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Aguilar D, Davis BR. Aspirin Dosing in Cardiovascular Disease and Diabetes: Insights From ADAPTABLE. Diabetes Care 2024; 47:52-53. [PMID: 38117997 DOI: 10.2337/dci23-0078] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Affiliation(s)
- David Aguilar
- Division of Cardiovascular Medicine, LSU Health New Orleans School of Medicine, New Orleans, LA
| | - Barry R Davis
- Department of Biostatistics and Data Science, UTHealth Houston School of Public Health, Houston, TX
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Yamal JM, Martinez J, Osani MC, Du XL, Simpson LM, Davis BR. Mortality and Morbidity Among Individuals With Hypertension Receiving a Diuretic, ACE Inhibitor, or Calcium Channel Blocker: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2344998. [PMID: 38048133 PMCID: PMC10696481 DOI: 10.1001/jamanetworkopen.2023.44998] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/14/2023] [Indexed: 12/05/2023] Open
Abstract
Importance The long-term relative risk of antihypertensive treatments with regard to mortality and morbidity is not well understood. Objective To determine the long-term posttrial risk of primary and secondary outcomes among trial participants who were randomized to either a thiazide-type diuretic, calcium channel blocker (CCB), or angiotensin-converting enzyme (ACE) inhibitor with up to 23 years of follow-up. Design, Setting, and Participants This prespecified secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a multicenter randomized, double-blind, active-controlled clinical trial, followed up with participants aged 55 years or older with a diagnosis of hypertension and at least 1 other coronary heart disease risk factor for up to 23 years, from February 23, 1994, to December 31, 2017. Trial participants were linked with administrative databases for posttrial mortality (N = 32 804) and morbidity outcomes (n = 22 754). Statistical analysis was performed from January 2022 to October 2023. Interventions Participants were randomly assigned to receive a thiazide-type diuretic (n = 15 002), a CCB (n = 8898), or an ACE inhibitor (n = 8904) for planned in-trial follow-up of approximately 4 to 8 years and posttrial passive follow-up for up to 23 years. Main Outcomes and Measures The primary end point was mortality due to cardiovascular disease (CVD). Secondary outcomes included all-cause mortality, combined fatal and nonfatal (morbidity) CVD, and both mortality and morbidity for coronary heart disease, stroke, heart failure, end-stage renal disease, and cancer. Results A total of 32 804 participants (mean [SD] age, 66.9 [7.7] years; 17 411 men [53.1%]; and 11 772 Black participants [35.9%]) were followed up for all-cause mortality and a subgroup of 22 754 participants (mean [SD] age, 68.7 [7.2] years; 12 772 women [56.1%]; and 8199 Black participants [36.0%]) were followed up for fatal or nonfatal CVD through 2017 (mean [SD] follow-up, 13.7 [6.7] years; maximum follow-up, 23.9 years). Cardiovascular disease mortality rates per 100 persons were 23.7, 21.6, and 23.8 in the diuretic, CCB, and ACE inhibitor groups, respectively, at 23 years after randomization (adjusted hazard ratio [AHR], 0.97 [95% CI, 0.89-1.05] for CCB vs diuretic; AHR, 1.06 [95% CI, 0.97-1.15] for ACE inhibitor vs diuretic). The long-term risks of most secondary outcomes were similar among the 3 groups. Compared with the diuretic group, the ACE inhibitor group had a 19% increased risk of stroke mortality (AHR, 1.19 [95% CI, 1.03-1.37]) and an 11% increased risk of combined fatal and nonfatal hospitalized stroke (AHR, 1.11 [95% CI, 1.03-1.20]). Conclusions and Relevance In this secondary analysis of a randomized clinical trial in an adult population with hypertension and coronary heart disease risk factors, CVD mortality was similar between all 3 groups. ACE inhibitors increased the risk of stroke outcomes by 11% compared with diuretics, and this effect persisted well beyond the trial period. Trial Registration ClinicalTrials.gov Identifier: NCT00000542.
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Affiliation(s)
- Jose-Miguel Yamal
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston
| | - Journey Martinez
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston
| | - Mikala C. Osani
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston
- Zimmer Biomet, Warsaw, Indiana
| | - Xianglin L. Du
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston
| | - Lara M. Simpson
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston
| | - Barry R. Davis
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston
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Du XL, Martinez J, Yamal JM, Simpson LM, Davis BR. The 18-year risk of cancer, angioedema, insomnia, depression, and erectile dysfunction in association with antihypertensive drugs: post-trial analyses from ALLHAT-Medicare linked data. Front Cardiovasc Med 2023; 10:1272385. [PMID: 38045916 PMCID: PMC10691487 DOI: 10.3389/fcvm.2023.1272385] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose This study aimed to determine the 18-year risk of cancer, angioedema, insomnia, depression, and erectile dysfunction in association with antihypertensive drug use. Methods This is a post-trial passive follow-up study of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants between 1994 and 1998 that was conducted by linking their follow-up data with Medicare claims data until 2017 of subjects who were free of outcomes at baseline on 1 January 1999. The main outcomes were the occurrence of cancer (among n = 17,332), angioedema (among n = 17,340), insomnia (among n = 17,340), depression (among n = 17,330), and erectile dysfunction (among n = 7,444 men) over 18 years of follow-up. Results The 18-year cumulative incidence rate of cancer other than non-melanoma skin cancer from Medicare inpatient claims was 23.9% for chlorthalidone, 23.4% for amlodipine, and 25.3% for lisinopril. There were no statistically significant differences in the 18-year risk of cancer, depression, and erectile dysfunction among the three drugs based on the adjusted hazard ratios. The adjusted 18-year risk of angioedema was elevated in those receiving lisinopril than in those receiving amlodipine (hazard ratio: 1.63, 95% CI: 1.14-2.33) or in those receiving chlorthalidone (1.33, 1.00-1.79), whereas the adjusted 18-year risk of insomnia was statistically significantly decreased in those receiving lisinopril than in those receiving amlodipine (0.90, 0.81-1.00). Conclusions The 18-year risk of angioedema was significantly higher in patients receiving lisinopril than in those receiving amlodipine or chlorthalidone; the risk of insomnia was significantly lower in patients receiving lisinopril than in those receiving amlodipine; and the risk of cancer, depression, and erectile dysfunction (in men) was not statistically significantly different among the three drug groups.
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Affiliation(s)
- Xianglin L. Du
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Journey Martinez
- Department of Biostatistics and Data Science, Coordinating Center for Clinical Trials, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, Coordinating Center for Clinical Trials, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Lara M. Simpson
- Department of Biostatistics and Data Science, Coordinating Center for Clinical Trials, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Barry R. Davis
- Department of Biostatistics and Data Science, Coordinating Center for Clinical Trials, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
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Bidel Z, Nazarzadeh M, Canoy D, Copland E, Gerdts E, Woodward M, Gupta AK, Reid CM, Cushman WC, Wachtell K, Teo K, Davis BR, Chalmers J, Pepine CJ, Rahimi K. Sex-Specific Effects of Blood Pressure Lowering Pharmacotherapy for the Prevention of Cardiovascular Disease: An Individual Participant-Level Data Meta-Analysis. Hypertension 2023; 80:2293-2302. [PMID: 37485657 DOI: 10.1161/hypertensionaha.123.21496] [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] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Whether the relative effects of blood pressure (BP)-lowering treatment on cardiovascular outcomes differ by sex, particularly when BP is not substantially elevated, has been uncertain. METHODS We conducted an individual participant-level data meta-analysis of randomized controlled trials of pharmacological BP lowering. We pooled the data and categorized participants by sex, systolic BP categories in 10-mm Hg increments from <120 to ≥170 mm Hg, and age categories spanning from <55 to ≥85 years. We used fixed-effect one-stage individual participant-level data meta-analyses and applied Cox proportional hazard models, stratified by trial, to analyze the data. RESULTS We included data from 51 randomized controlled trials involving 358 636 (42% women) participants. Over 4.2 years of median follow-up, a 5-mm Hg reduction in systolic BP decreased the risk of major cardiovascular events both in women and men (hazard ratio [95% CI], 0.92 [0.89-0.95] for women and 0.90 [0.88-0.93] for men; P for interaction, 1). There was no evidence for heterogeneity of relative treatment effects by sex for the major cardiovascular disease, its components, or across the different baseline BP categories (all P for interaction, ≥0.57). The effects in women and men were consistent across age categories and the types of antihypertensive medications (all P for interaction, ≥0.14). CONCLUSIONS The effects of BP reduction were similar in women and men across all BP and age categories at randomization and with no evidence to suggest that drug classes had differing effects by sex. This study does not substantiate sex-based differences in BP-lowering treatment.
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Affiliation(s)
- Zeinab Bidel
- Deep Medicine, Oxford Martin School (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
- Nuffield Department of Women's and Reproductive Health (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, United Kingdom (Z.B., D.C., E.C., K.R.)
| | - Milad Nazarzadeh
- Deep Medicine, Oxford Martin School (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
- Nuffield Department of Women's and Reproductive Health (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
| | - Dexter Canoy
- Deep Medicine, Oxford Martin School (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
- Nuffield Department of Women's and Reproductive Health (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, United Kingdom (Z.B., D.C., E.C., K.R.)
| | - Emma Copland
- Deep Medicine, Oxford Martin School (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
- Nuffield Department of Women's and Reproductive Health (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, United Kingdom (Z.B., D.C., E.C., K.R.)
| | - Eva Gerdts
- Department of Clinical Science, Centre for Research on Cardiac Disease in Women, University of Bergen, Norway (E.G.)
| | - Mark Woodward
- The George Institute for Global Health, School of Public Health, Imperial College London, United Kingdom (M.W.)
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.W., J.C.)
| | - Ajay K Gupta
- William Harvey Research Institute, Queen Mary University of London, United Kingdom (A.K.G.)
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (C.M.R.)
| | - William C Cushman
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis (W.C.C.)
| | - Kristian Wachtell
- Department of Cardiology, NewYork-Presbyterian/Weill Cornell Medical Center (K.W.)
| | - Koon Teo
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada (K.T.)
| | - Barry R Davis
- The University of Texas School of Public Health, Houston (B.R.D.)
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.W., J.C.)
| | - Carl J Pepine
- College of Medicine, University of Florida, Gainesville (C.J.P.)
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
- Nuffield Department of Women's and Reproductive Health (Z.B., M.N., D.C., E.C., K.R.), University of Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, United Kingdom (Z.B., D.C., E.C., K.R.)
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Juraschek SP, Hu JR, Cluett JL, Ishak AM, Mita C, Lipsitz LA, Appel LJ, Beckett NS, Coleman RL, Cushman WC, Davis BR, Grandits G, Holman RR, Miller ER, Peters R, Staessen JA, Taylor AA, Thijs L, Wright JT, Mukamal KJ. Orthostatic Hypotension, Hypertension Treatment, and Cardiovascular Disease: An Individual Participant Meta-Analysis. JAMA 2023; 330:1459-1471. [PMID: 37847274 PMCID: PMC10582789 DOI: 10.1001/jama.2023.18497] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/28/2023] [Indexed: 10/18/2023]
Abstract
Importance There are ongoing concerns about the benefits of intensive vs standard blood pressure (BP) treatment among adults with orthostatic hypotension or standing hypotension. Objective To determine the effect of a lower BP treatment goal or active therapy vs a standard BP treatment goal or placebo on cardiovascular disease (CVD) or all-cause mortality in strata of baseline orthostatic hypotension or baseline standing hypotension. Data Sources Individual participant data meta-analysis based on a systematic review of MEDLINE, EMBASE, and CENTRAL databases through May 13, 2022. Study Selection Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) with orthostatic hypotension assessments. Data Extraction and Synthesis Individual participant data meta-analysis extracted following PRISMA guidelines. Effects were determined using Cox proportional hazard models using a single-stage approach. Main Outcomes and Measures Main outcomes were CVD or all-cause mortality. Orthostatic hypotension was defined as a decrease in systolic BP of at least 20 mm Hg and/or diastolic BP of at least 10 mm Hg after changing position from sitting to standing. Standing hypotension was defined as a standing systolic BP of 110 mm Hg or less or standing diastolic BP of 60 mm Hg or less. Results The 9 trials included 29 235 participants followed up for a median of 4 years (mean age, 69.0 [SD, 10.9] years; 48% women). There were 9% with orthostatic hypotension and 5% with standing hypotension at baseline. More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline orthostatic hypotension (hazard ratio [HR], 0.81; 95% CI, 0.76-0.86) similarly to those with baseline orthostatic hypotension (HR, 0.83; 95% CI, 0.70-1.00; P = .68 for interaction of treatment with baseline orthostatic hypotension). More intensive BP treatment or active therapy lowered risk of CVD or all-cause mortality among those without baseline standing hypotension (HR, 0.80; 95% CI, 0.75-0.85), and nonsignificantly among those with baseline standing hypotension (HR, 0.94; 95% CI, 0.75-1.18). Effects did not differ by baseline standing hypotension (P = .16 for interaction of treatment with baseline standing hypotension). Conclusions and Relevance In this population of hypertension trial participants, intensive therapy reduced risk of CVD or all-cause mortality regardless of orthostatic hypotension without evidence for different effects among those with standing hypotension.
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Affiliation(s)
- Stephen P. Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer L. Cluett
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Anthony M. Ishak
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Healthcare Associates, Beth Israel–Lahey Health System, Boston, Massachusetts
| | - Carol Mita
- Countway Library, Harvard University, Boston, Massachusetts
| | - Lewis A. Lipsitz
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research and Harvard Medical School, Boston, Massachusetts
| | | | | | - Ruth L. Coleman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, England
| | - William C. Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis
| | - Barry R. Davis
- Department of Biostatistics and Data Science, Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston
| | - Greg Grandits
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis
| | - Rury R. Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, England
| | | | - Ruth Peters
- The George Institute for Global Health, Sydney, Australia
- Department of Biomedical Sciences, University of New South Wales, Sydney, Australia
- School of Public Health, Imperial College London, London, England
| | | | - Addison A. Taylor
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas
| | | | - Jackson T. Wright
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Kenneth J. Mukamal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Ghosh A, Chan W, Younes N, Davis BR. A Dynamic Risk Model for Multitype Recurrent Events. Am J Epidemiol 2023; 192:621-631. [PMID: 36549905 PMCID: PMC10404068 DOI: 10.1093/aje/kwac213] [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] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 10/17/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Recurrent events can occur more than once in the same individual; such events may be of different types, known as multitype recurrent events. They are very common in longitudinal studies. Often there is a terminating event, after which no further events can occur. The risk of any event, including terminating events such as death or cure, is typically affected by prior events. We propose a flexible joint multitype recurrent-events model that explicitly provides estimates of the change in risk for each event due to subject characteristics, including number and type of prior events and the absolute risk for every event type (terminating and nonterminating), and predicts event-free survival probability over a desired time period. The model is fully parametric, and therefore a standard likelihood function and robust standard errors can be constructed. We illustrate the model with applications to the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (1994-2002) and provide discussion of the results and model features.
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Affiliation(s)
- Alokananda Ghosh
- Correspondence to Dr. Alokananda Ghosh, Department of Biostatistics and Bioinformatics, Biostatistics Center, Milken Institute School of Public Health, George Washington University, 6110 Executive Boulevard, Rockville, MD 20852 (e-mail: ); or Dr. Wenyaw Chan, Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, 1200 Pressler Street, Houston, TX 77030 (e-mail: )
| | - Wenyaw Chan
- Correspondence to Dr. Alokananda Ghosh, Department of Biostatistics and Bioinformatics, Biostatistics Center, Milken Institute School of Public Health, George Washington University, 6110 Executive Boulevard, Rockville, MD 20852 (e-mail: ); or Dr. Wenyaw Chan, Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston, 1200 Pressler Street, Houston, TX 77030 (e-mail: )
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Sinha AK, Moye L, Piller LB, Yamal JM, Barcenas CH, Song J, Davis BR. Simultaneous population enrichment and endpoint selection in phase 3 randomized controlled trials: An adaptive group sequential design with two binary alternative primary endpoints. COMMUN STAT-THEOR M 2023. [DOI: 10.1080/03610926.2022.2163180] [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: 01/05/2023]
Affiliation(s)
- Arup K. Sinha
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas, USA
| | - Lemuel Moye
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas, USA
| | - Linda B. Piller
- Division of Epidemiology, Human Genetics and Environmental Sciences, The University of Texas School of Public Health, Houston, Texas, USA
| | - Jose-Miguel Yamal
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas, USA
| | - Carlos H. Barcenas
- Department of Breast Medical Oncology, Division of Cancer Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jaejoon Song
- Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA
| | - Barry R. Davis
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas, USA
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Kaushal S, Hare JM, Shah AM, Pietris NP, Bettencourt JL, Piller LB, Khan A, Snyder A, Boyd RM, Abdullah M, Mishra R, Sharma S, Slesnick TC, Si MS, Chai PJ, Davis BR, Lai D, Davis ME, Mahle WT. Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome (CHILD Study). Pediatr Cardiol 2022; 43:1481-1493. [PMID: 35394149 DOI: 10.1007/s00246-022-02872-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
Mortality in infants with hypoplastic left heart syndrome (HLHS) is strongly correlated with right ventricle (RV) dysfunction. Cell therapy has demonstrated potential improvements of RV dysfunction in animal models related to HLHS, and neonatal human derived c-kit+ cardiac-derived progenitor cells (CPCs) show superior efficacy when compared to adult human cardiac-derived CPCs (aCPCs). Neonatal CPCs (nCPCs) have yet to be investigated in humans. The CHILD trial (Autologous Cardiac Stem Cell Injection in Patients with Hypoplastic Left Heart Syndrome) is a Phase I/II trial aimed at investigating intramyocardial administration of autologous nCPCs in HLHS infants by assessing the feasibility, safety, and potential efficacy of CPC therapy. Using an open-label, multicenter design, CHILD investigates nCPC safety and feasibility in the first enrollment group (Group A/Phase I). In the second enrollment group, CHILD uses a randomized, double-blinded, multicenter design (Group B/Phase II), to assess nCPC efficacy based on RV functional and structural characteristics. The study plans to enroll 32 patients across 4 institutions: Group A will enroll 10 patients, and Group B will enroll 22 patients. CHILD will provide important insights into the therapeutic potential of nCPCs in patients with HLHS.Clinical Trial Registration https://clinicaltrials.gov/ct2/home NCT03406884, First posted January 23, 2018.
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Affiliation(s)
- Sunjay Kaushal
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL, 60611, USA.
| | - Joshua M Hare
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, 1501 NW 10th Avenue, 9th Floor, Miami, FL, 33136, USA.
| | - Aakash M Shah
- Division of Cardiac Surgery, University of Maryland School of Medicine, 110 S. Paca Street, 7th Floor, Baltimore, MD, 21228, USA
| | - Nicholas P Pietris
- Division of Pediatric Cardiology, University of Maryland School of Medicine, 110 S. Paca Street, 7th Floor, Baltimore, MD, 21228, USA
| | | | - Linda B Piller
- School of Public Health, UT Health, 1200 Pressler, Houston, TX, 77030, USA
| | - Aisha Khan
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, 1501 NW 10th Avenue, 9th Floor, Miami, FL, 33136, USA
| | - Abigail Snyder
- Division of Cardiac Surgery, University of Maryland School of Medicine, 110 S. Paca Street, 7th Floor, Baltimore, MD, 21228, USA
| | - Riley M Boyd
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL, 60611, USA
| | - Mohamed Abdullah
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL, 60611, USA
| | - Rachana Mishra
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL, 60611, USA
| | - Sudhish Sharma
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Chicago, IL, 60611, USA
| | - Timothy C Slesnick
- Wallace H. Coulter Department of Biomedical Engineering, Emory University School of Medicine, 1760 Haygood Drive W200, Atlanta, GA, 30322, USA
| | - Ming-Sing Si
- University of Michigan, CS Mott Children's Hospital, 1540 E. Hospital Drive, 11-735, Ann Arbor, MI, 48109, USA
| | - Paul J Chai
- Department of Cardiac Surgery, Emory University Children's Healthcare of Atlanta, 1405 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Barry R Davis
- School of Public Health, UT Health, 1200 Pressler, Houston, TX, 77030, USA
| | - Dejian Lai
- School of Public Health, UT Health, 1200 Pressler, Houston, TX, 77030, USA
| | - Michael E Davis
- Wallace H. Coulter Department of Biomedical Engineering, Emory University School of Medicine, 1760 Haygood Drive W200, Atlanta, GA, 30322, USA.,Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, 201 Uppergate Drive, Atlanta, GA, 30322, USA
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, 201 Uppergate Drive, Atlanta, GA, 30322, USA
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Ye J, Lai D, Moye LA, Davis BR. Applications of Covariate Adjusted Nonparametric Methods to CCTRN Clinical Trials. Commun Stat Case Stud Data Anal Appl 2022; 8:728-737. [PMID: 37181862 PMCID: PMC10181848 DOI: 10.1080/23737484.2022.2126414] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
CCTRN is a Cardiovascular Cell Therapy Research Network. There were three randomized double blinded controlled stem cell clinical trials conducted in its first phase. The main results of these three clinical trials were published with conventional parametric models such as T test and nonparametric test such as Wilcoxon rank sum test without adjusting covariates. In this article, we conducted further analysis of the primary outcomes of these studies using a class of covariate adjusted nonparametric methods.
