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Dresser GK, Urquhart BL, Freeman DJ, Arnold JMO, Bailey DG. Coffee - Antihypertensive Drug Interaction: A Hemodynamic and Pharmacokinetic Study With Felodipine. J Pharmacol Toxicol Methods 2017. [DOI: 10.1016/j.vascn.2017.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zhang KM, Dindoff K, Arnold JMO, Lane J, Swartzman LC. What matters to patients with heart failure? The influence of non-health-related goals on patient adherence to self-care management. Patient Educ Couns 2015; 98:927-934. [PMID: 25979423 DOI: 10.1016/j.pec.2015.04.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [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: 11/06/2014] [Revised: 04/02/2015] [Accepted: 04/19/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To describe the life goals of heart failure (HF) patients and to determine whether adherence is influenced by the extent to which these priorities are perceived as compatible with HF self-care regimens. METHOD Forty HF outpatients identified their top-five life goals and indicated the compatibility of HF self-care regimens (diet, exercise, weighing) with these priorities. HF knowledge, self-efficacy and reported adherence were also assessed. RESULTS Patients valued autonomy and social relationships as much as physical health. However, the rated importance of these domains did not predict adherence. Adherence positively correlated with the extent to which the regimen, specifically exercise, was considered compatible with life goals (r=.34, p<.05). Exercise adherence also correlated with illness severity and self-efficacy (rs=-.42 and .36, p<.05, respectively). The perceived compatibility of physical activity with personal goals predicted 11% of the variance in exercise adherence above and beyond that accounted for by illness severity and self-efficacy (FΔ (1, 36)=7.11, p<.05). CONCLUSIONS Patients' goals outside of the illness management context influence self-care practices. PRACTICE IMPLICATIONS Exploring patients' broad life goals may increase opportunities to resolve ambivalence and enhance motivation for self-care adherence.
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Affiliation(s)
- Karen M Zhang
- Department of Psychology, University of Western Ontario, London, ON, Canada.
| | - Kathleen Dindoff
- School of Language & Liberal Studies, Fanshawe College, London, ON, Canada
| | - J Malcolm O Arnold
- Division of Cardiology, London Health Sciences Centre, London, ON, Canada
| | - Jeanine Lane
- Department of Psychology, Ryerson University, Toronto, ON, Canada
| | - Leora C Swartzman
- Department of Psychology, University of Western Ontario, London, ON, Canada
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Moe GW, Ezekowitz JA, O'Meara E, Lepage S, Howlett JG, Fremes S, Al-Hesayen A, Heckman GA, Abrams H, Ducharme A, Estrella-Holder E, Grzeslo A, Harkness K, Koshman SL, McDonald M, McKelvie R, Rajda M, Rao V, Swiggum E, Virani S, Zieroth S, Arnold JMO, Ashton T, D'Astous M, Chan M, De S, Dorian P, Giannetti N, Haddad H, Isaac DL, Kouz S, Leblanc MH, Liu P, Ross HJ, Sussex B, White M. The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Focus Update: anemia, biomarkers, and recent therapeutic trial implications. Can J Cardiol 2014; 31:3-16. [PMID: 25532421 DOI: 10.1016/j.cjca.2014.10.022] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [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: 10/12/2014] [Revised: 10/16/2014] [Accepted: 10/19/2014] [Indexed: 12/20/2022] Open
Abstract
The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides discussion on the management recommendations on 3 focused areas: (1) anemia; (2) biomarkers, especially natriuretic peptides; and (3) clinical trials that might change practice in the management of patients with heart failure. First, all patients with heart failure and anemia should be investigated for reversible causes of anemia. Second, patients with chronic stable heart failure should undergo natriuretic peptide testing. Third, considerations should be given to treat selected patients with heart failure and preserved systolic function with a mineralocorticoid receptor antagonist and to treat patients with heart failure and reduced ejection fraction with an angiotensin receptor/neprilysin inhibitor, when the drug is approved. As with updates in previous years, the topics were chosen in response to stakeholder feedback. The 2014 Update includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers to best manage patients with heart failure.
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Affiliation(s)
- Gordon W Moe
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | | | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | - Serge Lepage
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Steve Fremes
- Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Abdul Al-Hesayen
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Howard Abrams
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | | | - Adam Grzeslo
- Joseph Brant Memorial Hospital, Burlington, Ontario, Canada; Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Michael McDonald
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert McKelvie
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Miroslaw Rajda
- QE II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vivek Rao
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Sean Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Shelley Zieroth
- St Boniface General Hospital, Cardiac Sciences Program, Winnipeg, Manitoba, Canada
| | | | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Sabe De
- Cape Breton Regional Hospital, Sydney, Nova Scotia, Canada
| | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec and Université Laval, Québec, Canada
| | | | - Peter Liu
- Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather J Ross
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Sussex
- Health Sciences Centre, St John's, Newfoundland, Canada
| | - Michel White
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
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Holly TA, Bonow RO, Arnold JMO, Oh JK, Varadarajan P, Pohost GM, Haddad H, Jones RH, Velazquez EJ, Birkenfeld B, Asch FM, Malinowski M, Barretto R, Kalil RAK, Berman DS, Sun JL, Lee KL, Panza JA. Myocardial viability and impact of surgical ventricular reconstruction on outcomes of patients with severe left ventricular dysfunction undergoing coronary artery bypass surgery: results of the Surgical Treatment for Ischemic Heart Failure trial. J Thorac Cardiovasc Surg 2014; 148:2677-84.e1. [PMID: 25152476 DOI: 10.1016/j.jtcvs.2014.06.090] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 06/19/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVES In the Surgical Treatment for Ischemic Heart Failure trial, surgical ventricular reconstruction plus coronary artery bypass surgery was not associated with a reduction in the rate of death or cardiac hospitalization compared with bypass alone. We hypothesized that the absence of viable myocardium identifies patients with coronary artery disease and left ventricular dysfunction who have a greater benefit with coronary artery bypass graft surgery and surgical ventricular reconstruction compared with bypass alone. METHODS Myocardial viability was assessed by single photon computed tomography in 267 of the 1000 patients randomized to bypass or bypass plus surgical ventricular reconstruction in the Surgical Treatment for Ischemic Heart Failure. Myocardial viability was assessed on a per patient basis and regionally according to prespecified criteria. RESULTS At 3 years, there was no difference in mortality or the combined outcome of death or cardiac hospitalization between those with and without viability, and there was no significant interaction between the type of surgery and the global viability status with respect to mortality or death plus cardiac hospitalization. Furthermore, there was no difference in mortality or death plus cardiac hospitalization between those with and without anterior wall or apical scar, and no significant interaction between the presence of scar in these regions and the type of surgery with respect to mortality. CONCLUSIONS In patients with coronary artery disease and severe regional left ventricular dysfunction, assessment of myocardial viability does not identify patients who will derive a mortality benefit from adding surgical ventricular reconstruction to coronary artery bypass graft surgery.
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Dasgupta K, Quinn RR, Zarnke KB, Rabi DM, Ravani P, Daskalopoulou SS, Rabkin SW, Trudeau L, Feldman RD, Cloutier L, Prebtani A, Herman RJ, Bacon SL, Gilbert RE, Ruzicka M, McKay DW, Campbell TS, Grover S, Honos G, Schiffrin EL, Bolli P, Wilson TW, Lindsay P, Hill MD, Coutts SB, Gubitz G, Gelfer M, Vallée M, Prasad GR, Lebel M, McLean D, Arnold JMO, Moe GW, Howlett JG, Boulanger JM, Larochelle P, Leiter LA, Jones C, Ogilvie RI, Woo V, Kaczorowski J, Burns KD, Petrella RJ, Hiremath S, Milot A, Stone JA, Drouin D, Lavoie KL, Lamarre-Cliche M, Tremblay G, Hamet P, Fodor G, Carruthers SG, Pylypchuk GB, Burgess E, Lewanczuk R, Dresser GK, Penner SB, Hegele RA, McFarlane PA, Khara M, Pipe A, Oh P, Selby P, Sharma M, Reid DJ, Tobe SW, Padwal RS, Poirier L. The 2014 Canadian Hypertension Education Program Recommendations for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension. Can J Cardiol 2014; 30:485-501. [DOI: 10.1016/j.cjca.2014.02.002] [Citation(s) in RCA: 196] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 02/03/2014] [Accepted: 02/03/2014] [Indexed: 12/20/2022] Open
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Moe GW, Ezekowitz JA, O'Meara E, Howlett JG, Fremes SE, Al-Hesayen A, Heckman GA, Ducharme A, Estrella-Holder E, Grzeslo A, Harkness K, Lepage S, McDonald M, McKelvie RS, Nigam A, Rajda M, Rao V, Swiggum E, Virani S, Van Le V, Zieroth S, Arnold JMO, Ashton T, D'Astous M, Dorian P, Giannetti N, Haddad H, Isaac DL, Kouz S, Leblanc MH, Liu P, Ross HJ, Sussex B, White M. The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: focus on rehabilitation and exercise and surgical coronary revascularization. Can J Cardiol 2013; 30:249-63. [PMID: 24480445 DOI: 10.1016/j.cjca.2013.10.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [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: 09/24/2013] [Revised: 10/09/2013] [Accepted: 10/09/2013] [Indexed: 12/25/2022] Open
Abstract
The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides focused discussions on the management recommendations on 2 topics: (1) exercise and rehabilitation; and (2) surgical coronary revascularization in patients with heart failure. First, all patients with stable New York Heart Association class I-III symptoms should be considered for enrollment in a tailored exercise training program, to improve exercise tolerance and quality of life. Second, selected patients with suitable coronary anatomy should be considered for bypass graft surgery. As in previous updates, the topics were chosen in response to stakeholder feedback. The 2013 Update also includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers manage their patients with heart failure.
