBs) and angiotensin-converting enzyme inhibitors (ACEIs). Lung cancer occurrence was lower in Asian-based studies, especially in Mongolian-dominated and Caucasian-dominated patient populations. No significant decrease in lung cancer occurrence was found in RCTs or in patients receiving telmisartan, losartan, candesartan, irbesartan, or other placebo or in American and European-dominated patient populations. CONCLUSION Compared with ACEIs and CCBs, ARBs significantly reduce the risk of lung cancer, especially in Asian and Mongolian populations. Valsartan has the best effect in reducing the risk of lung cancer in ARB drugs.
Collapse
|
28
|
Ferrario CM, Saha A, VonCannon JL, Meredith WJ, Ahmad S. Does the Naked Emperor Parable Apply to Current Perceptions of the Contribution of Renin Angiotensin System Inhibition in Hypertension? Curr Hypertens Rep 2022; 24:709-721. [PMID: 36272015 DOI: 10.1007/s11906-022-01229-x] [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: 10/17/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To address contemporary hypertension challenges, a critical reexamination of therapeutic accomplishments using angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, and a greater appreciation of evidence-based shortcomings from randomized clinical trials are fundamental in accelerating future progress. RECENT FINDINGS Medications targeting angiotensin II mechanism of action are essential for managing primary hypertension, type 2 diabetes, heart failure, and chronic kidney disease. While the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to control blood pressure is undisputed, practitioners, hypertension specialists, and researchers hold low awareness of these drugs' limitations in preventing or reducing the risk of cardiovascular events. Biases in interpreting gained knowledge from data obtained in randomized clinical trials include a pervasive emphasis on using relative risk reduction over absolute risk reduction. Furthermore, recommendations for clinical practice in international hypertension guidelines fail to address the significance of a residual risk several orders of magnitude greater than the benefits. We analyze the limitations of the clinical trials that have led to current recommended treatment guidelines. We define and quantify the magnitude of the residual risk in published hypertension trials and explore how activation of alternate compensatory bioprocessing components within the renin angiotensin system bypass the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to achieve a significant reduction in total and cardiovascular deaths. We complete this presentation by outlining the current incipient but promising potential of immunotherapy to block angiotensin II pathology alone or possibly in combination with other antihypertensive drugs. A full appreciation of the magnitude of the residual risk associated with current renin angiotensin system-based therapies constitutes a vital underpinning for seeking new molecular approaches to halt or even reverse the cardiovascular complications of primary hypertension and encourage investigating a new generation of ACE inhibitors and ARBs with increased capacity to reach the intracellular compartments at which Ang II can be generated.
Collapse
Affiliation(s)
- Carlos M Ferrario
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA.
| | - Amit Saha
- Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Jessica L VonCannon
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Wayne J Meredith
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Sarfaraz Ahmad
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| |
Collapse
|
29
|
Mao Y, Ge S, Qi S, Tian QB. Benefits and risks of antihypertensive medication in adults with different systolic blood pressure: A meta-analysis from the perspective of the number needed to treat. Front Cardiovasc Med 2022; 9:986502. [PMID: 36337902 PMCID: PMC9626501 DOI: 10.3389/fcvm.2022.986502] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background The blood pressure (BP) threshold for initial pharmacological treatment remains controversial. The number needed to treat (NNT) is a significant indicator. This study aimed to explore the benefits and risks of antihypertensive medications in participants with different systolic BPs (SBPs), and cardiovascular disease status from the perspective of the NNT. Methods We conducted a meta-analysis of 52 randomized placebo-controlled trials. The data were extracted from published articles and pooled to calculate NNTs. The participants were divided into five groups, based on the mean SBP at entry (120–129.9, 130–139.9, 140–159.9, 160–179.9, and ≥180 mmHg). Furthermore, we stratified patients into those with and without cardiovascular disease. The primary outcomes were the major adverse cardiovascular events (MACEs), and adverse events (AEs) leading to discontinuation. Results Antihypertensive medications were not associated with MACEs, however, it increased AEs, when the SBP was <140 mmHg. For participants with cardiovascular disease or at a high risk of heart failure and stroke, antihypertensive treatment reduced MACEs when SBP was ≥130 mmHg. Despite this, only 2–4 subjects had reduced MACEs per 100 patients receiving antihypertensive medications for 3.50 years. The number of individuals who needed to treat to avoid MACEs declined with an increased cardiovascular risk. Conclusion Pharmacological treatment could be activated when SBP reaches 140 mmHg. For people with cardiovascular disease or at a higher risk of stroke and heart failure, 130 mmHg may be a better therapeutic threshold. It could be more cost-effective to prioritize antihypertensive medications for people with a high risk of developing cardiovascular disease.
Collapse
|
30
|
Razo C, Welgan CA, Johnson CO, McLaughlin SA, Iannucci V, Rodgers A, Wang N, LeGrand KE, Sorensen RJD, He J, Zheng P, Aravkin AY, Hay SI, Murray CJL, Roth GA. Effects of elevated systolic blood pressure on ischemic heart disease: a Burden of Proof study. Nat Med 2022; 28:2056-2065. [PMID: 36216934 PMCID: PMC9556328 DOI: 10.1038/s41591-022-01974-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/27/2022] [Indexed: 12/28/2022]
Abstract
High systolic blood pressure (SBP) is a major risk factor for ischemic heart disease (IHD), the leading cause of death worldwide. Using data from published observational studies and controlled trials, we estimated the mean SBP-IHD dose-response function and burden of proof risk function (BPRF), and we calculated a risk outcome score (ROS) and corresponding star rating (one to five). We found a very strong, significant harmful effect of SBP on IHD, with a mean risk-relative to that at 100 mm Hg SBP-of 1.39 (95% uncertainty interval including between-study heterogeneity 1.34-1.44) at 120 mm Hg, 1.81 (1.70-1.93) at 130 mm Hg and 4.48 (3.81-5.26) at 165 mm Hg. The conservative BPRF measure indicated that SBP exposure between 107.5 and 165.0 mm Hg raised risk by 101.36% on average, yielding a ROS of 0.70 and star rating of five. Our analysis shows that IHD risk was already increasing at 120 mm Hg SBP, rising steadily up to 165 mm Hg and increasing less steeply above that point. Our study endorses the need to prioritize and strengthen strategies for screening, to raise awareness of the need for timely diagnosis and treatment of hypertension and to increase the resources allocated for understanding primordial prevention of elevated blood pressure.
