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Papakonstantinou PE, Kalogera V, Charitos D, Polyzos D, Benia D, Batsouli A, Lampropoulos K, Xydonas S, Gupta D, Lip GYH. When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer. Blood Rev 2024; 65:101171. [PMID: 38310007 DOI: 10.1016/j.blre.2024.101171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/05/2024]
Abstract
Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.
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Affiliation(s)
| | - Vasiliki Kalogera
- Third Cardiology Department, School of Medicine, National and Kapodistrian University of Athens, "Sotiria" Chest Hospital, Mesogeion Ave 152, 11527 Athens, Greece
| | - Dimitrios Charitos
- First Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitrios Polyzos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitra Benia
- Cardiology Department, General Hospital-Health Center of Kithira, Aroniadika, 80200 Kithira Island, Greece
| | - Athina Batsouli
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Konstantinos Lampropoulos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece; School of Medicine, European University of Cyprus, Diogenous 6, 2404 Egkomi, Cyprus
| | - Sotirios Xydonas
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, L14 3PE Liverpool, United Kingdom.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Thomas Dr., L14 3PE Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Aalborg, Denmark.
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Chang HC, Chen YY, Kuo TT, Lin YJ, Chien KL, Chang HY, Hung CL, Chung FP. Sodium Glucose Transporter 2 Inhibitors Versus Metformin on Cardiovascular and Renal Outcomes in Patients With Diabetes With Low Cardiovascular Risk: A Nationwide Cohort Study. J Am Heart Assoc 2024; 13:e032397. [PMID: 38591334 DOI: 10.1161/jaha.123.032397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND This study investigated whether initial SGLT2 (sodium-glucose cotransporter 2) inhibitor-based treatment is superior to metformin-based regimens as a primary prevention strategy among low-risk patients with diabetes. METHODS AND RESULTS In this nationwide cohort study, a total of 38 496 patients with diabetes with low cardiovascular risk were identified (age 62.0±11.6 years, men 50%) from January 1 to December 31, 2016. Patients receiving SGLT2 inhibitors-based and metformin-based regimens were 1:2 matched by propensity score. Study outcomes included all-cause mortality, cardiovascular death, hospitalization for heart failure, stroke, and progression to end-stage renal disease. Compared with 1928 patients receiving metformin-based regimens, 964 patients receiving SGLT2 inhibitor-based regimens had similar all-cause mortality (hazard ratio [HR], 0.75 [95% CI, 0.51-1.12]), cardiovascular death (HR, 0.69 [95% CI, 0.25-1.89]), hospitalization for heart failure (HR, 1.06 [95% CI, 0.59-1.92]), stroke (HR, 0.78 [95% CI, 0.48-1.27]), and progression to end-stage renal disease (HR, 0.88 [95% CI, 0.32-2.39]). However, SGLT2 inhibitors were associated with a lower risk of all-cause mortality (HR, 0.47 [95% CI, 0.23-0.99]; P for interaction=0.008) and progression to end-stage renal disease (HR, 0.22 [95% CI, 0.06-0.82]; P for interaction=0.04) in patients under the age of 65. CONCLUSIONS In comparison to metformin-based regimens, SGLT2 inhibitor-based regimens showed a similar risk of all-cause mortality and adverse cardiorenal events. SGLT2 inhibitors might be considered as first-line therapy in select low-risk patients, for example, younger patients with diabetes.
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Affiliation(s)
- Hao-Chih Chang
- Department of Medicine Taipei Veterans General Hospital Taoyuan Branch Taoyuan Taiwan
- Cardiovascular Research Center, School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
| | - Yun-Yu Chen
- Cardiovascular Research Center, School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine Taipei Veterans General Hospital Taipei Taiwan
- Department of Medical Research Taichung Veterans General Hospital Taichung Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health National Taiwan University Taipei Taiwan
- Department of Post Baccalaureate National Chung Hsing University Taichung Taiwan
- College of Life Sciences National Chung Hsing University Taichung Taiwan
| | - Tzu-Ting Kuo
- Division of Cardiovascular Surgery, Department of Surgery Taipei Veterans General Hospital Taipei Taiwan
| | - Yenn-Jiang Lin
- Cardiovascular Research Center, School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine Taipei Veterans General Hospital Taipei Taiwan
- Institute of Clinical Medicine National Yang Ming Chiao Tung University Taipei Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, College of Public Health National Taiwan University Taipei Taiwan
| | - Hung-Yu Chang
- Heart Center Cheng Hsin General Hospital Taipei Taiwan
| | - Chung-Lieh Hung
- Division of Cardiology, Department of Internal Medicine MacKay Memorial Hospital Taipei Taiwan
- Institue of Biomedical Sciences MacKay Medical College New Taipei Taiwan
| | - Fa-Po Chung
- Cardiovascular Research Center, School of Medicine National Yang Ming Chiao Tung University Taipei Taiwan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine Taipei Veterans General Hospital Taipei Taiwan
- Institute of Clinical Medicine National Yang Ming Chiao Tung University Taipei Taiwan
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Wechsler PM, Pandya A, Parikh NS, Razzak JA, White H, Navi BB, Kamel H, Liberman AL. Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke. J Am Heart Assoc 2024; 13:e032808. [PMID: 38533952 DOI: 10.1161/jaha.123.032808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS. METHODS AND RESULTS We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case. CONCLUSIONS Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.
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Affiliation(s)
- Paul M Wechsler
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Ankur Pandya
- Department of Health Policy and Management Harvard T.H. Chan School of Public Health Boston MA
| | - Neal S Parikh
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Junaid A Razzak
- Department of Emergency Medicine Weill Cornell Medicine New York NY
| | - Halina White
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Babak B Navi
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Hooman Kamel
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Ava L Liberman
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
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Lee SJ, Liu S, Blackwill H, Stradling D, Shafie M, Yu W. Cardiomyopathy in Patients With Acute Ischemic Stroke and Methamphetamine Use: Relevance for Cardioembolic Stroke and Outcome. J Am Heart Assoc 2024; 13:e033667. [PMID: 38533970 DOI: 10.1161/jaha.123.033667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/01/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Methamphetamine use has emerged as a major risk factor for cardiovascular and cerebrovascular disease in young adults. The aim of this study was to investigate a possible association of methamphetamine use with cardioembolic stroke. METHODS AND RESULTS We performed a retrospective study of patients with acute ischemic stroke admitted at our medical center between 2019 and 2022. All patients were screened for methamphetamine use and cardiomyopathy, defined as left ventricular ejection fraction ≤45%. Among 938 consecutive patients, 46 (4.9%) were identified as using methamphetamine. Compared with the nonmethamphetamine group (n=892), the methamphetamine group was significantly younger (52.8±9.6 versus 69.7±15.2 years; P<0.001), included more men (78.3% versus 52.8%; P<0.001), and had a significantly higher rate of cardiomyopathy (30.4% versus 14.0%; P<0.01). They were also less likely to have a history of atrial fibrillation (8.7% versus 33.4%; P<0.01) or hyperlipidemia (28.3% versus 51.7%; P<0.01). Compared with patients with cardiomyopathy without methamphetamine use, the patients with cardiomyopathy with methamphetamine use had significantly lower left ventricular ejection fraction (26.0±9.59% versus 32.47±9.52%; P<0.01) but better functional outcome at 3 months, likely attributable to significantly younger age and fewer comorbidities. In the logistic regression model of clinical variables, methamphetamine-associated cardiomyopathy was found to be significantly associated with cardioembolic stroke (odds ratio, 1.79 [95% CI, 1.04-3.06]; P<0.05). CONCLUSIONS We demonstrate that methamphetamine use is significantly associated with cardiomyopathy and cardioembolic stroke in young adults.
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Affiliation(s)
- Sook Joung Lee
- Department of Neurology University of California Irvine CA
- Department of Physical Medicine and Rehabilitation, College of Medicine The Catholic University of Korea Seoul Republic of Korea
| | - Shimeng Liu
- Department of Neurology University of California Irvine CA
- Department Neurology, Tiantan Hospital Capital Medical University Beijing China
| | | | - Dana Stradling
- Department of Neurology University of California Irvine CA
| | | | - Wengui Yu
- Department of Neurology University of California Irvine CA
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Kamogawa N, Miwa K, Toyoda K, Jensen M, Inoue M, Yoshimura S, Fukuda-Doi M, Kitazono T, Boutitie F, Ma H, Ringleb P, Wu O, Schwamm LH, Warach S, Hacke W, Davis SM, Donnan GA, Gerloff C, Thomalla G, Koga M. Thrombolysis for Wake-Up Stroke Versus Non-Wake-Up Unwitnessed Stroke: EOS Individual Patient Data Meta-Analysis. Stroke 2024; 55:895-904. [PMID: 38456303 PMCID: PMC10978262 DOI: 10.1161/strokeaha.123.043358] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Stroke with unknown time of onset can be categorized into 2 groups; wake-up stroke (WUS) and unwitnessed stroke with an onset time unavailable for reasons other than wake-up (non-wake-up unwitnessed stroke, non-WUS). We aimed to assess potential differences in the efficacy and safety of intravenous thrombolysis (IVT) between these subgroups. METHODS Patients with an unknown-onset stroke were evaluated using individual patient-level data of 2 randomized controlled trials (WAKE-UP [Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke], THAWS [Thrombolysis for Acute Wake-Up and Unclear-Onset Strokes With Alteplase at 0.6 mg/kg]) comparing IVT with placebo or standard treatment from the EOS (Evaluation of Unknown-Onset Stroke Thrombolysis trial) data set. A favorable outcome was prespecified as a modified Rankin Scale score of 0 to 1 at 90 days. Safety outcomes included symptomatic intracranial hemorrhage at 22 to 36 hours and 90-day mortality. The IVT effect was compared between the treatment groups in the WUS and non-WUS with multivariable logistic regression analysis. RESULTS Six hundred thirty-four patients from 2 trials were analyzed; 542 had WUS (191 women, 272 receiving alteplase), and 92 had non-WUS (42 women, 43 receiving alteplase). Overall, no significant interaction was noted between the mode of onset and treatment effect (P value for interaction=0.796). In patients with WUS, the frequencies of favorable outcomes were 54.8% and 45.5% in the IVT and control groups, respectively (adjusted odds ratio, 1.47 [95% CI, 1.01-2.16]). Death occurred in 4.0% and 1.9%, respectively (P=0.162), and symptomatic intracranial hemorrhage in 1.8% and 0.3%, respectively (P=0.194). In patients with non-WUS, no significant difference was observed in favorable outcomes relative to the control (37.2% versus 29.2%; adjusted odds ratio, 1.76 [0.58-5.37]). One death and one symptomatic intracranial hemorrhage were reported in the IVT group, but none in the control. CONCLUSIONS There was no difference in the effect of IVT between patients with WUS and non-WUS. IVT showed a significant benefit in patients with WUS, while there was insufficient statistical power to detect a substantial benefit in the non-WUS subgroup. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: CRD42020166903.
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Affiliation(s)
- Naruhiko Kamogawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Center for Advancing Clinical and Translational Sciences, National Cerebral, and Cardiovascular Center, Suita, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Florent Boutitie
- Hospices Civils de Lyon, Service de Biostatistique, Lyon, France; Université Lyon 1, Villeurbanne, France; Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Villeurbanne, France
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Ona Wu
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, MA, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Steven Warach
- Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Stephen M Davis
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, the University of Melbourne, Melbourne, VIC, Australia
| | - Geoffrey A Donnan
- Departments of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, the University of Melbourne, Melbourne, VIC, Australia
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Wan M, Yang K, Zhang G, Yang C, Wei Y, He Y, Jiang X. Efficacy, safety, and cost-effectiveness analysis of Cerebrolysin in acute ischemic stroke: A rapid health technology assessment. Medicine (Baltimore) 2024; 103:e37593. [PMID: 38552072 PMCID: PMC10977584 DOI: 10.1097/md.0000000000037593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 02/22/2024] [Indexed: 04/02/2024] Open
Abstract
This study conducts a rapid health technology assessment to systematically evaluate the effectiveness, safety, and cost-effectiveness of Cerebrolysin as an adjunctive therapy for acute ischemic stroke to provide evidence-based medicine for clinical decisions of Cerebrolysin. All systematic reviews/meta-analyses, pharmacoeconomic studies, and health technology assessment reports of Cerebrolysin for the treatment of acute ischemic stroke before August 17, 2023, were retrieved from PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang, Weipu, Sinomed database and the official website of health technology assessment. According to the inclusion and exclusion criteria, 2 researchers independently carried out screening, data extraction, and quality evaluation and descriptively analyzed the results of the included studies. A total of 14 pieces of literature were incorporated, comprising 8 systematic reviews/meta-analyses and 6 pharmacoeconomic studies. In terms of effectiveness, compared to control groups, the use of Cerebrolysin as a treatment for acute ischemic stroke demonstrates certain advantages, including enhancement in total efficacy rate, neurological function, upper limb motor dysfunction, and facilitation of the recovery of activities of daily living. Especially in patients with moderate to severe acute ischemic stroke, Cerebrolysin has demonstrated the ability to enhance neurological function recovery and ameliorate disabilities. Regarding safety, adverse reactions were mild or comparable to those in the control group. The primary findings of economic studies reveal that advocating for the use of Cerebrolysin offers certain cost-effectiveness advantages. Cerebrolysin contributes to improved clinical efficacy and evaluation indexes while demonstrating favorable safety and economic benefits.
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Affiliation(s)
- Miaomiao Wan
- Department of Clinical Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ke Yang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Gonghao Zhang
- College of First Clinical Medical, Guangxi Medical University, Nanning, China
| | - Chunxia Yang
- College of Pharmacy, Guangxi Medical University, Nanning, China
| | - Yuqing Wei
- College of Pharmacy, Guangxi Medical University, Nanning, China
| | - Yeqian He
- College of Pharmacy, Guangxi Medical University, Nanning, China
| | - Xia Jiang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Liuzzo G, Patrono C. Balancing the benefits and risks of anticoagulation in patients with subclinical atrial fibrillation. Eur Heart J 2024; 45:754-755. [PMID: 38190438 DOI: 10.1093/eurheartj/ehad859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Affiliation(s)
- Giovanna Liuzzo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University School of Medicine, Largo F.Vito 1, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Carlo Patrono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University School of Medicine, Largo F.Vito 1, 00168 Rome, Italy
- Department of Pharmacology, Catholic University School of Medicine, Largo F.Vito 1, 00168 Rome, Italy
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Albert SG, Shrestha E, Ahir V. Stroke Prevention by Antihyperglycemic Drugs in Type 2 Diabetes Mellitus. Endocr Pract 2024; 30:246-252. [PMID: 38097111 DOI: 10.1016/j.eprac.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVES The American Heart Association/American Stroke Association and the American Association of Clinical Endocrinology provided guidelines for patients with transient ischemic attacks or strokes (TIA/stroke) and diabetes mellitus with the use of glucose-lowering agents (GLA) effective in preventing major adverse cardiovascular events (MACE). This review evaluated GLA for specific differences in TIA/stroke prevention. METHODS Previous reviews and meta-analyses were evaluated for outcomes of MACE, cardiovascular death (CVD), hospitalization for heart failure, and TIA/stroke. The GLA were glucagon-like peptide 1-receptor agonists (GLP-1RA, 6-trials, n = 46 541), sodium-glucose transport 2 inhibitors (SGLT2i, 5-trials, n = 46 959), insulin-providing regimens (IP, 4-trials, n = 26 223), and thiazolidinediones (TZD, 1-trial, n = 5238). RESULTS There were reductions in MACE for each class. Relative risk (rr) reductions for TIA/stroke were found with GLP-1RA (rr = 0.840, 95% CI: 0.759, 0.936, P =.001) but not with SGLT2i, IP, or TZD. Cardiovascular deaths were decreased with GLP-1RA (rr = 0.873, CI: 0.804, 0.947, P =.001) and SGLT2i (rr = 0.835, CI: 0.706, 0.987, P =.034), but not with TZD or IP. Hospitalizations for heart failure were decreased only with SGLT2i (rr = 0.699, CI: 0.626, 0.781, P <.001). Increased CVD correlated with aggressive lowering of A1c (r = -0.611, P =.012) and showed a trend with the relative risk of hypoglycemia (r = 0.447, P =.08). For GLP-1RA, there was no increase in hypoglycemia and a direct correlation with a decreased rr for stroke with decreases in A1c (r = 0.917, P =.010). CONCLUSION Improvements in A1c with GLP-1RA were associated with stroke prevention in patients with diabetes and with TIA or stroke. Reductions in cardiovascular mortality include therapy with GLP-1RA and SGLT2i. Aggressive lowering of A1c, however, was associated with increased CVD.