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Affiliation(s)
- Gordon W Moe
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | | | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | | | - Steve E Fremes
- Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Abdul Al-Hesayen
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Anique Ducharme
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | | | - Adam Grzeslo
- Joseph Brant Memorial Hospital, Burlington, Ontario, Canada; Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Serge Lepage
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michael McDonald
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert S McKelvie
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Anil Nigam
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
| | - Miroslaw Rajda
- QE II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vivek Rao
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Sean Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Vy Van Le
- Centre Hospitalier Universitaire de l'Université de Montréal, Québec, Canada
| | - Shelley Zieroth
- Cardiac Sciences Program, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | | | | | | | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, and Université Laval, Québec, Canada
| | | | - Peter Liu
- Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather J Ross
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Sussex
- Health Sciences Centre, St John's, Newfoundland, Canada
| | - Michel White
- Institut de Cardiologie de Montréal, Montreal, Québec, Canada
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Hackam DG, Quinn RR, Ravani P, Rabi DM, Dasgupta K, Daskalopoulou SS, Khan NA, Herman RJ, Bacon SL, Cloutier L, Dawes M, Rabkin SW, Gilbert RE, Ruzicka M, McKay DW, Campbell TS, Grover S, Honos G, Schiffrin EL, Bolli P, Wilson TW, Feldman RD, Lindsay P, Hill MD, Gelfer M, Burns KD, Vallée M, Prasad GVR, Lebel M, McLean D, Arnold JMO, Moe GW, Howlett JG, Boulanger JM, Larochelle P, Leiter LA, Jones C, Ogilvie RI, Woo V, Kaczorowski J, Trudeau L, Petrella RJ, Milot A, Stone JA, Drouin D, Lavoie KL, Lamarre-Cliche M, Godwin M, Tremblay G, Hamet P, Fodor G, Carruthers SG, Pylypchuk GB, Burgess E, Lewanczuk R, Dresser GK, Penner SB, Hegele RA, McFarlane PA, Sharma M, Reid DJ, Tobe SW, Poirier L, Padwal RS. The 2013 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol 2013; 29:528-42. [PMID: 23541660 DOI: 10.1016/j.cjca.2013.01.005] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 01/14/2013] [Accepted: 01/15/2013] [Indexed: 12/26/2022] Open
Abstract
We updated the evidence-based recommendations for the diagnosis, assessment, prevention, and treatment of hypertension in adults for 2013. This year's update includes 2 new recommendations. First, among nonhypertensive or stage 1 hypertensive individuals, the use of resistance or weight training exercise does not adversely influence blood pressure (BP) (Grade D). Thus, such patients need not avoid this type of exercise for fear of increasing BP. Second, and separately, for very elderly patients with isolated systolic hypertension (age 80 years or older), the target for systolic BP should be < 150 mm Hg (Grade C) rather than < 140 mm Hg as recommended for younger patients. We also discuss 2 additional topics at length (the pharmacological treatment of mild hypertension and the possibility of a diastolic J curve in hypertensive patients with coronary artery disease). In light of several methodological limitations, a recent systematic review of 4 trials in patients with stage 1 uncomplicated hypertension did not lead to changes in management recommendations. In addition, because of a lack of prospective randomized data assessing diastolic BP thresholds in patients with coronary artery disease and hypertension, no recommendation to set a selective diastolic cut point for such patients could be affirmed. However, both of these issues will be examined on an ongoing basis, in particular as new evidence emerges.
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Affiliation(s)
- Daniel G Hackam
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada.
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Daskalopoulou SS, Khan NA, Quinn RR, Ruzicka M, McKay DW, Hackam DG, Rabkin SW, Rabi DM, Gilbert RE, Padwal RS, Dawes M, Touyz RM, Campbell TS, Cloutier L, Grover S, Honos G, Herman RJ, Schiffrin EL, Bolli P, Wilson T, Feldman RD, Lindsay MP, Hemmelgarn BR, Hill MD, Gelfer M, Burns KD, Vallée M, Prasad GVR, Lebel M, McLean D, Arnold JMO, Moe GW, Howlett JG, Boulanger JM, Larochelle P, Leiter LA, Jones C, Ogilvie RI, Woo V, Kaczorowski J, Trudeau L, Bacon SL, Petrella RJ, Milot A, Stone JA, Drouin D, Lamarre-Cliché M, Godwin M, Tremblay G, Hamet P, Fodor G, Carruthers SG, Pylypchuk G, Burgess E, Lewanczuk R, Dresser GK, Penner B, Hegele RA, McFarlane PA, Sharma M, Campbell NRC, Reid D, Poirier L, Tobe SW. The 2012 Canadian Hypertension Education Program Recommendations for the Management of Hypertension: Blood Pressure Measurement, Diagnosis, Assessment of Risk, and Therapy. Can J Cardiol 2012; 28:270-87. [PMID: 22595447 DOI: 10.1016/j.cjca.2012.02.018] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Revised: 02/24/2012] [Accepted: 02/24/2012] [Indexed: 01/13/2023] Open
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Arnold JMO, Porepa L. Acute Decompensated Heart Failure: The Quest to Live Longer and Feel Better. J Am Coll Cardiol 2012; 59:1449-51. [DOI: 10.1016/j.jacc.2012.01.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 01/03/2012] [Indexed: 11/16/2022]
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Rabi DM, Daskalopoulou SS, Padwal RS, Khan NA, Grover SA, Hackam DG, Myers MG, McKay DW, Quinn RR, Hemmelgarn BR, Cloutier L, Bolli P, Hill MD, Wilson T, Penner B, Burgess E, Lamarre-Cliché M, McLean D, Schiffrin EL, Honos G, Mann K, Tremblay G, Milot A, Chockalingam A, Rabkin SW, Dawes M, Touyz RM, Burns KD, Ruzicka M, Campbell NR, Vallée M, Prasad GR, Lebel M, Campbell TS, Lindsay MP, Herman RJ, Larochelle P, Feldman RD, Arnold JMO, Moe GW, Howlett JG, Trudeau L, Bacon SL, Petrella RJ, Lewanczuk R, Stone JA, Drouin D, Boulanger JM, Sharma M, Hamet P, Fodor G, Dresser GK, Carruthers SG, Pylypchuk G, Gilbert RE, Leiter LA, Jones C, Ogilvie RI, Woo V, McFarlane PA, Hegele RA, Poirier L, Tobe SW. The 2011 Canadian Hypertension Education Program Recommendations for the Management of Hypertension: Blood Pressure Measurement, Diagnosis, Assessment of Risk, and Therapy. Can J Cardiol 2011; 27:415-433.e1-2. [PMID: 21801975 DOI: 10.1016/j.cjca.2011.03.015] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 03/22/2011] [Accepted: 03/23/2011] [Indexed: 10/14/2022] Open
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McKelvie RS, Moe GW, Cheung A, Costigan J, Ducharme A, Estrella-Holder E, Ezekowitz JA, Floras J, Giannetti N, Grzeslo A, Harkness K, Heckman GA, Howlett JG, Kouz S, Leblanc K, Mann E, O'Meara E, Rajda M, Rao V, Simon J, Swiggum E, Zieroth S, Arnold JMO, Ashton T, D'Astous M, Dorian P, Haddad H, Isaac DL, Leblanc MH, Liu P, Sussex B, Ross HJ. The 2011 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Sleep Apnea, Renal Dysfunction, Mechanical Circulatory Support, and Palliative Care. Can J Cardiol 2011; 27:319-38. [DOI: 10.1016/j.cjca.2011.03.011] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 03/15/2011] [Indexed: 10/18/2022] Open
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Shan L, Li J, Wei M, Ma J, Wan L, Zhu W, Li Y, Zhu H, Arnold JMO, Peng T. Disruption of Rac1 signaling reduces ischemia-reperfusion injury in the diabetic heart by inhibiting calpain. Free Radic Biol Med 2010; 49:1804-14. [PMID: 20883775 DOI: 10.1016/j.freeradbiomed.2010.09.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 09/01/2010] [Accepted: 09/20/2010] [Indexed: 12/13/2022]
Abstract
Diabetes increases myocardial ischemia/reperfusion (I/R) injury. However, the underlying mechanisms remain incompletely understood. This study investigated the role of Rac1 signaling and calpain in exacerbated I/R injury in diabetic hearts. Mice with cardiac-specific deletion of Rac1 (Rac1-ko) and transgenic mice with cardiac-specific superoxide dismutase-2 (SOD2) or calpastatin overexpression were rendered diabetic with streptozotocin. Isolated perfused hearts were subjected to global I/R. After I/R, Rac1 activity was significantly enhanced in diabetic compared with nondiabetic hearts. Diabetic hearts displayed more severe I/R injury than nondiabetic hearts, as evidenced by more lactate dehydrogenase release and apoptosis and decreased cardiac function. These adverse impacts of diabetes were abrogated in Rac1-ko hearts or by perfusion with the Rac1 inhibitor NSC23766. In an in vivo I/R mouse model, infarct size was much smaller in diabetic Rac1-ko compared with wild-type mice. Inhibition of Rac1 signaling prevented NADPH oxidase activation, reactive oxygen species production, and protein carbonyl accumulation, leading to inhibition of calpain activation. Furthermore, SOD2 or calpastatin overexpression significantly reduced I/R injury in diabetic hearts and improved cardiac function after I/R. In summary, Rac1 activation increases I/R injury in diabetic hearts and the role of Rac1 signaling is mediated, at least in part, through calpain activation.
