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Choi Y, Kang DY, Lee J, Lee J, Kim M, Kim H, Park J, Cho S, Lee J, Cha SJ, Kim TO, Lee PH, Ahn JM, Park SJ, Park DW. Ticagrelor Versus Clopidogrel in East Asian Patients With Acute Coronary Syndrome and Diabetes Mellitus. JACC Asia 2022; 2:666-674. [PMID: 36444315 PMCID: PMC9700022 DOI: 10.1016/j.jacasi.2022.07.005] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND It is still unknown whether diabetes mellitus (DM) affects the relative safety and efficacy of ticagrelor vs clopidogrel in East Asian patients with acute coronary syndrome (ACS). OBJECTIVES The authors sought to assess the safety and efficacy of ticagrelor vs clopidogrel according to the diabetic status of East Asian patients with ACS undergoing invasive management. METHODS This prespecified analysis of the TICA KOREA (Clinically Significant Bleeding With Ticagrelor Versus Clopidogrel in Korean Patients With Acute Coronary Syndromes Intended for Invasive Management) trial included 800 Korean patients. The primary safety endpoint was clinically significant bleeding (PLATO [Platelet Inhibition and Clinical Outcomes] major or minor bleeding) at 12 months; the efficacy endpoint was major adverse cardiovascular events (cardiovascular death, myocardial infarction, and stroke). RESULTS Of 800 patients, 216 (27.0%) had DM. The incidence of clinically significant bleeding within 12 months was significantly higher with ticagrelor than clopidogrel in the nondiabetic group (10.2% vs 4.3%; HR: 2.45; 95% CI: 1.27-4.70; P = 0.007) and tended to be higher in the diabetic group (13.8% vs 8.0%; HR: 1.87; 95% CI: 0.54-4.36; P = 0.15); there was no significant interaction between treatment-arm and DM (P for interaction = 0.64). The incidences of major adverse cardiovascular events were not significantly different after ticagrelor or clopidogrel both in the diabetic group (10.8% vs 6.0%; HR: 1.90; 95% CI: 0.71-5.07; P = 0.20) and in the nondiabetic group (8.5% vs 5.7%; HR: 1.51; 95% CI: 0.81-2.81; P = 0.19) without significant interaction (P-for-interaction = 0.71). CONCLUSIONS In Korean ACS patients undergoing early invasive management, diabetes status did not affect the relative safety and efficacy of ticagrelor and clopidogrel. (Safety and Efficacy of Ticagrelor Versus Clopidogrel in Asian/Korean Patients With Acute Coronary Syndromes Intended for Invasive Management [TICA KOREA]; NCT02094963).
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Affiliation(s)
- Yeonwoo Choi
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - JungBok Lee
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinho Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mijin Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hoyun Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsun Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Suji Cho
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Junghoon Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung Joo Cha
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae Oh Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Pil Hyung Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Kanji R, Gue YX, Farag MF, Spencer NH, Mutch NJ, Gorog DA. Determinants of Endogenous Fibrinolysis in Whole Blood Under High Shear in Patients With Myocardial Infarction. JACC Basic Transl Sci 2022; 7:1069-1082. [PMID: 36687271 PMCID: PMC9849272 DOI: 10.1016/j.jacbts.2022.05.007] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 01/25/2023]
Abstract
Hypofibrinolysis is a recently-recognized risk factor for recurrent cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI), but the mechanistic determinants of this are not well understood. In patients with STEMI, we show that the effectiveness of endogenous fibrinolysis in whole blood is determined in part by fibrinogen level, high sensitivity C-reactive protein, and shear-induced platelet reactivity, the latter directly related to the speed of thrombin generation. Our findings strengthen the evidence for the role of cellular components and bidirectional crosstalk between coagulatory and inflammatory pathways as determinants of hypofibrinolysis.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom
| | - Ying X. Gue
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Mohamed F. Farag
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Neil H. Spencer
- Statistical Services and Consultancy Unit, Hertfordshire Business School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Nicola J. Mutch
- Aberdeen Cardiovascular and Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Diana A. Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom,Address for correspondence: Prof Diana A. Gorog, Faculty of Medicine, National Heart and Lung Institute, Imperial College, Dovehouse Street, London SW3 6LY, United Kingdom.
