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Gumz ML, Shimbo D, Abdalla M, Balijepalli RC, Benedict C, Chen Y, Earnest DJ, Gamble KL, Garrison SR, Gong MC, Hogenesch JB, Hong Y, Ivy JR, Joe B, Laposky AD, Liang M, MacLaughlin EJ, Martino TA, Pollock DM, Redline S, Rogers A, Dan Rudic R, Schernhammer ES, Stergiou GS, St-Onge MP, Wang X, Wright J, Oh YS. Toward Precision Medicine: Circadian Rhythm of Blood Pressure and Chronotherapy for Hypertension - 2021 NHLBI Workshop Report. Hypertension 2023; 80:503-522. [PMID: 36448463 PMCID: PMC9931676 DOI: 10.1161/hypertensionaha.122.19372] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Healthy individuals exhibit blood pressure variation over a 24-hour period with higher blood pressure during wakefulness and lower blood pressure during sleep. Loss or disruption of the blood pressure circadian rhythm has been linked to adverse health outcomes, for example, cardiovascular disease, dementia, and chronic kidney disease. However, the current diagnostic and therapeutic approaches lack sufficient attention to the circadian rhythmicity of blood pressure. Sleep patterns, hormone release, eating habits, digestion, body temperature, renal and cardiovascular function, and other important host functions as well as gut microbiota exhibit circadian rhythms, and influence circadian rhythms of blood pressure. Potential benefits of nonpharmacologic interventions such as meal timing, and pharmacologic chronotherapeutic interventions, such as the bedtime administration of antihypertensive medications, have recently been suggested in some studies. However, the mechanisms underlying circadian rhythm-mediated blood pressure regulation and the efficacy of chronotherapy in hypertension remain unclear. This review summarizes the results of the National Heart, Lung, and Blood Institute workshop convened on October 27 to 29, 2021 to assess knowledge gaps and research opportunities in the study of circadian rhythm of blood pressure and chronotherapy for hypertension.
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Affiliation(s)
- Michelle L Gumz
- Department of Physiology and Aging; Center for Integrative Cardiovascular and Metabolic Disease, Department of Medicine, Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL (M.L.G.)
| | - Daichi Shimbo
- Department of Medicine, The Columbia Hypertension Center, Columbia University Irving Medical Center, New York, NY (D.S.)
| | - Marwah Abdalla
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, NY (M.A.)
| | - Ravi C Balijepalli
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (R.C.B., Y.H., J.W., Y.S.O.)
| | - Christian Benedict
- Department of Pharmaceutical Biosciences, Molecular Neuropharmacology, Uppsala University, Sweden (C.B.)
| | - Yabing Chen
- Department of Pathology, University of Alabama at Birmingham, and Research Department, Birmingham VA Medical Center, AL (Y.C.)
| | - David J Earnest
- Department of Neuroscience & Experimental Therapeutics, Texas A&M University, Bryan, TX (D.J.E.)
| | - Karen L Gamble
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, AL (K.L.G.)
| | - Scott R Garrison
- Department of Family Medicine, University of Alberta, Canada (S.R.G.)
| | - Ming C Gong
- Department of Physiology, University of Kentucky, Lexington, KY (M.C.G.)
| | | | - Yuling Hong
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (R.C.B., Y.H., J.W., Y.S.O.)
| | - Jessica R Ivy
- University/British Heart Foundation Centre for Cardiovascular Science, The Queen's Medical Research Institute, The University of Edinburgh, United Kingdom (J.R.I.)
| | - Bina Joe
- Department of Physiology and Pharmacology and Center for Hypertension and Precision Medicine, University of Toledo College of Medicine and Life Sciences, OH (B.J.)
| | - Aaron D Laposky
- National Center on Sleep Disorders Research, Division of Lung Diseases, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (A.D.L.)
| | - Mingyu Liang
- Center of Systems Molecular Medicine, Department of Physiology, Medical College of Wisconsin, Milwaukee, WI (M.L.)
| | - Eric J MacLaughlin
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, Amarillo, TX (E.J.M.)
| | - Tami A Martino
- Center for Cardiovascular Investigations, Department of Biomedical Sciences, University of Guelph, Ontario, Canada (T.A.M.)
| | - David M Pollock
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, AL (D.M.P.)
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.R.)
| | - Amy Rogers
- Division of Molecular and Clinical Medicine, University of Dundee, United Kingdom (A.R.)
| | - R Dan Rudic
- Department of Pharmacology and Toxicology, Augusta University, GA (R.D.R.)
| | - Eva S Schernhammer
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (E.S.S.)
| | - George S Stergiou
- Hypertension Center, STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Athens, Greece (G.S.S.)
| | - Marie-Pierre St-Onge
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center' New York, NY (M.-P.S.-O.)
| | - Xiaoling Wang
- Georgia Prevention Institute, Department of Medicine, Augusta University, GA (X.W.)
| | - Jacqueline Wright
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (R.C.B., Y.H., J.W., Y.S.O.)
| | - Young S Oh
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD (R.C.B., Y.H., J.W., Y.S.O.)
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Mohan A, Majd Z, Johnson ML, Essien EJ, Barner J, Serna O, Gallardo E, Fleming ML, Ordonez N, Holstad MM, Abughosh SM. A Motivational Interviewing Intervention to Improve Adherence to ACEIs/ARBs among Nonadherent Older Adults with Comorbid Hypertension and Diabetes. Drugs Aging 2023; 40:377-390. [PMID: 36847995 PMCID: PMC9969383 DOI: 10.1007/s40266-023-01008-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Hypertension and diabetes mellitus are independent risk factors for cardiovascular diseases. Due to the cardioprotective nature of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), they are recommended for patients with comorbid hypertension and diabetes. However, poor adherence to ACEIs/ARBs among older adults is a major public health concern. This study aimed to assess the effectiveness of a telephonic motivational interviewing (MI) intervention conducted by pharmacy students among a nonadherent older population (≥ 65 years old) with diabetes and hypertension. METHODS Patients continuously enrolled in a Medicare Advantage Plan who received an ACEI/ARB prescription between July 2017 and December 2017 were identified. Group-based trajectory modeling (GBTM) was used to identify distinct patterns of ACEI/ARB adherence during the 1-year baseline period: adherent, gaps in adherence, gradual decline, and rapid decline in adherence. Patients from the three nonadherent trajectories were randomized into MI intervention or control group. The intervention consisted of an initial call and five follow-up calls administered by MI-trained pharmacy students and tailored to the baseline ACEI/ARB adherence trajectories. The primary outcome was adherence to ACEI/ARB during the 6- and 12-month periods post-MI implementation. The secondary outcome was discontinuation, defined as no refills for ACEI/ARB during the 6- and 12-month periods post-MI implementation. Multivariable regression analyses examined the impact of MI intervention on ACEI/ARB adherence and discontinuation while adjusting for baseline covariates. RESULTS A total of 240 patients in the intervention group and 480 patients as randomly selected controls were included in this study. At 6 months, patients receiving the MI intervention had significantly better adherence (β = 0.06; p = 0.03) compared with the controls. Linear and logistic regression models also showed patients in the intervention group were more likely to be adherent than controls within 12 months of intervention implementation (β = 0.06; p = 0.02 and OR: 1.46; 95% CI 1.05-2.04, respectively). MI intervention did not have any significant impact on the ACEI/ARB discontinuation. CONCLUSION Patients who received the MI intervention were more likely to be adherent at 6 and 12 months following the intervention initiation, despite gaps in the follow-up calls due to COVID-19. Pharmacist-led MI intervention is an effective behavioral strategy to improve medication adherence among older adults and tailoring the intervention to past adherence patterns may enhance the intervention effectiveness. This study was registered with the United States National Institutes of Health (ClinicalTrials.gov identifier NCT03985098).
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Affiliation(s)
- Anjana Mohan
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA
| | - Zahra Majd
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA
| | - Michael L Johnson
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA
| | - Ekere J Essien
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA
| | - Jamie Barner
- Health Outcomes Division, The University of Texas at Austin, Austin, TX, USA
| | | | | | - Marc L Fleming
- Pharmaceutical Economics and Policy, Chapman University School of Pharmacy, Irvine, CA, USA
| | - Nancy Ordonez
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Marcia M Holstad
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Susan M Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA.
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The impact of angiotensin-converting-enzyme inhibitors versus angiotensin receptor blockers on 3-year clinical outcomes in elderly (≥ 65) patients with acute myocardial infarction without hypertension. Heart Vessels 2023; 38:898-908. [PMID: 36795168 DOI: 10.1007/s00380-023-02244-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE This study aimed to investigate the impact of angiotensin-converting-enzyme inhibitors (ACEI) and angiotensin II type 1 receptor blockers (ARB) on 3-year clinical outcomes in elderly (≥ 65) acute myocardial infarction (AMI) patients without a history of hypertension who underwent successful percutaneous coronary intervention (PCI) with drug-eluting stents (DES). METHODS A total of 13,104 AMI patients who were registered in the Korea AMI registry (KAMIR)-National Institutes of Health (NIH) were included in the study. The primary endpoint was 3-year major adverse cardiac events (MACE), which was defined as the composite of all-cause death, recurrent myocardial infarction (MI), and any repeat revascularization. To adjust baseline potential confounders, an inverse probability weighting (IPTW) analysis was performed. RESULTS The patients were divided into two groups: the ACEI group, n = 872 patients and the ARB group, n = 508 patients. After IPTW matching, baseline characteristics were balanced. During the 3-year clinical follow-up, the incidence of MACE was not different between the two groups. However, incidence of stroke (hazard ratio [HR], 0.375; 95% confidence interval [CI], 0.166-0.846; p = 0.018) and re-hospitalization due to heart failure (HF) (HR, 0.528; 95% CI, 0.289-0.965; p = 0.038) in the ACEI group were significantly lower than in the ARB group. CONCLUSION In elderly AMI patients who underwent PCI with DES without a history of hypertension, the use of ACEI was significantly associated with reduced incidences of stroke, and re-hospitalization due to HF than those with the use of ARB.
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104
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Smolderen KG, Romain G, Provance JB, Scierka LE, Mao J, Goodney PP, Henke PK, Sedrakyan A, Mena-Hurtado C. Guideline-Directed Medical Therapy and Long-Term Mortality and Amputation Outcomes in Patients Undergoing Peripheral Vascular Interventions. JACC Cardiovasc Interv 2023; 16:332-343. [PMID: 36792257 PMCID: PMC10359106 DOI: 10.1016/j.jcin.2022.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Lack of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) may increase mortality and amputation risk. OBJECTIVES The authors sought to study the association between GDMT and mortality/amputation and to examine GDMT variability among providers and health systems. METHODS We performed an observational study using patients in the Vascular Quality Initiative registry undergoing PVI between 2017 and 2018. Two-year all-cause mortality and major amputation data were derived from Medicare claims data. Compliance with GDMT was defined as receiving a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker if hypertensive. Propensity 1:1 matching was applied for GDMT vs no GDMT and survival analyses were performed to compare outcomes between groups. RESULTS Of 15,891 patients undergoing PVIs, 48.8% received GDMT and 6,120 patients in each group were matched. Median follow-up was 9.6 (IQR: 4.5-16.2) months for mortality and 8.4 (IQR: 3.5-15.4) for amputation. Mean age was 72.0 ± 9.9 years. Mortality risk was higher among patients who did not receive GDMT versus those on GDMT (31.2% vs 24.5%; HR: 1.37, 95% CI: 1.25-1.50; P < 0.001), as well as, risk of amputation (16.0% vs 13.2%; HR: 1.20; 95% CI: 1.08-1.35; P < 0.001). GDMT rates across sites and providers ranging from 0% to 100%, with lower performance translating into higher risk. CONCLUSIONS Almost one-half of the patients receiving PVI in this national quality registry were not on GDMT, and this was associated with increased risk of mortality and major amputation. Quality improvement efforts in vascular care should focus on GDMT in patients undergoing PVI.
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Affiliation(s)
- Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Psychology Section, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeremy B Provance
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lindsey E Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Phillip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, New Hampshire, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Art Sedrakyan
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Fishel Bartal M, Blackwell SC, Pedroza C, Lawal D, Amro F, Samuel J, Chauhan SP, Sibai BM. Oral combined hydrochlorothiazide and lisinopril vs nifedipine for postpartum hypertension: a comparative-effectiveness pilot randomized controlled trial. Am J Obstet Gynecol 2023; 228:571.e1-571.e10. [PMID: 36787814 DOI: 10.1016/j.ajog.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitors and diuretics may be underutilized for postpartum hypertension because of their teratogenicity during pregnancy. OBJECTIVE We evaluated whether combined oral hydrochlorothiazide and lisinopril therapy produced superior short-term blood pressure control when compared with nifedipine among postpartum individuals with hypertension requiring pharmacologic treatment. STUDY DESIGN We performed a pilot randomized controlled trial (October 2021 to June 2022) that included individuals with chronic hypertension or hypertensive disorders of pregnancy with 2 systolic blood pressure measurements ≥150 mm Hg and/or diastolic blood pressure measurements ≥100 mm Hg within 72 hours after delivery. Participants were randomized to receive either combined hydrochlorothiazide and lisinopril therapy or nifedipine therapy after stratifying the participants by diagnosis (chronic hypertension vs hypertensive disorders of pregnancy). The primary outcome was stage 2 hypertension (systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg) determined using a home blood pressure monitor on days 7 to 10 after delivery or at readmission to the hospital for blood pressure control. The secondary outcomes included severe maternal morbidity (any of the following: intensive care unit admission; hemolysis, elevated liver enzymes, low platelet count syndrome; eclampsia; stroke; cardiomyopathy; or maternal death), need for intravenous medications after randomization, hospital length of stay, blood pressure during first clinic visit, medication compliance, and adverse events. A pilot trial with 70 individuals was planned given the limited available data on combined hydrochlorothiazide and lisinopril therapy use in postpartum care. We calculated relative risks and 95% credible intervals in an intention-to-treat analysis. Finally, we conducted a preplanned Bayesian analysis to estimate the probability of benefit or harm with a neutral informative prior. RESULTS Of 111 eligible individuals, 70 (63%) agreed and were randomized (31 in the hydrochlorothiazide and lisinopril group and 36 in the nifedipine group; 3 withdrew consent after randomization), and the characteristics were similar at baseline between the groups. The primary outcome was unavailable for 9 (12.8%) participants. The primary outcome occurred in 27% of participants in the hydrochlorothiazide and lisinopril group and in 43% of the participants in the nifedipine group (posterior adjusted relative risk, 0.74; 95% credible interval, 0.40-1.31). Bayesian analysis indicated an 85% posterior probability of a reduction in the primary outcome with combined hydrochlorothiazide and lisinopril therapy relative to nifedipine treatment. No differences were noted in the secondary outcomes or adverse medication events. CONCLUSION The results of the pilot trial suggest a high probability that combined hydrochlorothiazide and lisinopril therapy produces superior short-term BP control when compared with nifedipine. These findings should be confirmed in a larger trial.