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Affiliation(s)
- Stewart G Albert
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, St Louis, Missouri.
| | - Ekta Shrestha
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, St Louis, Missouri
| | - Vaishaliben Ahir
- Department of Internal Medicine, Division of Endocrinology, Saint Louis University School of Medicine, St Louis, Missouri
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Bohula EA, Marston NA, Ruzza A, Murphy SA, De Ferrari GM, Diaz R, Leiter LA, Elliott-Davey M, Wang H, Bhatia AK, Giugliano RP, Sabatine MS. Rationale and design of the effect of evolocumab in patients at high cardiovascular risk without prior myocardial infarction or stroke (VESALIUS-CV) trial. Am Heart J 2024; 269:179-190. [PMID: 38160917 DOI: 10.1016/j.ahj.2023.12.004] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/07/2023] [Accepted: 12/10/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The reduction of low-density lipoprotein cholesterol (LDL-C) with evolocumab, a fully human monoclonal antibody inhibitor of proprotein convertase subtilisin/kexin type 9 (PCSK9i), reduces the risk of major adverse cardiovascular events in patients with established atherosclerotic cardiovascular disease (ASCVD) with a prior MI, prior stroke, or symptomatic peripheral artery disease, with no offsetting safety concerns. The effect of evolocumab on CV outcomes in lower risk patients without a history of MI or stroke has not been explored. STUDY DESIGN VESALIUS-CV is a randomized, double-blind, placebo-controlled, global clinical trial designed to evaluate the effect of evolocumab on the risk of major cardiovascular events in patients at high cardiovascular risk but without a prior ischemic event. The study population consists of 12,301 patients with atherosclerosis or high-risk diabetes mellitus without a prior MI or stroke; an LDL-C ≥ 90 mg/dL, or non-high-density lipoprotein cholesterol (non-HDL-C) ≥ 120 mg/dL, or apolipoprotein B ≥ 80 mg/dL; and treated with optimized lipid-lowering therapy. Patients were randomized in a 1:1 ratio to evolocumab 140 mg subcutaneously every 2 weeks or matching placebo. The primary efficacy objective is to assess whether evolocumab reduces the risk of the dual primary composite endpoints of coronary heart disease (CHD) death, myocardial infarction (MI), or ischemic stroke (triple primary endpoint) and of CHD death, MI, ischemic stroke, or ischemia-driven arterial revascularization (quadruple primary endpoint). Recruitment began in June 2019 and completed in November 2021. The trial is planned to continue until at least 751 patients experience an adjudicated triple endpoint, at least 1254 experience an adjudicated quadruple endpoint, and the median follow-up is ≥4.5 years. CONCLUSION VESALIUS-CV will determine whether the addition of evolocumab to optimized lipid-lowering therapy reduces cardiovascular events in patients at high cardiovascular risk without a prior MI or stroke. TRIAL REGISTRATION NCT03872401.
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Affiliation(s)
- Erin A Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Nicholas A Marston
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gaetano M De Ferrari
- Department of Medical Sciences, University of Turin and Department of Cardiology, Azienda Ospedaliera Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Rafael Diaz
- Estudios Clínicos Latino America, Santa Fe, Argentina
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute of St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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10
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Sajobi TT, Arimoro OI, Ademola A, Singh N, Bala F, Almekhlafi MA, Deschaintre Y, Coutts SB, Thirunavukkarasu S, Khosravani H, Appireddy R, Moreau F, Gubitz GJ, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar JS, Williams H, Field TS, Manosalva A, Siddiqui M, Zafar A, Imoukhuede O, Hunter G, Demchuk AM, Mishra SM, Gioia LC, Jalini S, Cayer C, Phillips SJ, Elamin E, Shoamanesh A, Subramaniam S, Kate MP, Jacquin G, Camden MC, Benali F, Alhabli I, Horn M, Stotts G, Hill MD, Gladstone DJ, Poppe AY, Sehgal A, Zhang Q, Lethebe B, Doram C, Shamy M, Kenney C, Buck BH, Swartz RH, Menon BK. Quality of Life After Intravenous Thrombolysis for Acute Ischemic Stroke: Results From the AcT Randomized Controlled Trial. Stroke 2024; 55:524-531. [PMID: 38275116 DOI: 10.1161/strokeaha.123.044690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/30/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Recent evidence from thrombolysis trials indicates the noninferiority of intravenous tenecteplase to intravenous alteplase with respect to good functional outcomes in patients with acute stroke. We examined whether the health-related quality of life (HRQOL) of patients with acute stroke differs by the type of thrombolysis treatment received. In addition, we examined the association between the modified Rankin Scale score 0 to 1 and HRQOL and patient-reported return to prebaseline stroke functioning at 90 days. METHODS Data were from all patients included in the AcT trial (Alteplase Compared to Tenecteplase), a pragmatic, registry-linked randomized trial comparing tenecteplase with alteplase. HRQOL at 90-day post-randomization was assessed using the 5-item EuroQOL questionnaire (EQ5D), which consists of 5 items and a visual analog scale (VAS). EQ5D index values were estimated from the EQ5D items using the time tradeoff approach based on Canadian norms. Tobit regression and quantile regression models were used to evaluate the adjusted effect of tenecteplase versus alteplase treatment on the EQ5D index values and VAS score, respectively. The association between return to prebaseline stroke functioning and the modified Rankin Scale score 0 to 1 and HRQOL was quantified using correlation coefficient (r) with 95% CI. RESULTS Of 1577 included in the intention-to-treat analysis patients, 1503 (95.3%) had complete data on the EQ5D. Of this, 769 (51.2%) were administered tenecteplase and 717 (47.7%) were female. The mean EQ5D VAS score and EQ5D index values were not significantly higher for those who received intravenous tenecteplase compared with those who received intravenous alteplase (P=0.10). Older age (P<0.01), more severe stroke assessed using the National Institutes of Health Stroke Scale (P<0.01), and longer stroke onset-to-needle time (P=0.004) were associated with lower EQ5D index and VAS scores. There was a strong association (r, 0.85 [95% CI, 0.81-0.89]) between patient-reported return to prebaseline functioning and modified Rankin Scale score 0 to 1 Similarly, there was a moderate association between return to prebaseline functioning and EQ5D index (r, 0.45 [95% CI, 0.40-0.49]) and EQ5D VAS scores (r, 0.42 [95% CI, 0.37-0.46]). CONCLUSIONS Although there is no differential effect of thrombolysis type on patient-reported global HRQOL and EQ 5D-5L index values in patients with acute stroke, sex- and age-related differences in HRQOL were noted in this study. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03889249.
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Affiliation(s)
- Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Olayinka I Arimoro
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
| | - Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Nishita Singh
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
- University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
| | - Fouzi Bala
- Department of Diagnostic and Interventional Neuroradiology, Tours University Hospital, France (F. Bala)
| | - Mohammed A Almekhlafi
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
| | - Yan Deschaintre
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Shelagh B Coutts
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
| | - Sibi Thirunavukkarasu
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Houman Khosravani
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (H.K., D.J.G., R.H.S.)
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada (R.A., S.J.)
| | | | - Gordon J Gubitz
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.J.G., S.J.P., A. Shoamanesh)
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre, McMaster University, Hamilton, ON, Canada (L.C.)
| | - Dar Dowlatshahi
- Department of Medicine, Ottawa Heart Research Institute, University of Ottawa, ON, Canada (D.D., M. Shamy)
| | - George Medvedev
- Department of Medicine, University of British Columbia & Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
- University of British Columbia, Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
| | - Jennifer Mandzia
- London Health Sciences Centre and Western University, ON, Canada (J.M.)
| | | | - Jai Shiva Shankar
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
- University of Manitoba, Winnipeg, Canada (N.S., J.S.S.)
| | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, The University of British Columbia, Vancouver, Canada (T.S.F.)
| | | | | | - Atif Zafar
- St. Michael's Hospital, Toronto, ON, Canada (A.Z.)
| | | | - Gary Hunter
- University of Saskatchewan, Saskatoon, Canada (G.H.)
| | - Andrew M Demchuk
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Sachin M Mishra
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Laura C Gioia
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Shirin Jalini
- Division of Neurology, Department of Medicine, Queen's University, Kingston, ON, Canada (R.A., S.J.)
| | - Caroline Cayer
- Centre de recherche du CHUS, Centre intégré Universitaire de Santé et des Services Sociaux de l'Estrie, Sherbrooke, QC, Canada (C.C.)
| | - Stephen J Phillips
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.J.G., S.J.P., A. Shoamanesh)
| | | | - Ashkan Shoamanesh
- Queen Elizabeth Health Sciences Centre, Halifax, NS, Canada (G.J.G., S.J.P., A. Shoamanesh)
| | - Suresh Subramaniam
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Mahesh P Kate
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Gregory Jacquin
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Marie-Christine Camden
- Enfant-Jésus Hospital, Centre Hospitalier Universitaire de Québec, Laval University, Canada (M.-C.C.)
| | - Faysal Benali
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Grant Stotts
- Department of Medicine, University of British Columbia & Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
- University of British Columbia, Fraser Health Authority, New Westminster, BC, Canada (G.M., G.S.)
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
| | - David J Gladstone
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (H.K., D.J.G., R.H.S.)
| | - Alexandre Y Poppe
- Département of Neurosciences, Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
- Centre Hospitalier de l'Université de Montréal, QC, Canada (Y.D., L.C.G., G.J., A.Y.P.)
| | - Arshia Sehgal
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Qiao Zhang
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brendan Lethebe
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
| | - Craig Doram
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Michel Shamy
- Department of Medicine, Ottawa Heart Research Institute, University of Ottawa, ON, Canada (D.D., M. Shamy)
| | - Carol Kenney
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (S.T., S.M.M., M.P.K., B.H.B.)
| | - Richard H Swartz
- Division of Neurology, Department of Medicine, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (H.K., D.J.G., R.H.S.)
| | - Bijoy K Menon
- Department of Community Health Sciences, University of Calgary, AB, Canada (T.T.S., O.I.A., A.A., M.A.A., S.B.C., A.M.D., M.D.H., B.L., B.K.M.)
- Department of Clinical Neurosciences (T.T.S., A.A., M.A.A., S.B.C., A.M.D., S.S., F. Benali, I.A., M.H., M.D.H., A. Sehgal, Q.Z., C.D., C.K., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.), Cumming School of Medicine, University of Calgary, AB, Canada
- Hotchkiss Brain Institute, Calgary, AB, Canada (M.A.A., S.B.C., A.M.D., M.D.H., B.K.M.)
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11
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Ataş İ, Ersunan G, Bỉlỉr Ö, Yavaşỉ Ö, Altuntaş M, Karakullukçu S. The utility of NIRS in follow-up of patients with acute ischaemic stroke treated with IV thrombolysis and mechanical thrombectomy in the emergency department. J Thromb Thrombolysis 2024; 57:466-472. [PMID: 38085469 DOI: 10.1007/s11239-023-02920-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 03/26/2024]
Abstract
Revascularization treatments (IV thrombolysis, mechanical thrombectomy) related to ischemic stroke have developed in recent years. With devices such as NIRS, non-invasive monitoring of treatment efficacy is provided. In this study, we aimed to use near-infrared spectroscopy (NIRS) as an objective monitoring method to see the effect of intravenous (IV) thrombolysis or mechanical thrombectomy treatments applied for cerebral oxygenation in patients with acute ischemic stroke. This study was carried out as a prospective study involving patients admitted to the emergency department in the years 2021-2022. NIRS measured regional oxygen saturation (rSO2) of both hemispheres of the brain before IV thrombolysis treatment, during the treatment at 0. min, 15. min, 30. min, 45. min, 60. min, after the treatment, and before and after the mechanical thrombectomy procedure. The significance level of the change in rSO2 values measured by NIRS was examined. 80 patients were included in the study. IV thrombolysis was applied to 58 patients, mechanical thrombectomy was applied to 5 of them, and both treatments were applied to 17 of them. In patients receiving IV thrombolysis, a significant difference was found in the affected hemisphere between the NIRS values measured at 0.min-15.min, 0.min-30.min, 0.min-45.min, 0.min-60.min, 0.min-post-treatment, 15.min-60.min (p < 0.001). In the patients included in the study, there was a strong and significant negative correlation between the deltaNIHSS value and the deltaNIRS values in the affected hemisphere (r=- 0.307, p = 0.013). There was a significant increase in the NIRS measurement values during and after the IV thrombolysis treatment in the affected hemisphere in the group with clinical improvement (p < 0.001). It is thought that IV thrombolysis or mechanical thrombectomy treatment applied to patients admitted to the emergency department with acute ischemic stroke can be followed objectively by NIRS.
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Affiliation(s)
- İsmail Ataş
- Department of Emergency Medicine, Rize State Hospital, 53100, Rize, Turkey.
| | - Gökhan Ersunan
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, 53020, Rize, Turkey
| | - Özlem Bỉlỉr
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, 53020, Rize, Turkey
| | - Özcan Yavaşỉ
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, 53020, Rize, Turkey
| | - Mehmet Altuntaş
- Department of Emergency Medicine, Recep Tayyip Erdoğan University Training and Research Hospital, 53020, Rize, Turkey
| | - Serdar Karakullukçu
- Department of Public Health, Karadeniz Technical University, 61080, Trabzon, Turkey
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12
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Xie H, Chen Y, Ge W, Xu X, Liu C, Lan Z, Yang Y. Can the combination of antiplatelet or alteplase thrombolytic therapy with argatroban benefit patients suffering from acute stroke? a systematic review, meta-analysis, and meta-regression. PLoS One 2024; 19:e0298226. [PMID: 38412157 PMCID: PMC10898750 DOI: 10.1371/journal.pone.0298226] [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] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 01/19/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The effectiveness of administering argatroban as a treatment approach following antiplatelet therapy or alteplase thrombolytic therapy in patients with acute stroke is presently uncertain. However, it is important to highlight the potential benefits of combining this medication with known thrombolytics or antiplatelet therapy. One notable advantage of argatroban is its short half-life, which helps minimize excessive anticoagulation and risk of bleeding complications in inadvertent cases of hemorrhagic stroke. By conducting a meticulous review and meta-analysis, we aim to further explore the common use of argatroban and examine the plausible advantages of combining this medication with established thrombolytic and antiplatelet therapies. METHOD In this study, we performed a rigorous and methodical search for both randomized controlled trials and retrospective analyses. Our main objective was to analyze the impact of argatroban on the occurrence of hemorrhagic events and the mRS scores of 0-2. We utilized a meta-analysis to assess the relative risk (RR) associated with using argatroban versus not using it. RESULTS In this study, we analyzed data from 11 different studies, encompassing a total of 8,635 patients. Out of these patients, 3999(46.3%) received argatroban treatment while the remaining 4636(53.7%)did not. The primary outcome of 90-day functional independence (modified Rankin scale (mRS) score≤2) showed that the risk ratio (RR) for patients using argatroban after alteplase thrombolytic therapy compared to those not using argatroban was(RR, 1.00 ([95% CI, 0.92-1.09]; P = 0.97), indicating no statistical significance. However, for patients using argatroban after antiplatelet therapy, was (RR,1.09 [95% CI, 1.04-1.14]; P = 0.0001), which was statistically significant. In terms of hemorrhagic events, the RR for patients using argatroban compared to those not using argatroban was (RR,1.08 [95% CI, 0.88-1.33]; P = 0.46), indicating no statistical significance. CONCLUSION The results of this study suggest that further research into combination therapy with argatroban and antiplatelet agents may be warranted, however more rigorous RCTs are needed to definitively evaluate the effects of combination treatment.