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Affiliation(s)
- Limei Shan
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, ON, Canada
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Li J, Zhu H, Shen E, Wan L, Arnold JMO, Peng T. Deficiency of rac1 blocks NADPH oxidase activation, inhibits endoplasmic reticulum stress, and reduces myocardial remodeling in a mouse model of type 1 diabetes. Diabetes 2010; 59:2033-42. [PMID: 20522592 PMCID: PMC2911061 DOI: 10.2337/db09-1800] [Citation(s) in RCA: 133] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Our recent study demonstrated that Rac1 and NADPH oxidase activation contributes to cardiomyocyte apoptosis in short-term diabetes. This study was undertaken to investigate if disruption of Rac1 and inhibition of NADPH oxidase would prevent myocardial remodeling in chronic diabetes. RESEARCH DESIGN AND METHODS Diabetes was induced by injection of streptozotocin in mice with cardiomyocyte-specific Rac1 knockout and their wild-type littermates. In a separate experiment, wild-type diabetic mice were treated with vehicle or apocynin in drinking water. Myocardial hypertrophy, fibrosis, endoplasmic reticulum (ER) stress, inflammatory response, and myocardial function were investigated after 2 months of diabetes. Isolated adult rat cardiomyocytes were cultured and stimulated with high glucose. RESULTS In diabetic hearts, NADPH oxidase activation, its subunits' expression, and reactive oxygen species production were inhibited by Rac1 knockout or apocynin treatment. Myocardial collagen deposition and cardiomyocyte cross-sectional areas were significantly increased in diabetic mice, which were accompanied by elevated expression of pro-fibrotic genes and hypertrophic genes. Deficiency of Rac1 or apocynin administration reduced myocardial fibrosis and hypertrophy, resulting in improved myocardial function. These effects were associated with a normalization of ER stress markers' expression and inflammatory response in diabetic hearts. In cultured cardiomyocytes, high glucose-induced ER stress was inhibited by blocking Rac1 or NADPH oxidase. CONCLUSIONS Rac1 via NADPH oxidase activation induces myocardial remodeling and dysfunction in diabetic mice. The role of Rac1 signaling may be associated with ER stress and inflammation. Thus, targeting inhibition of Rac1 and NADPH oxidase may be a therapeutic approach for diabetic cardiomyopathy.
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Affiliation(s)
- Jianmin Li
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Pathology, the First Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang, China
| | - Huaqing Zhu
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - E Shen
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Li Wan
- Department of Pathology, the First Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang, China
| | - J. Malcolm O. Arnold
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada
| | - Tianqing Peng
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Pathology, University of Western Ontario, London, Ontario, Canada
- Corresponding author: Tianqing Peng,
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Hackam DG, Khan NA, Hemmelgarn BR, Rabkin SW, Touyz RM, Campbell NRC, Padwal R, Campbell TS, Lindsay MP, Hill MD, Quinn RR, Mahon JL, Herman RJ, Schiffrin EL, Ruzicka M, Larochelle P, Feldman RD, Lebel M, Poirier L, Arnold JMO, Moe GW, Howlett JG, Trudeau L, Bacon SL, Petrella RJ, Milot A, Stone JA, Drouin D, Boulanger JM, Sharma M, Hamet P, Fodor G, Dresser GK, Carruthers SG, Pylypchuk G, Burgess ED, Burns KD, Vallée M, Prasad GVR, Gilbert RE, Leiter LA, Jones C, Ogilvie RI, Woo V, McFarlane PA, Hegele RA, Tobe SW. The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 - therapy. Can J Cardiol 2010; 26:249-58. [PMID: 20485689 DOI: 10.1016/s0828-282x(10)70379-2] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010. OPTIONS AND OUTCOMES For lifestyle and pharmacological interventions, randomized trials and systematic reviews of trials were preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the general lack of long-term morbidity and mortality data in this field. Progressive renal impairment was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease. EVIDENCE A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence. RECOMMENDATIONS For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial therapy should include thiazide diuretics, angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy. Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or betablockers are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered. VALIDATION All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually. SPONSORS The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada.
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Affiliation(s)
- Daniel G Hackam
- Department of Medicine and Epidemiology, Division of Clinical Pharmacology and Clinical Neurological Sciences, University of Western Ontario, London, Ontario.
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Abstract
OBJECTIVE Hyperglycemia induces reactive oxygen species (ROS) and apoptosis in cardiomyocytes, which contributes to diabetic cardiomyopathy. The present study was to investigate the role of Rac1 in ROS production and cardiomyocyte apoptosis during hyperglycemia. RESEARCH DESIGN AND METHODS Mice with cardiomyocyte-specific Rac1 knockout (Rac1-ko) were generated. Hyperglycemia was induced in Rac1-ko mice and their wild-type littermates by injection of streptozotocin (STZ). In cultured adult rat cardiomyocytes, apoptosis was induced by high glucose. RESULTS The results showed a mouse model of STZ-induced diabetes, 7 days of hyperglycemia-upregulated Rac1 and NADPH oxidase activation, elevated ROS production, and induced apoptosis in the heart. These effects of hyperglycemia were significantly decreased in Rac1-ko mice or wild-type mice treated with apocynin. Interestingly, deficiency of Rac1 or apocynin treatment significantly reduced hyperglycemia-induced mitochondrial ROS production in the heart. Deficiency of Rac1 also attenuated myocardial dysfunction after 2 months of STZ injection. In cultured cardiomyocytes, high glucose upregulated Rac1 and NADPH oxidase activity and induced apoptotic cell death, which were blocked by overexpression of a dominant negative mutant of Rac1, knockdown of gp91(phox) or p47(phox), or NADPH oxidase inhibitor. In type 2 diabetic db/db mice, administration of Rac1 inhibitor, NSC23766, significantly inhibited NADPH oxidase activity and apoptosis and slightly improved myocardial function. CONCLUSIONS Rac1 is pivotal in hyperglycemia-induced apoptosis in cardiomyocytes. The role of Rac1 is mediated through NADPH oxidase activation and associated with mitochondrial ROS generation. Our study suggests that Rac1 may serve as a potential therapeutic target for cardiac complications of diabetes.
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Affiliation(s)
- E. Shen
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Yanwen Li
- Department of Microbiology, Imperial College London, London, U.K
| | - Ying Li
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Limei Shan
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Huaqing Zhu
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Qingping Feng
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada
| | - J. Malcolm O. Arnold
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada
| | - Tianqing Peng
- Critical Illness Research, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada
- Department of Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Pathology, University of Western Ontario, London, Ontario, Canada
- Corresponding author: Tianqing Peng,
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Li Y, Arnold JMO, Pampillo M, Babwah AV, Peng T. Taurine prevents cardiomyocyte death by inhibiting NADPH oxidase-mediated calpain activation. Free Radic Biol Med 2009; 46:51-61. [PMID: 18950702 DOI: 10.1016/j.freeradbiomed.2008.09.025] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [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: 06/06/2008] [Revised: 09/08/2008] [Accepted: 09/17/2008] [Indexed: 11/30/2022]
Abstract
Taurine has been shown to prevent cardiomyocyte apoptosis. This study investigated the effects of taurine on NADPH oxidase and calpain activation in mediating apoptosis in cardiomyocytes. Apoptosis was induced by norepinephrine (NE) in cultured adult rat ventricular cardiomyocytes. NE (5 microM) increased NADPH oxidase activation and reactive oxygen species (ROS) production and induced apoptosis. These effects of NE on cardiomyocytes were diminished by taurine (0.5 mg/kg) but not beta-alanine. Inhibition of gp91(phox)-NADPH oxidase or ROS production protected cardiomyocytes from apoptosis. NE also induced calpain-1 activation in cardiomyocytes. This effect of NE on calpain was abrogated by gp91(phox)-NADPH oxidase inhibition or ROS scavengers and was mimicked by H(2)O(2) (25 microM) in cardiomyocytes. Pharmacological inhibitors of calpain or overexpression of calpastatin, a specific calpain inhibitor, blocked calpain activation and prevented cardiomyocyte apoptosis during NE stimulation. Furthermore, taurine treatment inhibited NE- or H(2)O(2)-induced calpain activation in cardiomyocytes. In conclusion, NADPH oxidase induces calpain activation, leading to apoptosis in NE-induced cardiomyocytes. Taurine inhibits NADPH oxidase and calpain activation. Thus, inhibition of NADPH oxidase-mediated calpain activation may be an important mechanism for taurine's antiapoptotic action in cardiomyocytes.
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Affiliation(s)
- Ying Li
- Lawson Health Research Institute, Department of Medicine, University of Western Ontario, London, Canada
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Meris A, Amigoni M, Uno H, Thune JJ, Verma A, Køber L, Bourgoun M, McMurray JJ, Velazquez EJ, Maggioni AP, Ghali J, Arnold JMO, Zelenkofske S, Pfeffer MA, Solomon SD. Left atrial remodelling in patients with myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: the VALIANT Echo study. Eur Heart J 2008; 30:56-65. [PMID: 19001474 DOI: 10.1093/eurheartj/ehn499] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS To assess the relationship between left atrial (LA) size and outcome after high-risk myocardial infarction (MI) and to study dynamic changes in LA size during long-term follow-up. METHODS AND RESULTS The VALIANT Echocardiography study prospectively enrolled 610 patients with left ventricular (LV) dysfunction, heart failure (HF), or both following MI. We assessed LA volume indexed to body surface area (LAVi) at baseline, 1 month, and 20 months after MI. Baseline LAVi was an independent predictor of all-cause death or HF hospitalization (P = 0.004). In patients who survived to 20 months, LAVi increased a mean of 3.00 +/- 7.08 mL/m(2) from baseline. Hypertension, lower estimated glomerular filtration rate, and LV mass were the only baseline independent predictors of LA remodelling. Changes in LA size were related to worsening in MR and increasing in LV volumes. LA enlargement during the first month was significantly greater in patients who subsequently died or were hospitalized for HF than in patients without events. CONCLUSION Baseline LA size is an independent predictor of death or HF hospitalization following high-risk MI. Moreover, LA remodelling during the first month after infarction is associated with adverse outcome.
