1
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Saraiva JFK, Bellodi AC, Enumo SR, Machado WL, Fonseca HA, Saraiva DB, Avezum A. P5310College students under stress have elevated cardiovascular risk factors associated to eating disorders. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
High prevalence of cardiovascular diseases in the global adult population refers to the need for prevention. Tracking phenomenon studies have inferred that since childhood, risk and protection factors can be identified, thus supporting public health policies.
Purpose
To evaluate the prevalence of stress and the cardiovascular risk factor in Brazilian students.
Methods
A cross-sectional study was carried out in our city with 3,471 students, both sexes, from 7 to 13 years old, 51.7% of whom were non-Caucasian, aiming to analyze 31 variables: a) biological markers for cardiovascular risk (weight, height, waist circumference, systolic blood pressure, diastolic blood pressure, heart rate, HDL cholesterol, LDL cholesterol, total cholesterol, triglycerides, use of medications); b) health-related behavioural variables (ingestion of fruits, vegetables, meats, fish, dairy products, sweets, sugary drinks, fast food, snacks, lunch at home or at school, daily study hours, physical activity at school and out of school, means of transport to go to school, screen time); c) emotional variables (perceived stress at school and at home); d) socio-demographic data (sex, age, ethnicity). Data were collected in schools and tabulated; Network analysis considered 16 composite variables.
Results
A total of 17.5% of obesity and 16.2% of overweight verified at the studied population. Children and adolescents, under stress, are shown to have higher cholesterol levels, followed by increased use of medications or supplements, and increased physical activity, higher ratios for boys and non-white ethnicity individuals. Eating lunch provided by the school and being a female served as a protective factor for cardiovascular risk.
Conclusion
Considering the already known impact of stress on children's physical and psychological development and cardiovascular risk, it is urgent to establish public policies aimed at preventing these conditions, which have been severely perceived in very young, non-white and resident of a periphery of metropolises individuals.
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Affiliation(s)
- J F K Saraiva
- Pontifical Catholic University of Campinas (PUCCAMP), Campinas, Brazil
| | - A C Bellodi
- Pontifical Catholic University of Campinas (PUCCAMP), Campinas, Brazil
| | - S R Enumo
- Pontifical Catholic University of Campinas (PUCCAMP), Campinas, Brazil
| | - W L Machado
- Pontifical Catholic University of Campinas (PUCCAMP), Campinas, Brazil
| | - H A Fonseca
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - D B Saraiva
- Pontifical Catholic University of Campinas (PUCCAMP), Campinas, Brazil
| | - A Avezum
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
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Avezum A, Cordeiro Mattos A, Oliveira GBF, Pinto IM, Rombaldi AR, Fonseca HAR, Bocchese JI, Saback G, Taborga PRC, Silva TO, Campoa RN, Ferreira MHB, Savioli Neto F, Magalhaes CC, Saraiva JFK. P6368Blood pressure control in a registry of clinical practice, PINNACLE-BRAZIL REGISTRY. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Abstract
Introduction
The prevalence of hypertension is estimated to be nearly 50% among Brazilian adults. Achieving an adequate control of this CVD risk factor is challenging but truly relevant on a public health perspective, as this is the top-ranking cause of all deaths globally.
Purpose
We aimed to describe crude and simple metrics of blood pressure management (including its control), as based on current guideline-derived recommendations, after one year of the clinical practice registry
Methods
Patients with documented Hypertension were included by using electronic case report form based on the ACC PINNACLE Registry. The registry has been enrolling patients from general practitioners and specialists. The main goal of the PINNACLE program is to improve the quality of care in “real world” clinical practice. Patients data were evaluated after 01 year of follow-up on regular clinical appointments and the differences on clinical practice were evaluated
Results
Currently, PINNACLE-Brazil has enrolled 7598 patients, with 87% of diagnosed hypertension. Percentage of patients with a diagnosis of hypertension who had a blood pressure measurement <140/90 mmHg was 47.9% (baseline) and 57.3% (follow-up). Percentage of patients who had a blood pressure <140/90 mm Hg, or who had a blood pressure ≥140/90 mm Hg and were prescribed ≥2 antihypertensive medications were 67.1% on baseline and 71.2% after 1 year.
Conclusion
The preliminary data of PINNACLE Registry in Brazil shows that a significant proportion of hypertensive patients (nearly half) have not presented with adequate control of blood pressure levels and, moreover, a large proportion have not been treated with recommended combination of 02 or more antihypertensive medications to reach targeted BP levels the quality of care was improving after 01 year of registry.
Acknowledgement/Funding
ACC Foundation
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Affiliation(s)
- A Avezum
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | | | - G B F Oliveira
- Institute Dante Pazzanese of Cardiology, Sao Paulo, Brazil
| | - I M Pinto
- Institute Dante Pazzanese of Cardiology, Sao Paulo, Brazil
| | - A R Rombaldi
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - H A R Fonseca
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - J I Bocchese
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - G Saback
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - P R C Taborga
- Clinica de Especialidades GLOBALMED, Sao PAulo, Brazil
| | - T O Silva
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - R N Campoa
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - M H B Ferreira
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - F Savioli Neto
- Institute Dante Pazzanese of Cardiology, Sao Paulo, Brazil
| | - C C Magalhaes
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - J F K Saraiva
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
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Saraiva JFK, Cordeiro Mattos A, Saraiva GBF, Pinto IM, Rombaldi AR, Kato NH, Gomes Da Silva LF, Minelli C, Carvalho ITN, Dantas JMM, De Souza Filho JM, Figuinha FCR, Segre CAW, Fonseca HAR, Avezum A. P6444Cardiovascular secondary prevention setting and lipid controlu, update data from PINNACLE BRAZIL REGISTRY. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.1038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Lipid control is highly effective and improves clinical outcomes in coronary artery disease (CAD) patients, thus is one of the pillars of the cardiovascular secondary prevention.
Purpose
The aim of this preliminary analysis was to describe the lipid management in CAD patients in Brazil after one year of the clinical practice registry.
Methods
Patients with documented CAD were included by using electronic case report form based on the ACC PINNACLE Registry. The registry has been enrolling patients from general practitioners and specialists. Patients data were evaluated after 01 year of follow-up on regular clinical appointments and the differences on clinical practice were evaluated
Results
Currently, PINNACLE-Brazil enrolled individuals, with 2234 (29.4%) patients with CAD. Prescription of statin therapy was identified in 85.6% baseline and 78.3% follow-up. CAD patients with LDL-c <100 mg/dL were 47.3% baseline and 38.5% follow-up and at least one lipid profile assessment occurred in 60.9% baseline and 51.2% follow-up. CAD patients who have an LDL-c result <100 mg/dL, or >100 mg/dL with a documented plan to achieve LDL-c <100 mg/dL, were 48.1% (baseline) and 38.5% (follow-up).