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Affiliation(s)
- Haiyan Xie
- Department of Clinical Pharmacy, The Third Hospital of Quzhou, Quzhou, Zhejiang, 324003, China
| | - Ying Chen
- Hangzhou Fuyang District Hospital of Traditional Chinese Medicine, Zhejiang, 311499, China
| | - Wukun Ge
- Department of Clinical Pharmacy, Ninghai First Hospital, Zhejiang, 315600, China
| | - Xiuping Xu
- Department of Emergency Internal Medicine, The Third Hospital of Quzhou, Quzhou, Zhejiang, 324003,China
| | - Chengjiang Liu
- Department of General Medicine, Affiliated Anqing First People’s Hospital of Anhui Medical University, HeFei, 246000, China
| | - Zhiyong Lan
- Department of Psychiatry Department, The Third Hospital of Quzhou, Quzhou, Zhejiang, 324003, China
| | - Yina Yang
- Department of Neurology, Ninghai First Hospital, Zhejiang, 315600, China
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13
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Petch J, Nelson W, Wu M, Ghassemi M, Benz A, Fatemi M, Di S, Carnicelli A, Granger C, Giugliano R, Hong H, Patel M, Wallentin L, Eikelboom J, Connolly SJ. Optimizing warfarin dosing for patients with atrial fibrillation using machine learning. Sci Rep 2024; 14:4516. [PMID: 38402362 PMCID: PMC10894214 DOI: 10.1038/s41598-024-55110-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 02/20/2024] [Indexed: 02/26/2024] Open
Abstract
While novel oral anticoagulants are increasingly used to reduce risk of stroke in patients with atrial fibrillation, vitamin K antagonists such as warfarin continue to be used extensively for stroke prevention across the world. While effective in reducing the risk of strokes, the complex pharmacodynamics of warfarin make it difficult to use clinically, with many patients experiencing under- and/or over- anticoagulation. In this study we employed a novel implementation of deep reinforcement learning to provide clinical decision support to optimize time in therapeutic International Normalized Ratio (INR) range. We used a novel semi-Markov decision process formulation of the Batch-Constrained deep Q-learning algorithm to develop a reinforcement learning model to dynamically recommend optimal warfarin dosing to achieve INR of 2.0-3.0 for patients with atrial fibrillation. The model was developed using data from 22,502 patients in the warfarin treated groups of the pivotal randomized clinical trials of edoxaban (ENGAGE AF-TIMI 48), apixaban (ARISTOTLE) and rivaroxaban (ROCKET AF). The model was externally validated on data from 5730 warfarin-treated patients in a fourth trial of dabigatran (RE-LY) using multilevel regression models to estimate the relationship between center-level algorithm consistent dosing, time in therapeutic INR range (TTR), and a composite clinical outcome of stroke, systemic embolism or major hemorrhage. External validation showed a positive association between center-level algorithm-consistent dosing and TTR (R2 = 0.56). Each 10% increase in algorithm-consistent dosing at the center level independently predicted a 6.78% improvement in TTR (95% CI 6.29, 7.28; p < 0.001) and a 11% decrease in the composite clinical outcome (HR 0.89; 95% CI 0.81, 1.00; p = 0.015). These results were comparable to those of a rules-based clinical algorithm used for benchmarking, for which each 10% increase in algorithm-consistent dosing independently predicted a 6.10% increase in TTR (95% CI 5.67, 6.54, p < 0.001) and a 10% decrease in the composite outcome (HR 0.90; 95% CI 0.83, 0.98, p = 0.018). Our findings suggest that a deep reinforcement learning algorithm can optimize time in therapeutic range for patients taking warfarin. A digital clinical decision support system to promote algorithm-consistent warfarin dosing could optimize time in therapeutic range and improve clinical outcomes in atrial fibrillation globally.
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Affiliation(s)
- Jeremy Petch
- Centre for Data Science and Digital Health, Hamilton Health Sciences, Hamilton, ON, Canada.
- Population Health Research Institute, Hamilton, ON, Canada.
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - Walter Nelson
- Centre for Data Science and Digital Health, Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Statistical Sciences, University of Toronto, Toronto, ON, Canada
| | - Mary Wu
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
| | - Marzyeh Ghassemi
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Institute for Medical and Evaluative Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
- Vector Institute, Toronto, ON, Canada
| | - Alexander Benz
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Cardiology, University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Shuang Di
- Centre for Data Science and Digital Health, Hamilton Health Sciences, Hamilton, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Anthony Carnicelli
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Christopher Granger
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Robert Giugliano
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hwanhee Hong
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Manesh Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - John Eikelboom
- Population Health Research Institute, Hamilton, ON, Canada
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, ON, Canada
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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14
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Breen TJ, Raphael CE, Ingraham B, Lane C, Huxley S, Roger VL, Jaffe A, Lewis B, Sandoval YB, Prasad A, Rihal CS, Gulati R, Singh M. Incidence and outcomes of high bleeding risk patients with type 1 and type 2 myocardial infarction in a community-based cohort: Application of the Academic Research Consortium High Bleeding Risk Criteria. Int J Cardiol 2024; 396:131565. [PMID: 37913957 PMCID: PMC10841724 DOI: 10.1016/j.ijcard.2023.131565] [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: 06/26/2023] [Revised: 09/29/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND AND AIMS The incidence and outcomes of high bleeding risk (HBR) patients in a community cohort according to the Academic Research Consortium (ARC) criteria is not known. We hypothesized that HBR is common and associated with worse outcomes for all-comers with myocardial infarction. METHODS We prospectively collected all patients with cardiac troponin T > 99th percentile upper limit of normal (≥0.01 ng/mL) in Olmsted County between 2003 and 2012. Events were retrospectively classified as type 1 myocardial infarction (T1MI), type 2 myocardial infarction (T2MI), or myocardial injury. Patients were further classified as HBR based on the "ARC-HBR definition." Outcomes included all-cause mortality, cardiovascular mortality, recurrent MI, stroke, and major bleeding. RESULTS 2419 patients were included in the final study; 1365 were classified as T1MI and 1054 as T2MI. Patients were followed for a median of 5.5 years. ARC-HBR was more common in T2MI than T1MI (73% vs 46%, p < 0.001). Among patients with T1MI, HBR was associated with higher all-cause mortality (HR 3.7, 95% CI 3.2-4.5, p < 0.001), cardiovascular mortality (4.7, 3.6-6.3, p < 0.001), recurrent MI (2.1, 1.6-2.7, p < 0.001), stroke (4.9, 2.9-8.4, p < 0.001), and major bleeding (6.5, 3.7-11.4, p < 0.001). For T2MI, HBR was similarly associated with higher all-cause mortality (HR 2.1, 95% CI 1.8-2.5, p < 0.001), cardiovascular mortality (2.7, 1.8-4.0, p < 0.001), recurrent MI (1.7, 1.1-2.6, p = 0.02) and major bleeding (HR 15.6, 3.8-63.8, p < 0.001). CONCLUSION HBR is common among unselected patients with T1MI and T2MI and is associated with increased overall and cardiovascular mortality, recurrent cardiovascular events, and major bleeding on long-term follow up.
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Affiliation(s)
- Thomas J Breen
- Department of Cardiovascular Medicine, Yale University, 20 York Street, New Haven, CT 06510, United States of America.
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Brenden Ingraham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Conor Lane
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Sam Huxley
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Veronique L Roger
- Division of Intramural Research, National Heart Lung and Blood Institute, Bethesda, MD 20814, United States of America
| | - Allan Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Bradley Lewis
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Yader B Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
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15
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Marx N, Kolkailah AA, Rosenstock J, Johansen OE, Cooper ME, Alexander JH, Toto RD, Wanner C, Espeland MA, Mattheus M, Schnaidt S, Perkovic V, Gollop ND, McGuire DK. Hypoglycemia and Cardiovascular Outcomes in the CARMELINA and CAROLINA Trials of Linagliptin: A Secondary Analysis of Randomized Clinical Trials. JAMA Cardiol 2024; 9:134-143. [PMID: 38170502 PMCID: PMC10765314 DOI: 10.1001/jamacardio.2023.4602] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 10/06/2023] [Indexed: 01/05/2024]
Abstract
Importance Previous studies have reported an association between hypoglycemia and cardiovascular (CV) events in people with type 2 diabetes (T2D), but it is unclear if this association is causal or identifies a high-risk patient phenotype. Objective To evaluate the associations between hypoglycemia and CV outcomes. Design, Setting, and Participants This secondary analysis was a post hoc assessment of the multinational, double-blind CARMELINA (Cardiovascular and Renal Microvascular Outcome Study With Linagliptin; 2013-2016) and CAROLINA (Cardiovascular Outcome Trial of Linagliptin vs Glimepiride in Type 2 Diabetes; 2010-2018) randomized clinical trials of the antihyperglycemic drug, linagliptin, a dipeptidyl peptidase 4 inhibitor. Participants were adults with T2D at high CV risk with or without high kidney risk. By design, participants in the CARMELINA trial had longer duration of T2D and had a higher CV risk than participants in the CAROLINA trial. Data analyses were conducted between June 2021 and June 2023. Intervention Linagliptin or placebo in the CARMELINA trial, and linagliptin or glimepiride in the CAROLINA trial. Main Outcomes and Measures The primary outcome for both trials was CV death, myocardial infarction (MI), or stroke (3-point major adverse CV events [3P-MACE]). For the present analyses, hospitalization for heart failure (HF) was added. Hypoglycemia was defined as plasma glucose less than 54 mg/dL or severe hypoglycemia (episodes requiring the assistance of another person). Associations between the first hypoglycemic episode and subsequent CV events and between nonfatal CV events (MI, stroke, hospitalization for HF) and subsequent hypoglycemic episodes were assessed using multivariable Cox proportional hazards regression models. Sensitivity analyses explored the risk of CV events within 60 days after each hypoglycemic episode. Results In the CARMELINA trial (6979 patients; 4390 males [62.9%]; mean [SD] age, 65.9 [9.1] years), there was an association between hypoglycemia and subsequent 3P-MACE plus hospitalization for HF (hazard ratio [HR], 1.23; 95% CI, 1.04-1.46) as well as between nonfatal CV events and subsequent hypoglycemia (HR, 1.39; 95% CI, 1.06-1.83). In the CAROLINA trial (6033 patients; 3619 males (60.0%); mean [SD] age, 64.0 [9.5] years), there was no association between hypoglycemia and subsequent 3P-MACE plus hospitalization for HF (HR, 1.00; 95% CI, 0.76-1.32) and between nonfatal CV events and subsequent hypoglycemia (HR, 1.44; 95% CI, 0.96-2.16). In analyses of CV events occurring within 60 days after hypoglycemia, there was either no association or too few events to analyze. Conclusions and Relevance This study found bidirectional associations between hypoglycemia and CV outcomes in the CARMELINA trial but no associations in either direction in the CAROLINA trial, challenging the notion that hypoglycemia causes adverse CV events. The findings from the CARMELINA trial suggest that both hypoglycemia and CV events more likely identify patients at high risk for both. Trial Registration ClinicalTrials.gov Identifier: NCT01897532 (CARMELINA) and NCT01243424 (CAROLINA).
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Affiliation(s)
- Nikolaus Marx
- Department of Internal Medicine I, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Ahmed A. Kolkailah
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas
| | | | - Odd Erik Johansen
- Therapeutic Area Cardiometabolism, Boehringer Ingelheim KS, Asker, Norway
| | - Mark E. Cooper
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - John H. Alexander
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Robert D. Toto
- Department of Internal Medicine, Division of Nephrology, The University of Texas Southwestern Medical Center, Dallas
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Mark A. Espeland
- Division of Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michaela Mattheus
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim am Rhein, Germany
| | - Sven Schnaidt
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach an der Riß, Germany
| | - Vlado Perkovic
- Renal and Metabolic Division, The George Institute for Global Health, University of New South Wales Sydney, Newtown, New South Wales, Australia
| | - Nicholas D. Gollop
- Therapeutic Area Cardiometabolism, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Darren K. McGuire
- Division of Cardiology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas
- Parkland Health, Dallas, Texas
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16
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Zhang Z, Bao Y, Gu Y, Zhang M, Li X. Cost-effectiveness analysis of CYP2C19 genotype-guided antiplatelet therapy for patients with acute minor ischemic stroke and high-risk transient ischemic attack in China. Br J Clin Pharmacol 2024; 90:483-492. [PMID: 37795861 DOI: 10.1111/bcp.15921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/03/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023] Open
Abstract
AIMS The study aimed to estimate the cost-effectiveness of CYP2C19 genotype-guided antiplatelet therapy using cilostazol and ticagrelor as an alternative to clopidogrel, compared to conventional antiplatelet therapy with clopidogrel and aspirin. METHODS A 90-day decision tree and 30-year Markov model were employed to assess the costs and quality-adjusted life years (QALYs) of personalized antiplatelet therapy for patients with minor ischemic stroke and high-risk transient ischemic attack, compared to conventional antiplatelet therapy in the Chinese healthcare system. The primary outcome was the incremental cost-effectiveness ratio (ICER). The data sources included clinical trials, published literature, official documents and local prices. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to confirm the robustness of the findings. RESULTS The base-case analysis indicated that the CYP2C19 genotype-guided antiplatelet strategy was cost-effective, and cilostazol group and ticagrelor group yielded an ICER of 3327.40 US dollars (USD)/QALY and 3426.92 USD/QALY, respectively, which were less than threshold. The one-way sensitivity analysis showed the results were robust, where the most sensitive parameter was the disability distribution in the modified Rankin scale 3-5. The probabilistic analysis showed that the CYP2C19 genotype-guided antiplatelet therapy with either cilostazol or ticagrelor was 100% cost-effective under the willingness-to-pay threshold. CONCLUSIONS CYP2C19 genotype-guided antiplatelet therapy using cilostazol and ticagrelor as an alternative to clopidogrel appeared to be more cost-effective than conventional antiplatelet therapy for acute minor ischemic stroke and high-risk transient ischemic attack patients over 30 years in China.
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Affiliation(s)
- Zhuolin Zhang
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Yuwen Bao
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
| | - Yajie Gu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Mengdie Zhang
- School of Pharmacy, Nanjing Medical University, Nanjing, China
| | - Xin Li
- School of Pharmacy, Nanjing Medical University, Nanjing, China
- School of Health Policy and Management, Nanjing Medical University, Nanjing, China
- Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
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17
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Zheng Y, Fukasawa T, Yamaguchi F, Takeuchi M, Kawakami K. Cardiovascular Safety of Atomoxetine and Methylphenidate in Patients With Attention-Deficit/Hyperactivity Disorder in Japan: A Self-Controlled Case Series Study. J Atten Disord 2024; 28:439-450. [PMID: 38084080 DOI: 10.1177/10870547231214993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To investigate the association between atomoxetine or methylphenidate use and arrhythmia, heart failure (HF), stroke, and myocardial infarction (MI) in attention-deficit/hyperactivity disorder (ADHD) patients mainly focused on the people of working age. METHODS In a self-controlled case series study using a Japanese claims database, we identified events of arrhythmia, HF, stroke, and MI among 15,472 atomoxetine new users and 12,059 methylphenidate new users. Adjusted incidence rate ratios (aIRRs) of outcome events were estimated using multivariable conditional Poisson regression. RESULTS An increased risk of arrhythmia was observed during the first 7 days after the initial atomoxetine exposure (aIRR 6.22, 95% CI [1.90, 20.35]) and in the subsequent exposure (3.23, [1.58, 6.64]). No association was found between methylphenidate exposure and arrhythmia, nor between atomoxetine or methylphenidate exposure and HF. The limited number of stroke and MI cases prevented thorough analysis. CONCLUSIONS Clinicians should consider monitoring for arrhythmia after patients initiating or re-initiating atomoxetine.
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Affiliation(s)
- Yunlong Zheng
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan
| | - Toshiki Fukasawa
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan
- Department of Digital Health and Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan
| | - Fumitaka Yamaguchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Japan
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18
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Kohn TP, Agrawal P, Ory J, Hare JM, Ramasamy R. Rises in Hematocrit Are Associated With an Increased Risk of Major Adverse Cardiovascular Events in Men Starting Testosterone Therapy: A Retrospective Cohort Claims Database Analysis. J Urol 2024; 211:285-293. [PMID: 37948758 DOI: 10.1097/ju.0000000000003786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE Elevated hematocrit (Hct) can result in increased risk of major adverse cardiovascular events (MACE) in men receiving testosterone therapy (TTh). However, the impact of the magnitude of the change in Hct from baseline after starting TTh has never been assessed. MATERIALS AND METHODS To assess whether an increase in Hct after initiating TTh is associated with an increased risk of MACE within 3 and 24 months of initiating TTh, we queried the TriNetX Research network database for men over the age of 18 with Hct values obtained within 6 months before starting TTh, and who had follow-up Hct measurements within 3 and 24 months after beginning TTh from 2010 to 2021. Men with and without a subsequent increase in Hct after initiating TTh were propensity matched. MACE was defined as myocardial infarction, stroke, or death. RESULTS After matching, 10,511 men who experienced an any increase in Hct after initiating TTh and an equal number of controls who did have an increase in Hct were included. Compared to controls who did not have an increase in Hct after starting TTh, the men who had an increase in subsequent Hct had a significantly increased risk of MACE compared to men with no change in Hct. CONCLUSIONS We demonstrate that increases in Hct from baseline are associated with increased risk of MACE, compared to men whose Hct remains stable while receiving TTh.
