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Choy JS, Hubbard T, Golts EM, Bhatt DL, Navia JA, Kassab GS. Pre-arterialization of coronary veins prior to retroperfusion of ischemic myocardium: percutaneous closure device. Front Cardiovasc Med 2023; 10:1208903. [PMID: 37790598 PMCID: PMC10543752 DOI: 10.3389/fcvm.2023.1208903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023] Open
Abstract
Background Chronic coronary retroperfusion to treat myocardial ischemia has previously failed due to edema and hemorrhage of coronary veins suddenly exposed to arterial pressures. The objective of this study was to selectively adapt the coronary veins to become arterialized prior to coronary venous retroperfusion to avoid vascular edema and hemorrhage. Methods and results In 32 animals (Group I = 19 and Group II = 13), the left anterior descending (LAD) artery was occluded using an ameroid occlusion model. In Group I, the great cardiac vein was blocked with suture ligation (Group IA = 11) or with occlusion device (Group IB = 8) to arterialize the venous system within 2 weeks at intermediate pressure (between arterial and venous levels) before a coronary venous bypass graft (CVBG) was implemented through a left internal mammary artery (LIMA) anastomosis. Group II only received the LAD artery occlusion and served as control. Serial echocardiograms showed recovery of left ventricular (LV) function with this adaptation-arterialization approach, with an increase in ejection fraction (EF) in Group I from 38% ± 5% after coronary occlusion to 53% ± 7% eight weeks after CVBG, whereas in Group II the EF never recovered (41% ± 2%-33% ± 7%). The remodeling of the venous system not only allowed restoration of myocardial function when CVBG was implemented but possibly promoted a novel form of "collateralization" between the native arterioles and the newly arterialized venules, which revascularized the ischemic myocardium. Conclusions These findings form a potential rationale for a venous arterialization-revascularization treatment for the refractory angina and the "no-option" patients using a hybrid percutaneous (closure device for arterialization)/surgical approach (CVBG) to revascularize the myocardium.
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Affiliation(s)
- Jenny S. Choy
- Department of Biomedical Engineering, California Medical Innovations Institute, San Diego, CA, United States
| | | | - Eugene M. Golts
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, CA, United States
| | - Deepak L. Bhatt
- Icahn School of Medicine at Mount Sinai Health System, New York, NY, United States
| | - José A. Navia
- Department of Cardiac Surgery, Austral University, Pilar, Buenos Aires, Argentina
| | - Ghassan S. Kassab
- Department of Biomedical Engineering, California Medical Innovations Institute, San Diego, CA, United States
- 3DT Holdings, LLC, San Diego, CA, United States
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2
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Fujita Y, Kawamoto A. Therapeutic Angiogenesis Using Autologous CD34-Positive Cells for Vascular Diseases. Ann Vasc Dis 2022; 15:241-252. [PMID: 36644256 PMCID: PMC9816028 DOI: 10.3400/avd.ra.22-00086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/13/2022] [Indexed: 12/25/2022] Open
Abstract
CD34 is a cell surface marker, which is expressed in various somatic stem/progenitor cells such as bone marrow (BM)-derived hematopoietic stem cells and endothelial progenitor cells (EPCs), skeletal muscle satellite cells, epithelial hair follicle stem cells, and adipose tissue mesenchymal stem cells. CD34+ cells in BM and peripheral blood are known as a rich source of EPCs. Thus, vascular regeneration therapy using granulocyte colony stimulating factor (G-CSF) mobilized- or BM CD34+ cells has been carried out in patients with various vascular diseases such as chronic severe lower limb ischemia, acute myocardial infarction, refractory angina, ischemic cardiomyopathy, and dilated cardiomyopathy as well as ischemic stroke. Pilot and randomized clinical trials demonstrated the safety, feasibility, and effectiveness of the CD34+ cell therapy in peripheral arterial, cardiovascular, and cerebrovascular diseases. This review provides an overview of the preclinical and clinical reports of CD34+ cell therapy for vascular regeneration.