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Affiliation(s)
- Michal Fishel Bartal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX; Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Sean C Blackwell
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Claudia Pedroza
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX
| | - Daramoye Lawal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Farah Amro
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Joyce Samuel
- Center for Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX
| | - Suneet P Chauhan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Baha M Sibai
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
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Yedlapati SH, Mendu A, Tummala VR, Maganti SS, Nasir K, Khan SU. Vaccines and cardiovascular outcomes: lessons learned from influenza epidemics. Eur Heart J Suppl 2023; 25:A17-A24. [PMID: 36937374 PMCID: PMC10021491 DOI: 10.1093/eurheartjsupp/suac110] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Cardiovascular disease (CVD) is the leading cause of death in the world and is largely preventable. An increasing amount of evidence suggests that annual influenza vaccination reduces CVD-related morbidity and mortality. Despite various clinical guidelines recommending annual influenza vaccination for the general population for influenza-like illness risk reduction, with a particular emphasis on people with CVD, vaccination rates fall consistently below the goal established by the World Health Organization. This review outlines the importance of influenza vaccination, mechanisms of cardiovascular events in influenza, summarizing the available literature on the effects of influenza vaccine in CVD and the benefits of influenza vaccine during the COVID-19 pandemic.
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Affiliation(s)
- Siva H Yedlapati
- Department of Medicine, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
| | - Anuradha Mendu
- Department of Medicine, Erie County Medical Center, 462 Grider Street, Buffalo, NY 14215, USA
| | - Venkat R Tummala
- Department of Biology, Virginia Commonwealth University, 1000 W Cary St, Richmond, VA 23284, USA
| | - Sowmith S Maganti
- Department of Biology, Virginia Commonwealth University, 1000 W Cary St, Richmond, VA 23284, USA
| | - Khurram Nasir
- Department of Cardiology, DeBakey Heart and Vascular Center, 6565 Fannin St, Houston, TX 77030, USA
| | - Safi U Khan
- Department of Cardiology, DeBakey Heart and Vascular Center, 6565 Fannin St, Houston, TX 77030, USA
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Zhou J, Zhang Y, Tu W. A reference-free R-learner for treatment recommendation. Stat Methods Med Res 2023; 32:404-424. [PMID: 36540907 DOI: 10.1177/09622802221144326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Assigning optimal treatments to individual patients based on their characteristics is the ultimate goal of precision medicine. Deriving evidence-based recommendations from observational data while considering the causal treatment effects and patient heterogeneity is a challenging task, especially in situations of multiple treatment options. Herein, we propose a reference-free R-learner based on a simplex algorithm for treatment recommendation. We showed through extensive simulation that the proposed method produced accurate recommendations that corresponded to optimal treatment outcomes, regardless of the reference group. We used the method to analyze data from the Systolic Blood Pressure Intervention Trial (SPRINT) and achieved recommendations consistent with the current clinical guidelines.
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Affiliation(s)
- Junyi Zhou
- Design and Inovation, 7129Amgen Inc., Thousand Oaks, CA, USA
| | - Ying Zhang
- Department of Biostatistics, 12284University of Nebraska Medical Center, Omaha, NE, USA
| | - Wanzhu Tu
- Department of Biostatistics and Health Data Science, Indiana University-School of Medicine and Fairbanks School of Public Health, Indianapolis, IN, USA
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108
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Premorbid Use of Beta-Blockers or Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers in Patients with Acute Ischemic Stroke. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2023; 2023:7733857. [PMID: 36778208 PMCID: PMC9908343 DOI: 10.1155/2023/7733857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/07/2022] [Accepted: 10/14/2022] [Indexed: 02/05/2023]
Abstract
This study was designed to investigate the impact of the preexisting use of beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), or angiotensin receptor blockers (ARBs) on the cellular immune response in peripheral blood and the clinical outcomes of patients with acute ischemic stroke. We retrospectively collected clinical data from a cohort of 69 patients with premorbid beta-blockers and 56 patients with premorbid ACEIs/ARBs. Additionally, we selected a cohort of 107 patients with acute ischemic stroke to be the control of the same age and sex. We analyzed cellular immune parameters in peripheral blood 1 day after the appearance of symptoms, including the frequencies of circulating white blood cell subpopulations, the neutrophil-to-lymphocyte ratio (NLR), and the lymphocyte-to-monocyte ratio (LMR). We found that the count of lymphocytes and the lymphocyte-to-monocyte ratio were significantly higher in the peripheral blood of patients treated with beta-blockers before stroke than in matched controls. However, the premorbid use of ACEIs/ARBs did not considerably impact the circulating immune parameters listed above in patients with acute ischemic stroke. Furthermore, we found that premorbid use of beta-blockers or ACEIs/ARBs did not significantly change functional outcomes in patients 3 months after the onset of stroke. These results suggest that premorbid use of beta-blockers, but not ACEIs/ARBs, reversed lymphopenia associated with acute ischemic stroke. As cellular immune changes in peripheral blood could be an independent predictor of stroke prognosis, more large-scale studies are warranted to further verify the impact of premorbid use of beta-blockers or ACEIs/ARBs on the prognosis of patients with ischemic stroke. Our research is beneficial to understanding the mechanism of the systemic immune response induced by stroke and has the potential for a therapeutic strategy in stroke interventions and treatment.
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Hagood NL, Heincelman M, Thomas MK. Use of point-of-care ultrasound by internists to rapidly diagnose acute decompensated heart failure. Respir Med Case Rep 2023; 41:101789. [DOI: 10.1016/j.rmcr.2022.101789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
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Mehran R, Steg PG, Pfeffer MA, Jering K, Claggett B, Lewis EF, Granger C, Køber L, Maggioni A, Mann DL, McMurray JJV, Rouleau JL, Solomon SD, Ducrocq G, Berwanger O, De Pasquale CG, Landmesser U, Petrie M, Leng DSK, van der Meer P, Lefkowitz M, Zhou Y, Braunwald E. The Effects of Angiotensin Receptor-Neprilysin Inhibition on Major Coronary Events in Patients With Acute Myocardial Infarction: Insights From the PARADISE-MI Trial. Circulation 2022; 146:1749-1757. [PMID: 36321459 DOI: 10.1161/circulationaha.122.060841] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND In patients who survive an acute myocardial infarction (AMI), angiotensin-converting enzyme inhibitors decrease the risk of subsequent major cardiovascular events. Whether angiotensin-receptor blockade and neprilysin inhibition with sacubitril/valsartan reduce major coronary events more effectively than angiotensin-converting enzyme inhibitors in high-risk patients with recent AMI remains unknown. We aimed to compare the effects of sacubitril/valsartan on coronary outcomes in patients with AMI. METHODS We conducted a prespecified analysis of the PARADISE-MI trial (Prospective ARNI vs ACE Inhibitors Trial to Determine Superiority in Reducing Heart Failure Events After MI), which compared sacubitril/valsartan (97/103 mg twice daily) with ramipril (5 mg twice daily) for reducing heart failure events after myocardial infarction in 5661 patients with AMI complicated by left ventricular systolic dysfunction, pulmonary congestion, or both. In the present analysis, the prespecified composite coronary outcome was the first occurrence of death from coronary heart disease, nonfatal myocardial infarction, hospitalization for angina, or postrandomization coronary revascularization. RESULTS Patients were randomly assigned at a median of 4.4 [3.0-5.8] days after index AMI (ST-segment-elevation myocardial infarction 76%, non-ST-segment-elevation myocardial infarction 24%), by which time 89% of patients had undergone coronary reperfusion. Compared with ramipril, sacubitril/valsartan decreased the risk of coronary outcomes (hazard ratio, 0.86 [95% CI, 0.74-0.99], P=0.04) over a median follow-up of 22 months. Rates of the components of the composite outcomes were lower in patients on sacubitril/valsartan but were not individually significantly different. CONCLUSIONS In survivors of an AMI with left ventricular systolic dysfunction and pulmonary congestion, sacubitril/valsartan-compared with ramipril-reduced the risk of a prespecified major coronary composite outcome. Dedicated studies are necessary to confirm this finding and elucidate its mechanism. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02924727.
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Affiliation(s)
- Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, AP-HP (Assistance Publique-Hôpitaux de Paris), FACT (French Alliance for Cardiovascular Trials) and INSERM U-1148, France (P.G.S.)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Karola Jering
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, CA (E.F.L.)
| | | | - Lars Køber
- Professor of Cardiology, Department of Clinical Medicine, University of Copenhagen, Denmark (L.K.)
| | - Aldo Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy (A.M.)
| | - Douglas L Mann
- Washington University Medical Center, St Louis, MO (D.L.M.)
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Scotland (J.J.V.M., M.P.)
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Gregory Ducrocq
- Département de Cardiologie, Hôpital Bichat Assistance Publique Hôpitaux de Paris. France (G.D.)
| | - Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, São Paulo-SP, Brazil (O.B.)
| | - Carmine G De Pasquale
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia (C.G.D.P.)
| | - Ulf Landmesser
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Germany (U.L.)
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Scotland (J.J.V.M., M.P.)
| | | | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (P.v.d.M.)
| | - Martin Lefkowitz
- Novartis Pharmaceutical Corporation, East Hanover, NJ (M.L., Y.Z.)
| | - Yinong Zhou
- Novartis Pharmaceutical Corporation, East Hanover, NJ (M.L., Y.Z.)
| | - Eugene Braunwald
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
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Ferrario CM, Saha A, VonCannon JL, Meredith WJ, Ahmad S. Does the Naked Emperor Parable Apply to Current Perceptions of the Contribution of Renin Angiotensin System Inhibition in Hypertension? Curr Hypertens Rep 2022; 24:709-721. [PMID: 36272015 DOI: 10.1007/s11906-022-01229-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW To address contemporary hypertension challenges, a critical reexamination of therapeutic accomplishments using angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, and a greater appreciation of evidence-based shortcomings from randomized clinical trials are fundamental in accelerating future progress. RECENT FINDINGS Medications targeting angiotensin II mechanism of action are essential for managing primary hypertension, type 2 diabetes, heart failure, and chronic kidney disease. While the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to control blood pressure is undisputed, practitioners, hypertension specialists, and researchers hold low awareness of these drugs' limitations in preventing or reducing the risk of cardiovascular events. Biases in interpreting gained knowledge from data obtained in randomized clinical trials include a pervasive emphasis on using relative risk reduction over absolute risk reduction. Furthermore, recommendations for clinical practice in international hypertension guidelines fail to address the significance of a residual risk several orders of magnitude greater than the benefits. We analyze the limitations of the clinical trials that have led to current recommended treatment guidelines. We define and quantify the magnitude of the residual risk in published hypertension trials and explore how activation of alternate compensatory bioprocessing components within the renin angiotensin system bypass the ability of angiotensin converting enzyme inhibitors and angiotensin II receptor blockers to achieve a significant reduction in total and cardiovascular deaths. We complete this presentation by outlining the current incipient but promising potential of immunotherapy to block angiotensin II pathology alone or possibly in combination with other antihypertensive drugs. A full appreciation of the magnitude of the residual risk associated with current renin angiotensin system-based therapies constitutes a vital underpinning for seeking new molecular approaches to halt or even reverse the cardiovascular complications of primary hypertension and encourage investigating a new generation of ACE inhibitors and ARBs with increased capacity to reach the intracellular compartments at which Ang II can be generated.