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Affiliation(s)
- Taylor P Kohn
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pranjal Agrawal
- The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jesse Ory
- Department of Urology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Joshua M Hare
- The Interdisciplinary Stem Cell Institute and Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Ranjith Ramasamy
- Desai Sethi Urological Institute, Miller School of Medicine, University of Miami, Miami, Florida
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19
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Anthony KM, Collins JM, Love SAM, Stewart JD, Buchheit SF, Gondalia R, Schwartz GG, Huang DY, Meliker JR, Zhang Z, Barac A, Desai P, Hayden KM, Honigberg MC, Jaiswal S, Natarajan P, Bick AG, Kooperberg C, Manson JE, Reiner AP, Whitsel EA. Radon Exposure, Clonal Hematopoiesis, and Stroke Susceptibility in the Women's Health Initiative. Neurology 2024; 102:e208055. [PMID: 38170948 PMCID: PMC10870742 DOI: 10.1212/wnl.0000000000208055] [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] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 10/30/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Studies suggest that clonal hematopoiesis of indeterminate potential (CHIP) may increase risk of hematologic malignancy and cardiovascular disease, including stroke. However, few studies have investigated plausible environmental risk factors for CHIP such as radon, despite the climate-related increases in and documented infrequency of testing for this common indoor air pollutant.The purpose of this study was to estimate the risk of CHIP related to radon, an established environmental mutagen. METHODS We linked geocoded addresses of 10,799 Women's Health Initiative Trans-Omics for Precision Medicine (WHI TOPMed) participants to US Environmental Protection Agency-predicted, county-level, indoor average screening radon concentrations, categorized as follows: Zone 1 (>4 pCi/L), Zone 2 (2-4 pCi/L), and Zone 3 (<2 pCi/L). We defined CHIP as the presence of one or more leukemogenic driver mutations with variant allele frequency >0.02. We identified prevalent and incident ischemic and hemorrhagic strokes; subtyped ischemic stroke using Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria; and then estimated radon-related risk of CHIP as an odds ratio (OR) and 95% CI using multivariable-adjusted, design-weighted logistic regression stratified by age, race/ethnicity, smoking status, and stroke type/subtype. RESULTS The percentages of participants with CHIP in Zones 1, 2, and 3 were 9.0%, 8.4%, and 7.7%, respectively (ptrend = 0.06). Among participants with ischemic stroke, Zones 2 and 1 were associated with higher estimated risks of CHIP relative to Zone 3: 1.39 (1.15-1.68) and 1.46 (1.15-1.87), but not among participants with hemorrhagic stroke: 0.98 (0.68-1.40) and 1.03 (0.70-1.52), or without stroke: 1.04 (0.74-1.46) and 0.95 (0.63-1.42), respectively (pinteraction = 0.03). Corresponding estimates were particularly high among TOAST-subtyped cardioembolism: 1.78 (1.30-2.47) and 1.88 (1.31-2.72), or other ischemic etiologies: 1.37 (1.06-1.78) and 1.50 (1.11-2.04), but not small vessel occlusion: 1.05 (0.74-1.49) and 1.00 (0.68-1.47), respectively (pinteraction = 0.10). Observed patterns of association among strata were insensitive to attrition weighting, ancestry adjustment, prevalent stroke exclusion, separate analysis of DNMT3A driver mutations, and substitution with 3 alternative estimates of radon exposure. DISCUSSION The robust elevation of radon-related risk of CHIP among postmenopausal women who develop incident cardioembolic stroke is consistent with a potential role of somatic genomic mutation in this societally burdensome form of cerebrovascular disease, although the mechanism has yet to be confirmed.
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Affiliation(s)
- Kurtis M Anthony
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Jason M Collins
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Shelly-Ann M Love
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - James D Stewart
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Sophie F Buchheit
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Rahul Gondalia
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Gary G Schwartz
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - David Y Huang
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Jaymie R Meliker
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Zhenzhen Zhang
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Ana Barac
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Pinkal Desai
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Kathleen M Hayden
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Michael C Honigberg
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Siddhartha Jaiswal
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Pradeep Natarajan
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Alexander G Bick
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Charles Kooperberg
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - JoAnn E Manson
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Alexander P Reiner
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
| | - Eric A Whitsel
- From the Department of Epidemiology (K.M.A., J.M.C., S.-A.M.L., J.D.S., R.G., E.A.W.), Gillings School of Global Public Health, University of North Carolina, Chapel Hill; Brown University (S.F.B.), Providence, RI; Department of Population Health (G.G.S.), University of North Dakota School of Medicine & Health Sciences, Grand Forks; Department of Neurology (D.Y.H.), School of Medicine, University of North Carolina, Chapel Hill; Program in Public Health (J.R.M.), Stony Brook University, Stony Brook, NY; Division of Oncological Sciences (Z.Z.), Knight Cancer Institute, Oregon Health & Science University, Portland; Department of Cardiology (A.B.), Medstar Washington Hospital Center, Washington, DC; Department of Medicine (A.B.), Georgetown University, Washington, DC; Division of Hematology and Oncology (P.D.), Weill Cornell Medicine, New York; Department of Social Sciences and Health Policy (K.M.H.), Wake Forest University School of Medicine, Winston-Salem, NC; Cardiology Division (M.C.H.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (M.C.H., P.N.), Broad Institute of Harvard and MIT, Cambridge, MA; Department of Pathology (S.J.), Stanford University School of Medicine, CA; Cardiovascular Research Center and Center for Genomic Medicine (P.N.), Massachusetts General Hospital, Boston; Department of Medicine (P.N.), Harvard Medical School, Boston; Division of Genetic Medicine (A.G.B.), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Division of Public Health Sciences (C.K., A.P.R.), Fred Hutchinson Cancer Center, Seattle, WA; Department of Medicine (J.E.M.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Epidemiology (A.P.R.), University of Washington, Seattle; and Department of Medicine (E.A.W.), School of Medicine, University of North Carolina, Chapel Hill
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Jiang D, Wang L, Han X, Pan Z, Wang Z, Wang Y, Li J, Guo J, Liu Y, Huang S, Guan T. Short-term effects of ambient oxidation, and its interaction with fine particles on first-ever stroke: A national case-crossover study in China. Sci Total Environ 2024; 907:168017. [PMID: 37879462 DOI: 10.1016/j.scitotenv.2023.168017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/30/2023] [Accepted: 10/20/2023] [Indexed: 10/27/2023]
Abstract
Stroke is a significant global cause of disability and death, and its burden has been on the rise, while ambient air pollution has been conclusively linked to stroke incidence. However, knowledge about effects of atmospheric oxidation on stroke and its interactions with fine particles (PM2.5) are still limited. In this study, we investigated the short-term effects of ambient NO2, O3, and their combined oxidation (Owt) on first-ever stroke, based on data from the China National Stroke Screening Survey (CNSSS) conducted from 2013 to 2015. We found significant association between ambient NO2 exposure at lag0 day with first-ever stroke, with a 13.1 % (95 % CI: 3.5 %, 23.6 %) increase in the first-ever stroke risk per 10 μg/m3 exposure. We also found a significant interaction between NO2 and PM2.5 (p < 0.05): first-ever stroke risk increased 23.8 % (95 % CI: 9.6 %, 39.8 %) per 10 μg/m3 NO2 exposure in population exposed to higher PM2.5 concentrations, while no significant association was found in population exposed to lower PM2.5 concentrations. The results of stratified analyses indicated that physical inactivity enhanced the detrimental effects of O3 and Owt exposure, while smoking and transient ischemic attack (TIA) history enhanced the detrimental effects of NO2 exposure. However, TIA history appeared to mitigate the adverse effects of O3 exposure. This study is helpful to better understand the impact of ambient oxidation on stroke, as well as its interaction with PM2.5, and has implications for policies and standards for atmospheric protection and governance.
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Affiliation(s)
- Dongxia Jiang
- Department of Occupational and Environmental Health Sciences, School of Public Health, Peking University, Beijing 100191, China
| | - Luyang Wang
- Beijing Key Lab of Indoor Air Quality Evaluation and Control, Beijing 100084, China
| | - Xueyan Han
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Zhaoyang Pan
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Zhaokun Wang
- Department of Occupational and Environmental Health Sciences, School of Public Health, Peking University, Beijing 100191, China
| | - Yaqi Wang
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing 100191, China
| | - Jing Li
- Institute of Child and Adolescent Health, School of Public Health, Peking University, Beijing 100191, China
| | - Jian Guo
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China; Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuanli Liu
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Shaodan Huang
- Department of Occupational and Environmental Health Sciences, School of Public Health, Peking University, Beijing 100191, China; Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing 100191, China.
| | - Tianjia Guan
- School of Health Policy and Management, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China.
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21
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Mahajan R, Kalita J. Tizanidine Induced Hypotension: Report of a Case and Review of the Literature. Curr Drug Saf 2024; 19:313-316. [PMID: 37489780 DOI: 10.2174/1574886318666230725113855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/13/2023] [Accepted: 06/26/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Spasticity is a common sequelae of stroke, and often these patients receive anti-spastic drugs such as baclofen or tizanidine. Stroke patients have multiple co-morbidities such as hypertension, diabetes, and seizure. Tizanidine is an α2 and imidazole receptor agonist at a spinal and supraspinal level resulting in reduced central sympathetic outflow and causing hypotension rarely, especially in those receiving beta-blockers or angiotensin-converting enzyme inhibitors. CASE PRESENTATION We report a 56-year-old hypertensive male presenting with altered sensorium who had recurrent intracerebral hemorrhage with left spastic hemiplegia and focal seizures. He was on amlodipine, atenolol, telmisartan and oxcarbazepine. After 3 doses of tizanidine 2mg, his blood pressure dropped from 140/90 to 80/40 mmHg and pulse from 82 bpm to 44 bpm. His blood counts, serum chemistry, procalcitonin, and Trop I were normal. ECG revealed sinus bradycardia. After 8 hours of withdrawing tizanidine, his blood pressure became 110/70 mmHg, and on the next day, it became 140/82 mmHg. His attendants were taught physiotherapy to minimize spasticity. CONCLUSION This patient highlights the need for close monitoring of patients receiving tizanidine co-medication with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. These drugs have a synergistic effect on reducing the renin-angiotensin-aldosterone system, thereby hypotension and bradycardia.
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Affiliation(s)
- Roopali Mahajan
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India
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22
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Flint AC, Eaton A, Melles RB, Hartman J, Cullen SP, Chan SL, Rao VA, Nguyen-Huynh MN, Kapadia B, Patel NU, Klingman JG. Comparative safety of tenecteplase vs alteplase for acute ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107468. [PMID: 38039801 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/20/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023] Open
Abstract
INTRODUCTION Tenecteplase has been compared to alteplase in acute stroke randomized trials, with similar outcomes and safety measures, but higher doses of tenecteplase have been associated with higher hemorrhage rates in some studies. Limited data are available on the safety of tenecteplase outside of clinical trials. METHODS We examined the safety measures of intracranial hemorrhage, angioedema, and serious extracranial adverse events in a 21-hospital integrated healthcare system that switched from alteplase (0.9 mg/kg, maximum dose 90 mg) to tenecteplase (0.25 mg/kg, maximum dose 25 mg) for acute ischemic stroke. RESULTS Among 3,689 subjects, no significant differences were seen between tenecteplase and alteplase in the rate of intracranial hemorrhage (ICH), parenchymal hemorrhage, or volume of parenchymal hemorrhage. Symptomatic hemorrhage (sICH) was not different between the two agents: sICH by NINDS criteria was 2.0 % for alteplase vs 2.3 % for tenecteplase (P = 0.57), and sICH by SITS criteria was 0.8 % vs 1.1 % (P = 0.39). Adjusted logistic regression models also showed no differences between tenecteplase and alteplase: the odds ratio for tenecteplase (vs alteplase) modeling sICH by NINDS criteria was 0.9 (95 % CI 0.33 - 2.46, P = 0.83) and the odds ratio for tenecteplase modeling sICH by SITS criteria was 1.12 (95 % CI 0.25 - 5.07, P = 0.89). Rates of angioedema and serious extracranial adverse events were low and did not differ between tenecteplase and alteplase. Elapsed door-to-needle times showed a small improvement after the switch to tenecteplase (51.8 % treated in under 30 min with tenecteplase vs 43.5 % with alteplase, P < 0.001). CONCLUSION In use outside of clinical trials, complication rates are similar between tenecteplase and alteplase. In the context of a stroke telemedicine program, the rates of hemorrhage observed with either agent were lower than expected based on prior trials and registry data. The more easily prepared tenecteplase was associated with a lower door-to-needle time.
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Affiliation(s)
- Alexander C Flint
- Division of Research, Kaiser Permanente Northern California, Department of Neuroscience, Kaiser Permanente Redwood City, 1150 Veterans Blvd, Redwood City, CA 94025, USA.
| | | | | | | | - Sean P Cullen
- Department of Neuroscience, KP Redwood City, CA, USA
| | - Sheila L Chan
- Department of Neuroscience, KP Redwood City, CA, USA
| | - Vivek A Rao
- Department of Neuroscience, KP Redwood City, CA, USA
| | | | - Brij Kapadia
- Department of Radiology, KP San Leandro, CA, USA
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23
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Huang K, Jia J, Liang F, Li J, Niu X, Yang X, Chen S, Cao J, Shen C, Liu X, Yu L, Lu F, Wu X, Zhao L, Li Y, Hu D, Huang J, Liu Y, Gu D, Liu F, Lu X. Fine Particulate Matter Exposure, Genetic Susceptibility, and the Risk of Incident Stroke: A Prospective Cohort Study. Stroke 2024; 55:92-100. [PMID: 38018834 DOI: 10.1161/strokeaha.123.043812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/12/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Both genetic factors and environmental air pollution contribute to the risk of stroke. However, it is unknown whether the association between air pollution and stroke risk is influenced by the genetic susceptibilities of stroke and its risk factors. METHODS This prospective cohort study included 40 827 Chinese adults without stroke history. Satellite-based monthly fine particulate matter (PM2.5) estimation at 1-km resolution was used for exposure assessment. Based on 534 identified genetic variants from genome-wide association studies in East Asians, we constructed 6 polygenic risk scores for stroke and its risk factors, including atrial fibrillation, blood pressure, type 2 diabetes, body mass index, and triglyceride. The Cox proportional hazards model was applied to evaluate the hazard ratios and 95% CIs for the associations of PM2.5 and polygenic risk score with incident stroke and the potential effect modifications. RESULTS Over a median follow-up of 12.06 years, 3147 incident stroke cases were documented. Compared with the lowest quartile of PM2.5 exposure, the hazard ratio (95% CI) for stroke in the highest quartile group was 2.72 (2.42-3.06). Among individuals at high genetic risk, the relative risk of stroke was 57% (1.57; 1.40-1.76) higher than those at low genetic risk. Although no statistically significant interaction was found, participants with both the highest PM2.5 and high genetic risk showed the highest risk of stroke, with ≈4× that of the lowest PM2.5 and low genetic risk group (hazard ratio, 3.55 [95% CI, 2.84-4.44]). Similar upward gradients were observed in the risk of stroke when assessing the joint effects of PM2.5 and genetic risks of blood pressure, type 2 diabetes, body mass index, atrial fibrillation, and triglyceride. CONCLUSIONS Long-term exposure to PM2.5 was associated with a higher risk of incident stroke across different genetic susceptibilities. Our findings highlighted the great importance of comprehensive assessment of air pollution and genetic risk in the prevention of stroke.
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Affiliation(s)
- Keyong Huang
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
| | - Jiajing Jia
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
| | - Fengchao Liang
- School of Public Health and Emergency Management (F. Liang), Southern University of Science and Technology, Shenzhen, China
| | - Jianxin Li
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoge Niu
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
- Department of Nephrology, Henan Provincial Key Laboratory of Kidney Disease and Immunology, Henan Provincial Clinical Research Center for Kidney Disease, Henan Provincial People's Hospital and People's Hospital of Zhengzhou University, China (X.N.)
| | - Xueli Yang
- Tianjin Key Laboratory of Environment, Nutrition and Public Health, Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, China (X.Y.)
| | - Shufeng Chen
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
| | - Jie Cao
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
| | - Chong Shen
- Research Units of Cohort Study on Cardiovascular Diseases and Cancers (C.S.), Chinese Academy of Medical Sciences, Beijing, China
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, China (C.S.)
| | - Xiaoqing Liu
- Division of Epidemiology, Guangdong Provincial People's Hospital and Cardiovascular Institute, Guangzhou, China (X. Liu)
| | - Ling Yu
- Department of Cardiology, Fujian Provincial People's Hospital, Fuzhou, China (L.Y.)
| | - Fanghong Lu
- Cardio-Cerebrovascular Control and Research Center, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, China (F. Lu)
| | - Xianping Wu
- Sichuan Center for Disease Control and Prevention, Chengdu, China (X.W.)
| | - Liancheng Zhao
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Li
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
| | - Dongsheng Hu
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Department of Epidemiology and Health Statistics, College of Public Health, Zhengzhou University, China (D.H.)