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le Roux CW, Fils-Aimé N, Camacho F, Gould E, Barakat M. The relationship between early weight loss and weight loss maintenance with naltrexone-bupropion therapy. EClinicalMedicine 2022; 49:101436. [PMID: 35747175 PMCID: PMC9156890 DOI: 10.1016/j.eclinm.2022.101436] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 04/01/2022] [Accepted: 04/14/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Extended-release (ER) naltrexone/bupropion (NB) was associated with greater weight loss than placebo in four randomized, 56-week trials. The association of NB with longer-term maintenance of weight loss remains unknown. METHODS We conducted a post-hoc analysis of four phase III, randomized, double-blind, placebo-controlled, 56-week studies (COR-I, COR-II, COR-BMOD, and COR-DM), the placebo-controlled cardiovascular outcomes trial LIGHT (208 weeks), and the randomized, open-label trial IGNITE (78 weeks). Included subjects were treated with NB 32 mg/360 mg or placebo, with baseline, week 16, and final time point data. The primary outcome was Kaplan-Meier-estimated weight loss maintenance in each study for up to 204 weeks. FINDINGS Our analysis included data from 10,198 particpants (NB=5412; placebo=4786). Proportions of patients with ≥5% or ≥10% weight loss maintenance were numerically higher for NB vs. placebo in all studies and time points. Differences were statistically significant for ≥5% weight loss maintenance in COR-BMOD and COR-I/-II at weeks 52 and 56 and the LIGHT study at weeks 52, 104, and 208. For ≥10% weight loss maintenance, differences were statistically significant in COR-I/COR-II at weeks 52 and 56. INTERPRETATION These data suggest that NB could be used as part of long-term, comprehensive weight loss and weight loss maintenance strategies. FUNDING Orexigen Therapeutics, Inc. and Bausch Health Canada.
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Key Words
- AHEAD, Action in Health for Diabetes
- BMI, body mass index
- BMOD, behavior modification therapy
- CBT, cognitive behavioral therapy
- CI, confidence interval
- CLI, comprehensive lifestyle intervention
- COR, Contrave Obesity Research
- COR-BMOD
- COR-DM
- COR-I
- COR-II
- DM, diabetes mellitus
- ER, extended-release
- IGNITE
- LIGHT
- MACE, major adverse cardiovascular events
- Maintenance
- NAFLD, non-alcoholic fatty liver disease
- NB, naltrexone/bupropion
- NWCR, National Weight Control Registry
- Naltrexone/bupropion
- SAEs, serious adverse events
- SD, standard deviation
- SMD, standardized mean difference
- Weight loss
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Affiliation(s)
- Carel W. le Roux
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Ireland
- Corresponding author at: Diabetes Complications Research centre, UCD Conway Institute, University College Dublin, Belfield, Dublin 4, Ireland.
| | | | | | - Errol Gould
- Currax Pharmaceuticals LLC, Brentwood, TN, United States of America
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Ahn JH, Tantry US, Kang MG, Park HW, Koh JS, Bae JS, Cho SY, Kim KH, Jang JY, Park JR, Park Y, Hwang SJ, Kwak CH, Hwang JY, Gurbel PA, Jeong YH. Residual Inflammatory Risk and its Association With Events in East Asian Patients After Coronary Intervention. JACC Asia 2022; 2:323-337. [PMID: 36338415 PMCID: PMC9627808 DOI: 10.1016/j.jacasi.2021.11.014] [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] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/29/2021] [Accepted: 11/10/2021] [Indexed: 06/16/2023]
Abstract
BACKGROUND East Asian population has a low level of inflammation compared with Western population. The prognostic implication of residual inflammatory risk (RIR) remains uncertain in East Asians. OBJECTIVES This study sought to provide an analysis to estimate early-determined RIR and its association with clinical outcomes in East Asian patients with coronary artery disease (CAD). METHODS In an East Asian registry including patients with CAD undergoing percutaneous coronary intervention (PCI) (n = 4,562), RIR status was determined by measuring high-sensitivity C-reactive protein (hsCRP) serially at admission and at 1-month follow-up. Patients were stratified into 4 groups according to hsCRP criteria (≥2 mg/L): 1) persistent low RIR (lowon admission-low1 month: 51.0%); 2) fortified RIR (lowon admission-high 1 month: 10.3%); 3) attenuated RIR (highon admission-low1 month: 20.5%); and 4) persistent high RIR (highon admission-high1 month: 18.3%). The risks of all-cause death, ischemic events, and major bleeding were evaluated. RESULTS In our cohort, median levels of hsCRP were significantly decreased over time (1.3 to 0.9 mg/L; P < 0.001). Compared with hsCRP on admission, hsCRP at 1 month showed the greater associations with all-cause death and ischemic event. During clinical follow-up, risks of clinical events were significantly different across the groups (log-rank test, P < 0.001). Compared with other RIR groups, persistent high RIR showed the higher risk for all-cause death (HRadjusted, 1.92; 95% CI: 1.44 to 2.55; P < 0.001), ischemic events (HRadjusted, 1.26; 95% CI: 1.02 to 1.56; P = 0.032), and major bleeding (HRadjusted, 1.98; 95% CI: 1.30 to 2.99; P < 0.001), respectively. CONCLUSIONS Approximately one-fifth of East Asian patients with CAD have persistent high RIR, which shows the close association with occurrence of ischemic and bleeding events. (Gyeongsang National University Hospital Registry [GNUH]; NCT04650529).