Collapse
Affiliation(s)
- Christian Razo
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
| | | | - Catherine O Johnson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Susan A McLaughlin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Vincent Iannucci
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Anthony Rodgers
- The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Nelson Wang
- The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Kate E LeGrand
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Reed J D Sorensen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jiawei He
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Peng Zheng
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Aleksandr Y Aravkin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Gregory A Roth
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Division of Cardiology, University of Washington, Seattle, WA, USA
| |
Collapse
|
31
|
LIONTOS A, BIROS D, PAPAGIANNOPOULOS C, ANASTASIOU G, ADAMIDIS PS, BAKOGIANNIS K, MILIONIS H, LIBEROPOULOS E, ELISAF M, LIAMIS G. The Effect of Commonly Used Fixed-Dose Single Pill Combinations of Renin-Angiotensin-System Blockers and Calcium Channel Blockers on HOMA-IR Index in Hypertensive Patients with Impaired Fasting Glucose: a 12-Week Randomized Open-Label Prospective Study. MAEDICA 2022; 17:561-570. [PMID: 36540585 PMCID: PMC9720647 DOI: 10.26574/maedica.2022.17.3.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Backround: The effect of antihypertensive drugs on glucose homeostasis and insulin resistance remains an issue under investigation. There is evidence that renin-angiotensin system (RAS) blockers may favorably affect glucose metabolism, while treatment with calcium channel blockers (CCBs) is considered to have an overall neutral metabolic effect. However, the effects on glycemic indices may differ among agents within the same class of antihypertensive drugs. Objective: To evaluate the effects of different fixed-dose single pill combinations of RAS blockers with CCBs on homeostatic model assessment for insulin resistance (HOMA-IR). Methods:Drug-naive patients with arterial hypertension (AH) and impaired fasting glucose (IFG) were randomly allocated to open-label fixed, single pill combinations of valsartan 160 mg/day plus amlodipine 5 mg/day (VAL/AMLO group, n = 54), delapril 30 mg/day and manidipine 10 mg/day (DEL/MANI group, n = 53) or telmisartan 80 mg/day and amlodipine 5 mg/day (TEL/AMLO group, n = 51) for 12 weeks. Glycemic indices and HOMA-IR were determined at baseline and post-treatment. Results:A total of 158 patients were included. All treatment combinations effectively reduced blood pressure (systolic and diastolic) to similar levels (all p < 0.001). A decrease in the HOMA-IR index by 22.55% (p <0.01) was noted following treatment with TEL/AMLO, while an increase by 1.4% (p = 0.57) and 12.65% (p = 0.072) was observed in the VAL/AMLO group and the DEL/MANI group, respectively. These changes were significantly different between TEL/AMLO and DEL/MANI (p < 0.05) as well as between TEL/AMLO and VAL/AMLO (p < 0.001). Conclusion:Despite similar antihypertensive action, the effect of fixed, single pill combinations with TEL/AMLO, VAL/AMLO and DEL/MANI on insulin resistance is in favor of TEL/AMLO. Trial registration: The study protocol was published online in https://diavgeia.gov.gr/ (No: ÂÈ6Ó46906Ç-ÁÅÓ) via the Ministry of Digital Governance, after receiving approval from the Scientific Council and Administrative Council of University Hospital of Ioannina (No. of approval: 1/12-06-2014 (issue 150). https://diavgeia.gov.gr/decision/view/%CE%92%CE%986%CE%A346906%CE%97- %CE%91%CE%95%CE%A3 h t t p s : / / d i a v g e i a . g o v . g r / d o c / % C E % 9 2 % C E % 9 8 6 % C E % A 3 4 6 9 0 6 % C E % 9 7 - %CE%91%CE%95%CE%A3?inline=true.
Collapse
Affiliation(s)
- Angelos LIONTOS
- First Department of Internal Medicine, Faculty of Medicine, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
| | - Dimitrios BIROS
- First Department of Internal Medicine, Faculty of Medicine, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
| | - Christos PAPAGIANNOPOULOS
- Department of Hygiene Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgia ANASTASIOU
- Second Department of Internal Medicine, Faculty of Medicine, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
| | - Petros-Spyridon ADAMIDIS
- Second Department of Internal Medicine, Faculty of Medicine, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
| | - Konstantinos BAKOGIANNIS
- Second Department of Internal Medicine, Faculty of Medicine, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
| | - Haralampos MILIONIS
- First Department of Internal Medicine, Faculty of Medicine, University Hospital of Ioannina, University of Ioannina, Ioannina, Greece
| | - Evangelos LIBEROPOULOS
- First Department of Propaedeutic Internal Medicine, Medical School, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Moses ELISAF
- Department of Hygiene Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece
| | - George LIAMIS
- Department of Hygiene Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
32
|
Dawson J, Béjot Y, Christensen LM, De Marchis GM, Dichgans M, Hagberg G, Heldner MR, Milionis H, Li L, Pezzella FR, Taylor Rowan M, Tiu C, Webb A. European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack. Eur Stroke J 2022; 7:I-II. [PMID: 36082250 PMCID: PMC9446324 DOI: 10.1177/23969873221100032] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.