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Verma A, Meris A, Skali H, Ghali JK, Arnold JMO, Bourgoun M, Velazquez EJ, McMurray JJ, Kober L, Pfeffer MA, Califf RM, Solomon SD. Prognostic Implications of Left Ventricular Mass and Geometry Following Myocardial Infarction. JACC Cardiovasc Imaging 2008; 1:582-91. [DOI: 10.1016/j.jcmg.2008.05.012] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 05/01/2008] [Accepted: 05/28/2008] [Indexed: 01/19/2023]
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Roy D, Talajic M, Nattel S, Wyse DG, Dorian P, Lee KL, Bourassa MG, Arnold JMO, Buxton AE, Camm AJ, Connolly SJ, Dubuc M, Ducharme A, Guerra PG, Hohnloser SH, Lambert J, Le Heuzey JY, O'Hara G, Pedersen OD, Rouleau JL, Singh BN, Stevenson LW, Stevenson WG, Thibault B, Waldo AL. Rhythm control versus rate control for atrial fibrillation and heart failure. N Engl J Med 2008; 358:2667-77. [PMID: 18565859 DOI: 10.1056/nejmoa0708789] [Citation(s) in RCA: 1085] [Impact Index Per Article: 67.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is common practice to restore and maintain sinus rhythm in patients with atrial fibrillation and heart failure. This approach is based in part on data indicating that atrial fibrillation is a predictor of death in patients with heart failure and suggesting that the suppression of atrial fibrillation may favorably affect the outcome. However, the benefits and risks of this approach have not been adequately studied. METHODS We conducted a multicenter, randomized trial comparing the maintenance of sinus rhythm (rhythm control) with control of the ventricular rate (rate control) in patients with a left ventricular ejection fraction of 35% or less, symptoms of congestive heart failure, and a history of atrial fibrillation. The primary outcome was the time to death from cardiovascular causes. RESULTS A total of 1376 patients were enrolled (682 in the rhythm-control group and 694 in the rate-control group) and were followed for a mean of 37 months. Of these patients, 182 (27%) in the rhythm-control group died from cardiovascular causes, as compared with 175 (25%) in the rate-control group (hazard ratio in the rhythm-control group, 1.06; 95% confidence interval, 0.86 to 1.30; P=0.59 by the log-rank test). Secondary outcomes were similar in the two groups, including death from any cause (32% in the rhythm-control group and 33% in the rate-control group), stroke (3% and 4%, respectively), worsening heart failure (28% and 31%), and the composite of death from cardiovascular causes, stroke, or worsening heart failure (43% and 46%). There were also no significant differences favoring either strategy in any predefined subgroup. CONCLUSIONS In patients with atrial fibrillation and congestive heart failure, a routine strategy of rhythm control does not reduce the rate of death from cardiovascular causes, as compared with a rate-control strategy. (ClinicalTrials.gov number, NCT00597077.)
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Affiliation(s)
- Denis Roy
- Montreal Heart Institute and the Université de Montréal, Montreal, QC H1T 1C8, Canada.
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Mitchell GF, Conlin PR, Dunlap ME, Lacourcière Y, Arnold JMO, Ogilvie RI, Neutel J, Izzo JL, Pfeffer MA. Response to Wave Reflection in Systolic Hypertension: Smaller Stature, Shorter Aorta: Higher Pulse Pressure? and Questions Regarding the Aortic Measurements of Mitchell et al. Hypertension 2008. [DOI: 10.1161/hypertensionaha.108.111781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | - Joel Neutel
- Orange County Research Center, Tustin, Calif
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Tsuyuki RT, Arnold JMO. The Canadian Cardiovascular Society Consensus Conference recommendations on heart failure update 2007: A summary for pharmacists. Can Pharm J (Ott) 2008. [DOI: 10.3821/1913-701x(2008)141[98:tccscc]2.0.co;2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Mitchell GF, Conlin PR, Dunlap ME, Lacourcière Y, Arnold JMO, Ogilvie RI, Neutel J, Izzo JL, Pfeffer MA. Aortic Diameter, Wall Stiffness, and Wave Reflection in Systolic Hypertension. Hypertension 2008; 51:105-11. [DOI: 10.1161/hypertensionaha.107.099721] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gary F. Mitchell
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Paul R. Conlin
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Mark E. Dunlap
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Yves Lacourcière
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - J. Malcolm O. Arnold
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Richard I. Ogilvie
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Joel Neutel
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Joseph L. Izzo
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
| | - Marc A. Pfeffer
- From Cardiovascular Engineering Inc (G.F.M.), Waltham, Mass; Brigham and Women’s Hospital (P.R.C., M.A.P.), Boston, Mass; MetroHealth Medical Center (M.E.D.), Cleveland, Ohio; the Centre hospitalier de l’Universite Laval (Y.L.), Ste. Foy, QB; London Health Sciences Centre (J.M.O.A.), London, ON; Toronto Western Hospital (R.I.O.), Toronto, ON; Orange County Research Center (J.N.), Tustin, Calif; and SUNY at Buffalo (J.L.I.), NY
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Solomon SD, Lin J, Solomon CG, Jablonski KA, Rice MM, Steffes M, Domanski M, Hsia J, Gersh BJ, Arnold JMO, Rouleau J, Braunwald E, Pfeffer MA. Influence of albuminuria on cardiovascular risk in patients with stable coronary artery disease. Circulation 2007; 116:2687-93. [PMID: 18025537 DOI: 10.1161/circulationaha.107.723270] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with chronic kidney disease are at increased risk for cardiovascular morbidity and mortality. We assessed the association between albuminuria and the risks for death and cardiovascular events among patients with stable coronary disease. METHODS AND RESULTS We studied patients enrolled in the Prevention of Events with an ACE inhibitor (PEACE) trial, in which patients with chronic stable coronary disease and preserved systolic function were randomized to trandolapril or placebo and followed up for a median of 4.8 years. The urinary albumin to creatinine ratio (ACR) assessed in a core laboratory in 2977 patients at baseline and in 1339 patients at follow-up (mean 34 months) was related to estimated glomerular filtration rate and outcomes. The majority of patients (73%) had a baseline ACR within the normal range (<17 mug/mg for men and <25 mug/mg for women). Independent of the estimated glomerular filtration rate and other baseline covariates, a higher ACR, even within the normal range, was associated with increased risks for all-cause mortality (P<0.001) and cardiovascular death (P=0.01). The effect of trandolapril therapy on outcomes was not modified significantly by the level of albuminuria. Nevertheless, trandolapril therapy was associated with a significantly lower mean follow-up ACR (12.5 versus 14.6 mug/mg, P=0.0002), after adjustment for baseline ACR, time between collections, and other covariates. An increase in ACR over time was associated with increased risk of cardiovascular death (hazard ratio per log ACR 1.74, 95% CI 1.08 to 2.82). CONCLUSIONS Albuminuria, even in low levels within the normal range, is an independent predictor of cardiovascular and all-cause mortality.
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Affiliation(s)
- Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
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Mann JFE, Sheridan P, McQueen MJ, Held C, Arnold JMO, Fodor G, Yusuf S, Lonn EM. Homocysteine lowering with folic acid and B vitamins in people with chronic kidney disease--results of the renal Hope-2 study. Nephrol Dial Transplant 2007; 23:645-53. [PMID: 18003666 DOI: 10.1093/ndt/gfm485] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Elevated plasma homocysteine levels are reported to be associated with higher rates of vascular diseases. Plasma homocysteine increases in chronic kidney disease (CKD) and could contribute to the increased cardiovascular risk in CKD. METHODS Participants aged 55 years or older with CKD, defined as estimated GFR<60 ml/min and at high cardiovascular risk, were randomly assigned to the combination of folic acid, 2.5 mg, vitamin B6, 50 mg and vitamin B12, 1 mg (n = 307) or placebo (n = 312) daily for 5 years. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction and stroke. RESULTS Mean baseline plasma homocysteine was 15.9 +/- 7.3 micromol/l in the active treatment group and 15.7 +/- 5.7 micromol/l in placebo group and decreased to 11.9 +/- 3.3 micromol/l (P < 0.001) on active treatment (15.5 +/- 4.5 on placebo). Primary outcome events occurred in 90 participants (29.3%) on active therapy and in 80 (25.6%) on placebo (relative risk, 1.19; 95% confidence interval, 0.88-1.61; P = 0.25). There were no significant treatment benefits on death from cardiovascular causes (1.24; 0.84-1.83), myocardial infarction (1.10; 0.76-1.61) and stroke (1.00; 0.54-1.85). More participants in the active treatment group were hospitalized for heart failure (1.98; 1.21-3.26; P = 0.007) and for unstable angina (1.70; 1.02-2.83; P = 0.04). Incidence of primary outcome increased with decreasing GFR. CONCLUSIONS Active treatment with B vitamins lowered homocysteine levels in participants with CKD but did not reduce cardiovascular risk.
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Affiliation(s)
- Johannes F E Mann
- Department of Medicine, Munich General Hospitals and KfH Kidney Centre, Munich, Germany.
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Verma A, Anavekar NS, Meris A, Thune JJ, Arnold JMO, Ghali JK, Velazquez EJ, McMurray JJV, Pfeffer MA, Solomon SD. The Relationship Between Renal Function and Cardiac Structure, Function, and Prognosis After Myocardial Infarction. J Am Coll Cardiol 2007; 50:1238-45. [PMID: 17888840 DOI: 10.1016/j.jacc.2007.06.018] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [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: 03/02/2007] [Revised: 06/06/2007] [Accepted: 06/20/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The purpose of this study was to determine whether alterations in cardiac structure or function contribute to the increased risk associated with renal impairment after myocardial infarction (MI). BACKGROUND Renal impairment is associated with adverse cardiovascular outcomes after MI. METHODS Echocardiography was performed on 603 patients with left ventricular (LV) dysfunction, heart failure (HF), or both after MI. Patients were grouped according to their estimated glomerular filtration rate (eGFR), and measures of cardiac structure and function were related to baseline eGFR. The relationship between eGFR and cardiac structure and function and clinical outcomes of death or HF was assessed with multivariable Cox regression. RESULTS Ejection fraction, infarct segment length, right ventricular function, and mitral deceleration time were not influenced by renal function. Patients with reduced eGFR had smaller LV and larger left atrial (LA) volumes and higher left ventricular mass index (LVMI) and LV mass/LV volume ratio. A greater proportion of the patients with reduced eGFR had LV hypertrophy. The relationship between eGFR and the outcome of death or HF was attenuated by including baseline differences in LVMI, and both LVMI and LA volume conferred additional prognostic information in a multivariable model. CONCLUSIONS Renal impairment was associated with smaller LV and larger LA volumes and increased LVMI. Systolic function was similar when compared with patients with normal renal function. Thus, reduced systolic function cannot account for worse outcomes in patients with renal impairment after MI. Indirect measures of diastolic function suggest that diastolic dysfunction might be an important mediator of increased risk in this population.