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Affiliation(s)
- Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Udaya S. Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Min Gyu Kang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Hyun Woong Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jae Seok Bae
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Sang Young Cho
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Kye-Hwan Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jeong Yoon Jang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jeong Rang Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Seok-Jae Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Choong Hwan Kwak
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Jin-Yong Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Paul A. Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
- Institute of the Health Sciences, Gyeongsang National University, Jinju, South Korea
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Kang MG, Koo BK, Tantry US, Kim K, Ahn JH, Park HW, Park JR, Hwang SJ, Hwang JY, Gurbel PA, Samady H, Koh JS, Jeong YH. Association Between Thrombogenicity Indices and Coronary Microvascular Dysfunction in Patients With Acute Myocardial Infarction. JACC Basic Transl Sci 2021; 6:749-61. [PMID: 34754989 DOI: 10.1016/j.jacbts.2021.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 08/24/2021] [Accepted: 08/28/2021] [Indexed: 12/22/2022]
Abstract
Our study supports the feasibility of measuring thrombogenicity in patients with acute myocardial infarction, with intent to predict periprocedural and long-term clinical events, in real-world clinical practice. Preprocedural assessment of ex vivo thrombogenicity (eg, platelet-fibrin clot strength by thromboelastography) was significantly associated with the risk of coronary microvascular dysfunction. A combined risk stratification with coronary microvascular dysfunction and platelet-fibrin clot strength increased the prognostic implication to predict the rates of long-term clinical outcomes.
The association between thrombogenicity and coronary microvascular dysfunction (CMD) has been poorly explored in patients with acute myocardial infarction (AMI). In our real-world clinical practice (N = 116), thrombogenicity was evaluated with thromboelastography and conventional hemostatic measures, and CMD was defined as index of microcirculatory resistance of >40 U using the invasive physiologic test. High platelet-fibrin clot strength (P-FCS) (≥68 mm) significantly increased the risk of postprocedural CMD (odds ratio: 4.35; 95% CI: 1.74-10.89). Patients with both CMD and high P-FCS had a higher rate of ischemic events compared to non-CMD subjects with low P-FCS (odds ratio: 5.58; 95% CI: 1.31-23.68). This study showed a close association between heightened thrombogenicity and CMD and their prognostic implications after reperfusion in acute myocardial infarction patients.