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Affiliation(s)
- Yasuyuki Fujita
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Kobe, Hyogo, Japan
| | - Atsuhiko Kawamoto
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Kobe, Hyogo, Japan,Corresponding author: Atsuhiko Kawamoto, MD, PhD. Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, 1-5-4 Minatojima-Minamimachi, Chuo-ku, Kobe, Hyogo 650-0047, Japan Tel: +81-78-304-5772, Fax: +81-78-304-5263, E-mail:
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3
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Lantz R, Quesada O, Mattingly G, Henry TD. Contemporary Management of Refractory Angina. Interv Cardiol Clin 2022; 11:279-292. [PMID: 35710283 PMCID: PMC9275781 DOI: 10.1016/j.iccl.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Refractory angina (RA) is defined as chest pain caused by coronary ischemia in patients on maximal medical therapy and is not amenable to revascularization despite advanced coronary artery disease (CAD). The long-term prognosis has improved with optimal medical therapy including risk factor modification. Still, patients are left with major impairment in quality of life and have high resource utilization with limited treatment options. We review the novel invasive and noninvasive therapies under investigation for RA.
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Affiliation(s)
- Rebekah Lantz
- The Lindner Research Center at the Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA
| | - Odayme Quesada
- Women's Heart Program at The Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA. https://twitter.com/Odayme
| | - Georgia Mattingly
- The Lindner Research Center at the Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, 2123 Auburn Avenue, Suite 424, Cincinnati, OH 45219, USA.
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4
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Madeira S, Brízido C, Raposo L, Brito J, Vale N, Leal S, Gonçalves PDA, Gabriel HM, Teles RC, Almeida M. Non-pharmacological treatment of refractory angina: The coronary sinus reducer, the new kid on the block. Rev Port Cardiol 2021; 40:371-382. [PMID: 33879377 DOI: 10.1016/j.repc.2020.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/28/2020] [Accepted: 09/07/2020] [Indexed: 12/28/2022] Open
Abstract
Refractory angina is defined as persistent angina (≥3 months) despite optimal medical and interventional therapies. It is increasing in frequency, due to the success of current medical and interventional therapies in improving the prognosis of coronary artery disease. Long-term mortality is similar to that of patients with asymptomatic stable disease, but it affects patients' quality of life, and has a significant impact on health care resources. Several therapeutic targets have been investigated, most with disappointing results. Many of the techniques have been abandoned because of lack of efficacy, safety issues, or economic and logistic limitations to wider applicability. The primary focus of this review is the coronary sinus Reducer, supporting evidence for which, although scarce, is promising regarding safety and efficacy in improving anginal symptoms and quality of life. It is also accessible to virtually all interventional cardiology departments.
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Affiliation(s)
- Sérgio Madeira
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal.
| | - Catarina Brízido
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Luís Raposo
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - João Brito
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Nélson Vale
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Sílvio Leal
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Pedro de Araújo Gonçalves
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Henrique Mesquita Gabriel
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Rui Campante Teles
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Manuel Almeida
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
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5
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Madeira S, Brízido C, Raposo L, Brito J, Vale N, Leal S, Gonçalves PDA, Gabriel HM, Teles RC, Almeida M. Non-pharmacological treatment of refractory angina: The coronary sinus reducer, the new kid on the block. Rev Port Cardiol 2021; 40:371-382. [PMID: 34187640 DOI: 10.1016/j.repce.2020.09.003] [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: 04/21/2020] [Accepted: 09/07/2020] [Indexed: 11/30/2022] Open
Abstract
Refractory angina is defined as persistent angina (≥3 months) despite optimal medical and interventional therapies. It is increasing in frequency, due to the success of current medical and interventional therapies in improving the prognosis of coronary artery disease. Long-term mortality is similar to that of patients with asymptomatic stable disease, but it affects patients' quality of life, and has a significant impact on health care resources. Several therapeutic targets have been investigated, most with disappointing results. Many of the techniques have been abandoned because of lack of efficacy, safety issues, or economic and logistic limitations to wider applicability. The primary focus of this review is the coronary sinus Reducer, supporting evidence for which, although scarce, is promising regarding safety and efficacy in improving anginal symptoms and quality of life. It is also accessible to virtually all interventional cardiology departments.
