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Peikert A, Vaduganathan M, Claggett BL, Kulac IJ, Foà A, Desai AS, Jhund PS, Carberry J, Lam CSP, Kosiborod MN, Inzucchi SE, Martinez FA, de Boer RA, Hernandez AF, Shah SJ, Køber L, Ponikowski P, Sabatine MS, Petersson M, Langkilde AM, McMurray JJV, Solomon SD. Dapagliflozin in patients with heart failure and previous myocardial infarction: A participant-level pooled analysis of DAPA-HF and DELIVER. Eur J Heart Fail 2024; 26:912-924. [PMID: 38487939 DOI: 10.1002/ejhf.3184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/13/2024] [Accepted: 02/14/2024] [Indexed: 05/31/2024] Open
Abstract
AIMS Patients with heart failure (HF) and history of myocardial infarction (MI) face a higher risk of disease progression and clinical events. Whether sodium-glucose cotransporter 2 inhibitors may modify clinical trajectory in such individuals remains incompletely understood. METHODS AND RESULTS The DAPA-HF and DELIVER trials compared dapagliflozin with placebo in patients with symptomatic HF with left ventricular ejection fraction (LVEF) ≤40% and > 40%, respectively. In this pooled participant-level analysis, we assessed efficacy and safety outcomes by history of MI. The primary outcome in both trials was the composite of cardiovascular death or worsening HF. Of the total of 11 007 patients, 3731 (34%) had a previous MI and were at higher risk of the primary outcome across the spectrum of LVEF in covariate-adjusted models (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.02-1.24). Dapagliflozin reduced the risk of the primary outcome to a similar extent in patients with (HR 0.83, 95% CI 0.72-0.96) and without previous MI (HR 0.76, 95% CI 0.68-0.85; pinteraction = 0.36), with consistent benefits on key secondary outcomes as well. Serious adverse events did not occur more frequently with dapagliflozin, irrespective of previous MI. CONCLUSION History of MI confers increased risks of adverse cardiovascular outcomes in patients with HF across the LVEF spectrum, even among those with preserved ejection fraction. Dapagliflozin consistently and safely reduces the risk of cardiovascular death or worsening HF, regardless of previous MI.
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Affiliation(s)
- Alexander Peikert
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- University Heart Center Graz, Department of Cardiology, Medical University of Graz, Graz, Austria
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ian J Kulac
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alberto Foà
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Jaclyn Carberry
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore, Singapore
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, The Netherlands
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, MO, USA
| | | | | | - Rudolf A de Boer
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Wroclaw, Poland
| | - Marc S Sabatine
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Christensen DM, Strange JE, El-Chouli M, Falkentoft AC, Malmborg M, Nouhravesh N, Gislason G, Schou M, Torp-Pedersen C, Sehested TSG. Temporal Trends in Noncardiovascular Morbidity and Mortality Following Acute Myocardial Infarction. J Am Coll Cardiol 2023; 82:971-981. [PMID: 37648355 DOI: 10.1016/j.jacc.2023.06.024] [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: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Due to improved management, diagnosis, and care of myocardial infarction (MI), patients may now survive long enough to increasingly develop serious noncardiovascular conditions. OBJECTIVES This study aimed to test this hypothesis by investigating the temporal trends in noncardiovascular morbidity and mortality following MI. METHODS We conducted a registry-based nationwide cohort study of all Danish patients with MI during 2000 to 2017. Outcomes were cardiovascular and noncardiovascular mortality, incident cancer, incident renal disease, and severe infectious disease. RESULTS From 2000 to 2017, 136,293 consecutive patients were identified (63.2% men, median age 69 years). The 1-year risk of cardiovascular mortality between 2000 to 2002 and 2015 to 2017 decreased from 18.4% to 7.6%, whereas noncardiovascular mortality decreased from 5.8% to 5.0%. This corresponded to an increase in the proportion of total 1-year mortality attributed to noncardiovascular causes from 24.1% to 39.5%. Furthermore, increases in 1-year risk of incident cancer (1.9%-2.4%), incident renal disease (1.0%-1.6%), and infectious disease (5.5%-9.1%) were observed (all P trend <0.01). In analyses standardized for changes in patient characteristics, the increased risk of cancer in 2015 to 2017 compared with 2000 to 2002 was no longer significant (standardized risk ratios for cancer: 0.99 [95% CI: 0.91-1.07]; renal disease: 1.28 [95% CI: 1.15-1.41]; infectious disease: 1.28 [95% CI: 1.23-1.34]). CONCLUSIONS Although cardiovascular mortality following MI improved substantially during 2000 to 2017, the risk of noncardiovascular morbidity increased. Moreover, noncardiovascular causes constitute an increasing proportion of post-MI mortality. These findings suggest that further attention on noncardiovascular outcomes is warranted in guidelines and clinical practice and should be considered in the design of future clinical trials.
