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Su X, Yan B, Wang L, Lv J, Cheng H, Chen Y. Effect of antiplatelet therapy on cardiovascular and kidney outcomes in patients with chronic kidney disease: a systematic review and meta-analysis. BMC Nephrol 2019; 20:309. [PMID: 31390997 PMCID: PMC6686545 DOI: 10.1186/s12882-019-1499-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 07/29/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The benefits and risks of antiplatelet therapy for patients with chronic kidney disease (CKD) remain controversial. We undertook a systematic review and meta-analysis to investigate the effects of antiplatelet therapy on major clinical outcomes. METHODS We systematically searched MEDLINE, Embase, and the Cochrane Library for trials published before April 2019 without language restriction. We included rrandomized controlled trials that involved adults with CKD and compared antiplatelet agents with controls. RESULTS Fifty eligible trials that included at least one event were identified, providing data for 27773patients with CKD, including 4518 major cardiovascular events and 1962 all-cause deaths. Antiplatelet therapy produced a 15% (OR, 0.85; 95% CI 0.74-0.94) reduction in the odds of major cardiovascular events (P = 0.002), a 48% reduction for access failure events (OR, 0.52; 95% CI, 0.31-0.73), but had no significantly effect on all-cause death (OR, 0.87; 95% CI, 0.71-1.01) or kidney failure events (OR, 0.87; 95% CI, 0.32-1.55). Adverse events were significantly increased by antiplatelet therapy, including major (OR, 1.33; 95% CI, 1.11-1.59) or minor bleeding (OR, 1.66; 95% CI, 1.27-2.05). Among every 1000 persons with CKD treated with antiplatelet therapy for 12 months, 23 major cardiovascular events will be prevented while nine major bleeding events will occur. CONCLUSIONS Major prevention with antiplatelet agents (cardiovascular events and access failure), might outweigh the risk of bleeding, and there seemed to be an overall net benefit. Individual evaluation and careful monitoring are required.
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Affiliation(s)
- Xiaole Su
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Street, Chaoyang District, Beijing, China.,Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, No.382, Wuyi Road, Xinghualing Distirct, Taiyuan, China
| | - Bingjuan Yan
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, No.382, Wuyi Road, Xinghualing Distirct, Taiyuan, China
| | - Lihua Wang
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, No.382, Wuyi Road, Xinghualing Distirct, Taiyuan, China
| | - Jicheng Lv
- Division of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, No.8, Xishiku Street, Xicheng District, Beijing, China
| | - Hong Cheng
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Street, Chaoyang District, Beijing, China
| | - Yipu Chen
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, No. 2, Anzhen Street, Chaoyang District, Beijing, China.
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Raman M, Green D, Middleton RJ, Kalra PA. OLDER PEOPLE WITH CHRONIC KIDNEY DISEASE: DEFINITION, AND INFLUENCE OF BIOMARKERS AND MEDICATIONS UPON CARDIOVASCULAR AND RENAL OUTCOMES. J Ren Care 2016; 42:150-61. [PMID: 27364740 DOI: 10.1111/jorc.12164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a global problem. With an ageing population the burden on the health services has increased due to the growing number of older people with CKD. This group of individuals is far different to the younger CKD population and their risk of cardiovascular death is far greater than the risk of progressing to end stage kidney disease (ESKD). OBJECTIVE In this review we explore the role of certain biomarkers and medications in predicting the risk of progression to ESKD and death in old people with CKD. METHODS An electronic literature search of EMBASE and MEDLINE databases was performed using Healthcare Databases Advanced Search (HDAS) in December 2014. RESULTS Albuminuria is a key biomarker in predicting the risk of death and progression to ESKD. Cystatin C appears to be superior in predicting the risk of cardiovascular and non-cardiovascular death compared to GFR or creatinine. Several inflammatory biomarkers can be used to predict the risk of death and progression to CKD but measuring and monitoring them in routine clinical practice will be expensive and impractical. The effects of long-term RAAS inhibition in older people are not well established. Older people especially those with CKD receive suboptimal secondary preventive measures. Due to multiple comorbidities older people with CKD are usually receiving a number of medications. This can potentially lead to significant adverse drug events (ADE) due to drug interactions. CONCLUSION Novel non-traditional risk factors like albuminuria, Cystatin C and inflammatory biomarkers play an important role in predicting their risk of death and progression to ESKD. The efficacy and safety of medications in older people with CKD is not well established and requires more extensive, focused study.
