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Friedman KG, Gauvreau K, Hamaoka-Okamoto A, Tang A, Berry E, Tremoulet AH, Mahavadi VS, Baker A, deFerranti SD, Fulton DR, Burns JC, Newburger JW. Coronary Artery Aneurysms in Kawasaki Disease: Risk Factors for Progressive Disease and Adverse Cardiac Events in the US Population. J Am Heart Assoc 2016; 5:JAHA.116.003289. [PMID: 27633390 PMCID: PMC5079009 DOI: 10.1161/jaha.116.003289] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The natural history of coronary artery aneurysms (CAA) after intravenous immunoglobulin (IVIG) treatment in the United States is not well described. We describe the natural history of CAA in US Kawasaki disease (KD) patients and identify factors associated with major adverse cardiac events (MACE) and CAA regression. Methods and Results We evaluated all KD patients with CAA at 2 centers from 1979 to 2014. Factors associated with CAA regression, maximum CA z‐score over time (zMax), and MACE were analyzed. We performed a matched analysis of treatment effect on likelihood of CAA regression. Of 2860 KD patients, 500 (17%) had CAA, including 90 with CAA z‐score >10. Most (91%) received IVIG within 10 days of illness, 32% received >1 IVIG, and 27% received adjunctive anti‐inflammatory medications. CAA regression occurred in 75%. Lack of CAA regression and higher CAA zMax were associated with earlier era, larger CAA z‐score at diagnosis, and bilateral CAA in univariate and multivariable analyses. MACE occurred in 24 (5%) patients and was associated with higher CAA z‐score at diagnosis and lack of IVIG treatment. In a subset of patients (n=132) matched by age at KD and baseline CAA z‐score, those receiving IVIG plus adjunctive medication had a CAA regression rate of 91% compared with 68% for the 3 other groups (IVIG alone, IVIG ≥2 doses, or IVIG ≥2 doses plus adjunctive medication). Conclusions CAA regression occurred in 75% of patients. CAA z‐score at diagnosis was highly predictive of outcomes, which may be improved by early IVIG treatment and adjunctive therapies.
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Affiliation(s)
- Kevin G Friedman
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberly Gauvreau
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Alexander Tang
- Department of Cardiology, Children's Hospital Boston, Boston, MA
| | - Erika Berry
- Department of Pediatrics, University of California San Diego, La Jolla, CA Rady Children's Hospital San Diego, San Diego, CA
| | - Adriana H Tremoulet
- Department of Pediatrics, University of California San Diego, La Jolla, CA Rady Children's Hospital San Diego, San Diego, CA
| | - Vidya S Mahavadi
- Department of Pediatrics, University of California San Diego, La Jolla, CA Rady Children's Hospital San Diego, San Diego, CA
| | - Annette Baker
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sarah D deFerranti
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - David R Fulton
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane C Burns
- Department of Pediatrics, Harvard Medical School, Boston, MA Rady Children's Hospital San Diego, San Diego, CA
| | - Jane W Newburger
- Department of Cardiology, Children's Hospital Boston, Boston, MA Department of Pediatrics, Harvard Medical School, Boston, MA
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302
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Hegeman TW, Glorioso TJ, Hess E, Barón AE, Ho PM, Maddox TM, Bradley SM, Burke RE. Facility-Level Percutaneous Coronary Intervention Readmission Rates Are Not Associated With Facility-Level Mortality: Insights From the VA Clinical Assessment, Reporting, and Tracking (CART) Program. J Am Heart Assoc 2016; 5:JAHA.116.003503. [PMID: 27628574 PMCID: PMC5079017 DOI: 10.1161/jaha.116.003503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Thirty-day readmission after percutaneous coronary intervention (PCI) is common, costly, and linked to poor patient outcomes. Accordingly, facility-level 30-day readmission rates have been considered as a potential quality measure. However, it is unknown whether facility-level 30-day readmission rates are associated with facility-level mortality. We sought to determine the effect of 30-day readmissions after PCI on mortality at both the patient and facility level in the Veterans Administration hospital system. METHODS AND RESULTS We included all patients who underwent PCI in the Veterans Administration hospital system nationally from October 2007 through August 2012, comparing all-cause mortality rates between patients with and without 30-day readmissions following PCI. Patients were then aggregated at the hospital level to evaluate the correlation between hospital-level readmission rates with hospital-level 1-year mortality rates. Among 41 069 patients undergoing PCI at 62 sites, 12.2% were readmitted within 30 days of discharge. Patients with 30-day readmission had higher risk-adjusted mortality (hazard ratio 1.53, 95% CI 1.44-1.63, P<0.0001). Facilities varied widely in 30-day readmission rates (systemwide range of 6.6-19.4%, median 11.8%, interquartile range 10.0-13.2%); however, adjusted facility-level readmission rates were not correlated with adjusted 1-year mortality rates. CONCLUSIONS Thirty-day readmissions after PCI are common and are a significant risk factor for mortality for individual patients even after robust statistical adjustment for clinical confounding. However, lack of correlation between readmission and mortality at the facility level suggests that quality improvement based on facility-level readmission rates will not modify mortality in this high-risk group.
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Affiliation(s)
- Timothy W Hegeman
- University of Colorado School of Medicine, Aurora, CO Colorado Cardiovascular Outcomes Research Consortium, Denver, CO
| | - Thomas J Glorioso
- Colorado Cardiovascular Outcomes Research Consortium, Denver, CO VA Eastern Colorado Health Care System, Denver, CO Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Edward Hess
- Colorado Cardiovascular Outcomes Research Consortium, Denver, CO VA Eastern Colorado Health Care System, Denver, CO Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Anna E Barón
- University of Colorado School of Medicine, Aurora, CO Colorado Cardiovascular Outcomes Research Consortium, Denver, CO VA Eastern Colorado Health Care System, Denver, CO Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - P Michael Ho
- University of Colorado School of Medicine, Aurora, CO Colorado Cardiovascular Outcomes Research Consortium, Denver, CO VA Eastern Colorado Health Care System, Denver, CO
| | - Thomas M Maddox
- University of Colorado School of Medicine, Aurora, CO Colorado Cardiovascular Outcomes Research Consortium, Denver, CO VA Eastern Colorado Health Care System, Denver, CO
| | - Steven M Bradley
- University of Colorado School of Medicine, Aurora, CO Colorado Cardiovascular Outcomes Research Consortium, Denver, CO VA Eastern Colorado Health Care System, Denver, CO
| | - Robert E Burke
- University of Colorado School of Medicine, Aurora, CO VA Eastern Colorado Health Care System, Denver, CO
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303
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Mackenzie IS, Ford I, Walker A, Hawkey C, Begg A, Avery A, Taggar J, Wei L, Struthers AD, MacDonald TM. Multicentre, prospective, randomised, open-label, blinded end point trial of the efficacy of allopurinol therapy in improving cardiovascular outcomes in patients with ischaemic heart disease: protocol of the ALL-HEART study. BMJ Open 2016; 6:e013774. [PMID: 27609859 PMCID: PMC5020706 DOI: 10.1136/bmjopen-2016-013774] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Ischaemic heart disease (IHD) is one of the most common causes of death in the UK and treatment of patients with IHD costs the National Health System (NHS) billions of pounds each year. Allopurinol is a xanthine oxidase inhibitor used to prevent gout that also has several positive effects on the cardiovascular system. The ALL-HEART study aims to determine whether allopurinol improves cardiovascular outcomes in patients with IHD. METHODS AND ANALYSIS The ALL-HEART study is a multicentre, controlled, prospective, randomised, open-label blinded end point (PROBE) trial of allopurinol (up to 600 mg daily) versus no treatment in a 1:1 ratio, added to usual care, in 5215 patients aged 60 years and over with IHD. Patients are followed up by electronic record linkage and annual questionnaires for an average of 4 years. The primary outcome is the composite of non-fatal myocardial infarction, non-fatal stroke or cardiovascular death. Secondary outcomes include all-cause mortality, quality of life and cost-effectiveness of allopurinol. The study will end when 631 adjudicated primary outcomes have occurred. The study is powered at 80% to detect a 20% reduction in the primary end point for the intervention. Patient recruitment to the ALL-HEART study started in February 2014. ETHICS AND DISSEMINATION The study received ethical approval from the East of Scotland Research Ethics Service (EoSRES) REC 2 (13/ES/0104). The study is event-driven and results are expected after 2019. Results will be reported in peer-reviewed journals and at scientific meetings. Results will also be disseminated to guideline committees, NHS organisations and patient groups. TRIAL REGISTRATION NUMBER 32017426, pre-results.
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Affiliation(s)
- Isla S Mackenzie
- Medicines Monitoring Unit (MEMO) and Hypertension Research Centre, Division of Molecular and Clinical Medicine, University of Dundee and Ninewells Hospital, Dundee, UK
| | - Ian Ford
- Glasgow Clinical Trials Unit, Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Andrew Walker
- Glasgow Clinical Trials Unit, Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Chris Hawkey
- Nottingham Centre for Digestive Disorders, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan Begg
- Townhead Medical Practice, Montrose, UK
| | - Anthony Avery
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Jaspal Taggar
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Li Wei
- Robertson Centre for Biostatistics, Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Allan D Struthers
- Division of Molecular and Clinical Medicine, University of Dundee and Ninewells Hospital, Dundee, UK
| | - Thomas M MacDonald
- Medicines Monitoring Unit (MEMO) and Hypertension Research Centre, Division of Molecular and Clinical Medicine, University of Dundee and Ninewells Hospital, Dundee, UK
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Abstract
This review discusses two distinct, yet related, mechanisms of sodium-glucose cotransporter 2 (SGLT2) inhibition: Calorie restriction mimicry (CRM) and pro-ketogenic effect, which may explain their cardiovascular benefits. We term these adaptive CRM and pro-ketogenic effects of SGLT2 inhibition, the Robin Hood hypothesis. In English history, Robin Hood was a "good person," who stole from the rich and helped the poor. He supported redistribution of resources as he deemed fit for the common good. In a similar fashion, SGLT2 inhibition provides respite to the overloaded glucose metabolism while utilizing lipid stores for energy production.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, Haryana, India
| | - Arpit Jain
- Department of Medicine, Boehringer Ingelheim India Pvt, Ltd., Delhi, India
| | - Jignesh Ved
- Department of Medicine, Boehringer Ingelheim Pvt Ltd, Mumbai, Maharashtra, India
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305
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Lazzeroni D, Gaibazzi N, Bini M, Bussolati G, Camaiora U, Cassi R, Geroldi S, Ugolotti PT, Brambilla L, Brambilla V, Castiglioni P, Coruzzi P. Prognostic value of new left atrial volume index severity partition cutoffs after cardiac rehabilitation program in patients undergoing cardiac surgery. Cardiovasc Ultrasound 2016; 14:35. [PMID: 27552988 PMCID: PMC4994378 DOI: 10.1186/s12947-016-0077-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/13/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Previous studies showed that left atrial enlargement is an independent marker of adverse outcomes in both primary and secondary cardiovascular prevention. However, no data are available on long-term outcomes in patients undergoing valve surgery and/or coronary artery by-pass graft (CABG) surgery. Aim of the study was to evaluate long-term prognostic role of left atrial volume index (LAVi) after cardiac surgery, using the cutoff values recently proposed by the European Association of Cardiovascular Imaging and American Society of Echocardiography. METHODS We created a retrospective registry of 1703 consecutive patients who underwent cardiovascular rehabilitation program after cardiac surgery, including CABG, valve surgery and valve + CABG surgery. LAVi was calculated as ratio of left atrium volume to body surface area, in ml/m(2) at discharge; 563 patients with available LAVi data were included in the study. RESULTS In the whole population LAVi was 36 ± 14 ml/m(2) (mean ± SD) and the follow-up time was 5 ± 1.5 years. Increased LAVi (>34 ml/m(2)) predicted major adverse cardiovascular and cerebrovascular events (MACCEs) (HR = 2.1; CI95 %: 1.4-3.1; p < 0.001) and cardiovascular mortality (HR = 2.2; CI95 %: 1.0-4.5; p = 0.032). An increased LAVi remained MACCEs predictor after adjustement for age, gender, diabetes, atrial fibrillation at discharge, echocardiographic E/A ratio and left ventricular ejection fraction (HR = 1.8; CI95 %: 1.0-3.0; p = 0.036). When the study population was split according to increasing LAVi values, left atrium enlargement resulted a predictor of progressively worse adverse outcome. CONCLUSIONS LAVi is a predictor of long-term adverse cardiovascular outcome after cardiac surgery, even after correction for main clinical and echocardiographic variables. The recently recommended LAVi severity cutoffs appear adequate to effectively stratify outcome in patients undergoing rehabilitation after cardiac surgery.