Conclusion
The preliminary results of PINNACLE-Brazil show that, despite the relatively high prescription rate of statin therapy, LDL-c targeted level for CVD secondary prevention has not been achieved in the majority of patients after 01 year of follow-up. Nationwide knowledge translation initiatives are needed to improve the CVD burden in Brazil
Acknowledgement/Funding
ACC Foundation
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Affiliation(s)
- J F K Saraiva
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | | | - G B F Saraiva
- Institute Dante Pazzanese of Cardiology, Sao Paulo, Brazil
| | - I M Pinto
- Institute Dante Pazzanese of Cardiology, Sao Paulo, Brazil
| | - A R Rombaldi
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - N H Kato
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | | | - C Minelli
- Hospital Matão, Ribeirão Preto, Brazil
| | - I T N Carvalho
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - J M M Dantas
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | | | - F C R Figuinha
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - C A W Segre
- Instituto do Coracao FMUSP, Sao Paulo, Brazil
| | - H A R Fonseca
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
| | - A Avezum
- Cardiology Society of Sao Paulo (SOCESP), Sao Paulo, Brazil
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Saraiva F, Fonseca H, Pinto I, Baruzzi A, Stefanini E, Piscopo A, Avezum A. PO147 Infarct Project – Socesp: Design of a Protocol For Improvement of Pharmaco-Invasive Treatment In Acute Myocardial Infarction at Lower and Upper-Middle-Income Regions. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Avezum A, Cesar L, Mendes J, Timerman A, Saraiva D, Magalhães C, Saraiva F. PO385 Lipid Profile of a Young Student Population at São Paulo State City. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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6
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Piscopo A, Piscopo I, Piscopo I, Fonseca F, Fonseca F, Pinto I, Pinto I, Saraiva F, Saraiva F, Avezum A. PO377 A New Mannequin Made by Recyclable PET Bottle for Training Thoracic Compressions at Schools. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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7
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Saraiva J, Pinto I, Mattos A, Oliveira G, Magalhães C, Ferreira J, Chagas A, Wajngarten M, Serrano C, Rombaldi A, Saback G, Taborga P, Campoa R, Ferreira M, Avezum A. PO459 Lipid Control In the Cardiovascular Secondary Prevention Setting. Preliminary Data From Pinnacle-Brazil Registry. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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8
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Saraiva J, Mattos A, Oliveira G, Pinto I, Magalhães C, Ferreira J, Chagas A, Wajngarten M, Rombaldi A, Minelli C, Silva L, Dantas J, Carvalho I, Martin J, Avezum A. PO458 The Evidence-based Recommendations For Heart Failure (HF) Management - Preliminary Data From Pinnacle-Brazil Registry. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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9
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Avezum A, Mattos A, Oliveira G, Pinto I, Magalhães C, Ferreira J, Chagas A, Wajngarten M, Rombaldi A, Precoma D, Souza J, Kato N, Fernandes C, Figuinha F, Saraiva J. PO383 The Rates of Oral Anticoagulation Use in Patients With Atrial Fibrillation – Preliminary Data from Pinnacle-Brazil Registry. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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10
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Piscopo A, Piscopo I, Fonseca F, Pinto I, Saraiva F, Avezum A. PO378 Cardiopulmonary Resuscitation (CPR) Mass Training for High School Children in Public Schools in São Paulo - Brazil - Using PET Bottle Mannequins and Recycled Material. Glob Heart 2018. [DOI: 10.1016/j.gheart.2018.09.293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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11
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Kloosterman M, Conen D, Oldgren J, Wong J, Connolly SJ, Avezum A, Yusuf S, Ezekowitz MD, Wallentin L, Ntep-Gweth M, Barrett TW, Mcintyre WF, Parkash R, Van Gelder IC, Healey JS. 47Characteristics and outcomes of atrial fibrillation in patients without conventional risk factors: A RE-LY AF registry analysis. Europace 2018. [DOI: 10.1093/europace/euy015.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- M Kloosterman
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, Netherlands
| | - D Conen
- Population Health Research Institute, Hamilton, Canada
| | - J Oldgren
- Uppsala Clinical Research Center, Uppsala, Sweden
| | - J Wong
- Population Health Research Institute, Hamilton, Canada
| | - S J Connolly
- Population Health Research Institute, Hamilton, Canada
| | - A Avezum
- Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil
| | - S Yusuf
- Population Health Research Institute, Hamilton, Canada
| | - M D Ezekowitz
- Lankenau Hospital, Wynnewood, United States of America
| | - L Wallentin
- Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - T W Barrett
- Vanderbilt University, Nashville, United States of America
| | - W F Mcintyre
- Population Health Research Institute, Hamilton, Canada
| | - R Parkash
- QE II Health Sciences Center, Halifax, Canada
| | - I C Van Gelder
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, Netherlands
| | - J S Healey
- Population Health Research Institute, Hamilton, Canada
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Lamelas P, Mente A, Diaz R, Avezum A, Lanas F, Lopez Jaramillo P, Donell M, Rangarajan S, Teo K, Yusuf S. PT077 Association of Urinary Sodium Excretion With Blood Pressure and Cardiovascular Clinical Events in 17,033 Latin Americans. Glob Heart 2016. [DOI: 10.1016/j.gheart.2016.03.483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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13
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Rosengren A, Teo K, Rangarajan S, Kabali C, Khumalo I, Kutty VR, Gupta R, Yusuf R, Iqbal R, Ismail N, Altuntas Y, Kelishadi R, Diaz R, Avezum A, Chifamba J, Zatonska K, Wei L, Liao X, Lopez-Jaramillo P, Yusufali A, Seron P, Lear SA, Yusuf S. Psychosocial factors and obesity in 17 high-, middle- and low-income countries: the Prospective Urban Rural Epidemiologic study. Int J Obes (Lond) 2015; 39:1217-23. [PMID: 25869608 PMCID: PMC4766924 DOI: 10.1038/ijo.2015.48] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 10/21/2014] [Accepted: 11/23/2014] [Indexed: 02/05/2023]
Abstract
Background/Objectives: Psychosocial stress has been proposed to contribute to obesity, particularly abdominal, or central obesity, through chronic activation of the neuroendocrine systems. However, these putative relationships are complex and dependent on country and cultural context. We investigated the association between psychosocial factors and general and abdominal obesity in the Prospective Urban Rural Epidemiologic study. Subjects/Methods: This observational, cross-sectional study enrolled 151 966 individuals aged 35–70 years from 628 urban and rural communities in 17 high-, middle- and low-income countries. Data were collected for 125 290 individuals regarding education, anthropometrics, hypertension/diabetes, tobacco/alcohol use, diet and psychosocial factors (self-perceived stress and depression). Results: After standardization for age, sex, country income and urban/rural location, the proportion with obesity (body mass index ⩾30 kg m−2) increased from 15.7% in 40 831 individuals with no stress to 20.5% in 7720 individuals with permanent stress, with corresponding proportions for ethnicity- and sex-specific central obesity of 48.6% and 53.5%, respectively (P<0.0001 for both). Associations between stress and hypertension/diabetes tended to be inverse. Estimating the total effect of permanent stress with age, sex, physical activity, education and region as confounders, no relationship between stress and obesity persisted (adjusted prevalence ratio (PR) for obesity 1.04 (95% confidence interval: 0.99–1.10)). There was no relationship between ethnicity- and sex-specific central obesity (adjusted PR 1.00 (0.97–1.02)). Stratification by region yielded inconsistent associations. Depression was weakly but independently linked to obesity (PR 1.08 (1.04–1.12)), and very marginally to abdominal obesity (PR 1.01 (1.00–1.03)). Conclusions: Although individuals with permanent stress tended to be slightly more obese, there was no overall independent effect and no evidence that abdominal obesity or its consequences (hypertension, diabetes) increased with higher levels of stress or depression. This study does not support a causal link between psychosocial factors and abdominal obesity.