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Affiliation(s)
- Maharajan Raman
- Vascular Research Group, Salford Royal NHS Foundation Trust, Salford, UK.,Institute of Population Health, University of Manchester, Manchester, UK
| | - Darren Green
- Vascular Research Group, Salford Royal NHS Foundation Trust, Salford, UK.,Institute of Population Health, University of Manchester, Manchester, UK
| | - Rachel J Middleton
- Vascular Research Group, Salford Royal NHS Foundation Trust, Salford, UK.,Institute of Population Health, University of Manchester, Manchester, UK
| | - Philip A Kalra
- Vascular Research Group, Salford Royal NHS Foundation Trust, Salford, UK.,Institute of Population Health, University of Manchester, Manchester, UK
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Washam JB, Herzog CA, Beitelshees AL, Cohen MG, Henry TD, Kapur NK, Mega JL, Menon V, Page RL, Newby LK. Pharmacotherapy in Chronic Kidney Disease Patients Presenting With Acute Coronary Syndrome. Circulation 2015; 131:1123-49. [DOI: 10.1161/cir.0000000000000183] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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4
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Kalra PR, García-Moll X, Zamorano J, Kalra PA, Fox KM, Ford I, Ferrari R, Tardif JC, Tendera M, Greenlaw N, Steg PG. Impact of chronic kidney disease on use of evidence-based therapy in stable coronary artery disease: a prospective analysis of 22,272 patients. PLoS One 2014; 9:e102335. [PMID: 25051258 PMCID: PMC4106833 DOI: 10.1371/journal.pone.0102335] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/17/2014] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the frequency of chronic kidney disease (CKD), define the associated demographics, and evaluate its association with use of evidence-based drug therapy in a contemporary global study of patients with stable coronary artery disease. Methods 22,272 patients from the ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease (CLARIFY) were included. Baseline estimated glomerular filtration rate (eGFR) was calculated (CKD-Epidemiology Collaboration formula) and patients categorised according to CKD stage: >89, 60–89, 45–59 and <45 mL/min/1.73 m2. Results Mean (SD) age was 63.9±10.4 years, 77.3% were male, 61.8% had a history of myocardial infarction, 71.9% hypertension, 30.4% diabetes and 75.4% dyslipidaemia. Chronic kidney disease (eGFR<60 mL/min/1.73 m2) was seen in 22.1% of the cohort (6.9% with eGFR<45 mL/min/1.73 m2); lower eGFR was associated with increasing age, female sex, cardiovascular risk factors, overt vascular disease, other comorbidities and higher systolic but lower diastolic blood pressure. High use of secondary prevention was seen across all CKD stages (overall 93.4% lipid-lowering drugs, 95.3% antiplatelets, 75.9% beta-blockers). The proportion of patients taking statins was lower in patients with CKD. Antiplatelet use was significantly lower in patients with CKD whereas oral anticoagulant use was higher. Angiotensin-converting enzyme inhibitor use was lower (52.0% overall) and inversely related to declining eGFR, whereas angiotensin-receptor blockers were more frequently prescribed in patients with reduced eGFR. Conclusions Chronic kidney disease is common in patients with stable coronary artery disease and is associated with comorbidities. Whilst use of individual evidence-based medications for secondary prevention was high across all CKD categories, there remains an opportunity to improve the proportion who take all three classes of preventive therapies. Angiotensin-converting enzyme inhibitors were used less frequently in lower eGRF categories. Surprisingly the reverse was seen for angiotensin-receptor blockers. Further evaluation is required to fully understand these associations. The CLARIFY (ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) Registry is registered in the ISRCTN registry of clinical trials with the number ISRCTN43070564. http://www.controlled-trials.com/ISRCTN43070564.