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Affiliation(s)
- Jiabu Ye
- Merck & Co., Inc., Kenilworth, NJ 07033, USA
| | - Dejian Lai
- Department of Biostatistics and Data Science, The University of Texas School of Public Health
| | - Lemuel A Moye
- Department of Biostatistics and Data Science, The University of Texas School of Public Health
| | - Barry R Davis
- Department of Biostatistics and Data Science, The University of Texas School of Public Health
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Juraschek SP, Hu JR, Cluett JL, Ishak AM, Mita C, Lipsitz LA, Appel LJ, Beckett NS, Coleman RL, Cushman WC, Davis BR, Grandits G, Holman RR, Miller ER, Peters R, Staessen JA, Taylor AA, Wright JT, Mukamal KJ. Abstract P220: Effects Of Orthostatic Hypotension On Intensive Blood Pressure Treatment With Respect To All-cause Mortality: An Individual-level Meta-analysis. Hypertension 2022. [DOI: 10.1161/hyp.79.suppl_1.p220] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
In a recent individual level meta-analysis, intensive versus standard blood pressure (BP) treatment reduced participants’ risk of orthostatic hypotension (OH). Whether OH modified the relationship between intensive treatment and risk of cardiovascular disease (CVD) or death is unknown.
Methods:
We performed an individual participant data meta-analysis, updating a previous systematic review of MEDLINE, EMBASE, and CENTRAL databases through May 13, 2022, which included randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) on CVD or death. CVD events were adjudicated and included coronary heart disease, stroke, and congestive heart failure. OH was defined as a drop in SBP ≥20 mmHg and/or DBP ≥10 mmHg after changing positions from sitting to standing. Ultimately, 8 trials were identified with OH and outcomes data. Effects were examined overall and by trial type (BP goal or active agent), using Cox proportional hazard models adjusted for age and sex.
Results:
There were 27,974 participants followed for median of 4 years (mean age 69.5±10.7 years; 48.5% female; 8.6% with OH). Baseline OH was associated with a higher risk of CVD or death (HR 1.24; 95% CI: 1.10, 1.39). More intensive BP treatment or active therapy lowered risk of CVD or death among those without OH at baseline (HR 0.82; 95% CI: 0.76, 0.88) and with OH at baseline (HR 0.79; 95% CI: 0.63, 0.98). Effects did not differ by baseline OH (
P
-interaction 0.78) (
Table
).
Conclusion:
While baseline OH was associated with CVD or death, it did not increase the risk of CVD or death from intensive treatment. OH prior to the initiation of intensive therapy should not be viewed as a reason to avoid BP treatment.
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11
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Nazarzadeh M, Bidel Z, Canoy D, Copland E, Bennett DA, Dehghan A, Davey Smith G, Holman RR, Woodward M, Gupta A, Adler AI, Wamil M, Sattar N, Cushman WC, McManus RJ, Teo K, Davis BR, Chalmers J, Pepine CJ, Rahimi K. Blood pressure-lowering treatment for prevention of major cardiovascular diseases in people with and without type 2 diabetes: an individual participant-level data meta-analysis. Lancet Diabetes Endocrinol 2022; 10:645-654. [PMID: 35878651 PMCID: PMC9622419 DOI: 10.1016/s2213-8587(22)00172-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/05/2022] [Accepted: 06/07/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Controversy exists as to whether the threshold for blood pressure-lowering treatment should differ between people with and without type 2 diabetes. We aimed to investigate the effects of blood pressure-lowering treatment on the risk of major cardiovascular events by type 2 diabetes status, as well as by baseline levels of systolic blood pressure. METHODS We conducted a one-stage individual participant-level data meta-analysis of major randomised controlled trials using the Blood Pressure Lowering Treatment Trialists' Collaboration dataset. Trials with information on type 2 diabetes status at baseline were eligible if they compared blood pressure-lowering medications versus placebo or other classes of blood pressure-lowering medications, or an intensive versus a standard blood pressure-lowering strategy, and reported at least 1000 persons-years of follow-up in each group. Trials exclusively on participants with heart failure or with short-term therapies and acute myocardial infarction or other acute settings were excluded. We expressed treatment effect per 5 mm Hg reduction in systolic blood pressure on the risk of developing a major cardiovascular event as the primary outcome, defined as the first occurrence of fatal or non-fatal stroke or cerebrovascular disease, fatal or non-fatal ischaemic heart disease, or heart failure causing death or requiring hospitalisation. Cox proportional hazard models, stratified by trial, were used to estimate hazard ratios (HRs) separately by type 2 diabetes status at baseline, with further stratification by baseline categories of systolic blood pressure (in 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg). To estimate absolute risk reductions, we used a Poisson regression model over the follow-up duration. The effect of each of the five major blood pressure-lowering drug classes, including angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, β blockers, calcium channel blockers, and thiazide diuretics, was estimated using a network meta-analysis framework. This study is registered with PROSPERO, CRD42018099283. FINDINGS We included data from 51 randomised clinical trials published between 1981 and 2014 involving 358 533 participants (58% men), among whom 103 325 (29%) had known type 2 diabetes at baseline. The baseline mean systolic/diastolic blood pressure of those with and without type 2 diabetes was 149/84 mm Hg (SD 19/11) and 153/88 mm Hg (SD 21/12), respectively. Over 4·2 years median follow-up (IQR 3·0-5·0), a 5 mm Hg reduction in systolic blood pressure decreased the risk of major cardiovascular events in both groups, but with a weaker relative treatment effect in participants with type 2 diabetes (HR 0·94 [95% CI 0·91-0·98]) compared with those without type 2 diabetes (0·89 [0·87-0·92]; pinteraction=0·0013). However, absolute risk reductions did not differ substantially between people with and without type 2 diabetes because of the higher absolute cardiovascular risk among participants with type 2 diabetes. We found no reliable evidence for heterogeneity of treatment effects by baseline systolic blood pressure in either group. In keeping with the primary findings, analysis using stratified network meta-analysis showed no evidence that relative treatment effects differed substantially between participants with type 2 diabetes and those without for any of the drug classes investigated. INTERPRETATION Although the relative beneficial effects of blood pressure reduction on major cardiovascular events were weaker in participants with type 2 diabetes than in those without, absolute effects were similar. The difference in relative risk reduction was not related to the baseline blood pressure or allocation to different drug classes. Therefore, the adoption of differential blood pressure thresholds, intensities of blood pressure lowering, or drug classes used in people with and without type 2 diabetes is not warranted. FUNDING British Heart Foundation, UK National Institute for Health Research, and Oxford Martin School.
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Affiliation(s)
- Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Zeinab Bidel
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Dexter Canoy
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Emma Copland
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Derrick A Bennett
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Abbas Dehghan
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK; MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, Norfolk Place, London, UK
| | | | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Mark Woodward
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Ajay Gupta
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Amanda I Adler
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Malgorzata Wamil
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - William C Cushman
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Richard J McManus
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Barry R Davis
- University of Texas School of Public Health, Houston, TX, USA
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Carl J Pepine
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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12
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Hartnett ME, Wallace DK, Dean TW, Li Z, Boente CS, Dosunmu EO, Freedman SF, Golden RP, Kong L, Prakalapakorn SG, Repka MX, Smith LE, Wang H, Kraker RT, Cotter SA, Holmes JM, Rhodes JE, Rogers DL, Bremer DL, Jordan CO, McGregor ML, Reem RE, Maletic SA, McMillin MC, Tobe Miller R, Bind JE, Leary JA, Mhaskar RM, Stiltner TL, Yang MB, Gray ME, Motley WW, Schwartz TL, Cobb P, Hirsch P, Reed M, Lagory D, Topmiller S, Coats DK, Bhatt AR, Demny AB, Bui VK, Lynds JL, McCartney TP, Vanderveen DK, Mantagos JS, Wu C, Yoon G, Goldstein S, Winter T, Anzaldi R, Smith HA, Haider KM, Hynes EA, Allard M, Head A, Morse D, Siatkowski RM, Collinge JE, Satnes KJ, Blunt MH, Taylor KD, Dries DC, Hoffman RO, Farnsworth KJ, Sorenson S, Austin DS, Beck RW, Boyle NM, Connelly PL, Conner CL, Chandler DL, Donahue Q, Fimbel BP, Henderson RJ, Hercinovic A, Hoepner JE, Kaplon JD, Ortiz G, Robinson JL, Stutz KM, Sutherland DR, Toro DO, Woodard VC, Wu R, Everett DF, Astle WF, Birch EE, Chen AM, Enyedi LB, Erzurum SA, Lambert SR, Lee KA, Manh VA, Manny RE, Silver JL, Weise KK, Verderber LC, Diener-West M, Baker JD, Davis BR, Phelps DL, Poff SW, Saunders RA, Tychsen L, Hartnett ME, Wallace DK, Dean TW, Li Z, Boente CS, Dosunmu EO, Freedman SF, Golden RP, Kong L, Prakalapakorn SG, Repka MX, Smith LE, Wang H, Kraker RT, Cotter SA, Holmes JM. Plasma Levels of Bevacizumab and Vascular Endothelial Growth Factor After Low-Dose Bevacizumab Treatment for Retinopathy of Prematurity in Infants. JAMA Ophthalmol 2022; 140:337-344. [PMID: 35446359 PMCID: PMC8895318 DOI: 10.1001/jamaophthalmol.2022.0030] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Intravitreal bevacizumab effectively treats severe retinopathy of prematurity (ROP), but it enters the bloodstream and may reduce serum vascular endothelial growth factor (VEGF), potentially causing detrimental effects on developing organs in the premature infant. Objective To evaluate the association of intravitreal bevacizumab with plasma bevacizumab and VEGF concentrations at 2 and 4 weeks after predefined, de-escalating doses of intravitreal bevacizumab were administered to infants with severe ROP. Design, Setting, and Participants This phase 1 dose de-escalation case series study was conducted at 10 US hospitals of ophthalmology institutions from May 21, 2015, to May 7, 2019. Blood samples were collected 2 and 4 weeks after intravitreal bevacizumab injection. Participants included 83 premature infants with type 1 ROP in 1 or both eyes and no previous ROP treatment. Data were analyzed from April 2017 to August 2021. Interventions Study eyes received a single bevacizumab injection of 0.250 mg, 0.125 mg, 0.063 mg, 0.031 mg, 0.016 mg, 0.008 mg, 0.004 mg, or 0.002 mg. When the fellow eye required treatment, one dose higher was administered. Total dose administered at baseline was defined as the sum of doses given to each eye within 3 days of initial study-eye injection. Main Outcomes and Measures Plasma bevacizumab concentration at 2 and 4 weeks after injection and the percentage change in plasma VEGF concentrations from pretreatment levels. Results A total of 83 infants (mean [SD] age, 25 [2] weeks; 48 boys [58%]) were included in this study. Higher doses of bevacizumab administered at baseline were associated with higher plasma bevacizumab concentrations at 2 weeks (ρ, 0.53; 95% CI, 0.31-0.70) and 4 weeks (ρ, 0.44; 95% CI, 0.18-0.64). Plasma VEGF concentrations decreased by 50% or more from pretreatment levels in 40 of 66 infants (61%) at 2 weeks and 31 of 61 infants (51%) at 4 weeks, but no association was observed between the total dose of bevacizumab administered at baseline and percentage change in plasma VEGF concentrations 2 weeks (ρ, -0.04; 95% CI, -0.28 to 0.20) or 4 weeks (ρ, -0.17; 95% CI, -0.41 to 0.08) after injection. Conclusions and Relevance Results of this phase 1 dose de-escalation case series study revealed that bevacizumab doses as low as 0.002 mg were associated with reduced plasma VEGF levels for most infants at 2 and 4 weeks after intravitreal administration; however, no association was observed between total bevacizumab dose administered and reductions in plasma VEGF levels from preinjection to 2 weeks or 4 weeks. Additional studies are needed to evaluate the long-term effects of low-dose bevacizumab on neurodevelopment and retinal structure.
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Affiliation(s)
| | | | | | | | - Zhuokai Li
- Jaeb Center for Health Research, Tampa, Florida
| | | | - Eniolami O Dosunmu
- Cincinnati Children's Hospital Medical Center, Abrahamson Pediatric Eye Institute, Cincinnati, Ohio.,Department of Ophthalmology, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Lingkun Kong
- Texas Tech University Health Science Center, Lubbock
| | | | | | - Lois E Smith
- Boston Children's Hospital, Boston, Massachusetts
| | - Haibo Wang
- John A. Moran Eye Center, Salt Lake City, Utah
| | | | - Susan A Cotter
- Southern California College of Optometry at Marshall B. Ketchum University, Fullerton
| | - Jonathan M Holmes
- Department of Ophthalmology and Vision Science, University of Arizona, Tucson
| | - James E. Rhodes
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - David L. Rogers
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Don L. Bremer
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | - Rachel E. Reem
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Sara Ann Maletic
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | - Jill E. Bind
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Julie A. Leary
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | - Michael B. Yang
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Michael E. Gray
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | - Patricia Cobb
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Patricia Hirsch
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Melissa Reed
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Denise Lagory
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Steven Topmiller
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - David K. Coats
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Amit R. Bhatt
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Ann B. Demny
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Vanessa K. Bui
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | | | | | - Carolyn Wu
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Grace Yoon
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | - Tamar Winter
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Rocco Anzaldi
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Heather A. Smith
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | - Melissa Allard
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Annette Head
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - David Morse
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | - Kelli J. Satnes
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | - Kaci D. Taylor
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - David C. Dries
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | - Susan Sorenson
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | - Roy W. Beck
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Nicole M. Boyle
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | | | - Quayleen Donahue
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Brooke P. Fimbel
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | - Amra Hercinovic
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - James E. Hoepner
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Joseph D. Kaplon
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Gillaine Ortiz
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | | | - David O. Toro
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | - Rui Wu
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | - William F. Astle
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Eileen E. Birch
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Angela M. Chen
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Laura B. Enyedi
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - S. Ayse Erzurum
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Scott R. Lambert
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Katherine A. Lee
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Vivian A. Manh
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Ruth E. Manny
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Jayne L. Silver
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | | | - John D. Baker
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Barry R. Davis
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Dale L. Phelps
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | - Stephen W. Poff
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | - Lawrence Tychsen
- Writing Committee for the Pediatric Eye Disease Investigator Group
| | | | | | | | - Zhuokai Li
- Jaeb Center for Health Research, Tampa, Florida
| | | | - Eniolami O. Dosunmu
- Cincinnati Children’s Hospital Medical Center, Abrahamson Pediatric Eye Institute, Cincinnati, Ohio
- Department of Ophthalmology, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Lingkun Kong
- Texas Tech University Health Science Center, Lubbock
| | | | | | | | - Haibo Wang
- John A. Moran Eye Center, Salt Lake City, Utah
| | | | - Susan A. Cotter
- Southern California College of Optometry at Marshall B. Ketchum University, Fullerton
| | - Jonathan M. Holmes
- Department of Ophthalmology and Vision Science, University of Arizona, Tucson
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13
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Canoy D, Copland E, Nazarzadeh M, Ramakrishnan R, Pinho-Gomes AC, Salam A, Dwyer JP, Farzadfar F, Sundström J, Woodward M, Davis BR, Rahimi K. Antihypertensive drug effects on long-term blood pressure: an individual-level data meta-analysis of randomised clinical trials. Heart 2022; 108:1281-1289. [PMID: 35058294 PMCID: PMC9340038 DOI: 10.1136/heartjnl-2021-320171] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 11/30/2021] [Indexed: 12/12/2022]
Abstract
ObjectiveEvidence from randomised trials of pharmacological treatments on long-term blood pressure (BP) reduction is limited. We investigated the antihypertensive drug effects on BP over time and across different participant characteristics.MethodsWe conducted an individual patient-level data meta-analysis of 52 large-scale randomised clinical trials in the Blood Pressure Lowering Treatment Trialists’ Collaboration using mixed models to examine treatment effects on BP over 4 years of mean follow-up.ResultsThere were 363 684 participants (42% women), with baseline mean age=65 years and mean systolic/diastolic BP=152/87 mm Hg, and among whom 19% were current smokers, 49% had cardiovascular disease, 28% had diabetes and 69% were taking antihypertensive treatment at baseline. Drugs were effective in lowering BP showing maximal effect after 12 months and gradually attenuating towards later years. Based on measures taken ≥12 months postrandomisation, mean systolic/diastolic BP difference (95% CI) between more and less intense BP-lowering treatment was −11.1 (−11.3 to −10.8)/−5.6 (−5.7 to −5.4) mm Hg; between active treatment and placebo was −5.1 (−5.3 to −5.0)/−2.3 (−2.4 to −2.2) mm Hg; and between active and control arms for drug comparison trials was −1.4 (−1.5 to −1.3)/−0.6 (−0.7 to −0.6) mm Hg. BP reductions were observed across different baseline BP values and ages, and by sex, history of cardiovascular disease and diabetes and prior antihypertensive treatment use.ConclusionThese findings suggest that BP-lowering pharmacotherapy is effective in lowering BP, up to 4 years on average, in people with different characteristics. Appropriate treatment strategies are needed to sustain substantive long-term BP reductions.
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Affiliation(s)
- Dexter Canoy
- Deep Medicine, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Emma Copland
- Deep Medicine, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Milad Nazarzadeh
- Deep Medicine, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Rema Ramakrishnan
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ana-Catarina Pinho-Gomes
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Community Medicine, Centre for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Abdul Salam
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health India, Hyderabad, India
| | - Jamie P Dwyer
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Farshad Farzadfar
- Endocrinology and Metabolism Institute, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Johan Sundström
- Department of Medical Sciences, Uppsala Universitet, Uppsala, Sweden
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health UK, Imperial College London, London, UK
| | - Barry R Davis
- Department of Biostatistics, University of Texas School of Public Health, Houston, Texas, USA
| | - Kazem Rahimi
- Deep Medicine, Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
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14
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Du XL, Simpson LM, Osani MC, Yama JM, Davis BR. Risk of Developing Alzheimer's Disease and Related Dementias in ALLHAT Trial Participants Receiving Diuretic, ACE-Inhibitor, or Calcium-Channel Blocker with 18 Years of Follow-Up. J Alzheimers Dis Parkinsonism 2022; 12:541. [PMID: 35571234 PMCID: PMC9095428] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND There is no any large randomized clinical trial of antihypertensive drug treatment with 18-year passive follow-up to examine the risk of Alzheimer's Disease (AD) or Related Dementias (ADRD). METHODS Post-trial passive follow-up study of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants in 1994-1998 by linking with their Medicare claims data through 2017 among 17,158 subjects in 567 U.S. centers who were free of ADRD at baseline on January 1, 1999. Main outcome was the occurrence of ADRD over 18 years of follow-up. RESULTS The 18-year cumulative incidence rates were 30.9% for AD, 59.2% for non-AD dementias, and 60.9% for any ADRD. The 18-year cumulative incidence of AD was almost identical for the 3 drug groups (30.5% for chlorthalidone, 31.1% for amlodipine, and 31.4% for lisinopril). The hazard ratios of AD, non-AD dementias and total ADRD were not statistically significantly different among the 3 drug groups. The adjusted hazard ratio of AD was 1.04 (95% CI: 0.94-1.14) for chlorthalidone versus amlodipine, 1.02 (0.92-1.13) for lisinopril versus amlodipine, and 0.98 (0.89-1.08) for lisinopril versus chlorthalidone, which were not significantly different. The risk of AD and non-AD dementias was significantly higher in older subjects, females, blacks, non-Hispanics, subjects with lower education, and subjects with vascular diseases. CONCLUSION The risk of ADRD did not vary significantly by 3 antihypertensive drugs in ALLHAT trial participants with 18-years of follow-up. The risk of ADRD was significantly associated with age, gender, race/ethnicity, education, and history of vascular diseases.