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Key Words
- AMI, acute myocardial infarction
- CFR, coronary flow reserve
- CMD, coronary microvascular dysfunction
- IMR, index of microcirculatory resistance
- LASSO, least absolute shrinkage and selection operator
- MA, maximum amplitude
- MACE, major adverse cardiovascular events
- OR, odds ratio
- P-FCS, platelet-fibrin clot strength
- PCI, percutaneous coronary intervention
- PRU, P2Y12 reaction units
- R, reaction time
- TEG, thromboelastography
- TIMI, Thrombolysis in Myocardial Infarction
- Tmn, mean transit time
- acute myocardial infarction
- cardiovascular event
- clot strength
- coronary microvascular dysfunction
- thrombogenicity
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Planek MIC, Ruge M, Du Fay de Lavallaz JM, Kyung SB, Gomez JMD, Suboc TM, Williams KA, Volgman AS, Simmons JA, Rao AK. Cardiovascular findings on chest computed tomography associated with COVID-19 adverse clinical outcomes. Am Heart J Plus 2021; 11:100052. [PMID: 34667971 PMCID: PMC8511552 DOI: 10.1016/j.ahjo.2021.100052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE Chest computed tomography (chest CT) is routinely obtained to assess disease severity in COVID-19. While pulmonary findings are well-described in COVID-19, the implications of cardiovascular findings are less well understood. We evaluated the impact of cardiovascular findings on chest CT on the adverse composite outcome (ACO) of hospitalized COVID-19 patients. SETTING/PARTICIPANTS 245 COVID-19 patients who underwent chest CT at Rush University Health System were included. DESIGN Cardiovascular findings, including coronary artery calcification (CAC), aortic calcification, signs of right ventricular strain [right ventricular to left ventricular diameter ratio, pulmonary artery to aorta diameter ratio, interventricular septal position, and inferior vena cava (IVC) reflux], were measured by trained physicians. INTERVENTIONS/MAIN OUTCOME MEASURES These findings, along with pulmonary findings, were analyzed using univariable logistic analysis to determine the risk of ACO defined as intensive care admission, need for non-invasive positive pressure ventilation, intubation, in-hospital and 60-day mortality. Secondary endpoints included individual components of the ACO. RESULTS Aortic calcification was independently associated with an increased risk of the ACO (odds ratio 1.86, 95% confidence interval (1.11-3.17) p < 0.05). Aortic calcification, CAC, abnormal septal position, or IVC reflux of contrast were all significantly associated with 60-day mortality and major adverse cardiovascular events. IVC reflux was associated with in-hospital mortality (p = 0.005). CONCLUSION Incidental cardiovascular findings on chest CT are clinically important imaging markers in COVID-19. It is important to ascertain and routinely report cardiovascular findings on CT imaging of COVID-19 patients as they have potential to identify high risk patients.
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Key Words
- Ao, aorta
- Aortic calcification
- CAC, coronary artery calcification
- CAD, coronary artery disease
- CI, confidence intervals
- COVID-19
- CT, computed tomography
- CVD, cardiovascular disease
- Chest computed tomography
- Coronary artery calcification
- ECMO, extracorporeal membrane oxygenation
- ICU, intensive care unit
- IVC, inferior vena cava
- LV, left ventricular
- MACE, major adverse cardiovascular events
- PA, pulmonary artery
- RV, right ventricular
- Right ventricular strain
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Affiliation(s)
| | - Max Ruge
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA, United States of America
| | | | - Stella B. Kyung
- Division of Cardiology, Loyola University Medical Center, Chicago, IL, United States of America
| | | | - Tisha M. Suboc
- Division of Cardiology, Rush University Medical Center, Chicago, IL, United States of America
| | - Kim A. Williams
- Division of Cardiology, Rush University Medical Center, Chicago, IL, United States of America
| | | | - J. Alan Simmons
- Department of Research Core, Rush University Medical Center, Chicago, IL, United States of America
| | - Anupama K. Rao
- Division of Cardiology, Rush University Medical Center, Chicago, IL, United States of America
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Chiang CE, Ueng KC, Chao TH, Lin TH, Wu YJ, Wang KL, Sung SH, Yeh HI, Li YH, Liu PY, Chang KC, Shyu KG, Huang JL, Tsai CD, Hung HF, Liu ME, Chao TF, Cheng SM, Cheng HM, Chu PH, Yin WH, Wu YW, Chen WJ, Lai WT, Lin SJ, Yeh SJ, Hwang JJ, Hou CJY. 2021 Consensus Pathway of the Taiwan Society of Cardiology on Novel Therapy for Type 2 Diabetes. JACC Asia 2021; 1:129-146. [PMID: 36338159 PMCID: PMC9627904 DOI: 10.1016/j.jacasi.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/28/2021] [Accepted: 08/09/2021] [Indexed: 06/16/2023]
Abstract
Type 2 diabetes is a major threat to human health in the 21st century. More than half a billion people may suffer from this pandemic disease in 2030, leading to a huge burden of cardiovascular complications. Recently, 2 novel antidiabetic agents, glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, reduced cardiovascular complications in a number of randomized control trials. To integrate new information and to achieve a streamlined process for better patient care, a working group was appointed by the Taiwan Society of Cardiology to formulate a stepwise consensus pathway for these therapies to reduce cardiovascular events in patients with type 2 diabetes. This consensus pathway is complementary to clinical guidelines, acting as a reference to improve patient care.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kwo-Chang Ueng
