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Karády J, Mayrhofer T, Januzzi JL, Udelson JE, Fleg JL, Merkely B, Lu MT, Peacock WF, Nagurney JT, Koenig W, Ferencik M, Hoffmann U. Agreement among high-sensitivity cardiac troponin assays and non-invasive testing, clinical outcomes, and quality-of-care outcomes based on the 2020 European Society of Cardiology Guidelines. Eur Heart J Acute Cardiovasc Care 2024; 13:15-23. [PMID: 38001050 PMCID: PMC10853690 DOI: 10.1093/ehjacc/zuad146] [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] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/25/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023]
Abstract
AIMS Quality-of-care and safety of patients with suspected acute coronary syndrome (ACS) would benefit if management was independent of which high-sensitivity cardiac troponin (hs-cTn) assay was used for risk stratification. We aimed to determine the concordance of hs-cTn assays to risk-stratify patients with suspected ACS according to the European Society of Cardiology (ESC) 2020 Guidelines. METHODS AND RESULTS Blood samples were obtained at arrival and at 2 h from patients with suspected ACS using four hs-cTn assays. The patients were classified into rule-out/observe/rule-in strata based on the ESC 2020 Guidelines. Concordance was determined among the assays for rule-out/observe/rule-in strata. The prevalences of significant underlying disease (≥50% stenosis on coronary computed tomography or inducible myocardial ischaemia on stress testing) and adjudicated ACS, plus quality-of-care outcomes, were compared. Among 238 patients (52.7 ± 8.0 years; 40.3% female), the overall concordance across assays to classify patients into rule-out/observe/rule-in strata was 74.0% (176/238). Platforms significantly differed for rule-out (89.9 vs. 76.5 vs. 78.6 vs. 86.6%, P < 0.001) and observe strata (6.7 vs. 20.6 vs. 17.7 vs. 9.2%, P < 0.001), but not for rule-in strata (3.4 vs. 2.9 vs. 3.8 vs. 4.2%, P = 0.62). Among patients in ruled-out strata, 19.1-21.6% had significant underlying disease and 3.3-4.2% had ACS. The predicted disposition of patients and cost-of-care differed across the assays (all P < 0.001). When compared with observed strata, conventional troponin-based management and predicted quality-of-care outcomes significantly improved with hs-cTn-based strategies (direct discharge: 21.0 vs. 80.3-90.8%; cost-of-care: $3889 ± 4833 vs. $2578 ± 2896-2894 ± 4371, all P < 0.001). CONCLUSION Among individuals with suspected ACS, patient management may differ depending on which hs-cTn assay is utilized. More data are needed regarding the implications of inter-assay differences. TRAIL REGISTRATION NCT01084239.
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Affiliation(s)
- Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- Heart and Vascular Center, Semmelweis University, 9-11 Gaál József Street, Budapest 1122, Hungary
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - James E Udelson
- Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, 9-11 Gaál József Street, Budapest 1122, Hungary
| | - Michael T Lu
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
| | - William F Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Boston, MA, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wolfgang Koenig
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St Suite 400, Boston, MA 02114, USA
- Innovative Imaging Consulting LLC, 163 Longfellow Rd., Waltham, MA 02453, USA
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2
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Mathew RO, Kretov EI, Huang Z, Jones PG, Sidhu MS, O’Brien SM, Prokhorikhin AA, Rangaswami J, Newman J, Stone GW, Fleg JL, Spertus JA, Maron DJ, Hochman JS, Bangalore S. Body Mass Index and Clinical and Health Status Outcomes in Chronic Coronary Disease and Advanced Kidney Disease in the ISCHEMIA-CKD Trial. Am J Med 2024; 137:163-171.e24. [PMID: 37925061 PMCID: PMC10872316 DOI: 10.1016/j.amjmed.2023.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE This study aimed to assess whether an obesity paradox (lower event rates with higher body mass index [BMI]) exists in participants with advanced chronic kidney disease (CKD) and chronic coronary disease in the International Study of Comparative Health Effectiveness of Medical and Invasive Approaches (ISCHEMIA)-CKD, and whether BMI modified the effect of initial treatment strategy. METHODS Baseline BMI was analyzed as both a continuous and categorical variable (< 25, ≥ 25 to < 30, ≥ 30 kg/m2). Associations between BMI and the primary outcome of all-cause death or myocardial infarction (D/MI), and all-cause death, cardiovascular death, and MI individually were estimated. Associations with health status were also evaluated using the Seattle Angina Questionnaire-7, the Rose Dyspnea Scale, and the EuroQol-5D Visual Analog Scale. RESULTS Body mass index ≥ 30 kg/m2 vs < 25 kg/m2 demonstrated increased risk for MI (hazard ratio [HR] [95% confidence interval] = 1.81 [1.12-2.92]) and for D/MI (HR 1.45 [1.06-1.96]) with a HR for MI of 1.22 (1.05-1.40) per 5 kg/m2 increase in BMI in unadjusted analysis. In multivariate analyses, a BMI ≥ 30 kg/m2 was marginally associated with D/MI (HR 1.43 [1.00-2.04]) and greater dyspnea throughout follow-up (P < .05 at all time points). Heterogeneity of treatment effect between baseline BMI was not evident for any outcome. CONCLUSIONS In the ISCHEMIA-CKD trial, an obesity paradox was not detected. Higher BMI was associated with worse dyspnea, and a trend toward increased D/MI and MI risk. Larger studies to validate these findings are warranted.
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Affiliation(s)
- Roy O. Mathew
- Department of Medicine, Loma Linda VA Health Care System, Loma Linda, CA, USA
| | - Evgeny I. Kretov
- National Medical Research Center of Ministry of Health of Russia, Novosibirsk, Russia
| | - Zhen Huang
- Duke Clinical and Research Institute and Duke University, Durham, NC, USA
| | - Philip G. Jones
- University of Missouri – Kansas City (UMKC)’s Healthcare Institute for Innovations in Quality and Saint Luke’s Mid America Heart Institute/, Kansas City, MO, USA
| | | | - Sean M. O’Brien
- Duke Clinical and Research Institute and Duke University, Durham, NC, USA
| | | | - Janani Rangaswami
- George Washington University School of Medicine, Washington, DC, USA
- Washington DC Veteran Affairs Medical Center, Washington, DC, USA
| | - Jonathan Newman
- Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York, NY, USA
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jerome L. Fleg
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - John A. Spertus
- University of Missouri – Kansas City (UMKC)’s Healthcare Institute for Innovations in Quality and Saint Luke’s Mid America Heart Institute/, Kansas City, MO, USA
| | - David J. Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Judith S. Hochman
- Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York, NY, USA
| | - Sripal Bangalore
- Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York, NY, USA
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3
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Davis EF, Crousillat DR, Peteiro J, Lopez-Sendon J, Senior R, Shapiro MD, Pellikka PA, Lyubarova R, Alfakih K, Abdul-Nour K, Anthopolos R, Xu Y, Kunichoff DM, Fleg JL, Spertus JA, Hochman J, Maron D, Picard MH, Reynolds HR. Global Longitudinal Strain as Predictor of Inducible Ischemia in No Obstructive Coronary Artery Disease in the CIAO-ISCHEMIA Study. J Am Soc Echocardiogr 2024; 37:89-99. [PMID: 37722490 PMCID: PMC10842002 DOI: 10.1016/j.echo.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/18/2023] [Accepted: 09/05/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Global longitudinal strain (GLS) is a sensitive marker for identifying subclinical myocardial dysfunction in obstructive coronary artery disease (CAD). Little is known about the relationship between GLS and ischemia in patients with myocardial ischemia and no obstructive CAD (INOCA). OBJECTIVES To investigate the relationship between resting GLS and ischemia on stress echocardiography (SE) in patients with INOCA. METHODS Left ventricular GLS was calculated offline on resting SE images at enrollment (n = 144) and 1-year follow-up (n = 120) in the CIAO-ISCHEMIA (Changes in Ischemia and Angina over One year in International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial screen failures with no obstructive CAD on computed tomography [CT] angiography) study, which enrolled participants with moderate or severe ischemia by local SE interpretation (≥3 segments with new or worsening wall motion abnormality and no obstructive (<50% stenosis) on coronary computed tomography angiography. RESULTS Global longitudinal strain values were normal in 83.3% at enrollment and 94.2% at follow-up. Global longitudinal strain values were not associated with a positive SE at enrollment (GLS = -21.5% positive SE vs GLS = -19.9% negative SE, P = .443) or follow-up (GLS = -23.2% positive SE vs GLS = -23.1% negative SE, P = .859). Significant change in GLS was not associated with positive SE in follow-up (P = .401). Regional strain was not associated with colocalizing ischemia at enrollment or follow-up. Changes in GLS and number of ischemic segments from enrollment to follow-up showed a modest but not clinically meaningful correlation (β = 0.41; 95% CI, 0.16, 0.67; P = .002). CONCLUSIONS In this cohort of INOCA patients, resting GLS values were largely normal and did not associate with the presence, severity, or location of stress-induced ischemia. These findings may suggest the absence of subclinical myocardial dysfunction detectable by echocardiographic strain analysis at rest in INOCA.
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Affiliation(s)
- Esther F Davis
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Victorian Heart Institute and Victorian Heart Hospital, Victoria, Australia
| | - Daniela R Crousillat
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts; Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, Tampa, Florida; Department of Obstetrics and Gynecology, Tampa General-Heart and Vascular Institute, University of South Florida, Tampa, Florida
| | - Jesus Peteiro
- CHUAC, Universidad de A Coruña, CIBER-CV, A Coruna, Spain
| | | | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | - Michael D Shapiro
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | | | | | - Rebecca Anthopolos
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Yifan Xu
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Dennis M Kunichoff
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - Jerome L Fleg
- National Institute of Health-National Heart Lung, and Blood Institute, Bethesda, Maryland
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Judith Hochman
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York
| | - David Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Michael H Picard
- Echocardiography Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Harmony R Reynolds
- Cardiovascular Clinical Research Center, Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, New York, New York.
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Grimshaw C, Keteyian SJ, Benzo R, Finkelstein J, Forman DE, Gaalema DE, Peterson PN, Einhorn PT, Punturieri A, Shero S, Fleg JL. Baseline Characteristics and Barriers to Recruitment in Cardiac and Pulmonary Rehabilitation NIH-Funded Trials. J Cardiopulm Rehabil Prev 2023; 43:407-411. [PMID: 37643249 PMCID: PMC10615858 DOI: 10.1097/hcr.0000000000000824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
| | | | | | | | - Daniel E. Forman
- Department of Medicine (Cardiology and Geriatrics), University of Pittsburgh, and the Geriatrics, Research, Education, and Clinical Center (GRECC), VA Pittsburgh Healthcare System, Pittsburgh, PA
| | | | - Pamela N. Peterson
- Denver Health Medical Center and University of Colorado Anschutz Medical Center, Denver and Aurora CO
| | | | | | - Susan Shero
- National Heart, Lung, and Blood Institute, Bethesda MD
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Denfeld QE, Fleg JL. Stretching our Exercise Options for Symptom Palliation in Heart Failure. J Card Fail 2023; 29:1184-1186. [PMID: 37086816 DOI: 10.1016/j.cardfail.2023.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Quin E Denfeld
- Oregon Health & Science University, School of Nursing, Portland, OR; Oregon Health & Science University, Knight Cardiovascular Institute, Portland, OR.
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
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6
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Sachdev V, Sharma K, Keteyian SJ, Alcain CF, Desvigne-Nickens P, Fleg JL, Florea VG, Franklin BA, Guglin M, Halle M, Leifer ES, Panjrath G, Tinsley EA, Wong RP, Kitzman DW. Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2023; 81:1524-1542. [PMID: 36958952 DOI: 10.1016/j.jacc.2023.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities-peripheral vascular, skeletal muscle, and cardiovascular-that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research.
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Sachdev V, Sharma K, Keteyian SJ, Alcain CF, Desvigne-Nickens P, Fleg JL, Florea VG, Franklin BA, Guglin M, Halle M, Leifer ES, Panjrath G, Tinsley EA, Wong RP, Kitzman DW. Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology. Circulation 2023; 147:e699-e715. [PMID: 36943925 DOI: 10.1161/cir.0000000000001122] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities-peripheral vascular, skeletal muscle, and cardiovascular-that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research.
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8
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Sidhu MS, Alexander KP, Huang Z, Mathew RO, Newman JD, O'Brien SM, Pellikka PA, Lyubarova R, Bockeria O, Briguori C, Kretov EL, Mazurek T, Orso F, Roik MF, Sajeev C, Shutov EV, Rockhold FW, Borrego D, Balter S, Stone GW, Chaitman BR, Goodman SG, Fleg JL, Reynolds HR, Maron DJ, Hochman JS, Bangalore S. Cause-Specific Mortality in Patients With Advanced Chronic Kidney Disease in the ISCHEMIA-CKD Trial. JACC Cardiovasc Interv 2023; 16:209-218. [PMID: 36697158 PMCID: PMC10000310 DOI: 10.1016/j.jcin.2022.10.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND In ISCHEMIA-CKD, 777 patients with advanced chronic kidney disease and chronic coronary disease had similar all-cause mortality with either an initial invasive or conservative strategy (27.2% vs 27.8%, respectively). OBJECTIVES This prespecified secondary analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease) was conducted to determine whether an initial invasive strategy compared with a conservative strategy decreased the incidence of cardiovascular (CV) vs non-CV causes of death. METHODS Three-year cumulative incidences were calculated for the adjudicated cause of death. Overall and cause-specific death by treatment strategy were analyzed using Cox models adjusted for baseline covariates. The association between cause of death, risk factors, and treatment strategy were identified. RESULTS A total of 192 of the 777 participants died during follow-up, including 94 (12.1%) of a CV cause, 59 (7.6%) of a non-CV cause, and 39 (5.0%) of an undetermined cause. The 3-year cumulative rates of CV death were similar between the invasive and conservative strategies (14.6% vs 12.6%, respectively; HR: 1.13, 95% CI: 0.75-1.70). Non-CV death rates were also similar between the invasive and conservative arms (8.4% and 8.2%, respectively; HR: 1.25; 95% CI: 0.75-2.09). Sudden cardiac death (46.8% of CV deaths) and infection (54.2% of non-CV deaths) were the most common cause-specific deaths and did not vary by treatment strategy. CONCLUSIONS In ISCHEMIA-CKD, CV death was more common than non-CV or undetermined death during the 3-year follow-up. The randomized treatment assignment did not affect the cause-specific incidences of death in participants with advanced CKD and moderate or severe myocardial ischemia. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease [ISCHEMIA-CKD]; NCT01985360).