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Affiliation(s)
- Xianglin L. Du
- Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center at Houston, Houston, USA,Corresponding author: Xianglin L. Du, Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center at Houston, Houston, USA, Tel: 7135009956;
| | - Lara M. Simpson
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, USA
| | - Mikala C. Osani
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, USA
| | - Jose-Miguel Yama
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, USA
| | - Barry R. Davis
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, Houston, USA
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15
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Du XL, Simpson LM, Tandy BC, Bettencourt J, Davis BR. Effects of Posttrial Antihypertensive Drugs on Morbidity and Mortality: Findings from 15-Year Passive Follow-Up after ALLHAT Ended. Int J Hypertens 2021; 2021:2261144. [PMID: 34925915 PMCID: PMC8677412 DOI: 10.1155/2021/2261144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/17/2021] [Accepted: 11/25/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) ended in 2002, but it is important to study its long-term outcomes during the posttrial period by incorporating posttrial antihypertensive medication uses in the analysis. PURPOSES The primary aim is to explore the patterns of antihypertensive medication use during the posttrial period from Medicare Part-D data over the 11-year period from 2007 to 2017. The secondary aim is to examine the potential effects of these posttrial antihypertensive medications on the observed mortality and morbidity benefits. METHODS This is a posttrial passive follow-up study of ALLHAT participants in 567 US centers in 1994-1998 with the last date of active in-trial follow-up on March 31, 2002, by linking with their Medicare and National Death Index data through 2017 among 8,007 subjects receiving antihypertensive drugs (3,637 for chlorthalidone, 2,189 for amlodipine, and 2,181 for lisinopril). Outcomes included posttrial antihypertensive drug use, all-cause mortality, and cardiovascular disease (CVD) mortality. RESULTS Of 8007 subjects, 3,637 participants were initially randomized to diuretic (chlorthalidone). The majority (67.9%) of them still received diuretics in 2007, and 52.7%, 47.2%, and 44.0% received β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers (CCBs), respectively. Compared to participants who received diuretic-based antihypertensives, those who received CCB had a nonsignificantly higher risk of all-cause mortality (1.17, 0.99-1.37), whereas those who received ACE/ARB (angiotensin receptor blockers) had a significantly higher risk of all-cause mortality (1.26, 1.09-1.45). For the combined fatal or nonfatal hospitalized events, the risk of CVD was significantly higher in patients receiving CCB (1.30, 1.04-1.61) and ACE/ARB (1.49, 1.22-1.81) as compared to patients receiving diuretics. CONCLUSION After the conclusion of the ALLHAT, almost all patients switched to combination antihypertensive therapies, independently by the original drug class, and the combination therapies (mostly based on diuretics) reduced the incidence of major cardiovascular outcomes and mortality.
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Affiliation(s)
- Xianglin L. Du
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Lara M. Simpson
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Brian C. Tandy
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Judy Bettencourt
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
| | - Barry R. Davis
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX 77030, USA
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Du XL, Simpson LM, Tandy BC, Bettencourt JL, Davis BR. Risk of hospitalized and non-hospitalized gastrointestinal bleeding in ALLHAT trial participants receiving diuretic, ACE-inhibitor, or calcium-channel blocker. PLoS One 2021; 16:e0260107. [PMID: 34793552 PMCID: PMC8601451 DOI: 10.1371/journal.pone.0260107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 11/02/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES This post-trial data linkage analysis was to utilize the data of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants linked with their Medicare data to examine the risk of hospitalized and non-hospitalized gastrointestinal (GI) bleeding associated with antihypertensives. SETTINGS ALLHAT was a multicenter, randomized, double-blind, active-controlled trial conducted in a total of 42,418 participants aged ≥55 years with hypertension in 623 North American centers. Data for ALLHAT participants who were aged at ≥65 have been linked with their Medicare claims data. PARTICIPANTS A total of 16,676 patients (4,480 for lisinopril, 4,537 for amlodipine, and 7,659 for chlorthalidone) with complete Medicare claims data were available for the final analysis. RESULTS The cumulative incidences through March 31, 2002 of hospitalized GI bleeding were 5.4%, 5.8% and 5.4% for amlodipine, lisinopril, and chlorthalidone arms, respectively, but were not statistically significant among the 3 arms after adjusting for confounders in Cox regression models. The cumulative incidences of non-hospitalized GI bleeding were also similar across the 3 arms (12.0%, 12.2% and 12.0% for amlodipine, lisinopril, and chlorthalidone, respectively). The increased risk of GI bleeding by age was statistically significant after adjusting for confounders (HR = 1.04 per year, 95% CI: 1.03-1.05). Smokers also had a significantly higher risk of having hospitalized GI bleeding (1.45, 1.19-1.76). Hispanics, those who used aspirin or atenolol in-trial, had diabetes, more education, and a history of stroke had a significantly lower risk of having GI bleeding than their counterparts. Other factors such as gender, history of CHD, prior antihypertensive use, use of estrogen in women, and obesity did not have significant effects on the risk of GI bleeding. CONCLUSION There were no statistically significant differences on the risk of hospitalized or non-hospitalized GI bleeding among the 3 ALLHAT trial arms (amlodipine, lisinopril, and chlorthalidone) during the entire in-trial follow-up.
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Affiliation(s)
- Xianglin L. Du
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Lara M. Simpson
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Brian C. Tandy
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Judith L. Bettencourt
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | - Barry R. Davis
- Coordinating Center for Clinical Trials, Department of Biostatistics and Data Science, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States of America
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Nazarzadeh M, Bidel Z, Canoy D, Copland E, Wamil M, Majert J, Smith Byrne K, Sundström J, Teo K, Davis BR, Chalmers J, Pepine CJ, Dehghan A, Bennett DA, Smith GD, Rahimi K. Blood pressure lowering and risk of new-onset type 2 diabetes: an individual participant data meta-analysis. Lancet 2021; 398:1803-1810. [PMID: 34774144 PMCID: PMC8585669 DOI: 10.1016/s0140-6736(21)01920-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/18/2021] [Accepted: 08/17/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Blood pressure lowering is an established strategy for preventing microvascular and macrovascular complications of diabetes, but its role in the prevention of diabetes itself is unclear. We aimed to examine this question using individual participant data from major randomised controlled trials. METHODS We performed a one-stage individual participant data meta-analysis, in which data were pooled to investigate the effect of blood pressure lowering per se on the risk of new-onset type 2 diabetes. An individual participant data network meta-analysis was used to investigate the differential effects of five major classes of antihypertensive drugs on the risk of new-onset type 2 diabetes. Overall, data from 22 studies conducted between 1973 and 2008, were obtained by the Blood Pressure Lowering Treatment Trialists' Collaboration (Oxford University, Oxford, UK). We included all primary and secondary prevention trials that used a specific class or classes of antihypertensive drugs versus placebo or other classes of blood pressure lowering medications that had at least 1000 persons-years of follow-up in each randomly allocated arm. Participants with a known diagnosis of diabetes at baseline and trials conducted in patients with prevalent diabetes were excluded. For the one-stage individual participant data meta-analysis we used stratified Cox proportional hazards model and for the individual participant data network meta-analysis we used logistic regression models to calculate the relative risk (RR) for drug class comparisons. FINDINGS 145 939 participants (88 500 [60·6%] men and 57 429 [39·4%] women) from 19 randomised controlled trials were included in the one-stage individual participant data meta-analysis. 22 trials were included in the individual participant data network meta-analysis. After a median follow-up of 4·5 years (IQR 2·0), 9883 participants were diagnosed with new-onset type 2 diabetes. Systolic blood pressure reduction by 5 mm Hg reduced the risk of type 2 diabetes across all trials by 11% (hazard ratio 0·89 [95% CI 0·84-0·95]). Investigation of the effects of five major classes of antihypertensive drugs showed that in comparison to placebo, angiotensin-converting enzyme inhibitors (RR 0·84 [95% 0·76-0·93]) and angiotensin II receptor blockers (RR 0·84 [0·76-0·92]) reduced the risk of new-onset type 2 diabetes; however, the use of β blockers (RR 1·48 [1·27-1·72]) and thiazide diuretics (RR 1·20 [1·07-1·35]) increased this risk, and no material effect was found for calcium channel blockers (RR 1·02 [0·92-1·13]). INTERPRETATION Blood pressure lowering is an effective strategy for the prevention of new-onset type 2 diabetes. Established pharmacological interventions, however, have qualitatively and quantitively different effects on diabetes, likely due to their differing off-target effects, with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers having the most favourable outcomes. This evidence supports the indication for selected classes of antihypertensive drugs for the prevention of diabetes, which could further refine the selection of drug choice according to an individual's clinical risk of diabetes. FUNDING British Heart Foundation, National Institute for Health Research, and Oxford Martin School.
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Affiliation(s)
- Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Zeinab Bidel
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Dexter Canoy
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Emma Copland
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Malgorzata Wamil
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK
| | - Jeannette Majert
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK
| | - Karl Smith Byrne
- International Agency for Research on Cancer/WHO, Genomic Epidemiology Branch, Lyon, France
| | - Johan Sundström
- Clinical Epidemiology Unit, Department of Medical Sciences, Uppsala University, Uppsala, Sweden; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Barry R Davis
- The University of Texas School of Public Health, Houston, TX, USA
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Carl J Pepine
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Abbas Dehghan
- Department of Biostatistics and Epidemiology, School of Public Health, Imperial College London, London, UK
| | - Derrick A Bennett
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, Medical Science Division, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Bowling CB, Sloane R, Pieper C, Luciano A, Davis BR, Simpson LM, Einhorn PT, Oparil S, Muntner P. Sustained SBP control and long-term nursing home admission among Medicare beneficiaries. J Hypertens 2021; 39:2258-2264. [PMID: 34232161 PMCID: PMC9194789 DOI: 10.1097/hjh.0000000000002926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Sustaining SBP control reduces the risk for cardiovascular events that impair function but its association with nursing home admission has not been well studied. METHODS We conducted an analysis of sustained SBP control and long-term nursing home admissions using data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) linked to Medicare claims restricted to participants with fee-for-service coverage, at least eight study visits with SBP measurements, who were not living in a nursing home during a 48-month baseline BP assessment period (n = 6557). Sustained SBP control was defined as less than 140 mmHg at less than 50%, 50% to less than 75%, 75% to less than 100%, and 100% of visits. Nursing home admissions were identified using the Medicare Long Term Care Minimum Data Set. RESULTS The mean age of participants was 73.8 years and 44.3% were men. Over a median follow-up of 9.2 years, 844 participants (12.8%) had a nursing home admission. Rates of nursing home admission per 100 person-years were 16.3 for participants with SBP control at less than 50%, 14.1 at 50% to less than 75%, 7.8 at 75% to less than 100%, and 5.3 at 100% of visits. Compared with those with sustained SBP control at less than 50% of visits, hazard ratios (95% confidence intervals) for nursing home admission were 0.79 (0.66-0.93), 0.70 (0.58-0.84), and 0.57 (0.44-0.74) among participants with SBP control at 50% to less than 75%, 75% to less than 100%, and 100% of visits, respectively. CONCLUSION Among Medicare beneficiaries in ALLHAT, sustained SBP control was associated with a lower risk of long-term nursing home admission.
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Affiliation(s)
- C. Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, NC
- Department of Medicine, Duke University, Durham, NC
| | - Richard Sloane
- Center for Study of Aging and Human Development, Duke University, Durham, NC
| | - Carl Pieper
- Center for Study of Aging and Human Development, Duke University, Durham, NC
| | - Alison Luciano
- Center for Study of Aging and Human Development, Duke University, Durham, NC
| | - Barry R. Davis
- The University of Texas School of Public Health, Houston, TX
| | - Lara M. Simpson
- The University of Texas School of Public Health, Houston, TX
| | - Paula T. Einhorn
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL
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Woodhouse LJ, Montgomery AA, Mant J, Davis BR, Algra A, Mas JL, Staessen JA, Thijs L, Tonkin A, Kirby A, Pocock SJ, Chalmers J, Hankey GJ, Spence JD, Sandercock P, Diener HC, Uchiyama S, Sprigg N, Bath PM. Statistical reanalysis of vascular event outcomes in primary and secondary vascular prevention trials. BMC Med Res Methodol 2021; 21:218. [PMID: 34657596 PMCID: PMC8520648 DOI: 10.1186/s12874-021-01388-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vascular prevention trials typically use dichotomous event outcomes although this may be inefficient statistically and gives no indication of event severity. We assessed whether ordinal outcomes would be more efficient and how to best analyse them. METHODS Chief investigators of vascular prevention randomised controlled trials that showed evidence of either benefit or harm, or were included in a systematic review that overall showed benefit or harm, shared individual participant data from their trials. Ordered categorical versions of vascular event outcomes (such as stroke and myocardial infarction) were analysed using 15 statistical techniques and their results then ranked, with the result with the smallest p-value given the smallest rank. Friedman and Duncan's multiple range tests were performed to assess differences between tests by comparing the average ranks for each statistical test. RESULTS Data from 35 trials (254,223 participants) were shared with the collaboration. 13 trials had more than two treatment arms, resulting in 59 comparisons. Analysis approaches (Mann Whitney U, ordinal logistic regression, multiple regression, bootstrapping) that used ordinal outcome data had a smaller average rank and therefore appeared to be more efficient statistically than those that analysed the original binary outcomes. CONCLUSIONS Ordinal vascular outcome measures appear to be more efficient statistically than binary outcomes and provide information on the severity of event. We suggest a potential role for using ordinal outcomes in vascular prevention trials.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Barry R Davis
- The University of Texas Health Science Center at Houston, Houston, USA
| | - Ale Algra
- University Medical Center Utrecht, Utrecht, Netherlands
| | - Jean-Louis Mas
- Hopital Sainte-Anne, Université Paris-Descartes, Paris, France
| | - Jan A Staessen
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Lutgarde Thijs
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Andrew Tonkin
- Chronic Disease & Aging Unit, Monash University, Clayton, Australia
| | - Adrienne Kirby
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - John Chalmers
- George Institute for Global Health, Sydney, Australia
| | - Graeme J Hankey
- Department of Neurology, University of Western Australia, Crawley, Australia
| | | | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Nikola Sprigg
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK.
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Rahimi K, Bidel Z, Nazarzadeh M, Copland E, Canoy D, Wamil M, Majert J, McManus R, Adler A, Agodoa L, Algra A, Asselbergs FW, Beckett NS, Berge E, Black H, Boersma E, Brouwers FPJ, Brown M, Brugts JJ, Bulpitt CJ, Byington RP, Cushman WC, Cutler J, Devereaux RB, Dwyer JP, Estacio R, Fagard R, Fox K, Fukui T, Gupta AK, Holman RR, Imai Y, Ishii M, Julius S, Kanno Y, Kjeldsen SE, Kostis J, Kuramoto K, Lanke J, Lewis E, Lewis JB, Lievre M, Lindholm LH, Lueders S, MacMahon S, Mancia G, Matsuzaki M, Mehlum MH, Nissen S, Ogawa H, Ogihara T, Ohkubo T, Palmer CR, Patel A, Pfeffer MA, Pitt B, Poulter NR, Rakugi H, Reboldi G, Reid C, Remuzzi G, Ruggenenti P, Saruta T, Schrader J, Schrier R, Sever P, Sleight P, Staessen JA, Suzuki H, Thijs L, Ueshima K, Umemoto S, van Gilst WH, Verdecchia P, Wachtell K, Whelton P, Wing L, Woodward M, Yui Y, Yusuf S, Zanchetti A, Zhang ZY, Anderson C, Baigent C, Brenner BM, Collins R, de Zeeuw D, Lubsen J, Malacco E, Neal B, Perkovic V, Rodgers A, Rothwell P, Salimi-Khorshidi G, Sundström J, Turnbull F, Viberti G, Wang J, Chalmers J, Davis BR, Pepine CJ, Teo KK. Age-stratified and blood-pressure-stratified effects of blood-pressure-lowering pharmacotherapy for the prevention of cardiovascular disease and death: an individual participant-level data meta-analysis. Lancet 2021; 398:1053-1064. [PMID: 34461040 PMCID: PMC8473559 DOI: 10.1016/s0140-6736(21)01921-8] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effects of pharmacological blood-pressure-lowering on cardiovascular outcomes in individuals aged 70 years and older, particularly when blood pressure is not substantially increased, is uncertain. We compared the effects of blood-pressure-lowering treatment on the risk of major cardiovascular events in groups of patients stratified by age and blood pressure at baseline. METHODS We did a meta-analysis using individual participant-level data from randomised controlled trials of pharmacological blood-pressure-lowering versus placebo or other classes of blood-pressure-lowering medications, or between more versus less intensive treatment strategies, which had at least 1000 persons-years of follow-up in each treatment group. Participants with previous history of heart failure were excluded. Data were obtained from the Blood Pressure Lowering Treatment Triallists' Collaboration. We pooled the data and categorised participants into baseline age groups (<55 years, 55-64 years, 65-74 years, 75-84 years, and ≥85 years) and blood pressure categories (in 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg systolic blood pressure and from <70 mm Hg to ≥110 mm Hg diastolic). We used a fixed effects one-stage approach and applied Cox proportional hazard models, stratified by trial, to analyse the data. The primary outcome was defined as either a composite of fatal or non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring hospital admission. FINDINGS We included data from 358 707 participants from 51 randomised clinical trials. The age of participants at randomisation ranged from 21 years to 105 years (median 65 years [IQR 59-75]), with 42 960 (12·0%) participants younger than 55 years, 128 437 (35·8%) aged 55-64 years, 128 506 (35·8%) 65-74 years, 54 016 (15·1%) 75-84 years, and 4788 (1·3%) 85 years and older. The hazard ratios for the risk of major cardiovascular events per 5 mm Hg reduction in systolic blood pressure for each age group were 0·82 (95% CI 0·76-0·88) in individuals younger than 55 years, 0·91 (0·88-0·95) in those aged 55-64 years, 0·91 (0·88-0·95) in those aged 65-74 years, 0·91 (0·87-0·96) in those aged 75-84 years, and 0·99 (0·87-1·12) in those aged 85 years and older (adjusted pinteraction=0·050). Similar patterns of proportional risk reductions were observed for a 3 mm Hg reduction in diastolic blood pressure. Absolute risk reductions for major cardiovascular events varied by age and were larger in older groups (adjusted pinteraction=0·024). We did not find evidence for any clinically meaningful heterogeneity of relative treatment effects across different baseline blood pressure categories in any age group. INTERPRETATION Pharmacological blood pressure reduction is effective into old age, with no evidence that relative risk reductions for prevention of major cardiovascular events vary by systolic or diastolic blood pressure levels at randomisation, down to less than 120/70 mm Hg. Pharmacological blood pressure reduction should, therefore, be considered an important treatment option regardless of age, with the removal of age-related blood-pressure thresholds from international guidelines. FUNDING British Heart Foundation, National Institute of Health Research Oxford Biomedical Research Centre, Oxford Martin School.