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Affiliation(s)
- Carlos M Ferrario
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA.
| | - Amit Saha
- Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Jessica L VonCannon
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Wayne J Meredith
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
| | - Sarfaraz Ahmad
- Laboratory of Translational Hypertension and Vascular Research, Department of General Surgery, Wake Forest School of Medicine, Medical Center Blvd, Atrium Health Wake Forest Baptist, Winston Salem, NC, 27157, USA
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112
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Fu C, Zhang D, Chen H, Zhang H. Timed-averaged blood pressure showed a J-curve association with stroke in elderly chronic kidney disease patients. Ren Fail 2022; 44:1677-1686. [PMID: 36222093 PMCID: PMC9578479 DOI: 10.1080/0886022x.2022.2131574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/30/2022] Open
Abstract
BACKGROUND The risk factors for stroke in elderly patients with chronic kidney disease (CKD) are not well understood. This study aimed to explore the influence of systolic blood pressure (SBP) on the risk of stroke in a large cohort of elderly patients with stage 3-5 CKD. METHODS We retrospectively identified 665 patients hospitalized in Beijing Friendship Hospital from January 2000 to December 2021. Patients were followed up until the occurrence of stroke or death. Multivariate logistic regression analysis and Cox proportional hazard models were used to analyze the risk factors for stroke according to the presence or absence of CKD. The association between CKD and stroke was further evaluated regarding the role of SBP in the hypertensive population. RESULTS In individuals with CKD, a J-shaped relationship was observed between SBP levels and the risk of stroke. Participants with CKD and an SBP less than 125 mmHg had a significantly higher cumulative stroke survival rate than those whose SBP was between 125 and 139 mmHg. The cumulative stroke survival rate increased progressively for those with SBP higher than 140 mmHg. This J-shaped relationship was not found in patients without CKD. CONCLUSION In elderly patients with CKD, those with the lowest BP are at increased risk for incident stroke. This phenomenon could be different from that in the general population.
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Affiliation(s)
- Chen Fu
- Department of Nephrology, Beijing Jishuitan Hospital, Beijing, China
| | - Dongliang Zhang
- Department of Nephrology, Beijing Jishuitan Hospital, Beijing, China
| | - Haiping Chen
- Department of Geriatric Nephrology, Medical and Health Care Center, Beijing Friendship Hospital (affiliated with Capital Medical University), Beijing, China
| | - Hui Zhang
- Department of Nephrology, Tianjin Hospital, Tianjin, China
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Manfredi R, Verdoia M, Compagnucci P, Barbarossa A, Stronati G, Casella M, Dello Russo A, Guerra F, Ciliberti G. Angina in 2022: Current Perspectives. J Clin Med 2022; 11:jcm11236891. [PMID: 36498466 PMCID: PMC9737178 DOI: 10.3390/jcm11236891] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022] Open
Abstract
Angina is the main symptom of ischemic heart disease; mirroring a mismatch between oxygen supply and demand. Epicardial coronary stenoses are only responsible for nearly half of the patients presenting with angina; whereas in several cases; symptoms may underlie coronary vasomotor disorders; such as microvascular dysfunction or epicardial spasm. Various medications have been proven to improve the prognosis and quality of life; representing the treatment of choice in stable angina and leaving revascularization only in particular coronary anatomies or poorly controlled symptoms despite optimal medical therapy. Antianginal medications aim to reduce the oxygen supply-demand mismatch and are generally effective in improving symptoms; quality of life; effort tolerance and time to ischemia onset and may improve prognosis in selected populations. Since antianginal medications have different mechanisms of action and side effects; their use should be tailored according to patient history and potential drug-drug interactions. Angina with non-obstructed coronary arteries patients should be phenotyped with invasive assessment and treated accordingly. Patients with refractory angina represent a higher-risk population in which some therapeutic options are available to reduce symptoms and improve quality of life; but robust data from large randomized controlled trials are still lacking.
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Affiliation(s)
- Roberto Manfredi
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Monica Verdoia
- Division of Cardiology Ospedale degli Infermi, ASL, 13875 Biella, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Alessandro Barbarossa
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Giulia Stronati
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60126 Ancona, Italy
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, 60126 Ancona, Italy
- Correspondence:
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Armstrong PW, Bates ER, Gaudino M. Left main coronary disease: evolving management concepts. Eur Heart J 2022; 43:4635-4643. [PMID: 36173870 DOI: 10.1093/eurheartj/ehac542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 01/05/2023] Open
Abstract
Remarkable advances in the management of coronary artery disease have enhanced our approach to left main coronary artery (LMCA) disease. The traditional role of coronary artery bypass graft surgery has been challenged by the less invasive percutaneous coronary interventional approach. Additionally, major strides in optimal medical therapy now provide a rich menu of treatment choices in selected circumstances. Although a LMCA stenosis >70% is an acceptable threshold for revascularization, those patients with a LMCA narrowing between 40 and 69% present a more complex scenario. This review examines the relative merits of the different treatment options, addresses key diagnostic and therapeutic unknowns, and identifies future work likely to advance progress.
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Affiliation(s)
- Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, 4-120 Katz Group Centre for Pharmacy and Health Research, Edmonton, AB T6G 2E1, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-111 St., Edmonton, AB T6G 2B7, Canada
| | - Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive 2139 Cardiovascular Center, Ann Arbor, MI 48109, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th St, Box 110, New York, NY 10065, USA
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115
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Lauder L, Mahfoud F, Azizi M, Bhatt DL, Ewen S, Kario K, Parati G, Rossignol P, Schlaich MP, Teo KK, Townsend RR, Tsioufis C, Weber MA, Weber T, Böhm M. Hypertension management in patients with cardiovascular comorbidities. Eur Heart J 2022:6808663. [DOI: 10.1093/eurheartj/ehac395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/23/2022] [Accepted: 07/08/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Michel Azizi
- Université Paris Cité, INSERM CIC1418 , F-75015 Paris , France
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department, DMU CARTE , F-75015 Paris , France
- FCRIN INI-CRCT , Nancy , France
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School , Boston, MA , USA
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine , Tochigi , Japan
| | - Gianfranco Parati
- Department of Medicine and Surgery, Cardiology Unit, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS , Milan , Italy
| | - Patrick Rossignol
- FCRIN INI-CRCT , Nancy , France
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques - Plurithématique 14-33 and INSERM U1116 , Nancy , France
- CHRU de Nancy , Nancy , France
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School—Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia , Perth, WA , Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital , Perth, WA , Australia
| | - Koon K Teo
- Population Health Research Institute, McMaster University , Hamilton, ON , Canada
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
| | - Costas Tsioufis
- National and Kapodistrian University of Athens, 1st Cardiology Clinic, Hippocratio Hospital , Athens , Greece
| | | | - Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen , Wels , Austria
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
- Cape Heart Institute (CHI), Faculty of Health Sciences, University of Cape Town , Cape Town , South Africa
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Chen S, Liang W, Wu Y, Chen X, He X, Zhao J, He J, Dong Y, Staessen JA, Liu C, Wei F. Associations of short- and long-term mortality with admission blood pressure in Chinese patients with different heart failure subtypes. J Clin Hypertens (Greenwich) 2022; 24:1577-1586. [PMID: 36321681 PMCID: PMC9731597 DOI: 10.1111/jch.14589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/04/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
It remains unknown whether systolic (SBP) and diastolic (DBP) pressure on admission are associated with short- and long-term mortality in Chinese patients with heart failure with preserved (HFpEF), mildly reduced (HFmrEF), and reduced (HFrEF) ejection fraction. In 2706 HF patients (39.1% women; mean age, 68.8 years), we assessed the risk of 30-day, 1-year, and long-term (> 1 year) mortality with 1-SD increment in SBP and DBP, using multivariable logistic and Cox regression, respectively. During a median follow-up of 4.1 years, 1341 patients died. The 30-day, 1-year, and long-term mortality were 3.5%, 16.7%, and 39.4%, respectively. In multivariable-adjusted analyses additionally accounted for DBP or SBP, a higher SBP conferred a higher risk of long-term mortality (hazard ratio, 1.11; 95% CI, 1.02-1.22; p = .017) and a lower DBP was associated with a higher risk of all types of mortality (p ≤ .011) in all HF patients. Independent of potential confounders including DBP or SBP, in patients with HFpEF, higher SBP and lower DBP levels predicted a higher risk of long-term mortality with hazard ratios amounting to 1.16 (95% CI, 1.04-1.29; p = .007) and .89 (95% CI, .80-.99; p = .028), respectively. In patients with HFmrEF and HFrEF, irrespective of adjustments of potential confounders, DBP was associated with 1-year mortality with odds ratios ranging from .49 to .62 (p ≤ .006). In conclusion, lower DBP and higher SBP levels on admission were associated with a higher risk of different types of all-cause mortality in Chinese patients with different HF subtypes. Our observations highlight that admission BP may help to improve risk stratification.
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Affiliation(s)
- Shilan Chen
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Weihao Liang
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Yuzhong Wu
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Xuwei Chen
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Xin He
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Jingjing Zhao
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Jiangui He
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Yugang Dong
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina,National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Jan A. Staessen
- Research Institute Alliance for the Promotion of Preventive MedicineMechelenBelgium,Biomedical Science GroupUniversity of LeuvenLeuvenBelgium
| | - Chen Liu
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina,National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Fang‐Fei Wei
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
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Shobako N, Goto C, Nakagawa T, Yamato T, Kondo S, Nakamura F, Nakazeko T, Hirano Y, Honda K. Hypotensive and HbA1c reducing effect of novel dietary intervention program “COMB meal program”: Two randomized clinical trials. J Funct Foods 2022. [DOI: 10.1016/j.jff.2022.105279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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118
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Liu X, Tang L, Tang Y, Du C, Chen X, Xu C, Yan J. Closing gaps in medication taking for secondary prevention of coronary heart disease patients among US adults. Heliyon 2022; 8:e11530. [PMID: 36406714 PMCID: PMC9667245 DOI: 10.1016/j.heliyon.2022.e11530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/29/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022] Open
Abstract
Background The secondary preventive medical remedies used in the U.S. general population, particularly those with numerous co-morbidities, are poorly understood. We aimed to assess health outcomes and the extent of their adherence to guideline-based secondary prevention medications among U.S. coronary heart disease (CHD) patients. Methods We analysed information from the U.S. National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018 on people in the United States aged 18 to 85 who had a personal history of coronary heart disease (CHD). Logistic regression analyses were used to identify characteristics related to healthcare access that were linked with not taking any indicated drugs among CHD and other co-morbidity patients in the U.S. Results We gathered 4256 CHD patients aged 18 and above. Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), statins, and antiplatelet medications were taken by 50.94%, 48.26%, 53.41 %, and 19.78% of the population, respectively. Surprising, not received recommended drugs was reached up to 21.12%, and taking all four drugs was only 7.64%. In conclusion, the logistic regression analysis revealed that the chance of not taking prescribed drugs increased with age (18–39), race (Hispanic and Non-Hispanic Black), low income, lack of insurance, and the absence of co-morbidities (hypertension, heart failure, and diabetes mellitus). Conclusions The gap between the proposed secondary preventative measures and their actual execution remains sizable. In order to achieve ‘Healthy Aging’, a systematic approach for prevention of CHD is urgently needed.
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Affiliation(s)
- Xiaowei Liu
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, PR China
| | - Lijiang Tang
- Department of Cardiology, Zhejiang Hospital, Hangzhou, Zhejiang 310013, PR China
| | - Ying Tang
- Geriatrics Research Institute of Zhejiang Province, Zhejiang Provincial Key Lab of Geriatrics, Zhejiang Hospital, Hangzhou, Zhejiang 310013, PR China
| | - Changqing Du
- Department of Cardiology, Zhejiang Hospital, Hangzhou, Zhejiang 310013, PR China
| | - Xiaofeng Chen
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Cheng Xu
- Department of Cardiology, Taizhou Hospital, Wenzhou Medical University, Taizhou, Zhejiang 317000, PR China
| | - Jing Yan
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, PR China
- Corresponding author.
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Ho CLB, Reid CM. Update on trials examining effects of night-time blood pressure lowering drug treatment on prevention of cardiovascular disease. EXPLORATION OF MEDICINE 2022. [DOI: 10.37349/emed.2022.00107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Current evidence on benefits of night-time blood pressure (BP) lowering drug treatment on cardiovascular disease (CVD) prevention attributable to the Ambulatory Blood Pressure Monitoring in the Prediction of Cardiovascular Events and Effects of Chronotherapy (MAPEC) trial and Bedtime hypertension treatment improves cardiovascular risk reduction (Hygia) trials has raised concern on their validity and methodology. In this commentary, the authors have updated the progress of the ongoing trials that were planned to examine the effect of night-time BP lowering drug treatment on CVD prevention. As compared to MAPEC and Hygia trials, three pragmatic trials the Blood Pressure Medication Timing (BPMedtime) trial (US), the Treatment In Morning versus Evening (TIME) trial (UK), Bedmed and Bedmed-frail (Canada) were planned without ambulatory BP monitoring. The BPMedtime trial was stopped after the pilot phase due to underestimated sample size and insufficient funds. TIME trial (UK) had a similar issue when changing the sample size from 10,269 to more than 20,000 participants. The TIME trial was completed and the initial results showing that protection against heart attack, stroke and vascular death is not affected by whether antihypertensive medications are taken in the morning or evening. The full study of the TIME trial is published in December 2022. Bedmed and Bedmed-frail trials are ongoing and will be completed in 2023. Time of taking BP lowering drug should be determined by patients at their convenience to improve the adherence. There was no difference in adverse effects of taking BP lowering drugs at night or morning. Evidence on the effect of night-time treatment on CVD events is inconsistent. The results from ongoing trials in Canada will contribute evidence to the use of BP lowering drug treatment for the prevention of CVD.
