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Bawaskar P, Thomas N, Ismail K, Guo Y, Chhikara S, Athwal PSS, Ranum A, Jadhav A, Mendez AH, Nadkarni I, Frerichs D, Velangi P, Ergando T, Akram H, Kanda A, Shenoy C. Nonischemic or Dual Cardiomyopathy in Patients With Coronary Artery Disease. Circulation 2024; 149:807-821. [PMID: 37929565 PMCID: PMC10951941 DOI: 10.1161/circulationaha.123.067032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/02/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Randomized trials in obstructive coronary artery disease (CAD) have largely shown no prognostic benefit from coronary revascularization. Although there are several potential reasons for the lack of benefit, an underexplored possible reason is the presence of coincidental nonischemic cardiomyopathy (NICM). We investigated the prevalence and prognostic significance of NICM in patients with CAD (CAD-NICM). METHODS We conducted a registry study of consecutive patients with obstructive CAD on coronary angiography who underwent contrast-enhanced cardiovascular magnetic resonance imaging for the assessment of ventricular function and scar at 4 hospitals from 2004 to 2020. We identified the presence and cause of cardiomyopathy using cardiovascular magnetic resonance imaging and coronary angiography data, blinded to clinical outcomes. The primary outcome was a composite of all-cause death or heart failure hospitalization, and secondary outcomes were all-cause death, heart failure hospitalization, and cardiovascular death. RESULTS Among 3023 patients (median age, 66 years; 76% men), 18.2% had no cardiomyopathy, 64.8% had ischemic cardiomyopathy (CAD+ICM), 9.3% had CAD+NICM, and 7.7% had dual cardiomyopathy (CAD+dualCM), defined as both ICM and NICM. Thus, 16.9% had CAD+NICM or dualCM. During a median follow-up of 4.8 years (interquartile range, 2.9, 7.6), 1116 patients experienced the primary outcome. In Cox multivariable analysis, CAD+NICM or dualCM was independently associated with a higher risk of the primary outcome compared with CAD+ICM (adjusted hazard ratio, 1.23 [95% CI, 1.06-1.43]; P=0.007) after adjustment for potential confounders. The risks of the secondary outcomes of all-cause death and heart failure hospitalization were also higher with CAD+NICM or dualCM (hazard ratio, 1.21 [95% CI, 1.02-1.43]; P=0.032; and hazard ratio, 1.37 [95% CI, 1.11-1.69]; P=0.003, respectively), whereas the risk of cardiovascular death did not differ from that of CAD+ICM (hazard ratio, 1.15 [95% CI, 0.89-1.48]; P=0.28). CONCLUSIONS In patients with CAD referred for clinical cardiovascular magnetic resonance imaging, NICM or dualCM was identified in 1 of every 6 patients and was associated with worse long-term outcomes compared with ICM. In patients with obstructive CAD, coincidental NICM or dualCM may contribute to the lack of prognostic benefit from coronary revascularization.
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Affiliation(s)
- Parag Bawaskar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Nicholas Thomas
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Khaled Ismail
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Yugene Guo
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Sanya Chhikara
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Pal Satyajit Singh Athwal
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Alison Ranum
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Achal Jadhav
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Abel Hooker Mendez
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ishan Nadkarni
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Dominic Frerichs
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Pratik Velangi
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Tesfatsiyon Ergando
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Hassan Akram
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Adinan Kanda
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Reiter RJ, Sharma R, Chuffa LGDA, Simko F, Dominguez-Rodriguez A. Mitochondrial Melatonin: Beneficial Effects in Protecting against Heart Failure. Life (Basel) 2024; 14:88. [PMID: 38255703 PMCID: PMC10820220 DOI: 10.3390/life14010088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/24/2024] Open
Abstract
Cardiovascular disease is the cause of physical infirmity and thousands of deaths annually. Typically, during heart failure, cardiomyocyte mitochondria falter in terms of energy production and metabolic processing. Additionally, inflammation and the accumulation of non-contractile fibrous tissue contribute to cardiac malfunction. Melatonin, an endogenously produced molecule, experimentally reduces the initiation and progression of atherosclerotic lesions, which are often the basis of coronary artery disease. The current review critically analyzes published data related to the experimental use of melatonin to forestall coronary artery pathologies. Collectively, these studies document melatonin's anti-atherosclerotic actions in reducing LDL oxidation and triglyceride levels, lowering endothelial malfunction, limiting adhesion molecule formation, preventing macrophage polarization to the M1 pro-inflammatory phenotype, changing cellular metabolism, scavenging destructive reactive oxygen species, preventing the proliferation and invasion of arterial smooth muscle cells into the lesioned area, restricting the ingrowth of blood vessels from the vasa vasorum, and solidifying the plaque cap to reduce the chance of its rupture. Diabetic hyperglycemia, which aggravates atherosclerotic plaque formation, is also inhibited by melatonin supplementation in experimental animals. The potential value of non-toxic melatonin as a possible inhibitor of cardiac pathology in humans should be seriously considered by performing clinical trials using this multifunctional molecule.