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Affiliation(s)
- Anil Verma
- Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Solomon SD, Janardhanan R, Verma A, Bourgoun M, Daley WL, Purkayastha D, Lacourcière Y, Hippler SE, Fields H, Naqvi TZ, Mulvagh SL, Arnold JMO, Thomas JD, Zile MR, Aurigemma GP. Effect of angiotensin receptor blockade and antihypertensive drugs on diastolic function in patients with hypertension and diastolic dysfunction: a randomised trial. Lancet 2007; 369:2079-87. [PMID: 17586303 DOI: 10.1016/s0140-6736(07)60980-5] [Citation(s) in RCA: 273] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Diastolic dysfunction might represent an important pathophysiological intermediate between hypertension and heart failure. Our aim was to determine whether inhibitors of the renin-angiotensin-aldosterone system, which can reduce ventricular hypertrophy and myocardial fibrosis, can improve diastolic function to a greater extent than can other antihypertensive agents. METHODS Patients with hypertension and evidence of diastolic dysfunction were randomly assigned to receive either the angiotensin receptor blocker valsartan (titrated to 320 mg once daily) or matched placebo. Patients in both groups also received concomitant antihypertensive agents that did not inhibit the renin-angiotensin system to reach targets of under 135 mm Hg systolic blood pressure and under 80 mm Hg diastolic blood pressure. The primary endpoint was change in diastolic relaxation velocity between baseline and 38 weeks as determined by tissue doppler imaging. Analyses were done by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00170924. FINDINGS 186 patients were randomly assigned to receive valsartan; 198 were randomly assigned to receive placebo. 43 patients were lost to follow-up or discontinued the assigned intervention. Over 38 weeks, there was a 12.8 (SD 17.2)/7.1 (9.9) mm Hg reduction in blood pressure in the valsartan group and a 9.7 (17.0)/5.5 (10.2) mm Hg reduction in the placebo group. The difference in blood pressure reduction between the two groups was not significant. Diastolic relaxation velocity increased by 0.60 (SD 1.4) cm/s from baseline in the valsartan group (p<0.0001) and 0.44 (1.4) cm/s from baseline in the placebo group (p<0.0001) by week 38. However, there was no significant difference in the change in diastolic relaxation velocity between the groups (p=0.29). INTERPRETATION Lowering blood pressure improves diastolic function irrespective of the type of antihypertensive agent used.
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Affiliation(s)
- Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Vyas M, Izzo JL, Lacourcière Y, Arnold JMO, Dunlap ME, Amato JL, Pfeffer MA, Mitchell GF. Augmentation index and central aortic stiffness in middle-aged to elderly individuals. Am J Hypertens 2007; 20:642-7. [PMID: 17531921 DOI: 10.1016/j.amjhyper.2007.01.008] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [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: 10/30/2006] [Revised: 12/02/2006] [Accepted: 01/03/2007] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Increased aortic stiffness contributes to systolic hypertension and increased cardiovascular risk. The augmentation index (AI), ie, the percentage of central pulse pressure attributed to reflected wave overlap in systole, was proposed as a noninvasive indicator of increased arterial stiffness. We evaluated this hypothesis by investigating relations between AI and other direct measures of aortic stiffness. METHODS Tonometric carotid- and femoral-pressure waveforms, Doppler aortic flow, and aortic-root diameter were assessed in 123 individuals with uncomplicated systolic hypertension and 29 controls of comparable age and sex. Carotid-femoral pulse-wave velocity (PWV) was assessed from the carotid-femoral time delay and body-surface measurements. Aortic PWV was assessed from the ratio of the upstroke of carotid pressure and aortic flow velocity and was used to calculate proximal aortic compliance as [aortic area]/[1.06 x (aortic PWV)(2)]. RESULTS Partial correlations (adjusted for age, sex, presence of hypertension, height, weight, and systolic ejection period) showed no association between AI and carotid-femoral PWV (R = -0.05, P = .54). The AI was significantly though weakly related directly with aortic compliance (R = 0.21, P = .012) and inversely with aortic PWV (R = -0.198, P = .017). However, higher stiffness (lower compliance and higher PWV) was associated with lower AI. CONCLUSIONS Increased AI is not a reliable surrogate for increased aortic stiffness. Decreasing AI with decreasing compliance (increasing aortic stiffness) may be attributable to impedance matching and reduced wave reflection at the interface between the aorta and the muscular arteries.
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Affiliation(s)
- Mitul Vyas
- Cardiovascular Engineering, Inc., Waltham, Massachusetts 02453, USA
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Mitchell GF, Dunlap ME, Warnica W, Ducharme A, Arnold JMO, Tardif JC, Solomon SD, Domanski MJ, Jablonski KA, Rice MM, Pfeffer MA. Long-term trandolapril treatment is associated with reduced aortic stiffness: the prevention of events with angiotensin-converting enzyme inhibition hemodynamic substudy. Hypertension 2007; 49:1271-7. [PMID: 17452505 PMCID: PMC2553625 DOI: 10.1161/hypertensionaha.106.085738] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The Prevention of Events with Angiotensin Converting Enzyme inhibition (PEACE) trial evaluated angiotensin-converting enzyme inhibition with trandolapril versus placebo added to conventional therapy in patients with stable coronary disease and preserved left ventricular function. The PEACE hemodynamic substudy evaluated effects of trandolapril on pulsatile hemodynamics. Hemodynamic studies were performed in 300 participants from 5 PEACE centers a median of 52 months (range, 25 to 80 months) after random assignment to trandolapril at a target dose of 4 mg per day or placebo. Central pulsatile hemodynamics and carotid-femoral pulse wave velocity were assessed by using echocardiography, tonometry of the carotid and femoral arteries, and body surface transit distances. Patients randomly assigned to trandolapril tended to be older (mean+/-SD: 64.2+/-7.9 versus 62.9+/-7.7 years; P=0.14), with a higher body mass index (28.5+/-4.0 versus 27.8+/-3.9 kg/m(2); P=0.09) and lower ejection fraction (57.1+/-8.1% versus 58.7+/-8.4%; P<0.01). At the time of the hemodynamic substudy, the trandolapril group had lower mean arterial pressure (93.1+/-10.2 versus 96.3+/-11.3 mm Hg; P<0.01) and lower carotid-femoral pulse wave velocity (geometric mean [95% CI]: 10.4 m/s [10.0 to 10.9 m/s] versus 11.2 m/s [10.7 to 11.8 m/s]; P=0.02). The difference in carotid-femoral pulse wave velocity persisted (P<0.01) in an analysis that adjusted for baseline characteristics and follow-up mean pressure. In contrast, there was no difference in aortic compliance, characteristic impedance, augmentation index, or total arterial compliance. Angiotensin-converting enzyme inhibition with trandolapril produced a modest reduction in carotid-femoral pulse wave velocity, a measure of aortic wall stiffness, beyond what would be expected from blood pressure lowering or differences in baseline characteristics alone.
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Amigoni M, Meris A, Thune JJ, Mangalat D, Skali H, Bourgoun M, Warnica JW, Barvik S, Arnold JMO, Velazquez EJ, Van de Werf F, Ghali J, McMurray JJV, Køber L, Pfeffer MA, Solomon SD. Mitral regurgitation in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: prognostic significance and relation to ventricular size and function. Eur Heart J 2007; 28:326-33. [PMID: 17251259 DOI: 10.1093/eurheartj/ehl464] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Mitral regurgitation (MR) confers independent risk in patients with acute myocardial infarction. We utilized data from the VALsartan In Acute myocardial iNfarcTion echo study to relate baseline MR to left ventricular (LV) size, shape, and function, and to assess the relationship between baseline MR and progression of MR and cardiovascular (CV) outcomes. METHODS AND RESULTS We studied 496 patients with heart failure (HF) and/or systolic dysfunction after MI who underwent echocardiography at a median of 5 days after MI. MR severity, quantified as the regurgitant jet area/left atrial area ratio, was assessed at baseline, one and 20 months post-MI and related to LV size, shape, function, and clinical outcomes. Increased MR at baseline was associated with larger LV end-diastolic and end-systolic volumes, increased sphericity index, and reduced ejection fraction (P trend < 0.001). Moderate-severe MR was an independent predictor of total mortality [adjusted hazard ratio (HR) 2.4 (1.1-5.3)], CV mortality [adjusted HR 2.7 (1.2-6.1)], hospitalization for HF [adjusted HR 2.5 (1.1-5.5)], or death or HF hospitalization [adjusted HR 2.5 (1.4-4.6)]. Patients with progression of MR during the first post-MI month were substantially more likely to die or develop HF (adjusted HR per increased MR grade 3.0, 95% CI 1.8-4.9). Progression of MR over 20 months in survivors was associated with increased hospitalizations for HF (P < 0.001). CONCLUSION Following high-risk myocardial infarction, baseline mitral regurgitant severity is associated with larger LV volumes and worse LV function. Both baseline MR severity and progression of MR are associated with an increased likelihood of adverse outcomes.
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Affiliation(s)
- Maria Amigoni
- Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Thune JJ, Køber L, Pfeffer MA, Skali H, Anavekar NS, Bourgoun M, Ghali JK, Arnold JMO, Velazquez EJ, Solomon SD. Comparison of Regional Versus Global Assessment of Left Ventricular Function in Patients with Left Ventricular Dysfunction, Heart Failure, or Both After Myocardial Infarction: The Valsartan in Acute Myocardial Infarction Echocardiographic Study. J Am Soc Echocardiogr 2006; 19:1462-5. [PMID: 17138030 DOI: 10.1016/j.echo.2006.05.028] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [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: 04/06/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Left ventricular (LV) ejection fraction (EF) and wall-motion index (WMI) have both been shown to be independent predictors of outcome after myocardial infarction (MI). OBJECTIVES We sought to determine whether these two measurements of LV systolic function provide similar or complementary information about prognosis after MI. METHODS Echocardiography was performed in 610 patients with LV dysfunction, heart failure, or both after MI enrolled in the Valsartan in Acute MI trial. LVEF was estimated by biplane Simpson's rule, and WMI was assessed using a 16-segment model in 502 patients with echocardiograms of sufficient quality for wall-motion assessment. RESULTS Both LVEF and WMI were independent predictors of adverse outcome after MI. LVEF conferred no additional prognostic information in multivariable analysis including WMI (P = .39) or number of affected segments (P = .53), whereas WMI (P = .02) and total number of affected segments (P = .006) remained significant even when adjusting for LVEF. CONCLUSIONS Assessment of regional dysfunction by WMI or the number of affected segments has slightly more prognostic value than LVEF in patients with LV dysfunction, heart failure, or both after MI. Regional assessment might be a more sensitive predictor of outcome than global assessment in patients with acute MI.