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Affiliation(s)
- Chau Le Bao Ho
- Curtin University, Bentley 6102, Western Australia, Australia
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Joo SJ, Kim SY, Lee JG, Beom JW, Choi JH, Park HK, Boo KY, Yoon CH, Lee JH, Chae JK, Jeong MH. Association of the medical therapy with beta-blockers or inhibitors of renin-angiotensin system with clinical outcomes in patients with mildly reduced left ventricular ejection fraction after acute myocardial infarction. Medicine (Baltimore) 2022; 101:e30846. [PMID: 36281078 PMCID: PMC9592534 DOI: 10.1097/md.0000000000030846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
In the era of the initial optimal interventional and medical therapy for acute myocardial infarction (AMI), a number of patients with mildly reduced left ventricular ejection fraction (EF) (41%-49%) have been increasing. This observational study aimed to investigate the association between the medical therapy with oral beta-blockers or inhibitors of renin-angiotensin system (RAS) and 2-year clinical outcomes in patients with mildly reduced EF after AMI. Among patients enrolled in the Korea Acute Myocardial Infarction Registry-National Institute of Health, propensity-score matched patients who survived the initial attack and had mildly reduced EF were selected according to beta-blocker or RAS inhibitor therapy at discharge. Beta-blocker therapy at discharge was associated with lower 2-year major adverse cardiac events which was a composite of cardiac death, myocardial infarction, revascularization and re-hospitalization due to heart failure (8.7 vs 12.8/100 patient-years; hazard ratio [HR] 0.68; 95% confidence interval [CI] 0.50-0.93; P = .015), and no significant interaction between EF ≤ 45% and > 45% was observed (Pinteraction = 0.354). This association was mainly driven by lower myocardial infarction in patients with beta-blockers (HR 0.50; 95% CI 0.26-0.95; P = .035). Inhibitors of RAS at discharge were associated with lower re-hospitalization due to heart failure (1.8 vs 3.5/100 patient-years; HR 0.53; 95% CI 0.33-0.86; P = .010) without a significant interaction between EF ≤ 45% and > 45% (Pinteraction = 0.333). In patients with mildly reduced EF after AMI, the medical therapy with beta-blockers or RAS inhibitors at discharge was associated with better 2-year clinical outcomes.
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Affiliation(s)
- Seung-Jae Joo
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Song-Yi Kim
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Jae-Geun Lee
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Jong Wook Beom
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Joon-Hyouk Choi
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Republic of Korea
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Hyeung Keun Park
- Department of Health Policy and Management, Jeju National University College of Medicine, Jeju, Republic of Korea
| | - Ki Yung Boo
- Department of Internal Medicine, Jeju National University Hospital, Jeju, Republic of Korea
| | - Chang-Hwan Yoon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jung-Hee Lee
- Division of Cardiology, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Jei Keon Chae
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea
| | - Myung Ho Jeong
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
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Mao Y, Ge S, Qi S, Tian QB. Benefits and risks of antihypertensive medication in adults with different systolic blood pressure: A meta-analysis from the perspective of the number needed to treat. Front Cardiovasc Med 2022; 9:986502. [PMID: 36337902 PMCID: PMC9626501 DOI: 10.3389/fcvm.2022.986502] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/03/2022] [Indexed: 12/03/2022] Open
Abstract
Background The blood pressure (BP) threshold for initial pharmacological treatment remains controversial. The number needed to treat (NNT) is a significant indicator. This study aimed to explore the benefits and risks of antihypertensive medications in participants with different systolic BPs (SBPs), and cardiovascular disease status from the perspective of the NNT. Methods We conducted a meta-analysis of 52 randomized placebo-controlled trials. The data were extracted from published articles and pooled to calculate NNTs. The participants were divided into five groups, based on the mean SBP at entry (120–129.9, 130–139.9, 140–159.9, 160–179.9, and ≥180 mmHg). Furthermore, we stratified patients into those with and without cardiovascular disease. The primary outcomes were the major adverse cardiovascular events (MACEs), and adverse events (AEs) leading to discontinuation. Results Antihypertensive medications were not associated with MACEs, however, it increased AEs, when the SBP was <140 mmHg. For participants with cardiovascular disease or at a high risk of heart failure and stroke, antihypertensive treatment reduced MACEs when SBP was ≥130 mmHg. Despite this, only 2–4 subjects had reduced MACEs per 100 patients receiving antihypertensive medications for 3.50 years. The number of individuals who needed to treat to avoid MACEs declined with an increased cardiovascular risk. Conclusion Pharmacological treatment could be activated when SBP reaches 140 mmHg. For people with cardiovascular disease or at a higher risk of stroke and heart failure, 130 mmHg may be a better therapeutic threshold. It could be more cost-effective to prioritize antihypertensive medications for people with a high risk of developing cardiovascular disease.
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Rogers SC, Ko YA, Quyyumi AA, Hajjar I. Differential Sex-Specific Effects of Angiotensin-Converting Enzyme Inhibition and Angiotensin Receptor Blocker Therapy on Arterial Function in Hypertension: CALIBREX Trial. Hypertension 2022; 79:2316-2327. [PMID: 35916128 DOI: 10.1161/hypertensionaha.122.19105] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increased arterial stiffness is associated with adverse cardiovascular outcomes. We studied the sex-specific impact of angiotensin antagonists on vascular function in hypertension with the hypothesis that their effects on arterial stiffness may be variable in men and women. METHODS In 141 hypertensive participants with mild cognitive impairment (age 65.9±7.7, 57% female), candesartan (up to 32 mg, n=77) or lisinopril (up to 40 mg, n=64) were administered to achieve blood pressure <140/90 mm Hg. Pulse wave velocity, central pulse pressure, and central augmentation index were measured using applanation tonometry (SphygmoCor, Australia). Multivariate linear regression and mixed model analyses were performed using intention-to-treat and per protocol analyses for those completing the study. RESULTS Blood pressure reduction was similar among candesartan and lisinopril groups. Compared with candesartan, lisinopril therapy resulted in lower pulse wave velocity (0.5±0.8 versus -0.7±0.4 m/s, respectively; P=0.003) and central pulse pressure (-1±3 versus -7±4 mm Hg; P=0.03) after 1 year. There was a significant interaction by sex whereby the improvements in pulse wave velocity and central pulse pressure with lisinopril compared with candesartan were only observed in women. In contrast, there was greater improvement in augmentation index with candesartan compared with lisinopril (-4±7% versus -1.5±8%; P=0.05), with no sex differences. CONCLUSIONS Despite equipotent antihypertensive effects, lisinopril was more effective than candesartan at lowering arterial stiffness in women. In contrast, candesartan was more effective than lisinopril in improving pulse wave reflections in both sexes. These findings demonstrate differential sex-specific effects of renin-angiotensin system antagonists on arterial function in hypertension that may contribute to long-term cardiovascular and neurocognitive outcomes in this population.
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Affiliation(s)
- Steven C Rogers
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute (S.C.R., Y.-A.K., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Yi-An Ko
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute (S.C.R., Y.-A.K., A.A.Q.), Emory University School of Medicine, Atlanta, GA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA (Y.-A.K.)
| | - Arshed A Quyyumi
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute (S.C.R., Y.-A.K., A.A.Q.), Emory University School of Medicine, Atlanta, GA
| | - Ihab Hajjar
- Department of Neurology (I.H.), Emory University School of Medicine, Atlanta, GA
- Division of General Medicine and Geriatrics, Department of Medicine (I.H.), Emory University School of Medicine, Atlanta, GA
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Cruz-López EO, Ye D, Wu C, Lu HS, Uijl E, Mirabito Colafella KM, Danser AHJ. Angiotensinogen Suppression: A New Tool to Treat Cardiovascular and Renal Disease. Hypertension 2022; 79:2115-2126. [PMID: 35904033 PMCID: PMC9444253 DOI: 10.1161/hypertensionaha.122.18731] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Multiple types of renin-angiotensin system (RAS) blockers exist, allowing interference with the system at the level of renin, angiotensin-converting enzyme, or the angiotensin II receptor. Yet, in particular, for the treatment of hypertension, the number of patients with uncontrolled hypertension continues to rise, either due to patient noncompliance or because of the significant renin rises that may, at least partially, overcome the effect of RAS blockade (RAS escape). New approaches to target the RAS are either direct antisense oligonucleotides that inhibit angiotensinogen RNA translation, or small interfering RNA (siRNA) that function via the RNA interference pathway. Since all angiotensins stem from angiotensinogen, lowering angiotensinogen has the potential to circumvent the RAS escape phenomenon. Moreover, antisense oligonucleotides and small interfering RNA require injections only every few weeks to months, which might reduce noncompliance. Of course, angiotensinogen suppression also poses a threat in situations where the RAS is acutely needed, for instance in women becoming pregnant during treatment, or in cases of emergency, when severe hypotension occurs. This review discusses all preclinical data on angiotensinogen suppression, as well as the limited clinical data that are currently available. It concludes that it is an exciting new tool to target the RAS with high specificity and a low side effect profile. Its long-term action might revolutionize pharmacotherapy, as it could overcome compliance problems. Preclinical and clinical programs are now carefully investigating its efficacy and safety profile, allowing an optimal introduction as a novel drug to treat cardiovascular and renal diseases in due time.
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Affiliation(s)
- Edwyn O Cruz-López
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (E.O.C.L., D.Y., E.U., A.H.J.D.)
| | - Dien Ye
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (E.O.C.L., D.Y., E.U., A.H.J.D.)
| | - Congqing Wu
- Saha Cardiovascular Research Center (C.W., H.S.L.), University of Kentucky.,Department of Surgery (C.W.), University of Kentucky
| | - Hong S Lu
- Saha Cardiovascular Research Center (C.W., H.S.L.), University of Kentucky.,Department of Physiology (H.S.L.), University of Kentucky
| | - Estrellita Uijl
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (E.O.C.L., D.Y., E.U., A.H.J.D.)
| | | | - A H Jan Danser
- Division of Pharmacology and Vascular Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands (E.O.C.L., D.Y., E.U., A.H.J.D.)
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Razo C, Welgan CA, Johnson CO, McLaughlin SA, Iannucci V, Rodgers A, Wang N, LeGrand KE, Sorensen RJD, He J, Zheng P, Aravkin AY, Hay SI, Murray CJL, Roth GA. Effects of elevated systolic blood pressure on ischemic heart disease: a Burden of Proof study. Nat Med 2022; 28:2056-2065. [PMID: 36216934 PMCID: PMC9556328 DOI: 10.1038/s41591-022-01974-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/27/2022] [Indexed: 12/28/2022]
Abstract
High systolic blood pressure (SBP) is a major risk factor for ischemic heart disease (IHD), the leading cause of death worldwide. Using data from published observational studies and controlled trials, we estimated the mean SBP-IHD dose-response function and burden of proof risk function (BPRF), and we calculated a risk outcome score (ROS) and corresponding star rating (one to five). We found a very strong, significant harmful effect of SBP on IHD, with a mean risk-relative to that at 100 mm Hg SBP-of 1.39 (95% uncertainty interval including between-study heterogeneity 1.34-1.44) at 120 mm Hg, 1.81 (1.70-1.93) at 130 mm Hg and 4.48 (3.81-5.26) at 165 mm Hg. The conservative BPRF measure indicated that SBP exposure between 107.5 and 165.0 mm Hg raised risk by 101.36% on average, yielding a ROS of 0.70 and star rating of five. Our analysis shows that IHD risk was already increasing at 120 mm Hg SBP, rising steadily up to 165 mm Hg and increasing less steeply above that point. Our study endorses the need to prioritize and strengthen strategies for screening, to raise awareness of the need for timely diagnosis and treatment of hypertension and to increase the resources allocated for understanding primordial prevention of elevated blood pressure.
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Affiliation(s)
- Christian Razo
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
| | | | - Catherine O Johnson
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Susan A McLaughlin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Vincent Iannucci
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Anthony Rodgers
- The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Nelson Wang
- The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Kate E LeGrand
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Reed J D Sorensen
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jiawei He
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Peng Zheng
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Aleksandr Y Aravkin
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Applied Mathematics, University of Washington, Seattle, WA, USA
| | - Simon I Hay
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Gregory A Roth
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Division of Cardiology, University of Washington, Seattle, WA, USA
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Ramipril Improves Endothelial Function and Increases the Number of Endothelial Progenitor Cells in Patients With Systemic Lupus Erythematosus. J Clin Rheumatol 2022; 28:349-353. [PMID: 35662232 DOI: 10.1097/rhu.0000000000001869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND/OBJECTIVES Endothelial dysfunction and reduced number of endothelial progenitor cells (EPCs) in peripheral blood are contributing factors to cardiovascular disease in systemic lupus erythematosus (SLE) patients. Endothelial progenitor cell proliferation is regulated by vascular endothelial growth factor (VEGF). Angiotensin-converting enzyme inhibitors reduce cardiovascular mortality in patients with coronary heart disease. METHODS This was a randomized trial including 37 female SLE patients without cardiovascular risk factors allocated into 2 groups: 19 patients received ramipril 10 mg/d for 12 weeks (IG) and 18 patients maintained without ramipril (CG). Endothelial function was assessed by brachial artery ultrasound measuring flow-mediated dilation, and EPCs were quantified by flow cytometry and cell culture, at baseline and after 12 weeks. Serum VEGF levels were measured by enzyme-linked immunosorbent assay. Statistical analysis was intention to treat. p < 0.05 was considered significant. RESULTS After 12 weeks, higher flow-mediated dilation (6.17% vs. 11.14%, p < 0.001) was observed in IG, without change in CG (5.37% vs. 5.02%, p = 0.630). Higher number of EPC colony-forming units was also observed in IG (21.3 ± 10.4 vs. 31.6 ± 8.5, p < 0.001), without difference in CG ( p = 0.714). No difference was found in EPCs evaluated by flow cytometry. Vascular endothelial growth factor level increased after 12 weeks in IG ( p = 0.048), with no difference in CG ( p = 0.661). CONCLUSION Ramipril improved endothelial function and increased the numbers of EPCs evaluated by cell culture and VEGF levels in SLE patients without cardiovascular risk factors. These data suggest that angiotensin-converting enzyme inhibitor bring an extra benefit beyond the hypotensive action and should be considered as a preferred antihypertensive drug in SLE patients.