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Bowling CB, Sloane R, Pieper C, Luciano A, Davis BR, Simpson LM, Einhorn PT, Oparil S, Muntner P. Association of Sustained Blood Pressure Control with Lower Risk for High-Cost Multimorbidities Among Medicare Beneficiaries in ALLHAT. J Gen Intern Med 2021; 36:2221-2229. [PMID: 33564944 PMCID: PMC8342657 DOI: 10.1007/s11606-021-06623-w] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Clustering of chronic conditions is associated with high healthcare costs. Sustaining blood pressure (BP) control could be a strategy to prevent high-cost multimorbidity clusters. OBJECTIVE To determine the association between sustained systolic BP (SBP) control and incident multimorbidity cluster dyads and triads. DESIGN Cohort study of Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) linked to Medicare claims. PARTICIPANTS ALLHAT included adults with hypertension and ≥1 coronary heart disease risk factor. This analysis was restricted to 5234 participants with ≥ 8 SBP measurements during a 48-month BP assessment period. MAIN MEASURES SBP control was defined as <140 mm Hg at <50%, 50 to <75%, 75 to <100%, and 100% of study visits during the BP assessment period. High-cost multimorbidity clusters included dyads (stroke/chronic kidney disease [CKD], stroke/chronic obstructive pulmonary disease [COPD], stroke/heart failure [HF], stroke/asthma, COPD/CKD) and triads (stroke/CKD/asthma, stroke/CKD/COPD, stroke/CKD/depression, stroke/CKD/HF, stroke/HF/asthma) identified during follow-up. KEY RESULTS Incident dyads occurred in 1334 (26%) participants and triads occurred in 481 (9%) participants over a median follow-up of 9.2 years. Among participants with SBP control at <50%, 50 to <75%, 75 to <100%, and 100% of visits, 32%, 23%, 23%, and 19% of participants developed high-cost dyads, respectively, and 13%, 9%, 8%, and 5% of participants developed high-cost triads, respectively. Compared to those with sustained BP control at <50% of visits, adjusted HRs (95% CI) for incident dyads were 0.66 (0.57, 0.75), 0.67 (0.59, 0.77), and 0.51 (0.42, 0.62) for SBP control at 50 to <75%, 75 to <100%, and 100% of visits, respectively. The corresponding HRs (95% CI) for incident triads were 0.69 (0.55, 0.85), 0.56 (0.44, 0.71), and 0.32 (0.22, 0.47). CONCLUSIONS Among Medicare beneficiaries in ALLHAT, sustained SBP was associated with a lower risk of developing high-cost multimorbidity dyads and triads.
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Affiliation(s)
- C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, NC, USA. .,Department of Medicine, Duke University, Durham, NC, USA.
| | - Richard Sloane
- Center for Study of Aging and Human Development, Duke University, Durham, NC, USA
| | - Carl Pieper
- Center for Study of Aging and Human Development, Duke University, Durham, NC, USA
| | - Alison Luciano
- Center for Study of Aging and Human Development, Duke University, Durham, NC, USA
| | - Barry R Davis
- The University of Texas School of Public Health, Houston, TX, USA
| | - Lara M Simpson
- The University of Texas School of Public Health, Houston, TX, USA
| | - Paula T Einhorn
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, MD, USA
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
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Pinho-Gomes AC, Azevedo L, Copland E, Canoy D, Nazarzadeh M, Ramakrishnan R, Berge E, Sundström J, Kotecha D, Woodward M, Teo K, Davis BR, Chalmers J, Pepine CJ, Rahimi K. Blood pressure-lowering treatment for the prevention of cardiovascular events in patients with atrial fibrillation: An individual participant data meta-analysis. PLoS Med 2021; 18:e1003599. [PMID: 34061831 PMCID: PMC8168843 DOI: 10.1371/journal.pmed.1003599] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 03/25/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Randomised evidence on the efficacy of blood pressure (BP)-lowering treatment to reduce cardiovascular risk in patients with atrial fibrillation (AF) is limited. Therefore, this study aimed to compare the effects of BP-lowering drugs in patients with and without AF at baseline. METHODS AND FINDINGS The study was based on the resource provided by the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC), in which individual participant data (IPD) were extracted from trials with over 1,000 patient-years of follow-up in each arm, and that had randomly assigned patients to different classes of BP-lowering drugs, BP-lowering drugs versus placebo, or more versus less intensive BP-lowering regimens. For this study, only trials that had collected information on AF status at baseline were included. The effects of BP-lowering treatment on a composite endpoint of major cardiovascular events (stroke, ischaemic heart disease or heart failure) according to AF status at baseline were estimated using fixed-effect one-stage IPD meta-analyses based on Cox proportional hazards models stratified by trial. Furthermore, to assess whether the associations between the intensity of BP reduction and cardiovascular outcomes are similar in those with and without AF at baseline, we used a meta-regression. From the full BPLTTC database, 28 trials (145,653 participants) were excluded because AF status at baseline was uncertain or unavailable. A total of 22 trials were included with 188,570 patients, of whom 13,266 (7%) had AF at baseline. Risk of bias assessment showed that 20 trials were at low risk of bias and 2 trials at moderate risk. Meta-regression showed that relative risk reductions were proportional to trial-level intensity of BP lowering in patients with and without AF at baseline. Over 4.5 years of median follow-up, a 5-mm Hg systolic BP (SBP) reduction lowered the risk of major cardiovascular events both in patients with AF (hazard ratio [HR] 0.91, 95% confidence interval [CI] 0.83 to 1.00) and in patients without AF at baseline (HR 0.91, 95% CI 0.88 to 0.93), with no difference between subgroups. There was no evidence for heterogeneity of treatment effects by baseline SBP or drug class in patients with AF at baseline. The findings of this study need to be interpreted in light of its potential limitations, such as the limited number of trials, limitation in ascertaining AF cases due to the nature of the arrhythmia and measuring BP in patients with AF. CONCLUSIONS In this meta-analysis, we found that BP-lowering treatment reduces the risk of major cardiovascular events similarly in individuals with and without AF. Pharmacological BP lowering for prevention of cardiovascular events should be recommended in patients with AF.
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Affiliation(s)
| | - Luis Azevedo
- Department of Community Medicine, Information and Health Decision Sciences, Centre for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Emma Copland
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Dexter Canoy
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Milad Nazarzadeh
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Rema Ramakrishnan
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Eivind Berge
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute for Clinical Medicine, University of Tromsø, Norway
| | | | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Department of Epidemiology and Biostatistics, Imperial College, London, United Kingdom
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Barry R. Davis
- The University of Texas School of Public Health, Houston, Texas, United States of America
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Carl J. Pepine
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Kazem Rahimi
- Deep Medicine, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
- * E-mail:
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23
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Rahimi K, Bidel Z, Nazarzadeh M, Copland E, Canoy D, Ramakrishnan R, Pinho-Gomes AC, Woodward M, Adler A, Agodoa L, Algra A, Asselbergs FW, Beckett NS, Berge E, Black H, Brouwers FPJ, Brown M, Bulpitt CJ, Byington RP, Cushman WC, Cutler J, Devereaux RB, Dwyer J, Estacio R, Fagard R, Fox K, Fukui T, Gupta AK, Holman RR, Imai Y, Ishii M, Julius S, Kanno Y, Kjeldsen SE, Kostis J, Kuramoto K, Lanke J, Lewis E, Lewis JB, Lievre M, Lindholm LH, Lueders S, MacMahon S, Mancia G, Matsuzaki M, Mehlum MH, Nissen S, Ogawa H, Ogihara T, Ohkubo T, Palmer CR, Patel A, Pfeffer MA, Pitt B, Poulter NR, Rakugi H, Reboldi G, Reid C, Remuzzi G, Ruggenenti P, Saruta T, Schrader J, Schrier R, Sever P, Sleight P, Staessen JA, Suzuki H, Thijs L, Ueshima K, Umemoto S, van Gilst WH, Verdecchia P, Wachtell K, Whelton P, Wing L, Yui Y, Yusuf S, Zanchetti A, Zhang ZY, Anderson C, Baigent C, Brenner BM, Collins R, de Zeeuw D, Lubsen J, Malacco E, Neal B, Perkovic V, Rodgers A, Rothwell P, Salimi-Khorshidi G, Sundström J, Turnbull F, Viberti G, Wang J, Chalmers J, Teo KK, Pepine CJ, Davis BR. Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis. Lancet 2021; 397:1625-1636. [PMID: 33933205 PMCID: PMC8102467 DOI: 10.1016/s0140-6736(21)00590-0] [Citation(s) in RCA: 348] [Impact Index Per Article: 116.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effects of pharmacological blood pressure lowering at normal or high-normal blood pressure ranges in people with or without pre-existing cardiovascular disease remains uncertain. We analysed individual participant data from randomised trials to investigate the effects of blood pressure lowering treatment on the risk of major cardiovascular events by baseline levels of systolic blood pressure. METHODS We did a meta-analysis of individual participant-level data from 48 randomised trials of pharmacological blood pressure lowering medications versus placebo or other classes of blood pressure-lowering medications, or between more versus less intensive treatment regimens, which had at least 1000 persons-years of follow-up in each group. Trials exclusively done with participants with heart failure or short-term interventions in participants with acute myocardial infarction or other acute settings were excluded. Data from 51 studies published between 1972 and 2013 were obtained by the Blood Pressure Lowering Treatment Trialists' Collaboration (Oxford University, Oxford, UK). We pooled the data to investigate the stratified effects of blood pressure-lowering treatment in participants with and without prevalent cardiovascular disease (ie, any reports of stroke, myocardial infarction, or ischaemic heart disease before randomisation), overall and across seven systolic blood pressure categories (ranging from <120 to ≥170 mm Hg). The primary outcome was a major cardiovascular event (defined as a composite of fatal and non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring admission to hospital), analysed as per intention to treat. FINDINGS Data for 344 716 participants from 48 randomised clinical trials were available for this analysis. Pre-randomisation mean systolic/diastolic blood pressures were 146/84 mm Hg in participants with previous cardiovascular disease (n=157 728) and 157/89 mm Hg in participants without previous cardiovascular disease (n=186 988). There was substantial spread in participants' blood pressure at baseline, with 31 239 (19·8%) of participants with previous cardiovascular disease and 14 928 (8·0%) of individuals without previous cardiovascular disease having a systolic blood pressure of less than 130 mm Hg. The relative effects of blood pressure-lowering treatment were proportional to the intensity of systolic blood pressure reduction. After a median 4·15 years' follow-up (Q1-Q3 2·97-4·96), 42 324 participants (12·3%) had at least one major cardiovascular event. In participants without previous cardiovascular disease at baseline, the incidence rate for developing a major cardiovascular event per 1000 person-years was 31·9 (95% CI 31·3-32·5) in the comparator group and 25·9 (25·4-26·4) in the intervention group. In participants with previous cardiovascular disease at baseline, the corresponding rates were 39·7 (95% CI 39·0-40·5) and 36·0 (95% CI 35·3-36·7), in the comparator and intervention groups, respectively. Hazard ratios (HR) associated with a reduction of systolic blood pressure by 5 mm Hg for a major cardiovascular event were 0·91, 95% CI 0·89-0·94 for partipants without previous cardiovascular disease and 0·89, 0·86-0·92, for those with previous cardiovascular disease. In stratified analyses, there was no reliable evidence of heterogeneity of treatment effects on major cardiovascular events by baseline cardiovascular disease status or systolic blood pressure categories. INTERPRETATION In this large-scale analysis of randomised trials, a 5 mm Hg reduction of systolic blood pressure reduced the risk of major cardiovascular events by about 10%, irrespective of previous diagnoses of cardiovascular disease, and even at normal or high-normal blood pressure values. These findings suggest that a fixed degree of pharmacological blood pressure lowering is similarly effective for primary and secondary prevention of major cardiovascular disease, even at blood pressure levels currently not considered for treatment. Physicians communicating the indication for blood pressure lowering treatment to their patients should emphasise its importance on reducing cardiovascular risk rather than focusing on blood pressure reduction itself. FUNDING British Heart Foundation, UK National Institute for Health Research, and Oxford Martin School.
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Bolli R, Mitrani RD, Hare JM, Pepine CJ, Perin EC, Willerson JT, Traverse JH, Henry TD, Yang PC, Murphy MP, March KL, Schulman IH, Ikram S, Lee DP, O’Brien C, Lima JA, Ostovaneh MR, Ambale-Venkatesh B, Lewis G, Khan A, Bacallao K, Valasaki K, Longsomboon B, Gee AP, Richman S, Taylor DA, Lai D, Sayre SL, Bettencourt J, Vojvodic RW, Cohen ML, Simpson L, Aguilar D, Loghin C, Moyé L, Ebert RF, Davis BR, Simari RD. A Phase II study of autologous mesenchymal stromal cells and c-kit positive cardiac cells, alone or in combination, in patients with ischaemic heart failure: the CCTRN CONCERT-HF trial. Eur J Heart Fail 2021; 23:661-674. [PMID: 33811444 PMCID: PMC8357352 DOI: 10.1002/ejhf.2178] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [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: 12/04/2020] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 12/21/2022] Open
Abstract
AIMS CONCERT-HF is an NHLBI-sponsored, double-blind, placebo-controlled, Phase II trial designed to determine whether treatment with autologous bone marrow-derived mesenchymal stromal cells (MSCs) and c-kit positive cardiac cells (CPCs), given alone or in combination, is feasible, safe, and beneficial in patients with heart failure (HF) caused by ischaemic cardiomyopathy. METHODS AND RESULTS Patients were randomized (1:1:1:1) to transendocardial injection of MSCs combined with CPCs, MSCs alone, CPCs alone, or placebo, and followed for 12 months. Seven centres enrolled 125 participants with left ventricular ejection fraction of 28.6 ± 6.1% and scar size 19.4 ± 5.8%, in New York Heart Association class II or III. The proportion of major adverse cardiac events (MACE) was significantly decreased by CPCs alone (-22% vs. placebo, P = 0.043). Quality of life (Minnesota Living with Heart Failure Questionnaire score) was significantly improved by MSCs alone (P = 0.050) and MSCs + CPCs (P = 0.023) vs. placebo. Left ventricular ejection fraction, left ventricular volumes, scar size, 6-min walking distance, and peak oxygen consumption did not differ significantly among groups. CONCLUSIONS This is the first multicentre trial assessing CPCs and a combination of two cell types from different tissues in HF patients. The results show that treatment is safe and feasible. Even with maximal guideline-directed therapy, both CPCs and MSCs were associated with improved clinical outcomes (MACE and quality of life, respectively) in ischaemic HF without affecting left ventricular function or structure, suggesting possible systemic or paracrine cellular mechanisms. Combining MSCs with CPCs was associated with improvement in both these outcomes. These results suggest potential important beneficial effects of CPCs and MSCs and support further investigation in HF patients.
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Affiliation(s)
- Roberto Bolli
- University of Louisville, School of Medicine, Louisville, KY, USA
| | - Raul D. Mitrani
- University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Joshua M. Hare
- University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Carl J. Pepine
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Emerson C. Perin
- Texas Heart Institute, CHI St. Luke’s Health Baylor College of Medicine Medical Center, Houston, TX, USA
| | - James T. Willerson
- Texas Heart Institute, CHI St. Luke’s Health Baylor College of Medicine Medical Center, Houston, TX, USA
| | - Jay H. Traverse
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, and University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, OH, USA
| | | | | | - Keith L. March
- University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Sohail Ikram
- University of Louisville, School of Medicine, Louisville, KY, USA
| | - David P. Lee
- Stanford University School of Medicine, Stanford, CA, USA
| | - Connor O’Brien
- Stanford University School of Medicine, Stanford, CA, USA
| | - Joao A. Lima
- Johns Hopkins University, Cardiovascular Imaging, Baltimore, MD, USA
| | | | | | - Gregory Lewis
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aisha Khan
- University of Miami, Miller School of Medicine, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Ketty Bacallao
- University of Miami, Miller School of Medicine, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Krystalenia Valasaki
- University of Miami, Miller School of Medicine, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Bangon Longsomboon
- University of Miami, Miller School of Medicine, Interdisciplinary Stem Cell Institute, Miami, FL, USA
| | - Adrian P. Gee
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Sara Richman
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Doris A. Taylor
- Texas Heart Institute, CHI St. Luke’s Health Baylor College of Medicine Medical Center, Houston, TX, USA
| | - Dejian Lai
- UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Shelly L. Sayre
- UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Judy Bettencourt
- UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Rachel W. Vojvodic
- UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Michelle L. Cohen
- UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Lara Simpson
- UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - David Aguilar
- UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
- UTHealth University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Catalin Loghin
- UTHealth University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX, USA
| | - Lem Moyé
- UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Ray F. Ebert
- NIH, National Heart, Lung and Blood Institute, Bethesda, MD, USA
| | - Barry R. Davis
- UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
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Copland E, Canoy D, Nazarzadeh M, Bidel Z, Ramakrishnan R, Woodward M, Chalmers J, Teo KK, Pepine CJ, Davis BR, Kjeldsen S, Sundström J, Rahimi K. Antihypertensive treatment and risk of cancer: an individual participant data meta-analysis. Lancet Oncol 2021; 22:558-570. [PMID: 33794209 PMCID: PMC8024901 DOI: 10.1016/s1470-2045(21)00033-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Some studies have suggested a link between antihypertensive medication and cancer, but the evidence is so far inconclusive. Thus, we aimed to investigate this association in a large individual patient data meta-analysis of randomised clinical trials. METHODS We searched PubMed, MEDLINE, The Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from Jan 1, 1966, to Sept 1, 2019, to identify potentially eligible randomised controlled trials. Eligible studies were randomised controlled trials comparing one blood pressure lowering drug class with a placebo, inactive control, or other blood pressure lowering drug. We also required that trials had at least 1000 participant years of follow-up in each treatment group. Trials without cancer event information were excluded. We requested individual participant data from the authors of eligible trials. We pooled individual participant-level data from eligible trials and assessed the effects of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), β blockers, calcium channel blockers, and thiazide diuretics on cancer risk in one-stage individual participant data and network meta-analyses. Cause-specific fixed-effects Cox regression models, stratified by trial, were used to calculate hazard ratios (HRs). The primary outcome was any cancer event, defined as the first occurrence of any cancer diagnosed after randomisation. This study is registered with PROSPERO (CRD42018099283). FINDINGS 33 trials met the inclusion criteria, and included 260 447 participants with 15 012 cancer events. Median follow-up of included participants was 4·2 years (IQR 3·0-5·0). In the individual participant data meta-analysis comparing each drug class with all other comparators, no associations were identified between any antihypertensive drug class and risk of any cancer (HR 0·99 [95% CI 0·95-1·04] for ACEIs; 0·96 [0·92-1·01] for ARBs; 0·98 [0·89-1·07] for β blockers; 1·01 [0·95-1·07] for thiazides), with the exception of calcium channel blockers (1·06 [1·01-1·11]). In the network meta-analysis comparing drug classes against placebo, we found no excess cancer risk with any drug class (HR 1·00 [95% CI 0·93-1·09] for ACEIs; 0·99 [0·92-1·06] for ARBs; 0·99 [0·89-1·11] for β blockers; 1·04 [0·96-1·13] for calcium channel blockers; 1·00 [0·90-1·10] for thiazides). INTERPRETATION We found no consistent evidence that antihypertensive medication use had any effect on cancer risk. Although such findings are reassuring, evidence for some comparisons was insufficient to entirely rule out excess risk, in particular for calcium channel blockers. FUNDING British Heart Foundation, National Institute for Health Research, Oxford Martin School.