Collapse
Affiliation(s)
- Jesse Dawson
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
| | - Yannick Béjot
- Dijon Stroke Registry, Department of
Neurology, University Hospital of Dijon, Dijon, France
- Pathophysiology and Epidemiology of
Cardio-Cerebrovascular disease (PEC2), University of Burgundy, Dijon, France
| | - Louisa M Christensen
- Dept of Neurology, Copenhagen
University Hospital Bispebjerg, Kobenhavn, Denmark
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Martin Dichgans
- Institute for Stroke and Dementia
Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology
(SyNergy), Munich, Germany
| | - Guri Hagberg
- Oslo Stroke Unit, Department of
Neurology, Oslo University Hospital, Ullevål, Norway
- Department of medical research, Bærum
Hospital Vestre Viken Hospital Trust, Drammen, Norway
| | - Mirjam R Heldner
- Stroke Research Center Bern,
Department of Neurology, University and University Hospital Bern, Bern,
Switzerland
| | - Haralampos Milionis
- Department of Internal Medicine,
School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina,
Greece
| | - Linxin Li
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| | | | - Martin Taylor Rowan
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
| | - Cristina Tiu
- Department of Clinical Neurosciences,
University of Medicine and Pharmacy ‘Carol Davila’, Bucuresti, Romania
- Department of Neurology, University
Hospital Bucharest, Bucharest, Romania
| | - Alastair Webb
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| |
Collapse
|
33
|
Mullen MT, Anderson CS. Review of Long-Term Blood Pressure Control After Intracerebral Hemorrhage: Challenges and Opportunities. Stroke 2022; 53:2142-2151. [PMID: 35657328 DOI: 10.1161/strokeaha.121.036885] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood pressure (BP) is the most important modifiable risk factor for intracerebral hemorrhage (ICH). Elevated BP is associated with an increased risk of ICH, worse outcome after ICH, and in survivors, higher risks of recurrent ICH, ischemic stroke, myocardial infarction, and cognitive impairment/dementia. As intensive BP control probably improves the chances of recovery from acute ICH, the early use of intravenous or oral medications to achieve a systolic BP goal of <140 mm Hg within the first few hours of presentation is reasonable for being applied in most patients. In the long-term, oral antihypertensive drugs should be titrated as soon as possible to achieve a goal BP <130/80 mm Hg and again in all ICH patients regardless of age, location, or presumed mechanism of ICH. The degree of sustained BP reduction, rather than the choice of BP-lowering agent(s), is the most important factor for optimizing risk reduction, with varying combinations of thiazide-type diuretics, long-acting calcium channel blockers, ACE (angiotensin-converting enzyme) inhibitors or angiotensin receptor blockers, being the mainstay of therapy. As most patients will require multiple BP-lowering agents, and physician inertia and poor adherence are major barriers to effective BP control, single-pill combination therapy should be considered as the choice of management where available. Increased population and clinician awareness, and innovations to solving patient, provider, and social factors, have much to offer for improving BP control after ICH and more broadly across high-risk groups. It is critical that all physicians, especially those managing ICH patients, emphasize the importance of BP control in their practice.
Collapse
Affiliation(s)
- Michael T Mullen
- Department of Neurology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA (M.T.M.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.S.A.).,The George Institute China at Peking University Health Sciences Center, Beijing (C.S.A.)
| |
Collapse
|
34
|
Fooladi M, Cheki M, Shirazi A, Sheikhzadeh P, Amirrashedi M, Ghahramani F, Khoobi M. Histopathological Evaluation of Protective Effect of Telmisartan against Radiation-Induced Bone Marrow Injury. J Biomed Phys Eng 2022; 12:277-284. [PMID: 35698535 PMCID: PMC9175127 DOI: 10.31661/jbpe.v0i0.2012-1243] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/20/2021] [Indexed: 06/15/2023]
Abstract
BACKGROUND Radiation-induced hematopoietic suppression and myelotoxicity can occur due to the nuclear accidents, occupational irradiation and therapeutic interventions. Bone marrow dysfunction has always been one of the most important causes of morbidity and mortality after ionizing irradiation. OBJECTIVE This study aims to investigate the protective effect of telmisartan against radiation-induced bone marrow injuries in a Balb/c mouse model. MATERIAL AND METHODS In this experimental study, male Balb/c mice were divided into four groups as follow: group 1: mice received phosphate buffered saline (PBS) without irradiation, group 2: mice received a solution of telmisartan in PBS without irradiation, group 3: mice received PBS with irradiation, and group 4: mice received a solution of telmisartan in PBS with irradiation. A solution of telmisartan was prepared and administered orally at 12 mg/kg body weight for seven consecutive days prior to whole body exposing to a single sub-lethal dose of 5 Gy X-rays. Protection of bone marrow against radiation induced damage was investigated by Hematoxylin-Eosin (HE) staining assay at 3, 9, 15 and 30 days after irradiation. RESULTS Histopathological analysis indicated that administration of telmisartan reduced X-radiation-induced damage and improved bone marrow histology. The number of different cell types in bone marrow, including polymorphonuclear /mononuclear cells and megakaryocytes significantly increased in telmisartan treated group compared to the only irradiated group at all-time points. CONCLUSION The results of the present study demonstrated an efficient radioprotective effect of telmisartan in mouse bone marrow against sub-lethal X-irradiation.
Collapse
Affiliation(s)
- Masoomeh Fooladi
- PhD Candidate, Department of Medical Physics and Biomedical Engineering, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Cheki
- PhD, Department of Medical Imaging and Radiation Sciences, Faculty of Paramedicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Alireza Shirazi
- PhD Candidate, Department of Medical Physics and Biomedical Engineering, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Peyman Sheikhzadeh
- PhD, Department of Nuclear Medicine, Imam khomeini Hospital complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahsa Amirrashedi
- PhD Candidate, Department of Medical Physics and Biomedical Engineering, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- PhD Candidate, Research Center for Molecular and Cellular Imaging, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Ghahramani
- MSc, Radiotherapy-Oncology Center, Yas Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Khoobi
- PhD, Biomaterials Group, Pharmaceutical Sciences Research Center, The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
- PhD, Department of Medicinal Chemistry, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
35
|
Chi NF, Chung CP, Cheng HM, Liu CH, Lin CJ, Hsu LC, Tang SC, Lee JT, Po HL, Jeng JS, Wang TD, Lee IH. 2021 Taiwan Stroke Society Guidelines of blood pressure control for ischemic stroke prevention. J Chin Med Assoc 2022; 85:651-664. [PMID: 35507097 DOI: 10.1097/jcma.0000000000000738] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Since the publication of the 2015 Taiwan Stroke Society Blood Pressure for Treatment and Prevention of Stroke Guideline (2015 TSS BP Guideline), several new clinical studies have addressed whether a stricter blood pressure (BP) target would be effective for stroke prevention. METHODS TSS guideline consensus group provides recommendations on BP targets for stroke prevention based on updated evidences. RESULTS The present guideline covers five topics: (1) diagnosis of hypertension; (2) BP control and primary prevention of ischemic stroke; (3) BP control and secondary prevention of ischemic stroke; (4) BP control and secondary prevention of large artery atherosclerosis ischemic stroke; and (5) BP control and secondary prevention of small vessel occlusion ischemic stroke. CONCLUSION The BP target for most stroke patients with hypertension is <130/80 mm Hg.