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Elrakaybi A, Laubner K, Zhou Q, Hug MJ, Seufert J. Cardiovascular protection by SGLT2 inhibitors - Do anti-inflammatory mechanisms play a role? Mol Metab 2022; 64:101549. [PMID: 35863639 PMCID: PMC9352970 DOI: 10.1016/j.molmet.2022.101549] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Metabolic syndrome and related metabolic disturbances represent a state of low-grade inflammation, which accelerates insulin resistance, type 2 diabetes (T2D) and cardiovascular disease (CVD) progression. Among antidiabetic medications, sodium glucose co-transporter (SGLT) 2 inhibitors are the only agents which showed remarkable reductions in heart failure (HF) hospitalizations and major cardiovascular endpoints (MACE) as well as renal endpoints regardless of diabetes status in large randomized clinical outcome trials (RCTs). Although the exact mechanisms underlying these benefits are yet to be established, growing evidence suggests that modulating inflammation by SGLT2 inhibitors may play a key role. SCOPE OF REVIEW In this manuscript, we summarize the current knowledge on anti-inflammatory effects of SGLT2 inhibitors as one of the mechanisms potentially mediating their cardiovascular (CV) benefits. We introduce the different metabolic and systemic actions mediated by these agents which could mitigate inflammation, and further present the signalling pathways potentially responsible for their proposed direct anti-inflammatory effects. We also discuss controversies surrounding some of these mechanisms. MAJOR CONCLUSIONS SGLT2 inhibitors are promising anti-inflammatory agents by acting either indirectly via improving metabolism and reducing stress conditions or via direct modulation of inflammatory signalling pathways. These effects were achieved, to a great extent, in a glucose-independent manner which established their clinical use in HF patients with and without diabetes.
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Affiliation(s)
- Asmaa Elrakaybi
- Division of Endocrinology and Diabetology, Department of Medicine II, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; Department of Clinical Pharmacy, Ain Shams University, 11566 Cairo, Egypt
| | - Katharina Laubner
- Division of Endocrinology and Diabetology, Department of Medicine II, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Qian Zhou
- Department of Cardiology and Angiology I, Heart Centre, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; Department of Cardiology, University Hospital Basel, 4031 Basel, Switzerland
| | - Martin J Hug
- Pharmacy, Medical Centre - University of Freiburg, 79106 Freiburg, Germany
| | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Medicine II, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany.
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Călin P, Viorel M, Luchiana P, Mihaela C, Lavinia P. Masked nocturnal hypertension as a result of high prevalence of non-dippers among apparently well-controlled hypertensive patients with type 2 diabetes mellitus: data from a prospective study. Diabetol Metab Syndr 2022; 14:130. [PMID: 36109761 PMCID: PMC9479407 DOI: 10.1186/s13098-022-00899-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 08/29/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ambulatory blood pressure monitoring (ABPM) in patients with diabetes mellitus (DM) and hypertension (HTN) show the dipping patterns, identify masked uncontrolled hypertension (MUCH), and demonstrate the effectiveness of the blood pressure (BP) treatment. MUCH is associated with a two-fold higher risk of adverse events. Prevalence in patients with DM is between 13.3 and 66.4%. Our study aims to investigate the prevalence of MUCH and the BP patterns in a population of apparently well-controlled hypertensive patients with type 2 DM (T2DM). A second aspect was the assessment of the effectiveness of antihypertensive treatment. METHODS One hundred and sixty-three consecutively treated hypertensive patients with T2DM and an office BP between 130-139 and 80-89 mmHg performed a 24 h ABPM. The circadian BP variation, the presence of MUCH, and the correlations with the treatment were assessed. RESULTS There were 75 dippers (46.02%), 77 non-dippers (47.23%), 4 reverse dippers (2.45%), and 7 extreme dippers (4.30%). Eighty-one patients (77 non-dippers + 4 reverse dippers; 49.7%) had isolated nocturnal MUCH according to the mean night ABPM criteria. Dippers and extreme dippers (75 dippers + 7 extreme dippers; 51.3%) did not have any MUCH criteria. The patients took, on an average, 3 antihypertensive drugs with no difference between those with controlled HTN and the isolated nocturnal MUCH group. Significant factors associated with isolated nocturnal MUCH and a non-dipping BP pattern included age > 65 years (OR = 1.9), DM duration > 10 years (OR = 1.4), HTN duration > 6.5 years (OR = 1.2), obesity (OR = 1.6), and cardiovascular comorbidities (OR = 1.4). CONCLUSIONS The current study shows that half of the treated hypertensive patients with T2DM and office clinical normotension are non-dippers or reverse dippers. They experience isolated nocturnal MUCH due to their elevated nocturnal BP values, which comply with the actual definition of masked nocturnal hypertension. Bedtime chronotherapy in those patients could be linked to better effectiveness of antihypertensive treatment during the night with the important goal of reducing cardiovascular and cerebrovascular adverse events. ABPM should be performed in hypertensive patients with DM for better risk stratification and more effective control of HTN.
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Affiliation(s)
- Pop Călin
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
- Faculty of Medicine Arad, “Vasile Goldis” University, 310025 Arad, Romania
| | - Manea Viorel
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
| | - Pruna Luchiana
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
| | - Cosma Mihaela
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
| | - Pop Lavinia
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
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Ong GJ, Nguyen TH, Surikow SY, Horowitz JD. Risk factors for a broken heart: understanding drug-induced causes for Takotsubo syndrome and pharmacological treatment options. Expert Rev Clin Pharmacol 2022; 15:1017-1025. [DOI: 10.1080/17512433.2022.2121701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Gao Jing Ong
- Cardiology Unit, Central Adelaide Local Health Network, Adelaide, Australia
- Cardiovascular Pathophysiology and Therapeutics Group, Basil Hetzel Institute, University of Adelaide, Woodville, Australia
| | - Thanh Ha Nguyen
- Cardiovascular Pathophysiology and Therapeutics Group, Basil Hetzel Institute, University of Adelaide, Woodville, Australia
- Northern Adelaide Local Health Network, Elizabeth Vale, Australia
| | - Sven Y Surikow
- Cardiovascular Pathophysiology and Therapeutics Group, Basil Hetzel Institute, University of Adelaide, Woodville, Australia
- Northern Adelaide Local Health Network, Elizabeth Vale, Australia
| | - John D Horowitz
- Cardiovascular Pathophysiology and Therapeutics Group, Basil Hetzel Institute, University of Adelaide, Woodville, Australia
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Liu XH, Wang GL, Xu Q, Zhang L, Liu HJ. Effect of sacubitril/valsartan on the occurrence of cardiac arrhythmias and the risk of sudden cardiac death in heart failure: A meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:943377. [PMID: 36148074 PMCID: PMC9489142 DOI: 10.3389/fcvm.2022.943377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Sacubitril/valsartan therapy reduced the risks of death and of hospitalization for heart failure (HF). HF and cardiac arrhythmias have shared physiological mechanisems. Therefore, sacubitril/valsartan may exhibit anti-arrhythmic properties in HF. The purpose of this study was to evaluate the effect of sacubitril/valsartan on the occurrence of cardiac arrhythmias and the risk of sudden cardiac death (SCD) in HF. Methods This meta-analysis was performed according to PRISMA guidelines. We searched PubMed and Embase (from inception up to 6 February 2022) to identify randomized control trials (RCTs) on the effect of sacubitril/valsartan on the occurrence of cardiac arrhythmias and the risk of SCD in HF. Primary outcomes were the occurrence of atrial arrhythmias, ventricular arrhythmias, and SCD. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model for meta-analysis. Results We included 9 RCTs (published between 2012 and 2021) with 18,500 patients (9,244 sacubitril/valsartan vs. 9,256 active control). Enalapril and valsartan were used as active control in six and two studies, respectively. Follow-up ranged from 2 to 35 months. The cumulative occurrence of events was 76, 13, and 48 per 1,000 patient-years for atrial arrhythmias, ventricular arrhythmias and SCD, respectively. There was no significant association between sacubitril/valsartan therapy and the occurrence of atrial arrhythmias (RR 1.06; 95% CI: 0.97–1.17; P = 0.19) and ventricular arrhythmias (RR 0.86; 95% CI 0.68–1.10; P = 0.24). However, sacubitril/valsartan therapy significantly reduced the risk of SCD (RR 0.79; 95% CI 0.70–0.90; P = 0.03) compared with control. Conclusion No association between sacubitril/valsartan therapy and the occurrence of atrial and ventricular arrhythmias was found, but sacubitril/valsartan therapy significantly reduced the risk of SCD.
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Affiliation(s)
- Xue-Hui Liu
- Department of Cardiology, Yichang Hospital of Traditional Chinese Medicine, Yichang, China
- Traditional Chinese Medicine Hospital of China Three Gorges University, China Three Gorges University, Yichang, China
| | | | - Qiang Xu
- Department of Cardiology, Yichang Hospital of Traditional Chinese Medicine, Yichang, China
- Traditional Chinese Medicine Hospital of China Three Gorges University, China Three Gorges University, Yichang, China
| | - Lei Zhang
- Department of Cardiology, Yichang Hospital of Traditional Chinese Medicine, Yichang, China
- Traditional Chinese Medicine Hospital of China Three Gorges University, China Three Gorges University, Yichang, China
| | - Hong-Jun Liu
- Department of Cardiology, Yichang Hospital of Traditional Chinese Medicine, Yichang, China
- Traditional Chinese Medicine Hospital of China Three Gorges University, China Three Gorges University, Yichang, China
- *Correspondence: Hong-Jun Liu,
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Dawson J, Béjot Y, Christensen LM, De Marchis GM, Dichgans M, Hagberg G, Heldner MR, Milionis H, Li L, Pezzella FR, Taylor Rowan M, Tiu C, Webb A. European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack. Eur Stroke J 2022; 7:I-II. [PMID: 36082250 PMCID: PMC9446324 DOI: 10.1177/23969873221100032] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.
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Affiliation(s)
- Jesse Dawson
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
- Jesse Dawson, Institute of Cardiovascular
and Medical Sciences, College of Medical, Veterinary and Life Sciences,
University of Glasgow, Queen Elizabeth University Hospital, Glasgow G12 9QQ, UK.
| | - Yannick Béjot
- Dijon Stroke Registry, Department of
Neurology, University Hospital of Dijon, Dijon, France
- Pathophysiology and Epidemiology of
Cardio-Cerebrovascular disease (PEC2), University of Burgundy, Dijon, France
| | - Louisa M Christensen
- Dept of Neurology, Copenhagen
University Hospital Bispebjerg, Kobenhavn, Denmark
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Martin Dichgans
- Institute for Stroke and Dementia
Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology
(SyNergy), Munich, Germany
| | - Guri Hagberg
- Oslo Stroke Unit, Department of
Neurology, Oslo University Hospital, Ullevål, Norway
- Department of medical research, Bærum
Hospital Vestre Viken Hospital Trust, Drammen, Norway
| | - Mirjam R Heldner
- Stroke Research Center Bern,
Department of Neurology, University and University Hospital Bern, Bern,
Switzerland
| | - Haralampos Milionis
- Department of Internal Medicine,
School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina,
Greece
| | - Linxin Li
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| | | | - Martin Taylor Rowan
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
| | - Cristina Tiu
- Department of Clinical Neurosciences,
University of Medicine and Pharmacy ‘Carol Davila’, Bucuresti, Romania
- Department of Neurology, University
Hospital Bucharest, Bucharest, Romania
| | - Alastair Webb
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
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Park CS, Yang HM, Kang J, Han JK, Park KW, Kang HJ, Koo BK, Seung KB, Cha KS, Seong IW, Rha SW, Jeong MH, Kim HS. Long-term use of renin-angiotensin-system inhibitors after acute myocardial infarction is not associated with survival benefits: Analysis of data from the Korean acute myocardial infarction registry-national institutes of health registry. Front Cardiovasc Med 2022; 9:994419. [PMID: 36119742 PMCID: PMC9471088 DOI: 10.3389/fcvm.2022.994419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 08/08/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Renin-angiotensin-system inhibitors (RASi) have shown survival benefits after acute myocardial infarction (MI), but the role of routine long-term use of RASi remains unclear. Thereby, we explored the therapeutic effects of RASi medication at 1-year follow-up from acute MI. Methods Using the nationwide Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) registry, we included and analyzed 10,822 subjects. Patients were stratified into those taking RASi at 1-year follow-up (n = 7,696) and those not taking RASi at 1-year follow-up (n = 3,126). Patients were followed up for 2-years from the 1-year follow-up; 2-year all-cause mortality and cardiac mortality were analyzed as primary and secondary outcomes, respectively. Results The use of RASi at 1-year follow-up was not associated with decreased all-cause mortality (log-rank P = 0.195) or cardiac mortality (log-rank P = 0.337). In multivariate analyses, RASi medication at 1-year follow-up did not reduce all-cause mortality (P = 0.758) or cardiac mortality (P = 0.923), while RASi medication at discharge substantially reduced 1-year all-cause and cardiac mortality. Treatment with either an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker at 1-year follow-up did not show survival benefits from 1-year follow-up, respectively. The use of RASi at 1-year follow-up did not show a prognostic interaction between previous history of chronic kidney disease, post-MI acute heart failure, concomitant use of beta-blockers at 1-year follow-up, or 1-year LVEF. Conclusion Acute MI patients taking RASi at 1-year follow-up were not associated with improved 2-year all-cause mortality or cardiac mortality from the 1-year follow-up. This study provides valuable information regarding tailored medication strategy after acute MI. Clinical trial registration [www.ClinicalTrials.gov], identifier [KCT0000863].