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Affiliation(s)
- Sérgio Madeira
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal.
| | - Catarina Brízido
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Luís Raposo
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - João Brito
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Nélson Vale
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Sílvio Leal
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Pedro de Araújo Gonçalves
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Henrique Mesquita Gabriel
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Rui Campante Teles
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
| | - Manuel Almeida
- Departamento de Cardiologia de Intervenção do Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Carnaxide, Portugal
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6
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Prasad M, Corban MT, Henry TD, Dietz AB, Lerman LO, Lerman A. Promise of autologous CD34+ stem/progenitor cell therapy for treatment of cardiovascular disease. Cardiovasc Res 2021; 116:1424-1433. [PMID: 32022845 DOI: 10.1093/cvr/cvaa027] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/26/2019] [Accepted: 01/28/2020] [Indexed: 12/22/2022] Open
Abstract
CD34+ cells are haematopoietic stem cells used therapeutically in patients undergoing radiation or chemotherapy due to their regenerative potential and ability to restore the haematopoietic system. In animal models, CD34+ cells have been associated with therapeutic angiogenesis in response to ischaemia. Several trials have shown the potential safety and efficacy of CD34+ cell delivery in various cardiovascular diseases. Moreover, Phase III trials have now begun to explore the potential role of CD34+ cells in treatment of both myocardial and peripheral ischaemia. CD34+ cells have been shown to be safe and well-tolerated in the acute myocardial infarction (AMI), heart failure, and angina models. Several studies have suggested potential benefit of CD34+ cell therapy in patients with coronary microvascular disease as well. In this review, we will discuss the therapeutic potential of CD34+ cells, and describe the pertinent trials that have used autologous CD34+ cells in no-options refractory angina, AMI, and heart failure. Lastly, we will review the potential utility of autologous CD34+ cells in coronary endothelial and microvascular dysfunction.
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Affiliation(s)
- Megha Prasad
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN 55905, USA
| | - Michel T Corban
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN 55905, USA
| | - Timothy D Henry
- The Christ Hospital Heart and Vascular Center, The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH 45219, USA
| | - Allan B Dietz
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
| | - Lilach O Lerman
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN 55905, USA.,Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, USA
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, 200 First Street SW, Rochester, MN 55905, USA
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7
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Abstract
The combination of an aging population and improved survival rates among patients with coronary artery disease has resulted in an increase in the number of patients with refractory angina or anginal equivalent symptoms despite maximal medical therapy. Patients with refractory angina are often referred to the cardiac catheterization laboratory; however, they have often exhausted conventional revascularization options; thus, this population is often deemed as having "no options." We review the definition, prevalence, outcomes, therapeutic options, and treatment considerations for no-option refractory angina patients and focus on novel therapies for this complex and challenging population. We propose a multidisciplinary team approach for the evaluation and management of patients with refractory angina, ideally in a designated clinic. The severe limitations and symptomatology experienced by these patients highlight the need for additional research into the development of innovative treatments.
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Affiliation(s)
- Thomas J Povsic
- Department of Medicine, Program for Advanced Coronary Disease, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (T.J.P., E.M.O.)
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | - E Magnus Ohman
- Department of Medicine, Program for Advanced Coronary Disease, Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (T.J.P., E.M.O.)
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8
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Li D, Guo P, Chen L, Wu Y, Wang G, Xiao C. Outcomes of Surgical Patch Angioplasty of The Coronary Artery for Diffuse Coronary Artery Disease. Braz J Cardiovasc Surg 2020; 35:706-712. [PMID: 33118736 PMCID: PMC7598967 DOI: 10.21470/1678-9741-2019-0390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Diffuse coronary artery disease (CAD) has a poor prognosis and many patients are ineligible for conventional coronary artery bypass grafting (CABG). This study evaluated the 12-month outcomes of coronary artery reconstruction and surgical patch angioplasty of the coronary artery for diffuse CAD. Methods A retrospective cohort study of patients who underwent CABG with surgical patch angioplasty of the coronary artery (reconstruction group) or standard CABG alone (standard group) at the Cardiovascular Surgery Department of the local Hospital between January 2014 and January 2016. Follow-up was censored at 12 months after surgery. Results Cardiopulmonary bypass and aortic cross-clamping durations were longer in the reconstruction group (n=32) than in the standard group (n=125) (P<0.05). There were no differences in graft blood flow and postoperative levels of cardiac markers between the two groups (P>0.05). In the reconstruction group, one patient died; a vein graft showed occlusion. In the standard group, two patients died; one left internal mammary artery graft and three vein grafts showed occlusion. There were no significant differences in mortality, major adverse cardiovascular and cerebrovascular events, and patency between the two groups (P>0.05). Conclusion Coronary artery reconstruction and surgical patch angioplasty of the coronary artery can be performed for diffuse CAD. Patient outcomes were not significantly different from those of patients who underwent standard CABG.