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Affiliation(s)
| | - Karen P Alexander
- Duke Clinical Research Institute and Duke University, Durham, North Carolina, USA
| | - Zhen Huang
- Duke Clinical Research Institute and Duke University, Durham, North Carolina, USA
| | - Roy O Mathew
- Veterans Affairs Loma Linda Healthcare System, Loma Linda, California, USA
| | - Jonathan D Newman
- New York University Grossman School of Medicine, New York, New York, USA
| | - Sean M O'Brien
- Duke Clinical Research Institute and Duke University, Durham, North Carolina, USA
| | | | | | - Olga Bockeria
- National Research Center for Cardiovascular Surgery, Moscow, Russia
| | | | - Evgeny L Kretov
- National Medical Research Center of Ministry of Health of Russia, Novosibirsk, Russia
| | | | - Francesco Orso
- Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Marek F Roik
- Department of Internal Medicine and Cardiology, Infant Jesus Teaching Hospital, Medical University of Warsaw, Warsaw, Poland
| | | | - Evgeny V Shutov
- Russian Medical Academy of Continuous Professional Education, City Clinical Hospital named after S.P. Botkin, Moscow, Russia
| | - Frank W Rockhold
- Duke Clinical Research Institute and Duke University, Durham, North Carolina, USA
| | - David Borrego
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York, New York, USA
| | - Bernard R Chaitman
- St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis, Missouri, USA
| | - Shaun G Goodman
- St. Michael's Hospital, University of Toronto and the Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Jerome L Fleg
- National Institutes of Health, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Harmony R Reynolds
- New York University Grossman School of Medicine, New York, New York, USA
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Judith S Hochman
- New York University Grossman School of Medicine, New York, New York, USA
| | - Sripal Bangalore
- New York University Grossman School of Medicine, New York, New York, USA
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Ogunniyi MO, Mahmoud Z, Commodore-Mensah Y, Fleg JL, Fatade YA, Quesada O, Aggarwal NR, Mattina DJ, Moraes De Oliveira GM, Lindley KJ, Ovbiagele B, Roswell RO, Douglass PL, Itchhaporia D, Hayes SN. Eliminating Disparities in Cardiovascular Disease for Black Women. J Am Coll Cardiol 2022; 80:1762-1771. [PMID: 36302590 DOI: 10.1016/j.jacc.2022.08.769] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 10/31/2022]
Abstract
Black women are disproportionately affected by cardiovascular disease with an excess burden of cardiovascular morbidity and mortality. In addition, the racialized structure of the United States shapes cardiovascular disease research and health care delivery for Black women. Given the indisputable evidence of the disparities in health care delivery, research, and cardiovascular outcomes, there is an urgent need to develop and implement effective and sustainable solutions to advance cardiovascular health equity for Black women while considering their ethnic diversity, regions of origin, and acculturation. Innovative and culturally tailored strategies that consider the differential impact of social determinants of health and the unique challenges that shape their health-seeking behaviors should be implemented. A patient-centered framework that involves collaboration among clinicians, health care systems, professional societies, and government agencies is required to improve cardiovascular outcomes for Black women. The time is "now" to achieve health equity for all Black women.
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Karady J, Mayrhofer T, Nagurney JT, Udelson JE, Fleg JL, Peacock WF, Januzzi JL, Koenig W, Ferencik M, Hoffmann U. Agreement between four high-sensitivity cardiac troponin assays and non-invasive testing, clinical and quality of care outcomes based on the 2020 ESC guidelines: results from the ROMICAT II trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Quality of care and safety of patients with suspected acute coronary syndrome (ACS) would greatly benefit if management was independent of which high-sensitivity cardiac troponin (hs-cTn) assay was used for risk stratification.
Purpose
To assess the agreement of 4 hs-cTn assays to risk stratify patients with suspected ACS using the ESC2020 Guidelines 0/2-hour algorithm, and to assess their associations with non-invasive diagnostic testing, clinical- and quality of care outcomes.
Methods
We analyzed blood samples obtained at emergency department (ED) presentation and 2 hours later from patients with suspected ACS enrolled in the ROMICAT (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) II trial, using 4 hs-cTn assays (Roche Diagnostics, Elecsys 2010; Abbott Diagnostics, ARCHITECT i2000SR; Siemens Diagnostics, HsVista; Beckman Coulter, ACCESS). We determined the agreement between the assays to assign patients to rule-out, observe, and rule-in management pathways according to the ESC2020 Guidelines. Further, we assessed assay association with non-invasive diagnostic test findings and adjudicated clinical- and quality of care outcomes. Finally, we compared observed conventional troponin management with predicted management per ESC2020 guidelines using hs-cTn assays.
Results
Overall, assignment to ESC2020 Guideline management pathways among 238 patients with suspected ACS (age 52.7±8.0 years; 40.3% [96/238] female) was concordant across all hs-Tn assays in 74% of patients but differed for rule-out rates (89.9% vs 76.5% vs 78.6% vs 86.6%, p<0.001) and observation rates (6.7% vs 20.6% vs 17.7% vs 9.2%, p<0.001), but not for rule-in (3.4% vs 2.9% vs 3.8% vs 4.2%, p=0.623). Among those whose management recommendation was rule-out, 19.1–21.6% had obstructive CAD defined as coronary stenosis ≥50% on coronary CT angiography or inducible myocardial ischemia on perfusion imaging and 3.3–4.2% were diagnosed with ACS as adjudicated by independent panel. Predicted ED discharge rates based on hs-cTn assays were higher than those observed with conventional troponin (80.3% to 90.8% vs. 21.0%, respectively p<0.001). As a result, predicted costs of care were significantly lower based on strategies utilizing hs-cTn assays than with conventional troponin ($2,578±2,896 to $2,894±4,371 vs $3,889±4,833, respectively, p<0.001)
Conclusion
In a quarter of patients presenting to the ED with suspected ACS ESC2020 Guideline-based management may be different, depending on the hs-cTn assay. As compared to conventional troponin, hs-cTn is predicted to significantly increase direct ED discharges and lower costs of care.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- J Karady
- Massachusetts General Hospital , Boston , United States of America
| | - T Mayrhofer
- Massachusetts General Hospital , Boston , United States of America
| | - J T Nagurney
- Massachusetts General Hospital , Boston , United States of America
| | - J E Udelson
- Tufts Medical Center, Department of Medicine , Boston , United States of America
| | - J L Fleg
- National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences , Bethesda , United States of America
| | - W F Peacock
- Baylor College of Medicine, Department of Emergency Medicine , Houston , United States of America
| | - J L Januzzi
- Massachusetts General Hospital , Boston , United States of America
| | - W Koenig
- University of Ulm, Institute of Epidemiology and Medical Biometry , Ulm , Germany
| | - M Ferencik
- Oregon Health & Science University, Knight Cardiovascular Institute , Portland , United States of America
| | - U Hoffmann
- Massachusetts General Hospital , Boston , United States of America
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11
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Mathew RO, Maron DJ, Anthopolos R, Fleg JL, O’Brien SM, Rockhold FW, Briguori C, Roik MF, Mazurek T, Demkow M, Malecki R, Ye Z, Kaul U, Miglinas M, Stone GW, Wald R, Charytan DM, Sidhu MS, Hochman JS, Bangalore S. Guideline-Directed Medical Therapy Attainment and Outcomes in Dialysis-Requiring Versus Nondialysis Chronic Kidney Disease in the ISCHEMIA-CKD Trial. Circ Cardiovasc Qual Outcomes 2022; 15:e008995. [PMID: 36193750 PMCID: PMC9588677 DOI: 10.1161/circoutcomes.122.008995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) on dialysis (CKD G5D) have worse cardiovascular outcomes than patients with advanced nondialysis CKD (CKD G4-5: estimated glomerular filtration rate <30 mL/[min·1.73m2]). Our objective was to evaluate the relationship between achievement of cardiovascular guideline-directed medical therapy (GDMT) goals and clinical outcomes for CKD G5D versus CKD G4-5. METHODS This was a subgroup analysis of ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease) participants with CKD G4-5 or CKD G5D and moderate-to-severe myocardial ischemia on stress testing. Exposures included dialysis requirement at randomization and GDMT goal achievement during follow-up. The composite outcome was all-cause mortality or nonfatal myocardial infarction. Individual GDMT goal (smoking cessation, systolic blood pressure <140 mm Hg, low-density lipoprotein cholesterol <70 mg/dL, statin use, aspirin use) trajectory was modeled. Percentage point difference was estimated for each GDMT goal at 24 months between CKD G5D and CKD G4-5, and for association with key predictors. Probability of survival free from all-cause mortality or nonfatal myocardial infarction by GDMT goal achieved was assessed for CKD G5D versus CKD G4-5. RESULTS A total of 415 CKD G5D and 362 CKD G4-5 participants were randomized. Participants with CKD G5D were less likely to receive statin (-6.9% [95% CI, -10.3% to -3.7%]) and aspirin therapy (-3.0% [95% CI, -5.6% to -0.6%]), with no difference in other GDMT goal attainment. Cumulative exposure to GDMT achieved during follow-up was associated with reduction in all-cause mortality or nonfatal myocardial infarction (hazard ratio, 0.88 [95% CI, 0.87-0.90]; per each GDMT goal attained over 60 days), irrespective of dialysis status. CONCLUSIONS CKD G5D participants received statin or aspirin therapy less often. Cumulative exposure to GDMT goals achieved was associated with lower incidence of all-cause mortality or nonfatal myocardial infarction in participants with advanced CKD and chronic coronary disease, regardless of dialysis status. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01985360.
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Affiliation(s)
- Roy O. Mathew
- Department of Medicine, Loma Linda VA Health Care System, Loma Linda, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - David J. Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Jerome L. Fleg
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Sean M. O’Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, SC, USA
| | - Frank W. Rockhold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, SC, USA
| | | | - Marek F. Roik
- Department of Internal Medicine and Cardiology, Infant Jesus Teaching Hospital, Medical University of Warsaw, POL
| | | | | | | | - Zhiming Ye
- Guangdong Provincial People’s Hospital, Guangdong, CHN
| | - Upendra Kaul
- Batra Hospital and Medical Research Center, New Delhi, IND
| | - Marius Miglinas
- Vilnius University, Nephrology Center, Santaros Klinikos Hospital, Vilnius, LTU
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ron Wald
- St. Michael’s Hospital, Toronto, ON, CAN
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12
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Silva RS, Mendes FSNS, Fleg JL, Rodrigues Junior LF, Vieira MC, Xavier IGG, Costa HS, Reis MS, Mazzoli-Rocha F, Costa AR, Holanda MT, Veloso HH, Sperandio da Silva GM, Sousa AS, Saraiva RM, Hasslocher-Moreno AM, Mediano MFF. The association of exercise test variables with long-term mortality in patients with chronic Chagas disease. Front Med (Lausanne) 2022; 9:972514. [PMID: 36203775 PMCID: PMC9530636 DOI: 10.3389/fmed.2022.972514] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 08/22/2022] [Indexed: 11/24/2022] Open
Abstract
Background The identification of variables obtained in the exercise test (ET) associated with increased risk of death is clinically relevant and would provide additional information for the management of Chagas disease (CD). The objective of the present study was to evaluate the association of ET variables with mortality in patients with chronic CD. Methods This retrospective longitudinal observational study included 232 patients (median age 46.0 years; 50% women) with CD that were followed at the Evandro Chagas National Institute of Infectious Diseases (Rio de Janeiro, Brazil) and performed an ET between 1989 and 2000. The outcome of interest was all-cause mortality. Results There were 103 deaths (44.4%) during a median follow-up of 21.5 years (IQR 25–75% 8.0–27.8), resulting in 24.5 per 1,000 patients/year incidence rate. The ET variables associated with mortality after adjustments for potential confounders were increased maximal (HR 1.02; 95% CI 1.00–1.03 per mmHg) and change (HR 1.03; 95% CI 1.01–1.06 per mmHg) of diastolic blood pressure (DBP) during ET, ventricular tachycardia at rest (HR 3.95; 95% CI 1.14–13.74), during exercise (HR 2.73; 95% CI 1.44–5.20), and recovery (HR 2.60; 95% CI 1.14–5.91), and premature ventricular complexes during recovery (HR 2.06; 1.33–3.21). Conclusion Our findings suggest that ET provides important prognostic value for mortality risk assessment in patients with CD, with hemodynamic (increased DBP during exercise) and electrocardiographic (presence of ventricular arrhythmias) variables independently associated with an increased mortality risk in patients with CD. The identification of individuals at higher mortality risk can facilitate the development of intervention strategies (e.g., close follow-up) that may potentially have an impact on the longevity of patients with CD.
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Affiliation(s)
- Rudson S. Silva
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Fernanda S. N. S. Mendes
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Jerome L. Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, United States
| | - Luiz F. Rodrigues Junior
- Department of Research and Education, National Institute of Cardiology, Rio de Janeiro, RJ, Brazil
| | - Marcelo C. Vieira
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
- Center for Cardiology and Exercise, Aloysio de Castro State Institute of Cardiology, Rio de Janeiro, RJ, Brazil
| | - Isis G. G. Xavier
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Henrique S. Costa
- Physical Therapy Department, Federal University of Jequitinhonha and Mucuri Valleys, Diamantina, MG, Brazil
| | - Michel S. Reis
- Faculty of Physical Therapy, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Flavia Mazzoli-Rocha
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Andrea R. Costa
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Marcelo T. Holanda
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Henrique H. Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | | | - Andréa S. Sousa
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Roberto M. Saraiva
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | | | - Mauro F. F. Mediano
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
- Department of Research and Education, National Institute of Cardiology, Rio de Janeiro, RJ, Brazil
- *Correspondence: Mauro F. F. Mediano
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13
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Singam NSV, Tabi M, Fleg JL. Cardiovascular Mechanisms of Exercise Intolerance in Older Patients with Heart Failure. Rev Cardiovasc Med 2022. [DOI: 10.31083/j.rcm2309313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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14
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Goyal P, Kwak MJ, Al Malouf C, Kumar M, Rohant N, Damluji AA, Denfeld QE, Bircher KK, Krishnaswami A, Alexander KP, Forman DE, Rich MW, Wenger NK, Kirkpatrick JN, Fleg JL. Geriatric Cardiology: Coming of Age. JACC Adv 2022; 1:100070. [PMID: 37705890 PMCID: PMC10498100 DOI: 10.1016/j.jacadv.2022.100070] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Older adults with cardiovascular disease (CVD) contend with deficits across multiple domains of health due to age-related physiological changes and the impact of CVD. Multimorbidity, polypharmacy, cognitive changes, and diminished functional capacity, along with changes in the social environment, result in complexity that makes provision of CVD care to older adults challenging. In this review, we first describe the history of geriatric cardiology, an orientation that acknowledges the unique needs of older adults with CVD. Then, we introduce 5 essential principles for meeting the needs of older adults with CVD: 1) recognize and consider the potential impact of multicomplexity; 2) evaluate and integrate constructs of cognition into decision-making; 3) evaluate and integrate physical function into decision-making; 4) incorporate social environmental factors into management decisions; and 5) elicit patient priorities and health goals and align with care plan. Finally, we review future steps to maximize care provision to this growing population.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Min Ji Kwak
- Division of Geriatric and Palliative Medicine, McGovern Medical School, Houston, Texas, USA
| | - Christina Al Malouf
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Manish Kumar
- Department of Internal Medicine, Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Namit Rohant
- Division of Cardiology, University of Arizona, Tucson, Arizona, USA
| | - Abdulla A. Damluji
- Division of Cardiology, Inova Center of Outcomes Research, Falls Church, Virginia, USA
| | - Quin E. Denfeld
- School of Nursing and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Kim K. Bircher
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Ashok Krishnaswami
- Section of Geriatric Medicine, Division of Primary Care and Population Health, Stanford University, Stanford, California, USA
- Geriatric Research Education and Clinical Center (GRECC), U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, California, USA
- Division of Cardiology Kaiser Permanente San Jose Medical Center, San Jose, California, USA
| | - Karen P. Alexander
- Department of Medicine/Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel E. Forman
- Divisions of Geriatrics and Cardiology, Department of Medicine, University of Pittsburgh, and VA Pittsburgh GRECC, Pittsburgh, Pennsylvania, USA
| | - Michael W. Rich
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nanette K. Wenger
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - James N. Kirkpatrick
- Division of Cardiology and Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jerome L. Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
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15
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Bangalore S, Hochman JS, Stevens SR, Jones PG, Spertus JA, O’Brien SM, Reynolds HR, Boden WE, Fleg JL, Williams DO, Stone GW, Sidhu MS, Mathew RO, Chertow GM, Maron DJ. Clinical and Quality-of-Life Outcomes Following Invasive vs Conservative Treatment of Patients With Chronic Coronary Disease Across the Spectrum of Kidney Function. JAMA Cardiol 2022; 7:825-835. [PMID: 35767253 PMCID: PMC9244774 DOI: 10.1001/jamacardio.2022.1763] [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: 12/20/2021] [Accepted: 05/09/2022] [Indexed: 11/14/2022]
Abstract
Importance Prior trials of invasive vs conservative management of chronic coronary disease (CCD) have not enrolled patients with severe chronic kidney disease (CKD). As such, outcomes across kidney function are not well characterized. Objectives To evaluate clinical and quality-of-life (QoL) outcomes across the spectrum of CKD following conservative and invasive treatment strategies. Design, Setting, and Participants Participants from the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) and ISCHEMIA-Chronic Kidney Disease (CKD) trials were categorized by CKD stage: stage 1 (estimated glomerular filtration rate [eGFR] 90 mL/min/1.73m2 or greater), stage 2 (eGFR 60-89 mL/min/1.73m2), stage 3 (eGFR 30-59 mL/min/1.73m2), stage 4 (eGFR 15-29 mL/min/1.73m2), or stage 5 (eGFR less than 15 mL/min/1.73m2 or receiving dialysis). Enrollment took place from July 26, 2012, through January 31, 2018, with a median follow-up of 3.1 years. Data were analyzed from January 2020 to May 2021. Interventions Initial invasive management of coronary angiography and revascularization with guideline-directed medical therapy (GDMT) vs initial conservative management of GDMT alone. Main Outcomes and Measures The primary clinical outcome was a composite of death or nonfatal myocardial infarction (MI). The primary QoL outcome was the Seattle Angina Questionnaire (SAQ) summary score. Results Among the 5956 participants included in this analysis (mean [SD] age, 64 [10] years; 1410 [24%] female and 4546 [76%] male), 1889 (32%), 2551 (43%), 738 (12%), 311 (5%), and 467 (8%) were in CKD stages 1, 2, 3, 4, and 5, respectively. By self-report, 18 participants (<1%) were American Indian or Alaska Native; 1676 (29%), Asian; 267 (5%), Black; 861 (16%), Hispanic or Latino; 18 (<1%), Native Hawaiian or Other Pacific Islander; 3884 (66%), White; and 13 (<1%), multiple races or ethnicities. There was a monotonic increase in risk of the primary composite end point (3-year rates, 9.52%, 10.72%, 18.42%, 34.21%, and 38.01% respectively), death, cardiovascular death, MI, and stroke in individuals with higher CKD stages. Invasive management was associated with an increase in stroke (3-year event rate difference, 1%; 95% CI, 0.3 to 1.7) and procedural MI (1.6%; 95% CI, 0.9 to 2.3) and a decrease in spontaneous MI (-2.5%; 95% CI, -3.9 to -1.1) with no difference in other outcomes; the effect was similar across CKD stages. There was heterogeneity of treatment effect for QoL outcomes such that invasive management was associated with an improvement in angina-related QoL in individuals with CKD stages 1 to 3 and not in those with CKD stages 4 to 5. Conclusions and Relevance Among participants with CCD, event rates were inversely proportional to kidney function. Invasive management was associated with an increase in stroke and procedural MI and a reduced risk in spontaneous MI, and the effect was similar across CKD stages with no difference in other outcomes, including death. The benefit for QoL with invasive management was not observed in individuals with poorer kidney function.