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Affiliation(s)
- Paul R Kalra
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; NHLI Imperial College, ICMS, London, United Kingdom
| | - Xavier García-Moll
- Unitat Hospitalització, Servei de Cardiologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Philip A Kalra
- Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Kim M Fox
- NHLI Imperial College, ICMS, London, United Kingdom; Royal Brompton Hospital, London, United Kingdom
| | - Ian Ford
- University of Glasgow, Glasgow, United Kingdom
| | - Roberto Ferrari
- Department of Cardiology, Azienda Ospedaliero-Universitaria di Ferrara, Ospedale di Cona, Cona, Italy
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Zachariah D, Brown R, Kanagala P, Bashir A, Mohan M, Callan P, Rajendra R, Clark AL, Squire I, Gunning M, Lang CC, Kalra PR. The impact of age and chronic kidney disease on secondary prevention post-primary percutaneous coronary intervention. QJM 2014; 107:185-92. [PMID: 24194563 DOI: 10.1093/qjmed/hct222] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Historical data suggest elderly patients and those with chronic kidney disease (CKD) receive suboptimal secondary prevention following myocardial infarction (MI). We evaluated the impact of age and CKD on secondary prevention following primary percutaneous coronary intervention (PPCI) in a contemporary unselected cohort. DESIGN We studied 1169 consecutive patients from five UK centres receiving PPCI for ST elevation MI, with use of evidence-based secondary prevention at discharge assessed by age (<60, 60-75 and >75 years) and estimated glomerular filtration rate (eGFR). Follow-up prescribing practice was assessed in 567 patients. RESULTS One-fifth of patients receiving PPCI were >75 years. This group received fewer secondary prevention drugs at discharge compared to younger patients (P < 0.01 for β-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARB) and statins). By 6 weeks post-PPCI, there was a small drop-off in evidence-based therapy; β-blocker and statin use in those >75 years fell from 90% to 86% and 96% to 93%, respectively. CKD (eGFR<60 ml/min/1.73 m(2)) was seen in 17.6%. Declining renal function was associated with age, female sex and lower use of ACE inhibitor/ARB. At discharge 83.5% of patients with eGFR<60 ml/min/1.73 m(2) were receiving ACE inhibitors/ARB, dropping to 77.5% at 6 weeks (compared with 95% and 92%, respectively, in patients with eGFR >60 ml/min/1.73 m(2)). CONCLUSION The uptake of secondary prevention medication is high following PPCI in the UK, even in the elderly and in those with renal dysfunction. A focus on strategies to improve up-titration and continuation of drugs following discharge is required.
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Affiliation(s)
- D Zachariah
- Cardiology Department, Queen Alexandra hospital, Southwick Hill Rd, Cosham, Portsmouth, PO6 3LY, UK.
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Arkouche W, Giaime P, Mercadal L. [Fluid overload and arterial hypertension in hemodialysis patients]. Nephrol Ther 2013; 9:408-15. [PMID: 23953783 DOI: 10.1016/j.nephro.2013.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
Abstract
The water sodium overload is a factor of morbi-mortality and its treatment is one of the markers of adequacy of the hemodialysis treatment. Its first clinical assessment was improved by tools such as echocardiography and ultrasonography of the inferior vena cava, the per-dialytic curve of plasma volume, measuring BNP or proBNP and by impedancemetry. The combination of the evaluation of these parameters and of the clinical situation allows one to assess the extracellular overload, the state of the blood volume and the potential of plasma refilling. The latter is a key factor of the per-dialytic hemodynamic tolerance. It is itself a determining factor in weight can be achieved at the end of the session. Getting the "dry" weight can require modifications of the prescriptions of the hemodialysis sessions, a filling by albumin even a drugs support. Finally, the overload treatment is the central part of the treatment of arterial hypertension, which has to benefit however often from antihypertensive treatment the profit of which is demonstrated.
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Affiliation(s)
- Walid Arkouche
- Association pour l'utilisation du rein artificiel dans la région lyonnaise (AURAL), 69008 Lyon, France
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Jun M, Lv J, Perkovic V, Jardine MJ. Managing cardiovascular risk in people with chronic kidney disease: a review of the evidence from randomized controlled trials. Ther Adv Chronic Dis 2012; 2:265-78. [PMID: 23251754 DOI: 10.1177/2040622311401775] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Cardiovascular disease is the leading cause of death and morbidity in people with chronic kidney disease (CKD) making measures to modify cardiovascular risk a clinical priority. The relationship between risk factors and cardiovascular outcomes is often substantially different in people with CKD compared with the general population, leading to uncertainty around pathophysiological mechanisms and the validity of generalizations from the general population. Furthermore, published reports of subgroup analyses from clinical trials have suggested that a range of interventions may have different effects in people with kidney disease compared with those with normal kidney function. There is a relative scarcity of randomized controlled trials (RCTs) conducted in CKD populations, and most such trials are small and underpowered. As a result, evidence to support cardiovascular risk modification measures for people with CKD is largely derived from small trials and post hoc analyses of RCTs conducted in the general population. In this review, we examine the available RCT evidence on interventions aimed at preventing cardiovascular events in people with kidney disease to identify beneficial treatments as well as current gaps in knowledge that should be a priority for future research.