- Department of Biostatistics and Epidemiology, School of Public Health, Shenzhen University Health Science Center, China (D.H.)
| | - Jianfeng Huang
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Liu
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA (Y. Liu)
| | - Dongfeng Gu
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
- School of Medicine (D.G), Southern University of Science and Technology, Shenzhen, China
| | - Fangchao Liu
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
| | - Xiangfeng Lu
- Department of Epidemiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (K.H., J.J., J.L., X.N., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu)
- Key Laboratory of Cardiovascular Epidemiology (K.H., J.J., J.L., S.C., J.C., L.Z., Y. Li, J.H., D.G., F. Liu, X. Lu), Chinese Academy of Medical Sciences, Beijing, China
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Ma Y, Zhang J, Li D, Tang L, Li Y, Cui F, Wang J, Wen C, Yang J, Tian Y. Genetic Susceptibility Modifies Relationships Between Air Pollutants and Stroke Risk: A Large Cohort Study. Stroke 2024; 55:113-121. [PMID: 38134266 DOI: 10.1161/strokeaha.123.044284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 11/15/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND The extent to which genetic susceptibility modifies the associations between air pollutants and the risk of incident stroke is still unclear. This study was designed to investigate the separate and joint associations of long-term exposure to air pollutants and genetic susceptibility on stroke risk. METHODS The participants of this study were recruited by the UK Biobank between 2006 and 2010. These participants were followed up from the enrollment until the occurrence of stroke events or censoring of data. Hazard ratios (HRs) and 95% CIs for stroke events associated with long-term exposure to air pollutants were estimated by fitting both crude and adjusted Cox proportional hazards models. Additionally, the polygenic risk score was calculated to estimate whether the polygenic risk score modifies the associations between exposure to air pollutants and incident stroke. RESULTS A total of 502 480 subjects were included in this study. After exclusion, 452 196 participants were taken into the final analysis. During a median follow-up time of 11.7 years, 11 334 stroke events were observed, with a mean age of 61.60 years, and men accounted for 56.2% of the total cases. Long-term exposures to particulate matter with an aerodynamic diameter smaller than 2.5 µm (adjusted HR, 1.70 [95% CI, 1.43-2.03]) or particulate matter with an aerodynamic diameter smaller than 10 µm (adjusted HR, 1.50 [95% CI, 1.36-1.66]), nitrogen dioxide (adjusted HR, 1.10 [95% CI, 1.07-1.12]), and nitrogen oxide (adjusted HR, 1.04 [95% CI, 1.02-1.05]) were pronouncedly associated with increased risk of stroke. Meanwhile, participants with high genetic risk and exposure to high air pollutants had ≈45% (31%, 61%; particulate matter with an aerodynamic diameter smaller than 2.5 µm), 48% (33%, 65%; particulate matter with an aerodynamic diameter smaller than 10 µm), 51% (35%, 69%; nitrogen dioxide), and 39% (25%, 55%; nitrogen oxide) higher risk of stroke compared with those with low genetic risk and exposure to low air pollutants, respectively. Of note, we observed additive and multiplicative interactions between genetic susceptibility and air pollutants on stroke events. CONCLUSIONS Chronic exposure to air pollutants was associated with an increased risk of stroke, especially in populations at high genetic risk.
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Affiliation(s)
- Yudiyang Ma
- Ministry of Education Key Laboratory of Environment and Health, State Key Laboratory of Environmental Health (Incubating) (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Maternal and Child Health (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Zhang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital (J.Z., J.Y.)
- Institute of Cardiovascular Diseases, China Three Gorges University, Yichang (J.Z., J.Y.)
- Hubei Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China (J.Z., J.Y.)
| | - Dankang Li
- Ministry of Education Key Laboratory of Environment and Health, State Key Laboratory of Environmental Health (Incubating) (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Maternal and Child Health (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Linxi Tang
- Ministry of Education Key Laboratory of Environment and Health, State Key Laboratory of Environmental Health (Incubating) (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Maternal and Child Health (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yimeng Li
- Ministry of Education Key Laboratory of Environment and Health, State Key Laboratory of Environmental Health (Incubating) (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT (Y.L.)
| | - Feipeng Cui
- Ministry of Education Key Laboratory of Environment and Health, State Key Laboratory of Environmental Health (Incubating) (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Maternal and Child Health (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianing Wang
- Ministry of Education Key Laboratory of Environment and Health, State Key Laboratory of Environmental Health (Incubating) (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Maternal and Child Health (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chen Wen
- School of Architecture and Urban Planning, Huazhong University of Science and Technology, Wuhan, China (C.W.)
| | - Jian Yang
- Department of Cardiology, The First College of Clinical Medical Science, China Three Gorges University and Yichang Central People's Hospital (J.Z., J.Y.)
- Institute of Cardiovascular Diseases, China Three Gorges University, Yichang (J.Z., J.Y.)
- Hubei Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China (J.Z., J.Y.)
| | - Yaohua Tian
- Ministry of Education Key Laboratory of Environment and Health, State Key Laboratory of Environmental Health (Incubating) (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Maternal and Child Health (Y.M., D.L., L.T., F.C., J.W., Y.T.), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Nicholls SJ, Bhatt DL, Buse JB, Prato SD, Kahn SE, Lincoff AM, McGuire DK, Nauck MA, Nissen SE, Sattar N, Zinman B, Zoungas S, Basile J, Bartee A, Miller D, Nishiyama H, Pavo I, Weerakkody G, Wiese RJ, D'Alessio D. Comparison of tirzepatide and dulaglutide on major adverse cardiovascular events in participants with type 2 diabetes and atherosclerotic cardiovascular disease: SURPASS-CVOT design and baseline characteristics. Am Heart J 2024; 267:1-11. [PMID: 37758044 DOI: 10.1016/j.ahj.2023.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/11/2023] [Accepted: 09/16/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Tirzepatide, a once-weekly GIP/GLP-1 receptor agonist, reduces blood glucose and body weight in people with type 2 diabetes. The cardiovascular (CV) safety and efficacy of tirzepatide have not been definitively assessed in a cardiovascular outcomes trial. METHODS Tirzepatide is being studied in a randomized, double-blind, active-controlled CV outcomes trial. People with type 2 diabetes aged ≥40 years, with established atherosclerotic CV disease, HbA1c ≥7% to ≤10.5%, and body mass index ≥25 kg/m2 were randomized 1:1 to once weekly subcutaneous injection of either tirzepatide up to 15 mg or dulaglutide 1.5 mg. The primary outcome is time to first occurrence of any major adverse cardiovascular event (MACE), defined as CV death, myocardial infarction, or stroke. The trial is event-driven and planned to continue until ≥1,615 participants experience an adjudication-confirmed component of MACE. The primary analysis is noninferiority for time to first MACE of tirzepatide vs dulaglutide by demonstrating an upper confidence limit <1.05, which will also confirm superiority vs a putative placebo, and also to determine whether tirzepatide produces a greater CV benefit than dulaglutide (superiority analysis). RESULTS Over 2 years, 13,299 people at 640 sites in 30 countries across all world regions were randomized. The mean age of randomized participants at baseline was 64.1 years, diabetes duration 14.7 years, HbA1c 8.4%, and BMI 32.6 kg/m2. Overall, 65.0% had coronary disease, of whom 47.3% reported prior myocardial infarction and 57.4% had prior coronary revascularization. 19.1% of participants had a prior stroke and 25.3% had peripheral artery disease. The trial is fully recruited and ongoing. CONCLUSION SURPASS-CVOT will provide definitive evidence as to the CV safety and efficacy of tirzepatide as compared with dulaglutide, a GLP-1 receptor agonist with established CV benefit.
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Affiliation(s)
- Stephen J Nicholls
- Victorian Heart Institute, Monash University, VIC, Melbourne, Australia.
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY
| | - John B Buse
- University of North Carolina, Chapel Hill, NC
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and Diabetes, University of Pisa, Pisa, and Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Steven E Kahn
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, VA Puget Sound Health Care System and University of Washington, Seattle, WA
| | - A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research) and Department of Cardiovascular Medicine, Cleveland, OH
| | - Darren K McGuire
- University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, TX
| | - Michael A Nauck
- Diabetes, Endocrinology and Metabolism Section, Department of Medicine I, St. Josef-Hospital, Katholisches Klinikum Bochum gGmbH, Ruhr University of Bochum, Bochum, Germany
| | - Steven E Nissen
- Cleveland Clinic Coordinating Center for Clinical Research (C5Research) and Department of Cardiovascular Medicine, Cleveland, OH
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, United Kingdom
| | - Bernard Zinman
- University of Toronto, Lunenfeld-Tanenbaum Research Institute and Mount Sinai Hospital, Toronto, ON, Canada
| | - Sophia Zoungas
- Victorian Heart Institute, Monash University, VIC, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia
| | - Jan Basile
- Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston, SC
| | | | | | | | - Imre Pavo
- Eli Lilly and Company, Indianapolis, IN
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Kajiwara S, Hasegawa Y, Fujimori K, Tomiyasu S, Kameno K, Uchikawa H, Morioka M. Persistent brain exposure to high sodium induces stroke onset by upregulation of cerebral microbleeds and oxidative stress in hypertensive rats. Hypertens Res 2024; 47:78-87. [PMID: 37783768 DOI: 10.1038/s41440-023-01447-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 10/04/2023]
Abstract
High salt intake induces hypertension and enhances stroke onset. However, whether an increase in brain sodium exposure itself is harmful and has poor prognosis remains unknown. Therefore, we employed hypertensive rats that underwent intracerebroventricular (ICV) infusion of sodium for 28 days and evaluated stroke onset and related cytotoxic brain injuries. Forty-seven spontaneously hypertensive stroke-prone (SHRSP) and 39 normotensive rats (Wistar Kyoto rats [WKY]) underwent persistent ICV infusion of the following four solutions: artificial cerebrospinal fluid, 0.9%, 2.7%, and 9% saline for 28 days. We evaluated stroke onset and all-cause mortality between SHRSP and WKY at each ICV sodium concentration as the primary endpoints. Our secondary objective was to explore histological brain injuries associated with SHRSP induced by high sodium ICV. The results indicated that ICV infusion of 2.7% and 9% sodium showed a significant increase in stroke onset, decrease in body weight, and increase rate of brain water content in SHRSP compared to WKY. Increased blood pressure was not observed for ICV infusion of high sodium, while serum sodium concentration was significantly increased in SHRSP compared to WKY. Histological evaluations revealed that higher sodium infusion significantly increased the number of activated microglia, superoxide, neuronal cell loss, and microbleeds compared to WKY and SHRSP with 0.9% sodium. We conclude that persistent exposure to high sodium in the brain is one of the risk factors for stroke onset upregulating cerebral microbleeds and oxidative stress in hypertensive rats.
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Affiliation(s)
- Sosho Kajiwara
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Yu Hasegawa
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan.
- Department of Pharmaceutical Sciences, School of Pharmacy at Fukuoka, International University of Health and Welfare, Fukuoka, Japan.
| | - Kana Fujimori
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Satoshi Tomiyasu
- Department of Medical Technology and Sciences, School of Health Sciences at Fukuoka, International University of Health and Welfare, Fukuoka, Japan
| | - Koki Kameno
- Department of Neurosurgery, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Hiroki Uchikawa
- Department of Neurosurgery, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
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Murthy SB, Zhang C, Shah S, Schwamm LH, Fonarow GC, Smith EE, Bhatt DL, Ziai WC, Kamel H, Sheth KN. Antithrombotic and Statin Prescription After Intracerebral Hemorrhage in the Get With The Guidelines-Stroke Registry. Stroke 2023; 54:2972-2980. [PMID: 37942641 PMCID: PMC10842167 DOI: 10.1161/strokeaha.123.043194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/17/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Survivors of intracerebral hemorrhage (ICH) face an increased risk of ischemic cardiovascular events. Current ICH guidelines do not provide definitive recommendations regarding the use of antithrombotic and statin therapies. We, therefore, sought to study practice patterns and factors associated with the use of such medications after ICH. METHODS This was a cross-sectional study of patients with ICH in the Get With The Guidelines-Stroke registry, between 2011 and 2021. Patients transferred to another hospital, those who died during hospitalization, and those with missing information on discharge medications were excluded. The study exposure was the proportion of patients who were prescribed antithrombotic or statin medications. We first ascertained the proportion of patients prescribed antithrombotic and lipid-lowering medications at discharge overall and across strata defined by pre-ICH use and history of previous ischemic vascular disease or atrial fibrillation. We then studied factors associated with the discharge prescription of these medications after ICH, using multiple logistic regressions. RESULTS In the final cohort, 50 416 (10.4%) of 486 586 patients with ICH were prescribed antiplatelet medications, 173 322 (35.1%) of 493 491 patients with ICH were prescribed statins, and 27 085 (5.4%) of 486 585 patients with ICH were prescribed anticoagulation therapy at discharge. The proportion of patients with antiplatelet therapy was 16.6% with pre-ICH use and 15.6% in those with previous ischemic vascular disease. Statins were prescribed to 41.1% and 43.7% of patients on previous lipid-lowering therapy and ischemic vascular disease, respectively. Anticoagulation therapy was restarted in 11.1% of patients. In logistic regression analysis, factors associated with higher use of antithrombotic or statin therapies after ICH were younger age, male sex, pre-ICH medication use, previous ischemic vascular disease, atrial fibrillation, lower admission National Institutes of Health Stroke Scale, longer length of stay, and favorable discharge outcome. CONCLUSIONS Few patients with ICH are prescribed antithrombotic or statin therapies at hospital discharge. Given the emerging association between ICH and future major cardiovascular events, trials examining the net benefit of antiplatelet and lipid-lowering therapy after ICH are warranted.
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Affiliation(s)
- Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
- Department of Neurology (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
- Department of Neurology (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
| | - Shreyansh Shah
- Department of Neurology, Duke University Hospital, Durham, NC (S.S.)
| | - Lee H Schwamm
- Department of Biomedical Informatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan University of California, Los Angeles Medical Center (G.C.F.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, AB, Canada (E.E.S.)
| | - Deepak L Bhatt
- Department of Cardiovascular Medicine, Icahn School of Medicine at Mount Sinai Health System, New York, NY (D.L.B.)
| | - Wendy C Ziai
- Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
- Department of Neurology (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, The Yale Center for Brain and Mind Health (K.N.S.), Yale School of Medicine, New Haven, CT
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Lv X, Shi W, Yuan K, Zhang Y, Cao W, Li C, Xu L, Wu L, Sun S, Hong F. Hourly Air Pollution Exposure and Emergency Hospital Admissions for Stroke: A Multicenter Case-Crossover Study. Stroke 2023; 54:3038-3045. [PMID: 37901948 DOI: 10.1161/strokeaha.123.044191] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Daily exposure to ambient air pollution is associated with stroke morbidity and mortality; however, the association between hourly exposure to air pollutants and risk of emergency hospital admissions for stroke and its subtypes remains relatively unexplored. METHODS We obtained hourly concentrations of fine particulate matter (PM2.5), respirable particulate matter (PM10), nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and carbon monoxide (CO) from the China National Environmental Monitoring Center. We conducted a time-stratified case-crossover study among 86 635 emergency hospital admissions for stroke across 10 hospitals in 3 cities (Jinhua, Hangzhou, and Zhoushan) in Zhejiang province, China, between January 1, 2016 and December 31, 2021. Using a conditional logistic regression combined with a distributed lag linear model, we estimated the association between hourly exposure to multiple air pollutants and risk of emergency hospital admissions for total stroke, ischemic stroke, hemorrhagic stroke, and undetermined type. RESULTS Hourly exposure to PM2.5, PM10, NO2, and SO2 was associated with an increased risk of hospital admissions for total stroke and ischemic stroke. The associations were most pronounced during the concurrent hour of exposure and lasted for ≈2 hours. We found that the risk was more pronounced among male patients or those aged <65 years old. CONCLUSIONS Our findings suggest that exposure to PM2.5, PM10, NO2, and SO2, but not CO and O3, is associated with emergency hospital admissions for total stroke or ischemic stroke shortly after exposure. Implementing targeted pollution emission reduction measures may have significant public health implications in controlling and reducing the burden of stroke.
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Affiliation(s)
- Xin Lv
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China (X.L., W.S., K.Y., Y.Z., S.S.)
| | - Wanying Shi
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China (X.L., W.S., K.Y., Y.Z., S.S.)
| | - Kun Yuan
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China (X.L., W.S., K.Y., Y.Z., S.S.)
| | - Yangchang Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China (X.L., W.S., K.Y., Y.Z., S.S.)
| | - Wangnan Cao
- Department of Social Medicine and Health Education, School of Public Health, Peking University, Beijing, China (W.C.)
| | - Chunrong Li
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China (C.L.)
| | - Lufei Xu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Human Resources, Peking University Cancer Hospital and Institute, China (L.X.)
| | - Lizhi Wu
- Department of Environmental Health, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China (L.W.)
| | - Shengzhi Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Capital Medical University, Beijing, China (X.L., W.S., K.Y., Y.Z., S.S.)
- The Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, China (S.S., F.H.)
| | - Feng Hong
- The Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, China (S.S., F.H.)