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Affiliation(s)
| | | | | | - Philip G. Jones
- Saint Luke’s Mid America Heart Institute/University of Missouri, Kansas City
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute/University of Missouri, Kansas City
| | | | | | - William E. Boden
- Veterans Affairs New England Healthcare System, Boston, Massachusetts
| | - Jerome L. Fleg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York, New York
| | | | - Roy O. Mathew
- Columbia Veterans Affairs Health Care System, Columbia, South Carolina
| | - Glenn M. Chertow
- Department of Medicine, Stanford University, Stanford, California
| | - David J. Maron
- Department of Medicine, Stanford University, Stanford, California
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16
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Chaitman BR, Cyr DD, Alexander KP, Pracoń R, Bainey KR, Mathew A, Acharya A, Kunichoff DF, Fleg JL, Lopes RD, Sidhu MS, Anthopolos R, Rockhold FW, Stone GW, Maron DJ, Hochman JS, Bangalore S. Cardiovascular and Renal Implications of Myocardial Infarction in the ISCHEMIA-CKD Trial. Circ Cardiovasc Interv 2022; 15:e012103. [PMID: 35973009 PMCID: PMC10865178 DOI: 10.1161/circinterventions.122.012103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease) reported an initial invasive treatment strategy did not reduce the risk of death or nonfatal myocardial infarction (MI) compared with a conservative treatment strategy in patients with advanced chronic kidney disease, stable coronary disease, and moderate or severe myocardial ischemia. The cumulative frequency of different MI type after randomization and subsequent prognosis have not been reported. METHODS MI classification was based on the Third Universal Definition for MI. For procedural MI, the primary MI definition used creatine kinase-MB as the preferred biomarker, whereas the secondary MI definition used cTn (cardiac troponin); both definitions included elevated biomarker-only events with higher thresholds than nonprocedural MIs. The cumulative frequency of MI type according to treatment strategy was determined. The association of MI with subsequent all-cause death and new dialysis initiation was assessed by treating MI as a time-dependent covariate. RESULTS The 3-year incidence of type 1 or 2 MI with the primary MI definition was 11.2% in invasive treatment strategy and 13.6% in conservative treatment strategy (hazard ratio [HR], 0.66 [95% CI, 0.42-1.02]). Procedural MIs were more frequent in invasive treatment strategy and accounted for 9.8% and 28.3% of all MIs with the primary and secondary MI definitions, respectively. Patients had an increased risk of all-cause death after type 1 MI (adjusted HR, 4.35 [95% CI, 2.73-6.93]) and after procedural MI with the primary (adjusted HR, 2.75 [95% CI, 0.99-7.60]) and secondary MI definitions (adjusted HR, 2.91 [95% CI, 1.73-4.88]). Dialysis initiation was increased after a type 1 MI (HR, 6.45 [95% CI, 2.59-16.08]) compared with patients without an MI. CONCLUSIONS In ISCHEMIA-CKD, the invasive treatment strategy had higher rates of procedural MIs, particularly with the secondary MI definition, and lower rates of type 1 and 2 MIs. Procedural MIs, type 1 MIs, and type 2 MIs were associated with increased risk of subsequent death. Type 1 MI increased the risk of dialysis initiation. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01985360.
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Affiliation(s)
| | - Derek D. Cyr
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | - Radosław Pracoń
- Coronary and Structural Heart Diseases Department, Institute of Cardiology, Mazowieckie, Poland
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Anoop Mathew
- MOSC Medical College Hospital, Kolenchery, India
| | | | | | - Jerome L. Fleg
- National National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Renato D. Lopes
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | | | - Frank W. Rockhold
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA and the Cardiovascular Research Foundation, New York, NY, USA
| | - David J. Maron
- Stanford University School of Medicine, Stanford, CA, USA
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17
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Barkoudah E, Claggett BL, Lewis EF, O'Meara E, Clausell N, Diaz R, Fleg JL, Pitt B, Rouleau JL, Solomon SD, Pfeffer MA, Desai AS. Prognostic Impact of Cardiovascular versus Noncardiovascular Hospitalizations in Heart Failure with Preserved Ejection Fraction: Insights from TOPCAT. J Card Fail 2022; 28:1390-1397. [PMID: 35636727 DOI: 10.1016/j.cardfail.2022.05.004] [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] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients with heart failure (HF) with preserved ejection fraction (HFpEF) are commonly admitted to the hospital for both cardiovascular (CV) and noncardiovascular (non-CV) reasons. The prognostic implications of non-CV hospitalizations in this population are not well understood. In this study, we aimed to examine the prognostic implications of hospitalizations due to CV and non-CV reasons in a HFpEF population. METHODS AND RESULTS The Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial (TOPCAT) randomized 3,445 stable outpatients with chronic HF with left ventricular ejection fraction >=45% and either prior hospitalization for HF or elevated natriuretic peptides to treatment with spironolactone or placebo. Hospitalizations for any cause were reported by investigators during study follow-up and characterized according to prespecified category causes. This analysis focused on the subset of TOPCAT participants enrolled in the Americas (N=1,767), in which 2,973 hospitalizations were observed in 1,062 subjects (60%) over a mean follow-up of 3.3 years of study follow-up, of which 1,474 (49%) were ascribed to CV causes. Among 1,056 first hospitalizations, 478 (45%) were for CV reasons and 578 (55%) for non-CV reasons. Mortality rates were lowest for participants not hospitalized during the trial (3.2 per 100 patient-years (PY)), but similarly elevated following first hospitalization for CV and non-CV reasons (11.0 per 100 PY vs. 12.6 per 100 PY, respectively, p=0.24). Among those hospitalized for CV reasons, mortality rates were similar following hospitalization for HF and non-CV related reasons (15.2 per 100 PY vs. 12.6 per 100 PY, p=0.23). Recurrent hospitalization, whether due to CV or non-CV causes, was associated with heightened risk for subsequent mortality, with similar death rates following hospitalization twice for CV reasons (18.5 per 100 PY), twice for non-CV reasons (21.6 per 100 PY), or once each for CV and non-CV reasons (18.4 per 100 PY). CONCLUSION Among patients with HFpEF, hospitalization for any cause is associated with heightened risk for post-discharge mortality, with even higher risk associated with recurrent hospitalization. Given the high burden of non-CV hospitalizations in this population, targeted management of comorbid medical illness may be critical to reducing morbidity and mortality.
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Affiliation(s)
- Ebrahim Barkoudah
- Cardiovascular Division; Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA
| | - Eileen O'Meara
- Montreal Heart Institute Department of Medicine and Research Centre, and Université de Montréal, 5000 Belanger Street, Montréal, Québec, Canada
| | - Nadine Clausell
- Division of Cardiology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Bertram Pitt
- Division of Cardiology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI
| | - Jean L Rouleau
- Montreal Heart Institute Department of Medicine and Research Centre, and Université de Montréal, 5000 Belanger Street, Montréal, Québec, Canada
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Briguori C, Mathew RO, Huang Z, Mavromatis K, Hickson LJ, Lau WL, Mathew A, Mahajan S, Wheeler DC, Claes KJ, Chen G, Nolasco FEB, Stone GW, Fleg JL, Sidhu MS, Rockhold FW, Chertow GM, Hochman JS, Maron DJ, Bangalore S. Dialysis Initiation in Patients With Chronic Coronary Disease and Advanced Chronic Kidney Disease in ISCHEMIA-CKD. J Am Heart Assoc 2022; 11:e022003. [PMID: 35261290 PMCID: PMC9075321 DOI: 10.1161/jaha.121.022003] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 12/10/2021] [Indexed: 01/21/2023]
Abstract
Background In participants with concomitant chronic coronary disease and advanced chronic kidney disease (CKD), the effect of treatment strategies on the timing of dialysis initiation is not well characterized. Methods and Results In ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease), 777 participants with advanced CKD and moderate or severe ischemia were randomized to either an initial invasive or conservative management strategy. Herein, we compare the proportion of randomized participants with non-dialysis-requiring CKD at baseline (n=362) who initiated dialysis and compare the time to dialysis initiation between invasive versus conservative management arms. Using multivariable Cox regression analysis, we also sought to identify the effect of invasive versus conservative chronic coronary disease management strategies on dialysis initiation. At a median follow-up of 23 months (25th-75th interquartile range, 14-32 months), dialysis was initiated in 18.9% of participants (36/190) in the invasive strategy and 16.9% of participants (29/172) in the conservative strategy (P=0.22). The median time to dialysis initiation was 6.0 months (interquartile range, 3.0-16.0 months) in the invasive group and 18.2 months (interquartile range, 12.2-25.0 months) in the conservative group (P=0.004), with no difference in procedural acute kidney injury rates between the groups (7.8% versus 5.4%; P=0.26). Baseline clinical factors associated with earlier dialysis initiation were lower baseline estimated glomerular filtration rate (hazard ratio [HR] associated with 5-unit decrease, 2.08 [95% CI, 1.72-2.56]; P<0.001), diabetes (HR, 2.30 [95% CI, 1.28-4.13]; P=0.005), hypertension (HR, 7.97 [95% CI, 1.09-58.21]; P=0.041), and Hispanic ethnicity (HR, 2.34 [95% CI, 1.22-4.47]; P=0.010). Conclusions In participants with non-dialysis-requiring CKD in ISCHEMIA-CKD, randomization to an invasive chronic coronary disease management strategy (relative to a conservative chronic coronary disease management strategy) is associated with an accelerated time to initiation of maintenance dialysis for kidney failure. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01985360.
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Affiliation(s)
| | | | - Zhen Huang
- Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
| | - Kreton Mavromatis
- Atlanta VA Healthcare System and Emory University School of MedicineAtlantaGA
| | | | - Wei Ling Lau
- Division of NephrologyDepartment of MedicineUniversity of California‐IrvineIrvineCA
| | - Anoop Mathew
- University of Alberta HospitalEdmontonAlbertaCanada
| | | | | | | | - Gang Chen
- Peking Union Medical College HospitalBeijingChina
| | | | - Gregg W. Stone
- Icahn School of Medicine at Mount SinaiNew YorkNY
- Cardiovascular Research FoundationNew YorkNY
| | | | | | - Frank W. Rockhold
- Duke Clinical Research InstituteDuke University Medical CenterDurhamNC
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19
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Bainey KR, Fleg JL, Hochman JS, Kunichoff DF, Anthopolos R, Chernyavskiy AM, Demkow M, Lopez-Quijano JM, Escobedo J, Poh KK, Ramos RB, Lima EG, Schuchlenz H, Ali ZA, Stone GW, Maron DJ, O'Brien SM, Spertus JA, Bangalore S. Predictors of outcome in the ISCHEMIA-CKD trial: Anatomy versus ischemia. Am Heart J 2022; 243:187-200. [PMID: 34582775 PMCID: PMC10627379 DOI: 10.1016/j.ahj.2021.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/02/2021] [Accepted: 09/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches-Chronic Kidney Disease) trial found no advantage to an invasive strategy compared to conservative management in reducing all-cause death or myocardial infarction (D/MI). However, the prognostic influence of angiographic coronary artery disease (CAD) burden and ischemia severity remains unknown in this population. We compared the relative impact of CAD extent and severity of myocardial ischemia on D/MI in patients with advanced chronic kidney disease (CKD). METHODS Participants randomized to invasive management with available data on coronary angiography and stress testing were included. Extent of CAD was defined by the number of major epicardial vessels with ≥50% diameter stenosis by quantitative coronary angiography. Ischemia severity was assessed by site investigators as moderate or severe using trial definitions. The primary endpoint was D/MI. RESULTS Of the 388 participants, 307 (79.1%) had complete coronary angiography and stress testing data. D/MI occurred in 104/307 participants (33.9%). Extent of CAD was associated with an increased risk of D/MI (P < .001), while ischemia severity was not (P = .249). These relationships persisted following multivariable adjustment. Using 0-vessel disease (VD) as reference, the adjusted hazard ratio (HR) for 1VD was 1.86, 95% confidence interval (CI) 0.94 to 3.68, P = .073; 2VD: HR 2.13, 95% CI 1.10 to 4.12, P = .025; 3VD: HR 4.00, 95% CI 2.06 to 7.76, P < .001. Using moderate ischemia as the reference, the HR for severe ischemia was 0.84, 95% CI 0.54 to 1.30, P = .427. CONCLUSION Among ISCHEMIA-CKD participants randomized to the invasive strategy, extent of CAD predicted D/MI whereas severity of ischemia did not.
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Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Jerome L Fleg
- National Heart Lung and Blood Institute, Bethesda, MD
| | | | | | | | - Alexander M Chernyavskiy
- E.Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation (E.Meshalkin NMRC), Novosibirsk, Russia
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | | | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Kian Keong Poh
- National University Heart Center Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Herwig Schuchlenz
- oLKH Graz II, Department fuer Kardiologie und Intensivmedizin, Graz, Austria
| | - Ziad A Ali
- Cardiovascular Research Foundation, New York, NY; Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY; St Francis Hospital, Roslyn, NY
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - David J Maron
- Stanford University School of Medicine, Stanford, CA
| | - Sean M O'Brien
- Duke Clinical Research Institute and Duke University, Durham, NC
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City (UMKC), Kansas City, MO
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20
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Shero ST, Benzo R, Cooper LS, Finkelstein J, Forman DE, Gaalema DE, Joseph L, Keteyian SJ, Peterson PN, Punturieri A, Zieman S, Fleg JL. Update on RFA Increasing Use of Cardiac and Pulmonary Rehabilitation in Traditional and Community Settings NIH-Funded Trials: ADDRESSING CLINICAL TRIAL CHALLENGES PRESENTED BY THE COVID-19 PANDEMIC. J Cardiopulm Rehabil Prev 2022; 42:10-14. [PMID: 34508036 PMCID: PMC8719437 DOI: 10.1097/hcr.0000000000000635] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We previously described the design of six NIH-funded clinical trials designed to increase uptake and reduce disparities in the use of cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) based on age, gender, race/ethnicity, and socioeconomic status. The onset of the COVID-19 global pandemic necessitated signifi cant revisions to the trials to ensure the safety of participants and research staff. This article described necessary modifi cations for assessments, interventions, and data collection to support a no-contact approach centered on the use of virtual/remote techniques that maintain both safety and the original intent and integrity of the trials. The general shift from site-based to home-based interventions and hybrid models of CR and PR will be increasingly important in a post-COVID world.