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Affiliation(s)
- Min Jun
- The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia
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8
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Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Ann Forciea M, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ, Harrington RA, Bates ER, Bhatt DL, Bridges CR, Eisenberg MJ, Ferrari VA, Fisher JD, Gardner TJ, Gentile F, Gilson MF, Hlatky MA, Jacobs AK, Kaul S, Moliterno DJ, Mukherjee D, Rosenson RS, Stein JH, Weitz HH, Wesley DJ. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. ACTA ACUST UNITED AC 2011; 5:259-352. [PMID: 21771565 DOI: 10.1016/j.jash.2011.06.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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9
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Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Forciea MA, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ. ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. Circulation 2011; 123:2434-506. [PMID: 21518977 DOI: 10.1161/cir.0b013e31821daaf6] [Citation(s) in RCA: 254] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | | | - Carl J. Pepine
- American College of Cardiology Foundation Representative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Deborah J. Wesley
- ACCF Task Force on Clinical Expert Consensus Documents Representative. Authors with no symbol by their name were included to provide additional content expertise apart from organizational representation
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Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Ann Forciea M, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol 2011; 57:2037-114. [PMID: 21524875 DOI: 10.1016/j.jacc.2011.01.008] [Citation(s) in RCA: 277] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Jardine MJ, Ninomiya T, Perkovic V, Cass A, Turnbull F, Gallagher MP, Zoungas S, Lambers Heerspink HJ, Chalmers J, Zanchetti A. Aspirin is beneficial in hypertensive patients with chronic kidney disease: a post-hoc subgroup analysis of a randomized controlled trial. J Am Coll Cardiol 2010; 56:956-65. [PMID: 20828648 DOI: 10.1016/j.jacc.2010.02.068] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 01/28/2010] [Accepted: 02/01/2010] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the benefit and risk associated with antiplatelet therapy in the chronic kidney disease (CKD) population. BACKGROUND Cardiovascular and possibly bleeding risks are elevated in patients with CKD. The balance of benefit and harm associated with antiplatelet therapy remains uncertain. METHODS The HOT (Hypertension Optimal Treatment) study randomly assigned participants with diastolic hypertension to aspirin (75 mg) or placebo. Study treatment effects were calculated using univariate proportional hazards regression models stratified by baseline estimated glomerular filtration rate (eGFR) with trends tested by adding interaction terms. End points included major cardiovascular events, total mortality, and major bleeding. RESULTS The study included 18,597 participants treated for 3.8 years. Baseline eGFR was < 60 ml/min/1.73 m(2) in 3,619 participants. Major cardiovascular events were reduced by 9% (95% confidence interval [CI]: -9% to 24%), 15% (95% CI: -17% to 39%), and 66% (95% CI: 33% to 83%) for patients with baseline eGFR of ≥ 60, 45 to 59, and < 45 ml/min/1.73 m(2), respectively (p trend = 0.03). Total mortality was reduced by 0% (95% CI: -20% to 17%), 11% (95% CI: -31% to 40%), and 49% (95% CI: 6% to 73%), respectively (p trend = 0.04). Major bleeding events were nonsignificantly greater with lower eGFR (hazard ratio [HR]: 1.52 [95% CI: 1.11 to 2.08], HR: 1.70 [95% CI: 0.74 to 3.88], and HR: 2.81 [95% CI: 0.92 to 8.84], respectively; p trend = 0.30). Among every 1,000 persons with eGFR < 45 ml/min/1.73 m(2) treated for 3.8 years, 76 major cardiovascular events and 54 all-cause deaths will be prevented while 27 excess major bleeds will occur. CONCLUSIONS Aspirin therapy produces greater absolute reduction in major cardiovascular events and mortality in hypertensive patients with CKD than with normal kidney function. An increased risk of major bleeding appears to be outweighed by the substantial benefits.