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Affiliation(s)
- A Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - K Teo
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - S Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - C Kabali
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - I Khumalo
- North-West University, Optentia Research Programme, Faculty of Humanities, Vanderbilpark, South Africa
| | - V R Kutty
- Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - R Gupta
- Fortis Escorts Hospital, JLN Marg, Jaipur, Rajasthan, India
| | - R Yusuf
- Independent University Bangladesh, Dhaka, Bangladesh
| | - R Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - N Ismail
- Department of Community Health, Universiti Kebangsaan, Kuala Lumpur, Malaysia
| | - Y Altuntas
- SB Pediatric Endocrinology and Metabolism, Training and Research Hospital, Istanbul, Turkey
| | - R Kelishadi
- Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - R Diaz
- Estudios Clinicos Latinoamerica ECLA, Rosario, Santa Fe, Argentina
| | - A Avezum
- Dante Pazzanese Institute of cardiology, Sao Paulo, Brazil
| | - J Chifamba
- Physiology Department, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - K Zatonska
- Department of Social Medicine, Medical University of Wrocław, Wrocław, Poland
| | - L Wei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - X Liao
- Sichuan University West China Hospital, Chengdu, Sichuan Province, China
| | - P Lopez-Jaramillo
- Fundacion Oftalmologica de Santander (FOSCAL) and Medical School, Universidad de Santander (UDES), Santander, Colombia
| | | | - P Seron
- Universidad de La Frontera, Temuco, Chile
| | - S A Lear
- Faculty of Health Sciences, Simon Fraser University and Division of Cardiology, Providence Health Care, Vancouver, BC, Canada
| | - S Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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Nicolau JC, Timerman A, Marin-Neto JA, Piegas LS, Barbosa CJDG, Franci A, Avezum A, Carvalho ACC, Markman Filho B, Polanczyk CA, Rochitte CE, Serrano Júnior CV, Precoma DB, Silva Junior DG, Albuquerque DC, Stefanini E, Knobel E, Jatene FB, Feres F, Morcerf FAP, Ganem F, Lima Filho FA, Feitosa Filho GS, Ferreira JFM, Meneghetti JC, Saraiva JFK, Silva LS, Maia LN, Baracioli LM, Lisboa LAF, Dallan LAO, Bodanese LC, Andrade MD, Oliveira Júnior M, Dutra OP, Coelho OR, Leães PE, Albuquerque PF, Lemos P, Kalil R, Costa RVC, Esporcate R, Marino RL, Botellho RV, Meneghelo RS, Sprovieri SR, Timerman S, Mathias Júnior W. [Guidelines of Sociedade Brasileira de Cardiologia for Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction (II Edition, 2007) 2013-2014 Update]. Arq Bras Cardiol 2014; 102:1-61. [PMID: 24862929 DOI: 10.5935/abc.2014s001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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Avezum A, Lopes RD, Schulte PJ, Lanas F, Hanna M, Pais P, Erol C, Diaz R, Granger CB, Alexander JH. Apixaban versus warfarin in patients with atrial fibrillation and valvular heart disease: findings from the ARISTOTLE study. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht310.4384] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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16
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Gerstein HC, Mohan V, Avezum A, Bergenstal RM, Chiasson JL, Garrido M, MacKinnon I, Rao PV, Zinman B, Jung H, Joldersma L, Bosch J, Yusuf S. Long-term effect of rosiglitazone and/or ramipril on the incidence of diabetes. Diabetologia 2011; 54:487-95. [PMID: 21116607 DOI: 10.1007/s00125-010-1985-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 10/22/2010] [Indexed: 02/07/2023]
Abstract
AIMS/HYPOTHESIS The Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) trial reported that 3 years of therapy with rosiglitazone reduced the primary outcome of diabetes or death by 60%. Here we investigated whether an effect on diabetes prevention persists more than 1.5 years after therapy has been discontinued. METHODS The DREAM On passive follow-up study was conducted at 49 of the 191 DREAM sites. Consenting participants were invited to have a repeat OGTT 1-2 years after active therapy ended. A diagnosis of diabetes at that time was based on either a fasting or 2 h plasma glucose level of ≥7.0 mmol/l or ≥11.1 mmol/l, respectively, or a confirmed diagnosis by a non-study physician. Regression to normoglycaemia was defined as a fasting and 2 h plasma glucose level of <6.1 mmol/l and <7.8 mmol/l, respectively. RESULTS After a median of 1.6 years after the end of the trial and 4.3 years after randomisation, rosiglitazone participants had a 39% lower incidence of the primary outcome (hazard ratio [HR] 0.61, 95% CI 0.53-0.70; p < 0.0001) and 17% more regression to normoglycaemia (95% CI 1.01-1.34; p = 0.034). When the analysis was restricted to the passive follow-up period, a similar incidence of both the primary outcome and regression was observed in people from both treatment groups (HR 1.00, 95% CI 0.81-1.24 and HR 1.14, 95% CI 0.97-1.32, respectively). Similar effects were noted when new diabetes was analysed separately from death. Ramipril did not have any significant long-term effect. CONCLUSIONS/INTERPRETATION Time-limited exposure to rosiglitazone reduces the longer term incidence of diabetes by delaying but not reversing the underlying disease process.
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McGorrian C, Yusuf S, Islam S, Jung H, Rangarajan S, Avezum A, Prabhakaran D, Almahmeed W, Rumboldt Z, Budaj A, Dans AL, Gerstein HC, Teo K, Anand SS. Estimating modifiable coronary heart disease risk in multiple regions of the world: the INTERHEART Modifiable Risk Score. Eur Heart J 2010; 32:581-9. [DOI: 10.1093/eurheartj/ehq448] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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18
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Chew DP, Anderson FA, Avezum A, Eagle KA, FitzGerald G, Gore JM, Dedrick R, Brieger D. The Authors' reply. Heart 2010. [DOI: 10.1136/hrt.2010.207936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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19
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Chew DP, Anderson FA, Avezum A, Eagle KA, FitzGerald G, Gore JM, Dedrick R, Brieger D. Six-month survival benefits associated with clinical guideline recommendations in acute coronary syndromes. Heart 2010; 96:1201-6. [PMID: 20530127 DOI: 10.1136/hrt.2009.184853] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIMS The authors sought to define which guideline-advocated therapies are associated with the greatest benefit with respect to 6-month survival in patients hospitalised with an acute coronary syndrome (ACS). METHODS AND RESULTS The authors conducted a nested case-control study of ACS patients within the Global Registry of Acute Coronary Events cohort between April 1999 and December 2007. The cases were ACS patients who survived to discharge but died within 6 months. The controls were patients who survived to 6 months, matched for ACS diagnosis, age and the Global Registry of Acute Coronary Events risk score. Rates of use of evidence-based medications and coronary interventions (angiography, percutaneous coronary intervention and coronary artery bypass graft surgery) were compared. Logistic regression including matched variables was used, and the attributable mortality from incomplete application of each therapy was calculated. A total of 1716 cases and 3432 controls were identified. Coronary artery bypass graft surgery and percutaneous coronary intervention were associated with the greatest 6-month survival benefit (OR for death 0.60 (95% CI 0.39 to 0.90) and 0.57 (0.48 to 0.72), respectively). Statins and clopidogrel provided the greatest independent pharmacologic benefit (ORs for death 0.85 (0.73 to 0.99) and 0.84 (0.72 to 0.99)) with lesser effects seen with other pharmacotherapies. CONCLUSIONS A diminishing benefit associated with each additional ACS therapy is evident. These data may provide a rational basis for selecting between therapeutic options when compliance or cost is an issue.