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Affiliation(s)
- Dong Li
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Pengfei Guo
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Lei Chen
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Yang Wu
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Gang Wang
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
| | - Cangsong Xiao
- Medical School of Chinese PLA Department of Cardiovascular Surgery Beijing China Department of Cardiovascular Surgery, Medical School of Chinese PLA, Beijing, China
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9
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Efficacy of cardiac shock wave therapy in patients with stable angina: The design of randomized, triple blind, sham-procedure controlled study. Anatol J Cardiol 2019; 19:100-109. [PMID: 29424731 PMCID: PMC5864803 DOI: 10.14744/anatoljcardiol.2017.8023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: Despite revascularization and optimal medical treatment (OMT), patients with angina often have a reduced quality of life due to inadequate relief from symptoms. Recent studies have shown that the application of shock waves may reduce angina symptoms and improve quality of life, exercise capacity, and myocardial perfusion due to the stimulation of angiogenesis. However, there is limited evidence due to small, single-arm, single-center studies of low to moderate quality. The purpose of this study is to evaluate the impact of cardiac shock wave therapy (CSWT) on exercise tolerance and angina symptoms in patients with coronary artery disease and objective evidence of myocardial ischemia who cannot undergo traditional revascularization and experience angina despite OMT in comparison to sham procedure. Methods: We designed a randomized, triple-blind, placebo-controlled, multicentre trial (NCT02339454) to assess the efficacy of CSWT in addition to OMT in patients with stable angina and myocardial ischemia documented by exercise treadmill test (ETT). All patients were treated with stable doses of standard medical treatment 4 weeks before screening. An increase in the total exercise duration on ETT by ≥90 s from the baseline at the end of the study was set as the primary endpoint. Secondary endpoints included angina class, Seattle angina questionnaire scores, symptoms, and ECG changes during stress test. Patients underwent nine sessions of CSWT or corresponding sham procedure applied to all segments of the left ventricle, within 9 weeks. Endpoint assessments were performed at 6-month follow-up. The imaging substudies assessed the potential of CSWT to reduce stress-induced myocardial ischemia detected by dobutamine stress echocardiography, cardiac single-photon emission computed tomography, and cardiac magnetic resonance imaging. Results: At two centers, 72 of the 323 screened patients were randomized in two groups (ratio 1:1): active treatment and placebo control. Study patients were predominantly males (70.8%); the mean age of the patients was 68.4±8.3 years. Of these, 44 patients had angina Canadian Cardiovascular Society class III, and 66.7% of the patients had a history of myocardial infarction. Conclusion: Using sham applicators, blinding study participants, investigators, and endpoints assessors to the study data as well as centralized randomization ensures rigorous methodology and low risk of bias in this large randomized controlled CSWT study.