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Affiliation(s)
- Chan Soon Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Han-Mo Yang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- *Correspondence: Han-Mo Yang,
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jung-Kyu Han
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Hyun-Jae Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ki-Bae Seung
- Cardiology Division, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Kwang Soo Cha
- Department of Internal Medicine, Pusan National University Hospital, Busan, South Korea
| | - In-Whan Seong
- Department of Internal Medicine, College of Medicine, Chungnam National University Hospital, Chungnam National University, Daejeon, South Korea
| | - Seung-Woon Rha
- Department of Internal Medicine, College of Medicine, Kyungpook National University, Daegu, South Korea
| | - Myung Ho Jeong
- Department of Internal Medicine and Heart Center, Chonnam National University Hospital, Gwangju, South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
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Gnanenthiran SR, Borghi C, Burger D, Caramelli B, Charchar F, Chirinos JA, Cohen JB, Cremer A, Di Tanna GL, Duvignaud A, Freilich D, Gommans DHF, Gracia-Ramos AE, Murray TA, Pelorosso F, Poulter NR, Puskarich MA, Rizas KD, Rothlin R, Schlaich MP, Schreinlecher M, Steckelings UM, Sharma A, Stergiou GS, Tignanelli CJ, Tomaszewski M, Unger T, van Kimmenade RRJ, Wainford RD, Williams B, Rodgers A, Schutte AE. Renin-Angiotensin System Inhibitors in Patients With COVID-19: A Meta-Analysis of Randomized Controlled Trials Led by the International Society of Hypertension. J Am Heart Assoc 2022; 11:e026143. [PMID: 36000426 PMCID: PMC9496439 DOI: 10.1161/jaha.122.026143] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Published randomized controlled trials are underpowered for binary clinical end points to assess the safety and efficacy of renin‐angiotensin system inhibitors (RASi) in adults with COVID‐19. We therefore performed a meta‐analysis to assess the safety and efficacy of RASi in adults with COVID‐19. Methods and Results MEDLINE, EMBASE, ClinicalTrials.gov, and the Cochrane Controlled Trial Register were searched for randomized controlled trials that randomly assigned patients with COVID‐19 to RASi continuation/commencement versus no RASi therapy. The primary outcome was all‐cause mortality at ≤30 days. A total of 14 randomized controlled trials met the inclusion criteria and enrolled 1838 participants (aged 59 years, 58% men, mean follow‐up 26 days). Of the trials, 11 contributed data. We found no effect of RASi versus control on all‐cause mortality (7.2% versus 7.5%; relative risk [RR], 0.95; [95% CI, 0.69–1.30]) either overall or in subgroups defined by COVID‐19 severity or trial type. Network meta‐analysis identified no difference between angiotensin‐converting enzyme inhibitors versus angiotensin II receptor blockers. RASi users had a nonsignificant reduction in acute myocardial infarction (2.1% versus 3.6%; RR, 0.59; [95% CI, 0.33–1.06]), but increased risk of acute kidney injury (7.0% versus 3.6%; RR, 1.82; [95% CI, 1.05–3.16]), in trials that initiated and continued RASi. There was no increase in need for dialysis or differences in congestive cardiac failure, cerebrovascular events, venous thromboembolism, hospitalization, intensive care admission, inotropes, or mechanical ventilation. Conclusions This meta‐analysis of randomized controlled trials evaluating angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers versus control in patients with COVID‐19 found no difference in all‐cause mortality, a borderline decrease in myocardial infarction, and an increased risk of acute kidney injury with RASi. Our findings provide strong evidence that RASi can be used safely in patients with COVID‐19.
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Affiliation(s)
- Sonali R Gnanenthiran
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Claudio Borghi
- Department of Medical and Surgical Sciences University of Bologna Italy
| | - Dylan Burger
- Department of Cellular and Molecular Medicine, Kidney Research Centre, Ottawa Hospital Research Institute University of Ottawa Canada
| | - Bruno Caramelli
- Interdisciplinary Medicine in Cardiology Unit, InCor University of Sao Paulo Brazil
| | - Fadi Charchar
- School of Health and Life Sciences Federation University Australia Ballarat VIC Australia
| | - Julio A Chirinos
- Division of Cardiovascular Medicine University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Jordana B Cohen
- Renal-Electrolyte and Hypertension Division and Department of Biostatistics, Epidemiology, and Informatics University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Antoine Cremer
- Department of Cardiology and Hypertension, Hypertension Excellence Center Hôpital Saint André, Centre Hospitalier Universitaire de Bordeaux & University Bordeaux Bordeaux France
| | - Gian Luca Di Tanna
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Alexandre Duvignaud
- Department of Infectious Diseases and Tropical Medicine, Division of Tropical Medicine and Clinical International Health Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux & University Bordeaux Bordeaux France
| | | | - D H Frank Gommans
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands.,Netherlands Heart Institute Utrecht The Netherlands
| | - Abraham E Gracia-Ramos
- Departamento de Medicina Interna, Hospital General, Centro Médico Nacional "La Raza" Instituto Mexicano del Seguro Social Mexico City Mexico.,Departamento de Medicina Interna Hospital Regional de Alta Especialidad de Zumpango Estado de Mexico Mexico
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health University of Minnesota Minneapolis MN
| | - Facundo Pelorosso
- Asociacion Argentina de Medicamentos Ciudad Autonoma de Buenos Aires Argentina.,Servicio de Anatomía Patologica, Hospital de Alta Complejidad El Calafate SAMIC Santa Cruz Argentina
| | - Neil R Poulter
- Imperial Clinical Trials Unit Imperial College London London UK
| | - Michael A Puskarich
- Department of Emergency Medicine Hennepin County Medical Center University of Minnesota Minneapolis MN
| | - Konstantinos D Rizas
- Medizinische Klinik und Poliklinik I Ludwig Maximilian University Hospital Munich Munich Germany
| | - Rodolfo Rothlin
- Asociacion Argentina de Medicamentos Ciudad Autonoma de Buenos Aires Argentina.,Sociedad Argentina de Farmacología Clínica, Asociacion Medica Argentina Buenos Aires Argentina
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School, Royal Perth Hospital Unit-Royal Perth Hospital Medical Research Foundation University of Western Australia Perth Australia
| | - Michael Schreinlecher
- Department of Internal Medicine III, Cardiology and Angiology Medical University of Innsbruck Innsbruck Austria
| | | | - Abhinav Sharma
- Division of Cardiology McGill University Health Centre Montreal Quebec Canada
| | - George S Stergiou
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital National and Kapodistrian University of Athens Athens Greece
| | | | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health University of Manchester Manchester UK.,Manchester Academic Health Science Centre Manchester University National Health Service Foundation Trust Manchester Manchester UK
| | - Thomas Unger
- Cardiovascular Research Institute Maastricht-School for Cardiovascular Diseases Maastricht University Maastricht The Netherlands
| | - Roland R J van Kimmenade
- Department of Cardiology Radboud University Medical Center Nijmegen The Netherlands.,Netherlands Heart Institute Utrecht The Netherlands
| | - Richard D Wainford
- Department of Pharmacology and Experimental Therapeutics and the Whitaker Cardiovascular Institute Boston University School of Medicine Boston MA
| | - Bryan Williams
- Institute of Cardiovascular Science University College London and National Institute for Health Research University College London Hospitals Biomedical Research Centre London UK
| | - Anthony Rodgers
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
| | - Aletta E Schutte
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
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Elsayed N, Unkart J, Abdelgawwad M, Naazie I, Lawrence PF, Malas MB. Role of Renin-Angiotensin-Aldosterone System Inhibition in Patients Undergoing Carotid Revascularization. J Am Heart Assoc 2022; 11:e025034. [PMID: 36000412 PMCID: PMC9496413 DOI: 10.1161/jaha.121.025034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Previous data suggest that using renin‐angiotensin‐aldosterone system inhibitors (RAASIs) improves survival in patients with cardiovascular diseases. We sought to investigate the association of different patterns of use of RAASIs on perioperative and 1‐year outcomes following carotid revascularization. Methods and Results We investigated patients undergoing carotid revascularization, either with carotid endarterectomy or transfemoral carotid artery stenting, in the VQI (Vascular Quality Initiative) VISION (Vascular Implant Surveillance and Interventional Outcomes Network) data set between 2003 and 2018. We divided our cohort into 3 groups: (1) no history of RAASI intake, (2) preoperative intake only, and (3) continuous pre‐ and postoperative intake. The final cohort included 73 174 patients; 44.4% had no intake, 50% had continuous intake, and 5.6% had only preoperative intake. Compared with continuous intake, preoperative and no intake were associated with higher odds of postoperative stroke (odds ratio [OR], 1.7 [95% CI, 1.5–1.9]; P<0.001; OR, 1.1 [95% CI, 1.03–1.2]; P=0.010); death (OR, 4.8 [95% CI, 3.8–6.1]; P<0.001; OR, 1.9 [95% CI, 1.6–2.2]; P<0.001); and stroke/death (OR, 2.05 [95% CI, 1.8–2.3]; P<0.001; OR, 1.2 [95% CI, 1.1–1.3]; P<0.001), respectively. At 1 year, preoperative and no intake were associated with higher odds of stroke (hazard ratio [HR], 1.4 [95% CI, 1.3–1.6]; P<0.001; HR, 1.15, [95% CI, 1.08–1.2]; P<0.001); death (HR, 1.7 [95% CI, 1.5–1.9]; P<0.001; HR, 1.3 [95% CI, 1.2–1.4]; P<0.001); and stroke/death (HR, 1.5 [95% CI, 1.4–1.7]; P<0.001; HR, 1.2 [95% CI, 1.17–1.3]; P<0.001), respectively. Conclusions Compared with subjects discontinuing or never starting RAASIs, use of RAASIs before and after carotid revascularization was associated with a short‐term stroke and mortality benefit. Future clinical trials examining prescribing patterns of RAASIs should aim to clarify the timing and potential to maximize the protective effects of RAASIs in high‐risk vascular patients.
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Affiliation(s)
- Nadin Elsayed
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
| | - Jonathan Unkart
- Department of Surgery State University New York Downstate University Health Sciences University Brooklyn NY
| | - Mohammad Abdelgawwad
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
| | - Isaac Naazie
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery David Geffen School of Medicine at UCLA Los Angeles CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery University of California San Diego La Jolla CA
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Naazie IN, Arhuidese I, Abdelgawwad MS, Unkart J, Conte MS, Malas MB. Association of Renin-Angiotensin-Aldosterone System Inhibitor Usage Patterns with Mid-Term Amputation Free Survival After Lower Extremity Bypass for Peripheral Arterial Disease. Ann Vasc Surg 2022; 88:79-89. [PMID: 36028182 DOI: 10.1016/j.avsg.2022.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 06/23/2022] [Accepted: 07/17/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Different renin-angiotensin-aldosterone system inhibitor (RAASI) usage patterns exist among patients undergoing lower extremity bypass (LEB) for peripheral arterial disease (PAD). We studied the association of RAASI usage patterns with LEB outcomes to determine which pattern is associated improved survival after LEB. METHODS We evaluated PAD patients who underwent LEB between January 2014 and December 2018 in the Vascular Quality Initiative (VQI) Medicare matched database. Study cohorts included no RAASI use, preoperative RAASI use only, postoperative RAASI use only, and continuous RAASI use both pre-and postoperatively. Logistic and Cox regression was used to adjust for potential confounders. Primary outcome was 2-year amputation free survival (AFS). RESULTS Of 19,012 patients included, 1574 (8.3%) were on RAASIs preoperatively only, 1051 (5.5%) postoperatively only, and 8484 (45.2%) continuously. Compared to no RAASI use, isolated preoperative RAASI use was associated with 2.8-fold increased odds of 30-day mortality (aOR, 2.75; 95%CI, 2.15-3.51; P<0.001) whereas continuous RAASI use had 56% lower odds of 30-day mortality (aOR, 0.44; 95%CI, 0.34-0.58; P<0.001). Two-year AFS was 63.2% for no RAASI use and 60.4%, 66.2% and 73.4% for preoperative, postoperative, and continuous RAASI use respectively (P<0.001). While no RAASI use and postoperative RAASI use had comparable adjusted risks of 2-year major amputation or death (aHR, 0.94; 95%CI, 0.83-1.06; P=0.312), this risk was 14% higher for preoperative RAASI use (aHR, 1.14; 95%CI, 1.04-1.26; P=0.006) and 23% lower for continuous RAASI use (aHR, 0.77; 95%CI, 0.72-0.82; P<0.001). CONCLUSIONS Isolated preoperative RAASI use was associated with worse 30-day mortality and 2-year AFS while continuous RAASI use was associated with improved 30-day mortality and 2-year AFS. Optimum survival benefit may be derived from continuous RAAS inhibition in the pre- and postoperative periods.
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Affiliation(s)
- Isaac N Naazie
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Isibor Arhuidese
- Division of Vascular Surgery, Department of Surgery, University of South Florida, Tampa, FL
| | - Mohammad S Abdelgawwad
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA
| | - Jonathan Unkart
- Department of Surgery, State University of New York Downstate University Health Sciences University, Brooklyn, NY
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco, CA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, CA.