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Wolfe J, Siegler JE. Reader Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant. Neurology 2023; 101:1032-1033. [PMID: 38012014 PMCID: PMC10727211 DOI: 10.1212/wnl.0000000000208002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
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Lewis A, Ganesh A, Galetta S. Editors' Note: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant. Neurology 2023; 101:1032. [PMID: 38012016 PMCID: PMC10727220 DOI: 10.1212/wnl.0000000000208043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
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Ip YMB, Hong Leung TW. Author Response: Association of Alternative Anticoagulation Strategies and Outcomes in Patients With Ischemic Stroke While Taking a Direct Oral Anticoagulant. Neurology 2023; 101:1033. [PMID: 38012015 PMCID: PMC10727227 DOI: 10.1212/wnl.0000000000208004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
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Ryuzaki S, Kondo Y, Nakano M, Nakano M, Kajiyama T, Ito R, Kitagawa M, Sugawara M, Chiba T, Yoshino Y, Kobayashi Y. Antithrombotic Regimen After Percutaneous Left Atrial Appendage Closure - A Real-World Study. Circ J 2023; 87:1820-1827. [PMID: 37344404 DOI: 10.1253/circj.cj-22-0687] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
BACKGROUND Antithrombotic therapy after left atrial appendage closure (LAAC) in patients at high risk of bleeding remains controversial. We present real-world clinical outcomes of LAAC.Methods and Results: Data from 74 consecutive patients who received LAAC therapy between January 2020 and June 2022 were analyzed. Patients received 1 of 3 antithrombotic therapies according to the bleeding risk category or clinical event. Regimen 1 was based on a prior study, regimen 2 comprised a lower antiplatelet drug dose without dual antiplatelet therapy, and regimen 3 was antiplatelet drug administration for as long as possible to patients with uncontrollable bleeding who were required to stop anticoagulant drugs. Overall, 73 (98.6%) procedures were successful. Of them, 16 (21.9%) patients were selected for regimen 1, 46 (63.0%) for regimen 2, and 11 (15.1%) for regimen 3. Device-related thrombosis (13% vs. 0% vs. 0%, P=0.0257) only occurred with regimen 1. There was no difference in major bleeding event rates (6% vs. 2% vs. 9%, P=0.53). CONCLUSIONS The post-LAAC antithrombotic regimen was modified without major concerns.
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Affiliation(s)
- Satoko Ryuzaki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Miyo Nakano
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Masahiro Nakano
- Department of Advanced Cardiorhythm Therapeutics, Chiba University Graduate School of Medicine
| | - Takatsugu Kajiyama
- Department of Advanced Cardiorhythm Therapeutics, Chiba University Graduate School of Medicine
| | - Ryo Ito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Mari Kitagawa
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Masafumi Sugawara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Toshinori Chiba
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yutaka Yoshino
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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Yamauchi T, Okumura Y, Nagashima K, Watanabe R, Saito Y, Yokoyama K, Matsumoto N, Miyauchi K, Miyazaki S, Hayashi H, Matsue Y, Nishizaki Y, Nojiri S, Minamino T, Daida H. External Validation of the HELT-E 2S 2 Score in Japanese Patients With Nonvalvular Atrial Fibrillation - A Pooled Analysis of the RAFFINE and SAKURA Registries. Circ J 2023; 87:1777-1787. [PMID: 37558457 DOI: 10.1253/circj.cj-23-0318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
BACKGROUND The HELT-E2S2score, which assigns 1 point to Hypertension, Elderly aged 75-84 years, Low body mass index <18.5 kg/m2, and Type of atrial fibrillation (AF: persistent/permanent), and 2 points to Extreme Elderly aged ≥85 years and previous Stroke, has been proposed as a new risk stratification for strokes in Japanese AF patients, but has not yet undergone external validation.Methods and Results: We evaluated the prognostic performance of the HELT-E2S2score for stroke risk stratification using 2 large-scale registries in Japanese AF patients (n=7,020). During 23,241 person-years of follow-up (mean follow-up 1,208±450 days), 287 ischemic stroke events occurred. The C-statistic using the HELT-E2S2score was 0.661 (95% confidence interval [CI], 0.629-0.692), which was numerically higher than with the CHADS2score (0.644, 95% CI 0.613-0.675; P=0.15 vs. HELT-E2S2) or CHA2DS2-VASc score (0.650, 95% CI, 0.619-0.680; P=0.37 vs. HELT-E2S2). In the SAKURA AF Registry, the C-statistic of the HELT-E2S2score was consistently higher than the CHADS2and CHA2DS2-VASc scores across all 3 types of facilities comprising university hospitals, general hospitals, and clinics. However, in the RAFFINE Study, its superiority was only observed in general hospitals. CONCLUSIONS The HELT-E2S2score demonstrated potential value for risk stratification, particularly in a super-aged society such as Japan. However, its superiority over the CHADS2or CHA2DS2-VASc scores may vary across different hospital settings.
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Affiliation(s)
| | - Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | - Ryuta Watanabe
- Division of Cardiology, Nihon University Itabashi Hospital
| | - Yuki Saito
- Division of Cardiology, Nihon University Itabashi Hospital
| | | | | | - Katsumi Miyauchi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Sakiko Miyazaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Hidemori Hayashi
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Yuji Nishizaki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
- Medical Technology Innovation Center, Juntendo University
- Division of Medical Education, Juntendo University School of Medicine
| | - Shuko Nojiri
- Medical Technology Innovation Center, Juntendo University
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
- Japan Agency for Medical Research and Development-Core Research for Evolutionary Medical Science and Technology (AMED-CREST), Japan Agency for Medical Research and Development
| | - Hiroyuki Daida
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
- Faculty of Health Science, Juntendo University
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McKinnie CM, Effron MB. More Potent Antiplatelet Therapy in Acute Coronary Syndrome Patients With Prior Stroke: Proceed With Caution? Mayo Clin Proc 2023; 98:1590-1592. [PMID: 37923516 DOI: 10.1016/j.mayocp.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/22/2023] [Indexed: 11/07/2023]
Affiliation(s)
| | - Mark B Effron
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; University of Queensland-Ochsner Clinical School, New Orleans, LA.
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Bell DSH, Jerkins T. In praise of pioglitazone: An economically efficacious therapy for type 2 diabetes and other manifestations of the metabolic syndrome. Diabetes Obes Metab 2023; 25:3093-3102. [PMID: 37534526 DOI: 10.1111/dom.15222] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/26/2023] [Accepted: 07/06/2023] [Indexed: 08/04/2023]
Abstract
Pioglitazone improves glycaemic control, not only by lowering insulin resistance, but also by improving beta cell function. Because of the improved beta cell function the glycaemic control that occurs with pioglitazone is prolonged. Pioglitazone has positive effects not only on cardiac risk factors and surrogate measures of cardiovascular disease, it also lowers the incidence of cardiac events in patients with diabetes. The recurrence of transient ischaemic attack and ischaemic stroke is also reduced in non-diabetic, insulin-resistant subjects. Utilized at preclinical stages (but not later) of heart failure, pioglitazone improves diastolic function and avoids progression to heart failure. Pioglitazone, through suppression of atrial remodelling, also decreases the incidence of atrial fibrillation. The manifestations of diseases associated with insulin resistance (non-alcoholic steatohepatitis and polycystic ovary disease) are also improved with pioglitazone. Pioglitazone may possibly improve psoriasis and other dermopathies. Pioglitazone is therefore an inexpensive and efficacious drug for the insulin-resistant subject with diabetes that is underutilized because of biases that have evolved from the toxicities of other thiazolidinediones.
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Affiliation(s)
- David S H Bell
- Department of Endocrinology, Southside Endocrinology, Irondale, Alabama, USA
| | - Terri Jerkins
- Department of Endocrinology, Lipscomb University, Nashville, Tennessee, USA
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Grimm MO, Esteban E, Barthélémy P, Schmidinger M, Busch J, Valderrama BP, Charnley N, Schmitz M, Schumacher U, Leucht K, Foller S, Baretton G, Duran I, de Velasco G, Priou F, Maroto P, Albiges L. Tailored immunotherapy approach with nivolumab with or without nivolumab plus ipilimumab as immunotherapeutic boost in patients with metastatic renal cell carcinoma (TITAN-RCC): a multicentre, single-arm, phase 2 trial. Lancet Oncol 2023; 24:1252-1265. [PMID: 37844597 DOI: 10.1016/s1470-2045(23)00449-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Nivolumab plus ipilimumab is approved as first-line regimen for intermediate-risk or poor-risk metastatic renal cell carcinoma, and nivolumab monotherapy as second-line therapy for all risk groups. We aimed to examine the efficacy and safety of nivolumab monotherapy and nivolumab plus ipilimumab combination as an immunotherapeutic boost after no response to nivolumab monotherapy in patients with intermediate-risk and poor-risk clear-cell metastatic renal cell carcinoma. METHODS TITAN-RCC is a multicentre, single-arm, phase 2 trial, done at 28 hospitals and cancer centres across Europe (Austria, Belgium, Czech Republic, France, Germany, Italy, Spain, and the UK). Adults (aged ≥18 years) with histologically confirmed intermediate-risk or poor-risk clear-cell metastatic renal cell carcinoma who were formerly untreated (first-line population) or pretreated with one previous systemic therapy (anti-angiogenic or temsirolimus; second-line population) were eligible. Patients had to have a Karnofsky Performance Status score of at least 70 and measurable disease per Response Evaluation Criteria in Solid Tumours (version 1.1). Patients started with intravenous nivolumab 240 mg once every 2 weeks. On early progressive disease (week 8) or non-response at week 16, patients received two or four doses of intravenous nivolumab (3 mg/kg) and ipilimumab (1 mg/kg) boosts (once every 3 weeks), whereas responders continued with intravenous nivolumab (240 mg, once every 2 weeks), but could receive two to four boost doses of nivolumab plus ipilimumab for subsequent progressive disease. The primary endpoint was confirmed investigator-assessed objective response rate in the full analysis set, which included all patients who received at least one dose of study medication; safety was also assessed in this population. An objective response rate of more than 25% was required to reject the null hypothesis and show improvement, on the basis of results from the pivotal phase 3 CheckMate-025 trial. This study is registered with ClinicalTrials.gov, NCT02917772, and is complete. FINDINGS Between Oct 28, 2016, and Nov 30, 2018, 207 patients were enrolled and all received nivolumab induction (109 patients in the first-line group; 98 patients in the second-line group). 60 (29%) of 207 patients were female and 147 (71%) were male. 147 (71%) of 207 patients had intermediate-risk metastatic renal cell carcinoma and 51 (25%) had poor-risk disease. After median follow-up of 27·6 months (IQR 10·5-34·8), 39 (36%, 90% CI 28-44; p=0·0080) of 109 patients in the first-line group and 31 (32%, 24-40; p=0·083) of 98 patients in the second-line group had a confirmed objective response for nivolumab with and without nivolumab plus ipilimumab. Confirmed response to nivolumab at week 8 or 16 was observed in 31 (28%) of 109 patients in the first-line group and 18 (18%) of 98 patients in the second-line group. The most frequent grade 3-4 treatment-related adverse events (reported in ≥5% of patients) were increased lipase (15 [7%] of 207 patients), colitis (13 [6%]), and diarrhoea (13 [6%]). Three deaths were reported that were deemed to be treatment-related: one due to possible ischaemic stroke, one due to respiratory failure, and one due to pneumonia. INTERPRETATION In treatment-naive patients, nivolumab induction with or without nivolumab plus ipilimumab boosts significantly improved the objective response rate compared with that reported for nivolumab monotherapy in the CheckMate-025 trial. However, overall efficacy seemed inferior when compared with approved upfront nivolumab plus ipilimumab. For second-line treatment, nivolumab plus ipilimumab could be a rescue strategy on progression with approved nivolumab monotherapy. FUNDING Bristol Myers Squibb.
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Affiliation(s)
- Marc-Oliver Grimm
- Department of Urology, Jena University Hospital, Friedrich-Schiller University, Jena, Germany.
| | - Emilio Esteban
- Department of Medical Oncology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Philippe Barthélémy
- Department of Medical Oncology, Institut de Cancérologie Strasbourg Europe, Strasbourg, France
| | | | - Jonas Busch
- Department of Urology, University Hospital Charité Berlin, Berlin, Germany
| | - Begoña P Valderrama
- Department of Medical Oncology, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Marc Schmitz
- Institute of Immunology, Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Dresden, Germany; National Center for Tumor Diseases, Dresden, Germany; German Cancer Consortium, Dresden, Germany; German Cancer Research Center, Heidelberg, Germany
| | - Ulrike Schumacher
- Center for Clinical Studies, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Katharina Leucht
- Department of Urology, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Susan Foller
- Department of Urology, Jena University Hospital, Friedrich-Schiller University, Jena, Germany
| | - Gustavo Baretton
- Institute of Pathology, Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Ignacio Duran
- Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla, Santander, Spain
| | | | - Frank Priou
- Centre Hospitalier Départemental Vendee, Hopital Les Oudairies, La Roche Sur Yon, France
| | - Pablo Maroto
- Department of Medical Oncology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Laurence Albiges
- Department of Cancer Medicine, Gustave Roussy, University of Paris Saclay, Villejuif, France
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Liu Q, He S, Lin Y, Tan S, Zhou J, Yang J. Prior statin use in acute ischemic stroke patients with mechanical thrombectomy: A prospective cohort study in China. Clin Neurol Neurosurg 2023; 234:107988. [PMID: 37769498 DOI: 10.1016/j.clineuro.2023.107988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/16/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy (MT) has been proven to be effective for selected patients with acute ischemic stroke (AIS). However, conflicting findings have suggested the association between prior statin use and outcomes in AIS patients with MT, with a particular lack of information in the Chinese population. Via a prospective cohort study, we explored the safety and efficacy of prior statin use in Chinese AIS patients with MT. METHODS We consecutively enrolled AIS patients treated with MT from the First Affiliated Hospital of Chengdu Medical College and Nanjing First Hospital between June 2015 and June 2022 who were under prior statin use or not. Safety and efficacy outcomes were prospectively followed. The primary outcomes were defined as 90-day favorable outcomes (mRS score 0-2). Secondary outcomes included successful recanalization (TICI≥2b), early neurological improvement (decrease of National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points at 24 h), symptomatic intracerebral hemorrhage (sICH), and death at 90 days. RESULTS We enrolled 334 patients in total, 50 of whom (15.0%) undertaken statins administration before AIS. 117 (35.0%) patients had favorable outcomes at 90 days, 288 (86.2%) patients had successful recanalization, 108 (32.3%) patients achieved early neurological improvement, 41 (12.3%) patients had sICH and 73 (21.9%) patients died within 90 days. The 90-day favorable outcomes were not significantly different (adjusted OR=0.853, 95% CI 0.449-1.620, P = 0.626) between prior statins use group and no statins use group. There was no significant difference in recanalization (adjusted OR=1.466, 95% CI 0.536-4.009, P = 0.456), early neurological improvement (adjusted OR=1.568, 95% CI 0.811-3.032, P = 0.181), sICH (adjusted OR=0.850, 95% CI 0.325-2.224, P = 0.741), ICH (adjusted OR=1.029, 95% CI 0.479-2.490, P = 0.942), and 90-day mortality (adjusted OR=0.381, 95% CI 0.091-1.586, P = 0.185) between the two groups. CONCLUSIONS Prior statin use may be safe for Chinese AIS patients with MT, but its efficacy warrants further research.
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Affiliation(s)
- Quan Liu
- Department of Emergency, Chengdu Second People's Hospital, Chengdu, China
| | - Song He
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Yapeng Lin
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Song Tan
- Department of Neurology, Sichuan Provincial People's Hospital, School of Medicine,University of Electronic Science and Technology of China, Chengdu, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
| | - Jie Yang
- Department of Neurology, Sichuan Provincial People's Hospital, School of Medicine,University of Electronic Science and Technology of China, Chengdu, China.
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Zheng L, Jing X, Zhang X, Zhong C, Qiu D, Yan Q, Gao Z. Mediation analysis of urinary metals and stroke risk by inflammatory markers. Chemosphere 2023; 341:140084. [PMID: 37689152 DOI: 10.1016/j.chemosphere.2023.140084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/02/2023] [Accepted: 09/04/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND The association between metals and stroke has been reported, but the mediating role of inflammation between metals and stroke remains unclear. METHODS We included 9326 adults from the National Health and Nutrition Examination Survey in this study. Through least absolute selection and shrinkage operator (LASSO) regression, weighted quantile sum (WQS) regression, logistic regression, linear regression, restricted cubic spline analysis, and mediation analysis, we explored the association between metals and stroke, as well as the association between metals and inflammatory indicators, and further evaluated the mediating effect of inflammatory indicators on the association between selected metals and stroke risk. RESULTS The results of the present study suggested positive associations between mixed metals, cadmium and uranium and stroke risk. There is a positive correlation and dose‒response relationship between cadmium and C-reactive protein (CRP). Moreover, CRP mediates 10.1% of the association between cadmium and stroke. CONCLUSIONS At the epidemiological level, CRP mediates the association between cadmium and stroke risk, suggesting that inflammation may be a potential mechanism for metal-induced stroke.
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Affiliation(s)
- Lei Zheng
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Xi Jing
- The First School of Clinical Medicine, Nanjing Medical University, Nanjing, People's Republic of China
| | - Xianli Zhang
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Chunyu Zhong
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Dezhi Qiu
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Qing Yan
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, People's Republic of China.
| | - Zhe Gao
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, People's Republic of China.