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Affiliation(s)
- Susan T. Shero
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Roberto Benzo
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Lawton S. Cooper
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Joseph Finkelstein
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Daniel E. Forman
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Diann E. Gaalema
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Lyndon Joseph
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Steven J. Keteyian
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Pamela N. Peterson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Antonello Punturieri
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Susan Zieman
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
| | - Jerome L. Fleg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland (Ms Shero and Drs Cooper, Punturieri, and Fleg); Mayo Clinic, Rochester, Minnesota (Dr Benzo); Icahn School of Medicine at Mount Sinai, New York, New York (Dr Finkelstein); University of Pittsburgh and VA Pittsburgh Healthcare Systems, Pittsburgh, Pennsylvania (Dr Forman); University of Vermont, Burlington (Dr Gaalema); National Institute on Aging, Bethesda, Maryland (Drs Joseph and Zieman); Henry Ford Hospital, Detroit, Michigan (Dr Keteyian); Denver Health Medical Center, Denver, Colorado, and University of Colorado Anschutz Medical Center, Aurora (Dr Peterson)
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21
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Lindley KJ, Aggarwal NR, Briller JE, Davis MB, Douglass P, Epps KC, Fleg JL, Hayes S, Itchhaporia D, Mahmoud Z, Moraes De Oliveira GM, Ogunniyi MO, Quesada O, Russo AM, Sharma J, Wood MJ. Socioeconomic Determinants of Health and Cardiovascular Outcomes in Women: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:1919-1929. [PMID: 34736568 DOI: 10.1016/j.jacc.2021.09.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [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: 06/28/2021] [Revised: 09/07/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
Socioeconomic disparities in cardiovascular risk factors and outcomes exist among women, particularly those of minority racial or ethnic backgrounds. Barriers to optimal cardiovascular health begin early in life-with inadequate access to effective contraception, postpartum follow-up, and maternity leave-and result in excess rates of myocardial infarction, stroke, and cardiovascular death in at-risk populations. Contributing factors include reduced access to care, low levels of income and social support, and lack of diversity among cardiology clinicians and within clinical trials. These barriers can be mitigated by optimizing care access via policy change and improving physical access to care in women with geographic or transportation limitations. Addressing structural racism through policy change and bolstering structured community support systems will be key to reducing adverse cardiovascular outcomes among women of racial and ethnic minorities. Diversification of the cardiology workforce to more closely represent the patients we serve will be beneficial to all women.
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Affiliation(s)
- Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA.
| | - Niti R Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/NitiCardio
| | - Joan E Briller
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA. https://twitter.com/MelindaDavisMD
| | - Paul Douglass
- Division of Cardiology, Wellstar Atlanta Medical Center, Atlanta, Georgia, USA
| | - Kelly C Epps
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Sharonne Hayes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dipti Itchhaporia
- Jeffrey M. Carlton Heart & Vascular Institute, Hoag Memorial Hospital Presbyterian, Newport Beach, California, USA
| | - Zainab Mahmoud
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri, USA
| | | | - Modele O Ogunniyi
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA. https://twitter.com/modeldoc
| | - Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart and Vascular Institute, Cincinnati, Ohio, USA. https://twitter.com/odayme
| | - Andrea M Russo
- Cardiovascular Division, Department of Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA. https://twitter.com/AndreaRussoEP
| | - Jyoti Sharma
- Division of Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Malissa J Wood
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/drmalissawood
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22
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Newman JD, Anthopolos R, Mancini GBJ, Bangalore S, Reynolds HR, Kunichoff DF, Senior R, Peteiro J, Bhargava B, Garg P, Escobedo J, Doerr R, Mazurek T, Gonzalez-Juanatey J, Gajos G, Briguori C, Cheng H, Vertes A, Mahajan S, Guzman LA, Keltai M, Maggioni AP, Stone GW, Berger JS, Rosenberg YD, Boden WE, Chaitman BR, Fleg JL, Hochman JS, Maron DJ. Outcomes of Participants With Diabetes in the ISCHEMIA Trials. Circulation 2021; 144:1380-1395. [PMID: 34521217 DOI: 10.1161/circulationaha.121.054439] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy. METHODS The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function). RESULTS Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min-1·1.73-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes. CONCLUSIONS Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.
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Affiliation(s)
- Jonathan D Newman
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Rebecca Anthopolos
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - G B John Mancini
- Center for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (G.B.J.M.)
| | - Sripal Bangalore
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Harmony R Reynolds
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Dennis F Kunichoff
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, UK (R.S.)
| | - Jesus Peteiro
- Complejo Hospitalario Universitario de A Coruña (CHUAC), Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Universidad de A Coruña, A Coruña, Spain (J.P.)
| | | | - Pallav Garg
- London Health Sciences Center, Western University, Ontario, Canada (P.G.)
| | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City (J.E.)
| | - Rolf Doerr
- Praxisklinik Herz und Gefaesse, Dresden, Germany (R.D.)
| | | | - Jose Gonzalez-Juanatey
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Institution, Spain (J.G-J.)
| | - Grzegorz Gajos
- Department of Coronary Disease and Heart Failure, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland (G.G.)
| | - Carlo Briguori
- Laboratory of Interventional Cardiology and Department of Cardiology, Mediterranea Cardiocentro, Naples, Italy (C.B.)
| | - Hong Cheng
- Beijing Anzhen Hospital, Capital Medical University, China (H.C.)
| | - Andras Vertes
- Dél-pesti Centrumkóház Hospital, National Institute of Hematology and Infectious Disease, Cardiovascular Department, Budapest, Hungary (A.V.)
| | | | - Luis A Guzman
- Instituto Médico Docencia Asistencia Médica e Investigación Clínica, Cordoba, Argentina (L.A.G.)
| | | | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy (A.P.M.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York (G.W.S.)
| | - Jeffrey S Berger
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Yves D Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (Y.D.R., J.L.F.)
| | - William E Boden
- Veterans Affairs New England Healthcare System, Boston University School of Medicine, MA (W.E.B.)
| | - Bernard R Chaitman
- St Louis University School of Medicine Center for Comprehensive Cardiovascular Care, MO (B.R.C.)
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (Y.D.R., J.L.F.)
| | | | - David J Maron
- Department of Medicine, Stanford University, CA (D.J.M.)
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23
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Herzog CA, Simegn MA, Xu Y, Costa SP, Mathew RO, El-Hajjar MC, Gulati S, Maldonado RA, Daugas E, Madero M, Fleg JL, Anthopolos R, Stone GW, Sidhu MS, Maron DJ, Hochman JS, Bangalore S. Kidney Transplant List Status and Outcomes in the ISCHEMIA-CKD Trial. J Am Coll Cardiol 2021; 78:348-361. [PMID: 33989711 PMCID: PMC8319110 DOI: 10.1016/j.jacc.2021.05.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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: 03/16/2021] [Revised: 04/26/2021] [Accepted: 05/03/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) and coronary artery disease frequently undergo preemptive revascularization before kidney transplant listing. OBJECTIVES In this post hoc analysis from ISCHEMIA-CKD (International Study of Comparative Health Effectiveness of Medical and Invasive Approaches-Chronic Kidney Disease), we compared outcomes of patients not listed versus those listed according to management strategy. METHODS In the ISCHEMIA-CKD trial (n = 777), 194 patients (25%) with chronic coronary syndromes and at least moderate ischemia were listed for transplant. The primary (all-cause mortality or nonfatal myocardial infarction) and secondary (death, nonfatal myocardial infarction, hospitalization for unstable angina, heart failure, resuscitated cardiac arrest, or stroke) outcomes were analyzed using Cox multivariable modeling. Heterogeneity of randomized treatment effect between listed versus not listed groups was assessed. RESULTS Compared with those not listed, listed patients were younger (60 years vs 65 years), were less likely to be of Asian race (15% vs 29%), were more likely to be on dialysis (83% vs 44%), had fewer anginal symptoms, and were more likely to have coronary angiography and coronary revascularization irrespective of treatment assignment. Among patients assigned to an invasive strategy versus conservative strategy, the adjusted hazard ratios for the primary outcome were 0.91 (95% confidence interval [CI]: 0.54-1.54) and 1.03 (95% CI: 0.78-1.37) for those listed and not listed, respectively (pinteraction= 0.68). Adjusted hazard ratios for secondary outcomes were 0.89 (95% CI: 0.55-1.46) in listed and 1.17 (95% CI: 0.89-1.53) in those not listed (pinteraction = 0.35). CONCLUSIONS In ISCHEMIA-CKD, an invasive strategy in kidney transplant candidates did not improve outcomes compared with conservative management. These data do not support routine coronary angiography or revascularization in patients with advanced CKD and chronic coronary syndromes listed for transplant. (ISCHEMIA-Chronic Kidney Disease Trial [ISCHEMIA-CKD]; NCT01985360).
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Affiliation(s)
- Charles A Herzog
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA.
| | - Mengistu A Simegn
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA
| | - Yifan Xu
- NYU Grossman School of Medicine, New York, New York, USA
| | | | - Roy O Mathew
- Columbia V.A. Health Care System, Columbia, South Carolina, USA
| | | | - Sanjeev Gulati
- Fortis Flt Lt Rajan Dhall Hospital, New Delhi, Delhi, India
| | | | - Eric Daugas
- Department of Nephrology, Bichat, Assistance Publique-Hôpitaux, Paris, France
| | - Magdelena Madero
- Instituto Nacional de Cardiologia Ignacio Chavez, Mexico City, Mexico
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | | | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York, New York, USA
| | - Mandeep S Sidhu
- Albany Medical College and Albany Medical Center, Albany, New York, USA
| | - David J Maron
- Department of Medicine, Stanford University, Stanford, California, USA
| | | | - Sripal Bangalore
- NYU Grossman School of Medicine, New York, New York, USA. https://twitter.com/sripalbangalore
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Reynolds HR, Picard MH, Spertus JA, Peteiro J, Lopez-Sendon JL, Senior R, El-Hajjar MC, Celutkiene J, Shapiro MD, Pellikka PA, Kunichoff DF, Anthopolos R, Alfakih K, Abdul-Nour K, Khouri M, Bershtein L, De Belder M, Poh KK, Beltrame JF, Min JK, Fleg JL, Li Y, Maron DJ, Hochman JS. Natural History of Patients with Ischemia and No Obstructive Coronary Artery Disease: The CIAO-ISCHEMIA Study. Circulation 2021; 144:1008-1023. [PMID: 34058845 DOI: 10.1161/circulationaha.120.046791] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [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] [Indexed: 02/06/2023]
Abstract
Background: Ischemia with no obstructive coronary artery disease (INOCA) is common and has an adverse prognosis. We set out to describe the natural history of symptoms and ischemia in INOCA. Methods: CIAO-ISCHEMIA (Changes in Ischemia and Angina over One year in ISCHEMIA trial screen failures with INOCA) was an international cohort study conducted from 2014-2019 involving angina assessments (Seattle Angina Questionnaire [SAQ]) and stress echocardiograms 1-year apart. This was an ancillary study that included patients with history of angina who were not randomized in the ISCHEMIA trial. Stress-induced wall motion abnormalities were determined by an echocardiographic core laboratory blinded to symptoms, coronary artery disease (CAD) status and test timing. Medical therapy was at the discretion of treating physicians. The primary outcome was the correlation between changes in SAQ Angina Frequency score and change in echocardiographic ischemia. We also analyzed predictors of 1-year changes in both angina and ischemia, and compared CIAO participants with ISCHEMIA participants with obstructive CAD who had stress echocardiography before enrollment, as CIAO participants did. Results: INOCA participants in CIAO were more often female (66% of 208 vs. 26% of 865 ISCHEMIA participants with obstructive CAD, p<0.001), but the magnitude of ischemia was similar (median 4 ischemic segments [IQR 3-5] both groups). Ischemia and angina were not significantly correlated at enrollment in CIAO (p=0.46) or ISCHEMIA stress echocardiography participants (p=0.35). At 1 year, the stress echocardiogram was normal in half of CIAO participants and 23% had moderate or severe ischemia (≥3 ischemic segments). Angina improved in 43% and worsened in 14%. Change in ischemia over one year was not significantly correlated with change in angina (rho=0.029). Conclusions:Improvement in ischemia and improvement in angina were common in INOCA, but not correlated. Our INOCA cohort had a similar degree of inducible wall motion abnormalities to concurrently enrolled ISCHEMIA participants with obstructive CAD. Our results highlight the complex nature of INOCA pathophysiology and the multifactorial nature of angina. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02347215.
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Affiliation(s)
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO
| | - Jesus Peteiro
- CHUAC, Universidad de A Coruña,/CIBER-CV, A Coruna, Spain
| | | | - Roxy Senior
- Royal Brompton Hospital, London, UK; Northwick Park Hospital, Harrow, UK
| | | | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine/ State Research Institute Centre For Innovative Medicine, Vilnius, Lithuania
| | | | - Patricia A Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, UNITED STATES
| | | | | | | | | | | | - Leonid Bershtein
- Internal Medicine & Cardiology, North-Western State Medical University n.a. I.I Mechnikov, Saint Petersburg, Russia, RUSSIAN FEDERATION
| | | | - Kian Keong Poh
- National University Heart Centre, Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - John F Beltrame
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - James K Min
- University of Adelaide /Central Adelaide Local Health Network, South Australia, Adelaide, Australia
| | | | - Yi Li
- New York University Grossman School of Medicine, New York, NY
| | - David J Maron
- National Heart, Lung, and Blood Institute, Bethesda, MD
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Karády J, Mayrhofer T, Ferencik M, Nagurney JT, Udelson JE, Kammerlander AA, Fleg JL, Peacock WF, Januzzi JL, Koenig W, Hoffmann U. Discordance of High-Sensitivity Troponin Assays in Patients With Suspected Acute Coronary Syndromes. J Am Coll Cardiol 2021; 77:1487-1499. [PMID: 33766254 PMCID: PMC8040768 DOI: 10.1016/j.jacc.2021.01.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND High-sensitivity cardiac troponin (hs-cTn) assays have different analytic characteristics. OBJECTIVES The goal of this study was to quantify differences between assays for common analytical benchmarks and to determine whether they may result in differences in the management of patients with suspected acute coronary syndrome (ACS). METHODS The authors included patients with suspected ACS enrolled in the ROMICAT (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) I and II trials, with blood samples taken at emergency department presentation (ROMICAT-I and -II) or at 2 and 4 h thereafter (ROMICAT-II). hs-cTn concentrations were measured using 3 assays (Roche Diagnostics, Elecsys 2010 platform; Abbott Diagnostics, ARCHITECT i2000SR; Siemens Diagnostics, HsVista). Per blood sample, we determined concordance across analytic benchmarks (99th percentile). Per-patient, the authors determined concordance of management recommendations (rule-out/observe/rule-in) per the 0/2-h algorithm, and their association with diagnostic test findings (coronary artery stenosis >50% on coronary computed tomography angiography or inducible ischemia on perfusion imaging) and ACS. RESULTS Among 1,027 samples from 624 patients (52.8 ± 10.0 years; 39.4% women), samples were classified as 99th percentile (7.2% vs. 6.0% vs. 6.2%) by Roche, Abbott, and Siemens, respectively. A total of 37.4% (n = 384 of 1,027) of blood samples were classified into the same analytical benchmark category, with low concordance across benchmarks (99th percentile 43.6%). Serial samples were available in 242 patients (40.1% women; mean age: 52.8 ± 8.0 years). The concordance of management recommendations across assays was 74.8% (n = 181 of 242) considering serial hs-cTn measurements. Of patients who were recommended to discharge, 19.6% to 21.1% had positive diagnostic test findings and 2.8% to 4.3% had ACS at presentation. CONCLUSIONS Caregivers should be aware that there are significant differences between hs-cTn assays in stratifying individual samples and patients with intermediate likelihood of ACS according to analytical benchmarks that may result in different management recommendations. (Rule Out Myocardial Infarction by Computer Assisted Tomography [ROMICAT]; NCT00990262) (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239).