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Affiliation(s)
- Davide Lazzeroni
- Fondazione Don Carlo Gnocchi, University of Parma, Fondazione Don Gnocchi, Piazzale dei servi n° 3, 43121, Parma, Italy.
| | - Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Parma, Italy
| | - Matteo Bini
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Giacomo Bussolati
- Fondazione Don Carlo Gnocchi, University of Parma, Fondazione Don Gnocchi, Piazzale dei servi n° 3, 43121, Parma, Italy
| | - Umberto Camaiora
- Fondazione Don Carlo Gnocchi, University of Parma, Fondazione Don Gnocchi, Piazzale dei servi n° 3, 43121, Parma, Italy
| | - Roberto Cassi
- Fondazione Don Carlo Gnocchi, University of Parma, Fondazione Don Gnocchi, Piazzale dei servi n° 3, 43121, Parma, Italy
| | - Simone Geroldi
- Fondazione Don Carlo Gnocchi, University of Parma, Fondazione Don Gnocchi, Piazzale dei servi n° 3, 43121, Parma, Italy
| | - Pietro Tito Ugolotti
- Fondazione Don Carlo Gnocchi, University of Parma, Fondazione Don Gnocchi, Piazzale dei servi n° 3, 43121, Parma, Italy
| | - Lorenzo Brambilla
- Fondazione Don Carlo Gnocchi, University of Parma, Fondazione Don Gnocchi, Piazzale dei servi n° 3, 43121, Parma, Italy
| | - Valerio Brambilla
- Fondazione Don Carlo Gnocchi, University of Parma, Fondazione Don Gnocchi, Piazzale dei servi n° 3, 43121, Parma, Italy
| | | | - Paolo Coruzzi
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
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306
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Goodney PP, Newhall KA, Bekelis K, Gottlieb D, Comi R, Chaudrain S, Faerber AE, Mackenzie TA, Skinner JS. Consistency of Hemoglobin A1c Testing and Cardiovascular Outcomes in Medicare Patients With Diabetes. J Am Heart Assoc 2016; 5:JAHA.116.003566. [PMID: 27509909 PMCID: PMC5015285 DOI: 10.1161/jaha.116.003566] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Background Annual hemoglobin A1c testing is recommended for patients with diabetes mellitus. However, it is unknown how consistently patients with diabetes mellitus receive hemoglobin A1c testing over time, or whether testing consistency is associated with adverse cardiovascular outcomes. Methods and Results We identified 1 574 415 Medicare patients (2002–2012) with diabetes mellitus over the age of 65. We followed each patient for a minimum of 3 years to determine their consistency in hemoglobin A1C testing, using 3 categories: low (testing in 0 or 1 of 3 years), medium (testing in 2 of 3 years), and high (testing in all 3 years). In unweighted and inverse propensity‐weighted cohorts, we examined associations between testing consistency and major adverse cardiovascular events, defined as death, myocardial infarction, stroke, amputation, or the need for leg revascularization. Overall, 70.2% of patients received high‐consistency testing, 17.6% of patients received medium‐consistency testing, and 12.2% of patients received low‐consistency testing. When compared to high‐consistency testing, low‐consistency testing was associated with a higher risk of adverse cardiovascular events or death in unweighted analyses (hazard ratio [HR]=1.21; 95% CI, 1.20–1.23; P<0.001), inverse propensity‐weighted analyses (HR=1.16; 95% CI, 1.15–1.17; P<0.001), and weighted analyses limited to patients who had at least 4 physician visits annually (HR=1.15; 95% CI, 1.15–1.16; P<0.001). Less‐consistent testing was associated with worse results for each cardiovascular outcome and in analyses using all years as the exposure. Conclusions Consistent annual hemoglobin A1c testing is associated with fewer adverse cardiovascular outcomes in this observational cohort of Medicare patients of diabetes mellitus.
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Affiliation(s)
- Philip P Goodney
- Dartmouth-Hitchcock Medical Center, Lebanon, NH The VA Outcomes Group, White River Junction, VT The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH
| | - Karina A Newhall
- Dartmouth-Hitchcock Medical Center, Lebanon, NH The VA Outcomes Group, White River Junction, VT
| | | | - Daniel Gottlieb
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH
| | | | | | - Adrienne E Faerber
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH
| | - Todd A Mackenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH
| | - Jonathan S Skinner
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, NH
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307
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Abstract
Over the last two decades, several invasive and non-invasive coronary atherosclerosis imaging modalities have emerged as predictors of cardiovascular outcomes in at-risk population. These modalities have demonstrated independent or incremental prognostic information over existing/standard risk stratification schemes, such as the Framingham risk score (FRS), by identifying characteristics of coronary artery diseases (CADs). In this review, we begin with discussing the importance of pre-test probability and quality of outcome measure, followed by specific findings of each modality in relation to prognosis. We focused on both short and long term prognostic aspects of coronary computed tomography (CT) (including coronary calcium score and coronary angiography) and magnetic resonance imaging as non-invasive tools, as well as invasive modalities including intravascular ultrasound (IVUS), optical coherence tomography (OCT), near infrared spectroscopy and Angioscopy.
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Affiliation(s)
- Faraz Pathan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Kazuaki Negishi
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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308
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Wu JJ, Strober BE, Hansen PR, Ahlehoff O, Egeberg A, Qureshi AA, Robertson D, Valdez H, Tan H, Wolk R. Effects of tofacitinib on cardiovascular risk factors and cardiovascular outcomes based on phase III and long-term extension data in patients with plaque psoriasis. J Am Acad Dermatol 2016; 75:897-905. [PMID: 27498960 DOI: 10.1016/j.jaad.2016.06.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 05/27/2016] [Accepted: 06/06/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Psoriasis is a systemic inflammatory condition that is associated with a higher risk of cardiovascular (CV) disease. Tofacitinib is being investigated as a treatment for psoriasis. OBJECTIVE We sought to evaluate the effects of tofacitinib on CV risk factors and major adverse CV events (MACEs) in patients with plaque psoriasis. METHODS Changes in select CV risk factors and the incidence rate (IR) of MACEs were evaluated in patients who were treated with tofacitinib. RESULTS Tofacitinib treatment was associated with small, dose-dependent increases in total cholesterol, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) cholesterol, while the total/HDL cholesterol ratio was unchanged. There were no changes in blood pressure and glycated hemoglobin levels; C-reactive protein levels decreased. The IRs of a MACE were low and similar for both tofacitinib doses. Among 3623 subjects treated with tofacitinib, the total patient-years of exposure was 5204, with a median follow-up of 527 days, and the IR of MACEs was 0.37 (95% confidence interval, 0.22-0.57) patients with events per 100 patient-years. LIMITATIONS There was relatively short follow-up time for patients who had MACEs. CONCLUSIONS While treatment with tofacitinib is associated with a small increase in cholesterol levels, the total/HDL cholesterol ratio does not change, there are no unfavorable changes in several CV risk factors, and the incidence of MACEs is low.
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Affiliation(s)
- Jashin J Wu
- Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.
| | - Bruce E Strober
- University of Connecticut Health Center, Farmington, Connecticut; Probity Medical Research, Waterloo, Ontario, Canada
| | - Peter R Hansen
- Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Ole Ahlehoff
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, The Heart Centre, Copenhagen, Denmark
| | - Alexander Egeberg
- Department of Cardiology, Herlev and Gentofte Hospital, Hellerup, Denmark; Department of Dermato-Allergology, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - Abrar A Qureshi
- Department of Dermatology, Warren Alpert Medical School, Brown University, Providence, Rhode Island; Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
| | | | | | - Huaming Tan
- Pfizer location in Groton, Groton, Connecticut
| | - Robert Wolk
- Pfizer location in Groton, Groton, Connecticut
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309
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Coleman GC, Shaw PW, Balfour PC, Gonzalez JA, Kramer CM, Patel AR, Salerno M. Prognostic Value of Myocardial Scarring on CMR in Patients With Cardiac Sarcoidosis. JACC Cardiovasc Imaging 2016; 10:411-420. [PMID: 27450877 DOI: 10.1016/j.jcmg.2016.05.009] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/20/2016] [Accepted: 05/25/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study sought to perform a systematic review and meta-analysis to understand the prognostic value of myocardial scarring as evidenced by late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging in patients with known or suspected cardiac sarcoidosis. BACKGROUND Although CMR is increasingly used for the diagnosis of cardiac sarcoidosis, the prognostic value of CMR has been less well described in this population. METHODS PubMed, Cochrane CENTRAL, and metaRegister of Controlled Trials were searched for CMR studies with ≥1 year of prognostic data. Primary endpoints were all-cause mortality and a composite outcome of arrhythmogenic events (ventricular arrhythmia, implantable cardioverter-defibrillator shock, sudden cardiac death) plus all-cause mortality during follow-up. Summary effect estimates were generated with random-effects modeling. RESULTS Ten studies were included, involving a total of 760 patients with a mean follow-up of 3.0 ± 1.1 years. Patients had a mean age of 53 years, 41% were male, 95.3% had known extracardiac sarcoidosis, and 21.6% had known cardiac sarcoidosis. The average ejection fraction was 57.8 ± 9.1%. Patients with LGE had higher odds for all-cause mortality (odds ratio [OR]: 3.06; p < 0.03) and higher odds of the composite outcome (OR: 10.74; p < 0.00001) than those without LGE. Patients with LGE had an increased annualized event rate of the composite outcome (11.9% vs. 1.1%; p < 0.0001). CONCLUSIONS In patients with known or suspected cardiac sarcoidosis, the presence of LGE on CMR imaging is associated with increased odds of both all-cause mortality and arrhythmogenic events.
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Affiliation(s)
- G Cameron Coleman
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Peter W Shaw
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | | | - Jorge A Gonzalez
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Christopher M Kramer
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia
| | - Amit R Patel
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois; Department of Radiology, University of Chicago Medicine, Chicago, Illinois
| | - Michael Salerno
- Department of Medicine, University of Virginia, Charlottesville, Virginia; Department of Biomedical Engineering, University of Virginia, Charlottesville, Virginia.
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310
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Affiliation(s)
- Paulette Wehner
- Department of Cardiovascular Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, WV Department of Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, WV
| | - William Nitardy
- Department of Cardiovascular Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, WV Department of Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, WV
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Kankanala SR, Syed R, Gong Q, Ren B, Rao X, Zhong J. Cardiovascular safety of dipeptidyl peptidase-4 inhibitors: recent evidence on heart failure. Am J Transl Res 2016; 8:2450-2458. [PMID: 27347354 PMCID: PMC4891459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 04/17/2016] [Indexed: 06/06/2023]
Abstract
The cardiovascular safety of DPP4 inhibitors as a class, especially in regards to heart failure, has been questioned after the publication of first trials (SAVOR-TIMI 53 and EXAMINE) assessing the cardiovascular risks of DPP4 inhibitors alogliptin and sitagliptin in 2013. Although there were no increased risks in composite cardiovascular outcomes, the SAVOR-TIMI 53 trial reported a 27% increase in hospitalization for heart failure in diabetic patients who received the DPP4 inhibitor saxagliptin. There has been substantial increase in knowledge on the heart failure effect of DPP4 inhibition since 2013. This review will summarize the role of the DPP4/incretin axis in heart failure and discuss the findings from recent large scale clinical trials assessing the effects of DPP4 inhibitors on heart failure.
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Affiliation(s)
- Saumya Reddy Kankanala
- Division of Cardiovascular Medicine, University of Maryland School of MedicineBaltimore, MD 21201, USA
| | - Rafay Syed
- Division of Cardiovascular Medicine, University of Maryland School of MedicineBaltimore, MD 21201, USA
| | - Quan Gong
- Department of Immunology, School of Medicine, Yangtze UniversityJingzhou, Hubei 434023, China
| | - Boxu Ren
- Department of Immunology, School of Medicine, Yangtze UniversityJingzhou, Hubei 434023, China
| | - Xiaoquan Rao
- Division of Cardiovascular Medicine, University of Maryland School of MedicineBaltimore, MD 21201, USA
| | - Jixin Zhong
- Division of Cardiovascular Medicine, University of Maryland School of MedicineBaltimore, MD 21201, USA
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Huang HL, Jimmy Juang JM, Chou HH, Hsieh CA, Jang SJ, Cheng ST, Ko YL. Immediate results and long-term cardiovascular outcomes of endovascular therapy in octogenarians and nonoctogenarians with peripheral arterial diseases. Clin Interv Aging 2016; 11:535-43. [PMID: 27217735 PMCID: PMC4862757 DOI: 10.2147/cia.s106119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Purpose To investigate the clinical outcomes of endovascular therapy (EVT) in octogenarians and nonoctogenarians with peripheral arterial disease. Methods A retrospective analysis of 511 patients (654 affected legs) who underwent EVT between July 2005 and December 2013 was conducted in a prospectively maintained database. Immediate results and long-term vascular outcomes were analyzed and compared between octogenarians and nonoctogenarians. Results Octogenarians were more likely to be female and have atrial fibrillation (AF), whereas nonoctogenarians had higher rates of obesity, claudication, and medical comorbidities. There were no differences in the rates of EVT success, 30-day major adverse vascular events, and 6-month functional improvement between groups. Over the 10-year follow-up period, the rates of 3-year limb salvage, sustained clinical success, freedom from major cerebrovascular and cardiovascular events, and composite vascular events were similar between groups, but the survival rate was better in nonoctogenarians than in octogenarians (73% vs 63%, respectively, P=0.004). In Cox regression analysis, dependence on dialysis and AF were significant predictors of death (odds ratio [OR] 4.44 in dialyzed and 2.83 in AF patients), major cerebrovascular and cardiovascular events (OR 3.49 and 2.45), and composite vascular events (OR 3.14 and 2.25). Conclusion EVT in octogenarians was feasible, without an increased risk of periprocedural complications. The rates of limb salvage, sustained clinical success, and long-term vascular events were comparable between groups. Dialysis dependence and AF are independent predictors for poor prognosis in patients with peripheral arterial disease. However, these observations require further confirmation in larger scale studies.