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Ross H, Howlett J, Arnold JMO, Liu P, O'Neill BJ, Brophy JM, Simpson CS, Sholdice MM, Knudtson M, Ross DB, Rottger J, Glasgow K. Treating the right patient at the right time: access to heart failure care. Can J Cardiol 2006; 22:749-54. [PMID: 16835668 PMCID: PMC2560514 DOI: 10.1016/s0828-282x(06)70290-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [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: 01/24/2023] Open
Abstract
Heart failure affects over 500,000 Canadians, and 50,000 new patients are diagnosed each year. The mortality remains staggering, with a five-year age-adjusted rate of 45%. Disease management programs for heart failure patients have been associated with improved outcomes, the use of evidence-based therapies, improved quality of care, and reduced costs, mortality and hospitalizations. Currently, national benchmarks and targets for access to care for cardiovascular procedures or office consultations do not exist. The present paper summarizes the currently available data, particularly focusing on the risk of adverse events as a function of waiting time, as well as on the identification of gaps in existing data on heart failure. Using best evidence and expert consensus, the present article also focuses on timely access to care for acute and chronic heart failure, including timely access to heart failure disease management programs and physician care (heart failure specialists, cardiologists, internists and general practitioners).
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Affiliation(s)
- H Ross
- Department of Medicine, University Health Network, University of Toronto, Toronto, Canada.
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Janardhanan R, Daley WL, Naqvi TZ, Mulvagh SL, Aurigemma G, Zile M, Arnold JMO, Artis E, Purkayastha D, Thomas JD, Solomon SD. Rationale and design: the VALsartan In Diastolic Dysfunction (VALIDD) Trial: evolving the management of diastolic dysfunction in hypertension. Am Heart J 2006; 152:246-52. [PMID: 16875904 DOI: 10.1016/j.ahj.2006.01.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [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: 10/03/2005] [Accepted: 01/24/2006] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although 50% of hypertensive patients in the community are estimated to have diastolic dysfunction, there is no specific guideline for diastolic dysfunction therapy at present despite the condition's clear association with increased cardiovascular risk. Although the efficacy of angiotensin II receptor blockers (ARBs) in hypertension and left ventricular hypertrophy regression has been established, the effect of angiotensin II receptor blockade on intrinsic parameters of diastolic function has not been evaluated in large-scale studies. METHODS The VALIDD Trial is an investigator-initiated randomized, controlled, double-blind clinical trial on approximately 350 patients designed to explore whether antihypertensive therapy with the ARB valsartan, in addition to standard therapy, would improve intrinsic diastolic properties of the myocardium in patients with hypertension and evidence of diastolic dysfunction. The result of such therapy will be compared with placebo after 38 weeks of treatment. The primary efficacy variable is change in early diastolic lateral mitral annular relaxation velocity measured by tissue Doppler imaging on week 38. CONCLUSIONS We expect the VALIDD Trial to provide novel insights into the specific effects of ARBs on diastolic dysfunction, as assessed by tissue Doppler imaging, in hypertensive patients. The trial may provide clinically useful data on whether such therapy can directly improve diastolic function in patients with hypertension.
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Affiliation(s)
- Rajesh Janardhanan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Stewart DJ, Hilton JD, Arnold JMO, Gregoire J, Rivard A, Archer SL, Charbonneau F, Cohen E, Curtis M, Buller CE, Mendelsohn FO, Dib N, Page P, Ducas J, Plante S, Sullivan J, Macko J, Rasmussen C, Kessler PD, Rasmussen HS. Angiogenic gene therapy in patients with nonrevascularizable ischemic heart disease: a phase 2 randomized, controlled trial of AdVEGF121 (AdVEGF121) versus maximum medical treatment. Gene Ther 2006; 13:1503-11. [PMID: 16791287 DOI: 10.1038/sj.gt.3302802] [Citation(s) in RCA: 198] [Impact Index Per Article: 11.0] [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: 11/09/2022]
Abstract
The demonstration that angiogenic growth factors can stimulate new blood vessel growth and restore perfusion in animal models of myocardial ischemia has led to the development of strategies designed for the local production of angiogenic growth factors in patients who are not candidates for conventional revascularization. The results of recent clinical trials of proangiogenesis gene therapy have been disappointing; however, significant limitations in experimental design, in particular in gene transfer strategies, preclude drawing definitive conclusions. In the REVASC study cardiac gene transfer was optimized by direct intramyocardial delivery of a replication-deficient adenovirus-containing vascular endothelial growth factor (AdVEGF121, 4 x 10(10) particle units (p.u.)). Sixty-seven patients with severe angina due to coronary artery disease and no conventional options for revascularization were randomized to AdVEGF121 gene transfer via mini-thoracotomy or continuation of maximal medical treatment. Exercise time to 1 mm ST-segment depression, the predefined primary end-point analysis, was significantly increased in the AdVEGF121 group compared to control at 26 weeks (P=0.026), but not at 12 weeks. As well, total exercise duration and time to moderate angina at weeks 12 and 26, and in angina symptoms as measured by the Canadian Cardiovascular Society Angina Class and Seattle Angina Questionnaire were all improved by VEGF gene transfer (all P-values at 12 and 26 weeks < or =0.001). However, if anything the results of nuclear perfusion imaging favored the control group, although the AdVEGF121 group achieved higher workloads. Overall there was no significant difference in adverse events between the two groups, despite the fact that procedure-related events were seen only in the thoracotomy group. Therefore, administration of AdVEGF121 by direct intramyocardial injections resulted in objective improvement in exercise-induced ischemia in patients with refractory ischemic heart disease.
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Affiliation(s)
- D J Stewart
- Division of Cardiology, St Michael's Hospital, 30 Bond Street, Rm. 6050 Queen Wing, Toronto, Ontario, Canada.
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Affiliation(s)
- Ross T. Tsuyuki
- From the Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta (RTT) and the Division of Cardiology, Faculty of Medicine, University of Western Ontario (JMOA)
| | - J. Malcolm O. Arnold
- From the Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta (RTT) and the Division of Cardiology, Faculty of Medicine, University of Western Ontario (JMOA)
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Lonn E, Held C, Arnold JMO, Probstfield J, McQueen M, Micks M, Pogue J, Sheridan P, Bosch J, Genest J, Yusuf S. Rationale, design and baseline characteristics of a large, simple, randomized trial of combined folic acid and vitamins B6 and B12 in high-risk patients: the Heart Outcomes Prevention Evaluation (HOPE)-2 trial. Can J Cardiol 2006; 22:47-53. [PMID: 16450017 PMCID: PMC2538982 DOI: 10.1016/s0828-282x(06)70238-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [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: 12/21/2022] Open
Abstract
BACKGROUND Epidemiological studies suggest that mild to moderate elevation in plasma homocysteine concentration is associated with increased risk of atherothrombotic cardiovascular (CV) disease. Simple, inexpensive and nontoxic therapy with folic acid and vitamins B6 and B12 reduces plasma homocysteine levels by approximately 25% to 30% and may reduce CV events. Therefore, a large, randomized clinical trial--the Heart Outcomes Prevention Evaluation (HOPE)-2 study--is being conducted to evaluate this therapy in patients at high risk for CV events. OBJECTIVES To evaluate whether long-term therapy with folic acid and vitamins B6 and B12 reduces the risk of major CV events in a high-risk population. The primary study outcome is the composite of death from CV causes, myocardial infarction and stroke. METHODS A total of 5522 patients aged 55 years or older with pre-existing CV disease or with diabetes and additional risk factor(s) at 145 centres in 13 countries were randomly assigned to daily therapy with combined folic acid 2.5 mg, vitamin B6 50 mg and vitamin B12 1 mg, or to placebo. Follow-up will average five years, to be completed by the end of 2005. RESULTS The patients' baseline characteristics confirmed their high-risk status. Baseline homocysteine levels varied between countries and regions. HOPE-2 is one of the largest trials of folate and vitamins B6 and B12 and is expected to significantly contribute to the evaluation of the role of homocysteine lowering in CV prevention.
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Affiliation(s)
- E Lonn
- Hamilton Health Sciences Corporation, Hamilton, Ontario.
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Svendsen A, Arnold JMO, Parker J. Caring for patients with heart failure. Can Nurse 2006; 102:14-5, 17. [PMID: 16579216] [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] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Affiliation(s)
- Anna Svendsen
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia
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Lu X, Hamilton JA, Shen J, Pang T, Jones DL, Potter RF, Arnold JMO, Feng Q. Role of tumor necrosis factor-α in myocardial dysfunction and apoptosis during hindlimb ischemia and reperfusion. Crit Care Med 2006; 34:484-91. [PMID: 16424732 DOI: 10.1097/01.ccm.0000199079.64231.c1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [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: 11/26/2022]
Abstract
OBJECTIVE Peripheral vascular surgery involving limb ischemia/reperfusion is associated with tumor necrosis factor-alpha production and an increased risk of cardiac complications. The objective of this study was to investigate the role of tumor necrosis factor-alpha in myocardial apoptosis and dysfunction following hindlimb ischemia/reperfusion. DESIGN Randomized perspective animal study. SETTING Research laboratory. SUBJECTS Adults male tumor necrosis factor-alpha(-/-) and littermate wild-type mice. INTERVENTIONS Bilateral hindlimb ischemia/reperfusion was induced in wild-type and tumor necrosis factor-alpha(-/-) mice using tourniquet occlusion. After 2 hrs of hindlimb ischemia, the tourniquets were released, allowing reperfusion for 0.5-24 hrs. MEASUREMENTS AND MAIN RESULTS In wild-type mice, hindlimb ischemia/reperfusion resulted in myocardial depression early during the reperfusion period (p < .05). These effects were temporally correlated with enhanced levels of myocardial and plasma tumor necrosis factor-alpha. All variables were restored to baseline levels by 24 hrs of reperfusion. Myocardial apoptosis, assessed by cell death enzyme-linked immunosorbent assay, terminal deoxynucleotidyl transferase-mediated biotin-dUTP nick-end labeling staining, and caspase-3 activity, was also significantly higher at 6 hrs of reperfusion (p < .05) but returned to baseline levels by 24 hrs. Interestingly, cardiac dysfunction and myocardial apoptosis were abolished in tumor necrosis factor-alpha mice subjected to the same degree of hindlimb ischemia/reperfusion as the wild-type mice. Treatment of etanercept restored cardiac function in wild-type mice. CONCLUSIONS Tumor necrosis factor-alpha contributes significantly to myocardial dysfunction and apoptosis in hindlimb ischemia/reperfusion. Although a causal link between myocardial apoptosis and cardiac dysfunction is not established, our study does suggest that tumor necrosis factor-alpha may be a potential therapeutic target for cardiac injury in clinical situations involving prolonged remote ischemia/reperfusion.