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Affiliation(s)
| | - Jarl Emanuel Strange
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark; Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Mohamad El-Chouli
- Danish Heart Foundation, Copenhagen, Denmark; Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | | | - Morten Malmborg
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Nina Nouhravesh
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Gunnar Gislason
- Danish Heart Foundation, Copenhagen, Denmark; Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands Hospital, Hillerød, Denmark; Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Thomas S G Sehested
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
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Docherty KF, Jackson AM, Macartney M, Campbell RT, Petrie MC, Pfeffer MA, McMurray JJ, Jhund PS. Declining risk of heart failure hospitalization following first acute myocardial infarction in Scotland between 1991-2016. Eur J Heart Fail 2023; 25:1213-1224. [PMID: 37401485 PMCID: PMC10946471 DOI: 10.1002/ejhf.2965] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 06/22/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023] Open
Abstract
AIM Mortality from acute myocardial infarction (AMI) has declined, increasing the pool of survivors at risk of later development of heart failure (HF). However, coronary reperfusion limits infarct size and secondary prevention therapies have improved. In light of these competing influences, we examined long-term trends in the risk of HF hospitalization (HFH) following a first AMI occurring in Scotland over 25 years. METHODS AND RESULTS All patients in Scotland discharged alive after a first AMI between 1991 and 2015 were followed until a first HFH or death until the end of 2016 (minimum follow-up 1 year, maximum 26 years). A total of 175 672 people with no prior history of HF were discharged alive after a first AMI during the period of study. A total of 21 445 (12.2%) patients had a first HFH during a median follow-up of 6.7 years. Incidence of HFH (per 1000 person-years) at 1 year following discharge from a first AMI decreased from 59.3 (95% confidence interval [CI] 54.2-64.7) in 1991 to 31.3 (95% CI 27.3-35.8) in 2015, with consistent trends seen for HF occurring within 5 and 10 years. Accounting for the competing risk of death, the adjusted risk of HFH at 1 year after discharge decreased by 53% (95% CI 45-60%), with similar decreases at 5 and 10 years. CONCLUSION The incidence of HFH following AMI in Scotland has decreased since 1991. These trends suggest that better treatment of AMI and secondary prevention are having an impact on the risk of HF at a population level.
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Affiliation(s)
| | - Alice M. Jackson
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | | | - Ross T. Campbell
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Mark C. Petrie
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Marc A. Pfeffer
- Cardiovascular Division, Brigham & Women's HospitalHarvard Medical SchoolBostonMAUSA
| | | | - Pardeep S. Jhund
- BHF Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
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Christensen DM, Strange JE, Falkentoft AC, El-Chouli M, Ravn PB, Ruwald AC, Fosbøl E, Køber L, Gislason G, Sehested TSG, Schou M. Frailty, Treatments, and Outcomes in Older Patients With Myocardial Infarction: A Nationwide Registry-Based Study. J Am Heart Assoc 2023:e030561. [PMID: 37421279 PMCID: PMC10382124 DOI: 10.1161/jaha.123.030561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/30/2023] [Indexed: 07/10/2023]
Abstract
Background Guidelines recommend that patients with myocardial infarction (MI) receive equal care regardless of age. However, withholding treatment may be justified in elderly and frail patients. This study aimed to investigate trends in treatments and outcomes of older patients with MI according to frailty. Methods and Results All patients aged ≥75 years with first-time MI during 2002 to 2021 were identified through Danish nationwide registries. Frailty was categorized using the Hospital Frailty Risk Score. One-year risk and hazard ratios (HRs) for days 0 to 28 and 29 to 365 were calculated for all-cause death. A total of 51 022 patients with MI were included (median, 82 years; 50.2% women). Intermediate/high frailty increased from 26.7% in 2002 to 2006 to 37.1% in 2017 to 2021. Use of treatment increased substantially regardless of frailty: for example, 28.1% to 48.0% (statins), 21.8% to 33.7% (dual antiplatelet therapy), and 7.6% to 28.0% (percutaneous coronary intervention) for high frailty (all P-trend <0.001). One-year death decreased for low frailty (35.1%-17.9%), intermediate frailty (49.8%-31.0%), and high frailty (62.8%-45.6%), all P-trend <0.001. Age- and sex-adjusted 29- to 365-day HRs (2017-2021 versus 2002-2006) were 0.53 (0.48-0.59), 0.62 (0.55-0.70), and 0.62 (0.46-0.83) for low, intermediate, and high frailty, respectively (P-interaction=0.23). When additionally adjusted for treatment, HRs attenuated to 0.74 (0.67-0.83), 0.83 (0.74-0.94), and 0.78 (0.58-1.05), respectively, indicating that increased use of treatment may account partially for the observed improvements. Conclusions Use of guideline-based treatments and outcomes improved concomitantly in older patients with MI, irrespective of frailty. These results indicate that guideline-based management of MI may be reasonable in the elderly and frail.