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Affiliation(s)
- Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Jyh-Ming Jimmy Juang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsin-Hua Chou
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chien-An Hsieh
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shih-Jung Jang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Shih-Tsung Cheng
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Lin Ko
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
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313
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Schernthaner-Reiter MH, Schernthaner G. Combination therapy of SGLT2 inhibitors with incretin-based therapies for the treatment of type 2 diabetes mellitus: Effects and mechanisms of action. Expert Rev Endocrinol Metab 2016; 11:281-296. [PMID: 30058933 DOI: 10.1586/17446651.2016.1151783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Type 2 diabetes mellitus (T2DM) is a growing health problem worldwide; its pathogenesis is multifactorial and its progressive nature often necessitates a combination therapy with multiple antihyperglycemic agents. Sodium glucose cotransporter 2 (SGLT2) inhibitors and the incretin-based therapies - dipeptidyl peptidase 4(DPP-4) inhibitors and glucagon-like peptide 1 (GLP-1) receptor agonists - were introduced for the treatment of T2DM within the last decade. Evidence of the beneficial effects of these antihyperglycemic agents on micro- and macrovascular complications have started to emerge, which will become important in individualizing different combinations of antihyperglycemic agents to different patient populations. We review here the mechanisms of action, glycemic and cardiovascular effects of SGLT2 inhibitors and incretin-based therapies and their combination in the treatment of T2DM.
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Affiliation(s)
- Marie Helene Schernthaner-Reiter
- a Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III , Medical University of Vienna , Vienna , Austria
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314
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Picciotto S, Ljungman PL, Eisen EA. Straight Metalworking Fluids and All-Cause and Cardiovascular Mortality Analyzed by Using G-Estimation of an Accelerated Failure Time Model With Quantitative Exposure: Methods and Interpretations. Am J Epidemiol 2016; 183:680-8. [PMID: 26968943 DOI: 10.1093/aje/kwv232] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 08/25/2015] [Indexed: 11/13/2022] Open
Abstract
Straight metalworking fluids have been linked to cardiovascular mortality in analyses using binary exposure metrics, accounting for healthy worker survivor bias by using g-estimation of accelerated failure time models. A cohort of 38,666 Michigan autoworkers was followed (1941-1994) for mortality from all causes and ischemic heart disease. The structural model chosen here, using continuous exposure, assumes that increasing exposure from 0 to 1 mg/m(3) in any single year would decrease survival time by a fixed amount. Under that assumption, banning the fluids would have saved an estimated total of 8,468 (slope-based 95% confidence interval: 2,262, 28,563) person-years of life in this cohort. On average, 3.04 (slope-based 95% confidence interval: 0.02, 25.98) years of life could have been saved for each exposed worker who died from ischemic heart disease. Estimates were sensitive to both model specification for predicting exposure (multinomial or logistic regression) and characterization of exposure as binary or continuous in the structural model. Our results provide evidence supporting the hypothesis of a detrimental relationship between straight metalworking fluids and mortality, particularly from ischemic heart disease, as well as an instructive example of the challenges in obtaining and interpreting results from accelerated failure time models using a continuous exposure in the presence of competing risks.
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315
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Asayama K, Ohkubo T, Hanazawa T, Watabe D, Hosaka M, Satoh M, Yasui D, Staessen JA, Imai Y. Does Antihypertensive Drug Class Affect Day-to-Day Variability of Self-Measured Home Blood Pressure? The HOMED-BP Study. J Am Heart Assoc 2016; 5:e002995. [PMID: 27009620 PMCID: PMC4943272 DOI: 10.1161/jaha.115.002995] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Recent literature suggests that blood pressure variability (BPV) predicts outcome beyond blood pressure level (BPL) and that antihypertensive drug classes differentially influence BPV. We compared calcium channel blockers, angiotensin‐converting enzyme inhibitors, and angiotensin receptor blockade for effects on changes in self‐measured home BPL and BPV and for their prognostic significance in newly treated hypertensive patients. Methods and Results We enrolled 2484 patients randomly allocated to first‐line treatment with a calcium channel blocker (n=833), an angiotensin‐converting enzyme inhibitor (n=821), or angiotensin receptor blockade (n=830). Home blood pressures in the morning and evening were measured for 5 days off treatment before randomization and for 5 days after 2 to 4 weeks of randomized drug treatment. We assessed BPL and BPV changes as estimated by variability independent of the mean and compared cardiovascular outcomes. Home BPL response in each group was significant (P≤0.0001) but small in the angiotensin‐converting enzyme inhibitor group (systolic/diastolic: 4.6/2.8 mm Hg) compared with the groups treated with a calcium channel blocker (systolic/diastolic: 8.3/3.9 mm Hg) and angiotensin receptor blockade (systolic/diastolic: 8.2/4.5 mm Hg). In multivariable adjusted analyses, changes in home variability independent of the mean did not differ among the 3 drug classes (P≥0.054). Evening variability independent of the mean before treatment significantly predicted hard cardiovascular events independent of the corresponding home BPL (P≤0.022), whereas BPV did not predict any cardiovascular outcome based on the morning measurement (P≥0.056). Home BPV captured after monotherapy had no predictive power for cardiovascular outcome (P≥0.22). Conclusions Self‐measured home evening BPV estimated by variability independent of the mean had prognostic significance, whereas antihypertensive drug classes had no significant impact on BPV changes. Home BPL should remain the primary focus for risk stratification and treatment. Clinical Trial Registration URL: http://www.umin.ac.jp/ctr/index.htm. Unique identifier: C000000137.
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Affiliation(s)
- Kei Asayama
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Takayoshi Ohkubo
- Department of Hygiene and Public Health, Teikyo University School of Medicine, Tokyo, Japan Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Tomohiro Hanazawa
- Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan Japan Development and Medical Affairs, GlaxoSmithKline KK, Tokyo, Japan
| | - Daisuke Watabe
- Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan Department of Pharmacy, National Cancer Center Hospital, Tokyo, Japan
| | - Miki Hosaka
- Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Michihiro Satoh
- Department of Pharmaceutical Sciences, Tohoku University Hospital, Sendai, Japan
| | | | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium R&D VitaK Group, Maastricht University, Maastricht, The Netherlands
| | - Yutaka Imai
- Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
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316
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Abstract
INTRODUCTION The safety of agents used to treat type 2 diabetes (T2D), a chronic disease requiring life-long intervention, is of particular interest. Saxagliptin is a potent and selective DPP-4 inhibitor that has emerged as a therapeutic option for T2D. AREAS COVERED Its safety was assessed in a development program of 20 phase 2/3 randomized clinical trials and in SAVOR-TIMI 53 trial that evaluated the cardiovascular outcomes. In order to capture any further safety signals, mainly in the long-term, a post-marketing safety surveillance is ongoing. This paper discusses the tolerability and safety profile of the agent, including cardiovascular, renal, pancreatic, hepatic and bone adverse events. EXPERT OPINION Saxagliptin is a safe therapeutic option for patients with T2D, with low risk of hypoglycemia and good tolerability. It demonstrated cardiovascular safety (including in patients with pre-existing cardiovascular disease and/or HF) and safety with respect to all-cause mortality and adverse events of special interest. In SAVOR-TIMI53, saxagliptin was associated with an unexpected increased risk of HF hospitalization, mainly in the first 12 months; a mechanistic explanation for this has not been found. Further research needs to elucidate the effect of antidiabetic drugs on the heart, by including biomarkers and echocardiographic sub-studies within large outcome trials.
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Affiliation(s)
- Simona Cernea
- a Department M3/Internal Medicine IV , University of Medicine and Pharmacy , Târgu Mureş , Romania.,b Diabetes, Nutrition and Metabolic Diseases , Emergency County Clinical Hospital , Târgu Mureş , Romania
| | - Avivit Cahn
- c Diabetes Unit, Department of Internal Medicine , Hadassah Hebrew University Hospital , Jerusalem , Israel
| | - Itamar Raz
- c Diabetes Unit, Department of Internal Medicine , Hadassah Hebrew University Hospital , Jerusalem , Israel
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317
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Shin S, Kim H. The effect of sitagliptin on cardiovascular risk profile in Korean patients with type 2 diabetes mellitus: a retrospective cohort study. Ther Clin Risk Manag 2016; 12:435-44. [PMID: 27042085 PMCID: PMC4801131 DOI: 10.2147/tcrm.s105285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND A 2013 postmarketing study suggested a possible link between saxagliptin use and hospital admission for heart failure. Cardiovascular (CV) effects of sitagliptin, the most commonly prescribed antidiabetic in the same class as saxagliptin, have not been evaluated much in Asian patients with type 2 diabetes. This study sought to ascertain the CV safety of sitagliptin in Korean patients. METHODS A retrospective cohort study of 4,860 patients who were classified into the sitagliptin and metformin groups was conducted using electronic patient data retrieved from a major tertiary care medical center in Korea. Primary composite end points included CV death, myocardial infarction, and ischemic stroke. Secondary composite end points included the aforementioned individual primary outcomes plus hospitalization due to unstable angina, heart failure, or coronary revascularization. A Cox proportional-hazards model was used to compare CV risk associated with drug exposure. RESULTS Following propensity score (PS) matching in a 1:2 ratio, 1,620 patients in the sitagliptin group and 3,240 patients in the metformin group were identified for cohort entry. The PS-matched hazard ratio (HR) and 95% confidence interval (CI) for sitagliptin relative to metformin were, respectively, 0.831 and 0.536-1.289 (P=0.408) for primary end point and 1.140 and 0.958-1.356 (P=0.139) for secondary end point. Heart failure hospitalization rates did not differ significantly between the two groups, with the PS-matched HR of 0.762 and 95% CI of 0.389-1.495 (P=0.430). When only those patients at high risk of ischemic heart disease were included for analysis, no excess CV risk was observed with sitagliptin compared with metformin. Overall, there were no substantial between-group differences in rates of adverse events, such as hypoglycemia and incident pancreatic disease. CONCLUSION Sitagliptin was not associated with elevated risk of CV complications including myocardial infarction, ischemic stroke, heart failure, and coronary revascularization, compared to metformin therapy among Korean patients with type 2 diabetes.
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Affiliation(s)
- Sooyoung Shin
- College of Pharmacy, Ajou University, Suwon, Republic of Korea
| | - Hyunah Kim
- College of Pharmacy, Sookmyung Women's University, Seoul, Republic of Korea
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318
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Gallwitz B. Cardiovascular Outcomes with Empagliflozin - News for Type 2 Diabetes Therapy. Eur Endocrinol 2016; 12:31-32. [PMID: 29632584 PMCID: PMC5813455 DOI: 10.17925/ee.2016.12.01.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/10/2016] [Indexed: 11/24/2022]
Abstract
Cardiovascular safety has to be proven for antidiabetic therapy for type 2 diabetes according to the guidance from regulatory bodies. Recently, the results of the respective study for the sodium-glucose transporter-2 (SGLT-2) inhibitor empagliflozin were published. Unlike similar studies for other antidiabetic agents that proved cardiovascular safety by non-inferiority compared with standard treatment with regard to a combined cardiovascular primary endpoint, empagliflozin showed superiority with a significantly lower incidence of cardiovascular events.
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319
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Abstract
Managing cardiovascular (CV) risk is an important part of caring for patients with type 2 diabetes mellitus, as the disease itself confers CV risk. Many CV risk factors (such as hypertension, dyslipidemia, and obesity) have been found to be more common among individuals with diabetes than in the general population. A growing body of evidence provides guidance for clinicians on how to balance control of hyperglycemia with management of these risk factors. Newer classes of antihyperglycemic agents have been associated with beneficial effects on several CV risk factors; several studies evaluating the effect of these newer diabetic medications on CV outcomes have been published, and several more are in progress. While evidence continues to unfold about the benefits of risk factor control in patients with type 1 diabetes mellitus, this article reviews evidence related to risk-factor control in patients with type 2 diabetes mellitus as well as recent findings on the effect of newer drug classes on CV risk factors and outcomes. Favorably altering CV risk factors appears to improve outcomes, and is more important now than ever before.