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Gaist D, García Rodríguez LA, Hallas J, Hald SM, Möller S, Høyer BB, Selim M, Goldstein LB. Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage. Neurology 2023; 101:e1793-e1806. [PMID: 37648526 PMCID: PMC10634647 DOI: 10.1212/wnl.0000000000207792] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/12/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Survivors of spontaneous intracerebral hemorrhage (ICH) may have indications for statin therapy. The effect of statins on the risk of subsequent hemorrhagic and ischemic stroke (IS) in this setting is uncertain. We sought to determine the risk of any stroke (ischemic stroke, IS or recurrent ICH), IS, and recurrent ICH associated with statin use among ICH survivors. METHODS Using the Danish Stroke Registry, we identified all patients admitted to a hospital in Denmark (population 5.8 million) with a first-ever ICH between January 2003 and December 2021 who were aged 50 years or older and survived >30 days. Patients were followed up until August 2022. Within this cohort, we conducted 3 nested case-control analyses for any stroke, IS, and recurrent ICH. We matched controls for age, sex, time since first-ever ICH, and history of prior IS. The primary exposure was statin use before or on the date of subsequent stroke or the equivalent date in matched controls. Using conditional logistic regression, we calculated adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) for any stroke, IS, and recurrent ICH associated with statin exposure. RESULTS We identified 1,959 patients with any stroke (women 45.3%; mean [SD] age, 72.6 [9.7] years) who were matched to 7,400 controls; 1,073 patients with IS (women 42.0%; mean [SD] age, 72.4 [10.0] years) who were matched to 4,035 controls and 984 patients with recurrent ICH (women 48.7%; mean [SD] age, 72.7 [9.2] years) who were matched to 3,755 controls. Statin exposure was associated with a lower risk of both any stroke (cases 38.6%, controls 41.1%; aOR 0.88; 95% CI 0.78-0.99) and IS (cases 39.8%, controls 41.8%, aOR 0.79; 95% CI 0.67-0.92), but was not associated with recurrent ICH risk (cases 39.1%, controls 40.8%, aOR 1.05; 95% CI 0.88-1.24). DISCUSSION Exposure to statins was not associated with an increased risk of recurrent ICH but was associated with a lower risk of any stroke, largely due to a lower risk of IS. Confirmation of these findings in randomized trials is needed. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that statin use in patients with ICH is associated with a lower risk of any stroke and IS and not with increased risk of recurrent ICH.
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Affiliation(s)
- David Gaist
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington.
| | - Luis Alberto García Rodríguez
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Jesper Hallas
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Stine Munk Hald
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Sören Möller
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Birgit Bjerre Høyer
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Magdy Selim
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
| | - Larry B Goldstein
- From the Research Unit for Neurology (D.G., S.M.H.), Odense University Hospital; University of Southern Denmark, Odense, Denmark; Centro Español Investigación Farmacoepidemiológica (L.A.G.R.), Madrid, Spain; Department of Clinical Pharmacology (J.H.), Pharmacy and Environmental Medicine, University of Southern Denmark; Open Patient Data Explorative Network (OPEN) (S.M.), Odense University Hospital; Odense Patient Data Explorative Network (OPEN) (B.B.H.), Odense University Hospital, Denmark; Beth Israel Deaconess Medical Center (M.S.), Harvard Medical School; and Department of Neurology and Kentucky Neuroscience Institute (L.B.G.), University of Kentucky, Lexington
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Ganesh A, Galetta S. Editors' Note: Oral Anticoagulants and the Risk of Dementia in Patients With Nonvalvular Atrial Fibrillation: A Population-Based Cohort Study. Neurology 2023; 101:728. [PMID: 37845049 PMCID: PMC10585667 DOI: 10.1212/wnl.0000000000207888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
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Abstract
BACKGROUND Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from porcine brain, which has potential neuroprotective properties. It is widely used in the treatment of acute ischaemic stroke in Russia, Eastern Europe, China, and other Asian and post-Soviet countries. This is an update of a review first published in 2010 and last updated in 2020. OBJECTIVES To assess the benefits and harms of Cerebrolysin or Cerebrolysin-like agents for treating acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, Web of Science Core Collection, with Science Citation Index, and LILACS in May 2022 and a number of Russian databases in June 2022. We also searched reference lists, ongoing trials registers, and conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing Cerebrolysin or Cerebrolysin-like agents started within 48 hours of stroke onset and continued for any length of time, with placebo or no treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Three review authors independently applied the inclusion criteria, assessed trial quality and risk of bias, extracted data, and applied GRADE criteria to the evidence. MAIN RESULTS Seven RCTs (1773 participants) met the inclusion criteria of the review. In this update we added one RCT of Cerebrolysin-like agent Cortexin, which contributed 272 participants. We used the same approach for risk of bias assessment that was re-evaluated for the previous update: we added consideration of the public availability of study protocols and reported outcomes to the selective outcome reporting judgement, through identification, examination, and evaluation of study protocols. For the Cerebrolysin studies, we judged the risk of bias for selective outcome reporting to be unclear across all studies; for blinding of participants and personnel to be low in three studies and unclear in the remaining four; and for blinding of outcome assessors to be low in three studies and unclear in four studies. We judged the risk of bias for generation of allocation sequence to be low in one study and unclear in the remaining six studies; for allocation concealment to be low in one study and unclear in six studies; and for incomplete outcome data to be low in three studies and high in the remaining four studies. The manufacturer of Cerebrolysin supported three multicentre studies, either totally, or by providing Cerebrolysin and placebo, randomisation codes, research grants, or statisticians. We judged two studies to be at high risk of other bias and the remaining five studies to be at unclear risk of other bias. We judged the study of Cortexin to be at low risk of bias for incomplete outcome data and at unclear risk of bias for all other domains. All-cause death: Cerebrolysin or Cortexin probably result in little to no difference in all-cause death (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.65 to 1.41; 6 trials, 1689 participants; moderate-certainty evidence). None of the included studies reported on poor functional outcome, defined as death or dependence at the end of the follow-up period, early death (within two weeks of stroke onset), quality of life, or time to restoration of capacity for work. Only one study clearly reported on the cause of death: cerebral infarct (four in the Cerebrolysin and two in the placebo group), heart failure (two in the Cerebrolysin and one in the placebo group), pulmonary embolism (two in the placebo group), and pneumonia (one in the placebo group). Non-death attrition (secondary outcome): Cerebrolysin or similar peptide mixtures may result in little to no difference in non-death attrition, but the evidence is very uncertain, with a considerable level of heterogeneity (RR 0.72, 95% CI 0.38 to 1.39; 6 trials, 1689 participants; very low-certainty evidence). Serious adverse events (SAEs): Cerebrolysin probably results in little to no difference in the total number of people with SAEs (RR 1.16, 95% CI 0.81 to 1.66; 3 trials, 1335 participants; moderate-certainty evidence). This comprised fatal SAEs (RR 0.90, 95% CI 0.59 to 1.38; 3 trials, 1335 participants; moderate-certainty evidence) and an increase in the total number of people with non-fatal SAEs (RR 2.39, 95% CI 1.10 to 5.23; 3 trials, 1335 participants; moderate-certainty evidence). In the subgroup of dosing schedule 30 mL for 10 days (cumulative dose 300 mL), the increase was more prominent (RR 2.87, 95% CI 1.24 to 6.69; 2 trials, 1189 participants). Total number of people with adverse events: Cerebrolysin or similar peptide mixtures may result in little to no difference in the total number of people with adverse events (RR 1.03, 95% CI 0.92 to 1.14; 4 trials, 1607 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Moderate-certainty evidence indicates that Cerebrolysin or Cerebrolysin-like peptide mixtures derived from cattle brain probably have no beneficial effect on preventing all-cause death in acute ischaemic stroke. Moderate-certainty evidence suggests that Cerebrolysin probably has no beneficial effect on the total number of people with serious adverse events. Moderate-certainty evidence also indicates a potential increase in non-fatal serious adverse events with Cerebrolysin use.
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Affiliation(s)
- Liliya Eugenevna Ziganshina
- Centre for Knowledge Translation, Federal State Budgetary Educational Institution of Continuing Professional Education "Russian Medical Academy of Continuing Professional Education", The Ministry of Health of the Russian Federation (RMANPO), Moscow, Russian Federation
- Department of Pharmacology, Kazan State Medical University (KSMU), The Ministry of Health of the Russian Federation, Kazan, Russian Federation
- Department of General and Clinical Pharmacology, RUDN University named after Patrice Lumumba, Moscow, Russian Federation
| | - Tatyana Abakumova
- Department of Biochemistry, Biotechnology and Pharmacology, Kazan (Volga region) Federal University, Kazan, Russian Federation
| | - Dilyara Nurkhametova
- Centre for Knowledge Translation, Federal State Budgetary Educational Institution of Continuing Professional Education "Russian Medical Academy of Continuing Professional Education", The Ministry of Health of the Russian Federation (RMANPO), Moscow, Russian Federation
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Soliman A, Habibi S, Dasanu CA. Unusual stroke-like symptoms with oxaliplatin use. J Oncol Pharm Pract 2023; 29:1766-1769. [PMID: 37323007 DOI: 10.1177/10781552231181525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Oxaliplatin has become the mainstay of treatment for many cancers, but its use can be accompanied by unusual side effects. CASE REPORT We describe herein a 74-year-old patient with pancreatic cancer who developed severe motor weakness affecting lower extremities after starting treatment with oxaliplatin on three separate occasions. Our patient also experienced slurred speech, with decreased ability to phonate and word-finding difficulty. Brain imaging studies did not suggest recent brain ischemia, and the symptoms resolved within 15-20 h. MANAGEMENT AND OUTCOME Oxaliplatin had to be discontinued due to suboptimal tolerance and a short-lived clinical response. After discontinuation of oxaliplatin, she did not experience any more similar symptoms. A score of 9 on the Naranjo nomogram supported a definite causality relationship between oxaliplatin and the observed neurologic toxicity. DISCUSSION Rare reports of stroke-like events have previously been described with oxaliplatin. While the exact mechanism of these phenomena is not known, alterations in neuronal sodium channels might be involved. Clinicians, pharmacists, and patients need to be aware of these rare but important side effects of oxaliplatin. Nonetheless, work-up for a cerebrovascular accident is still warranted as hypercoagulability related to malignancy can also predispose the patients to strokes.
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Affiliation(s)
- Abram Soliman
- Department of Internal Medicine, Eisenhower Health, Rancho Mirage, CA, USA
| | - Shaghayegh Habibi
- Department of Internal Medicine, Eisenhower Health, Rancho Mirage, CA, USA
| | - Constantin A Dasanu
- Lucy Curci Cancer Center, Eisenhower Health, Rancho Mirage, CA, USA
- Department of Medical Oncology and Hematology, University of California in San Diego Health System, San Diego, CA, USA
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Yang R, Wu J, Yu H, Wang S, Chen H, Wang M, Qin X, Wu T, Wu Y, Hu Y. Is statin therapy after ischaemic stroke associated with increased intracerebral hemorrhage? The association may be dependent on intensity of statin therapy. Int J Stroke 2023; 18:948-956. [PMID: 37070670 DOI: 10.1177/17474930231172623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
BACKGROUND There has been concern that statin therapy may be associated with an increased risk of intracerebral hemorrhage (ICH). We investigated whether the intensity and type of statin therapy instituted after ischemic stroke (IS) were associated with risk of future ICH in a region of northern China with a high incidence of stroke. METHODS Newly diagnosed IS patients who were not treated with lipid-lowering drugs in the Beijing Employee Medical Claims Data database from 2010 to 2017 were included. The primary exposure variable was any statin prescription within 1 month of the first documented stroke diagnosis. High-intensity statin therapy was defined as atorvastatin ⩾ 80 mg, simvastatin ⩾ 80 mg, pravastatin ⩾ 40 mg, and rosuvastatin ⩾ 20 mg per day or equivalent combination. An adjusted Cox proportional hazards model was used to estimate the hazard ratio (HR) for ICH during follow-up in groups exposed and not exposed to statins. RESULTS Of 62,252 participants with IS and 628 ICH readmissions were recorded during a median follow-up of 3.17 years. The risk of ICH among statin users (N = 43,434) was similar to that among nonusers (N = 18,818) with an adjusted HR and 95% confidence interval (CI) of 0.86 (0.73, 1.02). Compared with non-statin therapy, patients with low/moderate-intensity therapy had a lower risk of ICH (0.62: 0.52, 0.75), while patients with high-intensity therapy had a substantially higher risk (2.12: 1.72, 2.62). For patients with different types of statin therapy, adherence to rosuvastatin had the lowest risk of ICH compared to adherence to atorvastatin (0.46: 0.34, 0.63), followed by simvastatin (0.60: 0.45, 0.81). CONCLUSION In patients with IS, any statin therapy was not associated with an increased risk of ICH. However there appeared to be differential risk according to the dose of statin with high-intensity statin therapy being associated with an increased risk of ICH, while low/moderate-intensity therapy was associated with a lower risk.
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Affiliation(s)
- Ruotong Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Ministry of Education, Peking University, Beijing, China
| | - Junhui Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Ministry of Education, Peking University, Beijing, China
- School of Nursing, Peking University, Beijing, China
| | - Huan Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Ministry of Education, Peking University, Beijing, China
| | - Siyue Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Ministry of Education, Peking University, Beijing, China
| | - Hongbo Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Ministry of Education, Peking University, Beijing, China
- School of Nursing, Peking University, Beijing, China
| | - Mengying Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Ministry of Education, Peking University, Beijing, China
| | - Xueying Qin
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Ministry of Education, Peking University, Beijing, China
| | - Tao Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Ministry of Education, Peking University, Beijing, China
| | - Yiqun Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Ministry of Education, Peking University, Beijing, China
| | - Yonghua Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Medical Informatics Center, Peking University, Beijing, China
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Ayele HT, Reynier P, Azoulay L, Platt RW, Benayoun S, Filion KB. The Cardiovascular Safety of Five-Alpha-Reductase Inhibitors Among Men with Benign Prostatic Hyperplasia: A Population-Based Cohort Study. Am J Med 2023; 136:1000-1010.e7. [PMID: 37481022 DOI: 10.1016/j.amjmed.2023.06.021] [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: 11/09/2022] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Five-alpha reductase inhibitors (5αRIs) are used to treat benign prostatic hyperplasia (BPH). However, the cardiovascular effects of 5αRIs remain poorly understood. The study objective was to compare the rate of hospitalization for heart failure among men with BPH prescribed 5αRIs to that of men with BPH not prescribed BPH medications. METHODS Using the Clinical Practice Research Datalink linked with hospitalization and vital statistics data, we conducted a population-based cohort study among patients newly diagnosed with BPH. We defined exposure as the current use of 5αRIs, current use of alpha-blockers, and no current use of BPH medications in a time-varying approach. The primary endpoint was hospitalization for heart failure, and secondary endpoints were myocardial infarction, stroke, and cardiovascular death. We used time-dependent Cox-proportional hazards models to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS Our cohort included 94,440 men with incident BPH. A total of 3893 hospitalizations for heart failure occurred over 527,660 person-years of follow-up (incidence rate 7.38; 95% CI, 7.15-7.61, per 1000 person-years). Compared with no current use of BPH medications, current use of 5αRIs was not associated with an increased risk of hospitalization for heart failure (HR 0.94; 95% CI, 0.86-1.03), myocardial infarction (HR 0.92; 95% CI, 0.81-1.05), stroke (HR 0.94; 95% CI, 0.85-1.05), or cardiovascular death (HR 0.89; 95% CI, 0.80-0.99). CONCLUSIONS The use of 5αRIs was not associated with an increased risk of hospitalization for heart failure, myocardial infarction, stroke, or cardiovascular death compared with non-use.
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Affiliation(s)
- Henok Tadesse Ayele
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Serge Benayoun
- Department of Surgery, Urology Unit, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics, Occupational Health, McGill University, Montreal, Quebec, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Medicine, McGill University, Montreal, Quebec, Canada.