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Affiliation(s)
- Emma Copland
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Dexter Canoy
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Zeinab Bidel
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rema Ramakrishnan
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Department of Epidemiology and Biostatistics, The George Institute for Global Health, Imperial College London, London, UK; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Koon K Teo
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Carl J Pepine
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Barry R Davis
- School of Public Health, University of Texas, Houston, TX, USA
| | - Sverre Kjeldsen
- Department of Cardiology, University of Oslo, Ullevaal Hospital, Oslo, Norway
| | - Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Juraschek SP, Hu JR, Cluett JL, Ishak A, Mita C, Lipsitz LA, Appel LJ, Beckett NS, Coleman RL, Cushman WC, Davis BR, Grandits G, Holman RR, Miller ER, Peters R, Staessen JA, Taylor AA, Thijs L, Wright JT, Mukamal KJ. Effects of Intensive Blood Pressure Treatment on Orthostatic Hypotension : A Systematic Review and Individual Participant-based Meta-analysis. Ann Intern Med 2021; 174:58-68. [PMID: 32909814 PMCID: PMC7855528 DOI: 10.7326/m20-4298] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [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: 12/13/2022] Open
Abstract
BACKGROUND Although intensive blood pressure (BP)-lowering treatment reduces risk for cardiovascular disease, there are concerns that it might cause orthostatic hypotension (OH). PURPOSE To examine the effects of intensive BP-lowering treatment on OH in hypertensive adults. DATA SOURCES MEDLINE, EMBASE, and Cochrane CENTRAL from inception through 7 October 2019, without language restrictions. STUDY SELECTION Randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) that involved more than 500 adults with hypertension or elevated BP and that were 6 months or longer in duration. Trial comparisons were groups assigned to either less intensive BP goals or placebo, and the outcome was measured OH, defined as a decrease of 20 mm Hg or more in systolic BP or 10 mm Hg or more in diastolic BP after changing position from seated to standing. DATA EXTRACTION 2 investigators independently abstracted articles and rated risk of bias. DATA SYNTHESIS 5 trials examined BP treatment goals, and 4 examined active agents versus placebo. Trials examining BP treatment goals included 18 466 participants with 127 882 follow-up visits. Trials were open-label, with minimal heterogeneity of effects across trials. Intensive BP treatment lowered risk for OH (odds ratio, 0.93 [95% CI, 0.86 to 0.99]). Effects did not differ by prerandomization OH (P for interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged. LIMITATIONS Assessments of OH were done while participants were seated (not supine) and did not include the first minute after standing. Data on falls and syncope were not available. CONCLUSION Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute, National Institutes of Health. (PROSPERO: CRD42020153753).
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Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
| | - Jiun-Ruey Hu
- Vanderbilt University Medical Center, Nashville, Tennessee (J.H.)
| | - Jennifer L Cluett
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
| | - Anthony Ishak
- Healthcare Associates, Beth Israel-Lahey Health System, Boston, Massachusetts (A.I.)
| | - Carol Mita
- Countway Library, Harvard University, Boston, Massachusetts (C.M.)
| | - Lewis A Lipsitz
- Beth Israel Deaconess Medical Center, Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, and Harvard Medical School, Boston, Massachusetts (L.A.L.)
| | | | - Nigel S Beckett
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (N.S.B.)
| | - Ruth L Coleman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom (R.L.C., R.R.H.)
| | - William C Cushman
- University of Tennessee Health Science Center, Memphis, Tennessee (W.C.C.)
| | - Barry R Davis
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas (B.R.D.)
| | - Greg Grandits
- School of Public Health, University of Minnesota, Minneapolis, Minnesota (G.G.)
| | - Rury R Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom (R.L.C., R.R.H.)
| | - Edgar R Miller
- Johns Hopkins University, Baltimore, Maryland (L.J.A., E.R.M.)
| | - Ruth Peters
- University of New South Wales, Sydney, and Neuroscience Research Australia, Randwick, New South Wales, Australia (R.P.)
| | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, and NPA Alliance for the Promotion of Preventive Medicine (APPREMED), Mechelen, Belgium (J.A.S.)
| | - Addison A Taylor
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas (A.A.T.)
| | - Lutgarde Thijs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, University of Leuven, Leuven, Belgium (L.T.)
| | - Jackson T Wright
- Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio (J.T.W.)
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (S.P.J., J.L.C., K.J.M.)
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Berkelmans GFN, Gudbjörnsdottir S, Visseren FLJ, Wild SH, Franzen S, Chalmers J, Davis BR, Poulter NR, Spijkerman AM, Woodward M, Pressel SL, Gupta AK, van der Schouw YT, Svensson AM, van der Graaf Y, Read SH, Eliasson B, Dorresteijn JAN. Prediction of individual life-years gained without cardiovascular events from lipid, blood pressure, glucose, and aspirin treatment based on data of more than 500 000 patients with Type 2 diabetes mellitus. Eur Heart J 2020; 40:2899-2906. [PMID: 30629157 DOI: 10.1093/eurheartj/ehy839] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/31/2018] [Accepted: 11/27/2018] [Indexed: 01/07/2023] Open
Abstract
AIMS Although group-level effectiveness of lipid, blood pressure, glucose, and aspirin treatment for prevention of cardiovascular disease (CVD) has been proven by trials, important differences in absolute effectiveness exist between individuals. We aim to develop and validate a prediction tool for individualizing lifelong CVD prevention in people with Type 2 diabetes mellitus (T2DM) predicting life-years gained without myocardial infarction or stroke. METHODS AND RESULTS We developed and validated the Diabetes Lifetime-perspective prediction (DIAL) model, consisting of two complementary competing risk adjusted Cox proportional hazards functions using data from people with T2DM registered in the Swedish National Diabetes Registry (n = 389 366). Competing outcomes were (i) CVD events (vascular mortality, myocardial infarction, or stroke) and (ii) non-vascular mortality. Predictors were age, sex, smoking, systolic blood pressure, body mass index, haemoglobin A1c, estimated glomerular filtration rate, non- high-density lipoprotein cholesterol, albuminuria, T2DM duration, insulin treatment, and history of CVD. External validation was performed using data from the ADVANCE, ACCORD, ASCOT and ALLHAT-LLT-trials, the SMART and EPIC-NL cohorts, and the Scottish diabetes register (total n = 197 785). Predicted and observed CVD-free survival showed good agreement in all validation sets. C-statistics for prediction of CVD were 0.83 (95% confidence interval: 0.83-0.84) and 0.64-0.65 for internal and external validation, respectively. We provide an interactive calculator at www.U-Prevent.com that combines model predictions with relative treatment effects from trials to predict individual benefit from preventive treatment. CONCLUSION Cardiovascular disease-free life expectancy and effects of lifelong prevention in terms of CVD-free life-years gained can be estimated for people with T2DM using readily available clinical characteristics. Predictions of individual-level treatment effects facilitate translation of trial results to individual patients.
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Affiliation(s)
- Gijs F N Berkelmans
- Department of Vascular Medicine, University Medical Center Utrecht, GA Utrecht, the Netherlands
| | - Soffia Gudbjörnsdottir
- Swedish National Diabetes Register, Center of Registers in Region, Medicinaregatan 18C, Gothenburg, Sweden
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, GA Utrecht, the Netherlands
| | - Sarah H Wild
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot place, EH89AG Edinburgh, UK and the Scottish Diabetes Research Network Epidemiology Group
| | - Stefan Franzen
- Swedish National Diabetes Register, Center of Registers in Region, Medicinaregatan 18C, Gothenburg, Sweden
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5, 1 King Street, Newtown NSW, Australia
| | - Barry R Davis
- Department of Biostatistics, University of Texas School of Public Health, Houston, TX, USA
| | - Neil R Poulter
- ICCH, Imperial College London, Level 2 Faculty building, South Kensington campus, London, UK
| | - Annemieke M Spijkerman
- National Institute for Public Health and the Environment (RIVM), 3720 BA, Bilthoven, the Netherlands
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5, 1 King Street, Newtown NSW, Australia.,Department of Epidemiology, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD, USA.,The George Institute for Global Health, University of Oxford, Hayes House, 75 George Street, Oxford, UK
| | - Sara L Pressel
- Department of Biostatistics, University of Texas School of Public Health, Houston, TX, USA
| | - Ajay K Gupta
- ICCH, Imperial College London, Level 2 Faculty building, South Kensington campus, London, UK.,William Harvey Research Institute, Queen Mary University of London, Mile End Road, London, UK
| | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, HP: str 6.131, GA Utrecht, the Netherlands
| | - Ann-Marie Svensson
- Swedish National Diabetes Register, Center of Registers in Region, Medicinaregatan 18C, Gothenburg, Sweden
| | - Yolanda van der Graaf
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, HP: str 6.131, GA Utrecht, the Netherlands
| | - Stephanie H Read
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot place, EH89AG Edinburgh, UK and the Scottish Diabetes Research Network Epidemiology Group
| | - Bjorn Eliasson
- Swedish National Diabetes Register, Center of Registers in Region, Medicinaregatan 18C, Gothenburg, Sweden
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Center Utrecht, GA Utrecht, the Netherlands
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28
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Bolli R, Perin EC, Willerson JT, Yang PC, Traverse JH, Henry TD, Pepine CJ, Mitrani RD, Hare JM, Murphy MP, March KL, Ikram S, Lee DP, O’Brien C, Durand JB, Miller K, Lima JA, Ostovaneh MR, Ambale-Venkatesh B, Gee AP, Richman S, Taylor DA, Sayre SL, Bettencourt J, Vojvodic RW, Cohen ML, Simpson LM, Lai D, Aguilar D, Loghin C, Moyé L, Ebert RF, Davis BR, Simari RD. Allogeneic Mesenchymal Cell Therapy in Anthracycline-Induced Cardiomyopathy Heart Failure Patients: The CCTRN SENECA Trial. JACC CardioOncol 2020; 2:581-595. [PMID: 33403362 PMCID: PMC7781291 DOI: 10.1016/j.jaccao.2020.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Anthracycline-induced cardiomyopathy (AIC) may be irreversible with a poor prognosis, disproportionately affecting women and young adults. Administration of allogeneic bone marrow-derived mesenchymal stromal cells (allo-MSCs) is a promising approach to heart failure (HF) treatment. OBJECTIVES SENECA (Stem Cell Injection in Cancer Survivors) was a phase 1 study of allo-MSCs in AIC. METHODS Cancer survivors with chronic AIC (mean age 56.6 years; 68% women; NT-proBNP 1,426 pg/ml; 6 enrolled in an open-label, lead-in phase and 31 subjects randomized 1:1) received 1 × 108 allo-MSCs or vehicle transendocardially. Primary objectives were safety and feasibility. Secondary efficacy measures included cardiac function and structure measured by cardiac magnetic resonance imaging (CMR), functional capacity, quality of life (Minnesota Living with Heart Failure Questionnaire), and biomarkers. RESULTS A total of 97% of subjects underwent successful study product injections; all allo-MSC-assigned subjects received the target dose of cells. Follow-up visits were well-attended (92%) with successful collection of endpoints in 94% at the 1-year visit. Although 58% of subjects had non-CMR compatible devices, CMR endpoints were successfully collected in 84% of subjects imaged at 1 year. No new tumors were reported. There were no significant differences between allo-MSC and vehicle groups with regard to clinical outcomes. Secondary measures included 6-min walk test (p = 0.056) and Minnesota Living with Heart Failure Questionnaire score (p = 0.048), which tended to favor the allo-MSC group. CONCLUSIONS In this first-in-human study of cell therapy in patients with AIC, transendocardial administration of allo-MSCs appears safe and feasible, and CMR was successfully performed in the majority of the HF patients with devices. This study lays the groundwork for phase 2 trials aimed at assessing efficacy of cell therapy in patients with AIC.
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Affiliation(s)
- Roberto Bolli
- Department of Medicine, Division of Cardiovascular Medicine, University of Louisville, School of Medicine, Louisville, Kentucky, USA
| | - Emerson C. Perin
- Division of Cardiology Research, Texas Heart Institute, CHI St. Luke’s Health Baylor College of Medicine Medical Center, Houston, Texas, USA
| | - James T. Willerson
- Division of Cardiology Research, Texas Heart Institute, CHI St. Luke’s Health Baylor College of Medicine Medical Center, Houston, Texas, USA
| | - Phillip C. Yang
- Department of Medicine and Cardiovascular Institute, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jay H. Traverse
- Department of Medicine, Cardiovascular Division, Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, and University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio, USA
| | - Carl J. Pepine
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Raul D. Mitrani
- Department of Medicine, Cardiovascular Division, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Joshua M. Hare
- Department of Molecular and Cellular Pharmacology, Division of Cardiology, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Michael P. Murphy
- Department of Surgery, Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Keith L. March
- Department of Medicine, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sohail Ikram
- Department of Medicine, Division of Cardiovascular Medicine, University of Louisville, School of Medicine, Louisville, Kentucky, USA
| | - David P. Lee
- Department of Medicine and Cardiovascular Institute, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Connor O’Brien
- Department of Medicine and Cardiovascular Institute, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jean-Bernard Durand
- Department of Cardiology, Division of Internal Medicine, M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Kathy Miller
- Department of Medicine, Division of Hematology/Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joao A. Lima
- Department of Medicine, Cardiology Division, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mohammad R. Ostovaneh
- Department of Medicine, Cardiology Division, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Adrian P. Gee
- Department of Pediatrics, Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas, USA
| | - Sara Richman
- Department of Pediatrics, Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas, USA
| | - Doris A. Taylor
- Department of Regenerative Medicine Research, Texas Heart Institute, CHI St. Luke's Health Baylor College of Medicine Medical Center, Houston, Texas, USA
| | - Shelly L. Sayre
- Department of Biostatistics & Data Science, UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Judy Bettencourt
- Department of Biostatistics & Data Science, UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Rachel W. Vojvodic
- Department of Biostatistics & Data Science, UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Michelle L. Cohen
- Department of Biostatistics & Data Science, UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Lara M. Simpson
- Department of Biostatistics & Data Science, UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Dejian Lai
- Department of Biostatistics & Data Science, UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - David Aguilar
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Catalin Loghin
- Department of Medicine, Division of Cardiovascular Medicine, UTHealth University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas, USA
| | - Lem Moyé
- Department of Biostatistics & Data Science, UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA
| | - Ray F. Ebert
- Division of Cardiovascular Sciences, Basic & Early Translational Research Program, National Institutes of Health, National Heart, Lung, and Blood Institute, Washington, DC, USA
| | - Barry R. Davis
- Department of Biostatistics & Data Science, UTHealth University of Texas Health Science Center at Houston School of Public Health, Houston, Texas, USA,Address for correspondence: Dr. Barry R. Davis, UTHealth School of Public Health, 1200 Pressler, W-916, Houston, Texas 77584. @UTexasSPH
| | - Robert D. Simari
- Division of Cardiovascular Diseases, University of Kansas School of Medicine, Kansas City, Kansas, USA
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29
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Juraschek SP, Hu JR, Cluett J, Ishak A, Mita C, Lipsitz L, Appel LJ, Beckett N, Coleman RL, CUSHMAN WILLIAM, Davis BR, Grandits G, Holman RR, Miller ER, Peters R, Staessen JA, Taylor A, Thijs L, Wright JT, Mukamal KJ. Abstract MP36: Effects Of Intensive Blood Pressure Treatment On Orthostatic Hypotension: An Individual-level Meta-analysis. Hypertension 2020. [DOI: 10.1161/hyp.76.suppl_1.mp36] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Intensive blood pressure (BP) treatment reduces the risk of cardiovascular disease, but there are ongoing concerns that it also might be harmful by increasing the risk of orthostatic hypotension (OH). However, individual trials have been inconclusive.
Methods:
In this individual participant data meta-analysis, we systematically reviewed MEDLINE, EMBASE, and CENTRAL databases through October 7, 2019 for randomized trials of BP pharmacologic treatment (more intensive BP goal or active agent) on measured OH. OH was defined as a drop in SBP ≥20 mmHg or DBP ≥10 mmHg after changing positions from seated to standing. Ultimately, five trials of BP treatment goal were identified. Effects were examined overall and in subgroups of baseline characteristics, including diabetes, standing BP pre-randomization (<110 vs ≥110 mm Hg), and pre-randomization OH.
Results:
There were 18,466 participants with 127,998 follow-up visits. Most trials demonstrated low risk of bias with minimal heterogeneity of effects across trials (
I
2
= 0.0%). Intensive BP treatment significantly lowered risk of OH (OR 0.93; 95% CI: 0.86, 0.99). Effects were strongest among adults without diabetes (OR 0.90 vs 1.10;
P
-interaction = 0.015) and adults with lower standing SBP (OR 0.66 for <110 mmHg vs 0.96 for ≥110 mmHg;
P
-interaction = 0.02). Effects did not differ by pre-randomization OH (
P
-interaction = 0.80). In sensitivity analyses that included 4 additional placebo-controlled trials, overall and subgroup findings were unchanged (
Figure
).
Conclusion:
OH prior to or in the setting of more intensive BP treatment should not be viewed as a reason to avoid or to de-escalate treatment for hypertension.