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Affiliation(s)
- D P Chew
- Department of Cardiovascular Medicine, Flinders University, Adelaide, South Australia, Australia.
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O’Donnell M, Xavier D, Diener C, Sacco R, Lisheng L, Zhang H, Pias P, Truelsen T, Chin S, Rangarajan S, DeVilliers L, Damasceno A, Mondo C, Lanas F, Avezum A, Diaz R, Varigos J, Hankey G, Teal P, Kapral M, Ryglewicz D, Czlonkowska A, Skowronska M, Lopez-Jaramillo P, Dans T, Langhorne P, Yusuf S. Rationale and Design of INTERSTROKE: A Global Case-Control Study of Risk Factors for Stroke. Neuroepidemiology 2010; 35:36-44. [DOI: 10.1159/000306058] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 01/08/2010] [Indexed: 11/19/2022] Open
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Rosengren A, Subramanian SV, Islam S, Chow CK, Avezum A, Kazmi K, Sliwa K, Zubaid M, Rangarajan S, Yusuf S. Education and risk for acute myocardial infarction in 52 high, middle and low-income countries: INTERHEART case-control study. Heart 2009; 95:2014-22. [PMID: 19822574 DOI: 10.1136/hrt.2009.182436] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the effect of education and other measures of socioeconomic status (SES) on risk of acute myocardial infarction (AMI) in patients and controls from countries with diverse economic circumstances (high, middle, and low income countries). DESIGN Case-control study. SETTING 52 countries from all inhabited regions of the world. PARTICIPANTS 12242 cases and 14622 controls. MAIN OUTCOME MEASURES First non-fatal AMI. RESULTS SES was measured using education, family income, possessions in the household and occupation. Low levels of education (< or =8 years) were more common in cases compared to controls (45.0% and 38.1%; p<0.0001). The odds ratio (OR) for low education adjusted for age, sex and region was 1.56 (95% confidence interval 1.47 to 1.66). After further adjustment for psychosocial, lifestyle, other factors and mutually for other socioeconomic factors, the OR associated with education < or =8 years was 1.31 (1.20 to 1.44) (p<0.0001). Modifiable lifestyle factors (smoking, exercise, consumption of vegetables and fruits, alcohol and abdominal obesity) explained about half of the socioeconomic gradient. Family income, numbers of possessions and non-professional occupation were only weakly or not at all independently related to AMI. In high-income countries (World Bank Classification), the risk factor adjusted OR associated with low education was 1.61 (1.33 to 1.94), whereas it was substantially lower in low-income and middle-income countries: 1.25 (1.14 to 1.37) (p for interaction 0.045). CONCLUSION Of the SES measures we studied, low education was the marker most consistently associated with increased risk for AMI globally, most markedly in high-income countries.
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Affiliation(s)
- A Rosengren
- Institute of Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital/Ostra, SE-416 85 Goteborg, Sweden.
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Brieger D, FitzGerald G, Fox KAA, Eagle KA, Budaj A, Avezum A, Costa B, Granger CB, Anderson FA, Steg PG. The authors' reply:. Heart 2009. [DOI: 10.1136/hrt.2009.171959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Avezum A, Maia LN, Marcílio CS, Mattos AJC, Marin Neto JA, Bertolami MC, Nobre F. A 029 Comparison between the Population Knowledge about Risk Factors of Cardiovascular and Risk Absolute Attributed to the Population – PrevenAção and INTERHEART. ATHEROSCLEROSIS SUPP 2009. [DOI: 10.1016/s1567-5688(09)71692-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mattos AJC, Avezum A, Marcílio CS, Rangarajan S, Yusuf S. A 025 Prevalence of Cardiovascular Disease, Alcohol Consumption, Tobacco and Exhibition to the Tobacco. PURE Study. ATHEROSCLEROSIS SUPP 2009. [DOI: 10.1016/s1567-5688(09)71688-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Marcílio CS, Avezum A, Mattos AJC, Delghan M, Yusuf S. A 026 Healthy Food and Markers of Risk Cardiovascular between Urban and Rural Populations. PURE Study. ATHEROSCLEROSIS SUPP 2009. [DOI: 10.1016/s1567-5688(09)71689-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Brieger D, Fox KAA, Fitzgerald G, Eagle KA, Budaj A, Avezum A, Granger CB, Costa B, Anderson FA, Steg PG. Predicting freedom from clinical events in non-ST-elevation acute coronary syndromes: the Global Registry of Acute Coronary Events. Heart 2009; 95:888-94. [PMID: 19246481 DOI: 10.1136/hrt.2008.153387] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To identify patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) with a low likelihood of any adverse in-hospital event. DESIGN, SETTING AND PATIENTS Data were analysed from 24 097 patients with NSTEMI or unstable angina included in the Global Registry of Acute Coronary Events (January 2001 to September 2007). MAIN OUTCOME MEASURES In-hospital events were myocardial infarction, arrhythmia, congestive heart failure or shock, major bleeding, stroke or death. Two-thirds of the patients were randomly chosen for model development and the remainder for model validation. Multiple logistic regression identified predictors of freedom from an in-hospital event, and a Freedom-from-Event score was developed. RESULTS Of the 16 127 patients in the model development group, 19.1% experienced an in-hospital adverse event. Fifteen factors independently predicted freedom from an adverse event: younger age; lower Killip class; unstable angina presentation; no hypotension; no ST deviation; no cardiac arrest at presentation; normal creatinine; decreased pulse rate; no hospital transfer; no history of diabetes, heart failure, peripheral arterial disease, or atrial fibrillation; prehospital use of statins, and no chronic warfarin. In the validation group, 18.6% experienced an adverse event. The model discriminated well between patients experiencing an in-hospital event and those who did not in both derivation and validation groups (c-statistic = 0.77 in both). Patients in the three lowest risk deciles had a very low in-hospital mortality (<0.5%) and an uncomplicated clinical course (>93% event-free in hospital). The model also predicted freedom from postdischarge events (death, myocardial infarction, stroke; c-statistic = 0.77). CONCLUSIONS The GRACE Freedom-from-Event score can predict the in-hospital course of NSTE-ACS, and identifies up to 30% of the admitted population at low risk of death or any adverse in-hospital event.
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Affiliation(s)
- D Brieger
- Concord Repatriation General Hospital, Coronary Care Unit, Concord, NSW Australia.