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Affiliation(s)
- Jan N Basile
- a Professor of Medicine, Seinsheimer Cardiovascular Health Program , Medical University of South Carolina, Ralph H. Johnson VA Medical Center , Charleston , SC , USA
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320
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Li J, Tong Y, Zhang Y, Tang L, Lv Q, Zhang F, Hu R, Tong N. Effects on All-cause Mortality and Cardiovascular Outcomes in Patients With Type 2 Diabetes by Comparing Insulin With Oral Hypoglycemic Agent Therapy: A Meta-analysis of Randomized Controlled Trials. Clin Ther 2016; 38:372-386.e6. [PMID: 26774276 DOI: 10.1016/j.clinthera.2015.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/11/2015] [Accepted: 12/08/2015] [Indexed: 02/05/2023]
Abstract
PURPOSE Retrospective, case-control studies and prospective randomized controlled trials (RCTs) on insulin treatment for diabetic patients yielded contradictory mortality and cardiovascular outcomes. We aimed to evaluate the effects of insulin versus oral hypoglycemic agents (OHAs) on all-cause mortality and cardiovascular outcomes in patients with type 2 diabetes (T2D). METHODS We searched Medline, Embase, Cochrane Central Register of Controlled Trials, Chinese Biological Medicine Database, China National Knowledge Infrastructure, Chinese Technical Periodicals, and Wanfang Data, up to July 10, 2015, for RCTs on insulin and OHAs that assessed all-cause mortality and/or cardiovascular death as primary end points. We derived pooled risk ratios (RRs) as summary statistics. RESULTS Three trials were included in which 7649 patients received insulin and 8322 received OHAs, with mean (SD) diabetes duration of 5.0 (6.2) and 4.4 (5.9) years, respectively. Insulin did not differ from OHAs in all-cause mortality (RR = 1.00; 95% CI, 0.93-1.07), cardiovascular death (RR = 1.00; 95% CI, 0.91-1.09), myocardial infarction (RR = 1.04; 95% CI, 0.93-1.16), angina (RR = 0.97; 95% CI, 0.88-1.06), sudden death (RR = 1.02; 95% CI, 0.66-1.56), or stroke (RR = 1.01; 95% CI, 0.88-1.15). Insulin reduced the risk of heart failure compared with OHAs (RR = 0.87; 95% CI, 0.75-0.99). In the subgroup of secondary prevention of cardiovascular diseases (CVDs) or very high risk of CVDs, insulin did not differ from OHAs in all-cause mortality (RR = 0.99; 95% CI, 0.92-1.07), cardiovascular death (RR = 0.99; 95% CI, 0.90-1.09), myocardial infarction (RR = 1.01; 95% CI, 0.88-1.15), heart failure (RR = 0.69; 95% CI, 0.34-1.40), or stroke (RR = 1.05; 95% CI, 0.90-1.21). IMPLICATIONS Insulin did not provide a clear benefit over OHAs in all-cause mortality or cardiovascular outcomes in the patients with T2D. Insulin therapy has many shortcomings, including inconvenience (injection, strict blood glucose monitoring), hypoglycemia, and obvious weight gain. Thus, we conclude that no robust evidence supports the active use of insulin for this population at present.
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Affiliation(s)
- Juan Li
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
| | - Yuzhen Tong
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
| | - Yuwei Zhang
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
| | - Lizhi Tang
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
| | - Qingguo Lv
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
| | - Fang Zhang
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
| | - Ruijie Hu
- Department of Medicine, Xi׳an No. 4 Hospital, Xi׳an, China
| | - Nanwei Tong
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China.
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321
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Blin P, Dureau-Pournin C, Lassalle R, Abouelfath A, Droz-Perroteau C, Moore N. A population database study of outcomes associated with vitamin K antagonists in atrial fibrillation before DOAC. Br J Clin Pharmacol 2015; 81:569-78. [PMID: 26493768 PMCID: PMC4767200 DOI: 10.1111/bcp.12807] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 10/07/2015] [Accepted: 10/14/2015] [Indexed: 01/22/2023] Open
Abstract
AIMS This study aimed to describe the real-life incidence of bleeding, arterial thrombotic events and death during vitamin K antagonist (VKA) treatment in atrial fibrillation (AF). METHODS This was a cohort study in Echantillon Généraliste de Bénéficiaires, the 1/97 sample of the French national healthcare claims and hospitalization database, of new VKA users with definite or probable AF and no other indication, and of patients without AF, from 2007 to 2011. Prespecified outcomes were all-cause death, hospitalization for bleeding, arterial thrombotic event (ATE), or acute coronary syndrome (ACS) or any of the above (composite outcome). RESULTS Of 8894 new VKA users, 3345 had probable or certain AF, 51.7% were male, mean age was 75.1 years, 87.1% had a CHA2 DS2 -VASc score ≥ 2 and 11.6% a HAS-BLED score > 3. Among AF patients, during VKA exposure the incidence rate of bleeding was 2.8 [95% confidence interval (CI) 2.2, 3.4] per 100 patient-years, including 0.6 (95% CI 0.3, 0.8) cerebral, 1.0 (95% CI 0.7, 1.3) digestive and 1.4 (95% CI 1.0, 1.7) other bleeds. There were 1.6 (95% CI 1.2, 2.0) ACS, 1.5 (95% CI 1.1, 1.8) ATE and 3.8 (95% CI 3.2, 4.4) deaths per 100 patient-years. The incidence rate of the composite outcome was 9.1 per 100 patient-years (95% CI 8.2, 10.0). When patients stopped VKA, bleeding decreased (RR 0.67, 95% CI 0.43, 1.04)), but death or thrombosis increased (RR 3.06, 95% CI 2.46, 3.81 and 1.75, 95% CI 1.14, 2.70, respectively). During VKA exposure non-AF patients had similar rates of bleeding, but fewer deaths, ACS and ischaemic events. CONCLUSIONS Real-life rates for bleeding, arterial thrombotic events, ACS and deaths in AF patients treated with VKA were similar to those observed in clinical trials.
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Affiliation(s)
- Patrick Blin
- Bordeaux Pharmacoepi, Inserm CIC1401, Bordeaux.,Adera, Bordeaux
| | | | - Regis Lassalle
- Bordeaux Pharmacoepi, Inserm CIC1401, Bordeaux.,Adera, Bordeaux
| | | | | | - Nicholas Moore
- Bordeaux Pharmacoepi, Inserm CIC1401, Bordeaux.,University of Bordeaux, F33076, Bordeaux, France
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322
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Estes JP, Nguyen DV, Dalrymple LS, Mu Y, Şentürk D. Time-varying effect modeling with longitudinal data truncated by death: conditional models, interpretations, and inference. Stat Med 2015; 35:1834-47. [PMID: 26646582 DOI: 10.1002/sim.6836] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 11/14/2015] [Indexed: 11/07/2022]
Abstract
Recent studies found that infection-related hospitalization was associated with increased risk of cardiovascular (CV) events, such as myocardial infarction and stroke in the dialysis population. In this work, we develop time-varying effects modeling tools in order to examine the CV outcome risk trajectories during the time periods before and after an initial infection-related hospitalization. For this, we propose partly conditional and fully conditional partially linear generalized varying coefficient models (PL-GVCMs) for modeling time-varying effects in longitudinal data with substantial follow-up truncation by death. Unconditional models that implicitly target an immortal population is not a relevant target of inference in applications involving a population with high mortality, like the dialysis population. A partly conditional model characterizes the outcome trajectory for the dynamic cohort of survivors, where each point in the longitudinal trajectory represents a snapshot of the population relationships among subjects who are alive at that time point. In contrast, a fully conditional approach models the time-varying effects of the population stratified by the actual time of death, where the mean response characterizes individual trends in each cohort stratum. We compare and contrast partly and fully conditional PL-GVCMs in our aforementioned application using hospitalization data from the United States Renal Data System. For inference, we develop generalized likelihood ratio tests. Simulation studies examine the efficacy of estimation and inference procedures.
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Affiliation(s)
- Jason P Estes
- Department of Biostatistics, University of California, Los Angeles, 90095, California, U.S.A
| | - Danh V Nguyen
- Department of Medicine, UC Irvine School of Medicine, Orange, 92868-3298, California, U.S.A.,Institute for Clinical and Translational Science, University of California, Irvine, 92687-1385, California, U.S.A
| | - Lorien S Dalrymple
- Division of Nephrology, Department of Medicine, University of California, Sacramento, 95817, California, U.S.A
| | - Yi Mu
- Graduate Group in Epidemiology, University of California, Davis, 95616, California, U.S.A
| | - Damla Şentürk
- Department of Biostatistics, University of California, Los Angeles, 90095, California, U.S.A.,Department of Statistics, University of California, Los Angeles, 90095, California, U.S.A
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323
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Floyd JS, Wiggins KL, Sitlani CM, Flory JH, Dublin S, Smith NL, Heckbert SR, Psaty BM. Case-control study of second-line therapies for type 2 diabetes in combination with metformin and the comparative risks of myocardial infarction and stroke. Diabetes Obes Metab 2015; 17:1194-7. [PMID: 26179389 PMCID: PMC4626290 DOI: 10.1111/dom.12537] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 06/20/2015] [Accepted: 07/02/2015] [Indexed: 01/12/2023]
Abstract
We conducted a population-based case-control study to assess the myocardial infarction (MI) and stroke risks associated with sulphonylureas and insulin when used in combination with metformin. Cases had type 2 diabetes and used metformin + insulin or metformin + sulphonylureas at the time of a first MI or first stroke between 1995 and 2010; controls used the same treatment combinations and were randomly sampled from the same population. MI and stroke diagnoses and potential confounders were validated by medical record reviews. Compared with metformin + sulphonylurea, metformin + insulin was associated with similar risks of MI or stroke [odds ratio 0.98 (95% confidence interval 0.63-1.52)]. Meta-analysis with another observational study improved the precision of the risk estimate [relative risk 0.92 (95% confidence interval 0.69-1.24)]. Current evidence suggests that there may not be large differences in cardiovascular risk associated with the use of insulin or sulphonylureas when used in combination with metformin.
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Affiliation(s)
- J S Floyd
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - K L Wiggins
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
| | - C M Sitlani
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - J H Flory
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY, USA
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - S Dublin
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
| | - N L Smith
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
| | - S R Heckbert
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
| | - B M Psaty
- Cardiovascular Health Research Unit, University of Washington, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Group Health Research Institute, Seattle, WA, USA
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Berezin AE, Kremzer AA, Martovitskaya YV, Samura TA, Berezina TA, Zulli A, Klimas J, Kruzliak P. The utility of biomarker risk prediction score in patients with chronic heart failure. Int J Clin Exp Med 2015; 8:18255-18264. [PMID: 26770427 PMCID: PMC4694327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/04/2015] [Indexed: 06/05/2023]
Abstract
UNLABELLED Chronic heart failure (CHF) remains a leading cause of cardiovascular death worldwide. Current risk models allow better prognosis, however further tools for assessing risk are needed. Thus, this study was aimed to evaluate whether biomarker risk prediction score is powerful tool for risk assessment of three-year fatal and non-fatal cardiovascular events in CHF patients. METHODS A prospective study on the incidence of fatal and non-fatal cardiovascular events, as well as the frequency of occurrence of death from any cause in a cohort of 388 patients with CHF during 3 years of observation was performed. Circulating levels of NT-pro brain natriuretic peptide (NT-pro-BNP), galectin-3, high-sensitivity C-reactive protein (hs-CRP), osteoprotegerin and its soluble receptor sRANKL, osteopontin, osteonectin, adiponectin, endothelial apoptotic microparticles (EMPs) and mononuclear progenitor cells (MPCs) were measured at baseline. RESULTS Median follow-up of patients included in the study was 2.76 years. There were 285 cardiovascular events determined, including 43 deaths and 242 readmissions. Independent predictors of clinical outcomes in patients with CHF were NT-pro-BNP, galectin-3, hs-CRP, osteoprotegerin, CD31(+)/annexin V(+) EMPs and EMPs/CD14(+)CD309(+) MPCs ratio. Index of cardiovascular risk was calculated by mathematical summation of all ranks of independent predictors, which occurred in the patients included in the study. The findings showed that the average value of the index of cardiovascular risk in patients with CHF was 3.17 points (95% CI = 1.65-5.10 points). Kaplan-Meier analysis showed that patients with CHF and the magnitude of the risk of less than 4 units have an advantage in survival when compared with patients for whom obtained higher values of ranks cardiovascular risk score. CONCLUSION Biomarker risk score for cumulative cardiovascular events, constructed by measurement of circulating NT-pro-BNP, galectin-3, hs-CRP, osteoprotegerin, CD31(+)/annexin V(+) EMPs and EMPs/CD14(+)CD309(+) MPCs ratio, reliably predicts the probability survival of patients with CHF, regardless of age, gender, state of the contractile function of the left ventricle and the number of comorbidities.