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Affiliation(s)
- Meg J Jardine
- The George Institute for Global Health, Sydney, Australia; Concord Repatriation General Hospital, Sydney, Australia
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12
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Foraker RE, Rose KM, Whitsel EA, Suchindran CM, Wood JL, Rosamond WD. Neighborhood socioeconomic status, Medicaid coverage and medical management of myocardial infarction: atherosclerosis risk in communities (ARIC) community surveillance. BMC Public Health 2010; 10:632. [PMID: 20964853 PMCID: PMC3201018 DOI: 10.1186/1471-2458-10-632] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Accepted: 10/21/2010] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Pharmacologic treatments are efficacious in reducing post-myocardial infarction (MI) morbidity and mortality. The potential influence of socioeconomic factors on the receipt of pharmacologic therapy has not been systematically examined, even though healthcare utilization likely influences morbidity and mortality post-MI. This study aims to investigate the association between socioeconomic factors and receipt of evidence-based treatments post-MI in a community surveillance setting. METHODS We evaluated the association of census tract-level neighborhood household income (nINC) and Medicaid coverage with pharmacologic treatments (aspirin, beta [β]-blockers and angiotensin converting enzyme [ACE] inhibitors; optimal therapy, defined as receipt of two or more treatments) received during hospitalization or at discharge among 9,608 MI events in the ARIC community surveillance study (1993-2002). Prevalence ratios (PR, 95% CI), adjusted for the clustering of hospitalized MI events within census tracts and within patients, were estimated using Poisson regression. RESULTS Seventy-eight percent of patients received optimal therapy. Low nINC was associated with a lower likelihood of receiving β-blockers (0.93, 0.87-0.98) and a higher likelihood of receiving ACE inhibitors (1.13, 1.04-1.22), compared to high nINC. Patients with Medicaid coverage were less likely to receive aspirin (0.92, 0.87-0.98), compared to patients without Medicaid coverage. These findings were independent of other key covariates. CONCLUSIONS nINC and Medicaid coverage may be two of several socioeconomic factors influencing the complexities of medical care practice patterns.
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Affiliation(s)
- Randi E Foraker
- Division of Epidemiology, The Ohio State University, 320 West 10th Avenue, Columbus, OH 43210, USA
| | - Kathryn M Rose
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, 27599, USA
| | - Eric A Whitsel
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, 27599, USA
| | - Chirayath M Suchindran
- Department of Biostatistics, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, 27599, USA
| | - Joy L Wood
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, 27599, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, 27599, USA
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Berger PB, Best PJM. Does kidney function alter the benefit of reperfusion therapy for ST-segment elevation myocardial infarction? JACC Cardiovasc Interv 2010; 2:34-6. [PMID: 19463395 DOI: 10.1016/j.jcin.2008.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Accepted: 09/29/2008] [Indexed: 10/21/2022]
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Wenger NK. Drugs for cardiovascular disease prevention in women: implications of the AHA Guidelines--2007 Update. Drugs 2008; 68:339-58. [PMID: 18257610 DOI: 10.2165/00003495-200868030-00006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Lifestyle interventions constitute the initial strategy for the primary and secondary prevention of cardiovascular disease in women. However, pharmacotherapy is often indicated for control of major cardiovascular risk factors, and abundant clinical trial data support the morbidity and mortality benefit of a number of categories of drug therapy following a coronary event. Although women have increasingly been enrolled in clinical trials of pharmacotherapy, under representation of women in most research studies limits the gender-specific assessment of outcomes. Equally importantly, recent randomized clinical trial data have highlighted inappropriate preventive therapies for women (i.e. those lacking effectiveness and potentially imparting harm). Decision-making data for drug therapy for women also derive from a number of clinical trials conducted solely in women. The drug classes reviewed in this article include omega-3 fatty acids, aspirin, ACE inhibitors and angiotensin II receptor antagonists or blockers, beta-adrenoceptor antagonists (beta-blockers), aldosterone antagonists, antioxidants, folic acid and vitamins B(6) and B(12), and menopausal hormone therapy and selective estrogen-receptor modulators. Information is sparse regarding specific cardiovascular pharmacotherapies for elderly women, and women of racial and ethnic minorities. Owing to the under representation of the subset of women in many trials, analysis by age, race and ethnicity is not appropriate. This information gap presents a major challenge for future studies, as these subgroups constitute populations of women at high cardiovascular risk.
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Affiliation(s)
- Nanette K Wenger
- Emory University School of Medicine, Atlanta, Georgia, USAGrady Memorial Hospital, Atlanta, Georgia, USAEmory Heart and Vascular Center, Atlanta, Georgia 30303, USA.