Collapse
Affiliation(s)
- Nai-Fang Chi
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Hao-Ming Cheng
- Center for Evidence-based Medicine & Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
- Institute of Public Health, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Chi-Hung Liu
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan, ROC
| | - Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Li-Chi Hsu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Helen L Po
- Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Tzung-Dau Wang
- Department of Cardiology, National Taiwan University, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| |
Collapse
|
36
|
Wang TD, Chiang CE, Chao TH, Cheng HM, Wu YW, Wu YJ, Lin YH, Chen MYC, Ueng KC, Chang WT, Lee YH, Wang YC, Chu PH, Chao TF, Kao HL, Hou CJY, Lin TH. 2022 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the Management of Hypertension. ACTA CARDIOLOGICA SINICA 2022; 38:225-325. [PMID: 35673334 PMCID: PMC9121756 DOI: 10.6515/acs.202205_38(3).20220321a] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/22/2022] [Indexed: 11/23/2022]
Abstract
Hypertension is the most important modifiable cause of cardiovascular (CV) disease and all-cause mortality worldwide. Despite the positive correlations between blood pressure (BP) levels and later CV events since BP levels as low as 100/60 mmHg have been reported in numerous epidemiological studies, the diagnostic criteria of hypertension and BP thresholds and targets of antihypertensive therapy have largely remained at the level of 140/90 mmHg in the past 30 years. The publication of both the SPRINT and STEP trials (comprising > 8,500 Caucasian/African and Chinese participants, respectively) provided evidence to shake this 140/90 mmHg dogma. Another dogma regarding hypertension management is the dependence on office (or clinic) BP measurements. Although standardized office BP measurements have been widely recommended and adopted in large-scale CV outcome trials, the practice of office BP measurements has never been ideal in real-world practice. Home BP monitoring (HBPM) is easy to perform, more likely to be free of environmental and/or emotional stress, feasible to document long-term BP variations, of good reproducibility and reliability, and more correlated with hypertension-mediated organ damage (HMOD) and CV events, compared to routine office BP measurements. In the 2022 Taiwan Hypertension Guidelines of the Taiwan Society of Cardiology (TSOC) and the Taiwan Hypertension Society (THS), we break these two dogmas by recommending the definition of hypertension as ≥ 130/80 mmHg and a universal BP target of < 130/80 mmHg, based on standardized HBPM obtained according to the 722 protocol. The 722 protocol refers to duplicate BP readings taken per occasion ("2"), twice daily ("2"), over seven consecutive days ("7"). To facilitate implementation of the guidelines, a series of flowcharts encompassing assessment, adjustment, and HBPM-guided hypertension management are provided. Other key messages include that: 1) lifestyle modification, summarized as the mnemonic S-ABCDE, should be applied to people with elevated BP and hypertensive patients to reduce life-time BP burden; 2) all 5 major antihypertensive drugs (angiotensin-converting enzyme inhibitors [A], angiotensin receptor blockers [A], β-blockers [B], calcium-channel blockers [C], and thiazide diuretics [D]) are recommended as first-line antihypertensive drugs; 3) initial combination therapy, preferably in a single-pill combination, is recommended for patients with BP ≥ 20/10 mmHg above targets; 4) a target hierarchy (HBPM-HMOD- ambulatory BP monitoring [ABPM]) should be considered to optimize hypertension management, which indicates reaching the HBPM target first and then keeping HMOD stable or regressed, otherwise ABPM can be arranged to guide treatment adjustment; and 5) renal denervation can be considered as an alternative BP-lowering strategy after careful clinical and imaging evaluation.
Collapse
Affiliation(s)
- Tzung-Dau Wang
- Cardiovascular Center and Divisions of Cardiology and Hospital Medicine, Department of Internal Medicine, National Taiwan University Hospital
- Department of Internal Medicine, School of Medicine, National Taiwan University College of Medicine
| | - Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Ting-Hsing Chao
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan
| | - Hao-Min Cheng
- School of Medicine, Institute of Public Health and Community Medicine Research Center, and Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University
- Center for Evidence-based Medicine, Department of Medical Education, Taipei Veterans General Hospital, Taipei
| | - Yen-Wen Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Division of Cardiology, Cardiovascular Medical Center, and Department of Nuclear Medicine, Far Eastern Memorial Hospital
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital
| | - Yen-Hung Lin
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Michael Yu-Chih Chen
- Division of Cardiology, Department of Internal Medicine, Buddhist Tzu Chi General Hospital, Hualien
| | - Kwo-Chang Ueng
- Department of Internal Medicine, Chung-Shan Medical University Hospital, Taichung
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan
| | - Ying-Hsiang Lee
- Department of Medicine, Mackay Medical College, New Taipei City
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital
| | - Yu-Chen Wang
- Division of Cardiology, Department of Medicine, Asia University Hospital
- Department of Medical Laboratory Science and Biotechnology, Asia University
- Division of Cardiology, Department of Internal Medicine, China Medical University College of Medicine and Hospital, Taichung
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital
- School of Medicine, Chang Gung University, Taoyuan
| | - Tzu-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital
- Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei
| | - Hsien-Li Kao
- Department of Internal Medicine, School of Medicine, National Taiwan University College of Medicine
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei
| | - Charles Jia-Yin Hou
- Department of Medicine, Mackay Medical College, New Taipei City
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine Kaohsiung Medical University Hospital
- Faculty of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
37
|
Kitagawa K. Blood pressure management for secondary stroke prevention. Hypertens Res 2022; 45:936-943. [DOI: 10.1038/s41440-022-00908-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 11/09/2022]
|
38
|
Bath PM, Song L, Silva GS, Mistry E, Petersen N, Tsivgoulis G, Mazighi M, Bang OY, Sandset EC. Blood Pressure Management for Ischemic Stroke in the First 24 Hours. Stroke 2022; 53:1074-1084. [PMID: 35291822 DOI: 10.1161/strokeaha.121.036143] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High blood pressure (BP) is common after ischemic stroke and associated with a poor functional outcome and increased mortality. The conundrum then arises on whether to lower BP to improve outcome or whether this will worsen cerebral perfusion due to aberrant cerebral autoregulation. A number of large trials of BP lowering have failed to change outcome whether treatment was started prehospital in the community or hospital. Hence, nuances on how to manage high BP are likely, including whether different interventions are needed for different causes, the type and timing of the drug, how quickly BP is lowered, and the collateral effects of the drug, including on cerebral perfusion and platelets. Specific scenarios are also important, including when to lower BP before, during, and after intravenous thrombolysis and endovascular therapy/thrombectomy, when it may be necessary to raise BP, and when antihypertensive drugs taken before stroke should be restarted. This narrative review addresses these and other questions. Although further large trials are ongoing, it is increasingly likely that there is no simple answer. Different subgroups of patients may need to have their BP lowered (eg, before or after thrombolysis), left alone, or elevated.