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Affiliation(s)
- Alexander E Berezin
- Department of Internal Medicine, State Medical UniversityZaporozhye, Ukraine
| | - Alexander A Kremzer
- Department of Clinical Pharmacology, State Medical UniversityZaporozhye, Ukraine
| | | | - Tatyana A Samura
- Department of Clinical Pharmacology, State Medical UniversityZaporozhye, Ukraine
| | | | - Anthony Zulli
- The Centre for Chronic Disease Prevention & Management (CCDPM), Western CHRE, Victoria UniversitySt. Albans, Australia
| | - Jan Klimas
- Department of Pharmacology and Toxicology, Facultyof Pharmacy, Comenius UniversityBratislava, Slovak Republic
| | - Peter Kruzliak
- 2 Department of Internal Medicine, St. Anne’s University Hospital and Masaryk UniversityBrno, Czech Republic
- Laboratory of Structural Biology and Proteomics, Faculty of Pharmacy, University of Veterinary and Pharmaceutical SciencesBrno, Czech Republic
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325
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Losby JL, Osuji TA, House MJ, Davis R, Boyce SP, Greenberg MC, Whitehill JM. Value of a facilitated quality improvement initiative on cardiovascular disease risk: findings from an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL). J Eval Clin Pract 2015; 21:963-70. [PMID: 26223497 PMCID: PMC6178234 DOI: 10.1111/jep.12416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES In the United States, cardiovascular disease (CVD) is the leading cause of death. The US Centers for Disease Control and Prevention contracted an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL) programme as part of its effort to identify strategies to address CVD risk factors. METHODS This study analysed patient-level data from 7527 patients in 43 primary care practices. The researchers assessed average change in control rates for CVD-related measures across practices, and then across patients between baseline and a patient's last visit during the practice's tenure in the programme (referred to as 'end line') using repeated measures analysis of variance and random effects generalized least squares, respectively. RESULTS Among non-diabetic patients, there were significant increases in control rates for overall blood pressure (74.3% to 78.0%, P = 0.0002), systolic blood pressure (70.3% to 80.6%, P = 0.0099), diastolic blood pressure (90.1% to 92.7%, P = 0.0001) and low-density lipoprotein (LDL; 48.6% to 53.1%, P = 0.0001) between baseline and end line. Among diabetic patients, there was a significant increase in diastolic blood pressure control (59.8% to 61.9%, P = 0.0141). While continuous CVD-related outcomes show an overall trend between baseline and end line, patients with uncontrolled measures at baseline showed a decrease between baseline and end line relative to their counterparts who were controlled at baseline. CONCLUSIONS Findings from the AT GOAL evaluation support the value of a facilitated quality improvement (QI) initiative on managing CVD risk.
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Affiliation(s)
- Jan L. Losby
- Behavioral Scientist, Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Marnie J. House
- Senior Technical Specialist, ICF International, Atlanta, GA, USA
| | - Rachel Davis
- Senior Health Scientist, Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - John M. Whitehill
- ORISE Evaluation Fellow, Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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326
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Affiliation(s)
- Ana Barac
- MedStar Heart & Vascular Institute, MedStar Washington Hospital Center, 110 Irving Street, NW, Suite 1F1222, Washington, DC 20010, USA
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327
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Hess CN, Roe MT, Clare RM, Chiswell K, Kelly J, Tcheng JE, Hagstrom E, James SK, Khouri MG, Hirsch BR, Kong DF, Abernethy AP, Krucoff MW. Relationship Between Cancer and Cardiovascular Outcomes Following Percutaneous Coronary Intervention. J Am Heart Assoc 2015; 4:JAHA.115.001779. [PMID: 26150477 PMCID: PMC4608066 DOI: 10.1161/jaha.115.001779] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Cardiovascular disease and cancer increasingly coexist, yet relationships between cancer and long-term cardiovascular outcomes post–percutaneous coronary intervention (PCI) are not well studied. Methods and Results We examined stented PCI patients at Duke (1996–2010) using linked data from the Duke Information Systems for Cardiovascular Care and the Duke Tumor Registry (a cancer treatment registry). Our primary outcome was cardiovascular mortality. Secondary outcomes included composite cardiovascular mortality, myocardial infarction, or repeat revascularization and all-cause mortality. We used adjusted cause-specific hazard models to examine outcomes among cancer patients (cancer treatment pre-PCI) versus controls (no cancer treatment pre-PCI). Cardiovascular mortality was explored in a cancer subgroup with recent (within 1 year pre-PCI) cancer and in post-PCI cancer patients using post-PCI cancer as a time-dependent variable. Among 15 008 patients, 3.3% (n=496) were cancer patients. Observed rates of 14-year cardiovascular mortality (31.4% versus 27.7%, P=0.31) and composite cardiovascular death, myocardial infarction, or revascularization (51.1% versus 55.8%, P=0.37) were similar for cancer versus control groups; all-cause mortality rates were higher (79.7% versus 49.3%, P<0.01). Adjusted risk of cardiovascular mortality was similar for cancer patients versus controls (hazard ratio 0.95; 95% CI 0.76 to 1.20) and for patients with versus without recent cancer (hazard ratio 1.46; 95% CI 0.92 to 2.33). Post-PCI cancer, present in 4.3% (n=647) of patients, was associated with cardiovascular mortality (adjusted hazard ratio 1.51; 95% CI 1.11 to 2.03). Conclusions Cancer history was present in a minority of PCI patients but was not associated with worse long-term cardiovascular outcomes. Further investigation into PCI outcomes in this population is warranted.
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Affiliation(s)
- Connie N Hess
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (C.N.H., M.T.R., J.E.T., M.G.K., D.F.K., M.W.K.) Duke Clinical Research Institute, Durham, NC (C.N.H., M.T.R., R.M.C., K.C., J.E.T., B.R.H., D.F.K., M.W.K.)
| | - Matthew T Roe
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (C.N.H., M.T.R., J.E.T., M.G.K., D.F.K., M.W.K.) Duke Clinical Research Institute, Durham, NC (C.N.H., M.T.R., R.M.C., K.C., J.E.T., B.R.H., D.F.K., M.W.K.)
| | - Robert M Clare
- Duke Clinical Research Institute, Durham, NC (C.N.H., M.T.R., R.M.C., K.C., J.E.T., B.R.H., D.F.K., M.W.K.)
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, NC (C.N.H., M.T.R., R.M.C., K.C., J.E.T., B.R.H., D.F.K., M.W.K.)
| | - Joseph Kelly
- Center for Learning Healthcare, Duke Clinical Research Institute, Durham, NC (J.K., A.P.A.)
| | - James E Tcheng
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (C.N.H., M.T.R., J.E.T., M.G.K., D.F.K., M.W.K.) Duke Clinical Research Institute, Durham, NC (C.N.H., M.T.R., R.M.C., K.C., J.E.T., B.R.H., D.F.K., M.W.K.)
| | - Emil Hagstrom
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Sweden (E.H., S.K.J.)
| | - Stefan K James
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Sweden (E.H., S.K.J.)
| | - Michel G Khouri
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (C.N.H., M.T.R., J.E.T., M.G.K., D.F.K., M.W.K.)
| | - Bradford R Hirsch
- Duke Clinical Research Institute, Durham, NC (C.N.H., M.T.R., R.M.C., K.C., J.E.T., B.R.H., D.F.K., M.W.K.) Duke Cancer Institute, Durham, NC (B.R.H., A.P.A.)
| | - David F Kong
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (C.N.H., M.T.R., J.E.T., M.G.K., D.F.K., M.W.K.) Duke Clinical Research Institute, Durham, NC (C.N.H., M.T.R., R.M.C., K.C., J.E.T., B.R.H., D.F.K., M.W.K.)
| | - Amy P Abernethy
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC (A.P.A.) Center for Learning Healthcare, Duke Clinical Research Institute, Durham, NC (J.K., A.P.A.) Duke Cancer Institute, Durham, NC (B.R.H., A.P.A.)
| | - Mitchell W Krucoff
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (C.N.H., M.T.R., J.E.T., M.G.K., D.F.K., M.W.K.) Duke Clinical Research Institute, Durham, NC (C.N.H., M.T.R., R.M.C., K.C., J.E.T., B.R.H., D.F.K., M.W.K.)
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328
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Bangalore S, Breazna A, DeMicco DA, Wun CC, Messerli FH. Visit-to-visit low-density lipoprotein cholesterol variability and risk of cardiovascular outcomes: insights from the TNT trial. J Am Coll Cardiol 2015; 65:1539-48. [PMID: 25881936 DOI: 10.1016/j.jacc.2015.02.017] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 01/24/2015] [Accepted: 02/03/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Studies demonstrate that lowering low-density lipoprotein cholesterol (LDL-C) using a statin is associated with significant reduction in cardiovascular events. Whether visit-to-visit variability in LDL-C levels affects cardiovascular outcomes is unknown. OBJECTIVES This study sought to evaluate the role of visit-to-visit variability in LDL-C levels on cardiovascular outcomes. METHODS We evaluated patients with coronary artery disease and LDL-C <130 mg/dl enrolled in the TNT (Treating to New Targets) trial, randomly assigned to receive atorvastatin 80 mg/day versus 10 mg/day and with at least one post-baseline measurement of LDL-C. Visit-to-visit LDL-C variability was evaluated from 3 months into random assignment through the use of various measurements of LDL-C variability: SD, average successive variability (ASV), coefficient of variation, and variation independent of mean, with the first 2 measurements used as the primary measurements. Primary outcome was any coronary event, and secondary outcomes were any cardiovascular event, death, myocardial infarction, or stroke. RESULTS Among 9,572 patients, SD and ASV were significantly lower with atorvastatin 80 mg/day versus 10 mg/day (SD: 12.03 ± 9.70 vs. 12.52 ± 7.43; p = 0.005; ASV: 12.84 ± 10.48 vs. 13.76 ± 8.69; p < 0.0001). In the adjusted model, each 1-SD increase in LDL-C variability (by ASV) increased the risk of any coronary event by 16% (hazard ratio [HR]: 1.16; 95% confidence interval [CI]: 1.10 to 1.23; p < 0.0001), any cardiovascular event by 11% (HR: 1.11; 95% CI: 1.07 to 1.15; p < 0.0001), death by 23% (HR: 1.23; 95% CI: 1.14 to 1.34; p < 0.0001), myocardial infarction by 10% (HR: 1.10; 95% CI: 1.02 to 1.19; p = 0.02), and stroke by 17% (HR: 1.17; 95% CI: 1.04 to 1.31; p = 0.01), independent of treatment effect and achieved LDL-C levels. Results were largely consistent when adjusted for medication adherence. CONCLUSIONS In subjects with coronary artery disease, visit-to-visit LDL-C variability is an independent predictor of cardiovascular events.
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Affiliation(s)
- Sripal Bangalore
- Division of Cardiology, New York University School of Medicine, New York, New York.
| | | | | | | | - Franz H Messerli
- Division of Cardiology, St. Luke's-Roosevelt Hospital, Mount Sinai School of Medicine, New York, New York
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329
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Yu OHY, Yin H, Azoulay L. The combination of DPP-4 inhibitors versus sulfonylureas with metformin after failure of first-line treatment in the risk for major cardiovascular events and death. Can J Diabetes 2015; 39:383-9. [PMID: 25840943 DOI: 10.1016/j.jcjd.2015.02.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 02/02/2015] [Accepted: 02/05/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine whether the combination of dipeptidyl-peptidase 4 (DPP-4) inhibitors vs. sulfonylureas with metformin after failure of first-line treatment is associated with a decreased risk for major adverse cardiovascular events (myocardial infarction and stroke) and for all-cause mortality. METHOD Using the UK Clinical Practice Research Datalink, a cohort of patients newly treated with metformin or sulfonylurea monotherapy between January 1, 1988, and December 31, 2011, was identified and was followed until December 31, 2012. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models to compare the DPP-4 inhibitor-metformin combination to the sulfonylurea-metformin combination so as to study the risk for a composite endpoint consisting of myocardial infarction, stroke and all-cause mortality. The models were adjusted for high-dimensional propensity score deciles. RESULTS The cohort consisted of 11,807 patients that included 2286 on a DPP-4 inhibitor-metformin combination and 9521 on a sulfonylurea-metformin combination. The crude incidence rates (95% CIs) of the composite endpoint were 1.2% (0.8% to 1.7%) and 2.2% (1.9% to 2.5%) per year for the DPP-4 inhibitor-metformin and sulfonylurea-metformin combinations, respectively. In the high-dimensional propensity score-adjusted model, the use of the DPP-4 inhibitor-metformin combination was associated with a 38% decreased risk for the composite endpoint (adjusted HR: 0.62; 95% CI 0.40 to 0.98), compared with the sulfonylurea-metformin combination. CONCLUSIONS The use of a DPP-4 inhibitor combination with metformin, compared with a sulfonylurea-metformin combination, was associated with decreased risks for major cardiovascular events and all-cause mortality.