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Avezum A, Braga J, Santos I, Guimarães HP, Marin-Neto JA, Piegas LS. Cardiovascular disease in South America: current status and opportunities for prevention. Heart 2009; 95:1475-82. [PMID: 19224906 DOI: 10.1136/hrt.2008.156331] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
South America comprises widely different environments consisting of many complex and heterogeneous ethnicities, societies and cultures. During recent decades conspicuous advances in human and societal development have been made. South America now faces three major demographic shifts: population growth; urbanisation (almost 90% of the population live in urban areas) and ageing. Recently, an epidemiological transition has been seen. Urbanisation has brought unfavourable and prominent changes, such as increased smoking rates, stress, lack of physical activity and poor diets (more fat and calories). Consequently, owing to the interaction between environment and genetic susceptibility, the modifications induced by urbanisation have resulted in enhancement of the cardiovascular risk factors and cardiovascular disease (CVD). This situation is responsible for the burden of CVD in South America, requiring effective action towards better detection and control of cardiovascular risk factors aimed at reducing the burden of disease in the region, which tends to be higher and increasingly serious.
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Affiliation(s)
- A Avezum
- Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, SP, Brazil.
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Jolly SS, Pogue J, Haladyn K, Peters RJ, Fox KA, Avezum A, Gersh BJ, Rupprecht HJ, Yusuf S, Mehta SR. Effects of aspirin dose on ischaemic events and bleeding after percutaneous coronary intervention: insights from the PCI-CURE study. Eur Heart J 2008; 30:900-7. [DOI: 10.1093/eurheartj/ehn417] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Connolly S, Yusuf S, Budaj A, Camm J, Chrolavicius S, Commerford PJ, Flather M, Fox KAA, Hart R, Hohnloser S, Joyner C, Pfeffer M, Anand I, Arthur H, Avezum A, Bethala-Sithya M, Blumenthal M, Ceremuzynski L, De Caterina R, Diaz R, Flaker G, Frangin G, Franzosi MG, Gaudin C, Golitsyn S, Goldhaber S, Granger C, Halon D, Hermosillo A, Hunt D, Jansky P, Karatzas N, Keltai M, Lanas F, Lau CP, Le Heuzey JY, Lewis BS, Morais J, Morillo C, Oto A, Paolasso E, Peters RJ, Pfisterer M, Piegas L, Pipillis T, Proste C, Sitkei E, Swedberg K, Synhorst D, Talajic M, Trégou V, Valentin V, van Mieghem W, Weintraub W, Varigos J. Rationale and design of ACTIVE: the atrial fibrillation clopidogrel trial with irbesartan for prevention of vascular events. Am Heart J 2006; 151:1187-93. [PMID: 16781218 DOI: 10.1016/j.ahj.2005.06.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2005] [Accepted: 06/15/2005] [Indexed: 01/13/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most frequently occurring cardiac arrhythmia with often serious clinical consequences. Many patients have contraindications to anticoagulation, and it is often underused in clinical practice. The addition of clopidogrel to aspirin (ASA) has been shown to reduce vascular events in a number of high-risk populations. Irbesartan is an angiotensin receptor-blocking agent that reduces blood pressure and has other vascular protective effects. METHODS AND RESULTS ACTIVE W is a noninferiority trial of clopidogrel plus ASA versus oral anticoagulation in patients with AF and at least 1 risk factor for stroke. ACTIVE A is a double-blind, placebo-controlled trial of clopidogrel in patients with AF and with at least 1 risk factor for stroke who receive ASA because they have a contraindication for oral anticoagulation or because they are unwilling to take an oral anticoagulant. ACTIVE I is a partial factorial, double-blind, placebo-controlled trial of irbesartan in patients participating in ACTIVE A or ACTIVE W. The primary outcomes of these studies are composites of vascular events. A total of 14000 patients will be enrolled in these trials. CONCLUSIONS ACTIVE is the largest trial yet conducted in AF. Its results will lead to a new understanding of the role of combined antiplatelet therapy and the role of blood pressure lowering with an angiotensin II receptor blocker in patients with AF.
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Devlin G, Anderson FA, Heald S, López-Sendón J, Avezum A, Elliott J, Dabbous OH, Brieger D. Management and outcomes of lower risk patients presenting with acute coronary syndromes in a multinational observational registry. Heart 2005; 91:1394-9. [PMID: 15761048 PMCID: PMC1769180 DOI: 10.1136/hrt.2004.054007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To document patterns of risk stratification, management practices, and outcomes among patients with acute coronary syndromes (ACS) presenting without high risk features. PATIENTS The study was based on 11,885 consecutive patients presenting with non-ST segment elevation ACS enrolled in GRACE (global registry of acute coronary events). Patients without dynamic ST segment changes, positive troponin (or other cardiac markers), or haemodynamic or arrhythmic instability were defined as being at lower risk. MAIN OUTCOME MEASURES Management and outcomes were compared with high risk presentations. RESULTS Of 11,885 patients presenting with unstable angina or non-ST segment elevation myocardial infarction, 4252 (36%) were regarded as being at lower risk. Functional testing for risk stratification was performed in 1163 of 4207 (28%) lower risk and 1531 of 7521 (20%) high risk patients (p < 0.0001). Coronary angiography was performed in 1930 of 4190 (46%) and 3860 of 7544 (51%), and echocardiography in 1692 of 4190 (40%) and 4348 of 7533 (58%) of lower risk and high risk patients, respectively (p < 0.0001 for both). Over one third of patients did not undergo further risk assessment with angiography or functional testing (2746 of 7437 (37%) high risk, 1499 of 4148 (36%) lower risk, not significant). Death occurring in hospital was more likely in the high risk cohort (41 of 4227 (1.0%) lower risk v 215 of 7586 (2.8%) high risk, p < 0.0001), whereas rates of recurrent angina during admission and readmission were similar in both groups (1354 of 4231 (32%) high risk, 2313 of 7587 (31%) lower risk, not significant). In the six months after discharge, death or myocardial infarction occurred in 79 of 3223 (2.5%) lower risk patients and 302 of 5451 (5.5%) high risk patients (p < 0.0001). CONCLUSIONS Globally, further risk stratification after ACS presentation is suboptimal, regardless of presenting characteristics. Although in-hospital death and myocardial infarction are uncommon, recurrent ischaemia is encountered often in both groups. It remains to be seen whether better outcomes may be achieved with wider application of risk stratification and appropriately directed management strategies.
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Affiliation(s)
- G Devlin
- Waikato Hospital, Hamilton, New Zealand.