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Cífková R, Strilchuk L. Sex differences in hypertension. Do we need a sex-specific guideline? Front Cardiovasc Med 2022; 9:960336. [PMID: 36082119 PMCID: PMC9445242 DOI: 10.3389/fcvm.2022.960336] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/03/2022] [Indexed: 01/02/2023] Open
Abstract
Hypertension is the most prevalent cardiovascular disorder and the leading cause of death worldwide in both sexes. The prevalence of hypertension is lower in premenopausal women than in men of the same age, but sharply increases after the menopause, resulting in higher rates in women aged 65 and older. Awareness, treatment, and control of hypertension are better in women. A sex-pooled analysis from 4 community-based cohort studies found increasing cardiovascular risk beginning at lower systolic blood pressure thresholds for women than men. Hormonal changes after the menopause play a substantial role in the pathophysiology of hypertension in postmenopausal women. Female-specific causes of hypertension such as the use of contraceptive agents and assisted reproductive technologies have been identified. Hypertensive disorders in pregnancy are associated with increased risk of maternal, fetal, and neonatal morbidity and mortality, as well as with a greater risk of developing cardiovascular disease later in life. Hypertension-mediated organ damage was found to be more prevalent in women, thus increasing the cardiovascular risk. Sex differences in pharmacokinetics have been observed, but their clinical implications are still a matter of debate. There are currently no sufficient data to support sex-based differences in the efficacy of antihypertensive treatment. Adverse drug reactions are more frequently reported in women. Women are still underrepresented in large clinical trials in hypertension, and not all of them report sex-specific results. Therefore, it is of utmost importance to oblige scientists to include women in clinical trials and to consider sex as a biological variable.
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Affiliation(s)
- Renata Cífková
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer University Hospital, Prague, Czechia
- Department of Medicine II, Charles University in Prague, First Faculty of Medicine, Prague, Czechia
- *Correspondence: Renata Cífková
| | - Larysa Strilchuk
- Center for Cardiovascular Prevention, Charles University in Prague, First Faculty of Medicine and Thomayer University Hospital, Prague, Czechia
- Department of Therapy No 1, Medical Diagnostics, Hematology and Transfusiology, Lviv Danylo Halytsky National Medical University, Lviv, Ukraine
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Bedtime dosing of antihypertensive medications: systematic review and consensus statement: International Society of Hypertension position paper endorsed by World Hypertension League and European Society of Hypertension. J Hypertens 2022; 40:1847-1858. [PMID: 35983870 DOI: 10.1097/hjh.0000000000003240] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Antihypertensive drug therapy is one of the most efficient medical interventions for preventing disability and death globally. Most of the evidence supporting its benefits has been derived from outcome trials with morning dosing of medications. Accumulating evidence suggests an adverse prognosis associated with night-time hypertension, nondipping blood pressure (BP) profile and morning BP surge, with increased incidence of cardiovascular events during the first few morning hours. These observations provide justification for complete 24-h BP control as being the primary goal of antihypertensive treatment. Bedtime administration of antihypertensive drugs has also been proposed as a potentially more effective treatment strategy than morning administration. This Position Paper by the International Society of Hypertension reviewed the published evidence on the clinical relevance of the diurnal variation in BP and the timing of antihypertensive drug treatment, aiming to provide consensus recommendations for clinical practice. Eight published outcome hypertension studies involved bedtime dosing of antihypertensive drugs, and all had major methodological and/or other flaws and a high risk of bias in testing the impact of bedtime compared to morning treatment. Three ongoing, well designed, prospective, randomized controlled outcome trials are expected to provide high-quality data on the efficacy and safety of evening or bedtime versus morning drug dosing. Until that information is available, preferred use of bedtime drug dosing of antihypertensive drugs should not be routinely recommended in clinical practice. Complete 24-h control of BP should be targeted using readily available, long-acting antihypertensive medications as monotherapy or combinations administered in a single morning dose.
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137
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Yadav R, Pathak S, Hegde S. A Case Series Analysis of Major Vascular Revascularization. Cureus 2022; 14:e27595. [PMID: 36059291 PMCID: PMC9433795 DOI: 10.7759/cureus.27595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose Atherosclerosis is a generalized disorder and can begin to develop in the abdominal aorta by the second decade of life. The nature of these lesions in coronaries and aorta is atheromatous and less sclerotic when compared to peripheral arteries. A broad spectrum of presentations and different types of lesions demand a personalized approach for the best outcome. This study is a case series analysis of major vascular revascularization. We aim to study various revascularization surgeries and underline the wide range of vascular lesions to which it is applied. Methods This is a study based on accrual patient records of all major vascular revascularization surgical/interventional procedures conducted at a tertiary care center for one year. Results A total of 110 patients were operated on for vascular diseases. Among these, 86 (78.81%) were men, and 24 (21.81%) were women. The femoropopliteal segment (n=47) was most commonly involved, followed by the common carotid artery (n=20). Atherosclerosis was the main cause of vascular occlusion (81.8%), followed by aneurysm of the aorta (14.5%) and coarctation of the aorta (2.7%). Smoking (62.2%) accounted to be the leading risk factor, followed by hypertension, diabetes, and hyperlipidemia. The majority of patients had a good outcome (92.7%). Minor complications (7.3%) include seroma formation and wound infection, which were managed conservatively. The repair was performed by autologous vein graft in 30% of patients and by synthetic polytetrafluoroethylene (PTFE) graft in 70% of patients. Carotid artery stenting was the most common endovascular procedure performed (n=5). Femoropopliteal bypass grafting was the most common procedure, followed by carotid endarterectomy (n=20) and aortofemoral bypass (n=14). Conclusion The application of novel techniques such as cavo-atrial shunt in Budd-Chiari syndrome calls attention to the broadened scope of vascular surgery, and the modification of the conventional method of the carotid endarterectomy underscores the evolution of vascular revascularization. Our study thus highlighted that a wide spectrum of vascular lesions ranging from carotid artery stenosis to extensive below-knee disease, either atherosclerotic or aneurysmal, can be successfully treated with surgical revascularization techniques.
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Door to balloon time in primary percutaneous coronary intervention in ST elevation myocardial infarction: every minute counts. Coron Artery Dis 2022; 33:341-348. [PMID: 35880558 DOI: 10.1097/mca.0000000000001145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES This study examines relationships between door to balloon (D2B) time and subsequent admissions due to heart failure (HF), acute coronary syndrome (ACS), and mortality for up to 1 year. BACKGROUND Current guidelines set 90-min for D2B time for primary percutaneous coronary intervention (PPCI) as a goal, which has been shown to reduce mortality and adverse events. METHODS Using the MDclone ADAMS system integrated with our electronic medical records, we conducted retrospective analysis of all patients admitted due to ST-elevation myocardial infarction from home, without any history of HF or coronary disease, and who underwent PPCI during 2013-2019. Data on D2B time, baseline clinical and demographic characteristics, and outcomes of HF, ACS and mortality were collected. Adjusted HR for each of the outcomes was calculated by multivariate Cox model. RESULTS A total of 826 patients were included in the final analysis. D2B had no significant effect on incidence of heart failure admissions for up to 1-year follow-up. D2B had a significant effect on mortality at 180 days, showing a 30% increase for each 30-min increase (HR 1.308; CI, 1.046-1.635) as for ACS at 90 days (HR 1.307; 1.025-1.638). The 30-min D2B cutoff showed a significant increase in ACS recurrence throughout the follow-up period at 90 days (HR 2.871, 1.239-6.648), 180 days (HR 2.607, 1.255-5.413), and 1 year (HR 1.886, 1.073-3.317). CONCLUSIONS Patients with shorter D2B times had significantly reduced mortality and recurrence of ACS, with no effect on heart failure admission incidence.
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Pedro-Botet J, Barrios V, Sánchez-Margalet V, Tamargo J, Arrieta F, Gámez JM, Gimeno-Orna JA, Escobar C, Gómez-Doblas JJ, Pérez A. Tratamiento de la hipertrigliceridemia con icosapento de etilo en pacientes de alto/muy alto riesgo cardiovascular. Documento de consenso de la Sociedad Española de Cardiología y Sociedad Española de Diabetes. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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140
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Lerma EV. Diagnosis 101: Diabetic kidney disease. Clin Kidney J 2022; 15:1797-1799. [PMID: 36158143 PMCID: PMC9494539 DOI: 10.1093/ckj/sfac163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Chronic kidney disease (CKD) attributed to diabetes occurs in 20–40% of patients with diabetes mellitus (DM). DKD is recognized as the most common cause of end-stage kidney disease (ESKD) in the US (2) and most Western countries.
For quite some time, it has been recognized that treatments based on inhibition of the renin angiotensin system (RAS) can reduce the rates of cardiovascular morbidity and mortality in patients with DKD.
Recently however, several novel agents namely: SGLT2 inhibitors, DPP-4 inhibitors and GLP1 receptor agonists were demonstrated to not only improve glycemic control but also to improve cardiovascular and renal outcomes. Another agent, a nonsteroidal mineralocorticoid antagonist has also been shown to have cardiorenal benefits in patients with DKD.
With such new developments, one would expect that it would eventually translate into further slowing CKD progression in the DKD population, provided that patients are appropriately and timely diagnosed.
In this study, the authors attempt to investigate real world data looking at how well providers are establishing the diagnosis of DKD and its potential implications.
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Affiliation(s)
- Edgar V Lerma
- University of Illinois at Chicago College of Medicine/ Associates in Nephrology , S.C. Chicago, IL - Section of Nephrology - Department of Medicine - Chicago -Illinois – USA
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141
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Kalinić D, Škrbić R, Vulić D, Stojaković N, Stoisavljević-Šatara S, Stojiljković MP, Marković-Peković V, Golić Jelić A, Pilipović-Broćeta N, Wong ND, Godman B. Trends in Antihypertensive Medicine Utilization in the Republic of Srpska, Bosnia and Herzegovina: An Eleven-Year Follow-Up. Front Pharmacol 2022; 13:889047. [PMID: 35784727 PMCID: PMC9240340 DOI: 10.3389/fphar.2022.889047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/30/2022] [Indexed: 01/13/2023] Open
Abstract
Background: In last 2 decades, there have been substantial changes in the utilization patterns of antihypertensive medicines following new clinical trials and the introduction of new treatment guidelines. The aim of this study was to analyze utilization and prescribing patterns regarding antihypertensive medicines in the Republic of Srpska, Bosnia and Herzegovina during an 11-years follow-up according to national and European treatment guidelines. Methods: In this retrospective, observational study, medicine utilization data were analyzed between 2009–2019 period using the ATC/DDD methodology and expressed as the number of DDD/1,000 inhabitants/day (DID/TID). The medicine utilization 90% (DU90%) method was used for determine the quality of prescribing. Results: During the observed period, the use of antihypertensive medicines increased more than 3-times (125.97 DDD/TID in 2009 vs 414.95 DDD/TID in 2019), corresponding to a rise in the prevalence of hypertensive patients from 91.7/1,000 to 186.3/1,000 in the same period. This was mainly driven by increased use of angiotensin converting enzyme inhibitors with 241.69%, beta blockers with 146.87%, calcium channel blockers with 251.55%, and diuretics with 178.95%. Angiotensin receptor blockers were the fastest growing group of antihypertensive medicines in this period and their utilization increased nearly 40 times. Conclusions: The overall antihypertensive medicines utilization was largely influenced by national and ESH/ESC guidelines and strongly corresponded to the positive medicine list of the national health insurance fund. Antihypertensive medicines utilization is comparable with medicine utilization trends in other countries.
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Affiliation(s)
- Dragan Kalinić
- Centre for Biomedical Research, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
- *Correspondence: Dragan Kalinić,
| | - Ranko Škrbić
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Duško Vulić
- Centre for Specializations and Continuous Medical Education, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Nataša Stojaković
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Svjetlana Stoisavljević-Šatara
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Miloš P. Stojiljković
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Vanda Marković-Peković
- Department of Pharmacy, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Ana Golić Jelić
- Department of Pharmacy, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Nataša Pilipović-Broćeta
- Family Medicine Teaching Center, Primary Health Care of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Nathan D. Wong
- Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine, Irvine, CA, United States
| | - Brian Godman
- Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom
- Centre of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
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Merzel Šabović EK, Starbek Zorko M, Janić M. Killing Two Birds with One Stone: Potential Therapies Targeting Psoriasis and Atherosclerosis at the Same Time. Int J Mol Sci 2022; 23:ijms23126648. [PMID: 35743091 PMCID: PMC9224172 DOI: 10.3390/ijms23126648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/10/2022] [Accepted: 06/12/2022] [Indexed: 01/27/2023] Open
Abstract
Psoriasis is a chronic systemic inflammatory disease. Due to systemic inflammation, it is associated with many comorbidities. Among them, cardiovascular diseases represent the most common causes of morbidity and mortality in this population. Therefore, physicians treating patients with psoriasis should keep in mind that, as important as the treatment of psoriasis, awareness of cardiovascular risk deserves additional attention. Thus, in parallel with psoriasis treatment, a cardiovascular risk assessment must also be performed and addressed accordingly. In addition to encouraging non-pharmacologic strategies for a healthy lifestyle, physicians should be familiar with different pharmacologic options that can target psoriasis and reduce cardiovascular risk. In the present article, we present the pathophysiological mechanisms of the psoriasis and cardiometabolic interplay, our view on the interaction of psoriasis and cardiovascular disease, review the atherosclerotic effect of therapeutic options used in psoriasis, and vice versa, i.e., what the effect of medications used in the prevention of atherosclerosis could be on psoriasis.