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Affiliation(s)
- Oriana Hoi Yun Yu
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Division of Endocrinology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Hui Yin
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada; Department of Oncology, McGill University, Montreal, Quebec, Canada.
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330
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Price HI, Agnew MD, Gamble JM. Comparative cardiovascular morbidity and mortality in patients taking different insulin regimens for type 2 diabetes: a systematic review. BMJ Open 2015; 5:e006341. [PMID: 25762229 PMCID: PMC4360720 DOI: 10.1136/bmjopen-2014-006341] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 02/15/2015] [Accepted: 02/16/2015] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To summarise the literature evaluating the association between different insulin regimens and the incidence of cardiovascular morbidity and mortality in adults with type 2 diabetes. DESIGN Systematic review. METHODS Multiple biomedical databases (The Cochrane Library, PubMed, EMBASE, and International Pharmaceutical Abstracts) were searched from their inception to February 2014. References of included studies were hand searched. Randomised controlled trials (RCTs), cohort studies or case-control studies examining adults (≥18 years) with type 2 diabetes taking any type, dose and/or regimen of insulin were eligible for inclusion in this review. OUTCOME MEASURES Primary outcomes were cardiovascular morbidity and mortality including fatal and/or non-fatal myocardial infarction, fatal and/or non-fatal stroke, major adverse cardiac events and cardiovascular death. All-cause mortality was assessed as a secondary outcome. RESULTS Of the 3122 studies identified, 2 RCTs and 6 cohort studies were selected. No case-control studies met the inclusion criteria. The studies examined a total of 109,910 patients. Quantitative synthesis of the results from included studies was not possible due to a large amount of clinical heterogeneity. Each study evaluated cardiovascular outcomes across different insulin-exposure contrasts. RCTs did not identify any difference in cardiovascular risks among a fixed versus variable insulin regimen, or a prandial versus basal regimen, albeit clinically important risks and benefits cannot be ruled out due to wide CIs. Findings from cohort studies were variable with an increased and decreased risk of cardiovascular events and all-cause mortality being reported. CONCLUSIONS This systematic review of randomised and non-randomised studies identifies a substantive gap in the literature surrounding the cardiovascular morbidity and mortality of patients using different regimens of insulin. There is a need for more consistent high-quality evidence investigating the impact of insulin use on cardiovascular outcomes in patients with type 2 diabetes. TRIAL REGISTRATION NUMBER PROSPERO CRD42014007631.
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Affiliation(s)
- Hilary I Price
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Meghan D Agnew
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - John-Michael Gamble
- School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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331
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Abstract
Traditional treatments for type 1 and type 2 diabetes are often associated with side effects, including weight gain and hypoglycaemia that may offset the benefits of blood glucose lowering. The kidneys filter and reabsorb large amounts of glucose, and urine is almost free of glucose in normoglycaemia. The sodium-dependent glucose transporter (SGLT)-2 in the early proximal tubule reabsorbs the majority of filtered glucose. Remaining glucose is reabsorbed by SGLT1 in the late proximal tubule. Diabetes enhances renal glucose reabsorption by increasing the tubular glucose load and the expression of SGLT2 (as shown in mice), which maintains hyperglycaemia. Inhibitors of SGLT2 enhance urinary glucose excretion and thereby lower blood glucose levels in type 1 and type 2 diabetes. The load-dependent increase in SGLT1-mediated glucose reabsorption explains why SGLT2 inhibitors in normoglycaemic conditions enhance urinary glucose excretion to only ~50% of the filtered glucose. The role of SGLT1 in both renal and intestinal glucose reabsorption provides a rationale for the development of dual SGLT1/2 inhibitors. SGLT2 inhibitors lower blood glucose levels independent of insulin and induce pleiotropic actions that may be relevant in the context of lowering cardiovascular risk. Ongoing long-term clinical studies will determine whether SGLT2 inhibitors have a safety profile and exert cardiovascular benefits that are superior to traditional agents.
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MESH Headings
- Animals
- Blood Glucose/drug effects
- Blood Glucose/metabolism
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/physiopathology
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/physiopathology
- Humans
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/therapeutic use
- Kidney Tubules, Proximal/drug effects
- Kidney Tubules, Proximal/metabolism
- Kidney Tubules, Proximal/physiopathology
- Molecular Targeted Therapy
- Renal Elimination/drug effects
- Renal Reabsorption/drug effects
- Sodium-Glucose Transporter 1/antagonists & inhibitors
- Sodium-Glucose Transporter 1/metabolism
- Sodium-Glucose Transporter 2/metabolism
- Sodium-Glucose Transporter 2 Inhibitors
- Treatment Outcome
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Affiliation(s)
- Linda A Gallo
- Glycation and Diabetes Complications Research Group, Mater Research Institute - University of Queensland, Translational Research Institute, Woolloongabba, QLD, Australia
| | - Ernest M Wright
- Department of Physiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Volker Vallon
- Departments of Medicine and Pharmacology, University of California, San Diego, La Jolla, CA, USA VA San Diego Healthcare System, San Diego, CA, USA
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332
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Abstract
Cardiovascular disease is the leading cause of mortality in type 2 diabetes mellitus. Hyperinsulinemia is associated with increased cardiovascular risk, but the effects of exogenous insulin on cardiovascular disease progression have been less well studied. Insulin has been shown to have both cardioprotective and atherosclerosis-promoting effects in laboratory animal studies. Long-term clinical trials using insulin to attain improved diabetes control in younger type 1 and type 2 diabetes patients have shown improved cardiovascular outcomes. Shorter trials of intensive diabetes control with high insulin use in higher risk patients with type 2 diabetes have shown either no cardiovascular benefit or increased all cause and cardiovascular mortality. Glargine insulin is a basal insulin analog widely used to treat patients with type 1 and type 2 diabetes. This review focuses on the effects of glargine on cardiovascular outcomes. Glargine lowers triglycerides, leads to a modest weight gain, causes less hypoglycemia when compared with intermediate-acting insulin, and has a neutral effect on blood pressure. The Outcome Reduction With Initial Glargine Intervention (ORIGIN trial), a 6.2 year dedicated cardiovascular outcomes trial of glargine demonstrated no increased cardiovascular risk.
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Affiliation(s)
- Joshua J Joseph
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas W Donner
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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333
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Hanna A, Connelly KA, Josse RG, McIntyre RS. The non-glycemic effects of incretin therapies on cardiovascular outcomes, cognitive function and bone health. Expert Rev Endocrinol Metab 2015; 10:101-114. [PMID: 30289042 DOI: 10.1586/17446651.2015.972370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The incretin therapies, glucagon-like peptide-1 receptor agonists and dipeptidyl-peptidase-4 inhibitors, have been developed to lower blood glucose levels in patients with Type 2 diabetes. However, in addition to being a treatment strategy to improve metabolic control, incretin therapies have shown effects independent of glycemic control, including the potential to positively impact cardiovascular events, cognitive deficits and bone mineral density. This paper outlines the non-glycemic effects of incretin therapies on cardiovascular disease, cognitive function and bone health.
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Affiliation(s)
- Amir Hanna
- a 1 Department of Medicine, University of Toronto, Toronto, ON, Canada
- b 2 Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, ON, Canada
| | - Kim A Connelly
- c 3 Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael's Hospital and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Robert G Josse
- a 1 Department of Medicine, University of Toronto, Toronto, ON, Canada
- b 2 Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, ON, Canada
| | - Roger S McIntyre
- d 4 Mood Disorder Psychopharmacology Unit, University Health Network, University of Toronto, Toronto, ON, Canada
- e 5 Department of Psychiatry and Pharmacology, and Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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334
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Mann MC, Hobbs AJ, Hemmelgarn BR, Roberts DJ, Ahmed SB, Rabi DM. Effect of oral vitamin D analogs on mortality and cardiovascular outcomes among adults with chronic kidney disease: a meta-analysis. Clin Kidney J 2014; 8:41-8. [PMID: 25713709 PMCID: PMC4310425 DOI: 10.1093/ckj/sfu122] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 10/23/2014] [Indexed: 12/22/2022] Open
Abstract
Background Vitamin D deficiency is highly prevalent in patients with chronic kidney disease (CKD) and has been associated with all-cause and cardiovascular mortality in observational studies. However, evidence from randomized controlled trials (RCTs) supporting vitamin D supplementation is lacking. We sought to assess whether vitamin D supplementation alters the relative risk (RR) of all-cause and cardiovascular mortality, as well as serious adverse cardiovascular events, in patients with CKD, compared with placebo. Methods PubMed/MEDLINE, EMBASE, Cochrane Library, and selected nephrology journals and conference proceedings were searched in October 2013. RCTs considered for inclusion were those that assessed oral vitamin D supplementation versus placebo in adults with CKD (≤60 mL/min/1.73 m2), including end-stage CKD requiring dialysis. We calculated pooled RR of mortality (all-cause and cardiovascular) and that of cardiovascular events and stratified by CKD stage, vitamin D analog and diabetes prevalence. Results The search identified 4246 articles, of which 13 were included. No significant treatment effect of oral vitamin D on all-cause mortality (RR: 0.84; 95% CI: 0.47, 1.52), cardiovascular mortality (RR: 0.79; 95% CI: 0.26, 2.28) or serious adverse cardiovascular events (RR: 1.20; 95% CI: 0.49, 2.99) was observed. The pooled analysis demonstrated large variation in trials with respect to dosing (0.5 ug–200 000 IU/week) and duration (3–104 weeks). Conclusions Current RCTs do not provide sufficient or precise evidence that vitamin D supplementation affects mortality or cardiovascular risk in CKD. While its effect on biochemical endpoints is well documented, the results demonstrate a lack of appropriate patient-level data within the CKD literature, which warrants larger trials with clinical primary outcomes related to vitamin D supplementation.
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Affiliation(s)
- Michelle C Mann
- Department of Medical Sciences, Cumming School of Medicine , University of Calgary , Calgary, AB , Canada
| | - Amy J Hobbs
- Department of Community Health Sciences, Cumming School of Medicine , University of Calgary , Calgary, AB , Canada
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, Cumming School of Medicine , University of Calgary , Calgary, AB , Canada ; Division of Nephrology, Cumming School of Medicine , University of Calgary, Foothills Medical Centre , Calgary, AB , Canada
| | - Derek J Roberts
- Department of Community Health Sciences, Cumming School of Medicine , University of Calgary , Calgary, AB , Canada ; Department of Surgery, Cumming School of Medicine, University of Calgary, Foothills Medical Centre , Calgary, AB , Canada
| | - Sofia B Ahmed
- Department of Medical Sciences, Cumming School of Medicine , University of Calgary , Calgary, AB , Canada ; Division of Nephrology, Cumming School of Medicine , University of Calgary, Foothills Medical Centre , Calgary, AB , Canada
| | - Doreen M Rabi
- Department of Community Health Sciences, Cumming School of Medicine , University of Calgary , Calgary, AB , Canada
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Pujades-Rodriguez M, George J, Shah AD, Rapsomaniki E, Denaxas S, West R, Smeeth L, Timmis A, Hemingway H. Heterogeneous associations between smoking and a wide range of initial presentations of cardiovascular disease in 1937360 people in England: lifetime risks and implications for risk prediction. Int J Epidemiol 2014; 44:129-41. [PMID: 25416721 PMCID: PMC4339760 DOI: 10.1093/ije/dyu218] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background It is not known how smoking affects the initial presentation of a wide range of chronic and acute cardiovascular diseases (CVDs), nor the extent to which associations are heterogeneous. We estimated the lifetime cumulative incidence of 12 CVD presentations, and examined associations with smoking and smoking cessation. Methods Cohort study of 1.93 million people aged ≥30years, with no history of CVD, in 1997–2010. Individuals were drawn from linked electronic health records in England, covering primary care, hospitalizations, myocardial infarction (MI) registry and cause-specific mortality (the CALIBER programme). Results During 11.6 million person-years of follow-up, 114 859 people had an initial non-fatal or fatal CVD presentation. By age 90 years, current vs never smokers’ lifetime risks varied from 0.4% vs 0.2% for subarachnoid haemorrhage (SAH), to 8.9% vs 2.6% for peripheral arterial disease (PAD). Current smoking showed no association with cardiac arrest or sudden cardiac death [hazard ratio (HR) = 1.04, 95% confidence interval (CI) 0.91–1.19).The strength of association differed markedly according to disease type: stable angina (HR = 1.08, 95% CI 1.01–1.15),transient ischaemic attack (HR = 1.41, 95% CI 1.28-1.55), unstable angina (HR = 1.54, 95% CI 1.38–1.72), intracerebral haemorrhage (HR = 1.61, 95% CI 1.37–1.89), heart failure (HR = 1.62, 95% CI 1.47–1.79), ischaemic stroke (HR = 1.90, 95% CI 1.72–2.10), MI (HR = 2.32, 95% CI 2.20–2.45), SAH (HR = 2.70, 95% CI 2.27–3.21), PAD (HR = 5.16, 95% CI 4.80–5.54) and abdominal aortic aneurysm (AAA) (HR = 5.18, 95% CI 4.61–5.82). Population-attributable fractions were lower for women than men for unheralded coronary death, ischaemic stroke, PAD and AAA. Ten years after quitting smoking, the risks of PAD, AAA (in men) and unheralded coronary death remained increased (HR = 1.36, 1.47 and 2.74, respectively). Conclusions The heterogeneous associations of smoking with different CVD presentations suggests different underlying mechanisms and have important implications for research, clinical screening and risk prediction.