Collapse
Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (P.M.B.)
| | - Lili Song
- The George Institute China at Peking University Health Science Center, Beijing (L.S.)
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Sydney, Australia (L.S.)
| | - Gisele S Silva
- Neurology, Federal University of São Paulo (UNIFESP) and Hospital Israelita Albert Einstein, Brazil (G.S.S.)
| | - Eva Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (E.M.)
| | - Nils Petersen
- Department of Neurology, Divisions of Vascular Neurology and Neurocritical Care, Yale School of Medicine, New Haven (N.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.)
| | - Mikael Mazighi
- Department of Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, INSERM 1148, FHU Neurovasc, France (M.M.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
- The Norwegian Air Ambulance Foundation, Oslo (E.C.S.)
| |
Collapse
|
39
|
Abstract
High blood pressure (BP) is detrimental to brain health. High BP contributes to cognitive impairment and dementia through pathways independent of clinical stroke. Emerging evidence shows that the deleterious effect of high BP on cognition occurs across the life span, increasing the risk for early-onset and late-life dementia. The term vascular cognitive impairment includes cognitive disorders associated with cerebrovascular disease, regardless of the pathogenesis. This focused report is a narrative review that aims to summarize the epidemiology of BP and vascular cognitive impairment, including differences by sex, race, and ethnicity, as well as the management and reversibility of BP and vascular cognitive impairment. It also discusses knowledge gaps and future directions.
Collapse
Affiliation(s)
- Deborah A. Levine
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI
- Department of Neurology and Stroke Program, U-M, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI
| | - Mellanie V. Springer
- Department of Neurology and Stroke Program, U-M, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI
| | - Amy Brodtmann
- The Florey Institute of Neuroscience and Mental Health, Royal Melbourne Hospital, University of Melbourne, Australia
| |
Collapse
|
40
|
Guo QH, Liu CH, Wang JG. Blood Pressure Goals in Acute Stroke. Am J Hypertens 2022; 35:483-499. [PMID: 35323883 PMCID: PMC9203067 DOI: 10.1093/ajh/hpac039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 03/17/2022] [Accepted: 03/19/2022] [Indexed: 01/27/2023] Open
Abstract
Antihypertensive treatment is highly effective in both primary and secondary prevention of stroke. However, current guideline recommendations on the blood pressure goals in acute stroke are clinically empirical and generally conservative. Antihypertensive treatment is only recommended for severe hypertension. Several recent observational studies showed that the relationship between blood pressure and unfavorable clinical outcomes was probably positive in acute hemorrhagic stroke but J- or U-shaped in acute ischemic stroke with undetermined nadir blood pressure. The results of randomized controlled trials are promising for blood pressure management in hemorrhagic stroke but less so in ischemic stroke. A systolic blood pressure goal of 140 mm Hg is probably appropriate for acute hemorrhagic stroke. The blood pressure goal in acute ischemic stroke, however, is uncertain, and probably depends on the time window of treatment and the use of revascularization therapy. Further research is required to investigate the potential benefit of antihypertensive treatment in acute stroke, especially with regard to the possible reduction of blood pressure variability and more intensive blood pressure lowering in the acute and subacute phases of a stroke, respectively.
Collapse
Affiliation(s)
- Qian-Hui Guo
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Chu-Hao Liu
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | | |
Collapse
|
41
|
McGurgan IJ, Kelly PJ, Turan TN, Rothwell PM. Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke. Stroke 2022; 53:1085-1103. [PMID: 35291823 DOI: 10.1161/strokeaha.121.035851] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.
Collapse
Affiliation(s)
- Iain J McGurgan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (I.J.M., P.M.R.)
| | - Peter J Kelly
- Neurovascular Clinical Science Unit, Stroke Service and Department of Neurology, Mater University Hospital, Dublin, Ireland (P.J.K.)
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston (T.N.T.)
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (I.J.M., P.M.R.)