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10
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CD34+ Cell Therapy for No-Option Refractory Disabling Angina: Time for FDA Approval? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:177-178. [PMID: 30904135 DOI: 10.1016/j.carrev.2019.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/08/2019] [Indexed: 12/27/2022]
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11
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Kodera S, Morita H, Kiyosue A, Ando J, Takura T, Komuro I. Cost-Effectiveness of PCSK9 Inhibitor Plus Statin in Patients With Triple-Vessel Coronary Artery Disease in Japan. Circ J 2018; 82:2602-2608. [DOI: 10.1253/circj.cj-17-1455] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Satoshi Kodera
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Arihiro Kiyosue
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Jiro Ando
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Tomoyuki Takura
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
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12
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Yang W, Gage H, Jackson D, Raats M. The effectiveness and cost-effectiveness of plant sterol or stanol-enriched functional foods as a primary prevention strategy for people with cardiovascular disease risk in England: a modeling study. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:909-922. [PMID: 29110223 PMCID: PMC6105215 DOI: 10.1007/s10198-017-0934-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 10/04/2017] [Indexed: 05/08/2023]
Abstract
This study appraises the effectiveness and cost-effectiveness of consumption of plant sterol-enriched margarine-type spreads for the prevention of cardiovascular disease (CVD) in people with hypercholesterolemia in England, compared to a normal diet. A nested Markov model was employed using the perspective of the British National Health Service (NHS). Effectiveness outcomes were the 10-year CVD risk of individuals with mild (4-6 mmol/l) and high (above 6 mmol/l) cholesterol by gender and age groups (45-54, 55-64, 65-74, 75-85 years); CVD events avoided and QALY gains over 20 years. This study found that daily consumption of enriched spread reduces CVD risks more for men and older age groups. Assuming 50% compliance, 69 CVD events per 10,000 men and 40 CVD events per 10,000 women would be saved over 20 years. If the NHS pays the excess cost of enriched spreads, for the high-cholesterol group, the probability of enriched spreads being cost-effective is 100% for men aged over 64 years and women over 74, at £20,000/QALY threshold. Probabilities of cost-effectiveness are lower at younger ages, with mildly elevated cholesterol and over a 10-year time horizon. If consumers bear the full cost of enriched spreads, NHS savings arise from reduced CVD events.
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Affiliation(s)
- Wei Yang
- Department of Global Health and Social Medicine, King’s College London, London, WC2R 2LS UK
| | - Heather Gage
- School of Economics, University of Surrey, Guildford, Surrey, GU2 7XH UK
| | - Daniel Jackson
- School of Economics, University of Surrey, Guildford, Surrey, GU2 7XH UK
| | - Monique Raats
- School of Psychology, Faculty of Health and Medical Sciences, Food, Consumer Behaviour and Health Research Centre, University of Surrey, Guildford, Surrey, GU2 7XH UK
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13
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Poppi NT, Gowdak LHW, Dourado LOC, Adam EL, Leite TNP, Mioto BM, Krieger JE, César LAM, Pereira AC. A prospective study of patients with refractory angina: outcomes and the role of high-sensitivity troponin T. Clin Cardiol 2016; 40:11-17. [PMID: 27754552 DOI: 10.1002/clc.22599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/26/2016] [Accepted: 08/31/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The predictors of cardiovascular events in patients with chronic refractory angina are limited. High-sensitivity cardiac troponin T (hs-cTnT) assays are biomarkers that may be used to determine the prognosis of patients with stable coronary artery disease. HYPOTHESIS Hs-cTnT is a predictor of death and nonfatal myocardial infarction (MI) in patients with refractory angina. METHODS We prospectively enrolled 117 consecutive patients in this study. A heart team ruled out myocardial revascularization feasibility after assessing recent coronary angiograms; evidence of myocardial ischemia served as an inclusion criterion. Optimal medical therapy was encouraged via outpatient visits every 6 months; plasma hs-cTnT levels were determined at baseline. The primary endpoint was the composite incidence of death and nonfatal MI. RESULTS During a median follow-up period of 28.0 months (interquartile range, 18.0-47.5 months), an estimated 28.0-month cumulative event rate of 13.4% was determined via the Kaplan-Meier method. Univariate predictors of the composite endpoint were hs-cTnT levels and LV dysfunction. Following a multivariate analysis, only hs-cTnT was independently associated with the events in question, either as a continuous variable (hazard ratio per unit increase in the natural logarithm: 2.83, 95% confidence interval: 1.62-4.92, P < 0.001) or as a categorical variable (hazard ratio for concentrations above the 99th percentile: 5.14, 95% confidence interval: 2.05-12.91, P < 0.001). CONCLUSIONS In patients with chronic refractory angina, plasma concentration of hs-cTnT is the strongest predictor of death and nonfatal MI. Notably, none of the outcomes in question occurred in patients with baseline plasma levels <5.0 ng/L.