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Affiliation(s)
- Mar Pujades-Rodriguez
- Farr Institute of Health Informatics Research, University College London, London, UK, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and National Institute for Health Research, Biomedical Research Unit, Barts Health NHS Trust, London, UK
| | - Julie George
- Farr Institute of Health Informatics Research, University College London, London, UK, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and National Institute for Health Research, Biomedical Research Unit, Barts Health NHS Trust, London, UK
| | - Anoop Dinesh Shah
- Farr Institute of Health Informatics Research, University College London, London, UK, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and National Institute for Health Research, Biomedical Research Unit, Barts Health NHS Trust, London, UK
| | - Eleni Rapsomaniki
- Farr Institute of Health Informatics Research, University College London, London, UK, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and National Institute for Health Research, Biomedical Research Unit, Barts Health NHS Trust, London, UK
| | - Spiros Denaxas
- Farr Institute of Health Informatics Research, University College London, London, UK, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and National Institute for Health Research, Biomedical Research Unit, Barts Health NHS Trust, London, UK
| | - Robert West
- Farr Institute of Health Informatics Research, University College London, London, UK, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and National Institute for Health Research, Biomedical Research Unit, Barts Health NHS Trust, London, UK
| | - Liam Smeeth
- Farr Institute of Health Informatics Research, University College London, London, UK, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and National Institute for Health Research, Biomedical Research Unit, Barts Health NHS Trust, London, UK
| | - Adam Timmis
- Farr Institute of Health Informatics Research, University College London, London, UK, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and National Institute for Health Research, Biomedical Research Unit, Barts Health NHS Trust, London, UK
| | - Harry Hemingway
- Farr Institute of Health Informatics Research, University College London, London, UK, Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK and National Institute for Health Research, Biomedical Research Unit, Barts Health NHS Trust, London, UK
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336
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Sentürk D, Dalrymple LS, Mu Y, Nguyen DV. Weighted hurdle regression method for joint modeling of cardiovascular events likelihood and rate in the US dialysis population. Stat Med 2014; 33:4387-401. [PMID: 24930810 DOI: 10.1002/sim.6232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 02/08/2014] [Accepted: 05/22/2014] [Indexed: 11/08/2022]
Abstract
We propose a new weighted hurdle regression method for modeling count data, with particular interest in modeling cardiovascular events in patients on dialysis. Cardiovascular disease remains one of the leading causes of hospitalization and death in this population. Our aim is to jointly model the relationship/association between covariates and (i) the probability of cardiovascular events, a binary process, and (ii) the rate of events once the realization is positive-when the 'hurdle' is crossed-using a zero-truncated Poisson distribution. When the observation period or follow-up time, from the start of dialysis, varies among individuals, the estimated probability of positive cardiovascular events during the study period will be biased. Furthermore, when the model contains covariates, then the estimated relationship between the covariates and the probability of cardiovascular events will also be biased. These challenges are addressed with the proposed weighted hurdle regression method. Estimation for the weighted hurdle regression model is a weighted likelihood approach, where standard maximum likelihood estimation can be utilized. The method is illustrated with data from the United States Renal Data System. Simulation studies show the ability of proposed method to successfully adjust for differential follow-up times and incorporate the effects of covariates in the weighting.
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Affiliation(s)
- Damla Sentürk
- Department of Biostatistics, University of California, Los Angeles, CA 90095, U.S.A
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337
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Eapen DJ, Manocha P, Ghasemzadeh N, Patel RS, Al Kassem H, Hammadah M, Veledar E, Le NA, Pielak T, Thorball CW, Velegraki A, Kremastinos DT, Lerakis S, Sperling L, Quyyumi AA. Soluble urokinase plasminogen activator receptor level is an independent predictor of the presence and severity of coronary artery disease and of future adverse events. J Am Heart Assoc 2014; 3:e001118. [PMID: 25341887 PMCID: PMC4323820 DOI: 10.1161/jaha.114.001118] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction Soluble urokinase plasminogen activator receptor (suPAR) is an emerging inflammatory and immune biomarker. Whether suPAR level predicts the presence and the severity of coronary artery disease (CAD), and of incident death and myocardial infarction (MI) in subjects with suspected CAD, is unknown. Methods and Results We measured plasma suPAR levels in 3367 subjects (67% with CAD) recruited in the Emory Cardiovascular Biobank and followed them for adverse cardiovascular (CV) outcomes of death and MI over a mean 2.1±1.1 years. Presence of angiographic CAD (≥50% stenosis in ≥1 coronary artery) and its severity were quantitated using the Gensini score. Cox's proportional hazard survival and discrimination analyses were performed with models adjusted for established CV risk factors and C‐reactive protein levels. Elevated suPAR levels were independently associated with the presence of CAD (P<0.0001) and its severity (P<0.0001). A plasma suPAR level ≥3.5 ng/mL (cutoff by Youden's index) predicted future risk of MI (hazard ratio [HR]=3.2; P<0.0001), cardiac death (HR=2.62; P<0.0001), and the combined endpoint of death and MI (HR=1.9; P<0.0001), even after adjustment of covariates. The C‐statistic for a model based on traditional risk factors was improved from 0.72 to 0.74 (P=0.008) with the addition of suPAR. Conclusion Elevated levels of plasma suPAR are associated with the presence and severity of CAD and are independent predictors of death and MI in patients with suspected or known CAD.
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Affiliation(s)
- Danny J Eapen
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.)
| | - Pankaj Manocha
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.)
| | - Nima Ghasemzadeh
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.)
| | - Riyaz S Patel
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.) Department of Medicine, Cardiff University, Cardiff, UK (R.S.P.)
| | - Hatem Al Kassem
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.)
| | - Muhammad Hammadah
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.)
| | - Emir Veledar
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.)
| | - Ngoc-Anh Le
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.)
| | - Tomasz Pielak
- Clinical Research Center, Copenhagen University Hospital Copenhagen, Denmark (T.P., C.W.T.)
| | - Christian W Thorball
- Clinical Research Center, Copenhagen University Hospital Copenhagen, Denmark (T.P., C.W.T.)
| | | | | | - Stamatios Lerakis
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.) Medical School of Athens, Athens, Greece (A.V., D.T.K., S.L.)
| | - Laurence Sperling
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.)
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA (D.J.E., P.M., N.G., R.S.P., H.A.K., M.H., E.V., N.A.L., S.L., L.S., A.A.Q.)
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Corrao G, Soranna D, Merlino L, Mancia G. Similarity between generic and brand-name antihypertensive drugs for primary prevention of cardiovascular disease: evidence from a large population-based study. Eur J Clin Invest 2014; 44:933-9. [PMID: 25132063 DOI: 10.1111/eci.12326] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 08/11/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although generic and earlier brand-name counterparts are bioequivalent, their equivalence in preventing relevant clinical outcomes is of concern. OBJECTIVE To compare effectiveness of generic and brand-name antihypertensive drugs for preventing the onset of cardiovascular (CV) outcomes. DESIGN AND SUBJECTS A population-based, nested case-control study was carried out by including the cohort of 78 520 patients from Lombardy (Italy) aged 18 years or older who were newly treated with antihypertensive drugs during 2005. Cases were the 2206 patients who experienced a hospitalization for CV disease from initial prescription until 2011. One control for each case was randomly selected from the same cohort that generated cases. Logistic regression was used to model the CV risk associated with starting on and/or continuing with generic or brand-name agents. RESULTS There was no evidence that patients who started on generics experienced different CV risk than those on brand-name product (OR 0·86; 95% CI 0·63-1·17). Patients at whom generics were main dispensed had not significantly difference in CV outcomes than those mainly on brand-name agents (OR 1·19; 95% CI 0·86-1·63). Compared with patients who kept initial brand-name therapy, those who experienced brand-to-generic or generic-to-brand switches, and those always on generics, did not show differential CV risks, being the corresponding ORs (and 95% CIs), 1·18 (0·96-1·47), 0·87 (0·63-1·21) and 1·08 (0·80-1·46). CONCLUSIONS Our findings do not support the notion that brand-name antihypertensive agents are superior to generics for preventing CV outcomes in the real-world clinical practice.
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Affiliation(s)
- Giovanni Corrao
- Department of Statistics and Quantitative Methods, Division of Biostatistics, Epidemiology and Public Health, Laboratory of Healthcare research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
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339
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Abstract
The LookAhead trial was a randomized controlled trial comparing an Intensive Lifestyle Intervention (ILI) to a Diabetes Support and Education (DSE) in overweight and obese type 2 diabetes patients to track the development of cardiovascular disease over time. The triaI intervention was stopped for futility after a median follow-up of 9.6 years. While there was a differential effect on weight loss and fitness between the two groups, there was no effect on cardiovascular outcomes. Cardiovascular events were less than half the projected rate per year in the DSE group: thus there was a very low over-all rate of events in both groups. There were many other health benefits of ILI, including improved biomarkers of glucose and lipid control, less sleep apnea, lower liver fat, less depression, improved insulin sensitivity, less urinary incontinence, less kidney disease, reduced need of diabetes medications, maintenance of physical mobility, improved quality of life and lower costs.
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Affiliation(s)
- Xavier Pi-Sunyer
- Columbia University College of Physicians and Surgeons, P&S PO Box 30 DOM/NYORC, 630 West 168 Street, New York, NY 10032, , ,
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340
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Affiliation(s)
- Alexandra C Milin
- Department of Internal Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA
| | - Gabriel Vorobiof
- Department of Internal Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA
| | - Olcay Aksoy
- Department of Internal Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA
| | - Reza Ardehali
- Department of Internal Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA
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341
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Thomas D, Anderson D, Hulten E, McRae F, Ellis S, Malik JA, Villines TC, Slim AM. Open versus endovascular repair of abdominal aortic aneurysm: Incidence of cardiovascular events in 632 patients in a department of defense cohort over 6-year follow-up. Vascular 2014; 23:234-9. [PMID: 25134851 DOI: 10.1177/1708538114546207] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) is common with unacceptably high rates of mortality and morbidity with unknown rates of complications after repair in the Department of Defense (DoD). METHODS All patients treated at a DOD or VA clinic or medical facility with a diagnosis of AAA identified by ICD-9 code search were identified by Patient Administration Systems and Biostatistics Activity (PASBA) using the Standard Inpatient Data Record (SIDR) and Composite Ambulatory Patient Encounter Record (CAPER) from January 2006 till December 2011. The primary outcome was death, myocardial infarction (MI), stroke, and cardiac arrhythmia between subjects who underwent endovascular aortic repair (EVAR) or open aortic repair (OAR). RESULTS A total of 8314 patients were screened to identify 632 patients who underwent surgical repair of non-ruptured AAA. EVAR was performed in 497 patients (78.6%) and OAR in 135 patients (21.4%). Mortality at 30 days was less common in EVAR patients (1.6% vs. 6.7%, p = 0.004), but was not sustained (16.9% vs. 17.8%, p = 0.797). Mean survival free from mortality was not different between the two groups (EVAR vs. OAR: 6.14 ± 0.13 years vs. 6.11 ± 0.22 years, p = 0.378). The composite endpoint of MI, stroke, arrhythmia, or death was not different between groups at 30 days (EVAR vs. OAR: 12.9% vs. 14.1%, p = 0.774) or in long-term follow-up population (EVAR vs. OAR: 40.6% vs. 31.9%, p = 0.073) though there was a trend toward higher event rates in the EVAR. The composite endpoint of MI, stroke, and arrhythmia occurred in 198 patients (31%). CONCLUSION EVAR was associated with lower 30-day mortality rates; however, this benefit was not sustained in longer-term follow-up. There is no difference in the rates of stroke, myocardial infarction, or cardiac arrhythmia at 30 days or in long-term follow-up.