- Department of Internal Medicine, School of Medicine, Chung-Shan Medical University Hospital, Taichung, Taiwan
| | - Ting-Hsing Chao
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tsung-Hsien Lin
- Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Cardiovascular Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Hsien Sung
- Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hung-I Yeh
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
- Cardiovascular Center, MacKay Memorial Hospital, Taipei, Taiwan
| | - Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ping-Yen Liu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Kou-Gi Shyu
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Jin-Long Huang
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Cheng-Dao Tsai
- Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Huei-Fong Hung
- Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Ming-En Liu
- Division of Cardiology, Department of Internal Medicine, Hsinchu Mackay Memorial Hospital, Hsinchu, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Meng Cheng
- Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hao-Min Cheng
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Center for Evidence-Based Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Hsian Yin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yen-Wen Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- Department of Internal Medicine and Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Ter Lai
- Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shing-Jong Lin
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - San-Jou Yeh
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
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Eliasson A, Kashani M, Vernalis M. Results of a prospective cardiovascular disease prevention program. Prev Med Rep 2021; 22:101344. [PMID: 33842199 PMCID: PMC8020477 DOI: 10.1016/j.pmedr.2021.101344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/02/2021] [Accepted: 02/22/2021] [Indexed: 12/03/2022] Open
Abstract
The Cardiovascular Health Program (CHP) Registry is a 12-month, prospective study of therapeutic lifestyle change (TLC). Adult participants received comprehensive assessment of health behaviors and cardiovascular disease (CVD) risk factors. Personalized TLC action plans addressed modifiable health behaviors for diet, exercise, stress management, and sleep. Participants attended a half-day interactive workshop and met face-to-face with certified health coaches four times over 6 months. Monthly telephonic coaching for 6 more months completed the intervention. Measured outcomes included adherence to behavioral prescriptions, anthropometrics, CVD-relevant laboratory tests, and for a subset of participants, carotid intima-media thickness (CIMT). Of 965 participants, 648 (67%) completed the program and were included in the analysis. Participants were of mean age 55.4 ± 12.5 years, 57% women, and racially diverse. Adherence to prescribed TLC was substantial: dietary behaviors at goal rose from 53% to 86%, exercise 44% to 66%, perceived stress 65% to 79%, and sleep quality 28% to 49%. For participants with abnormal anthropometrics at baseline, there were improvements in body mass index in 63%, waist circumference (men 71%, women 74%), systolic BP 69%, and diastolic BP 71%. For participants with abnormal laboratory values at baseline, there were improvements in total cholesterol in 74%, LDL-cholesterol 65%, triglycerides 86%, fasting glucose 72%, and insulin resistance 71%. Improvements were not driven by prescribed medications. CIMT improved or showed no change in 70% of those measured, associated with significant improvements in sleep quality and longer total sleep time. Longer trials incorporating controls and major adverse CVD events are warranted.
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Key Words
- ACEi, angiotensin converting enzyme inhibitor
- ARB, angiotensin receptor blocker
- BMI, body mass index in kg/m2
- BP, blood pressure
- Behavioral intervention
- CCB, calcium channel blocker
- CHP, Cardiovascular Health Program
- CIMT, carotid intima-media thickness
- CLIA, Clinical Laboratory Improvement Amendments
- Cardiovascular disease
- Cardiovascular risk
- DPP4, mdipeptidyl peptidase 4 inhibitor
- Dias BP, diastolic blood pressure in mm Hg
- ESS, Epworth Sleepiness Scale
- FBG, fasting blood glucose in mg/dL
- HOMA-IR, homeostatic model assessment for insulin resistance
- IPAQ, International Physical Activity Questionnaire
- IRB, institutional review board
- LDL, low density lipoprotein
- MACE, major adverse cardiovascular events
- NDRI, nicotine and dopamine reuptake inhibitor
- NP, nurse practitioner
- PSQI, Pittsburgh Sleep Quality Index
- PSS, Perceived Stress Scale
- Prevention
- RYP, Rate-Your-Plate
- SARI, serotonin antagonist and reuptake inhibitor
- SD, standard deviation
- SNRI, serotonin-norepinephrine reuptake inhibitor
- SPSS, Statistical Package for the Social Science
- SSRI, selective serotonin reuptake inhibitor
- Statin, HMG-CoA reductase inhibitor
- Sys BP, systolic blood pressure in mm Hg
- TCA, tricyclic antidepressant
- TLC, therapeutic lifestyle change
- Therapeutic lifestyle change
- Tot Chol, total cholesterol in mg/dL
- Trig, triglycerides in mg/dL
- WC, waist circumference in cm
- α Blocker, alpha blocker
- β blocker, beta blocker
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Affiliation(s)
- Arn Eliasson