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Affiliation(s)
| | | | | | | | - Carol Mita
- Countway Library Harvard Univ, Boston, MA
| | | | | | | | - Ruth L Coleman
- Radcliffe Dept of Medicine, Univ of Oxford, Oxford, United Kingdom
| | | | | | | | - Rury R Holman
- Radcliffe Dept of Medicine, Univ of Oxford, Oxford, United Kingdom
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30
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Johnson K, Oparil S, Davis BR, Tereshchenko LG. Prevention of Heart Failure in Hypertension-Disentangling the Role of Evolving Left Ventricular Hypertrophy and Blood Pressure Lowering: The ALLHAT Study. J Am Heart Assoc 2020; 8:e011961. [PMID: 30943832 PMCID: PMC6507192 DOI: 10.1161/jaha.119.011961] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Hypertension is a known risk factor for heart failure (HF), possibly via the mechanism of cardiac remodeling and left ventricular hypertrophy (LVH). We studied the extent to which blood pressure (BP) change and evolving LVH contribute to the effect that lisinopril, doxazosin, and amlodipine have on HF compared with chlorthalidone. Methods and Results We conducted causal mediation analysis of ALLHAT (Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial) data (1994‐2002; in‐trial follow‐up). ALLHAT participants with available serial ECGs and BP measurements were included (n=29 892; mean age 67±4 years; 32% black; 56% men): 11 008 were randomized to chlorthalidone, 5967 to doxazosin, 6593 to amlodipine, and 6324 to lisinopril. Evolving ECG LVH and BP lowering served as mediators. Incident symptomatic HF was the primary outcome. Linear regression (for mediator) and logistic regression (for outcome) models were adjusted for mediator‐outcome confounders (demographic and clinical characteristics known to be associated both with both LVH/hypertension and HF). A large majority of participants (96%) had ECG LVH status unchanged, but 4% developed evolving ECG LVH. On average, BP decreased by 11/7 mm Hg. In adjusted Cox regression analyses, progressing ECG LVH (hazard ratio [HR] 1.78 [95% CI 1.43‐2.22]), resolving ECG LVH (HR 1.33 [95% CI 1.03‐1.70]), and baseline ECG LVH (1.17 [95% CI 1.04‐1.31]) carried risk of incident HF. After full adjustment, evolving ECG LVH mediated 4% of the effect of doxazosin on HF. Systolic BP lowering mediated 12% of the effect of doxazosin, and diastolic BP lowering mediated 10% of the effect of doxazosin, 7% of the effect of amlodipine, and borderline 9% of the effect of lisinopril on HF. Conclusions Evolving ECG LVH and BP change account for 4% to 13% of the mechanism by which antihypertensive medications prevent HF. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542. See Editorial Ferdinand and Maraboto
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Affiliation(s)
- Kyle Johnson
- The Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
| | - Suzanne Oparil
- Department of MedicineSchool of MedicineUniversity of Alabama at BirminghamAL
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31
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Morse BC, Boland BN, Morse JN, Jones YR, Simpson JP, Appleby DA, Davis BR, Taylor SM. DeBakey Type II Aortic Dissection: A Rare Catastrophic Complication of Pregnancy. Am Surg 2020. [DOI: 10.1177/000313481408000304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Bryan C. Morse
- Department of Surgery University of South Carolina School of Medicine–Greenville Greenville, South Carolina
| | - Brian N. Boland
- Department of Surgery University of South Carolina School of Medicine–Greenville Greenville, South Carolina
| | - Jessica N. Morse
- Department of Surgery University of South Carolina School of Medicine–Greenville Greenville, South Carolina
| | - Yonge R. Jones
- Department of Surgery University of South Carolina School of Medicine–Greenville Greenville, South Carolina
| | - Joshua P. Simpson
- Department of Surgery University of South Carolina School of Medicine–Greenville Greenville, South Carolina
| | - Douglas A. Appleby
- Department of Surgery University of South Carolina School of Medicine–Greenville Greenville, South Carolina
| | - Barry R. Davis
- Department of Surgery University of South Carolina School of Medicine–Greenville Greenville, South Carolina
| | - Spence M. Taylor
- Department of Surgery University of South Carolina School of Medicine–Greenville Greenville, South Carolina
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32
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Bowling CB, Sloane R, Pieper C, Luciano A, Davis BR, Simpson LM, Einhorn PT, Oparil S, Muntner P. Association of Sustained Blood Pressure Control with Multimorbidity Progression Among Older Adults. J Am Geriatr Soc 2020; 68:2059-2066. [PMID: 32501546 DOI: 10.1111/jgs.16558] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/09/2020] [Accepted: 04/26/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Due to the high costs and excess mortality associated with multimorbidity, there is a need to develop approaches for delaying its progression. High blood pressure (BP) is a common chronic condition and a risk factor for many additional chronic conditions, making it an ideal target for intervention. The purpose of this analysis was to determine the association between the level of sustained BP control and the progression of multimorbidity. DESIGN Retrospective cohort study. SETTING Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) linked to Medicare claims. PARTICIPANTS A total of 6,591 ALLHAT participants with Medicare who had systolic BP (SBP) measurements at eight or more study visits. MEASUREMENTS SBP control was categorized as lower than 140 mm Hg at less than 50%, 50% to less than 75%, 75% to less than 100%, and 100% of visits. Multimorbidity progression was defined by the number of incident chronic conditions, including arthritis, asthma, atrial fibrillation, cancer, chronic kidney disease, chronic obstructive pulmonary disease, coronary heart disease, dementia, depression, diabetes mellitus, heart failure, hyperlipidemia, osteoporosis, and stroke. Recurrent event survival analysis was used to calculate rate ratios (RRs) for the association of sustained SBP control with progression of multimorbidity. RESULTS Rates of incident conditions per 10 person-years (95% CIs) were 5.2 (5.1-5.4), 4.7 (4.5-4.8), 4.4 (4.2-4.5), and 4.0 (3.8-4.2) for participants with SBP control at less than 50%, 50% to less than 75%, 75% to less than 100%, and 100% of visits, respectively, over a median follow-up of 9.0 years. Compared with participants with SBP control at less than 50% of visits, adjusted RRs (95% CIs) for multimorbidity progression were 0.90 (0.86-0.95), 0.85 (0.81-0.89), and 0.77 (0.72-0.82) for those with SBP control at 50% to less than 75%, 75% to less than 100%, and 100% of visits, respectively. CONCLUSIONS Sustaining BP control may be an effective approach to slow multimorbidity progression and may reduce the population burden of multimorbidity.
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Affiliation(s)
- C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.,Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Richard Sloane
- Center for Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
| | - Carl Pieper
- Center for Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
| | - Alison Luciano
- Center for Study of Aging and Human Development, Duke University, Durham, North Carolina, USA
| | - Barry R Davis
- The University of Texas School of Public Health, Houston, Texas, USA
| | - Lara M Simpson
- The University of Texas School of Public Health, Houston, Texas, USA
| | - Paula T Einhorn
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland, USA
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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33
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Masso AH, Uribe C, Willerson JT, Cheong BY, Davis BR. Left Ventricular Noncompaction Detected by Cardiac Magnetic Resonance Screening: A Reexamination of Diagnostic Criteria. Tex Heart Inst J 2020; 47:183-193. [PMID: 32997774 DOI: 10.14503/thij-19-7157] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
In a previous cross-sectional screening study of 5,169 middle and high school students (mean age, 13.1 ± 1.78 yr) in which we estimated the prevalence of high-risk cardiovascular conditions associated with sudden cardiac death, we incidentally detected by cardiac magnetic resonance (CMR) 959 cases (18.6%) of left ventricular noncompaction (LVNC) that met the Petersen diagnostic criterion (noncompaction:compaction ratio >2.3). Short-axis CMR images were available for 511 of these cases (the Short-Axis Study Set). To determine how many of those cases were truly abnormal, we analyzed the short-axis images in terms of LV structural and functional variables and applied 3 published diagnostic criteria besides the Petersen criterion to our findings. The estimated prevalences were 17.5% based on trabeculated LV mass (Jacquier criterion), 7.4% based on trabeculated LV volume (Choi criterion), and 1.3% based on trabeculated LV mass and distribution (Grothoff criterion). Absent longitudinal clinical outcomes data or accepted diagnostic standards, our analysis of the screening data from the Short-Axis Study Set did not definitively differentiate normal from pathologic cases. However, it does suggest that many of the cases might be normal anatomic variants. It also suggests that cases marked by pathologically excessive LV trabeculation, even if asymptomatic, might involve unsustainable physiologic disadvantages that increase the risk of LV dysfunction, pathologic remodeling, arrhythmias, or mural thrombi. These disadvantages may escape detection, particularly in children developing from prepubescence through adolescence. Longitudinal follow-up of suspected LVNC cases to ascertain their natural history and clinical outcome is warranted.
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Affiliation(s)
- Anthony H Masso
- Department of Cardiology, The University of Texas School of Public Health, Houston, Texas 77030
| | - Carlo Uribe
- Department of Cardiology, The University of Texas School of Public Health, Houston, Texas 77030
| | - James T Willerson
- Department of Cardiology, The University of Texas School of Public Health, Houston, Texas 77030
| | - Benjamin Y Cheong
- Department of Cardiology, The University of Texas School of Public Health, Houston, Texas 77030.,Department of Cardiovascular Radiology, Texas Heart Institute, The University of Texas School of Public Health, Houston, Texas 77030
| | - Barry R Davis
- Department of Biostatistics, The University of Texas School of Public Health, Houston, Texas 77030
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34
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Juraschek SP, Simpson LM, Davis BR, Shmerling RH, Beach JL, Ishak A, Mukamal KJ. The effects of antihypertensive class on gout in older adults: secondary analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. J Hypertens 2020; 38:954-960. [PMID: 31977576 DOI: 10.1097/hjh.0000000000002359] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Gout is a common complication of blood pressure management and a frequently cited cause of medication nonadherence. Little trial evidence exists to inform antihypertensive selection with regard to gout risk. METHODS The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was a randomized clinical trial on the effects of first-step hypertension therapy with amlodipine, chlorthalidone, or lisinopril on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). Trial participants were linked to CMS and VA gout claims (ICD9 274.XX). We determined the effect of drug assignment on gout with Cox regression models. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) with gout. RESULTS Claims were linked to 23 964 participants (mean age 69.8 ± 6.8 years, 45% women, 31% black). Atenolol use was reported by 928 participants at the 1-month visit. Over a mean follow-up of 4.9 years, we documented 597 gout claims. Amlodipine reduced the risk of gout by 37% (hazard ratio 0.63; 95% CI 0.51--0.78) compared with chlorthalidone and by 26% (hazard ratio 0.74; 95% CI 0.58--0.94) compared with lisinopril. Lisinopril nonsignificantly lowered gout risk compared with chlorthalidone (hazard ratio 0.85; 95% CI 0.70--1.03). Atenolol use was not associated with gout risk (adjusted hazard ratio 1.18; 95% CI 0.78--1.80). Gout risk reduction was primarily observed after 1 year of follow-up. CONCLUSION Amlodipine lowered long-term gout risk compared with lisinopril or chlorthalidone. This finding may be useful in cases where gout risk is a principal concern among patients being treated for hypertension.This trial is registered at clinicaltrials.gov, number: NCT00000542.
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Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lara M Simpson
- Department of Biostatistics, Health Science Center at Houston, University of Texas, Houston, Texas
| | - Barry R Davis
- Department of Biostatistics, Health Science Center at Houston, University of Texas, Houston, Texas
| | - Robert H Shmerling
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jennifer L Beach
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Anthony Ishak
- Healthcare Associates, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Juraschek SP, Simpson LM, Davis BR, Beach JL, Ishak A, Mukamal KJ. Effects of Antihypertensive Class on Falls, Syncope, and Orthostatic Hypotension in Older Adults: The ALLHAT Trial. Hypertension 2019; 74:1033-1040. [PMID: 31476905 PMCID: PMC6739183 DOI: 10.1161/hypertensionaha.119.13445] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypertension treatment has been implicated in falls, syncope, and orthostatic hypotension (OH), common events among older adults. Whether the choice of antihypertensive agent influences the risk of falls, syncope, and OH in older adults is unknown. ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) was a randomized clinical trial that compared the effects of hypertension first-step therapy on fatal coronary heart disease or nonfatal myocardial infarction (1994-2002). In a subpopulation of ALLHAT participants, age 65 years and older, we determined the relative risk of falls, syncope, OH, or a composite based on Centers for Medicare and Medicaid Services and Veterans Affairs claims, using Cox regression. We also determined the adjusted association of self-reported atenolol use (ascertained at the 1-month visit for indications other than hypertension) on outcomes in Cox models adjusted for age, sex, and race. Among 23 964 participants (mean age 69.8±6.8 years, 45% women, 31% non-Hispanic black) followed for a mean of 4.9 years, we identified 267 falls, 755 syncopes, 249 OH, and 1157 composite claims. There were no significant differences in the cumulative incidences of events across randomized drug assignments. However, amlodipine increased risk of falls during the first year of follow-up compared with chlorthalidone (hazard ratio [95% CI]: 2.24 [1.06-4.74]; P=0.03) or lisinopril (hazard ratio [95% CI]: 2.61 [1.03-6.72]; P=0.04). Atenolol use (N=928) was not associated with any of the 3 individual or composite claims. In older adults, the choice of antihypertensive agent had no effect on risk of fall, syncope, or OH long-term. However, amlodipine increased risk of falls within 1 year of initiation. These short-term findings require confirmation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
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Affiliation(s)
- Stephen P Juraschek
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Lara M Simpson
- University of Texas, Health Science Center at Houston, Department of Biostatistics, Houston, TX
| | - Barry R Davis
- University of Texas, Health Science Center at Houston, Department of Biostatistics, Houston, TX
| | - Jennifer L Beach
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Anthony Ishak
- Healthcare Associates, Beth Israel Deaconess Medical Center
| | - Kenneth J Mukamal
- Beth Israel Deaconess Medical Center, Department of Medicine, Harvard Medical School, Boston, MA
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Shahu A, Herrin J, Dhruva SS, Desai NR, Davis BR, Krumholz HM, Spatz ES. Disparities in Socioeconomic Context and Association With Blood Pressure Control and Cardiovascular Outcomes in ALLHAT. J Am Heart Assoc 2019; 8:e012277. [PMID: 31362591 PMCID: PMC6761647 DOI: 10.1161/jaha.119.012277] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Observational studies demonstrate that communities of low socioeconomic status have higher blood pressure and worse cardiovascular outcomes. Yet, whether the clinical outcomes resulting from antihypertensive therapy vary by socioeconomic context in a randomized clinical trial, in which participants are treated under a standard protocol, is unknown. Methods and Results We used data from ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) to study the effect of socioeconomic context, defined as the county-level median household income, of study sites. We stratified sites into income quintiles and compared characteristics, blood pressure control, and cardiovascular outcomes among ALLHAT participants in the lowest- and highest-income quintiles. Among 27 862 qualifying participants, 2169 (7.8%) received care in the lowest-income sites (quintile 1) and 10 458 (37.6%) received care in the highest-income sites (quintile 5). Participants in quintile 1 were more likely to be women, to be black, to be Hispanic, to have fewer years of education, to live in the South, and to have fewer cardiovascular risk factors. After adjusting for baseline demographic and clinical characteristics, quintile 1 participants were less likely to achieve blood pressure control (<140/90 mm Hg) (odds ratio, 0.48; 95% CI, 0.37-0.63) and had greater all-cause mortality (hazard ratio [HR], 1.25; 95% CI, 1.10-1.41), heart failure hospitalizations/mortality (HR, 1.26; 95% CI, 1.03-1.55), and end-stage renal disease (HR, 1.86; 95% CI, 1.26-2.73), but lower angina hospitalizations (HR, 0.70; 95% CI, 0.59-0.83) and coronary revascularizations (HR, 0.71; 95% CI, 0.57-0.89). Conclusions Despite standardized treatment protocols, ALLHAT participants in the lowest-income sites experienced poorer blood pressure control and worse outcomes for some adverse cardiovascular events, emphasizing the importance of measuring and addressing socioeconomic context. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
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Affiliation(s)
- Andi Shahu
- Department of Medicine Johns Hopkins Hospital Baltimore MD
| | - Jeph Herrin
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Health Research & Educational Trust Chicago IL
| | - Sanket S Dhruva
- San Francisco Veterans Affairs Medical Center San Francisco CA.,University of California, San Francisco School of Medicine San Francisco CA
| | - Nihar R Desai
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Barry R Davis
- Coordinating Center for Clinical Trials University of Texas School of Public Health Houston TX
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT.,Department of Health Policy and Management Yale School of Public Health New Haven CT
| | - Erica S Spatz
- Section of Cardiovascular Medicine Department of Internal Medicine Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
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Sinha AK, Moye L, Piller LB, Yamal J, Barcenas CH, Lin J, Davis BR. Adaptive group‐sequential design with population enrichment in phase 3 randomized controlled trials with two binary co‐primary endpoints. Stat Med 2019; 38:3985-3996. [DOI: 10.1002/sim.8216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 04/28/2019] [Accepted: 05/09/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Arup K. Sinha
- Department of Biostatistics, School of Public HealthYale University New Haven Connecticut
| | - Lemuel Moye
- Department of Biostatistics, School of Public HealthThe University of Texas Health Science Center at Houston Houston Texas
| | - Linda B. Piller
- Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public HealthThe University of Texas Health Science Center at Houston Houston Texas
| | - Jose‐Miguel Yamal
- Department of Biostatistics, School of Public HealthThe University of Texas Health Science Center at Houston Houston Texas
| | - Carlos H. Barcenas
- Department of Breast Medical Oncology, Division of Cancer MedicineThe University of Texas MD Anderson Cancer Center Houston Texas
| | | | - Barry R. Davis
- Department of Biostatistics, School of Public HealthThe University of Texas Health Science Center at Houston Houston Texas
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Rahimi K, Canoy D, Nazarzadeh M, Salimi-Khorshidi G, Woodward M, Teo K, Davis BR, Chalmers J, Pepine CJ. Investigating the stratified efficacy and safety of pharmacological blood pressure-lowering: an overall protocol for individual patient-level data meta-analyses of over 300 000 randomised participants in the new phase of the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC). BMJ Open 2019; 9:e028698. [PMID: 31123005 PMCID: PMC6538087 DOI: 10.1136/bmjopen-2018-028698] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Previous research from the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) and others has shown that pharmacological blood pressure (BP)- lowering substantially reduces the risk of major cardiovascular events, including ischaemic heart disease, heart failure and stroke. In this new phase, the aim is to conduct individual patient-level data (IPD) meta-analyses involving eligible BP-lowering randomised controlled trials (RCTs) to address uncertainties relating to efficacy and safety of BP-lowering treatment. METHODS AND ANALYSIS RCTs investigating the effect of pharmacological BP-lowering, with a minimum of 1000 patient-years of follow-up in each trial arm, are eligible. Our systematic review identified 100 potentially eligible trials. We requested their investigators/sponsors to contribute baseline, follow-up and outcomes data. As of June 2018, the collaboration has obtained data from 49 trials (n=315 046 participants), with additional data currently in the process of being transferred from four RCTs (n=34 642 participants). In addition, data harmonisation has commenced. Scientific activities of the collaboration are overseen by the Steering Committee with input from all collaborators. Detailed protocols for individual meta-analyses will be developed and registered on public platforms. ETHICS AND DISSEMINATION Ethics approval has been obtained for this new and extended phase of the BPLTTC, the largest collaboration of de-identified IPD from RCTs. It offers an efficient and ethical manner of re-purposing existing data to answer clinically important questions relating to BP treatment as well as methodological questions relating to IPD meta-analyses. Among the immediate impacts will include reliable quantification of effects of treatment modifiers, such as baseline BP, age and prior disease, on both vascular and non-vascular outcomes. Analyses will further assess the impact of BP-lowering on important, but less well understood, outcomes, such as new-onset diabetes and renal disease. Findings will be published in peer-reviewed medical journals on behalf of the collaboration.
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Affiliation(s)
- Kazem Rahimi
- The George Institute for Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Dexter Canoy
- The George Institute for Global Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Milad Nazarzadeh
- The George Institute for Global Health, University of Oxford, Oxford, Oxfordshire, UK
- Collaboration Centre of Meta-Analysis Research, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran
| | | | - Mark Woodward
- University of New South Wales, Sydney, New South Wales, Australia
| | - Koon Teo
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Barry R Davis
- University of Texas Health Science Center, Houston, Texas, USA
| | - John Chalmers
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Carl J Pepine
- College of Medicine, University of Florida, Gainesville, Florida, USA
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Barzilay JI, Lai D, Davis BR, Pressel S, Previn HE, Arnett DK. The Interaction of a Diabetes Gene Risk Score With 3 Different Antihypertensive Medications for Incident Glucose-level Elevation. Am J Hypertens 2019; 32:343-349. [PMID: 30590387 DOI: 10.1093/ajh/hpy199] [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: 08/22/2018] [Revised: 11/27/2018] [Accepted: 12/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Elevations of fasting glucose (FG) levels are frequently encountered in people treated with thiazide diuretics. The risk is lower in people treated with ACE inhibitors (ACEi). To determine if genetic factors play a role in FG elevation, we examined the interaction of a diabetes gene risk score (GRS) with the use of 3 different antihypertensive medications. METHODS We examined 376 nondiabetic hypertensive individuals with baseline FG <100 mg/dl who were genotyped for 24 genes associated with risk of elevated glucose levels. All participants had ≥1 follow-up FG level over 6 years of follow-up. Participants were randomized to treatment with a thiazide-like diuretic (chlorthalidone), a calcium channel blocker (CCB; amlodipine), or an ACEi (lisinopril). Outcomes were an FG increase of ≥13 or ≥27 mg/dl, the upper 75% and 90% FG increase in the parent cohort from which the present cohort was obtained. Odds ratios were adjusted for factors that increase FG levels. RESULTS For every 1 allele increase in GRS, the adjusted odds ratios (ORs) were 1.06 (95% confidence interval (CI): 0.99, 1.14; P = 0.06) and 1.09 (95% CI: 0.99, 1.20; P = 0.08). When results were examined by randomized medications, participants randomized to amlodipine had statistically significant odds for either outcome (OR: 1.23; 95% CI: 1.03, 1.48; P = 0.01 and OR: 1.31; 95% CI: 1.06, 1.62; P = 0.01). No such risk increase was found in participants randomized to the other 2 medications. CONCLUSIONS A diabetes GRS predicts FG elevation in people treated with a CCB, but not with an ACEi or diuretic. These findings require confirmation. CLINICAL TRIALS REGISTRATION Trial number NCT00000542.