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Affiliation(s)
- Júlia Karády
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA; MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
| | - Thomas Mayrhofer
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA; School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Maros Ferencik
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, USA
| | - James E Udelson
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Andreas A Kammerlander
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Boston, Massachusetts, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wolfgang Koenig
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany; Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital-Harvard Medical School, Boston, Massachusetts, USA
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26
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Beldhuis IE, Myhre PL, Bristow M, Claggett B, Damman K, Fang JC, Fleg JL, McKinlay S, Lewis EF, O'Meara E, Pitt B, Shah SJ, Vardeny O, Voors AA, Pfeffer MA, Solomon SD, Desai AS. Spironolactone in Patients With Heart Failure, Preserved Ejection Fraction, and Worsening Renal Function. J Am Coll Cardiol 2021; 77:1211-1221. [PMID: 33663739 DOI: 10.1016/j.jacc.2020.12.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 04/22/2020] [Revised: 12/23/2020] [Accepted: 12/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Treatment of heart failure with preserved ejection fraction (HFpEF) with spironolactone is associated with lower risk of heart failure hospitalization (HFH) but increased risk of worsening renal function (WRF). The prognostic implications of spironolactone-associated WRF in HFpEF patients are not well understood. OBJECTIVES The purpose of this study was to investigate the association between WRF, spironolactone treatment, and clinical outcomes in patients with HFpEF. METHODS In 1,767 patients randomized to spironolactone or placebo in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial)-Americas study, we examined the incidence of WRF (doubling of serum creatinine) by treatment assignment. Associations between incident WRF and subsequent risk for the primary study endpoint of cardiovascular (CV) death, HFH, or aborted cardiac arrest and key secondary outcomes, including CV death, HFH, and all-cause mortality according to treatment assignment, were examined in time-updated Cox proportional hazards models with an interaction term. RESULTS WRF developed in 260 (14.7%) patients with higher rates in those assigned to spironolactone compared to placebo (17.8% vs. 11.6%; odds ratio: 1.66; 95% confidence interval: 1.27 to 2.17; p < 0.001). Regardless of treatment, incident WRF was associated with increased risk for the primary endpoint (hazard ratio: 2.04; 95% confidence interval: 1.52 to 2.72; p < 0.001) after multivariable adjustment. Although there was no statistical interaction between treatment assignment and WRF regarding the primary endpoint (interaction p = 0.11), spironolactone-associated WRF was associated with lower risk of CV death (interaction p = 0.003) and all-cause mortality (interaction p = 0.001) compared with placebo-associated WRF. CONCLUSIONS Among HFpEF patients enrolled in TOPCAT-Americas, spironolactone increased risk of WRF compared with placebo. Rates of CV death were lower with spironolactone in both patients with and without WRF.
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Affiliation(s)
- Iris E Beldhuis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA; University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands. https://twitter.com/iebeldhuis
| | - Peder L Myhre
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Medicine, Akershus University Hospital, Lorenskog, Norway. https://twitter.com/pmyhre
| | - Michael Bristow
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - James C Fang
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Sonja McKinlay
- New England Research Institutes, Watertown, Massachusetts, USA
| | - Eldrin F Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adriaan A Voors
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Regan JA, Kitzman DW, Leifer ES, Kraus WE, Fleg JL, Forman DE, Whellan DJ, Wojdyla D, Parikh K, O'Connor CM, Mentz RJ. Impact of Age on Comorbidities and Outcomes in Heart Failure With Reduced Ejection Fraction. JACC Heart Fail 2020; 7:1056-1065. [PMID: 31779928 DOI: 10.1016/j.jchf.2019.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/19/2019] [Accepted: 09/13/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVES This study sought to determine whether age modifies the impact of key comorbidities on clinical outcomes for patients with heart failure with reduced ejection fraction (HFrEF). BACKGROUND Comorbidities impact outcomes in HFrEF. However, the effect of age on the impact of comorbidities on prognosis is not clearly understood. METHODS Cox proportional hazards models were used assessed interactions between age and comorbidities on the primary composite endpoint (all-cause mortality or hospitalization) and secondary endpoints in the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) multicenter trial of 2,331 patients with HFrEF. RESULTS Age did not significantly modify the effect of any comorbidity on the primary endpoint. However, age significantly modified the effect of body mass index (BMI) on all-cause mortality (interaction p = 0.02). Among patients ≥70 years of age, there was a U-shaped relationship between BMI and 1-year mortality, where BMI of 20 kg/m2 corresponded to 17.6%; a BMI of 30 kg/m2 corresponded to 7.0%; and a BMI of 40 kg/m2 corresponded to 11%. For patients <60 years of age, mortality increased nonsignificantly from 3.2% to 3.7% with increasing BMI. Age also modified the effect of depressive symptoms on all-cause mortality (interaction p = 0.03). Among patients ≥70 years of age, a 1-year mortality rate significantly increased from 7.8% for a Beck Depression Inventory (BDI) score of 5% to 15.6% for BDI of 20. For patients <60 years of age, mortality was nonsignificantly related to BDI. Cumulative comorbidity scores were stronger predictors than age for mortality/hospitalization. CONCLUSIONS In chronic HFrEF, age markedly altered the impact of BMI and depressive symptoms on all-cause mortality, with much higher risk in older patients, but was not as strong a predictor of mortality/hospitalizations as cumulative comorbidity score. (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training [HF-ACTION]; NCT00047437).
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Affiliation(s)
- Jessica A Regan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina.
| | - Dalane W Kitzman
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Eric S Leifer
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - William E Kraus
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Daniel E Forman
- Department of Medicine, University of Pittsburgh and Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - David J Whellan
- Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Durham, North Carolina
| | - Kishan Parikh
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | | | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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Boden WE, Miller MG, McBride R, Harvey C, Snabes MC, Schmidt J, McGovern ME, Fleg JL, Desvigne-Nickens P, Anderson T, Kashyap M, Probstfield JL. Testosterone concentrations and risk of cardiovascular events in androgen-deficient men with atherosclerotic cardiovascular disease. Am Heart J 2020; 224:65-76. [PMID: 32335402 DOI: 10.1016/j.ahj.2020.03.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Whether androgen deficiency among men increases the risk of cardiovascular (CV) events or is merely a disease marker remains a subject of intense scientific interest. OBJECTIVES Among male subjects in the AIM-HIGH Trial with metabolic syndrome and low baseline levels of high-density lipoprotein (HDL)-cholesterol who were randomized to niacin or placebo plus simvastatin, we examined the relationship between low baseline testosterone (T) concentrations and subsequent CV outcomes during a mean 3-year follow-up. METHODS In this post hoc analysis of men with available baseline plasma T concentrations, we examined the relationship between clinical/demographic characteristics and T concentrations both as a continuous and dichotomous variable (<300 ng/dL ["low T"] vs. ≥300 ng/dL ["normal T"]) on rates of pre-specified CV outcomes, using Cox proportional hazards models. RESULTS Among 2118 male participants in whom T concentrations were measured, 643 (30%) had low T and 1475 had normal T concentrations at baseline. The low T group had higher rates of diabetes mellitus, hypertension, elevated body mass index, metabolic syndrome, higher blood glucose, hemoglobin A1c, and triglyceride levels, but lower levels of both low-density lipoprotein and HDL-cholesterol, and a lower rate of prior myocardial infarction (MI). Men with low T had a higher risk of the primary composite outcome of coronary heart disease (CHD) death, MI, stroke, hospitalization for acute coronary syndrome, or coronary or cerebral revascularization (20.1%) compared with the normal T group (15.2%); final adjusted HR 1.23, P = .07, and a higher risk of the CHD death, MI, and stroke composite endpoint (11.8% vs. 8.2%; final adjusted HR 1.37, P = .04), respectively. CONCLUSIONS In this post hoc analysis, there was an association between low baseline testosterone concentrations and increased risk of subsequent CV events in androgen-deficient men with established CV disease and metabolic syndrome, particularly for the composite secondary endpoint of CHD death, MI, and stroke. CONDENSED ABSTRACT In this AIM-HIGH Trial post hoc analysis of 2118 men with metabolic syndrome and low HDL-cholesterol with available baseline plasma testosterone (T) samples, 643 males (30%) had low T (mean: 229 ng/dL) and 1475 (70%) had normal T (mean: 444 ng/dL) concentrations. The "low T" group had a 24% higher risk of the primary 5-component endpoint (20.1%) compared with the normal T group (15.2%); final adjusted HR 1.23, P = .07). There was also a 31% higher risk of the secondary composite endpoint: coronary heart disease death, myocardial infarction, and stroke (11.8% vs. 8.2%, final adjusted HR 1.37, P = .04) in the low vs. normal T group, respectively.
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Sanford JA, Nogiec CD, Lindholm ME, Adkins JN, Amar D, Dasari S, Drugan JK, Fernández FM, Radom-Aizik S, Schenk S, Snyder MP, Tracy RP, Vanderboom P, Trappe S, Walsh MJ, Adkins JN, Amar D, Dasari S, Drugan JK, Evans CR, Fernandez FM, Li Y, Lindholm ME, Nogiec CD, Radom-Aizik S, Sanford JA, Schenk S, Snyder MP, Tomlinson L, Tracy RP, Trappe S, Vanderboom P, Walsh MJ, Lee Alekel D, Bekirov I, Boyce AT, Boyington J, Fleg JL, Joseph LJ, Laughlin MR, Maruvada P, Morris SA, McGowan JA, Nierras C, Pai V, Peterson C, Ramos E, Roary MC, Williams JP, Xia A, Cornell E, Rooney J, Miller ME, Ambrosius WT, Rushing S, Stowe CL, Jack Rejeski W, Nicklas BJ, Pahor M, Lu CJ, Trappe T, Chambers T, Raue U, Lester B, Bergman BC, Bessesen DH, Jankowski CM, Kohrt WM, Melanson EL, Moreau KL, Schauer IE, Schwartz RS, Kraus WE, Slentz CA, Huffman KM, Johnson JL, Willis LH, Kelly L, Houmard JA, Dubis G, Broskey N, Goodpaster BH, Sparks LM, Coen PM, Cooper DM, Haddad F, Rankinen T, Ravussin E, Johannsen N, Harris M, Jakicic JM, Newman AB, Forman DD, Kershaw E, Rogers RJ, Nindl BC, Page LC, Stefanovic-Racic M, Barr SL, Rasmussen BB, Moro T, Paddon-Jones D, Volpi E, Spratt H, Musi N, Espinoza S, Patel D, Serra M, Gelfond J, Burns A, Bamman MM, Buford TW, Cutter GR, Bodine SC, Esser K, Farrar RP, Goodyear LJ, Hirshman MF, Albertson BG, Qian WJ, Piehowski P, Gritsenko MA, Monore ME, Petyuk VA, McDermott JE, Hansen JN, Hutchison C, Moore S, Gaul DA, Clish CB, Avila-Pacheco J, Dennis C, Kellis M, Carr S, Jean-Beltran PM, Keshishian H, Mani D, Clauser K, Krug K, Mundorff C, Pearce C, Ivanova AA, Ortlund EA, Maner-Smith K, Uppal K, Zhang T, Sealfon SC, Zaslavsky E, Nair V, Li S, Jain N, Ge Y, Sun Y, Nudelman G, Ruf-zamojski F, Smith G, Pincas N, Rubenstein A, Anne Amper M, Seenarine N, Lappalainen T, Lanza IR, Sreekumaran Nair K, Klaus K, Montgomery SB, Smith KS, Gay NR, Zhao B, Hung CJ, Zebarjadi N, Balliu B, Fresard L, Burant CF, Li JZ, Kachman M, Soni T, Raskind AB, Gerszten R, Robbins J, Ilkayeva O, Muehlbauer MJ, Newgard CB, Ashley EA, Wheeler MT, Jimenez-Morales D, Raja A, Dalton KP, Zhen J, Suk Kim Y, Christle JW, Marwaha S, Chin ET, Hershman SG, Hastie T, Tibshirani R, Rivas MA. Molecular Transducers of Physical Activity Consortium (MoTrPAC): Mapping the Dynamic Responses to Exercise. Cell 2020; 181:1464-1474. [DOI: 10.1016/j.cell.2020.06.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/19/2020] [Accepted: 06/01/2020] [Indexed: 12/31/2022]
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Bangalore S, Maron DJ, O'Brien SM, Fleg JL, Kretov EI, Briguori C, Kaul U, Reynolds HR, Mazurek T, Sidhu MS, Berger JS, Mathew RO, Bockeria O, Broderick S, Pracon R, Herzog CA, Huang Z, Stone GW, Boden WE, Newman JD, Ali ZA, Mark DB, Spertus JA, Alexander KP, Chaitman BR, Chertow GM, Hochman JS. Management of Coronary Disease in Patients with Advanced Kidney Disease. N Engl J Med 2020; 382:1608-1618. [PMID: 32227756 PMCID: PMC7274537 DOI: 10.1056/nejmoa1915925] [Citation(s) in RCA: 273] [Impact Index Per Article: 68.3] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P = 0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P = 0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P = 0.03). CONCLUSIONS Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).
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Affiliation(s)
- Sripal Bangalore
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - David J Maron
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Sean M O'Brien
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Jerome L Fleg
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Evgeny I Kretov
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Carlo Briguori
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Upendra Kaul
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Harmony R Reynolds
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Tomasz Mazurek
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Mandeep S Sidhu
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Jeffrey S Berger
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Roy O Mathew
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Olga Bockeria
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Samuel Broderick
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Radoslaw Pracon
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Charles A Herzog
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Zhen Huang
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Gregg W Stone
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - William E Boden
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Jonathan D Newman
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Ziad A Ali
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Daniel B Mark
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - John A Spertus
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Karen P Alexander
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Bernard R Chaitman
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Glenn M Chertow
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
| | - Judith S Hochman
- From the New York University Grossman School of Medicine (S. Bangalore, H.R.R., J.S.B., J.D.N., J.S.H.), Mount Sinai Hospital (G.W.S.), the Cardiovascular Research Foundation (G.W.S., Z.A.A.), and Columbia University Irving Medical Center/New York Presbyterian Hospital (Z.A.A.), New York, Albany Medical College and Albany Medical Center, Albany (M.S.S.), and St. Francis Hospital, Roslyn (Z.A.A.) - all in New York; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (S.M.O., S. Broderick, Z.H., D.B.M., K.P.A.); the National, Heart, Lung and Blood Institute, Bethesda, MD (J.L.F.); E.N. Meshalkin National Medical Research Center, Novosibirsk (E.I.K.), and Bakulev National Medical Research Center for Cardiovascular Surgery, Moscow (O.B.) - both in Russia; Mediterranea Cardiocentro, Naples, Italy (C.B.); Batra Hospital and Medical Research Centre, New Delhi, India (U.K.); Medical University of Warsaw (T.M.) and the Department of Coronary and Structural Heart Diseases, Institute of Cardiology (R.P.) - both in Warsaw, Poland; Columbia Veterans Affairs (VA) Health Care System, Columbia, SC (R.O.M.); Hennepin Healthcare, University of Minnesota, Minneapolis (C.A.H.); VA New England Healthcare System and Boston University School of Medicine, Boston (W.E.B.); and Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City (J.A.S.) and St. Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St. Louis (B.R.C.)