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Affiliation(s)
- Nilson T Poppi
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil.,Clinical Unit of Chronic Coronary Heart Disease, InCor, University of São Paulo, São Paulo, Brazil
| | - Luís H W Gowdak
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil.,Laboratory of Genetics and Molecular Cardiology, InCor, University of São Paulo, São Paulo, Brazil
| | - Luciana O C Dourado
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil.,Clinical Unit of Chronic Coronary Heart Disease, InCor, University of São Paulo, São Paulo, Brazil
| | - Eduardo L Adam
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Thiago N P Leite
- Refractory Angina Research Group, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil
| | - Bruno M Mioto
- Clinical Unit of Chronic Coronary Heart Disease, InCor, University of São Paulo, São Paulo, Brazil
| | - José E Krieger
- Laboratory of Genetics and Molecular Cardiology, InCor, University of São Paulo, São Paulo, Brazil
| | - Luiz A M César
- Clinical Unit of Chronic Coronary Heart Disease, InCor, University of São Paulo, São Paulo, Brazil
| | - Alexandre C Pereira
- Laboratory of Genetics and Molecular Cardiology, InCor, University of São Paulo, São Paulo, Brazil
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Brown RA, Shantsila E, Varma C, Lip GYH. Epidemiology and pathogenesis of diffuse obstructive coronary artery disease: the role of arterial stiffness, shear stress, monocyte subsets and circulating microparticles. Ann Med 2016; 48:444-455. [PMID: 27282244 DOI: 10.1080/07853890.2016.1190861] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Despite falling age-adjusted mortality rates coronary artery disease (CAD) remains the leading cause of death worldwide. Advanced diffuse CAD is becoming an important entity of modern cardiology as more patients with historical revascularisation no longer have suitable anatomy for additional procedures. Advances in the treatment of diffuse obstructive CAD are hampered by a poor understanding of its development. Although the likelihood of developing clinically significant (obstructive) CAD is linked to traditional risk factors, the morphology of obstructive CAD among individuals is highly variable - some patients have diffuse stenotic disease, while others have a focal stenosis. This is challenging to explain in mechanistic terms as vascular endothelium is equally exposed to injury stimulants. Patients with diffuse disease are at high risk of adverse outcomes, particularly if unsuitable for revascularisation. We searched multiple electronic databases (MEDLINE, EMBASE and the Cochrane Database) and reviewed the epidemiology, pathogenesis and prognosis relating to advanced diffuse CAD with particular focus on the role of endothelial shear stress, large artery stiffness, monocyte subsets and circulating microparticles. Key messages Although traditional CAD risk factors correlate strongly with disease severity, significant individual variation in disease morphology exists. Advanced, diffuse CAD is difficult to treat effectively and can significantly impair quality of life and increases mortality. The pathophysiology associated with the progression of CAD is the result of complex maladaptive interaction between the endothelium, cells of the immune system and patterns of blood flow.
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Affiliation(s)
- Richard A Brown
- a University of Birmingham Institute of Cardiovascular Sciences, City Hospital , Birmingham , UK
| | - Eduard Shantsila
- a University of Birmingham Institute of Cardiovascular Sciences, City Hospital , Birmingham , UK.,b Cardiology Department, City Hospital , Birmingham , UK
| | - Chetan Varma
- b Cardiology Department, City Hospital , Birmingham , UK
| | - Gregory Y H Lip
- a University of Birmingham Institute of Cardiovascular Sciences, City Hospital , Birmingham , UK.,b Cardiology Department, City Hospital , Birmingham , UK
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Stemming Anginal Pain, Waiting for the Magic Cells. Crit Care Med 2015; 43:2256-7. [PMID: 26376253 DOI: 10.1097/ccm.0000000000001218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Geovanini GR, Gowdak LHW, Pereira AC, Danzi-Soares NDJ, Dourado LOC, Poppi NT, Cesar LAM, Drager LF, Lorenzi-Filho G. OSA and depression are common and independently associated with refractory angina in patients with coronary artery disease. Chest 2014; 146:73-80. [PMID: 24811214 DOI: 10.1378/chest.13-2885] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Refractory angina is a severe form of coronary artery disease (CAD) characterized by persistent angina despite optimal medical therapy. OSA and depression are common in patients with stable CAD and may contribute to a poor prognosis. We hypothesized that OSA and depression