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Affiliation(s)
- Eva Klara Merzel Šabović
- Department of Dermatovenerology, University Medical Centre Ljubljana, Gradiškova Ulica 10, SI-1000 Ljubljana, Slovenia;
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, SI-1000 Ljubljana, Slovenia;
- Correspondence:
| | - Mateja Starbek Zorko
- Department of Dermatovenerology, University Medical Centre Ljubljana, Gradiškova Ulica 10, SI-1000 Ljubljana, Slovenia;
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, SI-1000 Ljubljana, Slovenia;
| | - Miodrag Janić
- Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, SI-1000 Ljubljana, Slovenia;
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Zaloška Cesta 7, SI-1000 Ljubljana, Slovenia
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143
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Abstract
Management of stable coronary artery disease (CAD) centers on medication to prevent myocardial infarction and death. Many anti-anginal medications also have benefit for reducing symptoms, and have been proven to be effective against placebo control. Before effective preventive medications were available, patients with stable CAD often underwent revascularization with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI), on the plausible assumption that these procedures would prevent adverse events and reduce symptoms. However, recent randomized controlled trials have cast doubt on these assumptions.Considering results from the recent ISCHEMIA trial, we discuss the evidence base that underpins revascularization for stable CAD in contemporary practice. We also focus on patient groups at high risk of myocardial infarction and death, for whom revascularization is often recommended. We outline the areas of uncertainty, unanswered research questions, and key areas of potential miscommunication in doctor-patient consultations.
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Affiliation(s)
- Rasha K Al-Lamee
- National Heart and Lung Institute, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
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144
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Rouette J, McDonald EG, Schuster T, Brophy JM, Azoulay L. Treatment and prescribing trends of antihypertensive drugs in 2.7 million UK primary care patients over 31 years: a population-based cohort study. BMJ Open 2022; 12:e057510. [PMID: 35688595 PMCID: PMC9189823 DOI: 10.1136/bmjopen-2021-057510] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To describe the prescribing trends of antihypertensive drugs in primary care patients and assess the trajectory of antihypertensive drug prescriptions, from first-line to third-line, in patients with hypertension according to changes to the United Kingdom (UK) hypertension management guidelines. DESIGN Population-based cohort study. SETTING AND PARTICIPANTS We used the UK Clinical Practice Research Datalink, an electronic primary care database representative of the UK population. Between 1988 and 2018, we identified all adult patients with at least one prescription for a thiazide diuretic, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta-blocker or calcium channel blocker (CCB). PRIMARY AND SECONDARY OUTCOME MEASURES We estimated the period prevalence of patients with antihypertensive drug prescriptions for each calendar year over a 31-year period. Treatment trajectory was assessed by identifying patients with hypertension newly initiating an antihypertensive drug, and treatment changes were defined by a switch or add-on of a new class. This cohort was stratified before and after 2007, the year following important changes to UK hypertension management guidelines. RESULTS The cohort included 2 709 241 patients. The prevalence of primary care patients with antihypertensive drug prescriptions increased from 7.8% (1988) to 21.9% (2018) and was observed for all major classes except thiazide diuretics. Patients with hypertension initiated thiazide diuretics (36.8%) and beta-blockers (23.6%) as first-line drugs before 2007, and ACE inhibitors (39.9%) and CCBs (31.8%) after 2007. After 2007, 17.3% were not prescribed guideline-recommended first-line agents. Overall, patients were prescribed a median of 2 classes (IQR 1-2) after first-line treatment. CONCLUSION Nearly one-quarter of primary care patients were prescribed antihypertensive drugs by the end of the study period. Most patients with hypertension initiated guideline-recommended first-line agents. Not all patients, particularly females, were prescribed recommended agents however, potentially leading to suboptimal cardiovascular outcomes. Future research should aim to better understand the implication of this finding.
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Affiliation(s)
- Julie Rouette
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
| | - Emily G McDonald
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Experimental Medicine, McGill University, Montreal, Quebec, Canada
| | - Tibor Schuster
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Quebec, Canada
- Departmenf of Medicine, McGill University, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, Quebec, Canada
- Gerald Bronfman Department of Oncology, McGill University, Montreal, Quebec, Canada
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145
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Swaroop G. Post-myocardial Infarction Heart Failure: A Review on Management of Drug Therapies. Cureus 2022; 14:e25745. [PMID: 35812579 PMCID: PMC9264286 DOI: 10.7759/cureus.25745] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 12/11/2022] Open
Abstract
After myocardial infarction (MI), patients are at a greater risk of heart failure. Post-MI patients with left ventricular systolic dysfunction have a higher risk of mortality or morbidity. Strong and compelling data from randomized trials have demonstrated that drug therapies intended for preventing post-MI remodeling with neuro-hormonal inhibitors can considerably improve short- and long-term outcomes, including death, reinfarction, and worsening heart failure. This article aims at summarizing clinical data on established pharmacological therapies in treating post-MI patients with or without left ventricular systolic dysfunction (LVSD), and with or without signs and symptoms of heart failure.
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146
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Li XT. Beneficial effects of carvedilol modulating potassium channels on the control of glucose. Biomed Pharmacother 2022; 150:113057. [PMID: 35658228 DOI: 10.1016/j.biopha.2022.113057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 11/25/2022] Open
Abstract
The increased prevalence of hypertensive patients with type 2 diabetes mellitus (T2DM) is evident worldwide, leading to a higher risk of cardiovascular disease onset, which is substantially associated with disabilities and mortality in the clinic. In order to achieve the satisfyingly clinical outcomes and prognosis, the comprehensive therapies have been conducted with a beneficial effect on both blood pressure and glucose homeostasis, and clinical trials reveal that some kind of antihypertensive drugs such as angiotensin converting enzyme inhibitors (ACE-I) may, at least in part, meet the dual requirement during the disease management. As a nonselective β-blocker, carvedilol is employed for treating many cardiovascular diseases in clinical practice, including hypertension, angina pectoris and heart failure, and also exhibit the effectiveness for glycemic control and insulin resistance. Apart from alleviating sympathetic nervous system activity, several causes, such as lowering oxygen reactive species, may contribute to the effects of carvedilol on controlling plasma glucose levels, suggesting a feature of this drug having multiple targets. Interestingly, numerous distinct K+ channels expressed in pancreatic β-cells and peripheral insulin-sensitive tissues, which play a sentential role in glucose metabolism, are subjected to extensive modulation of carvdilol, establishing a linkage between K+ channels and drug's effects on the control of glucose. A variety of evidence shows that the impact of carvedilol on different K+ channels, including Kv, KAch, KATP and K2 P, can lead to positive influences for glucose homeostasis, contributing to its clinical beneficial effectiveness in treatment of hypertensive patients with T2DM. This review focus on the control of plasma glucose conferred by carvedilol modulation on K+ channels, providing the novel mechanistic explanation for drug's actions.
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Affiliation(s)
- Xian-Tao Li
- Department of Neuroscience, South-Central University for Nationalities, Wuhan 430074, China; School of Medicine, Guizhou University, Guiyang 550025, China.
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147
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Conde ID, Baumann F. Medical Management of Peripheral Arterial Disease. Tech Vasc Interv Radiol 2022; 25:100837. [DOI: 10.1016/j.tvir.2022.100837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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148
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Tang Y, Yan J, Tang L, Liu X. Risk factor control among heart failure patients in the United States: Results from the NHANES 1999-2018. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2022; 13:200128. [PMID: 35308899 PMCID: PMC8924309 DOI: 10.1016/j.ijcrp.2022.200128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/15/2022] [Accepted: 03/03/2022] [Indexed: 12/30/2022]
Abstract
Background Compliance with recommended pharmacological and non-pharmacological treatments to modify risk factors is associated with improved outcomes for patients with heart failure (HF). Methods We conducted an analysis of the National Health and Nutrition Examination Survey (NHANES) years 1999-2018 to evaluate the adequacy of risk factor control and compliance with recommended lifestyle and medications according to the clinical guidelines for the management of HF. Demographic, clinical, and healthcare-access factors associated with having risk factors uncontrolled or not receiving recommended medications were determined using logistic regression analyses. Results We collected 1906 participants aged 18 years or older with a self-reported history of HF. The majority were at target goals for blood pressure (45.07%), low-density lipoprotein cholesterol (22.04%), and glycated hemoglobin (72.15%), whereas only 19.09% and 27.38% were at targets for body mass index and waist circumference respectively. Besides, 79.49% and 67.23% of respondents reported smoking cessation and recommended alcohol consumption, whereas only 11.54% reported adequate physical activity. Proportion of taking beta blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) and diuretics was 54.77%, 52.62% and 49.37%, respectively. Finally, the logistic regression analysis showed that metabolic syndrome and diabetes mellitus were associated with a higher likelihood of having risk factor uncontrolled, while metabolic syndrome, diabetes mellitus, and chronic kidney disease were predictors for not receiving recommended medications. Conclusions Risk factor control and adherence to recommended lifestyle and medications are non-ideal among HF patients in the USA. A systematic approach for risk factor optimization in people with HF is urgently needed.
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Affiliation(s)
- Ying Tang
- Geriatrics Research Institute of Zhejiang Province, Zhejiang Provincial Key Lab of Geriatrics, Zhejiang Hospital, Hangzhou, Zhejiang, 310013, PR China
| | - Jing Yan
- Geriatrics Research Institute of Zhejiang Province, Zhejiang Provincial Key Lab of Geriatrics, Zhejiang Hospital, Hangzhou, Zhejiang, 310013, PR China.,Department of Cardiology, Zhejiang Hospital, Hangzhou, Zhejiang, 310013, PR China
| | - Lijiang Tang
- Department of Cardiology, Zhejiang Hospital, Hangzhou, Zhejiang, 310013, PR China.,Department of Medicine, School of Medicine, Zhejiang University of Traditional Chinese Medicine, Hangzhou, Zhejiang, 310000, PR China
| | - Xiaowei Liu
- Department of Cardiology, Zhejiang Hospital, Hangzhou, Zhejiang, 310013, PR China
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149
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Bachmann JC, Baumgart SJ, Uryga AK, Bosteen MH, Borghetti G, Nyberg M, Herum KM. Fibrotic Signaling in Cardiac Fibroblasts and Vascular Smooth Muscle Cells: The Dual Roles of Fibrosis in HFpEF and CAD. Cells 2022; 11:1657. [PMID: 35626694 PMCID: PMC9139546 DOI: 10.3390/cells11101657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 12/11/2022] Open
Abstract
Patients with heart failure with preserved ejection fraction (HFpEF) and atherosclerosis-driven coronary artery disease (CAD) will have ongoing fibrotic remodeling both in the myocardium and in atherosclerotic plaques. However, the functional consequences of fibrosis differ for each location. Thus, cardiac fibrosis leads to myocardial stiffening, thereby compromising cardiac function, while fibrotic remodeling stabilizes the atherosclerotic plaque, thereby reducing the risk of plaque rupture. Although there are currently no drugs targeting cardiac fibrosis, it is a field under intense investigation, and future drugs must take these considerations into account. To explore similarities and differences of fibrotic remodeling at these two locations of the heart, we review the signaling pathways that are activated in the main extracellular matrix (ECM)-producing cells, namely human cardiac fibroblasts (CFs) and vascular smooth muscle cells (VSMCs). Although these signaling pathways are highly overlapping and context-dependent, effects on ECM remodeling mainly act through two core signaling cascades: TGF-β and Angiotensin II. We complete this by summarizing the knowledge gained from clinical trials targeting these two central fibrotic pathways.
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Affiliation(s)
| | | | | | | | | | | | - Kate M. Herum
- Research and Early Development, Novo Nordisk A/S, Novo Nordisk Park, 2760 Maaloev, Denmark; (J.C.B.); (S.J.B.); (A.K.U.); (M.H.B.); (G.B.); (M.N.)
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150
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Kristensen AMD, Pareek M, Kragholm KH, Sehested TSG, Olsen MH, Prescott EB. Unstable Angina as a Component of Primary Composite Endpoints in Clinical Cardiovascular Trials: Pros and Cons. Cardiology 2022; 147:235-247. [PMID: 35537418 PMCID: PMC9393841 DOI: 10.1159/000524948] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/29/2022] [Indexed: 11/19/2022]
Abstract
Background Unstable angina (UA) is a component of acute coronary syndrome that is only occasionally included in primary composite endpoints in clinical cardiovascular trials. The aim of this paper is to elucidate the potential benefits and disadvantages of including UA in such contexts. Summary UA comprises <10% of patients with acute coronary syndromes in contemporary settings. Based on the pathophysiological similarities, it is ideal as a part of a composite endpoint along with myocardial infarction (MI). By adding UA as a component of a primary composite endpoint, the number of events and feasibility of the trial should increase, thus decreasing size and costs of trials. Furthermore, UA has both economic and quality of life implications on a societal and an individual level. However, there are important challenges associated with the use of UA as an endpoint. With the introduction of high-sensitivity troponins, the number of individuals diagnosed with UA has decreased to rather low levels, with a reciprocal increase in the number of MI. In addition, UA is particularly challenging to define given the subjective assessment of the index symptoms, rendering a high risk of bias. To minimize bias, strict criteria are warranted, and events should be adjudicated by a blinded endpoint adjudication committee. Key messages UA should only be chosen as a component of a primary composite endpoint in cardiovascular trials after thoroughly evaluating the pros and cons. If it is chosen to include UA, appropriate precautions should be taken to minimize possible bias.
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Affiliation(s)
- Anna Meta Dyrvig Kristensen
- Department of Cardiology, Copenhagen University Hospital − Bispebjerg and Frederiksberg, Copenhagen, Denmark
- *Anna Meta Dyrvig Kristensen,
| | - Manan Pareek
- Department of Cardiology, Copenhagen University Hospital − Herlev and Gentofte, Copenhagen, Denmark
| | | | - Thomas Steen Gyldenstierne Sehested
- Department of Cardiology, Copenhagen University Hospital − Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Michael Hecht Olsen
- Division of Cardiology, Department of Internal Medicine, Holbæk Hospital, Holbæk, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Eva Bossano Prescott
- Department of Cardiology, Copenhagen University Hospital − Bispebjerg and Frederiksberg, Copenhagen, Denmark
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