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Spertus JA, Jones PG, Maron DJ, Mark DB, O'Brien SM, Fleg JL, Reynolds HR, Stone GW, Sidhu MS, Chaitman BR, Chertow GM, Hochman JS, Bangalore S. Health Status after Invasive or Conservative Care in Coronary and Advanced Kidney Disease. N Engl J Med 2020; 382:1619-1628. [PMID: 32227754 PMCID: PMC7255621 DOI: 10.1056/nejmoa1916374] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [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] [Indexed: 01/14/2023]
Abstract
BACKGROUND In the ISCHEMIA-CKD trial, the primary analysis showed no significant difference in the risk of death or myocardial infarction with initial angiography and revascularization plus guideline-based medical therapy (invasive strategy) as compared with guideline-based medical therapy alone (conservative strategy) in participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease (an estimated glomerular filtration rate of <30 ml per minute per 1.73 m2 or receipt of dialysis). A secondary objective of the trial was to assess angina-related health status. METHODS We assessed health status with the Seattle Angina Questionnaire (SAQ) before randomization and at 1.5, 3, and 6 months and every 6 months thereafter. The primary outcome of this analysis was the SAQ Summary score (ranging from 0 to 100, with higher scores indicating less frequent angina and better function and quality of life). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate the treatment effect with the invasive strategy. RESULTS Health status was assessed in 705 of 777 participants. Nearly half the participants (49%) had had no angina during the month before randomization. At 3 months, the estimated mean difference between the invasive-strategy group and the conservative-strategy group in the SAQ Summary score was 2.1 points (95% credible interval, -0.4 to 4.6), a result that favored the invasive strategy. The mean difference in score at 3 months was largest among participants with daily or weekly angina at baseline (10.1 points; 95% credible interval, 0.0 to 19.9), smaller among those with monthly angina at baseline (2.2 points; 95% credible interval, -2.0 to 6.2), and nearly absent among those without angina at baseline (0.6 points; 95% credible interval, -1.9 to 3.3). By 6 months, the between-group difference in the overall trial population was attenuated (0.5 points; 95% credible interval, -2.2 to 3.4). CONCLUSIONS Participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease did not have substantial or sustained benefits with regard to angina-related health status with an initially invasive strategy as compared with a conservative strategy. (Funded by the National Heart, Lung, and Blood Institute; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).
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Affiliation(s)
- John A Spertus
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Philip G Jones
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - David J Maron
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Daniel B Mark
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Sean M O'Brien
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Jerome L Fleg
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Harmony R Reynolds
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Gregg W Stone
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Mandeep S Sidhu
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Bernard R Chaitman
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Glenn M Chertow
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Judith S Hochman
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
| | - Sripal Bangalore
- From Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City (J.A.S., P.G.J.), and the Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis (B.R.C.) - all in Missouri; the Department of Medicine, Stanford University School of Medicine, Stanford, CA (D.J.M., G.M.C.); Duke Clinical Research Institute, Durham, NC (D.B.M., S.M.O.); the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (J.L.F.); and New York University Grossman School of Medicine (H.R.R., J.S.H., S.B.), Icahn School of Medicine at Mount Sinai (G.W.S.), and the Cardiovascular Research Foundation (G.W.S.), New York, and Albany Medical College and Albany Medical Center, Albany (M.S.S.) - all in New York
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Abstract
Cardiovascular aging is a complex process of adaptive structural and functional changes over time. With advancing age, the arterial tree thickens and decreases in compliance, resulting in increased pulse wave velocity, systolic blood pressure, and left ventricular afterload. In response to these arterial changes, the myocardium remodels to maintain systolic function and diastolic filling. These adaptive mechanisms are not necessarily pathologic but increase the susceptibility for myocardial ischemia and heart failure in the presence of common age-associated comorbidities. This article reviews the pathophysiology of cardiovascular aging and discusses therapeutic interventions that may ameliorate these processes.
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Affiliation(s)
| | - Christopher Fine
- Division of Cardiovascular MedicineUniversity of LouisvilleLouisvilleKentucky
| | - Jerome L. Fleg
- Division of Cardiovascular SciencesNational Heart, Lung, and Blood InstituteBethesdaMaryland
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Goehler A, Mayrhofer T, Pursnani A, Ferencik M, Lumish HS, Barth C, Karády J, Chow B, Truong QA, Udelson JE, Fleg JL, Nagurney JT, Gazelle GS, Hoffmann U. Long-term health outcomes and cost-effectiveness of coronary CT angiography in patients with suspicion for acute coronary syndrome. J Cardiovasc Comput Tomogr 2020; 14:44-54. [PMID: 31303580 PMCID: PMC6930365 DOI: 10.1016/j.jcct.2019.06.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 10/11/2018] [Revised: 04/11/2019] [Accepted: 06/10/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Randomized trials have shown favorable clinical outcomes for coronary CT angiography (CTA) in patients with suspected acute coronary syndrome (ACS). Our goal was to estimate the cost-effectiveness of coronary CTA as compared to alternative management strategies for ACP patients over lifetime. METHODS Markov microsimulation model was developed to compare cost-effectiveness of competitive strategies for ACP patients: 1) coronary CTA, 2) standard of care (SOC), 3) AHA/ACC Guidelines, and 4) expedited emergency department (ED) discharge protocol with outpatient testing. ROMICAT-II trial was used to populate the model with low to intermediate risk of ACS patient data, whereas diagnostic test-, treatment effect-, morbidity/mortality-, quality of life- and cost data were obtained from the literature. We predicted test utilization, costs, 1-, 3-, 10-year and over lifetime cardiovascular morbidity/mortality for each strategy. We determined quality adjusted life years (QALY) and incremental cost-effectiveness ratio. Observed outcomes in ROMICAT-II were used to validate the short-term model. RESULTS Estimated short-term outcomes accurately reflected observed outcomes in ROMICAT-II as coronary CTA was associated with higher costs ($4,490 vs. $2,513-$4,144) and revascularization rates (5.2% vs. 2.6%-3.7%) compared to alternative strategies. Over lifetime, coronary CTA dominated SOC and ACC/AHA Guidelines and was cost-effective compared to expedited ED protocol ($49,428/QALY). This was driven by lower cardiovascular mortality (coronary CTA vs. expedited discharge: 3-year: 1.04% vs. 1.10-1.17; 10-year: 5.06% vs. 5.21-5.36%; respectively). CONCLUSION Coronary CTA in patients with suspected ACS renders affordable long-term health benefits as compared to alternative strategies.
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Affiliation(s)
- Alexander Goehler
- Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Amit Pursnani
- Cardiology Division, Evanston Hospital, Walgreen Building 3rd Floor, 2650, Ridge Ave, Evanston, IL, USA
| | - Maros Ferencik
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Knight Cardiovascular Institute, Oregon Health and Science University, 3180, SW Sam Jackson Park Rd., Portland, OR, USA
| | - Heidi S Lumish
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Cordula Barth
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Júlia Karády
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Benjamin Chow
- University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Quynh A Truong
- Department of Radiology, New York Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - James E Udelson
- Division of Cardiology, Tufts New England Medical Center, Boston, MA, USA
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - John T Nagurney
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - G Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Health Management and Policy, Harvard School of Public Health, Boston, MA, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Newman JD, Alexander KP, Gu X, O'Brien SM, Boden WE, Govindan SC, Senior R, Moorthy N, Rezende PC, Demkow M, Lopez-Sendon JL, Bockeria O, Pandit N, Gosselin G, Stone PH, Spertus JA, Stone GW, Fleg JL, Hochman JS, Maron DJ. Baseline Predictors of Low-Density Lipoprotein Cholesterol and Systolic Blood Pressure Goal Attainment After 1 Year in the ISCHEMIA Trial. Circ Cardiovasc Qual Outcomes 2019; 12:e006002. [PMID: 31718297 DOI: 10.1161/circoutcomes.119.006002] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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] [Indexed: 12/21/2022]
Abstract
BACKGROUND Risk factor control is the cornerstone of managing stable ischemic heart disease but is often not achieved. Predictors of risk factor control in a randomized clinical trial have not been described. METHODS AND RESULTS The ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) randomized individuals with at least moderate inducible ischemia and obstructive coronary artery disease to an initial invasive or conservative strategy in addition to optimal medical therapy. The primary aim of this analysis was to determine predictors of meeting trial goals for LDL-C (low-density lipoprotein cholesterol, goal <70 mg/dL) or systolic blood pressure (SBP, goal <140 mm Hg) at 1 year post-randomization. We included all randomized participants in the ISCHEMIA trial with baseline and 1-year LDL-C and SBP values by January 28, 2019. Among the 3984 ISCHEMIA participants (78% of 5179 randomized) with available data, 35% were at goal for LDL-C, and 65% were at goal for SBP at baseline. At 1 year, the percent at goal increased to 52% for LDL-C and 75% for SBP. Adjusted odds of 1-year LDL-C goal attainment were greater with older age (odds ratio [OR], 1.11 [95% CI, 1.03-1.20] per 10 years), lower baseline LDL-C (OR, 1.19 [95% CI, 1.17-1.22] per 10 mg/dL), high-intensity statin use (OR, 1.30 [95% CI, 1.12-1.51]), nonwhite race (OR, 1.32 [95% CI, 1.07-1.63]), and North American enrollment compared with other regions (OR, 1.32 [95% CI, 1.06-1.66]). Women were less likely than men to achieve 1-year LDL-C goal (OR, 0.68 [95% CI, 0.58-0.80]). Adjusted odds of 1-year SBP goal attainment were greater with lower baseline SBP (OR, 1.27 [95% CI, 1.22-1.33] per 10 mm Hg) and with North American enrollment (OR, 1.35 [95% CI, 1.04-1.76]). CONCLUSIONS In ISCHEMIA, older age, male sex, high-intensity statin use, lower baseline LDL-C, and North American location predicted 1-year LDL-C goal attainment, whereas lower baseline SBP and North American location predicted 1-year SBP goal attainment. Future studies should examine the effects of sex disparities, international practice patterns, and provider behavior on risk factor control.
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Affiliation(s)
| | | | - Xiangqiong Gu
- Duke Clinical Research Institute, Durham, NC (K.P.A., X.G., S.M.O.)
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, NC (K.P.A., X.G., S.M.O.)
| | | | | | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom (R.S.)
| | - Nagaraja Moorthy
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India (N.M.)
| | - Paulo C Rezende
- Heart Instituto do Coracao, University of Sao Paulo, Brazil (P.C.R.)
| | - Marcin Demkow
- Coronary and Structural Heart Diseases Department, Institute of Cardiology, Warsaw, Poland (M.D.)
| | | | - Olga Bockeria
- National Research Center for Cardiovascular Surgery, Moscow, Russia (O.B.)
| | | | | | | | - John A Spertus
- Saint Luke's Mid America Heart Institute/UMKC, MO (J.A.S.)
| | - Gregg W Stone
- Columbia University Medical Center and the Cardiovascular Research Foundation, NY (J.W.S.)
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35
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Karady J, Mayrhofer T, Ferencik M, Udelson JE, Fleg JL, Peacock WF, Januzzi Jr JL, Nagurney JT, Koenig WF, Hoffmann U. 3303Classification of patients with acute chest pain by analytical benchmarks and subsequent management recommendations - A comparison of three highly-sensitivity troponin assays in the ROMICAT trials. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Concordance of different highly-sensitive troponin (hsTn) assays in stratifying acute chest pain (ACP) patients according to analytical benchmarks and subsequent emergency department (ED) management recommendations are unknown.
Methods
We included patients enrolled in the ROMICAT (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography) I and II trials (n=624; 39.1% female; 52.8±10.0 years), who presented to the ED and were referred to further non-invasive diagnostic testing. In ROMICAT I, blood was obtained at 4 hours, and in ROMICAT II at ED presentation, and at 2 and 4 hours and was tested with three state-of-the-art hsTn assays (Roche Diagnostics, Elecsys 2010; Abbott ARCHITECT i2000SR; Siemens Diagnostics, HsVista). In a per sample analysis, we compared the concordance of assays for analytic benchmarks (below the level of detection (LOD)/LOD to 99th percentile/99th percentile to myocardial infarction (<LOD], ><LOD], >MI)/above MI). In a per patient analysis of serial hsTn testing in ROMICAT II, we determined concordance of management recommendations (rule out/observe/rule in) based on 2015ESC guidelines, results of coronary CT angiography and stress myocardial perfusion, and adjudicated endpoints of ACS.
Results
Overall, only 34.4% (353/1027) of samples were classified into the same benchmark category by all assays (table 1). In a per patient analysis, all assays agreed on the same of management recommendation in 25.3% (49/242) patients after the 1st hsTn, mostly driven by differences in discharge (6.6%, 21.1%, and 61.2%; respectively; all p<0.001). The concordance of management recommendations improved significantly to 67.4% (163/242; p<0.001) after the 2nd hsTn measurement but the final agreement for “observe” and “rule in” remained limited (13/90 and 5/18). Among patients in whom discharge was recommended, at least 18.8% (range: 18.8–21.0% across assays) had a positive imaging/stress test and at least 2.9% (range: 2.9–3.4%) had ACS.
Table 1. Classification of measurements from three hsTn assays in 1027 samples of patients with ACP according to analytical benchmarks <LOD LOD – 99th %tile* 99th %tile* – AMI** AMI**< Roche Elecsys, n (%) 578 (56.3) 328 (31.9) 95 (9.3) 26 (2.5) Abbott ARCHITECT, n (%) 176 (17.1) 788 (76.7) 14 (1.7) 49 (4.8) Siemens Vista, n (%) 96 (9.4) 861 (83.9) 33 (3.2) 37 (3.6) *Assay specific 99th percentiles; **as per ESC 2015 guidelines.
Conclusion
Differences in hsTn assay concordance for analytical benchmarks and subsequent ED management recommendations in patients with ACP are substantial raising concerns about the lack of uniform management.
Acknowledgement/Funding
Fulbright Visiting Student Researcher Grant
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Affiliation(s)
- J Karady
- Massachusetts General Hospital, Cardiac MR PET CT Program, Boston, United States of America
| | - T Mayrhofer
- Massachusetts General Hospital, Cardiac MR PET CT Program, Boston, United States of America
| | - M Ferencik
- Oregon Health & Science University, Knight Cardiovascular Institute, Portland, United States of America
| | - J E Udelson
- Tufts Medical Center, Department of Medicine, Boston, United States of America
| | - J L Fleg
- National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Bethesda, United States of America
| | - W F Peacock
- Baylor College of Medicine, Department of Emergency Medicine, Houston, United States of America
| | - J L Januzzi Jr
- Massachusetts General Hospital, Division of Cardiology, Boston, United States of America
| | - J T Nagurney
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, United States of America
| | - W F Koenig
- Technical University of Munich, Deutsches Herzzentrum München, Munich, Germany
| | - U Hoffmann
- Massachusetts General Hospital, Cardiac MR PET CT Program, Boston, United States of America
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36
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Myhre PL, O'Meara E, Claggett BL, de Denus S, Jarolim P, Anand IS, Beldhuis IE, Fleg JL, Lewis E, Pitt B, Rouleau JL, Solomon SD, Pfeffer MA, Desai AS. Cardiac Troponin I and Risk of Cardiac Events in Patients With Heart Failure and Preserved Ejection Fraction. Circ Heart Fail 2019; 11:e005312. [PMID: 30571192 DOI: 10.1161/circheartfailure.118.005312] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [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] [Indexed: 01/08/2023]
Abstract
BACKGROUND Levels of cTn (cardiac troponin) are frequently elevated in patients with heart failure (HF) and reduced ejection fraction (EF) and correlate with the risk for mortality. However, factors associated with high cTn concentrations and the association with cardiovascular events in patients with HF and preserved EF are unclear. METHODS AND RESULTS Of 1767 subjects with symptomatic HF with preserved EF from the Americas part of the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial), 236 underwent baseline measurements of high-sensitivity (hs) cTnI using the Abbott Architect STAT assay. Baseline factors correlated with hs-cTnI levels were assessed in stepwise linear regression models and the association between hs-cTnI and adjudicated study outcomes was examined in Cox models. The median hs-cTnI concentration at baseline was 6.3 ng/L (interquartile range, 3.4-12.9 ng/L) with levels detectable in 99.2% of patients. Higher hs-cTnI concentrations were associated with male sex, black race, lower estimated glomerular filtration rate and higher NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels. After multivariable adjustment, higher concentrations of hs-cTnI were associated with greater risk for the composite of cardiovascular death or HF hospitalization (69 events during mean follow-up 2.6±1.5 years): hazard ratio 1.42 (95% CI, 1.20-1.69), P<0.001 per doubling of hs-cTnI. Compared with those in the lowest quartile of hs-cTnI, patients in the highest quartile demonstrated a nearly 5-fold higher risk of cardiovascular death and HF hospitalization (hazard ratio 4.85 [1.99-11.83], P=0.001). There was no interaction between hs-cTnI and spironolactone treatment with regard to the primary composite end point (interaction P=0.94). CONCLUSIONS In ambulatory patients with HF with preserved EF, levels of hs-cTnI are higher in male patients with black race, lower estimated glomerular filtration rate, and higher NT-proBNP. As in those with HF and reduced EF, higher hs-cTnI levels are independently associated with risk for cardiovascular death and HF hospitalization. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT00094302.