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15
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Covic A, Gusbeth-Tatomir P, Goldsmith DJA. The epidemics of cardiovascular disease in elderly patients with chronic kidney disease--two facets of the same problem. Int Urol Nephrol 2007; 38:371-9. [PMID: 16868714 DOI: 10.1007/s11255-006-0044-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2005] [Indexed: 10/24/2022]
Abstract
There is increasing evidence that even mild renal dysfunction is a novel potent cardiovascular risk factor in the general elderly population. With more severe renal impairment, cardiovascular risk increases proportionately. This issue deserves attention, as chronic kidney disease (CKD) is predominantly a disease of the elderly, and the mean age of end-stage renal disease patients entering dialysis is growing constantly. In the dialysis population, when clinically significant cardiovascular disease (CVD) (particularly congestive heart failure) is present, survival is worse. Thus, every effort should be made to identify and treat cardiovascular risk factor in the early stages of CKD. However, elderly renal patients receive less proper cardiovascular therapy compared to non-renal subjects of the same age. This review deals briefly with the most significant data published in the last decade on CVD in elderly with CKD.
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Affiliation(s)
- Adrian Covic
- Nephrology Clinic and Dialysis and Transplantation Center, C. I. PARHON University Hospital, 6600, Iasi, Romania.
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16
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Ho PM, Magid DJ, Masoudi FA, McClure DL, Rumsfeld JS. Adherence to cardioprotective medications and mortality among patients with diabetes and ischemic heart disease. BMC Cardiovasc Disord 2006; 6:48. [PMID: 17173679 PMCID: PMC1762024 DOI: 10.1186/1471-2261-6-48] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Accepted: 12/15/2006] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Patients with diabetes and ischemic heart disease (IHD) are at high risk for adverse cardiac outcomes. Clinical practice guidelines recommend multiple cardioprotective medications to reduce recurrent events. We evaluated the association between cardioprotective medication adherence and mortality among patients with diabetes and IHD. METHODS In a retrospective cohort study of 3,998 patients with diabetes and IHD, we evaluated use of ACE inhibitors or angiotensin receptor blockers, beta-blockers, and statin medications. Receipt of cardioprotective medications was based on filled prescriptions. Medication adherence was calculated as the proportion of days covered (PDC) for filled prescriptions. The primary outcome of interest was all-cause mortality. RESULTS The majority of patients (92.8%) received at least 1 cardioprotective medication. Patients receiving any medications had lower unadjusted mortality rates compared to patients not receiving any medications (7.9% vs. 11.5%; p = 0.03). In multivariable analysis, receipt of any cardioprotective medication remained associated with lower all-cause mortality (OR 0.65; 95% CI 0.43-0.99). Among patients receiving cardioprotective medications, the majority (80.3%) were adherent (PDC > or = 0.80). Adherent patients had lower unadjusted mortality rates (6.7% vs. 12.1%; p < 0.01). In multivariable analysis, medication adherence remained associated with lower all-cause mortality (OR 0.52; 95% CI 0.39-0.69) compared to non-adherence. In contrast, there was no mortality difference between patients receiving cardioprotective medications who were non-adherent compared to patients not receiving any medications (OR 1.01; 95% CI 0.64-1.61). CONCLUSION In conclusion, medication adherence is associated with improved outcomes among patients with diabetes and IHD. Quality improvement interventions are needed to increase medication adherence in order for patients to maximize the benefit of cardioprotective medications.
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Affiliation(s)
- P Michael Ho
- Cardiology Section, Denver VA Medical Center, Denver, CO, USA.