| |
Collapse
|
42
|
Sipahi I. Risk of cancer with angiotensin-receptor blockers increases with increasing cumulative exposure: Meta-regression analysis of randomized trials. PLoS One 2022; 17:e0263461. [PMID: 35235571 PMCID: PMC8890666 DOI: 10.1371/journal.pone.0263461] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 01/19/2022] [Indexed: 12/31/2022] Open
Abstract
Angiotensin-receptor blockers (ARBs) are a class of drugs approved for the treatment of several common conditions, such as hypertension and heart failure. Recently, regulatory agencies have started to identify possibly carcinogenic nitrosamines and azido compounds in a multitude of formulations of several ARBs, resulting in progressive recalls. Furthermore, data from several randomized controlled trials suggested that there is also a clinically increased risk of cancer and specifically lung cancer with ARBs; whereas other trials suggested no increased risk. The purpose of this analysis was to provide additional insight into the ARB-cancer link by examining whether there is a relationship between degree of cumulative exposure to ARBs and risk of cancer in randomized trials. Trial-level data from ARB Trialists Collaboration including 15 randomized controlled trials was extracted and entered into meta-regression analyses. The two co-primary outcomes were the relationship between cumulative exposure to ARBs and risk of all cancers combined and the relationship between cumulative exposure and risk of lung cancer. A total of 74,021 patients were randomized to an ARB resulting in a total cumulative exposure of 172,389 person-years of exposure to daily high dose (or equivalent). 61,197 patients were randomized to control. There was a highly significant correlation between the degree of cumulative exposure to ARBs and risk of all cancers combined (slope = 0.07 [95% CI 0.03 to 0.11], p<0.001), and also lung cancer (slope = 0.16 [95% CI 0.05 to 0.27], p = 0.003). Accordingly, in trials where the cumulative exposure was greater than 3 years of exposure to daily high dose, there was a statistically significant increase in risk of all cancers combined (I2 = 31.4%, RR 1.11 [95% CI 1.03 to 1.19], p = 0.006). There was a statistically significant increase in risk of lung cancers in trials where the cumulative exposure was greater than 2.5 years (I2 = 0%, RR 1.21 [95% CI 1.02 to 1.44], p = 0.03). In trials with lower cumulative exposure to ARBs, there was no increased risk of all cancers combined or lung cancer. Cumulative exposure-risk relationship with ARBs was independent of background angiotensin-converting enzyme inhibitor treatment or the type of control (i.e. placebo or non-placebo control). Since this is a trial-level analysis. the effects of patient characteristics such as age and smoking status could not be examined due to lack of patient-level data. In conclusion, this analysis, for the first time, reveals that risk of cancer with ARBs (and specifically lung cancer) increases with increasing cumulative exposure to these drugs. The excess risk of cancer with long-term ARB use has public health implications.
Collapse
Affiliation(s)
- Ilke Sipahi
- Department of Cardiology, Acibadem University Medical School, Istanbul, Turkey
| |
Collapse
|
43
|
Angiotensin II Receptor Antagonist, Valsartan, Has Beneficial Effect in Lung Metastasis of Colorectal Cancer Treated with Fluorouracil. J Gastrointest Cancer 2022; 54:126-134. [PMID: 35083728 DOI: 10.1007/s12029-021-00717-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Lung metastasis is the main cause of death in patients with colorectal carcinoma (CRC). Angiotensin II has been confirmed to facilitate cancer cell progression and metastasis. In this study, the possible anti-metastatic effects of an angiotensin II receptor type 1 (AT1R) antagonist, valsartan, have been investigated in an experimental CRC lung metastasis model. METHODS An animal CRC lung metastasis model was used, involving intravenous injection of CRC cells. The experimental groups included (1) control group; (2) 5-FU (5-fluorouracil) group (5 mg/kg/every other day; ip); (3) valsartan group (40 mg/kg/day; po); and (4) valsartan + 5-FU group (combination group; valsartan 40 mg/kg/day, oral gavage, and 5-FU 5 mg/kg/every other day; ip). After 11 days, macroscopic and histological evaluations of lung tissues have been done for evaluation of lung metastatic nodules. In addition, inflammatory and angiogenic markers and oxidative stress index were measured in lung tissue. RESULTS Our results showed that administration of valsartan especially in combination with 5-FU significantly reduced lung metastatic nodule and metastatic area (p < 0.05) in macroscopic and histological evaluations stained by hematoxylin-eosin. Measurement of inflammatory, angiogenic, and oxidative/antioxidative markers in lung tissue indicated that the level of IL-6, angiogenic markers (VEGF and VEGFR-1), and antioxidative markers significantly reduced in combination group (p < 0.05) while the MDA as a marker of oxidative stress increased (p < 0.05). CONCLUSION These results suggest that valsartan in combination with standard chemotherapeutic agents can have a synergistic effect in treatment of lung metastasis of CRC.
Collapse
|
44
|
Seshadri S, Caunca MR, Rundek T. Vascular Dementia and Cognitive Impairment. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
45
|
Tharmaratnam D, Karayiannis CC, Collyer TA, Arima H, McClure LA, Chalmers J, Anderson CS, Benavente OR, White CL, Algra A, Moran C, Phan TG, Wang WC, Srikanth V. Is Blood Pressure Lowering in the Very Elderly With Previous Stroke Associated With a Higher Risk of Adverse Events? J Am Heart Assoc 2021; 10:e022240. [PMID: 34913363 PMCID: PMC9075242 DOI: 10.1161/jaha.121.022240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background We investigated whether blood pressure lowering for secondary prevention is associated with a reduction in recurrent stroke risk and/or a higher risk of adverse events in very elderly compared with younger trial participants. Methods and Results This is a random effects meta-analysis of randomized controlled trials of blood pressure lowering for secondary stroke prevention to evaluate age-stratified (<80, ≥80 years) risk of adverse events. Ovid-MEDLINE was searched for trials between 1970 and 2020. Summary-level data were acquired including outcomes of stroke, cardiovascular events, mortality, and adverse events. Seven trials were included comprising 38 596 participants, of whom 2336 (6.1%) were aged ≥80 years. There was an overall reduction in stroke risk in the intervention group compared with controls (risk ratio [RR], 0.90 [95% CI, 0.80, 0.98], I2=49%), and the magnitude of risk reduction did not differ by age subgroup (<80, ≥80 years). There was no increase in the risk of hypotensive symptoms in the intervention group for patients aged <80 years (RR, 1.19 [95% CI, 0.99], 1.44, I2=0%), but there was an increased risk in those ≥80 years (RR, 2.17 [95% CI, 1.22], 3.86, I2=0%). No increase was observed in the risk of falls, syncope, study withdrawal, or falls in either age subgroup. Conclusions Very elderly people in secondary prevention trials of blood pressure lowering have an increased risk of hypotensive symptoms, but with no statistical increase in the risk of falls, syncope, or mortality. However, evidence is lacking for frail elderly with multiple comorbidities who may be more vulnerable to adverse effects of blood pressure lowering.