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Affiliation(s)
- Peder L Myhre
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA. (P.L.M., B.L.C., I.E.B., E.L., S.D.S., M.A.P., A.S.D.)
- Division of Medicine, Akershus University Hospital, Lørenskog and University of Oslo, Norway (P.L.M.)
| | | | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA. (P.L.M., B.L.C., I.E.B., E.L., S.D.S., M.A.P., A.S.D.)
| | | | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Boston, MA. (P.J.)
| | - Inder S Anand
- Department of Cardiovascular Medicine, University of Minnesota, MN (I.S.A.)
| | - Iris E Beldhuis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA. (P.L.M., B.L.C., I.E.B., E.L., S.D.S., M.A.P., A.S.D.)
| | - Jerome L Fleg
- Division of Cardiovascular Diseases, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F.)
| | - Eldrin Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA. (P.L.M., B.L.C., I.E.B., E.L., S.D.S., M.A.P., A.S.D.)
| | - Bertram Pitt
- Division of Cardiology, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA. (P.L.M., B.L.C., I.E.B., E.L., S.D.S., M.A.P., A.S.D.)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA. (P.L.M., B.L.C., I.E.B., E.L., S.D.S., M.A.P., A.S.D.)
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA. (P.L.M., B.L.C., I.E.B., E.L., S.D.S., M.A.P., A.S.D.)
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37
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Wenger NK, Arnold A, Bairey Merz CN, Cooper-DeHoff RM, Ferdinand KC, Fleg JL, Gulati M, Isiadinso I, Itchhaporia D, Light-McGroary K, Lindley KJ, Mieres JH, Rosser ML, Saade GR, Walsh MN, Pepine CJ. Hypertension Across a Woman's Life Cycle. J Am Coll Cardiol 2019; 71:1797-1813. [PMID: 29673470 DOI: 10.1016/j.jacc.2018.02.033] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [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: 12/18/2017] [Revised: 02/16/2018] [Accepted: 02/19/2018] [Indexed: 01/17/2023]
Abstract
Hypertension accounts for 1 in 5 deaths among American women, posing a greater burden for women than men, and is among their most important risk factors for death and development of cardiovascular and other diseases. Hypertension affects women in all phases of life, with specific characteristics relating to risk factors and management for primary prevention of hypertension in teenage and young adult women; hypertension in pregnancy; hypertension during use of oral contraceptives and assisted reproductive technologies, lactation, menopause, or hormone replacement; hypertension in elderly women; and issues of race and ethnicity. All are detailed in this review, as is information relative to women in clinical trials of hypertension and medication issues. The overarching message is that effective treatment and control of hypertension improves cardiovascular outcomes. But many knowledge gaps persist, including the contribution of hypertensive disorders of pregnancy to cardiovascular disease risk, the role of hormone replacement, blood pressure targets for elderly women, and so on.
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Affiliation(s)
- Nanette K Wenger
- Division of Cardiology, Emory Heart and Vascular Center, Emory University School of Medicine, Atlanta, Georgia
| | - Anita Arnold
- Lee Health System, Florida State University School of Medicine, Fort Myers, Florida
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Rhonda M Cooper-DeHoff
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics, University of Florida, College of Pharmacy, Gainesville, Florida; Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida
| | - Keith C Ferdinand
- Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, Louisiana
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Martha Gulati
- Department of Medicine (Cardiology), University of Arizona-Phoenix, Phoenix, Arizona
| | - Ijeoma Isiadinso
- Division of Cardiology, Emory Heart and Vascular Center, Emory University School of Medicine, Atlanta, Georgia
| | - Dipti Itchhaporia
- Jeffrey M. Carlton Heart & Vascular Institute, Hoag Memorial Hospital Presbyterian, Newport Beach, California
| | - KellyAnn Light-McGroary
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer H Mieres
- Department of Cardiology, Hofstra Northwell School of Medicine, Hempstead, New York
| | - Mary L Rosser
- Division of General Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York
| | - George R Saade
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Mary Norine Walsh
- Heart Failure and Cardiac Transplantation Program, St. Vincent Heart Center, Indianapolis, Indiana
| | - Carl J Pepine
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainesville, Florida.
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38
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Fleg JL. Exercise Rehabilitation for Heart Failure: The Neglected Stepchild. JACC Heart Fail 2019; 7:706-708. [PMID: 31302048 DOI: 10.1016/j.jchf.2019.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
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Elam MB, Ginsberg HN, Lovato LC, Corson M, Largay J, Leiter LA, Lopez C, O'Connor PJ, Sweeney ME, Weiss D, Friedewald WT, Buse JB, Gerstein HC, Probstfield J, Grimm R, Ismail-Beigi F, Goff DC, Fleg JL, Rosenberg Y, Byington RP. Association of Fenofibrate Therapy With Long-term Cardiovascular Risk in Statin-Treated Patients With Type 2 Diabetes. JAMA Cardiol 2019; 2:370-380. [PMID: 28030716 DOI: 10.1001/jamacardio.2016.4828] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [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: 01/19/2023]
Abstract
Importance Patients with type 2 diabetes are at high risk of cardiovascular disease (CVD) in part owing to hypertriglyceridemia and low high-density lipoprotein cholesterol. It is unknown whether adding triglyceride-lowering treatment to statin reduces this risk. Objective To determine whether fenofibrate reduces CVD risk in statin-treated patients with type 2 diabetes. Design, Setting, and Participants Posttrial follow-up of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Lipid Study between July 2009 and October 2014; 5 years of follow-up were completed for a total of 9.7 years at general community and academic outpatient research clinics in the United States and Canada. Of the original 5518 ACCORD Lipid Trial participants, 4644 surviving participants were selected based on the presence of type 2 diabetes and either prevalent CVD or CVD risk factors and high-density lipoprotein levels less than 50 mg/dL (<55 mg/dL for women and African American individuals). Interventions Passive follow-up of study participants previously treated with fenofibrate or masked placebo. Main Outcomes and Measures Occurrence of cardiovascular outcomes including primary composite outcome of fatal and nonfatal myocardial infarction and stroke in all participants and in prespecified subgroups. Results The 4644 follow-on study participants were broadly representative of the original ACCORD study population and included significant numbers of women (n = 1445; 31%), nonwhite individuals (n = 1094; 21%), and those with preexisting cardiovascular events (n = 1620; 35%). Only 4.3% of study participants continued treatment with fenofibrate following completion of ACCORD. High-density lipoprotein and triglyceride values rapidly equalized among participants originally randomized to fenofibrate or placebo. Over a median total postrandomization follow-up of 9.7 years, the hazard ratio (HR) for the primary study outcome among participants originally randomized to fenofibrate vs placebo (HR, 0.93; 95% CI, 0.83-1.05; P = .25) was comparable with that originally observed in ACCORD (HR, 0.92; 95% CI, 0.79-1,08; P = .32). Despite these overall neutral results, we continued to find evidence that fenofibrate therapy effectively reduced CVD in study participants with dyslipidemia, defined as triglyceride levels greater than 204 mg/dL and high-density lipoprotein cholesterol levels less than 34 mg/dL (HR, 0.73; 95% CI, 0.56-0.95). Conclusions and Relevance Extended follow-up of ACCORD-lipid trial participants confirms the original neutral effect of fenofibrate in the overall study cohort. The continued observation of heterogeneity of treatment response by baseline lipids suggests that fenofibrate therapy may reduce CVD in patients with diabetes with hypertriglyceridemia and low high-density lipoprotein cholesterol. A definitive trial of fibrate therapy in this patient population is needed to confirm these findings. Trial Registration clinicaltrials.gov Identifier: NCT00000620.
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Affiliation(s)
- Marshall B Elam
- Memphis Veterans Affairs Medical Center and University of Tennessee Health Sciences Center, Memphis
| | - Henry N Ginsberg
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Laura C Lovato
- Wake Forest School of Medicine, Wake Forest, North Carolina
| | | | | | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute and Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Carlos Lopez
- Columbia University College of Physicians and Surgeons, New York, New York
| | | | | | - Daniel Weiss
- Diabetes Endocrine Nutrition Group, Mentor, Ohio
| | | | | | | | | | - Richard Grimm
- Berman Center for Outcomes and Clinical Research, Minneapolis, Minnesota
| | | | - David C Goff
- Colorado School of Public Health, Aurora, Colorado
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Bethesda, Maryland
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Division of Cardiovascular Sciences, Bethesda, Maryland
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Lyubarova R, Albers JJ, Marcovina SM, Yao Y, McBride R, Topliceanu A, Anderson T, Fleg JL, Desvigne-Nickens P, Kashyap ML, McGovern ME, Boden WE. Effects of Extended-Release Niacin on Quartile Lp-PLA2 Levels and Clinical Outcomes in Statin-treated Patients with Established Cardiovascular Disease and Low Baseline Levels of HDL-Cholesterol: Post Hoc Analysis of the AIM HIGH Trial. J Cardiovasc Pharmacol Ther 2019; 24:534-541. [DOI: 10.1177/1074248419852955] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Lipoprotein-associated phospholipase A2 (LpPLA2) is an inflammatory marker that has been associated with the presence of vulnerable plaque and increased risk of cardiovascular (CV) events. Objective: To assess the effect of extended-release niacin (ERN) on Lp-PLA2 activity and clinical outcomes. Methods: We performed a post hoc analysis in 3196 AIM-HIGH patients with established CV disease and low baseline levels of high-density lipoprotein cholesterol (HDL-C) who were randomized to ERN versus placebo on a background of simvastatin therapy (with or without ezetimibe) to assess the association between baseline Lp-PLA2 activity and the rate of the composite primary end point (CV death, myocardial infarction, stroke, hospitalization for unstable angina, and symptom-driven revascularization). Results: Participants randomized to ERN, but not those randomized to placebo, experienced a significant 8.9% decrease in LpPLA2. In univariate analysis, the highest quartile of LpPLA2 activity (>208 nmol/min/mL, Q4) was associated with higher event rates compared to the lower quartiles in the placebo group (log rank P = .032), but not in the ERN treated participants (log rank P = .718). However, in multivariate analysis, adjusting for sex, diabetes, baseline LDL-C, HDL-C, and triglycerides, there was no significant difference in outcomes between the highest Lp-PLA2 activity quartile versus the lower quartiles in both the placebo and the ERN groups. Conclusion: Among participants with stable CV disease on optimal medical therapy, elevated Lp-PLA2 was associated with higher CV events; however, addition of ERN mitigates this effect. This association in the placebo group was attenuated after multivariable adjustment, which suggests that Lp-PLA2 does not improve risk assessment beyond traditional risk factors.
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Affiliation(s)
- Radmila Lyubarova
- Division of Cardiology, Albany Medical Center, Albany Medical College, Albany, NY, USA
| | - John J. Albers
- University of Washington, Northwest Lipid Metabolism, And Diabetes Research Laboratories, Seattle, WA, USA
| | - Santica M. Marcovina
- University of Washington, Northwest Lipid Metabolism, And Diabetes Research Laboratories, Seattle, WA, USA
| | - Yao Yao
- Axio Research LLC, Seattle, WA, USA
| | | | - Alexandru Topliceanu
- Division of Cardiology, Albany Medical Center, Albany Medical College, Albany, NY, USA
| | - Todd Anderson
- University of Calgary and Libin Cardiovascular Institute, Foothills Medical Centre, Calgary, Canada
| | - Jerome L. Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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41
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Schrack JA, Leroux A, Fleg JL, Zipunnikov V, Simonsick EM, Studenski SA, Crainiceanu C, Ferrucci L. Using Heart Rate and Accelerometry to Define Quantity and Intensity of Physical Activity in Older Adults. J Gerontol A Biol Sci Med Sci 2019; 73:668-675. [PMID: 29509832 DOI: 10.1093/gerona/gly029] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Indexed: 11/13/2022] Open
Abstract
Background Physical activity (PA) prevents disease and promotes longevity; yet, few older adults meet the recommended daily guidelines. Wearable PA and heart rate monitors provide the opportunity to define age-related differences in the absolute and relative intensity of daily activities, and provide insight into the underlying factors influencing PA in older adults. Methods Participants in the Baltimore Longitudinal Study of Aging (n = 440, 52% male, aged 31 to 88 years) completed a clinical assessment and wore an Actiheart monitor in the free-living environment. The association between age and minutes per day in sedentary, light, moderate, and vigorous PA was assessed using relative intensity, as defined by heart rate reserve, and absolute intensity using activity count thresholds. Results In cross-sectional analyses, time spent in sedentary and light activities as defined by relative intensity did not differ across age (p > 0.05), whereas time spent in moderate and vigorous relative PA was higher for each 1 year increase in age (p < .01). Using absolute intensity PA thresholds, older adults registered fewer activity counts per day with more sedentary time and lesser amounts of light, moderate, and vigorous PA (p < .05). Persons with higher relative and lower absolute PA intensity had poorer functional performance and higher subclinical disease indicators. Conclusions These findings suggest that time spent in moderate or higher intensity activities may not be lower with age after considering changes in physiology, functional ability, and subclinical disease burden and highlight the need for more age- and ability-specific PA research to inform future interventions and public health guidelines.
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Affiliation(s)
- Jennifer A Schrack
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland
| | - Andrew Leroux
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Vadim Zipunnikov
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eleanor M Simonsick
- National Institute on Aging, National Institutes of Health, Baltimore, Maryland
| | | | - Ciprian Crainiceanu
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Luigi Ferrucci
- National Institute on Aging, National Institutes of Health, Baltimore, Maryland
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42
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Huynh T, Harty BJ, Claggett B, Fleg JL, McKinlay SM, Anand IS, Lewis EF, Joseph J, Desai AS, Sweitzer NK, Pitt B, Pfeffer MA, Rouleau JL. Comparison of Outcomes in Patients With Diabetes Mellitus Treated With Versus Without Insulin + Heart Failure With Preserved Left Ventricular Ejection Fraction (from the TOPCAT Study). Am J Cardiol 2019; 123:611-617. [PMID: 30612727 DOI: 10.1016/j.amjcard.2018.11.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 07/17/2018] [Revised: 11/04/2018] [Accepted: 11/12/2018] [Indexed: 01/09/2023]
Abstract
We aimed to evaluate the impact of diabetes mellitus (DM) and insulin treatment on clinical outcomes in patients with heart failure and preserved left ventricular ejection fraction enrolled in the TOPCAT study. We investigated the influence of DM status (insulin-treated [ITDM], non-insulin treated [NITDM], and no diabetes [non-DM]) at baseline on time to development of the primary end point, a composite of cardiovascular (CV) mortality, heart failure hospitalization, and aborted cardiac arrest. Secondary end points included the individual components of the primary end point, myocardial infarction, stroke, all-cause mortality, hyperkalemia, and worsened renal function. Due to marked regional differences in characteristics and outcomes of the TOPCAT patients, with much lower events in patients enrolled in Russia/Georgia, we restricted our analyses on findings from patients enrolled from the Americas. Compared to patients without DM, patients with ITDM had approximately 2-fold increased risk for the primary end point, heart failure hospitalization, and myocardial infarction (hazard ratios: 1.80, 1.97, and 2.27, respectively) and approximately 50% increases in all-cause and CV mortality. The risks for these outcomes were also increased in patients with ITDM in comparison to patients with NITDM as well (hazard ratios: 1.63, 1.65, and 2.73, respectively, and approximately 40% increases in all-cause and CV mortality). Patients with NITDM had similar risks for the primary end point and all secondary end points as patients without DM. In conclusion, the apparent increased risk of adverse outcomes in patients with heart failure and preserved left ventricular ejection fraction and ITDM merits future research to improve the prognosis of these high-risk patients.