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Santopinto JJ, Fox KAA, Goldberg RJ, Budaj A, Piñero G, Avezum A, Gulba D, Esteban J, Gore JM, Johnson J, Gurfinkel EP. Creatinine clearance and adverse hospital outcomes in patients with acute coronary syndromes: findings from the global registry of acute coronary events (GRACE). Heart 2003; 89:1003-8. [PMID: 12923009 PMCID: PMC1767853 DOI: 10.1136/heart.89.9.1003] [Citation(s) in RCA: 189] [Impact Index Per Article: 9.0] [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] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To determine whether creatinine clearance at the time of hospital admission is an independent predictor of hospital mortality and adverse outcomes in patients with acute coronary syndromes (ACS). DESIGN A prospective multicentre observational study, GRACE (global registry of acute coronary events), of patients with the full spectrum of ACS. SETTING Ninety four hospitals of varying size and capability in 14 countries across four continents. PATIENTS 11 774 patients hospitalised with ACS, including ST and non-ST segment elevation acute myocardial infarction and unstable angina. MAIN OUTCOME MEASURES Demographic and clinical characteristics, medication use, and in-hospital outcomes were compared for patients with creatinine clearance rates of > 60 ml/min (normal and minimally impaired renal function), 30-60 ml/min (moderate renal dysfunction), and < 30 ml/min (severe renal dysfunction). RESULTS Patients with moderate or severe renal dysfunction were older, were more likely to be women, and presented to participating hospitals with more comorbidities than those with normal or minimally impaired renal function. In comparison with patients with normal or minimally impaired renal function, patients with moderate renal dysfunction were twice as likely to die (odds ratio 2.09, 95% confidence interval 1.55 to 2.81) and those with severe renal dysfunction almost four times more likely to die (odds ratio 3.71, 95% confidence interval 2.57 to 5.37) after adjustment for other potentially confounding variables. The risk of major bleeding episodes increased as renal function worsened. CONCLUSION In patients with ACS, creatinine clearance is an important independent predictor of hospital death and major bleeding. These data reinforce the importance of increased surveillance efforts and use of targeted intervention strategies in patients with acute coronary disease complicated by renal dysfunction.
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Affiliation(s)
- J J Santopinto
- Intensive Care Unit, Leonidas Lucero's Hospital, Bahia Blanca, Argentina.
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Agnelli G, Cannon CP, Van De Werf F, Avezum A, Montalescot G, Lankes W, Kennelly BM, Mazurek T, Kasper RS, Brieger D. Combination therapy with low-molecular-weight heparin and glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: insights from the Global Registry of Acute Coronary Events (GRACE). J Thromb Haemost 2003. [DOI: 10.1111/j.1538-7836.2003.tb04648.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fox KAA, Goodman SG, Klein W, Brieger D, Steg PG, Dabbous O, Avezum A. Management of acute coronary syndromes. Variations in practice and outcome; findings from the Global Registry of Acute Coronary Events (GRACE). Eur Heart J 2002; 23:1177-89. [PMID: 12127920 DOI: 10.1053/euhj.2001.3081] [Citation(s) in RCA: 340] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
AIMS Despite advances in the treatment of acute coronary syndromes based on randomized trial data and published guidelines, the extent to which such treatments are applied in practice remains uncertain. Data from clinical trials derive from selected geographical areas and in highly selected populations of patients, and hence may not reflect the overall population. The aim of the study was to investigate variations in hospital management and outcome using unselected data collected in the prospective Global Registry of Acute Coronary Events (GRACE). METHODS AND RESULTS The 95 hospitals in GRACE were organized into 18 population-based clusters in 14 countries. Information was recorded about patient management and outcome during hospitalization and after discharge. Data on treatments administered were analysed by baseline condition, hospital type, by the presence or absence of a catheterization laboratory, and by geographical region. Of 11543 patients, 44% had an admission diagnosis of unstable angina, 36% presented with myocardial infarction, 9% were admitted to rule out a myocardial infarction, 7% had chest pain and 4% were hospitalized for 'other cardiac' and 'non-cardiac' diagnoses. Of the total GRACE population 38% had a final diagnosis of unstable angina, 30% ST-segment elevation myocardial infarction, 25% non-ST-segment elevation myocardial infarction, and 7% of 'other cardiac' and 'non-cardiac' final diagnoses. The event rates for hospital death or reinfarction were six and 2% for non-ST-segment elevation myocardial infarction, seven and 3% for ST-segment elevation myocardial infarction, and 3% hospital death for unstable angina. The use of aspirin was similar across all hospital types and geographical regions. In contrast, the use of percutaneous coronary intervention and glycoprotein IIb/IIIa inhibitors was higher (P<0.0001) in teaching hospitals and hospitals with catheterization laboratories and was also higher in the United States. At discharge a higher percentage (P<0.0001) of patients received angiotensin-converting enzyme inhibitors in hospitals without catheterization laboratories. The use of statins was lower in non-teaching hospitals and in centres without a catheterization laboratory. CONCLUSIONS The GRACE study reveals substantial differences in the management of patients based on hospital type and geographical location. Further analyses will determine whether such variations translate into differences in longer term outcomes. GRACE provides a multinational reference for the implementation of therapies of proven efficacy.
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Affiliation(s)
- K A A Fox
- The Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
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Silva E, Pedro M, Sogayar A, Mohovic T, Janiszewski M, Silva C, Abe T, Bento A, Janot G, Souza E, Rocha P, Avezum A, Andrade J, Matos J, Vieira P, Knobel E. Crit Care 2002; 6:P236. [DOI: 10.1186/cc1703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Rochitte CE, Kaneko R, Knobel M, Avezum A, Souza JAM, Brito FS, Knobel E. Door-to-balloon time in patients undergoing primary angioplasty and therapeutic decision on acute myocardial infarction. Crit Care 2001. [PMCID: PMC3226131 DOI: 10.1186/cc1334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Avezum A, Cavalcanti AB, Sousa AG, Farsky PS, Knobel M. [Adjuvant therapy in acute myocardial infarction: evidence based recommendations]. Rev Assoc Med Bras (1992) 2000; 46:363-8. [PMID: 11175574 DOI: 10.1590/s0104-42302000000400038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- A Avezum
- Departamento do Cardiologia do Instituto Dante Pazzonese/Hospital Albert Einstein, São Paulo, SP
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McKelvie RS, Yusuf S, Pericak D, Avezum A, Burns RJ, Probstfield J, Tsuyuki RT, White M, Rouleau J, Latini R, Maggioni A, Young J, Pogue J. Comparison of candesartan, enalapril, and their combination in congestive heart failure: randomized evaluation of strategies for left ventricular dysfunction (RESOLVD) pilot study. The RESOLVD Pilot Study Investigators. Circulation 1999; 100:1056-64. [PMID: 10477530 DOI: 10.1161/01.cir.100.10.1056] [Citation(s) in RCA: 613] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND We investigated the effects of candesartan (an angiotensin II antagonist) alone, enalapril alone, and their combination on exercise tolerance, ventricular function, quality of life (QOL), neurohormone levels, and tolerability in congestive heart failure (CHF). METHODS AND RESULTS Seven hundred sixty-eight patients in New York Heart Association functional class (NYHA-FC) II to IV with ejection fraction (EF) <0.40 and a 6-minute walk distance (6MWD) <500 m received either candesartan (4, 8, or 16 mg), candesartan (4 or 8 mg) plus 20 mg of enalapril, or 20 mg of enalapril for 43 weeks. There were no differences among groups with regard to 6MWD, NYHA-FC, or QOL. EF increased (P=NS) more with candesartan-plus-enalapril therapy (0.025+/-0.004) than with candesartan alone (0.015+/-0.004) or enalapril alone(0.015+/-0.005). End-diastolic (EDV) and end-systolic (ESV) volumes increased less with combination therapy (EDV 8+/-4 mL; ESV 1+/-4 mL; P<0.01) than with candesartan alone (EDV 27+/-4 mL; ESV 18+/-3 mL) or enalapril alone (EDV 23+/-7 mL; ESV 14+/-6 mL). Blood pressure decreased with combination therapy (6+/-1/4+/-1 mm Hg) compared with candesartan or enalapril alone (P<0.05). Aldosterone decreased (P<0.05) with combination therapy (23.2+/-5.3 pg/mL) at 17 but not 43 weeks compared with candesartan (0.7+/-7.8 pg/mL) or enalapril (-0.8+/-11. 3 pg/mL). Brain natriuretic peptide decreased with combination therapy (5.8+/-2.7 pmol/L; P<0.01) compared with candesartan (4. 4+/-3.8 pmol/L) and enalapril alone (4.0+/-5.0 pmol/L). CONCLUSIONS Candesartan alone was as effective, safe, and tolerable as enalapril. The combination of candesartan and enalapril was more beneficial for preventing left ventricular remodeling than either candesartan or enalapril alone.