- Cardiovascular Health Program Registry, Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, United States.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - Mariam Kashani
- Cardiovascular Health Program Registry, Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - Marina Vernalis
- Cardiovascular Health Program Registry, Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, United States.,Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
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Kaolawanich Y, Boonyasirinant T. Impact of aortic stiffness by velocity-encoded magnetic resonance imaging on late gadolinium enhancement to predict cardiovascular events. Int J Cardiol Heart Vasc 2020; 30:100635. [PMID: 33015313 PMCID: PMC7522332 DOI: 10.1016/j.ijcha.2020.100635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/04/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022]
Abstract
Background Increased aortic stiffness has been established as a marker in various cardiovascular diseases. Previous reports revealed a significant correlation between aortic stiffness and myocardial scarring using the late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR). However, prognostic data concerning aortic stiffness combining myocardial scarring remains limited. Method A total of 402 patients who had undergone clinical CMR for the evaluation of cardiac function, LGE, and aortic pulse wave velocity (PWV) using velocity encoded-CMR (VE-CMR) were included. Patients were classified into 4 groups using mean PWV and the presence of LGE as elevated or non-elevated PWV and positive or negative LGE. Patients received follow-up for major adverse cardiovascular events (MACE) comprising cardiovascular death, non-fatal myocardial infarction, hospitalization for heart failure, coronary revascularization, and ischemic stroke. Predictors of MACE and hard cardiac events (cardiovascular death or non-fatal myocardial infarction) were evaluated. Results During the average follow-up period of 47.7 months, 58 MACE occurred. Patients who had elevated PWV and positive LGE experienced the highest rate of MACE compared to the group with non-elevated PWV and negative LGE (HR 11.90, p < 0.001). Among patients who had LGE, those who had elevated PWV experienced a 2.4-times higher rate of MACE compared to those who had non-elevated PWV. Multivariate analysis showed that PWV and LGE were independent predictors of MACE and hard cardiac events. PWV had excellent intra- and inter-observer reproducibility (intra-: ICC = 0.98, p < 0.001, inter-: ICC = 0.97, p < 0.001). Conclusion Aortic stiffness using VE-CMR had prognostic value to predict cardiovascular events, with the added benefits of LGE.
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Key Words
- Aortic stiffness
- CI, confidence interval
- CMR, cardiovascular magnetic resonance
- Cardiovascular magnetic resonance imaging
- FOV, field of view
- HR, hazard ratio
- LA, left atrial/atrium
- LGE, late gadolinium enhancement
- LVEF, left ventricular ejection fraction
- Late gadolinium enhancement
- MACE, major adverse cardiovascular events
- PWV, pulse wave velocity
- Prognosis
- SD, standard deviation
- STEMI, ST-elevation myocardial infarction
- T, tesla
- TE, echo time
- TR, repetition time
- VE, velocity-encoded
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Affiliation(s)
- Yodying Kaolawanich
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thananya Boonyasirinant
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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10
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Al-Abdouh A, Khan SU, Barbarawi M, Upadhrasta S, Munira S, Bizanti A, Elias H, Jat A, Zhao D, Michos ED. Effects of Febuxostat on Mortality and Cardiovascular Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Mayo Clin Proc Innov Qual Outcomes 2020; 4:434-442. [PMID: 32793871 PMCID: PMC7411164 DOI: 10.1016/j.mayocpiqo.2020.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Objective To investigate the association between using febuxostat and cardiovascular events. Methods Systematic search of randomized controlled trials was performed using PubMed/MEDLINE, Cochrane review, and EMBASE databases through April 17, 2019. Meta-analysis was performed using random effect model and estimates were reported as risk difference (RD) with 95% CIs. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. The main outcomes of interest were cardiovascular mortality and all-cause mortality. Results A total of 15 randomized controlled trials (16,070 participants) were included. The mean ± SD age was 58.1±11.7 years. At the median follow-up of 6.4 months, use of febuxostat was not associated with statistically significant risk of cardiovascular mortality (RD, 0.12%; 95% CI, -0.25% to 0.49%; I2=48%; low certainty evidence), all-cause mortality (RD, 0.20%; 95% CI, -0.28% to 0.68%; I2 =60%; very low certainty evidence), major adverse cardiovascular events (RD, 0.40%; 95% CI, -0.34% to 1.13%; I2=26%; low certainty evidence), myocardial infarction (RD, -0.06%; 95% CI, -0.29% to 0.17%; I2 =0%; moderate certainty evidence), stroke (RD, 0.10%; 95% CI, -0.15% to 0.35%; I2=0%; moderate certainty evidence), or new-onset hypertension (RD, 1.58%; 95% CI, -0.63% to 3.78%; I2=58%; very low certainty evidence). These findings were consistent in patients with existing cardiovascular disease. Conclusion This meta-analysis suggested that use of febuxostat was not associated with higher risk of mortality or adverse cardiovascular outcomes in patients with gout and hyperuricemia. The results were limited by low to moderate certainty of evidence.