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Affiliation(s)
- Joshua I Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia and Division of Endocrinology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dejian Lai
- Department of Biostatistics, University of Texas School of Public Health, Houston, Texas, USA
| | - Barry R Davis
- Clinical Trial Center, University of Texas School of Public Health, Houston, Texas, USA
| | - Sara Pressel
- Clinical Trial Center, University of Texas School of Public Health, Houston, Texas, USA
| | - Hannah E Previn
- Department of Biostatistics, University of Texas School of Public Health, Houston, Texas, USA
| | - Donna K Arnett
- Department of Epidemiology, University of Kentucky College of Public Health, Lexington, Kentucky, USA
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40
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Bowling CB, Davis BR, Luciano A, Simpson LM, Sloane R, Pieper CF, Einhorn PT, Oparil S, Muntner P. Sustained blood pressure control and coronary heart disease, stroke, heart failure, and mortality: An observational analysis of ALLHAT. J Clin Hypertens (Greenwich) 2019; 21:451-459. [PMID: 30864748 DOI: 10.1111/jch.13515] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 10/25/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 12/31/2022]
Abstract
Achieving blood pressure (BP) control is associated with lower cardiovascular disease (CVD) risk, but less is known about CVD risk associated with sustained BP control over time. This observational analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) was restricted to participants with four to seven visits with systolic BP (SBP) measurements during a 22-month period (n = 24 309). The authors categorized participants as having sustained BP control (SBP < 140 mm Hg) at 100%, 75% to <100%, 50% to <75%, and <50% of visits during this period. Outcomes included fatal coronary heart disease (CHD)/nonfatal myocardial infarction (MI), stroke, heart failure (HF), a composite CVD outcome (fatal CHD/nonfatal MI, stroke, or HF), and mortality. Hazard ratios (HRs) for the association of category of sustained BP control for each outcome were obtained using proportional hazards models. SBP control was present among 20.0% of participants at 100%, 16.4% at 75% to less than 100%, 27.0% at 50% to less than 75%, and 36.6% at less than 50% of visits. Compared to those with SBP control at 100% visits, adjusted HR (95% CI) among those with SBP control at <50% of visits was 1.16 (0.93-1.44) for fatal CHD/nonfatal MI, 1.71 (1.26-2.32) for stroke, 1.63 (1.30-2.06) for HF, 1.39 (1.20-1.62) for the composite CVD outcome, and 1.14 (0.99-1.30) for mortality. Sustained SBP control may be beneficial for preventing stroke, HF, and CVD outcomes in adults taking antihypertensive medication.
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Affiliation(s)
- C Barrett Bowling
- Durham Veterans Affairs Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center (VAMC), Durham, North Carolina.,Department of Medicine, Duke University, Durham, North Carolina
| | - Barry R Davis
- The University of Texas School of Public Health, Houston, Texas
| | - Alison Luciano
- Center for Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Lara M Simpson
- The University of Texas School of Public Health, Houston, Texas
| | - Richard Sloane
- Center for Study of Aging and Human Development, Duke University, Durham, North Carolina
| | - Carl F Pieper
- Center for Study of Aging and Human Development, Duke University, Durham, North Carolina.,Deptartment of Biostatistics and BioInformtics, Duke University, Durham, North Carolina
| | - Paula T Einhorn
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute of the National Institutes of Health, Bethesda, Maryland
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
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41
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Pennells L, Kaptoge S, Wood A, Sweeting M, Zhao X, White I, Burgess S, Willeit P, Bolton T, Moons KGM, van der Schouw YT, Selmer R, Khaw KT, Gudnason V, Assmann G, Amouyel P, Salomaa V, Kivimaki M, Nordestgaard BG, Blaha MJ, Kuller LH, Brenner H, Gillum RF, Meisinger C, Ford I, Knuiman MW, Rosengren A, Lawlor DA, Völzke H, Cooper C, Marín Ibañez A, Casiglia E, Kauhanen J, Cooper JA, Rodriguez B, Sundström J, Barrett-Connor E, Dankner R, Nietert PJ, Davidson KW, Wallace RB, Blazer DG, Björkelund C, Donfrancesco C, Krumholz HM, Nissinen A, Davis BR, Coady S, Whincup PH, Jørgensen T, Ducimetiere P, Trevisan M, Engström G, Crespo CJ, Meade TW, Visser M, Kromhout D, Kiechl S, Daimon M, Price JF, Gómez de la Cámara A, Wouter Jukema J, Lamarche B, Onat A, Simons LA, Kavousi M, Ben-Shlomo Y, Gallacher J, Dekker JM, Arima H, Shara N, Tipping RW, Roussel R, Brunner EJ, Koenig W, Sakurai M, Pavlovic J, Gansevoort RT, Nagel D, Goldbourt U, Barr ELM, Palmieri L, Njølstad I, Sato S, Monique Verschuren WM, Varghese CV, Graham I, Onuma O, Greenland P, Woodward M, Ezzati M, Psaty BM, Sattar N, Jackson R, Ridker PM, Cook NR, D'Agostino RB, Thompson SG, Danesh J, Di Angelantonio E. Equalization of four cardiovascular risk algorithms after systematic recalibration: individual-participant meta-analysis of 86 prospective studies. Eur Heart J 2019; 40:621-631. [PMID: 30476079 PMCID: PMC6374687 DOI: 10.1093/eurheartj/ehy653] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 05/03/2018] [Accepted: 10/04/2018] [Indexed: 12/19/2022] Open
Abstract
AIMS There is debate about the optimum algorithm for cardiovascular disease (CVD) risk estimation. We conducted head-to-head comparisons of four algorithms recommended by primary prevention guidelines, before and after 'recalibration', a method that adapts risk algorithms to take account of differences in the risk characteristics of the populations being studied. METHODS AND RESULTS Using individual-participant data on 360 737 participants without CVD at baseline in 86 prospective studies from 22 countries, we compared the Framingham risk score (FRS), Systematic COronary Risk Evaluation (SCORE), pooled cohort equations (PCE), and Reynolds risk score (RRS). We calculated measures of risk discrimination and calibration, and modelled clinical implications of initiating statin therapy in people judged to be at 'high' 10 year CVD risk. Original risk algorithms were recalibrated using the risk factor profile and CVD incidence of target populations. The four algorithms had similar risk discrimination. Before recalibration, FRS, SCORE, and PCE over-predicted CVD risk on average by 10%, 52%, and 41%, respectively, whereas RRS under-predicted by 10%. Original versions of algorithms classified 29-39% of individuals aged ≥40 years as high risk. By contrast, recalibration reduced this proportion to 22-24% for every algorithm. We estimated that to prevent one CVD event, it would be necessary to initiate statin therapy in 44-51 such individuals using original algorithms, in contrast to 37-39 individuals with recalibrated algorithms. CONCLUSION Before recalibration, the clinical performance of four widely used CVD risk algorithms varied substantially. By contrast, simple recalibration nearly equalized their performance and improved modelled targeting of preventive action to clinical need.
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Affiliation(s)
- Lisa Pennells
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
| | - Stephen Kaptoge
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
| | - Angela Wood
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
| | - Mike Sweeting
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
| | - Xiaohui Zhao
- Department of Physiology, Development and Neuroscience, University of Cambridge, Downing Street, Cambridge, UK
| | - Ian White
- MRC Clinical Trials Unit, University College London, 90 High Holborn, London, UK
| | - Stephen Burgess
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
- MRC Biostatistics Unit, Cambridge Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge, UK
| | - Peter Willeit
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
- Department of Neurology and Neurosurgery, Medical University of Innsbruck, Anichstraße 35, Innsbruck, Austria
| | - Thomas Bolton
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
| | - Karel G M Moons
- Epidemiology: Methodology, Julius Center Research Program Methodology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, the Netherlands
| | - Yvonne T van der Schouw
- Department of Epidemiology, Julius Center Research Program Cardiovascular Epidemiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, the Netherlands
| | - Randi Selmer
- Division of Epidemiology, Norwegian Institute of Public Health, Postboks 222 Skøyen, Oslo, Norway
| | - Kay-Tee Khaw
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
| | - Vilmundur Gudnason
- Icelandic Heart Association, Hjartavernd Holtasmá¡ri 1, Kópavogur, Iceland
- Faculty of Medicine, University of Iceland, Vatnsmýrarvegur 16, Reykjavik, Iceland
| | - Gerd Assmann
- Assmann-Foundation for Prevention, Gronowskistraße 33, Münster, Germany
| | - Philippe Amouyel
- Institut Pasteur de Lille, 1 rue du Professeur Calmette, Lille, France
| | - Veikko Salomaa
- National Institute for Health and Welfare, Mannerheimintie 166, Helsinki, Finland
| | - Mika Kivimaki
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, UK
| | - Børge G Nordestgaard
- Department of Clinical Medicine, Copenhagen University Hospital, Blegdamsvej 3, Copenhagen, Denmark
| | - Michael J Blaha
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, 1800 Orleans St, Baltimore, MD, USA
| | - Lewis H Kuller
- Department of Epidemiology, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA, USA
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Neuenheimer Feld 581, Heidelberg, Germany
- University of Heidelberg, Grabengasse 1, Heidelberg, Germany
| | - Richard F Gillum
- Department of Medicine, Howard University College of Medicine, 2041 Georgia Avenue, Washington, DC, USA
| | - Christa Meisinger
- German Research Center for Environmental Health, Ingolstädter Landstraße 1, Neuherberg, Germany
| | - Ian Ford
- Institute of Health & Wellbeing, University of Glasgow, Boyd Orr Building, University Avenue, Glasgow, UK
| | - Matthew W Knuiman
- Faculty of Health and Medical Sciences, School of Population and Global Health, University of Western Australia, 35 Stirling Highway, Perth, Western Australia, Australia
| | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 3, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska University Hospital, Blå stråket 5, Gothenburg, Sweden
| | - Debbie A Lawlor
- Department of Social Medicine, University of Bristol, Bristol, UK
| | - Henry Völzke
- Institute of Community Medicine, University of Greifswald, Ellernholzstraße 1/2, Greifswald, Germany
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Tremona Rd, Southampton, UK
| | | | - Edoardo Casiglia
- Department of Medicine, University of Padova, 2 Via Giustiniani, Padova, Italy
| | - Jussi Kauhanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, 1 Yliopistonranta, Kuopio, Finland
| | - Jackie A Cooper
- Centre for Cardiovascular Genetics, University College London, 5 University Street, London, UK
| | - Beatriz Rodriguez
- Department of Geriatric Medicine, University of Hawaii, 1960 East-West Road, Honolulu, HI, USA
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Ing 40, 5 tr, Uppsala, Sweden
| | | | - Rachel Dankner
- Unit for Cardiovascular Epidemiology, The Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Paul J Nietert
- Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon Street, Charleston, SC, USA
| | - Karina W Davidson
- Department of Medicine, Columbia University Irving Medical Center, 622 West 168th Street, New York, NY, USA
| | - Robert B Wallace
- College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC, USA
| | - Cecilia Björkelund
- Department of Public Health and Community Medicine, University of Gothenburg, Medicinaregatan 16, Gothenburg, Sweden
| | - Chiara Donfrancesco
- Department of Cardiovascular, Dysmetabolic and Aging-Associated Diseases, Istituto Superiore di Sanità (ISS), 299 Viale Regina Elena, Rome, Italy
| | | | - Aulikki Nissinen
- National Institute for Health and Welfare, Mannerheimintie 166, Helsinki, Finland
| | - Barry R Davis
- Department of Biostatistics, The University of Texas School of Public Health, 1200 Pressler Street, Houston, TX, USA
| | - Sean Coady
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, 31 Center Drive, Bethesda, MD, USA
| | - Peter H Whincup
- Population Health Research Institute, St George's, University of London, Cranmer Terrace, London, UK
| | - Torben Jørgensen
- Research Centre for Prevention and Health, 5 Øster Farimagsgade, Copenhagen, Denmark
- Department of Public Health, University of Copenhagen, 5 Øster Farimagsgade, Copenhagen, Denmark
- Aalborg University, Fredrik Bajers Vej 5, Aalborg, Denmark
| | - Pierre Ducimetiere
- Faculté de Médecine, Université Paris Descartes, 12 Rue de l'Ecole de Médecine, Paris, France
| | - Maurizio Trevisan
- CUNY School of Medicine, City College of New York, 160 Convent Ave, New York, NY, USA
| | - Gunnar Engström
- Department of Clinical Sciences, Lund University, Jan Waldenströms gata 35, Malmö, Sweden
| | - Carlos J Crespo
- School of Community Health, Portland State University, 506 SW Mill St, Portland, OR, USA
| | - Tom W Meade
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Marjolein Visser
- Department of Health Sciences, Vrije Universiteit Amsterdam, VU University Medical Center, De Boelelaan 1085, Amsterdam, the Netherlands
| | - Daan Kromhout
- Department of Epidemiology, University Medical Centre Groningen, University of Grogingen, Hanzeplein 1, Groningen, the Netherlands
| | - Stefan Kiechl
- Department of Neurology and Neurosurgery, Medical University of Innsbruck, Anichstraße 35, Innsbruck, Austria
| | - Makoto Daimon
- Faculty of Medicine, Yamagata University, 1-4-12 Kojirakawa-machi, Yamagata, Japan
| | - Jackie F Price
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, UK
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands
| | - Benoît Lamarche
- Pavillon Ferdinand-Vandry, Université Laval, 2440 Hochelaga, Quebec, Canada
| | - Altan Onat
- Department of Cardiology, Cerrahpaşa Faculty of Medicine, Istanbul University, Beyazıt, Fatih, Istanbul, Turkey
| | | | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, Rotterdam, the Netherlands
| | - Yoav Ben-Shlomo
- Bristol Neuroscience, Bristol University, Queens Road, Bristol, UK
| | - John Gallacher
- Department of Psychiatry, University of Oxford, Warneford Hospital, Warneford Lane, Oxford, UK
| | - Jacqueline M Dekker
- The Institute for Health and Care Research, VU University Medical Center, De Boelelaan 1085, Amsterdam, the Netherlands
| | | | - Nawar Shara
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, 6525 Belcrest Road, Hyattsville, MD, USA
| | - Robert W Tipping
- Clinical Biostatistics, Merck, 2000 Galloping Hill Road, Kenilworth, NJ, USA
| | - Ronan Roussel
- Centre de Recherche des Cordeliers, INSERM, 15 rue de l'Ecole de Médecine, Paris, France
| | - Eric J Brunner
- Institute of Epidemiology & Health, University College London, 1-19 Torrington Place, London, UK
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, 21 Arcisstraße, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Biedersteiner Str. 29, Munich, Germany
| | - Masaru Sakurai
- Department of Social and Environmental Medicine, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Ishikawa, Japan
| | - Jelena Pavlovic
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, Rotterdam, the Netherlands
| | - Ron T Gansevoort
- Department of Internal Medicine, University Medical Centre Groningen, University of Grogingen, Hanzeplein 1, Groningen, the Netherlands
| | - Dorothea Nagel
- Klinikum der Universität München, Ludwig-Maximilians-Universität, 15 Marchioninistraße, Munich, Germany
| | - Uri Goldbourt
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, School of Public Health, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Elizabeth L M Barr
- Clinical Diabetes and Epidemiology, Baker Heart and Diabetes Institute, 75 Commercial Rd, Melbourne, Australia
| | - Luigi Palmieri
- Department of Cardiovascular, Dysmetabolic and Aging-Associated Diseases, Istituto Superiore di Sanità (ISS), 299 Viale Regina Elena, Rome, Italy
| | - Inger Njølstad
- Department of Public Health, University of Tromsø, Hansine Hansens veg 18, Tromsø, Norway
| | - Shinichi Sato
- Chiba Prefectural Institute of Public Health, 666-2 Nito-no-machi Chuo-ku, Chiba, Japan
| | - W M Monique Verschuren
- Department for Determinants of Chronic Diseases, National Institute for Public Health and the Environment (RIVM), Antonie van Leeuwenhoeklaan 9, Bilthoven, The Netherlands
| | - Cherian V Varghese
- Noncommunicable Diseases, Disability, Violence and Injury Prevention Department, World Health Organization, 20 Avenue Appia, Geneva 27, Switzerland
| | - Ian Graham
- School of Medicine, Trinity College Dublin, The University of Dublin, College Green, Dublin 2, Ireland
| | - Oyere Onuma
- Noncommunicable Diseases, Disability, Violence and Injury Prevention Department, World Health Organization, 20 Avenue Appia, Geneva 27, Switzerland
| | - Philip Greenland
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 420 East Superior Street, Chicago, IL, USA
| | - Mark Woodward
- The George Institute for Global Health, University of Oxford, 75 George Street, Oxford, UK
- The George Institute for Global Health, University of New South Wales, 1 King Street Newtown, Sydney, Australia
| | - Majid Ezzati
- Faculty of Medicine, School of Public Health, Norfolk Place, St Mary's Campus, Imperial College London, London, UK
| | - Bruce M Psaty
- Cardiovascular Health Research Unit, University of Washington, 1730 Minor Avenue, Seattle, WA, USA
| | - Naveed Sattar
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Rod Jackson
- Faculty of Medical and Health Sciences, University of Auckland, 261 Morrin Road, Auckland, New Zealand
| | - Paul M Ridker
- Brigham and Women's Hospital, Harvard Medical School, 900 Commonwealth Avenue, Boston, MA, USA
| | - Nancy R Cook
- Brigham and Women's Hospital, Harvard Medical School, 900 Commonwealth Avenue, Boston, MA, USA
| | - Ralph B D'Agostino
- Mathematics and Statistics Department, Boston University, 111 Cummington Mall, Boston, MA, USA
| | - Simon G Thompson
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
| | - John Danesh
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
| | - Emanuele Di Angelantonio
- Department of Public Health and Primary Care, University of Cambridge, 2 Worts' Causeway, Cambridge, UK
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Barzilay JI, Davis BR, Ghosh A, Pressel SL, Rahman M, Einhorn PT, Cushman WC, Whelton PK, Wright JT. Rapid eGFR change as a determinant of cardiovascular and renal disease outcomes and of mortality in hypertensive adults with and without type 2 diabetes. J Diabetes Complications 2018; 32:830-832. [PMID: 30030011 DOI: 10.1016/j.jdiacomp.2018.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 01/10/2018] [Revised: 07/05/2018] [Accepted: 07/07/2018] [Indexed: 12/21/2022]
Abstract
A rapid decline in estimated glomerular filtration rate over 2 years in a large hypertensive cohort was associated with similar risks for overall cardiovascular disease in people with or without diabetes mellitus, but with higher all-cause mortality, heart failure, and end stage renal disease risk in people with diabetes.
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Affiliation(s)
- Joshua I Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia, and the Division of Endocrinology, Emory University School of Medicine, Atlanta, GA, United States of America.
| | - Barry R Davis
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, TX, United States of America
| | - Alokananda Ghosh
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, TX, United States of America
| | - Sara L Pressel
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, TX, United States of America
| | - Mahboob Rahman
- Division of Nephrology, University Hospitals Case Western Reserve University, Cleveland, OH, United States of America
| | - Paula T Einhorn
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, United States of America
| | - William C Cushman
- Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, TN, United States of America
| | - Paul K Whelton
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, United States of America
| | - Jackson T Wright
- Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, United States of America
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43
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Haywood LJ, Davis BR, Piller LB, Simpson LM, Ghosh A, Einhorn PT, Ford CE, Probstfield JL, Soliman EZ, Wright JT. Risk Factors Influencing Outcomes of Atrial Fibrillation in ALLHAT. J Natl Med Assoc 2018; 110:343-351. [PMID: 30126559 DOI: 10.1016/j.jnma.2017.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 06/13/2017] [Revised: 06/30/2017] [Accepted: 07/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIMS ALLHAT, a randomized, double-blind, active-controlled, multicenter clinical trial of high risk hypertensive participants, compared treatment with an ACE-inhibitor (lisinopril) or calcium channel blocker (amlodipine) with a diuretic (chlorthalidone). Primary outcome was the occurrence of fatal coronary heart disease or nonfatal myocardial infarction. For this report, post-hoc analyses were conducted to determine the contribution of baseline characteristics of participants with or without baseline or incident atrial fibrillation (AF) and atrial flutter (AFL) to stroke, heart failure (HF), coronary heart disease (CHD), and mortality outcomes. METHODS AND RESULTS Minnesota Coding of baseline and biennial in-trial ECGs was used to determine the 334 baseline and 537 incident AF/AFL cases, respectively participants with AF/AFL: Cox regression was used to estimate hazard ratios of presence versus absence of either baseline or incident AF/AFL (as time-dependent covariate) for occurrence of stroke, CHD, HF, or mortality, while adjusting for selected baseline characteristics. Adjusted Cox regression was used to obtain hazard ratios (HRs) for presence versus absence of selected baseline characteristics among those with and without either baseline or incident AF/AFL. After adjusting for baseline characteristics, baseline AF/AFL was associated with stroke, HF, and mortality (HRs [95% CIs] 3.18, [2.34-4.33]; 2.65 [2.02-3.49]; and 2.10 [CI, 1.73-2.55], respectively, P < 0.05). Incident AF/AFL was a significant risk factor for HF and mortality (HRs 2.80 and 2.06, respectively, P < 0.05). Risk factor profiles for clinical outcomes for those with and without baseline or incident AF/AFL were largely similar. CONCLUSIONS AF/AFL is a significant risk factor for stroke, HF, and mortality. Additional risk factors for these outcomes were generally similar for participants with and without baseline or incident AF/AFL.