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Affiliation(s)
- Thao Huynh
- McGill Health University Center, Montreal, Quebec.
| | - Brian J Harty
- New England Research Institutes, Inc., Watertown, Massachusetts
| | - Brian Claggett
- Brigham and Women's Hospital Boston, Boston, Massachusetts
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Inder S Anand
- VA Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - Eldrin F Lewis
- Brigham and Women's Hospital Boston, Boston, Massachusetts
| | - Jacob Joseph
- Brigham and Women's Hospital Boston, Boston, Massachusetts
| | - Akshay S Desai
- Brigham and Women's Hospital Boston, Boston, Massachusetts
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Marc A Pfeffer
- Brigham and Women's Hospital Boston, Boston, Massachusetts
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43
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Mediano MFF, Leifer ES, Cooper LS, Keteyian SJ, Kraus WE, Mentz RJ, Fleg JL. Influence of Baseline Physical Activity Level on Exercise Training Response and Clinical Outcomes in Heart Failure: The HF-ACTION Trial. JACC Heart Fail 2018; 6:1011-1019. [PMID: 30497641 PMCID: PMC6317714 DOI: 10.1016/j.jchf.2018.09.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/11/2018] [Accepted: 09/20/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study sought to evaluate the influence of baseline physical activity (PA) on responses to aerobic exercise training and clinical events in outpatients with chronic systolic heart failure (HF) from the multicenter HF-ACTION (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure) trial. BACKGROUND The influence of baseline PA on exercise capacity, responses to exercise training and clinical outcomes in patients with chronic HF is unclear. METHODS Of 2,130 participants who provided consent for this analysis, 1,494 patients (64%) had complete baseline PA data, using a modified version of the International Physical Activity Questionnaire-Short Form questionnaire and were included in the analysis; 742 received usual care and 752 were allocated to the exercise training group. Changes in exercise capacity, all-cause mortality and hospitalization, cardiovascular (CV) mortality and hospitalization, and CV mortality and HF hospitalization were evaluated as a function of baseline PA tertile. RESULTS At baseline, the highest PA tertile showed greater peak oxygen uptake, cardiopulmonary exercise test duration, and 6-min walk test distance than the other 2 PA tertiles, as well as lower New York Heart Association functional class, lower Beck depression score, and lower atrial fibrillation prevalence than the lowest PA tertile. Compared to the lowest PA tertile, the middle tertile had 18% lower risk of CV death/CV hospitalizations, and the upper tertile showed 23% lower risk of CV death/HF hospitalizations. Exercise capacity and clinical outcome responses to training were similar and largely nonsignificant across baseline PA tertiles with significant benefit of training on exercise test duration for all tertiles. CONCLUSIONS In patients with chronic systolic HF, aerobic exercise training significantly improves exercise test duration to a similar extent across baseline PA tertiles. Although higher baseline PA was associated with lower risk of clinical events, no significant differences in event rates within each PA tertile were seen between subgroups randomized to exercise training versus usual care. (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure [HF-ACTION]; NCT00047437).
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Affiliation(s)
- Mauro F F Mediano
- Evandro Chagas National Institute of Infectious Disease, Oswaldo Cruz Foundation, Manguinhos, Rio de Janeiro, Brazil
| | - Eric S Leifer
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Lawton S Cooper
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | | | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
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44
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Probstfield JL, Boden WE, Anderson T, Branch K, Kashyap M, Fleg JL, Desvigne-Nickens P, McBride R, McGovern M. Cardiovascular outcomes during extended follow-up of the AIM-HIGH trial cohort. J Clin Lipidol 2018; 12:1413-1419. [DOI: 10.1016/j.jacl.2018.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/05/2018] [Accepted: 07/17/2018] [Indexed: 10/28/2022]
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45
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Bangalore S, Maron DJ, Fleg JL, O'Brien SM, Herzog CA, Stone GW, Mark DB, Spertus JA, Alexander KP, Sidhu MS, Chertow GM, Boden WE, Hochman JS. International Study of Comparative Health Effectiveness with Medical and Invasive Approaches-Chronic Kidney Disease (ISCHEMIA-CKD): Rationale and design. Am Heart J 2018; 205:42-52. [PMID: 30172098 PMCID: PMC6283671 DOI: 10.1016/j.ahj.2018.07.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 03/27/2018] [Accepted: 07/22/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) and stable ischemic heart disease are at markedly increased risk of cardiovascular events. Prior trials comparing a strategy of optimal medical therapy (OMT) with or without revascularization have largely excluded patients with advanced CKD. Whether a routine invasive approach when compared with a conservative strategy is beneficial in such patients is unknown. METHODS ISCHEMIA-CKD is a National Heart, Lung, and Blood Institute-funded randomized trial designed to determine the comparative effectiveness of an initial invasive strategy (cardiac catheterization and optimal revascularization [percutaneous coronary intervention or coronary artery bypass graft surgery, if suitable] plus OMT) versus a conservative strategy (OMT alone, with cardiac catheterization and revascularization [percutaneous coronary intervention or coronary artery bypass graft surgery, if suitable] reserved for failure of OMT) on long-term clinical outcomes in 777 patients with advanced CKD (defined as those with estimated glomerular filtration rate <30 mL/min/1.73m2 or on dialysis) and moderate or severe ischemia on stress testing. Participants were randomized in a 1:1 fashion to the invasive or a conservative strategy. The primary end point is a composite of death or nonfatal myocardial infarction. Major secondary endpoints are a composite of death, nonfatal myocardial infarction, hospitalization for unstable angina, hospitalization for heart failure, or resuscitated cardiac arrest; angina control; and disease-specific quality of life. Safety outcomes such as initiation of maintenance dialysis and a composite of initiation of maintenance dialysis or death will be reported. The trial is projected to have 80% power to detect a 22% to 24% reduction in the primary composite end point with the invasive strategy when compared with the conservative strategy. CONCLUSIONS ISCHEMIA-CKD will determine whether an initial invasive management strategy improves clinical outcomes when added to OMT in patients with advanced CKD and stable ischemic heart disease.
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Affiliation(s)
| | - David J Maron
- Stanford University School of Medicine, Stanford, CA
| | - Jerome L Fleg
- National Heart Lung and Blood Institute, Bethesda, MD
| | | | - Charles A Herzog
- Hennepin County Medical Center and University of Minnesota, Minneapolis, MN
| | - Gregg W Stone
- New York Presbyterian Hospital, Columbia University Medical Center and the Cardiovascular Research Foundation, New York, NY
| | | | - John A Spertus
- Mid-America Heart Institute/University of Missouri-Kansas City, Kansas City, MO
| | | | | | | | - William E Boden
- Veterans Affairs New England Healthcare System, Massachusetts Veterans Epidemiology, Research, and Informatics Center, Boston, MA
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46
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Singh S, Zieman S, Go AS, Fortmann SP, Wenger NK, Fleg JL, Radziszewska B, Stone NJ, Zoungas S, Gurwitz JH. Statins for Primary Prevention in Older Adults-Moving Toward Evidence-Based Decision-Making. J Am Geriatr Soc 2018; 66:2188-2196. [PMID: 30277567 DOI: 10.1111/jgs.15449] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/16/2018] [Accepted: 04/21/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine the efficacy and safety of statins for primary prevention of atherosclerotic cardiovascular disease (ASCVD) events in older adults, especially those aged 80 and older and with multimorbidity. METHODS The National Institute on Aging and the National Heart, Lung and Blood Institute convened A multidisciplinary expert panel from July 31 to August 1, 2017, to review existing evidence, identify knowledge gaps, and consider whether statin safety and efficacy data in persons aged 75 and older without ASCVD are sufficient; whether existing data can inform the feasibility, design, and implementation of future statin trials in older adults; and clinical trial options and designs to address knowledge gaps. This article summarizes the presentations and discussions at that workshop. RESULTS There is insufficient evidence regarding the benefits and harms of statins in older adults, especially those with concomitant frailty, polypharmacy, comorbidities, and cognitive impairment; a lack of tools to assess ASCVD risk in those aged 80 and older; and a paucity of evidence of the effect of statins on outcomes of importance to older adults, such as statin-associated muscle symptoms, cognitive function, and incident diabetes mellitus. Prospective, traditional, placebo-controlled, randomized clinical trials (RCTs) and pragmatic RCTs seem to be suitable options to address these critical knowledge gaps. Future trials have to consider greater representation of very old adults, women, underrepresented minorities, and individuals of differing health, cognitive, socioeconomic, and educational backgrounds. Feasibility analyses from existing large healthcare networks confirm appropriate power for death and cardiovascular outcomes for future RCTs in this area. CONCLUSION Existing data cannot address uncertainties about the benefits and harms of statins for primary ASCVD prevention in adults aged 75 and older, especially those with comorbidities, frailty, and cognitive impairment. Evidence from 1 or more RCTs could address these important knowledge gaps to inform person-centered decision-making. J Am Geriatr Soc 66:2188-2196, 2018.
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Affiliation(s)
- Sonal Singh
- University of Massachusetts Medical School and the Meyers Primary Care Institute, Worcester, Massachusetts
| | | | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Nanette K Wenger
- Division of Cardiology, Department of Medicine, Emory Women's Heart Center, Emory Heart and Vascular Center, Emory University, School of Medicine, Atlanta, Georgia
| | - Jerome L Fleg
- Division of Cardiovascular Diseases, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Neil J Stone
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,The George Institute for Global Health, Sydney, Australia
| | - Jerry H Gurwitz
- University of Massachusetts Medical School and the Meyers Primary Care Institute, Worcester, Massachusetts
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47
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Chaudhry RI, Mathew RO, Sidhu MS, Sidhu-Adler P, Lyubarova R, Rangaswami J, Salman L, Asif A, Fleg JL, McCullough PA, Maddux F, Bangalore S. Detection of Atherosclerotic Cardiovascular Disease in Patients with Advanced Chronic Kidney Disease in the Cardiology and Nephrology Communities. Cardiorenal Med 2018; 8:285-295. [PMID: 30078001 DOI: 10.1159/000490768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 04/06/2018] [Accepted: 06/10/2018] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Atherosclerotic cardiovascular disease (ASCVD) is a leading cause of morbidity and mortality among patients with chronic kidney disease (CKD) with a glomerular filtration rate of < 60 mL/min/1.73 m2 body surface area. The availability of high-quality randomized controlled trial data to guide management for the population with CKD and ASCVD is limited. Understanding current practice patterns among providers caring for individuals with CKD and CVD is important in guiding future trial questions. METHODS A qualitative survey study was performed. An electronic survey regarding the diagnosis and management of CVD in patients with CKD was conducted using a convenience sample of 450 practicing nephrology and cardiology providers. The survey was administered using Qualtrics® (https://www.qualtrics.com). RESULTS There were a total of 113 responses, 81 of which were complete responses. More than 90% of the respondents acknowledged the importance of CVD as a cause of morbidity and mortality in patients with CKD. Outside the kidney transplant evaluation setting, 5% of the respondents would screen an asymptomatic patient with advanced CKD for ASCVD. Outside the kidney transplant evaluation scenario, the respondents did not opt for invasive management strategies in advanced CKD. CONCLUSIONS The survey results reveal a lack of consensus among providers caring for patients with advanced CKD about the management of ASCVD in this setting. Future randomized controlled trials will be needed to better inform the clinical management of ASCVD in these patients. The limitations of the study include its small sample size and the relatively low response rate among the respondents.
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Affiliation(s)
- Rafia I Chaudhry
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York, USA
| | - Roy O Mathew
- Division of Nephrology, WJB Dorn VA Medical Center, Columbia, South Carolina, USA
| | - Mandeep S Sidhu
- Division of Cardiology, Albany Medical College, Albany, New York, USA
| | | | - Radmila Lyubarova
- Division of Cardiology, Albany Medical College, Albany, New York, USA
| | - Janani Rangaswami
- Division of Nephrology, Department of Medicine, Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Loay Salman
- Division of Nephrology and Hypertension, Albany Medical College, Albany, New York, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Seton Hall-Hackensack Meridian School of Medicine, Neptune City, New Jersey, USA
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | | | - Frank Maddux
- Fresenius Medical Care North America, Waltham, Massachusetts, USA
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48
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Puchner SB, Mayrhofer T, Park J, Lu MT, Liu T, Maurovich-Horvat P, Ghemigian K, Bittner DO, Fleg JL, Udelson JE, Truong QA, Hoffmann U, Ferencik M. Differences in the association of total versus local coronary artery calcium with acute coronary syndrome and culprit lesions in patients with acute chest pain: The coronary calcium paradox. Atherosclerosis 2018; 274:251-257. [PMID: 29703635 DOI: 10.1016/j.atherosclerosis.2018.04.017] [Citation(s) in RCA: 18] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 04/05/2018] [Accepted: 04/12/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIMS Total coronary artery calcium (CAC) burden is associated with an increased cardiovascular risk, while local CAC may represent stable plaques. We determined differences in relationship of total CAC with acute coronary syndrome (ACS) and local CAC with culprit lesions in patients with suspected ACS. METHODS We performed computed tomography (CT) for CAC and CT angiography to assess the presence of significant stenosis and high-risk plaque (positive remodeling, low CT attenuation, napkin-ring sign, spotty calcium) in 37 patients with ACS and 223 controls. Total and segmental Agatston scores were measured. Culprit lesions were assessed in subjects with ACS. RESULTS Patients (n = 260) with vs. without ACS had higher total CAC score (median 229, 25th-75th percentile 75-517 vs. 27, 25th-75th percentile 0-99, p<0.001), higher prevalence of significant stenosis (78% vs. 7%, p<0.001) and high-risk plaque (95% vs. 59%, p<0.001). In those with ACS, culprit (n = 41) vs. non-culprit (n = 200) lesions, had similar segmental CAC score (median 22, 25th-75th percentile 4-71 vs. 14, 25th-75th percentile 0-51; p=0.37), but higher prevalence of significant stenosis (81% vs. 11%, p<0.001) and high-risk plaque (76% vs. 51%, p=0.005). Significant stenosis (odds ratio 40.2, 95%CI 15.6-103.9, p<0.001) and high-risk plaque (odds ratio 3.4, 95%CI 1.3-9.1, p=0.02), but not segmental CAC score (odds ratio 1.0, 95%CI 1.0-1.0, p=0.47), were associated with culprit lesions of ACS. CONCLUSIONS Total CAC burden was associated with ACS but segmental CAC was not associated with culprit lesions. Our findings suggest that total but not local CAC is a marker of ACS risk and support the hypothesis that extensive local CAC is a marker of plaque stability.
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Affiliation(s)
- Stefan B Puchner
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Mayrhofer
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Jakob Park
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael T Lu
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ting Liu
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Khristine Ghemigian
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel O Bittner
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Cardiology, University Hospital Erlangen, Germany
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - James E Udelson
- Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA, USA
| | - Quynh A Truong
- Department of Radiology and Division of Cardiology, Weill Cornell Medical College, New York, NY, USA
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Maros Ferencik
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
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Mathew RO, Bangalore S, Sidhu MS, Fleg JL, Maddux FW. Increasing inclusion of patients with advanced chronic kidney disease in cardiovascular clinical trials. Kidney Int 2018; 93:787-788. [DOI: 10.1016/j.kint.2017.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 10/17/2022]
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Fleg JL. Preventing Readmission After Hospitalization for Acute Heart Failure. JACC: Heart Failure 2018; 6:153-155. [DOI: 10.1016/j.jchf.2017.12.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 12/23/2017] [Indexed: 01/11/2023]
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