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Affiliation(s)
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown, WV
| | | | | | - Srajum Munira
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD
| | - Anas Bizanti
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD
| | - Hadi Elias
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD
| | - Asadulla Jat
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD
| | - Di Zhao
- The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins University, Baltimore, MD
| | - Erin D Michos
- The Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD.,Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD.,Department of Epidemiology, Johns Hopkins University, Baltimore, MD
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11
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Toya T, Sara JD, Lerman B, Ahmad A, Taher R, Godo S, Corban MT, Lerman LO, Lerman A. Elevated plasma homocysteine levels are associated with impaired peripheral microvascular vasomotor response. Int J Cardiol Heart Vasc 2020; 28:100515. [PMID: 32322661 PMCID: PMC7171522 DOI: 10.1016/j.ijcha.2020.100515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/23/2022]
Abstract
Homocysteine > 10 μmol/L is associated with peripheral microvascular endothelial dysfunction (PMED). Homocysteine > 10 μmol/L was associated with PMED in older, obese, or hypertensive patients. The association of homocysteine and PMED was prominent in patients with B-vitamins. Homocysteine > 10 μmol/L was associated with higher major cardiovascular events in univariate analysis.
Background Hyperhomocysteinemia (HHcy) has been proposed as an important cardiovascular risk factor (cRF). However, little is known about the association between plasma homocysteine levels and peripheral microvascular endothelial dysfunction (PMED), which is an integrated index of vascular health. Methods This cross-sectional and retrospective cohort study included patients who underwent non-invasive PMED assessment using reactive hyperemia peripheral arterial tonometry (RH-PAT). The association between HHcy and PMED, and its impact on MACE (all-cause mortality and atherosclerotic cardiovascular events) was investigated. Results A total of 257 patients were enrolled (HHcy > 10.0 µmol/L, N = 51; lower levels of homocysteine [LHcy] ≤ 10 µmol/L, N = 206). Patients with HHcy were older, predominantly males, and with more comorbidities than patients with LHcy (p < 0.05 for all). RH-PAT index was lower in patients with HHcy versus LHcy (p = 0.01). A significant association between HHcy and PMED was observed in older (≥60 years), obese (≥30 kg/m2), present/past smokers and hypertensive patients. HHcy was significantly associated with PMED even after adjusting for other cRF and B-vitamins supplementation. HHcy was associated with an increased risk of MACE with a hazard ratio of 3.65 (95% CI 1.41–9.48, p = 0.01) and an adjusted hazard ratio of 2.44 (95% CI 0.91–6.51, p = 0.08) after adjustment for age (≥60 years). Conclusion HHcy was independently associated with PMED after adjusting for cRF and B-vitamins supplementation. Thus, the link between homocysteine and MACE could be mediated by endothelial dysfunction, and will require further clarification with future studies.