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Affiliation(s)
- Dustin Thomas
- Cardiology Service, Brooke Army Medical Center, San Antonio, TX, USA
| | - David Anderson
- Cardiology Service, Brooke Army Medical Center, San Antonio, TX, USA
| | - Edward Hulten
- Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Fiora McRae
- Cardiology Service, Brooke Army Medical Center, San Antonio, TX, USA
| | - Shane Ellis
- Cardiology Service, Brooke Army Medical Center, San Antonio, TX, USA
| | - Jamil A Malik
- Cardiology Service, Brooke Army Medical Center, San Antonio, TX, USA
| | - Todd C Villines
- Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Ahmad M Slim
- Cardiology Service, Brooke Army Medical Center, San Antonio, TX, USA
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342
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Holzmann M, Jernberg T, Szummer K, Sartipy U. Long-term cardiovascular outcomes in patients with chronic kidney disease undergoing coronary artery bypass graft surgery for acute coronary syndromes. J Am Heart Assoc 2014; 3:e000707. [PMID: 24595192 PMCID: PMC4187499 DOI: 10.1161/jaha.113.000707] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Patients with chronic kidney disease have an increased risk of death after myocardial infarction, coronary artery bypass graft surgery (CABG), and percutaneous coronary intervention. We sought to describe the association between chronic kidney disease and long‐term cardiovascular outcomes and death in patients who underwent CABG for acute coronary syndromes. Methods and Results All patients (N=12 956) from the Swedish Web System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry who underwent CABG for acute coronary syndromes in Sweden between 2000 and 2008 with complete information on preoperative serum creatinine values were included. Estimated glomerular filtration rates (eGFRs) were obtained, and hazard ratios with 95% CIs were calculated for the composite end point of myocardial infarction, heart failure, stroke, or death in relation to eGFR. During a mean follow‐up of 3.5 years, there were in total 2844 (22%) cardiovascular events and 1340 (10%) deaths. In patients with eGFR >60 mL/min per 1.73 m2, 45 to 60 mL/min per 1.73 m2, and 15 to 45 mL/min per 1.73 m2, there were 2896 (28%), 882 (43%), and 407 (61%) cardiovascular events or deaths, respectively. Hazard ratios with 95% CIs for death or any cardiovascular event in patients with eGFR 45 to 60 mL/min per 1.73 m2, and 15 to 45 mL/min per 1.73 m2 were 1.07 (0.98 to 1.15) and 1.36 (1.22 to 1.53) respectively, after multivariable adjustment. The corresponding figures for any cardiovascular event were 1.08 (0.98 to 1.19), and 1.24 (1.08 to 1.43). Conclusions Severe, but not moderate, renal dysfunction was independently associated with an increased risk of long‐term cardiovascular events and death in patients undergoing CABG for acute coronary syndromes.
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Affiliation(s)
- Martin Holzmann
- Departments of Emergency Medicine, Cardiothoracic Surgery and Anesthesiology, Cardiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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343
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Affiliation(s)
- Paula Chatterjee
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (P.C., K.E.J.)
- Harvard Medical School, VA Boston Healthcare System, Boston, MA (P.C., K.E.J.)
| | - Karen E. Joynt
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (P.C., K.E.J.)
- Cardiovascular Division, Brigham & Women's Hospital, Boston, MA (K.E.J.)
- Harvard Medical School, VA Boston Healthcare System, Boston, MA (P.C., K.E.J.)
- Cardiology Service, VA Boston Healthcare System, Boston, MA (K.E.J.)
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345
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Abstract
BACKGROUND AND OBJECTIVE Kawasaki disease (KD) may result in coronary aneurysm formation, but there is incomplete knowledge regarding its long-term effects. Our objective was to quantify the longer-term rates of adverse cardiac events in a modern North American KD cohort. METHODS Using the Kaiser Permanente Northern California population, we performed a retrospective cohort study in patients with a history of KD versus matched patients without KD. Chart review was used to confirm the diagnosis of KD and all outcomes of interest, including acute coronary syndrome, coronary revascularization, heart failure, ventricular arrhythmia, valve disease, aortic aneurysm, and all-cause mortality. All outcomes occurring at age ≥15 years were included in the primary analysis. Outcome rates were compared between the 2 groups by using Cox proportional hazards analysis. RESULTS The study included 546 KD patients and 2218 matched patients without KD. Seventy-nine percent of the KD patients received intravenous immunoglobulin and 5% had persistent coronary aneurysm. The average follow-up time was 14.9 years. Only 2 KD patients experienced outcomes after age 15 (0.246 events per 1000 person-years) compared with 7 events in the non-KD group (0.217 events per 1000 person-years), a nonsignificant difference (hazard ratio: 0.81; 95% confidence interval: 0.16-4.0). Within the KD subgroup, persistent coronary aneurysm predicted the occurrence of adverse events (P = .007). CONCLUSIONS This is the largest US study of longer-term cardiac outcomes after KD and reveals a low rate of adverse cardiovascular events through age 21. Additional validation studies, including studies with longer-term follow-up, should be performed.
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Affiliation(s)
- Taylor J Holve
- Department of Cardiology, Kaiser San Francisco Medical Center, San Francisco, California; and
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346
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Affiliation(s)
- Ravi I Thadhani
- From the Division of Nephrology, Massachusetts General Hospital (R.I.T.) and Division of Preventive Medicine, Brigham and Women's Hospital (J.E.M.), Harvard Medical School, Boston, MA
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Conzo G, Perna AF, Savica V, Palazzo A, Pietra CD, Ingrosso D, Satta E, Capasso G, Santini L, Docimo G. Impact of parathyroidectomy on cardiovascular outcomes and survival in chronic hemodialysis patients with secondary hyperparathyroidism. A retrospective study of 50 cases prior to the calcimimetics era. BMC Surg 2013; 13 Suppl 2:S4. [PMID: 24268127 PMCID: PMC3851167 DOI: 10.1186/1471-2482-13-s2-s4] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In chronic hemodialysis patients with secondary hyperparathyroidism, pathological modifications of bone and mineral metabolism increase the risk of cardiovascular morbidity and mortality. Parathyroidectomy, reducing the incidence of cardiovascular events, may improve outcomes; however, its effects on long-term survival are still subject of active research. METHODS From January 2004 to December 2006, 30 hemodialysis patients, affected by severe and unresponsive secondary hyperparathyroidism, underwent parathyroidectomy - 15 total parathyroidectomy and 15 total parathyroidectomy + subcutaneous autoimplantation. During a 5-year follow-up, patients did not receive a renal transplantation and were evaluated for biochemical modifications and major cardiovascular events - death, cardiovascular accidents, myocardial infarction and peripheral vascular disease. Results were compared with those obtained in a control group of 20 hemodialysis patients, affected by secondary hyperparathyroidism, and refusing surgical treatment, and following medical treatment only. RESULTS The groups were comparable in terms of age, gender, dialysis vintage, and comorbidities. Postoperative cardiovascular events were observed in 18/30 - 54% - surgical patients and in 4/20 - 20%- medical patients, with a mortality rate respectively of 23.3% in the surgical group vs. 15% in the control group. Parathyroidectomy was not associated with a reduced risk of cardiovascular morbidity and survival rate was unaffected by surgical treatment. CONCLUSIONS In secondary hyperparathyroidism hemodialysis patients affected by severe cardiovascular disease, surgery did not modify cardiovascular morbidity and mortality rates. Therefore, in secondary hyperparathyroidism hemodialysis patients, resistant to medical treatment, only an early indication to calcimimetics, or surgery, in the initial stage of chronic kidney disease - mineral bone disorders, may offer a higher long-term survival. Further studies will be useful to clarify the role of secondary hyperparathyroidism in determining unfavorable cardiovascular outcomes and mortality in hemodialysis population.
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Affiliation(s)
- Giovanni Conzo
- Department of Anaesthesiologic, Surgical and Emergency Sciences - VII Division of General and Endocrine Surgery-Second University of Naples - Italy
| | - Alessandra F Perna
- Department of Cardio-thoracic and Respiratory Sciences - First Division of Nephrology - Second University of Naples - Italy
| | | | - Antonietta Palazzo
- Department of Anaesthesiologic, Surgical and Emergency Sciences - VII Division of General and Endocrine Surgery-Second University of Naples - Italy
| | - Cristina Della Pietra
- Department of Anaesthesiologic, Surgical and Emergency Sciences - VII Division of General and Endocrine Surgery-Second University of Naples - Italy
| | - Diego Ingrosso
- Department of Biochemistry and Biophysics “F. Cedrangolo” - Second University of Naples - Italy
| | - Ersilia Satta
- Department of Cardio-thoracic and Respiratory Sciences - First Division of Nephrology - Second University of Naples - Italy
| | - Giovambattista Capasso
- Department of Cardio-thoracic and Respiratory Sciences - First Division of Nephrology - Second University of Naples - Italy
| | - Luigi Santini
- Department of Anaesthesiologic, Surgical and Emergency Sciences - VII Division of General and Endocrine Surgery-Second University of Naples - Italy
| | - Giovanni Docimo
- Department of Anaesthesiologic, Surgical and Emergency Sciences - VII Division of General and Endocrine Surgery-Second University of Naples - Italy
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Oliveras A, Armario P, Sierra C, Arroyo JA, Hernández-del-Rey R, Vazquez S, Larrousse M, Sans L, Roca-Cusachs A, de la Sierra A. Urinary albumin excretion at follow-up predicts cardiovascular outcomes in subjects with resistant hypertension. Am J Hypertens 2013; 26:1148-54. [PMID: 23747954 DOI: 10.1093/ajh/hpt074] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Renal function and albuminuria predict cardiovascular disease (CVD) in general population. However, their prognostic value in patients with resistant hypertension (RH) is somewhat unknown. OBJECTIVE To determine the ability of renal function and albuminuria to predict CVD in RH patients. METHODS One hundred and thirty-three RH (blood pressure [BP] ≥140/90mmHg despite treatment with ≥3 drugs) patients were evaluated. Median follow-up was 73 months. Primary endpoint was a composite of non-fatal cardiovascular events or cardiovascular death. Serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) were determined. Microalbuminuria was defined as a urinary albumin-to-creatinine ratio (UACR) ≥30mg/g. RESULTS Twenty-two patients (16.5%) reached the primary endpoint. Long-term elevated UACR (66 vs. 17mg/g, P=0.045), but not at baseline, was associated with the primary endpoint, after adjusting for age, prior CVD, and both eGFR and office systolic-BP at baseline and during follow-up. Although baseline SCr and eGFR were associated with CVD, significance was lost after baseline risk adjustment. Baseline microalbuminuria prevalence was 45% and 41% in patients with and without CVD (P=0.813), while percentages of patients with microalbuminuria at follow-up were 67% and 28%, respectively (P=0.002). More patients with de novo CVD, compared with those without CVD, developed microalbuminuria at follow-up (28% vs. 6%) or had persistent microalbuminuria (39% vs. 21%), while fewer patients with CVD had microalbuminuria regression (11% vs. 19%) or remained normoalbuminurics (22% vs. 53%; overall P=0.005). CONCLUSION In RH patients, the inability to microalbuminuria regression, either due to persistence or new appearance, independently predicts CVD.
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Affiliation(s)
- Anna Oliveras
- Hypertension Unit, Nephrology Department, Hospital Universitari del Mar, Barcelona, Catalonia, Spain
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349
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Affiliation(s)
- Sunil V. Rao
- The Duke Clinical Research Institute, Durham, NC (S.V.R., M.W.K.)
- Correspondence to: Sunil V. Rao, MD, 508 Fulton Street (111A), Durham, NC 27705. E‐mail:
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Tibble CA, Cavaiola TS, Henry RR. Longer acting GLP-1 receptor agonists and the potential for improved cardiovascular outcomes: a review of current literature. Expert Rev Endocrinol Metab 2013; 8:247-259. [PMID: 30780817 DOI: 10.1586/eem.13.20] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
With the rapidly rising incidence of Type 2 diabetes and an increasing variety of medications available for treatment, choosing the ideal regimen for patients can be challenging. Longer-acting glucagon-like peptide-1 (GLP-1) receptor agonists and devices have been recently developed and include once-weekly exenatide, dulaglutide, albiglutide, semaglutide and miniosmotic pump ITCA650. Some of the attractive qualities of the GLP-1 receptor agonist class include its association with weightloss and potential for cardiovascular benefits. The longer-acting forms have been shown in several studies to produce equal or greater reduction in A1c and weight compared with the standard twice-daily formulation of exenatide. They also result in lower reported incidence of nausea, in the setting of a less frequent injection schedule that would be desirable to many diabetic patients. There are emerging data to suggest patients treated with longer-acting GLP-1 receptor agonists have improved cardiac parameters, some of which are independent of weight and A1c reductions.
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Affiliation(s)
- Courtney Aavang Tibble
- b University of California at San DiegoSchool of Medicine, 9500 Gilman Dr, La Jolla,CA 92093, USA
| | - Tricia Santos Cavaiola
- b University of California at San DiegoSchool of Medicine, 9500 Gilman Dr, La Jolla,CA 92093, USA
| | - Robert R Henry
- a Veterans Affairs San Diego Healthcare System, 3350 La Jolla Village Drive CA 92122, USA.
- b University of California at San DiegoSchool of Medicine, 9500 Gilman Dr, La Jolla,CA 92093, USA
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