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Affiliation(s)
- Russel J. Reiter
- Department of Cell Systems and Anatomy, Long School of Medicine, UT Health San Antonio, San Antonio, TX 78229, USA
| | - Ramaswamy Sharma
- Applied Biomedical Sciences, School of Osteopathic Medicine, University of the Incarnate Word, San Antonio, TX 78235, USA
| | - Luiz Gustavo de Almeida Chuffa
- Department of Structural and Functional Biology-IBB/UNESP, Institute of Biosciences of Botucatu, Universidade Estadual Paulista, Botucatu 18618-689, São Paulo, Brazil;
| | - Fedor Simko
- Institute of Pathophysiology, Faculty of Medicine, Comenius University, 81108 Bratislava, Slovakia;
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Chivardi C, Morgan H, Sculpher MJ, Clayton T, Evans R, Dodd M, Petrie M, Rinaldi CA, O'Kane P, Brown L, Perera D, Saramago P. Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction: Cost-Effectiveness Analysis of the REVIVED-BCIS2 Trial. Circ Cardiovasc Qual Outcomes 2024; 17:e010533. [PMID: 37929587 PMCID: PMC10782932 DOI: 10.1161/circoutcomes.123.010533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is frequently undertaken in patients with ischemic left ventricular systolic dysfunction. The REVIVED (Revascularization for Ischemic Ventricular Dysfunction)-BCIS2 (British Cardiovascular Society-2) trial concluded that PCI did not reduce the incidence of all-cause death or heart failure hospitalization; however, patients assigned to PCI reported better initial health-related quality of life than those assigned to optimal medical therapy (OMT) alone. The aim of this study was to assess the cost-effectiveness of PCI+OMT compared with OMT alone. METHODS REVIVED-BCIS2 was a prospective, multicenter UK trial, which randomized patients with severe ischemic left ventricular systolic dysfunction to either PCI+OMT or OMT alone. Health care resource use (including planned and unplanned revascularizations, medication, device implantation, and heart failure hospitalizations) and health outcomes data (EuroQol 5-dimension 5-level questionnaire) on each patient were collected at baseline and up to 8 years post-randomization. Resource use was costed using publicly available national unit costs. Within the trial, mean total costs and quality-adjusted life-years (QALYs) were estimated from the perspective of the UK health system. Cost-effectiveness was evaluated using estimated mean costs and QALYs in both groups. Regression analysis was used to adjust for clinically relevant predictors. RESULTS Between 2013 and 2020, 700 patients were recruited (mean age: PCI+OMT=70 years, OMT=68 years; male (%): PCI+OMT=87, OMT=88); median follow-up was 3.4 years. Over all follow-ups, patients undergoing PCI yielded similar health benefits at higher costs compared with OMT alone (PCI+OMT: 4.14 QALYs, £22 352; OMT alone: 4.16 QALYs, £15 569; difference: -0.015, £6782). For both groups, most health resource consumption occurred in the first 2 years post-randomization. Probabilistic results showed that the probability of PCI being cost-effective was 0. CONCLUSIONS A minimal difference in total QALYs was identified between arms, and PCI+OMT was not cost-effective compared with OMT, given its additional cost. A strategy of routine PCI to treat ischemic left ventricular systolic dysfunction does not seem to be a justifiable use of health care resources in the United Kingdom. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920048.
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Affiliation(s)
- Carlos Chivardi
- Centre for Health Economics, University of York, United Kingdom (C.C., M.J.S., P.S.)
| | - Holly Morgan
- British Heart Foundation Center of Research Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (H.M., D.P.)
| | - Mark J. Sculpher
- Centre for Health Economics, University of York, United Kingdom (C.C., M.J.S., P.S.)
| | - Tim Clayton
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, United Kingdom (T.C., R.E., M.D.)
| | - Richard Evans
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, United Kingdom (T.C., R.E., M.D.)
| | - Matthew Dodd
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, United Kingdom (T.C., R.E., M.D.)
| | - Mark Petrie
- Cardiology Department, Institute of Cardiovascular and Metabolic Sciences, University of Glasgow, United Kingdom (M.P.)
| | - Christopher A. Rinaldi
- Centre for Health Economics, University of York, United Kingdom (C.C., M.J.S., P.S.)
- British Heart Foundation Center of Research Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (H.M., D.P.)
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, United Kingdom (T.C., R.E., M.D.)
- Cardiology Department, Institute of Cardiovascular and Metabolic Sciences, University of Glasgow, United Kingdom (M.P.)
- Cardiology Department, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, United Kingdom (A.R., D.P.)
- Cardiology Department, Royal Bournemouth and Christchurch Hospital, Bournemouth, United Kingdom (P.O.)
- MRC Clinical Trials Unit, University College London, United Kingdom (L.B.)
| | - Peter O'Kane
- Cardiology Department, Royal Bournemouth and Christchurch Hospital, Bournemouth, United Kingdom (P.O.)
| | - Louise Brown
- MRC Clinical Trials Unit, University College London, United Kingdom (L.B.)
| | - Divaka Perera
- British Heart Foundation Center of Research Excellence, School of Cardiovascular Medicine and Sciences, King’s College London, United Kingdom (H.M., D.P.)
- Cardiology Department, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, United Kingdom (A.R., D.P.)
| | - Pedro Saramago
- Centre for Health Economics, University of York, United Kingdom (C.C., M.J.S., P.S.)
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