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Del Brutto VJ, Yin R, Gardener H, Ying H, Gutierrez CM, Jameson A, Rose DZ, Alkhachroum A, Foster D, Dong C, Ancheta S, Sur NB, Perue GG, Rundek T, Asdaghi N, Sacco RL, Romano JG. Determinants and Temporal Trends of Dual Antiplatelet Therapy After Mild Noncardioembolic Stroke. Stroke 2023; 54:2552-2561. [PMID: 37675611 PMCID: PMC10530464 DOI: 10.1161/strokeaha.123.043769] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Short-term dual antiplatelet therapy (DAPT) reduces early stroke recurrence after mild noncardioembolic ischemic stroke (NCIS). We aim to evaluate temporal trends and determinants of DAPT prescription after mild NCIS in the Florida Stroke Registry, a statewide registry across Get With The Guidelines-Stroke participating hospitals. METHODS In this cross-sectional analysis of a cohort study, we included patients with mild NCIS (National Institutes of Health Stroke Scale score ≤3) who were potentially eligible for DAPT across 168 Florida Stroke Registry participating hospitals between January 2010 and September 2022. Using antiplatelet prescription as the dependent variable (DAPT versus single antiplatelet therapy), we fit logistic regression models adjusted for patient-related factors, hospital-related factors, clinical presentation, vascular risk factors, and ischemic stroke subtype, to obtain adjusted odds ratios (aORs) with 95% CIs. RESULTS From 283 264 Florida Stroke Registry ischemic stroke patients during the study period, 109 655 NCIS were considered eligible. Among these, 37 058 patients with National Institutes of Health Stroke Scale score >3 were excluded, resulting in a sample of 72 597 mild NCIS (mean age 68±14 years; female 47.3%). Overall, 24 693 (34.0%) patients with mild NCIS were discharged on DAPT and 47 904 (66.0%) on single antiplatelet therapy. DAPT prescription increased from 25.7% in 2010 to 52.8% in 2022 (β/year 2.5% [95% CI, 1.5%-3.4%]). Factors associated with DAPT prescription were premorbid antiplatelet therapy (aOR, 4.66 [95% CI, 2.20-9.88]), large-artery atherosclerosis (aOR, 1.68 [95% CI, 1.43-1.97]), diabetes (aOR, 1.29 [95% CI, 1.13-1.47]), and hyperlipidemia (aOR, 1.24 [95% CI, 1.10-1.39]), whereas female sex (aOR, 0.83 [95% CI, 0.75-0.93]), being non-Hispanic Black patients (compared with non-Hispanic White patients; aOR, 0.78 [95% CI, 0.68-0.90]), admission to a Thrombectomy-capable Stroke Center (compared with Comprehensive Stroke Center; aOR, 0.78 [95% CI, 0.66-0.92]), time-to-presentation 1 to 7 days from last seen well (compared with <24 h; aOR, 0.86 [95% CI, 0.76-0.96]), and small-vessel disease stroke (aOR, 0.81 [95% CI, 0.72-0.94]) were associated with not receiving DAPT at discharge. CONCLUSIONS Despite a temporal trend increase in DAPT prescription after mild NCIS, we found substantial underutilization of evidence-based DAPT associated with significant disparities in stroke care.
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Affiliation(s)
- Victor J. Del Brutto
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - Ruijie Yin
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - Hannah Gardener
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - Hao Ying
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | | | - Angus Jameson
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - David Z. Rose
- University of South Florida Morsani College of Medicine, Tampa, FL
| | - Ayham Alkhachroum
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | | | - Chuanhui Dong
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | | | - Nicole B. Sur
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - Gillian Gordon Perue
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - Tatjana Rundek
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - Negar Asdaghi
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - Ralph L. Sacco
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
| | - Jose G. Romano
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL
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Checkouri T, Gerschenfeld G, Seners P, Yger M, Ben Hassen W, Chausson N, Olindo S, Caroff J, Marnat G, Clarençon F, Baron JC, Turc G, Alamowitch S. Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase. Stroke 2023; 54:2491-2499. [PMID: 37622385 DOI: 10.1161/strokeaha.123.042691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) with alteplase or tenecteplase before mechanical thrombectomy is the recommended treatment for large-vessel occlusion acute ischemic stroke. There are divergent data on whether these agents differ in terms of early recanalization (ER) rates before mechanical thrombectomy, and little data on their potential differences stratified by ER predictors such as IVT to ER evaluation (IVT-to-EReval) time, occlusion site and thrombus length. METHODS We retrospectively compared the likelihood of ER after IVT with tenecteplase or alteplase in anterior circulation large-vessel occlusion acute ischemic stroke patients from the PREDICT-RECANAL (alteplase) and Tenecteplase Treatment in Ischemic Stroke (tenecteplase) French multicenter registries. ER was defined as a modified Thrombolysis in Cerebral Infarction score 2b-3 on the first angiographic run, or noninvasive vascular imaging in patients with early neurological improvement. Analyses were based on propensity score overlap weighting (leading to exact balance in patient history, stroke characteristics, and initial management between groups) and confirmed with adjusted logistic regression (sensitivity analysis). A stratified analysis based on pre-established ER predictors (IVT-to-EReval time, occlusion site, and thrombus length) was conducted. RESULTS Overall, 1865 patients were included. ER occurred in 156/787 (19.8%) and 199/1078 (18.5%) patients treated with tenecteplase or alteplase, respectively (odds ratio, 1.09 [95% CI, 0.83-1.44]; P=0.52). A differential effect of tenecteplase versus alteplase on the probability of ER according to thrombus length was observed (Pinteraction=0.003), with tenecteplase being associated with higher odds of ER in thrombi >10 mm (odds ratio, 2.43 [95% CI, 1.02-5.81]; P=0.04). There was no differential effect of tenecteplase versus alteplase on the likelihood of ER according to the IVT-to-EReval time (Pinteraction=0.40) or occlusion site (Pinteraction=0.80). CONCLUSIONS Both thrombolytics achieved ER in one-fifth of patients with large-vessel occlusion acute ischemic stroke without significant interaction with IVT-to-EReval time and occlusion site. Compared with alteplase, tenecteplase was associated with a 2-fold higher likelihood of ER in larger thrombi.
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Affiliation(s)
- Thomas Checkouri
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Gaspard Gerschenfeld
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Pierre Seners
- Service de Neurologie, GHU Paris Psychiatrie et Neurosciences, France (P.S.)
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neurologie, Hôpital Fondation Rothschild, Paris, France (P.S.)
| | - Marion Yger
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Wagih Ben Hassen
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neuroradiologie, GHU Paris Psychiatrie et Neurosciences, France (W.B.H.)
| | - Nicolas Chausson
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neurologie, Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes (N.C.)
| | | | - Jildaz Caroff
- AP-HP, Service de Neuroradiologie interventionnelle (NEURI), Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France (J.C.)
| | - Gaultier Marnat
- Service de Neuroradiologie diagnostique et interventionnelle (G.M.), France
- CHU de Bordeaux, France (G.M.)
| | - Frédéric Clarençon
- AP-HP, Service de Neuroradiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France (F.C.)
| | - Jean-Claude Baron
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
| | - Guillaume Turc
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
| | - Sonia Alamowitch
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
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Salamatullah HK, Bashrahil B, Alghamdi AM, Alsharm FS, Alkulli OA, Alzahrani Z, Alkhiri A, Alghamdi S, Makkawi S. Efficacy and safety of tenecteplase in comparison to alteplase in acute ischemic stroke: A systematic review and meta-analysis of randomized controlled trials. Clin Neurol Neurosurg 2023; 233:107961. [PMID: 37713743 DOI: 10.1016/j.clineuro.2023.107961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/01/2023] [Accepted: 09/03/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Alteplase is the standard medical therapy for acute ischemic stroke (AIS) patients who present within 4.5 h of symptom onset. Tenecteplase is a modified alteplase variant with pharmacological and practical advantages over alteplase. Many trials have investigated the efficacy and safety of tenecteplase against alteplase. This systematic review and meta-analysis aimed to compare the efficacy and safety of tenecteplase to alteplase across randomized controlled trials. METHOD Medline, Embase, and Cochrane CENTRAL were used to search the related articles until February 20, 2023. Randomized controlled trials (RCTs) that compared the effectiveness and safety of tenecteplase against alteplase for AIS patients were included. Screening, risk of bias assessment, and data extraction were performed following PRISMA guidelines. Data were pooled using a random-effect model. RESULTS Ten RCTs were included, with a total of 5123 patients. There was no significant difference between the two interventions in modified rankin scale 0-1 (mRS 0-1) (RR= 1.04, 95% CI [0.99-1.10], P = 0.11, I2 =0%) and early neurological improvement (RR= 1.06, 95% CI [0.97-1.15], P = 0.21, I2 =35). There was no difference in the rates of symptomatic intracranial hemorrhage (RR= 1.18, 95% CI [0.84-1.65], P = 0.35, I2 = 0%). Tenecteplase was associated with significantly higher complete recanalization rate compared to alteplase (RR= 1.17, 95% CI [1.00-1.36], P = 0.05, I2 =0%). For large vessel occlusion (LVO) patients assigned to tenecteplase, there was a significant improvement in mRS 0-1 (RR= 1.28, 95% CI [1.07-1.52], P = 0.006, I2 =0%). CONCLUSION Based on our meta-analysis, tenecteplase has similar efficacy and safety to alteplase, with a more promising effect in patients with LVO.
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Affiliation(s)
- Hassan K Salamatullah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Bader Bashrahil
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulaziz M Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Faisal S Alsharm
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Osama A Alkulli
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ziyad Alzahrani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Saeed Alghamdi
- Neuroscience Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Seraj Makkawi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Medicine, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia.
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48
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D'Ascenzo F, DE Filippo O, Angelini F, Piroli F, DE Lio G, Bocchino PP, Baldetti L, Melillo F, Chieffo A, Saglietto A, Omedè P, Montefusco A, Conrotto F, de Ferrari GM. Duration and kind of dual antiplatelet therapy for acute coronary syndrome patients: a network meta-analysis. Minerva Cardiol Angiol 2023; 71:494-503. [PMID: 35332750 DOI: 10.23736/s2724-5683.22.06038-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION For acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI), the choice of the duration and kind of dual antiplatelet therapy (DAPT) offering the most accurate balance between ischemic and bleeding risk remains unknown. EVIDENCE ACQUISITION A network meta-analysis was performed including all Randomized Controlled Trials (RCTs) comparing different DAPT regimens and duration in ACS patients undergoing PCI. Trial-defined MACE and major bleedings were the primary endpoints. Stroke, stent thrombosis (ST), all-cause and cardiovascular death, myocardial infarction (MI) represented secondary endpoints. EVIDENCE SYNTHESIS 13 RCTs encompassing 46145 patients were included. Mean age was 62 (61-64) years old, 42% being admitted with STEMI, 33% with NSTEMI and 25% with UA. The competitive arms were: clopidogrel and aspirin for 12 months (6 arms/18183 patients), clopidogrel and aspirin for 6 months (4/3329), clopidogrel and aspirin >12 months (3/2238), ticagrelor and aspirin for 12 months (6/12942) and prasugrel and aspirin for 12 months (3/9453). Trial-defined MACE and major bleedings, stroke and death were similar among the different arms. DAPT with prasugrel and aspirin for 12 months reduced MI compared to aspirin and clopidogrel for 12 months (OR 0.71, 95% CI: 0.54.0.94) and reduced the risk of ST compared to ticagrelor (OR 0.66, 95% CI: 0.49-0.90). Both prasugrel and ticagrelor reduced ST as compared to clopidogrel and aspirin for 12 months. CONCLUSIONS Different DAPT strategies yield similar risk of MACE, major bleeding, death and stroke in ACS patients. Prasugrel and aspirin for 12 months proved to be the most effective strategy regarding ST and MI.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Ovidio DE Filippo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Filippo Angelini
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy -
| | - Francesco Piroli
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Giulia DE Lio
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Pier P Bocchino
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery, San Raffaele University Hospital, Milan, Italy
| | - Francesco Melillo
- Cardiac Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery, San Raffaele University Hospital, Milan, Italy
| | - Alaide Chieffo
- Unit of Interventional Cardiology, Department of Cardiology and Cardiothoracic Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Saglietto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Pierluigi Omedè
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Antonio Montefusco
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Gaetano M de Ferrari
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, Turin, Italy
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Lin SM, Lin JY, Tu YK, Wu CH, Peng CCH, Munir KM, Bukhari K, Jaggon K, Fu Y, Loh CH, Huang HK. Association between bisphosphonate use and stroke risk: a meta-analysis. Osteoporos Int 2023; 34:1625-1636. [PMID: 37249610 DOI: 10.1007/s00198-023-06781-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/28/2023] [Indexed: 05/31/2023]
Abstract
Previous studies have suggested that bisphosphonates may reduce stroke risk. This meta-analysis, which included 21 studies with 741,274 participants, revealed that bisphosphonates might be associated with lower stroke risk. However, evidence derived from randomized controlled trials identified no statistically significant association. Future high-quality studies are still required to determine causality. PURPOSE Whether bisphosphonates may reduce the risk of stroke remains inconclusive. We conducted a systematic review and meta-analysis to evaluate the association between bisphosphonate use and the risk of stroke based on up-to-date evidence. METHODS We searched for studies evaluating the effects of bisphosphonate on the risk of stroke from inception until January 3, 2022, on PubMed, Embase, Scopus, and Cochrane libraries and updated our search until August 22, 2022, using PubMed to identify any new potential published studies. Two or more reviewers independently screened articles, extracted data, and assessed the study quality. We retrieved the data to synthesize the pooled relative risk (RR) of stroke associated with bisphosphonate use compared with controls; random-effects models were used for meta-analysis. RESULTS A total of 21 studies (7 randomized controlled trials [RCTs] and 14 observational studies) involving 741,274 participants were included in our meta-analysis. Overall, bisphosphonate use was associated with a lower risk of stroke, but the result was only borderline significant (pooled RR = 0.87, 95% confidence interval [CI]: 0.76-0.99, p = 0.048), and high between-study heterogeneity was found (I2 = 83.7%). Subgroup analyses showed that the evidence derived from RCTs suggested no significant association between bisphosphonate use and stroke risk (pooled RR = 0.93, 95% CI: 0.76-1.13, p = 0.462; I2 = 13.4%). CONCLUSION Our results suggest that bisphosphonate use is associated with a lower risk of stroke. However, the current evidence does not lead to a definite conclusion due to the borderline statistical significance and high between-study heterogeneity. Future studies, especially RCTs, are necessary to assess causality.
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Affiliation(s)
- Shu-Man Lin
- Department of Physical Medicine and Rehabilitation, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jhe-Yi Lin
- School of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital and School of Dentistry, National Taiwan University, Taipei, Taiwan
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Carol Chiung-Hui Peng
- Section of Endocrinology, Diabetes, Nutrition & Weight Management, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Kashif M Munir
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khulood Bukhari
- University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Kory Jaggon
- University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Yunting Fu
- Health Sciences and Human Services Library, University of Maryland, Baltimore, MD, USA
| | - Ching-Hui Loh
- School of Medicine, Tzu Chi University, Hualien, Taiwan.
- Center for Aging and Health, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.
| | - Huei-Kai Huang
- School of Medicine, Tzu Chi University, Hualien, Taiwan.
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
- Department of Family Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan.
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50
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Fagundes A, Ruff CT, Morrow DA, Murphy SA, Palazzolo MG, Chen CZ, Jarolim P, Antman EM, Braunwald E, Giugliano RP. Neutrophil-lymphocyte ratio and clinical outcomes in 19,697 patients with atrial fibrillation: Analyses from ENGAGE AF- TIMI 48 trial. Int J Cardiol 2023; 386:118-124. [PMID: 37211048 DOI: 10.1016/j.ijcard.2023.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/30/2023] [Accepted: 05/17/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND The neutrophil-to-lymphocyte ratio (NLR) is the ratio between neutrophil and lymphocyte counts measured in peripheral blood. NLR is easily calculable based on a routine blood test available worldwide and may reflect systemic inflammation. However, the relationship between NLR and clinical outcomes in atrial fibrillation (AF) patients is not well-described. METHODS We calculated NLR at baseline in ENGAGE AF-TIMI 48, a randomized trial comparing edoxaban versus warfarin in patients with AF followed for 2.8 years (median). The association of baseline NLR with major bleeding events, major adverse cardiac events (MACE), cardiovascular death, stroke/systemic embolism, and all-cause mortality were calculated. RESULTS The median baseline NLR in 19,697 patients was 2.53 (interquartile range 1.89-3.41). NLR was associated with major bleeding events (HR 1.60; 95% CI 1.41-1.80), stroke/systemic embolism (HR 1.25; 95% CI, 1.09-1.44), MI (HR 1.73; 95% CI 1.41-2.12), MACE (HR 1.70; 95% CI 1.56-1.84), CV (HR 1.93; 95% CI 1.74-2.13) and all-cause mortality (HR 2.00; 95% CI 1.83-2.18). The relationships between NLR and outcomes remained significant after adjustment for risk factors. Edoxaban consistently reduced major bleeding. MACE, and CV death across NLR groups vs. warfarin. CONCLUSIONS NLR represents a widely available, simple, arithmetic calculation that could be immediately and automatically reported during a white blood cell differential measurement to identify patients with AF at increased risk of bleeding, CV events, and mortality.
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Affiliation(s)
- Antonio Fagundes
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA; IDOR, D'Or Institute for Research and Education, DFStar Hospital, Brasília, DF, Brazil
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael G Palazzolo
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Cathy Z Chen
- Daiichi Sankyo Inc., Global Specialty Medical Affairs, Basking Ridge, NJ, USA
| | - Petr Jarolim
- Biomarker Research and Clinical Trials Laboratory, Brigham and Women's Hospital, Boston, MA, USA
| | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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