Collapse
Affiliation(s)
- Damien Tharmaratnam
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia.,Stroke and Ageing Research Group, Medicine School of Clinical Sciences Monash Medical Centre Monash University Melbourne Australia
| | - Christopher C Karayiannis
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia.,Stroke and Ageing Research Group, Medicine School of Clinical Sciences Monash Medical Centre Monash University Melbourne Australia
| | - Taya A Collyer
- Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia
| | - Hisatomi Arima
- Faculty of Medicine The George Institute for Global HealthUniversity of New South Wales Camperdown New South Wales Australia.,Department of Preventive Medicine and Public Health Faculty of Medicine Fukuoka University Fukuoka Japan
| | - Leslie A McClure
- Department of Epidemiology and Biostatistics Dornsife School of Public Health Drexel University Philadelphia PA
| | - John Chalmers
- Faculty of Medicine The George Institute for Global HealthUniversity of New South Wales Camperdown New South Wales Australia
| | - Craig S Anderson
- Faculty of Medicine The George Institute for Global HealthUniversity of New South Wales Camperdown New South Wales Australia
| | - Oscar R Benavente
- Division of Neurology Department of Medicine Brain Research Center University of British Columbia Vancouver British Columbia Canada
| | - Carole L White
- School of Nursing University of Texas Health Science Center at San Antonio TX
| | - Ale Algra
- Department of Neurology and Neurosurgery UMC Utrecht Brain Center, and Julius Center for Health Sciences and Primary Care University Medical Center Utrecht and Utrecht University Utrecht The Netherlands
| | - Chris Moran
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia.,Department of Aged Care The Alfred Melbourne Australia.,Geriatric Medicine Unit Peninsula Health Melbourne Australia
| | - Thanh G Phan
- Stroke Unit Department of Neurosciences Monash Health Melbourne Australia.,Stroke and Ageing Research Group, Medicine School of Clinical Sciences Monash Medical Centre Monash University Melbourne Australia
| | - Wei C Wang
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia
| | - Velandai Srikanth
- Department of Medicine Peninsula Health Melbourne Australia.,Peninsula Clinical School Central Clinical School Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Australia.,Stroke Unit Department of Neurosciences Monash Health Melbourne Australia.,Stroke and Ageing Research Group, Medicine School of Clinical Sciences Monash Medical Centre Monash University Melbourne Australia.,Geriatric Medicine Unit Peninsula Health Melbourne Australia
| | | |
Collapse
|
46
|
Hu J, Shen H, Huo P, Yang J, Fuller PJ, Wang K, Yang Y, Ma L, Cheng Q, Gong L, He W, Luo T, Mei M, Wang Y, Du Z, Luo R, Cai J, Li Q, Song Y, Yang S. Heightened Cardiovascular Risk in Hypertension Associated With Renin-Independent Aldosteronism Versus Renin-Dependent Aldosteronism: A Collaborative Study. J Am Heart Assoc 2021; 10:e023082. [PMID: 34889107 PMCID: PMC9075265 DOI: 10.1161/jaha.121.023082] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background While both renin-dependent and renin-independent aldosterone secretion contribute to aldosteronism, their relative associations with cardiovascular disease (CVD) risk has not been investigated. Methods and Results A total of 2909 participants from the FOS (Framingham Offspring Study) with baseline, serum aldosterone concentration, and plasma renin concentration who attended the sixth examination cycle and were followed up until 2014 and who were free of CVD were included. We further recruited 2612 hypertensive participants from the CONPASS (Chongqing Primary Aldosteronism Study). Captopril challenge test was performed to confirm renin-dependent or -independent aldosteronism in CONPASS. Among 1433 hypertensive subjects of FOS, when compared with those with serum aldosterone concentration <10 ng dL-1 (normal aldosterone), participants who had serum aldosterone concentration ≥10 ng dL-1 and plasma renin concentration ≤15 mIU L-1 (identified as renin-independent aldosteronism) showed a higher risk of CVD (hazard ratio, 1.40 [95% CI, 1.08-1.82]), while those who had serum aldosterone concentration ≥10 ng dL-1 and plasma renin concentration >15 mIU L-1 (identified as renin-dependent aldosteronism) showed an unchanged CVD risk. In CONPASS, renin-independent aldosteronism carried a significantly higher risk of CVD than normal aldosterone (odds ratio, 2.57 [95% CI, 1.13-5.86]), while the CVD risk remained unchanged in renin-dependent aldosteronism. Elevation of the urinary potassium-to-sodium excretion ratio, reflective of mineralocorticoid receptor activity, was only observed in participants with renin-independent aldosteronism. Conclusions Among patients with hypertension, renin-independent aldosteronism is more closely associated with CVD risk than renin-dependent aldosteronism.
Collapse
Affiliation(s)
- Jinbo Hu
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Hang Shen
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Peiqi Huo
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Jun Yang
- Centre for Endocrinology and Metabolism Hudson Institute of Medical Research Clayton Vic. Australia.,Department of Medicine Monash University Clayton Vic. Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism Hudson Institute of Medical Research Clayton Vic. Australia.,Department of Medicine Monash University Clayton Vic. Australia
| | - Kanran Wang
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Yi Yang
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Linqiang Ma
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Qingfeng Cheng
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Lilin Gong
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Wenwen He
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Ting Luo
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Mei Mei
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Yue Wang
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Zhipeng Du
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Rong Luo
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Jun Cai
- Hypertension CenterFuwai HospitalState Key Laboratory of Cardiovascular DiseaseNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Qifu Li
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Ying Song
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| | - Shumin Yang
- Department of Endocrinology the First Affiliated Hospital of Chongqing Medical University Chongqing China
| |
Collapse
|
47
|
Dziewas R, Michou E, Trapl-Grundschober M, Lal A, Arsava EM, Bath PM, Clavé P, Glahn J, Hamdy S, Pownall S, Schindler A, Walshe M, Wirth R, Wright D, Verin E. European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia. Eur Stroke J 2021; 6:LXXXIX-CXV. [PMID: 34746431 DOI: 10.1177/23969873211039721] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/27/2021] [Indexed: 12/30/2022] Open
Abstract
Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.