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Affiliation(s)
- R S McKelvie
- Hamilton Health Sciences Corporation-General Division, and McMaster University, Hamilton, Ontario, Canada.
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Piegas LS, Flather M, Pogue J, Hunt D, Varigos J, Avezum A, Anderson J, Keltai M, Budaj A, Fox K, Ceremuzynski L, Yusuf S. The Organization to Assess Strategies for Ischemic Syndromes (OASIS) registry in patients with unstable angina. Am J Cardiol 1999; 84:7M-12M. [PMID: 10505537 DOI: 10.1016/s0002-9149(99)00551-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Clinical approaches to the prevention of the potentially catastrophic consequences of coronary ischemic phenomena such as unstable angina and suspected non-Q-wave myocardial infarction (MI) differ across the world. In addition to prevailing physician beliefs in different societies, the level of access to catheterization laboratories largely determines whether an interventionist or conservative strategy is adopted. The Organization to Assess Strategies for Ischemic Syndromes (OASIS)--a prospective registry of approximately 8,000 patients with acute myocardial ischemia with no ST elevation, treated in 95 hospitals across 6 countries--furnished a unique window into regional differences in clinical management and the frequency and timing of invasive procedures (i.e., angiography, percutaneous transluminal coronary angioplasty [PTCA], and coronary artery bypass graft [CABG] surgery), as well as the outcomes of these trends. At 6 months after symptom onset, patients in the United States and Brazil, where the catheterization laboratory facilities are more accessible, underwent significantly (p <0.001) more angiography (69.4%), PTCA (23.6%), and CABG (25.2%) than in Canada and Australia, where the corresponding rates were 48.4%, 17.0%, and 16.8% (p <0.001), respectively; and in Hungary and Poland, where the respective rates were 23.5%, 5.8%, and 10.9% (p <0.001). This relatively aggressive approach led at 6 months to a more substantial decrease in refractory angina in the United States and Brazil than in Canada and Australia (20.4% vs 13.9%; p <0.001), but no improvement in rates of cardiovascular mortality and MI (10.5% versus 10.5%; p = 0.36). There was a significant (p < or = 0.012) increase in stroke, (1.9% vs 1.3%; p = 0.010) and major bleeding (1.9% vs 1.1%; p = 0.009) events. Furthermore, an inverse correlation emerged between baseline cardiovascular risk status and frequency of angiography and PTCA interventions preferentially for low-risk compared with high-risk patients. In concert with findings from other recent randomized trials, the OASIS Registry data suggest that although there are fewer hospital readmissions for unstable angina, there is a trend toward increased rates of death, MI, and stroke. These data urge a cautious approach to the use of invasive procedures in patients with unstable angina unless future trials demonstrate a clear benefit with an aggressive approach.
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Affiliation(s)
- L S Piegas
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brazil
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Avezum A. Systematic overviews and meta-analyses in cardiology. Evidence-based cardiology. VIII. Arq Bras Cardiol 1999; 72:423-30. [PMID: 10531687 DOI: 10.1590/s0066-782x1999000400003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- A Avezum
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
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Avezum A, Rossi Neto JM, Piegas L. Why do we need randomized and epidemiological studies on cardiovascular disease? Evidence-based cardiology VII. Arq Bras Cardiol 1999; 72:281-95. [PMID: 10513040 DOI: 10.1590/s0066-782x1999000300002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Over the last two decades the results of randomized clinical studies, which are powerful aids for correctly assessing therapeutical strategies, have consolidated cardiological practice. In addition, scientifically interesting hypotheses have been generated through the results of epidemiological studies. Properly conducted randomized studies without systematic errors and with statistical power adequate for demonstrating moderate and reasonable benefits in relevant clinical outcomes have provided reliable and strong results altering clinical practice, thus providing adequate treatment for patients with cardiovascular disease (CVD). The dissemination and use of evidence-based medicine in treating coronary artery disease (CAD), heart failure (HF), and in prevention will prevent hundreds of thousands of deaths annually in developed and developing countries. CVD is responsible for approximately 12 million deaths annually throughout the world, and approximately 60% of these deaths occur in developing countries. During recent years, an increase in mortality and morbidity rates due to CVD has occurred in developing countries. This increase is an indication that an epidemiological (demographic, economical, and health-related) transition is taking place in developing countries and this transition implies a global epidemic of CVD, which will require wide-ranging and globally effective strategies for prevention. The identification of conventional and emerging risk factors for CVD, as well as their management in high-risk individuals, has contributed to the decrease in the mortality rate due to CVD. Through a national collaboration, several multi-center and multinational randomized and epidemiological studies have been carried out throughout Brazil, thus contributing not only to a generalized scientific growth in different Brazilian hospitals but also to the consolidation of an increasingly evidence-based clinical practice.
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Affiliation(s)
- A Avezum
- Instituto Dante Pazzanese de Cardiologia, São Paulo
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Affiliation(s)
- A Avezum
- Instituto Dante Pazzanese de Cardiologia, São Paulo
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Yusuf S, Flather M, Pogue J, Hunt D, Varigos J, Piegas L, Avezum A, Anderson J, Keltai M, Budaj A, Fox K, Ceremuzynski L. Variations between countries in invasive cardiac procedures and outcomes in patients with suspected unstable angina or myocardial infarction without initial ST elevation. OASIS (Organisation to Assess Strategies for Ischaemic Syndromes) Registry Investigators. Lancet 1998; 352:507-14. [PMID: 9716054 DOI: 10.1016/s0140-6736(97)11162-x] [Citation(s) in RCA: 240] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are wide variations between countries in the use of invasive cardiac catheterisation and revascularisation procedures for patients with acute ischaemic syndromes. We studied the relation between rates of such procedures and rates of cardiovascular death, myocardial infarction, stroke, refractory angina, and major bleeding in a prospective, registry-based study in six countries with widely varying intervention rates. METHODS 7987 consecutive patients presenting with unstable angina or suspected myocardial infarction without ST-segment elevation were recruited prospectively from 95 hospitals in six countries and followed up for 6 months. FINDINGS The rates of all procedures were highest in patients in Brazil and the USA, intermediate in Canada and Australia, and lowest in Hungary and Poland. There were no significant differences in rates of cardiovascular death or myocardial infarction among these countries (4.7% overall [range 3.7-5.6] at 7 days; 11% overall [9-12] at 6 months). For the countries with the highest rates of invasive procedures (59%) versus the rest (21%) there was no difference in rate of cardiovascular death or myocardial infarction (adjusted odds ratio 0.88 at 7 days and 1.0 at 6 months). Rates of stroke were higher in Brazil and the USA than in the countries with lower intervention rates (adjusted odds ratio at 7 days 3.0, p=0.012; at 6 months 1.8, p=0.004) but rates of refractory angina at 7 days (0.7, p<0.001) and readmission for unstable angina at 6 months were lower (0.70, 0.63; both p<0.001). Comparison of results for hospitals without cardiac-catheterisation facilities and for those with such facilities gave adjusted odds ratios for cardiovascular death, myocardial infarction, or stroke at 6 months of 0.83 (10.6% vs 12.5%, p=0.05) and for refractory angina of 1.25 (19.3% vs 16.1%, p=0.09). INTERPRETATION Higher rates of invasive and revascularisation procedures were associated with lower rates of refractory angina or readmission for unstable angina, no apparent reduction in cardiovascular death or myocardial infarction, but with higher rates of stroke. Randomised trials should assess the relative impact of conservative and more aggressive approaches to invasive cardiac procedures and revascularisations in patients with unstable angina.