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Affiliation(s)
- Takumi Toya
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA.,Division of Cardiology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, Japan
| | - Jaskanwal D Sara
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Ben Lerman
- School of Medicine, St. George's University, St George's, West Indies, Grenada
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Riad Taher
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Shigeo Godo
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Michel T Corban
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, USA
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12
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Lewsey SC, Sharma K, Kilic A, Halushka MK, Vaishnav J, Wittstein IS, Tandri H, Calkins H, James CA, Gilotra NA. Dual-Organ Transplantation in a Woman With Right Ventricular Failure Secondary to Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Case Rep 2020; 2:59-63. [PMID: 34316965 PMCID: PMC8301681 DOI: 10.1016/j.jaccas.2019.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 11/28/2019] [Accepted: 12/02/2019] [Indexed: 11/25/2022]
Abstract
We report a case of a woman with arrhythmogenic right ventricular cardiomyopathy (ARVC) who presented with severe right-sided heart failure and cardiac cirrhosis that mandated heart-liver transplantation. This case highlights an emerging sex-based difference in ARVC where female sex is associated with a higher risk of heart failure than in male patients with ARVC. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Sabra C. Lewsey
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marc K. Halushka
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joban Vaishnav
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ilan S. Wittstein
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harikrishna Tandri
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cynthia A. James
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nisha A. Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Chitturi KR, Xu J, Araujo-Gutierrez R, Bhimaraj A, Guha A, Hussain I, Kassi M, Bernicker EH, Trachtenberg BH. Immune Checkpoint Inhibitor-Related Adverse Cardiovascular Events in Patients With Lung Cancer. JACC CardioOncol 2019; 1:182-192. [PMID: 34396181 PMCID: PMC8352266 DOI: 10.1016/j.jaccao.2019.11.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/10/2019] [Accepted: 11/11/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The purpose of this study was to evaluate whether immune checkpoint inhibitors (ICIs) are associated with an increased risk of major adverse cardiovascular events (MACE) compared with non-ICI therapies in patients with lung cancer. BACKGROUND ICIs activate the host immune system to target cancer cells. Though uncommon, cardiovascular immune-related adverse events can be life-threatening. METHODS A retrospective single-institution cohort study of 252 patients with pathologically confirmed lung cancer who received ICI or non-ICI therapy was analyzed. The primary endpoint was MACE, defined as a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and hospitalization for heart failure. RESULTS During a median follow-up of 6 months, MACE occurred in 13.3% of ICI-treated patients, with a median time to event of 51 days, compared with 10.3% and 64 days in non-ICI patients. ICIs were not associated with MACE (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 0.57 to 2.43; p = 0.66) in a univariable Fine-Gray regression analysis incorporating noncardiovascular death as a competing risk. Multivariable regression analyses determined that patients treated with ICIs with elevated serum troponin I >0.01 ng/ml (HR: 7.27; 95% CI: 2.72 to 19.43; p < 0.001) and B-type natriuretic peptide (BNP) >100 pg/ml (HR: 2.65; 95% CI: 1.01 to 6.92; p = 0.047) had an increased risk of MACE. Patients pre-treated or receiving combined immunotherapy with ICIs and vascular endothelial growth factor inhibitors (VEGFIs) or tyrosine kinase inhibitors (TKIs) had an increased risk of MACE (HR: 2.15; 95% CI: 1.05 to 4.37; p = 0.04). CONCLUSIONS ICIs were not independently associated with an increased risk of MACE in patients with lung cancer, although power is an important limitation in these analyses. ICI-associated cardiotoxicity was associated with elevations in serum troponin and BNP, and combined immunotherapy with VEGFIs or TKIs. Future studies are needed to further define the role of cardiac biomarkers as a monitoring strategy with ICI therapy.
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Key Words
- BNP
- BNP, B-type natriuretic peptide
- CI, confidence interval
- HR, hazard ratio
- ICI, immune checkpoint inhibitor
- IQR, interquartile range
- LVEF, left ventricular ejection fraction
- MACE
- MACE, major adverse cardiovascular events
- PD, programmed cell death protein
- PD-L1, programmed cell death-ligand 1
- TKI, tyrosine kinase inhibitor
- TnI, troponin I
- VEGFI, vascular endothelial growth factor inhibitor
- cardiotoxicity
- immune checkpoint inhibitors
- lung cancer
- troponin
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Affiliation(s)
| | - Jiaqiong Xu
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
- Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas, USA
| | | | - Arvind Bhimaraj
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Ashrith Guha
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Imad Hussain
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Mahwash Kassi
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Eric H. Bernicker
- Department of Medical Oncology, Houston Methodist Cancer Center, Houston, Texas, USA
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