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Affiliation(s)
| | - Jarl Emanuel Strange
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | | | | | - Pauline B Ravn
- Department of Cardiology Zealand University Hospital Roskilde Roskilde Denmark
| | | | - Emil Fosbøl
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology Rigshospitalet Copenhagen Denmark
| | - Gunnar Gislason
- Danish Heart Foundation Copenhagen Denmark
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
- The National Institute of Public Health University of Southern Denmark Copenhagen Denmark
| | - Thomas S G Sehested
- Danish Heart Foundation Copenhagen Denmark
- Department of Cardiology Zealand University Hospital Roskilde Roskilde Denmark
| | - Morten Schou
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
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Christensen DM, Schjerning AM, Smedegaard L, Charlot MG, Ravn PB, Ruwald AC, Fosbøl E, Køber L, Torp-Pedersen C, Schou M, Gerds T, Gislason G, Sehested TSG. Long-term mortality, cardiovascular events, and bleeding in stable patients 1 year after myocardial infarction: a Danish nationwide study. Eur Heart J 2022; 44:488-498. [PMID: 36433809 PMCID: PMC9902154 DOI: 10.1093/eurheartj/ehac667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/25/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022] Open
Abstract
AIMS Outcomes after myocardial infarction (MI) improved during recent decades alongside better risk factor management and implementation of guideline-recommended treatments. However, it is unknown whether this applies to stable patients who are event-free 1 year after MI. METHODS AND RESULTS Using nationwide Danish registries, we included all patients with first-time MI during 2000-17 who survived 1 year free from bleeding and cardiovascular events (n = 82 108, median age 64 years, 68.2% male). Follow-up started 1 year after MI and continued through January 2022. Crude risks of mortality, cardiovascular events, and bleeding were estimated in consecutive 3-year periods. Standardized risks were calculated with respect to the distribution of age, sex, comorbidities, and treatments in the latter period. Guideline-recommended treatment use increased during the study period: e.g. statins (68.6-92.5%) and percutaneous coronary intervention (23.9-68.2%). The crude 5-year risks of outcomes decreased (all P-trend <0.001): Mortality, 18.6% (95% confidence interval [CI]: 17.9-19.2) to 12.5% (CI: 11.9-13.1); Recurrent MI, 7.5% (CI: 7.1-8.0) to 5.5% (CI: 5.1-6.0); Bleeding, 3.9% (CI: 3.6-4.3) to 2.7% (CI: 2.4-3.0). Crude 5-year risk of mortality in 2015-17 was as low as 2.6% for patients aged <60 years. Use of guideline-recommended treatments was associated with improved outcomes: After standardization for changes in treatments, 5-year risk of mortality in 2000-02 was 15.5% (CI: 14.9-16.2). CONCLUSIONS For patients who were event-free 1 year after MI, the long-term risks of mortality, cardiovascular events, and bleeding decreased significantly, along with an improved use of guideline-recommended treatments between 2000 and 2017. In the most recent period, 1 year after MI, the risk of additional events was lower than previously reported.
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Affiliation(s)
| | - Anne-Marie Schjerning
- Danish Heart Foundation, Copenhagen, Denmark,Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Lærke Smedegaard
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Mette Gitz Charlot
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Pauline B Ravn
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark,Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Anne Christine Ruwald
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark,Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjællands University Hospital, Hillerød, Denmark,Department of Public Health, University of Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Gerds
- Danish Heart Foundation, Copenhagen, Denmark,Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Gunnar Gislason
- Danish Heart Foundation, Copenhagen, Denmark,Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark,The National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
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