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Affiliation(s)
- Xiangru Lu
- Cardiology Research Lab, Centre for Critical Illness Research, Lawson Health Research Institute, London Health Sciences Centre, Victoria Hospital, Ontario, Canada
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Arnold JMO, Liu P, Demers C, Dorian P, Giannetti N, Haddad H, Heckman GA, Howlett JG, Ignaszewski A, Johnstone DE, Jong P, McKelvie RS, Moe GW, Parker JD, Rao V, Ross HJ, Sequeira EJ, Svendsen AM, Teo K, Tsuyuki RT, White M. Canadian Cardiovascular Society consensus conference recommendations on heart failure 2006: diagnosis and management. Can J Cardiol 2006; 22:23-45. [PMID: 16450016 PMCID: PMC2538984 DOI: 10.1016/s0828-282x(06)70237-9] [Citation(s) in RCA: 276] [Impact Index Per Article: 15.3] [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: 11/23/2005] [Accepted: 11/30/2005] [Indexed: 02/07/2023] Open
Abstract
Heart failure remains a common diagnosis, especially in older individuals. It continues to be associated with significant morbidity and mortality, but major advances in both diagnosis and management have occurred and will continue to improve symptoms and other outcomes in patients. The Canadian Cardiovascular Society published its first consensus conference recommendations on the diagnosis and management of heart failure in 1994, followed by two brief updates, and reconvened this consensus conference to provide a comprehensive review of current knowledge and management strategies. New clinical trial evidence and meta-analyses were critically reviewed by a multidisciplinary primary panel who developed both recommendations and practical tips, which were reviewed by a secondary panel. The resulting document is intended to provide practical advice for specialists, family physicians, nurses, pharmacists and others who are involved in the care of heart failure patients. Management of heart failure begins with an accurate diagnosis, and requires rational combination drug therapy, individualization of care for each patient (based on their symptoms, clinical presentation and disease severity), appropriate mechanical interventions including revascularization and devices, collaborative efforts among health care professionals, and education and cooperation of the patient and their immediate caregivers. The goal is to translate best evidence-based therapies into clinical practice with a measureable impact on the health of heart failure patients in Canada.
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Mitchell GF, Lacourcière Y, Arnold JMO, Dunlap ME, Conlin PR, Izzo JL. Changes in Aortic Stiffness and Augmentation Index After Acute Converting Enzyme or Vasopeptidase Inhibition. Hypertension 2005; 46:1111-7. [PMID: 16230523 DOI: 10.1161/01.hyp.0000186331.47557.ae] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [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: 11/16/2022]
Abstract
Augmentation index (AI), a measure of enhanced wave reflection, has been proposed as a bedside measure of aortic stiffness. However, because AI is potentially sensitive to various factors other than vessel wall stiffness, the utility of AI as a stiffness indicator may be limited. To assess relations between AI and vascular properties, we used arterial tonometry and aortic Doppler flow to evaluate trough (24 hours) and peak (4 hours) pulsatile hemodynamics and pulse wave velocity in 159 individuals with systolic hypertension at the completion of a 12-week period of monotherapy with the vasopeptidase inhibitor omapatrilat (80 mg; n=75) or the converting enzyme inhibitor enalapril (40 mg; n=84). Characteristic impedance (Zc) was calculated from the ratio of change in carotid pressure and aortic flow in early systole. Systolic ejection period (SEP), timing of wave reflection, and AI were assessed from the carotid waveform. Comparable acute reductions in mean pressure were associated with greater reductions in peripheral resistance with enalapril, whereas neither drug had an acute effect on Zc. Both drugs reduced AI, but neither drug altered the timing of wave reflection. Both drugs increased heart rate and shortened SEP. Multiple regression analysis demonstrated that the acute reduction in AI was most affected by reductions in SEP and peripheral resistance. Change in AI was inversely related to change in Zc and pulse wave velocity did not enter the model. Our findings indicate that AI is a complex surrogate marker that is inversely related to changes in proximal aortic stiffness in systolic hypertension.
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Gwadry-Sridhar FH, Arnold JMO, Zhang Y, Brown JE, Marchiori G, Guyatt G. Pilot study to determine the impact of a multidisciplinary educational intervention in patients hospitalized with heart failure. Am Heart J 2005; 150:982. [PMID: 16290975 DOI: 10.1016/j.ahj.2005.08.016] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 08/27/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients with heart failure (HF) face challenges complying with multidrug regimens. OBJECTIVES To examine the impact of a compliance enhancing intervention on medication compliance and morbidity in HF. DESIGN Patients were randomized to either usual care or an inhospital educational intervention delivered by a multidisciplinary team (Intervention). SETTING Acute medical and surgical units at a teaching hospital. PATIENTS One hundred thirty four patients with a clinical diagnosis of HF and a left ventricular ejection fraction of < 40% requiring long-term medical treatment. MAIN OUTCOME MEASURES A validated HF-specific instrument provided a measure of knowledge. We characterized patients as noncompliant if pharmacy refill data suggested they had taken < or = 0.80 of their medication. We measured quality of life using the Minnesota Living with Heart Failure Questionnaire and the Short Form 36 and conducted a time to first event analysis of a composite end point including mortality, readmissions, and emergency department visits. RESULTS The Intervention group showed higher knowledge scores at discharge and 1 year (P = .05). The risk of noncompliance in Intervention patients varied from 0.78 (95% CI 0.33-1.89) for ACE-I (13% Intervention, 17% Control) to 1.02 (0.49-2.12) for diuretics (23% Intervention, 23% Control). Quality of life improved in both groups over time; the only difference between groups favored the Intervention (Minnesota Living with Heart Failure Questionnaire, P = .04). The composite end point occurred in 67% of control and 60% of Intervention patients (hazard ratio 0.85, 95% CI 0.55-1.30). CONCLUSIONS An inhospital educational intervention improved knowledge and, possibly, quality of life and may be useful as part of a comprehensive compliance enhancing strategy in patients with HF.
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Mitchell GF, Arnold JMO, Dunlap ME, O'Brien TX, Marchiori G, Warner E, Granger CB, Desai SS, Pfeffer MA. Pulsatile hemodynamic effects of candesartan in patients with chronic heart failure: the CHARM Program. Eur J Heart Fail 2005; 8:191-7. [PMID: 16188495 DOI: 10.1016/j.ejheart.2005.07.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2005] [Revised: 05/27/2005] [Accepted: 07/13/2005] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Abnormal large artery function and increased pulsatile load are exacerbated by excess angiotensin-II acting through the AT1 receptor and contribute to the pathogenesis and progression of chronic heart failure (CHF). AIMS To evaluate effects of the AT1 receptor blocker candesartan (N = 30) or placebo (N = 34) on pulsatile hemodynamics in participants with CHF in the CHARM program. METHODS AND RESULTS Noninvasive hemodynamics were assessed following 6 and 14 months of treatment and averaged. Using calibrated tonometry and aortic outflow Doppler, characteristic impedance was calculated as the ratio of the change in carotid pressure and aortic flow in early systole. Total arterial compliance was calculated by the diastolic area method. Brachial blood pressure, cardiac output and peripheral resistance did not differ between groups. Lower central pulse pressure in the candesartan group (57+/-20 vs. 67+/-17 mmHg, P = 0.043) was accompanied by lower characteristic impedance (200+/-78 vs. 240+/-74 dyne s/cm5, P = 0.039) and higher total arterial compliance (1.87+/-0.70 vs. 1.47+/-0.48 ml/mmHg, P = 0.008). Similar favorable differences were seen when analyses were stratified for ejection fraction (< or = 0.40 vs. >0.40) and baseline angiotensin converting enzyme inhibitor use. CONCLUSIONS Candesartan has a favorable effect on large artery function in patients with chronic heart failure.
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Affiliation(s)
- Gary F Mitchell
- Cardiovascular Engineering, Inc., 327 Fiske Street, Holliston, MA 01746, USA.
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Radford MJ, Arnold JMO, Bennett SJ, Cinquegrani MP, Cleland JGF, Havranek EP, Heidenreich PA, Rutherford JD, Spertus JA, Stevenson LW, Goff DC, Grover FL, Malenka DJ, Peterson ED, Redberg RF. ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with chronic heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Heart Failure Clinical Data Standards): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Failure Society of America. Circulation 2005; 112:1888-916. [PMID: 16162914 DOI: 10.1161/circulationaha.105.170073] [Citation(s) in RCA: 171] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
BACKGROUND We have previously demonstrated that ramipril reduces vascular events and new diagnoses of diabetes when given for a 4.5-year period. However, it is not known whether the benefits are observed in subgroups of patients at varying risk or on other proven therapies and whether the benefits are sustained beyond the current trial. The 2 aims of this investigation were to assess whether the benefits observed during the HOPE trial were (1) maintained after trial cessation during an additional 2.6 years of follow-up and (2) observed in subgroups based on risk and ancillary treatments. METHODS AND RESULTS Of the initial 267 study centers and 9297 patients, 174 centers and 4528 patients agreed to further follow-up. The rates of use of angiotensin-converting-enzyme inhibitors (ACEIs) in the 2 groups (72% ramipril versus 68% placebo) were similar after the end of the trial. During the posttrial follow-up, patients allocated to ramipril had a 19% further lower relative risk (RR) of myocardial infarction (95% confidence interval [CI], 0.65 to 1.01), a 16% lower RR (95% CI, 0.70 to 0.99) of revascularization, and a 34% lower RR of a new diagnosis of diabetes (95% CI, 0.46 to 0.95). Similar RR reductions in vascular events were observed during and after the active phase of the trial, regardless of baseline risk (RR of 0.76, 0.89, and 0.83 for low-, medium-, and high-risk patients, respectively) or ancillary treatments (RR of 0.90 for aspirin, 0.76 for beta-blockers, and 0.84 for lipid-lowering medication). CONCLUSIONS The benefits of ramipril observed during the active period of the HOPE trial were maintained during posttrial follow-up for cardiovascular death, stroke, and hospitalization for heart failure. Additional reductions in myocardial infarction, revascularization, and the development of diabetes were observed during the follow-up phase despite similar rates of ACEI use in the 2 randomized groups. These benefits were consistent regardless of patient risk or ancillary treatments.