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Vanasse A, Courteau J, Niyonsenga T. Revascularization and cardioprotective drug treatment in myocardial infarction patients: how do they impact on patients' survival when delivered as usual care. BMC Cardiovasc Disord 2006; 6:21. [PMID: 16674817 PMCID: PMC1473199 DOI: 10.1186/1471-2261-6-21] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Accepted: 05/04/2006] [Indexed: 01/29/2023] Open
Abstract
Background Randomized clinical trials showed the benefit of pharmacological and revascularization treatments in secondary prevention of myocardial infarction (MI), in selected population with highly controlled interventions. The objective of this study is to measure these treatments' impact on the cardiovascular (CV) mortality rate among patients receiving usual care in the province of Quebec. Methods The study population consisted of a "naturalistic" cohort of all patients ≥ 65 years old living in the Quebec province, who survived a MI (ICD-9: 410) in 1998. The studied dependant variable was time to death from a CV disease. Independent variables were revascularization procedure and cardioprotective drugs. Death from a non CV disease was also studied for comparison. Revascularization procedure was defined as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). The exposure to cardioprotective drugs was defined as the number of cardioprotective drug classes (Acetylsalicylic Acid (ASA), Beta-Blockers, Angiotensin-Converting Enzyme (ACE) Inhibitors, Statins) claimed within the index period (first 30 days after the index hospitalization). Age, gender and a comorbidity index were used as covariates. Kaplan-Meier survival curves, Cox proportional hazard models, logistic regressions and regression trees were used. Results The study population totaled 5596 patients (3206 men; 2390 women). We observed 1128 deaths (20%) within two years following index hospitalization, of them 603 from CV disease. The CV survival rate at two years is much greater for patients with revascularization, regardless of pharmacological treatments. For patients without revascularization, the CV survival rate increases with the number of cardioprotective drug classes claimed. Finally, Cox proportional hazard models, regression tree and logistic regression analyses all revealed that the absence of revascularization and, to a lower extent, absence of cardioprotective drugs were major predictors for CV death, even after adjusting for age, gender and comorbidity. Conclusion Considering usual care management of MI in the province of Quebec in 1998, CV survival is positively correlated to the presence of a revascularization procedure and to the intensity of cardioprotective pharmacological treatment. These results are coherent with data from randomized control trials.
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Affiliation(s)
- Alain Vanasse
- Family Medicine Department, Faculty of Medicine, Université de Sherbrooke, 3001, 12th Avenue North, Sherbrooke (QC), J1H 5N4, Canada
- PRIMUS Group, Clinical Research Center, Sherbrooke University Hospital, Sherbrooke (QC), Canada
| | - Josiane Courteau
- PRIMUS Group, Clinical Research Center, Sherbrooke University Hospital, Sherbrooke (QC), Canada
| | - Théophile Niyonsenga
- Stempel School of Public Health, Epidemiology & Biostatistics, Florida International University, Florida, USA
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Isbel NM, Haluska B, Johnson DW, Beller E, Hawley C, Marwick TH. Increased targeting of cardiovascular risk factors in patients with chronic kidney disease does not improve atheroma burden or cardiovascular function. Am Heart J 2006; 151:745-53. [PMID: 16504645 DOI: 10.1016/j.ahj.2005.06.017] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2004] [Accepted: 06/05/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although multiple risk factor intervention (MRFI) is recommended to reduce the increased morbidity and mortality of cardiovascular disease (CVD) in chronic kidney disease (CKD), its efficacy is unknown. We studied the efficacy of a MRFI program in CKD. METHODS This randomized controlled study of 200 patients with stage 4 or 5 CKD compared a physician-supervised, nurse-driven MRFI clinic (focused on dyslipidemia, hyperhomocysteinemia, blood pressure [BP], anemia, and hyperphosphatemia) with conventional care in CKD. One hundred eleven subjects completed 2 years of follow-up (median follow-up 674 days [interquartile range {IQR} 348-719 days]). Outcome measures were atheroma burden (carotid intimamedia thickness [IMT]) and endothelial function (brachial artery reactivity [BAR]). RESULTS The MRFI group showed significant improvements, compared with usual care, in serum low-density lipoprotein cholesterol (-30.9 mg/dL vs -12.7 mg/dL, P = .001), homocysteine (-6.95 vs -0.67 micromol/L, P < .001), systolic BP (-6.9 vs -0.2 mm Hg, P = .049), and diastolic BP (-4.8 vs -1.0 mm of Hg, P = .043). No significant changes were seen in serum phosphate or hemoglobin level. Despite observed improvements in risk factors, no differences from baseline were demonstrated for IMT (-0.00 vs -0.01 mm, P = .533) or BAR (0.09% vs 0.22%, P = .834). Forty-two patients reached a composite end point of CVD death, acute coronary syndrome, revascularization, nonfatal stroke, and amputation and this was similar between groups (23 vs 19 events, P = .475). CONCLUSIONS A MRFI program was not associated with improvement in vascular structure or function in stage 4 or 5 patients with CKD.
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Affiliation(s)
- Nicole M Isbel
- Department of Renal Medicine, Princess Alexandra Hospital, Brisbane, Australia.
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