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Affiliation(s)
- L Julian Haywood
- LAC+USC Medical Center, Keck School of Medicine, Los Angeles, CA, USA
| | - Barry R Davis
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, TX, USA
| | - Linda B Piller
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, TX, USA.
| | - Lara M Simpson
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, TX, USA
| | - Alokananda Ghosh
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, TX, USA
| | - Paula T Einhorn
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Charles E Ford
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, TX, USA
| | | | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center (EPICARE), Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jackson T Wright
- W T Dahms Clinical Research Unit, University Hospitals Case Medical Center, Cleveland, OH, USA
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44
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Angelini P, Cheong BY, Lenge De Rosen VV, Lopez A, Uribe C, Masso AH, Ali SW, Davis BR, Muthupillai R, Willerson JT. High-Risk Cardiovascular Conditions in Sports-Related Sudden Death: Prevalence in 5,169 Schoolchildren Screened via Cardiac Magnetic Resonance. Tex Heart Inst J 2018; 45:205-213. [PMID: 30374227 DOI: 10.14503/thij-18-6645] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Improving preparticipation screening of candidates for sports necessitates establishing the prevalence of high-risk cardiovascular conditions (hr-CVC) that predispose young people to sudden cardiac death (SCD). Our accurate, novel protocol chiefly involved the use of cardiac magnetic resonance (CMR) to estimate this prevalence. Middle and high school students from a general United States population were screened by means of questionnaires, resting electrocardiograms, and CMR to determine the prevalence of 3 types of hr-CVC: electrocardiographic abnormalities, cardiomyopathies, and anomalous coronary artery origin from the opposite sinus with intramural coronary course (ACAOS-IM). We examined the range of normal left ventricular size and function in the main study cohort (schoolchildren 11-14 yr old). We defined diagnostic criteria for hr-CVC and compared the cardiac measurements of these younger participants with those of older children whom we examined (age, 15-18 yr). From 5,169 completed diagnostic studies (mean participant age, 13.06 ± 1.78 yr), CMR results revealed 76 previously undiagnosed cases of hr-CVC (1.47% of the total cohort): 11 of dilated cardiomyopathy (14.5%), 3 of nonobstructive hypertrophic cardiomyopathy (3.9%), 23 ACAOS-IM cases (30.3%; 6 left-ACAOS and 17 right-ACAOS), 4 Wolff-Parkinson-White patterns (5.3%), 34 prolonged QT intervals (44.7%), and 1 Brugada pattern (1.3%). Cardiomyopathies were significantly more prevalent in the older children. Of note, we identified 959 cases (18.5%) of left ventricular noncompaction. If our estimate is accurate, only 1.47% of school-age sports participants will need focused secondary evaluations; the rest can probably be reassured about their cardiac health after one 30-minute screening study.
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45
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Barzilay JI, Davis BR, Pressel SL, Ghosh A, Rahman M, Einhorn PT, Cushman WC, Whelton PK, Wright JT. The Effects of eGFR Change on CVD, Renal, and Mortality Outcomes in a Hypertensive Cohort Treated With 3 Different Antihypertensive Medications. Am J Hypertens 2018; 31:609-614. [PMID: 29360915 DOI: 10.1093/ajh/hpx223] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 01/10/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Impaired renal function is a risk factor for cardiovascular disease, end-stage renal disease (ESRD), and mortality. The impact of short-term renal function decline on outcomes is less well studied. The association of antihypertensive medications with the impact of short-term estimated glomerular filtration rate (eGFR) decline is not known. METHODS We examined 20,207 hypertensive participants with baseline and 2-year creatinine levels from which eGFR changes were estimated. The associations between eGFR change with incident coronary heart disease (CHD), stroke, heart failure (HF), all-cause mortality, and ESRD during 2.9 years of in-trial follow up, and with mortality during in-trial and post-trial follow-up (7.6 years), were studied. Results were assessed by primary hypertension (HTN) treatment (chlorthalidone, lisinopril, and amlodipine) and adjusted for baseline eGFR levels. RESULTS In the short run, an eGFR decline below the cohort median (-1.28 ml/minute/1.73 m2/2 years) vs. above the median, or a 5 ml/min/1.73 m2/year decline vs. no decline, was associated with significant hazard risk for CHD (1.06-1.28), HF (1.24-1.91), ESRD (2.84-6.01), and mortality (1.08-1.19), but not with stroke risk. In the long term, there was a significant association with mortality (1.11-1.34). Interaction terms for outcomes by antihypertensive treatments were not statistically significant except for ESRD between amlodipine vs. chlorthalidone (hazard ratio: 3.17 [2.59, 3.88] vs. 2.41 [1.98, 2.97]; P interaction = 0.005) for a 5 ml/min/1.73 m2/year eGFR decline. CONCLUSION Decline in eGFR over 2 years is associated with increased risk of clinical outcomes beyond the effects of baseline eGFR. These risks were the same irrespective of the primary medication used to treat HTN.
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Affiliation(s)
- Joshua I Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia, and the Division of Endocrinology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Barry R Davis
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas, USA
| | - Sara L Pressel
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas, USA
| | - Alokananda Ghosh
- Coordinating Center for Clinical Trials, The University of Texas School of Public Health, Houston, Texas, USA
| | - Mahboob Rahman
- Division of Nephrology, University Hospitals Case Western Reserve University, Cleveland, Ohio, USA
| | - Paula T Einhorn
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - William C Cushman
- Preventive Medicine Section, Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Paul K Whelton
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Jackson T Wright
- Division of Nephrology and Hypertension, Case Western Reserve University, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
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Karmali KN, Lloyd-Jones DM, van der Leeuw J, Goff DC, Yusuf S, Zanchetti A, Glasziou P, Jackson R, Woodward M, Rodgers A, Neal BC, Berge E, Teo K, Davis BR, Chalmers J, Pepine C, Rahimi K, Sundström J. Blood pressure-lowering treatment strategies based on cardiovascular risk versus blood pressure: A meta-analysis of individual participant data. PLoS Med 2018; 15:e1002538. [PMID: 29558462 PMCID: PMC5860698 DOI: 10.1371/journal.pmed.1002538] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/16/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Clinical practice guidelines have traditionally recommended blood pressure treatment based primarily on blood pressure thresholds. In contrast, using predicted cardiovascular risk has been advocated as a more effective strategy to guide treatment decisions for cardiovascular disease (CVD) prevention. We aimed to compare outcomes from a blood pressure-lowering treatment strategy based on predicted cardiovascular risk with one based on systolic blood pressure (SBP) level. METHODS AND FINDINGS We used individual participant data from the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) from 1995 to 2013. Trials randomly assigned participants to either blood pressure-lowering drugs versus placebo or more intensive versus less intensive blood pressure-lowering regimens. We estimated 5-y risk of CVD events using a multivariable Weibull model previously developed in this dataset. We compared the two strategies at specific SBP thresholds and across the spectrum of risk and blood pressure levels studied in BPLTTC trials. The primary outcome was number of CVD events avoided per persons treated. We included data from 11 trials (47,872 participants). During a median of 4.0 y of follow-up, 3,566 participants (7.5%) experienced a major cardiovascular event. Areas under the curve comparing the two treatment strategies throughout the range of possible thresholds for CVD risk and SBP demonstrated that, on average, a greater number of CVD events would be avoided for a given number of persons treated with the CVD risk strategy compared with the SBP strategy (area under the curve 0.71 [95% confidence interval (CI) 0.70-0.72] for the CVD risk strategy versus 0.54 [95% CI 0.53-0.55] for the SBP strategy). Compared with treating everyone with SBP ≥ 150 mmHg, a CVD risk strategy would require treatment of 29% (95% CI 26%-31%) fewer persons to prevent the same number of events or would prevent 16% (95% CI 14%-18%) more events for the same number of persons treated. Compared with treating everyone with SBP ≥ 140 mmHg, a CVD risk strategy would require treatment of 3.8% (95% CI 12.5% fewer to 7.2% more) fewer persons to prevent the same number of events or would prevent 3.1% (95% CI 1.5%-5.0%) more events for the same number of persons treated, although the former estimate was not statistically significant. In subgroup analyses, the CVD risk strategy did not appear to be more beneficial than the SBP strategy in patients with diabetes mellitus or established CVD. CONCLUSIONS A blood pressure-lowering treatment strategy based on predicted cardiovascular risk is more effective than one based on blood pressure levels alone across a range of thresholds. These results support using cardiovascular risk assessment to guide blood pressure treatment decision-making in moderate- to high-risk individuals, particularly for primary prevention.
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Affiliation(s)
- Kunal N. Karmali
- Department of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Donald M. Lloyd-Jones
- Department of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Joep van der Leeuw
- University Medical Center Utrecht, Department of Vascular Medicine, Utrecht, Netherlands
| | - David C. Goff
- National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Bethesda, Maryland, United States of America
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | | | - Paul Glasziou
- Centre for Research in Evidence Based Practice, Bond University, Robina, Australia
| | - Rodney Jackson
- School of Population Health, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Mark Woodward
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
- The George Institute for Global Health, Sydney, Australia
| | | | - Bruce C. Neal
- The George Institute for Global Health, Sydney, Australia
| | - Eivind Berge
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Koon Teo
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Barry R. Davis
- School of Public Health, University of Texas, Dallas, Texas, United States of America
| | - John Chalmers
- The George Institute for Global Health, Sydney, Australia
| | - Carl Pepine
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Kazem Rahimi
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, and Uppsala Clinical Research Center, Uppsala, Sweden
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47
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Angelini P, Cheong BY, Lenge De Rosen VV, Lopez JA, Uribe C, Masso AH, Ali SW, Davis BR, Muthupillai R, Willerson JT. Magnetic Resonance Imaging–Based Screening Study in a General Population of Adolescents. J Am Coll Cardiol 2018; 71:579-580. [DOI: 10.1016/j.jacc.2017.11.051] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 10/18/2022]
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48
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Dewland TA, Soliman EZ, Yamal JM, Davis BR, Alonso A, Albert CM, Simpson LM, Haywood LJ, Marcus GM. Pharmacologic Prevention of Incident Atrial Fibrillation: Long-Term Results From the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005463. [PMID: 29212812 DOI: 10.1161/circep.117.005463] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/09/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although atrial fibrillation (AF) guidelines indicate that pharmacological blockade of the renin-angiotensin system may be considered for primary AF prevention in hypertensive patients, previous studies have yielded conflicting results. We sought to determine whether randomization to lisinopril reduces incident AF or atrial flutter (AFL) compared with chlorthalidone in a large clinical trial cohort with extended post-trial surveillance. METHODS AND RESULTS We performed a secondary analysis of the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), a randomized, double-blind, active-controlled clinical trial that enrolled hypertensive individuals ≥55 years of age with at least one other cardiovascular risk factor. Participants were randomly assigned to receive amlodipine, lisinopril, or chlorthalidone. Individuals with elevated fasting low-density lipoprotein cholesterol levels were also randomized to pravastatin versus usual care. The primary outcome was the development of either AF or AFL as diagnosed by serial study ECGs or by Medicare claims data. Among 14 837 participants without prevalent AF or AFL, 2514 developed AF/AFL during a mean 7.5±3.2 years of follow-up. Compared with chlorthalidone, randomization to either lisinopril (hazard ratio, 1.04; 95% confidence interval, 0.94-1.15; P=0.46) or amlodipine (hazard ratio, 0.93; 95% confidence interval, 0.84-1.03; P=0.16) was not associated with a significant reduction in incident AF/AFL. CONCLUSIONS Compared with chlorthalidone, treatment with lisinopril is not associated with a meaningful reduction in incident AF or AFL among older adults with a history of hypertension. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000542.
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Affiliation(s)
- Thomas A Dewland
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland (T.A.D.); Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); University of Texas School of Public Health, Houston (J.-M.Y., B.R.D., L.M.S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.); Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (C.M.A.); Keck School of Medicine, University of Southern California, Los Angeles (L.J.H.); and Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco (G.M.M.)
| | - Elsayed Z Soliman
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland (T.A.D.); Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); University of Texas School of Public Health, Houston (J.-M.Y., B.R.D., L.M.S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.); Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (C.M.A.); Keck School of Medicine, University of Southern California, Los Angeles (L.J.H.); and Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco (G.M.M.)
| | - Jose-Miguel Yamal
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland (T.A.D.); Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); University of Texas School of Public Health, Houston (J.-M.Y., B.R.D., L.M.S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.); Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (C.M.A.); Keck School of Medicine, University of Southern California, Los Angeles (L.J.H.); and Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco (G.M.M.)
| | - Barry R Davis
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland (T.A.D.); Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); University of Texas School of Public Health, Houston (J.-M.Y., B.R.D., L.M.S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.); Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (C.M.A.); Keck School of Medicine, University of Southern California, Los Angeles (L.J.H.); and Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco (G.M.M.)
| | - Alvaro Alonso
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland (T.A.D.); Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); University of Texas School of Public Health, Houston (J.-M.Y., B.R.D., L.M.S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.); Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (C.M.A.); Keck School of Medicine, University of Southern California, Los Angeles (L.J.H.); and Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco (G.M.M.)
| | - Christine M Albert
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland (T.A.D.); Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); University of Texas School of Public Health, Houston (J.-M.Y., B.R.D., L.M.S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.); Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (C.M.A.); Keck School of Medicine, University of Southern California, Los Angeles (L.J.H.); and Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco (G.M.M.)
| | - Lara M Simpson
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland (T.A.D.); Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); University of Texas School of Public Health, Houston (J.-M.Y., B.R.D., L.M.S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.); Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (C.M.A.); Keck School of Medicine, University of Southern California, Los Angeles (L.J.H.); and Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco (G.M.M.)
| | - L Julian Haywood
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland (T.A.D.); Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); University of Texas School of Public Health, Houston (J.-M.Y., B.R.D., L.M.S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.); Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (C.M.A.); Keck School of Medicine, University of Southern California, Los Angeles (L.J.H.); and Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco (G.M.M.)
| | - Gregory M Marcus
- From the Knight Cardiovascular Institute, Oregon Health & Science University, Portland (T.A.D.); Cardiology Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); University of Texas School of Public Health, Houston (J.-M.Y., B.R.D., L.M.S.); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA (A.A.); Center for Arrhythmia Prevention, Division of Preventive Medicine and Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (C.M.A.); Keck School of Medicine, University of Southern California, Los Angeles (L.J.H.); and Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco (G.M.M.).
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49
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Alvarez O, Nottage K, Simpson LM, Wood J, Davis BR, Fuh B, Sarnaik S, Aygun B, Helton K, Ware RE. Kidney function of transfused children with sickle cell anemia: Baseline data from the TWiTCH study with comparison to non-transfused cohorts. Am J Hematol 2017; 92:E637-E639. [PMID: 28741677 DOI: 10.1002/ajh.24871] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/17/2017] [Accepted: 07/21/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Ofelia Alvarez
- Division of Pediatric Hematology; University of Miami; Miami Florida
| | - Kerri Nottage
- Department of Hematology; St Jude Children's Research Hospital; Memphis Tennessee
| | - Lara M. Simpson
- Department of Biostatistics; University of Texas Science Health Center at Houston; Houston Texas
| | - John Wood
- Department of Pediatrics and Radiology, Division of Cardiology; Children's Hospital Los Angeles; Los Angeles California
| | - Barry R. Davis
- Department of Biostatistics; University of Texas Science Health Center at Houston; Houston Texas
| | - Beng Fuh
- Division of Pediatric Hematology/Oncology; Brody School of Medicine at East Carolina University; Greenville North Carolina
| | - Sharada Sarnaik
- Division of Pediatric Hematology/Oncology; Children's Hospital of Michigan; Detroit Michigan
| | - Banu Aygun
- Division of Pediatric Hematology/Oncology; Cohen Children's Medical Center of New York; New Hyde Park New York
| | - Kathleen Helton
- Department of Diagnostic Imaging; St Jude Children's Research Hospital; Memphis Tennesse
| | - Russell E. Ware
- Division of Hematology; Cincinnati Children's Hospital; Cincinnati Ohio
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50
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Paige E, Barrett J, Pennells L, Sweeting M, Willeit P, Di Angelantonio E, Gudnason V, Nordestgaard BG, Psaty BM, Goldbourt U, Best LG, Assmann G, Salonen JT, Nietert PJ, Verschuren WMM, Brunner EJ, Kronmal RA, Salomaa V, Bakker SJL, Dagenais GR, Sato S, Jansson JH, Willeit J, Onat A, de la Cámara AG, Roussel R, Völzke H, Dankner R, Tipping RW, Meade TW, Donfrancesco C, Kuller LH, Peters A, Gallacher J, Kromhout D, Iso H, Knuiman M, Casiglia E, Kavousi M, Palmieri L, Sundström J, Davis BR, Njølstad I, Couper D, Danesh J, Thompson SG, Wood A. Use of Repeated Blood Pressure and Cholesterol Measurements to Improve Cardiovascular Disease Risk Prediction: An Individual-Participant-Data Meta-Analysis. Am J Epidemiol 2017; 186:899-907. [PMID: 28549073 PMCID: PMC5860526 DOI: 10.1093/aje/kwx149] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 02/14/2017] [Accepted: 02/24/2017] [Indexed: 01/03/2023] Open
Abstract
The added value of incorporating information from repeated blood pressure and cholesterol measurements to predict cardiovascular disease (CVD) risk has not been rigorously assessed. We used data on 191,445 adults from the Emerging Risk Factors Collaboration (38 cohorts from 17 countries with data encompassing 1962-2014) with more than 1 million measurements of systolic blood pressure, total cholesterol, and high-density lipoprotein cholesterol. Over a median 12 years of follow-up, 21,170 CVD events occurred. Risk prediction models using cumulative mean values of repeated measurements and summary measures from longitudinal modeling of the repeated measurements were compared with models using measurements from a single time point. Risk discrimination (C-index) and net reclassification were calculated, and changes in C-indices were meta-analyzed across studies. Compared with the single-time-point model, the cumulative means and longitudinal models increased the C-index by 0.0040 (95% confidence interval (CI): 0.0023, 0.0057) and 0.0023 (95% CI: 0.0005, 0.0042), respectively. Reclassification was also improved in both models; compared with the single-time-point model, overall net reclassification improvements were 0.0369 (95% CI: 0.0303, 0.0436) for the cumulative-means model and 0.0177 (95% CI: 0.0110, 0.0243) for the longitudinal model. In conclusion, incorporating repeated measurements of blood pressure and cholesterol into CVD risk prediction models slightly improves risk prediction.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Angela Wood
- Correspondence to Dr. Angela Wood, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Strangeways Research Laboratory, Cambridge CB1 8RN, United Kingdom (e-mail: )
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