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Affiliation(s)
- Jackie Bosch
- Division of Cardiology, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
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Solomon SD, Skali H, Anavekar NS, Bourgoun M, Barvik S, Ghali JK, Warnica JW, Khrakovskaya M, Arnold JMO, Schwartz Y, Velazquez EJ, Califf RM, McMurray JV, Pfeffer MA. Changes in Ventricular Size and Function in Patients Treated With Valsartan, Captopril, or Both After Myocardial Infarction. Circulation 2005; 111:3411-9. [PMID: 15967846 DOI: 10.1161/circulationaha.104.508093] [Citation(s) in RCA: 209] [Impact Index Per Article: 11.0] [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] [Indexed: 11/16/2022]
Abstract
Background—
Angiotensin-converting enzyme (ACE) inhibitors have been shown to attenuate left ventricular (LV) enlargement in association with reducing mortality after myocardial infarction (MI). Preclinical data suggest that angiotensin receptor blockers (ARBs) may have similar structural and functional effects after MI. The Valsartan in Acute Myocardial Infarction (VALIANT) Echo study was designed to test the hypothesis that the ARB valsartan, either alone or in combination with captopril, could attenuate progressive LV enlargement or improve LV ejection fraction to a greater extent than captopril alone.
Methods and Results—
Six hundred ten patients enrolled in the main VALIANT study who experienced MI and evidence of LV dysfunction, heart failure, or both were enrolled in the VALIANT Echo study. Patients were randomized to receive valsartan 160 mg PO BID, captopril 50 mg PO TID, or valsartan 80 mg PO BID plus captopril 50 mg PO TID between 1 and 10 days after MI. Six hundred three patients had echocardiograms of sufficient quality for quantitative analysis. Echocardiograms were digitized, and endocardial borders were traced manually from 2 short-axis and 2 apical views. Ventricular volumes, ejection fractions, combined areas, and infarct segment length were measured, and changes in echocardiographic measures from baseline to 20 months were compared between treatment groups. Baseline clinical and echocardiographic characteristics were similar in the 3 treatment arms. The changes from baseline to 20 months in all echocardiographic parameters were similar in all 3 treatment arms. Baseline echocardiographic measures of ejection fraction, end-diastolic volume, and infarct segment length were highly predictive of outcomes including total mortality, death or hospitalization for heart failure, or death or any cardiovascular event (heart failure, MI, stroke, resuscitated sudden death), even after adjustment for known covariates.
Conclusions—
Treatment with the ACE inhibitor captopril, valsartan, or the combination of captopril plus valsartan resulted in similar changes in cardiac volume, ejection fraction, and infarct segment length between baseline and 20 months after MI. Baseline echocardiographic measures were powerfully and independently predictive of all major outcomes.
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Affiliation(s)
- Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass 02115, USA.
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Lonn E, Bosch J, Yusuf S, Sheridan P, Pogue J, Arnold JMO, Ross C, Arnold A, Sleight P, Probstfield J, Dagenais GR. Effects of long-term vitamin E supplementation on cardiovascular events and cancer: a randomized controlled trial. JAMA 2005; 293:1338-47. [PMID: 15769967 DOI: 10.1001/jama.293.11.1338] [Citation(s) in RCA: 775] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CONTEXT Experimental and epidemiological data suggest that vitamin E supplementation may prevent cancer and cardiovascular events. Clinical trials have generally failed to confirm benefits, possibly due to their relatively short duration. OBJECTIVE To evaluate whether long-term supplementation with vitamin E decreases the risk of cancer, cancer death, and major cardiovascular events. DESIGN, SETTING, AND PATIENTS A randomized, double-blind, placebo-controlled international trial (the initial Heart Outcomes Prevention Evaluation [HOPE] trial conducted between December 21, 1993, and April 15, 1999) of patients at least 55 years old with vascular disease or diabetes mellitus was extended (HOPE-The Ongoing Outcomes [HOPE-TOO]) between April 16, 1999, and May 26, 2003. Of the initial 267 HOPE centers that had enrolled 9541 patients, 174 centers participated in the HOPE-TOO trial. Of 7030 patients enrolled at these centers, 916 were deceased at the beginning of the extension, 1382 refused participation, 3994 continued to take the study intervention, and 738 agreed to passive follow-up. Median duration of follow-up was 7.0 years. INTERVENTION Daily dose of natural source vitamin E (400 IU) or matching placebo. MAIN OUTCOME MEASURES Primary outcomes included cancer incidence, cancer deaths, and major cardiovascular events (myocardial infarction, stroke, and cardiovascular death). Secondary outcomes included heart failure, unstable angina, and revascularizations. RESULTS Among all HOPE patients, there were no significant differences in the primary analysis: for cancer incidence, there were 552 patients (11.6%) in the vitamin E group vs 586 (12.3%) in the placebo group (relative risk [RR], 0.94; 95% confidence interval [CI], 0.84-1.06; P = .30); for cancer deaths, 156 (3.3%) vs 178 (3.7%), respectively (RR, 0.88; 95% CI, 0.71-1.09; P = .24); and for major cardiovascular events, 1022 (21.5%) vs 985 (20.6%), respectively (RR, 1.04; 95% CI, 0.96-1.14; P = .34). Patients in the vitamin E group had a higher risk of heart failure (RR, 1.13; 95% CI, 1.01-1.26; P = .03) and hospitalization for heart failure (RR, 1.21; 95% CI, 1.00-1.47; P = .045). Similarly, among patients enrolled at the centers participating in the HOPE-TOO trial, there were no differences in cancer incidence, cancer deaths, and major cardiovascular events, but higher rates of heart failure and hospitalizations for heart failure. CONCLUSION In patients with vascular disease or diabetes mellitus, long-term vitamin E supplementation does not prevent cancer or major cardiovascular events and may increase the risk for heart failure.
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Affiliation(s)
- Eva Lonn
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario
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Gustafsson F, Arnold JMO. Heart failure clinics and outpatient management: review of the evidence and call for quality assurance. Eur Heart J 2004; 25:1596-604. [PMID: 15351158 DOI: 10.1016/j.ehj.2004.06.023] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2004] [Revised: 05/22/2004] [Accepted: 06/17/2004] [Indexed: 11/28/2022] Open
Abstract
Despite major advances in treatment options for heart failure patients, morbidity and mortality remain unacceptably high. Frequent readmissions are distressful for patients and are associated with large costs for society. In an attempt to improve care for heart failure patients and thereby reduce morbidity and hospital readmissions, specialised heart failure clinics have emerged over the last 10 years. In particular, clinics relying, at least in part, on nurses specially trained in heart failure have gained popularity. This review of the published literature describes the wide variety of designs and the types of interventions taking place in such heart failure clinics. A total of 18 randomised studies comparing heart failure clinics using nurse intervention with conventional care have been published to date, and the majority of these have shown either a reduction in hospital readmissions or shortening of hospitalisations in the intervention group. These findings are supported by the results of several non-randomised, controlled investigations. Thus, it is concluded that heart failure clinics using nurse intervention should be an integrated part of the care process for patients with heart failure wherever possible. We argue that ongoing attention should be paid to the quality of care delivered by the clinics to ensure that the benefit of this intervention strategy persists. Thus, it would be of importance to continuously record relevant data describing the care process using specific indicators such as ACE-inhibitor and beta-blocker use and doses. One possible, practical method to apply such continuous quality assurance may be by means of electronic medical record databases.
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Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
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Teasell RW, Arnold JMO. Alpha-1 adrenoceptor hyperresponsiveness in three neuropathic pain states: complex regional pain syndrome 1, diabetic peripheral neuropathic pain and central pain states following spinal cord injury. Pain Res Manag 2004; 9:89-97. [PMID: 15211988 DOI: 10.1155/2004/150503] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [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: 11/17/2022]
Abstract
The pathophysiology of the pain associated with complex regional pain syndrome, spinal cord injury and diabetic peripheral neuropathy is not known. The pain of complex regional pain syndrome has often been attributed to abnormal sympathetic nervous system activity based on the presence of vasomotor instability and a frequently reported positive response, albeit a temporary response, to sympathetic blockade. In contrast, the pain below the level of spinal cord injury and diabetic peripheral neuropathy are generally seen as deafferentation phenomena. Each of these pain states has been associated with abnormal sympathetic nervous system function and increased peripheral alpha-1 adrenoceptor activity. This increased responsiveness may be a consequence of alpha-1 adrenoceptor postsynaptic hypersensitivity, or alpha-2 adrenoceptor presynaptic dysfunction with diminished noradrenaline reuptake, increased concentrations of noradrenaline in the synaptic cleft and increased stimulation of otherwise normal alpha-1 adrenoceptors. Plausible mechanisms based on animal research by which alpha-1 adrenoceptor hyperresponsiveness can lead to chronic neuropathic-like pain have been reported. This raises the intriguing possibility that sympathetic nervous system dysfunction may be an important factor in the generation of pain in many neuropathic pain states. Although results to date have been mixed, there may be a greater role for new drugs which target peripheral alpha-2 adrenoceptors (agonists) or alpha-1 adrenoceptors (antagonists).
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Affiliation(s)
- Robert W Teasell
- Physical Medicine and Rehabilitation, Lawson Research Institute, University of Western Ontario, and Parkwood Hospital, St. Joseph's Health Care London, 801 Commissioners Road East, London, Ontario N6C 5J1, Canada.
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