Collapse
Affiliation(s)
- Rainer Dziewas
- Department of Neurology, University Hospital Münster, Münster, Germany.,Department of Neurology and Neurorehabilitation, Klinikum Osnabrück, Osnabrück, Germany
| | - Emilia Michou
- Department of Speech Language Therapy, School of Health Rehabilitation Sciences, University of Patras, Greece.,Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | | | - Avtar Lal
- Guidelines Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Ethem Murat Arsava
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Pere Clavé
- Centro de Investigación Biomédica en Red de Enfermedades, Hepáticas y Digestivas (CIBERehd), Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain
| | - Jörg Glahn
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Hospital Ruhr-University Bochum, Germany
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Sue Pownall
- Department of Speech & Language Therapy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences, Phoniatric Unit, Sacco Hospital Milano, University of Milano, Milan, Italy
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College, Dublin, Ireland
| | - Rainer Wirth
- Department of Geriatric Medicine, Marien Hospital Herne, University Hospital Ruhr-University Bochum, Germany
| | - David Wright
- School of Pharmacy, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Eric Verin
- Department of Physical and Rehabilitation Medicine, Rouen University Hospital, Rouen, France
| |
Collapse
|
48
|
Leache L, Gutiérrez-Valencia M, Finizola RM, Infante E, Finizola B, Pardo Pardo J, Flores Y, Granero R, Arai KJ. Pharmacotherapy for hypertension-induced left ventricular hypertrophy. Cochrane Database Syst Rev 2021; 10:CD012039. [PMID: 34628642 PMCID: PMC8502530 DOI: 10.1002/14651858.cd012039.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension-induced LVH. OBJECTIVES To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension-induced LVH. SEARCH METHODS Cochrane Hypertension's Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) with at least 12 months' follow-up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension-induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all-cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. DATA COLLECTION AND ANALYSIS Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. MAIN RESULTS We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow-up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention-to-treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add-on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low-certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low-certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low-certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low-certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low-certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. AUTHORS' CONCLUSIONS We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low-certainty evidence requires that caution be used when interpreting the findings. High-quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension-induced LVH are warranted.
Collapse
Affiliation(s)
- Leire Leache
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
| | | | - Rosa M Finizola
- Unit of Special Projects, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Elizabeth Infante
- Unit of Systems, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Bartolome Finizola
- General Coordination, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Jordi Pardo Pardo
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada
| | - Yris Flores
- Echocardiography Department and Cardiac Tomography Department, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | | | - Kaduo J Arai
- Coronary Care Unit, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| |
Collapse
|
49
|
Lin SY, Chang SS, Lin CL, Lin CC, Hsu WH, Chou CH, Chi CY, Lin CD, Tu CY, Hsu CY, Kao CH. Association between angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and community-acquired pneumonia: A nationwide population propensity-score matching study. Int J Clin Pract 2021; 75:e14476. [PMID: 34107133 DOI: 10.1111/ijcp.14476] [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: 03/16/2021] [Accepted: 06/04/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Few large-scale cohort studies have investigated the association between community-acquired pneumonia and the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs). We aimed to study whether using ACEIs or ARBs had protective effects for community-acquired pneumonia. METHODS This database cohort study was conducted retrospectively in Taiwan. The hypertensive patients were the target population of this study. Patients with ARB use were defined as our first study cohort. The second study cohort comprised patients who used ACEI. Propensity-score matching at 1:1 was used between ARB users and non-ARB users. We recruited 67 944 participants for the ARB study and 58 062 participants for the ACEI study. The same matching was also performed between ACEI users and non-ACEI users. Cox proportional hazard regression was used to analyse the risk of the outcome of viral pneumonia. RESULTS The hazard ratio of community-acquired pneumonia for ARB users relative to non-ARB users was 0.33. The hazard ratio of community-acquired pneumonia was 0.71 times in ACEI users compared with ACEI nonusers. In stratification analysis, both ARB and ACEI both exhibited a protective effect for community-acquired pneumonia in each age and sex group. In the analysis of the effects of therapy duration, patients using ARB for fewer than 100 days exhibited a greater reduction in the risk of community-acquired pneumonia (adjusted HR = 0.58) compared with the non-ARB cohort. For the ACEI study, patients who used ACEI for 121-450 days were more likely to exhibit reduced risks of community-acquired pneumonia (adjusted HR = 0.5). CONCLUSION Both ACEI and ARB uses were associated with decreased risk of community-acquired pneumonia infection.
Collapse
Affiliation(s)
- Shih-Yi Lin
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Shih-Sheng Chang
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
- Division of Cardiovascular Medicine, Center of Health Evaluation and Promotion, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Cheng-Chieh Lin
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wu-Huei Hsu
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
- Department of Chest Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hui Chou
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
- Department of Infection, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Yu Chi
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
- Department of Infection, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Der Lin
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Yen Tu
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
- Department of Chest Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chung-Y Hsu
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Biomedical Sciences and School of Medicine, China Medical University, Taichung, Taiwan
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
| |
Collapse
|
50
|
Eckel RH, Bornfeldt KE, Goldberg IJ. Cardiovascular disease in diabetes, beyond glucose. Cell Metab 2021; 33:1519-1545. [PMID: 34289375 PMCID: PMC8411849 DOI: 10.1016/j.cmet.2021.07.001] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/21/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023]
Abstract
Despite the decades-old knowledge that diabetes mellitus is a major risk factor for cardiovascular disease, the reasons for this association are only partially understood. While this association is true for both type 1 and type 2 diabetes, different pathophysiological processes may be responsible. Lipids and other risk factors are indeed important, whereas the role of glucose is less clear. This lack of clarity stems from clinical trials that do not unambiguously show that intensive glycemic control reduces cardiovascular events. Animal models have provided mechanisms that link diabetes to increased atherosclerosis, and evidence consistent with the importance of factors beyond hyperglycemia has emerged. We review clinical, pathological, and animal studies exploring the pathogenesis of atherosclerosis in humans living with diabetes and in mouse models of diabetes. An increased effort to identify risk factors beyond glucose is now needed to prevent the increased cardiovascular disease risk associated with diabetes.
Collapse
Affiliation(s)
- Robert H Eckel
- Divisions of Endocrinology, Metabolism and Diabetes, and Cardiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Karin E Bornfeldt
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, and Department of Laboratory Medicine and Pathology, University of Washington Medicine Diabetes Institute, University of Washington, Seattle, WA, USA
| | - Ira J Goldberg
- Division of Endocrinology, Diabetes and Metabolism, NYU Grossman School of Medicine, New York, NY, USA
| |
Collapse
|