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Affiliation(s)
- S Yusuf
- McMaster University, Hamilton, Ontario, Canada.
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Avezum A, Tsuyuki RT, Pogue J, Yusuf S. Beta-blocker therapy for congestive heart failure: a systemic overview and critical appraisal of the published trials. Can J Cardiol 1998; 14:1045-53. [PMID: 9738164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To evaluate the effect of beta-blockers on mortality and morbidity, and to provide an appraisal of the reliability of the available data. DATA SOURCES MEDLINE search for trials of beta-blockers for congestive heart failure (CHF). STUDY SELECTION All randomized trials of beta-blockers versus placebo, or greater than one month's duration, in patients with CHF. Eighteen published trials involving 2986 patients were selected. DATA EXTRACTION Independently by two authors. DATA SYNTHESIS The Yusuf-Peto method for combining data was used. Data were available on mortality in 2841 patients (95%), on hospitalization for heart failure in 1514 (51%) and on heart transplantation in 2330 (79%). There was a lower rate of death in the active treatment group (131 of 1606) [8.2] versus 155 of 1235 [12.6%]; OR = 72; 99% CI 0.51 to 1.00), a lower rate of hospitalization for heart failure (137 of 756 [18.1%] versus 218 of 758 [28.7%]; OR = 0.54; 99% CI 0.39 to 0.74) and a trend towards a lower proportion of patients receiving heart transplantation (15 of 1354 [l.1%] versus 26 of 976 [2.7%]; OR = 0.45; 99% CI 0.20 to 1.03). Ventricular function improved; however, there was no effect on exercise duration. Although the effects on mortality were nominally statistically significant, the use of formal methods of interim monitoring adapted for meta-analyses suggests that substantially more patients still need to be studied in large scales trials to provide reliable and conclusive evidence. CONCLUSIONS While the available data on the use of beta-blockers in CHF appear to be promising, they are neither complete nor robust. The routine use of beta-blockers in patients with heart failure should wait the results of ongoing studies.
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Affiliation(s)
- A Avezum
- Dante Pazzanese Cardiology Institute, São Paulo, Brazil
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Avezum A. [Evidence based cardiology. I. Principles, rationale and applications of a new cardiology practice and critical analysis of the literature]. Arq Bras Cardiol 1998; 71:5-13. [PMID: 9755528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- A Avezum
- Instituto Dante Pazzanese de Cardiologia-São Paulo
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Avezum A. [Evidence based cardiology in focus. Solid and robust cardiology practice]. Arq Bras Cardiol 1998; 71:3. [PMID: 9755527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
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Tsuyuki RT, Yusuf S, Rouleau JL, Maggioni AP, McKelvie RS, Wiecek EM, Wang Y, Pogue J, Teo KK, White M, Avezum A, Latini R, Held P, Lindgren E, Probstfield J. Combination neurohormonal blockade with ACE inhibitors, angiotensin II antagonists and beta-blockers in patients with congestive heart failure: design of the Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) Pilot Study. Can J Cardiol 1997; 13:1166-74. [PMID: 9444298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) Pilot Study is a trial of combination neurohormonal blockade using an angiotensin II antagonist (candesartan), an angiotensin-converting enzyme inhibitor (enalapril) and a beta-blocker (metoprolol) in patients with congestive heart failure (CHF). OBJECTIVES Primary objectives of stage I are to determine the efficacy (via the 6 min walk test) and safety of candesartan alone, and in combination with enalapril, versus enalapril alone. Secondary objectives are to determine the effect of the above combinations on neurohormones, ventricular function, quality of life and symptoms. Stage II objectives are similar, evaluating the effect of the addition of metoprolol or placebo to the above medication(s). DESIGN Randomized, two-stage trial consisting of a three-way comparison (stage I), followed by a 3 x 2 partial factorial design (stage II). SETTING Sixty out-patient clinics in five countries. PATIENTS Patients with symptoms of CHF (New York Heart Association functional classes II to IV), ejection fraction less than 40% and 6 min walk distance of 500 m or less. INTERVENTIONS In stage I, 770 patients are randomized to receive candesartan alone, enalapril alone, or candesartan plus enalapril. After five months (end of stage I), patients are assessed for eligibility to be randomized in stage II. Those who are not candidates for randomization to beta-blocker or placebo are followed on their stage I medications until the end of the study. In stage II, patients are randomized to receive metoprolol or placebo for a further six months in addition to their stage I medications. Endpoints are measured at baseline, end of stage I (week 20) and end of stage II (week 46). STUDY STATUS: The study has recently completed follow-up in both stages. The findings from this study will be used to design a large scale mortality study that will help further define the role of neurohormonal blockade in patients with CHF.
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Affiliation(s)
- R T Tsuyuki
- HGH-McMaster Clinic, Hamilton General Hospital, Ontario
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Abstract
This review summarizes the results of several pharmacological interventions that have been evaluated in the management of acute myocardial infarction. Of these, thrombolytic therapy, aspirin, beta-blockers and angiotensin converting enzyme inhibitors have all been proven to reduce mortality risk and the latter three classes of drugs have also been shown to reduce morbidity. Routine use of heparin or nitrates is not recommended although they may be useful in specific circumstances such as post-infarction angina or large infarcts. Drugs that have as yet not been shown to have a role in the routine management of acute myocardial infarction include Class I antiarrhythmic agents, magnesium and calcium antagonists. Management of patients with acute myocardial infarction can now be appropriately based on the evidence generated from well conducted randomized clinical trials and appropriate therapeutic choices based on such information can be expected to reduce their morbidity and mortality risks.
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Affiliation(s)
- S Yusuf
- Division of Cardiology, McMaster University, Hamilton, Ontario, Canada
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Avezum A, Flather MD, Yusuf S. Adjunctive therapy for myocardial infarction. Arq Bras Cardiol 1995; 65:97-110. [PMID: 8546606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- A Avezum
- Division of Cardiology McMaster University, McMaster Clinic, Hamilton General Hospital, Ontario, Canada
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Avezum A, Pais P, Flather MD, Anand S, Yusuf S. Pharmacological treatment for myocardial infarction Part 2: Implications of clinical trials of other adjunctive therapies. Indian Heart J 1995; 47:95-105. [PMID: 7590849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- A Avezum
- Division of Cardiology, McMaster University, Hamilton General Hospital, Ontario, Canada
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