are more common and more severe in patients with refractory angina than in patients with stable CAD. METHODS We used standardized questionnaires and full polysomnography to compare consecutive patients with well-established refractory angina vs consecutive patients with stable CAD evaluated for coronary artery bypass graft surgery. RESULTS Patients with refractory angina (n = 70) compared with patients with stable CAD (n = 70) were similar in sex distribution (male, 61.5% vs 75.5%; P = .07) and BMI (29.5 ± 4 kg/m2 vs 28.5 ± 4 kg/m2, P = .06), and were older (61 ± 10 y vs 57 ± 7 y, P = .013), respectively. Patients with refractory angina had significantly more symptoms of daytime sleepiness (Epworth Sleepiness Scale score, 12 ± 6 vs 8 ± 5; P < .001), had higher depression symptom scores (Beck Depression Inventory score, 19 ± 8 vs 10 ± 8; P < .001) despite greater use of antidepressants, had a higher apnea-hypopnea index (AHI) (AHI, 37 ± 30 events/h vs 23 ± 20 events/h; P = .001), higher proportion of oxygen saturation < 90% during sleep (8% ± 13 vs 4% ± 9, P = .04), and a higher proportion of severe OSA (AHI ≥ 30 events/h, 48% vs 27%; P = .009) than patients with stable CAD. OSA (P = .017), depression (P < .001), higher Epworth Sleepiness Scale score (P = .007), and lower sleep efficiency (P = .016) were independently associated with refractory angina in multivariate analysis. CONCLUSIONS OSA and depression are independently associated with refractory angina and may contribute to poor cardiovascular outcome.
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Affiliation(s)
- Glaucylara R Geovanini
- Sleep Laboratory, Pulmonary Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Luis H W Gowdak
- Refractory Angina Research Group, University of São Paulo Medical School, São Paulo, Brazil
| | - Alexandre C Pereira
- Refractory Angina Research Group, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Luciana O C Dourado
- Refractory Angina Research Group, University of São Paulo Medical School, São Paulo, Brazil
| | - Nilson T Poppi
- Refractory Angina Research Group, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Luciano F Drager
- Sleep Laboratory, Pulmonary Division, University of São Paulo Medical School, São Paulo, Brazil; Hypertension Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Geraldo Lorenzi-Filho
- Sleep Laboratory, Pulmonary Division, University of São Paulo Medical School, São Paulo, Brazil.
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Smith DW, Davies EW, Wissinger E, Huelin R, Matza LS, Chung K. A systematic literature review of cardiovascular event utilities. Expert Rev Pharmacoecon Outcomes Res 2013; 13:767-90. [PMID: 24175732 DOI: 10.1586/14737167.2013.841545] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Cardiovascular disease (CVD) results in half of the non-communicable disease-related deaths worldwide. Rising treatment costs have increased the need for cost-utility models designed to compare the value of new and existing therapies. Cost-utility models require utilities, values representing the strength of preferences for various health states. This systematic literature review aimed to identify and evaluate utilities reported for stroke, myocardial infarction (MI) and angina. In total, 83 unique studies were identified that reported utilities for these events. Approximately two-thirds reported utility values for stroke, and most used the EuroQoL five dimension to derive utilities. Utility values were lower in patients who experienced cardiovascular (CV) events than in patients who did not. The utility estimates for each condition varied greatly, likely due to differences in assessment methodologies and patient populations. This variability must be considered when choosing values for cost-utility models. Comparisons among reported utilities are further complicated by inconsistent CV event definitions.
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Affiliation(s)
- Donald W Smith
- Evidera, 430 Bedford St. Suite 300 Lexington, MA 02420, USA
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18
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Jaarsma T, Deaton C, Fitzsimmons D, Fridlund B, Hardig BM, Mahrer-Imhof R, Moons P, Noureddine S, O’Donnell S, Pedersen SS, Stewart S, Strömberg A, Thompson DR, Tokem Y, Kjellström B. Research in cardiovascular care: A position statement of the Council on Cardiovascular Nursing and Allied Professionals of the European Society of Cardiology. Eur J Cardiovasc Nurs 2013; 13:9-21. [DOI: 10.1177/1474515113509761] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Tiny Jaarsma
- Department of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Christi Deaton
- School of Nursing, Midwifery & Social Work, Central Manchester University Hospitals NHS Foundation Trust, UK
| | | | - Bengt Fridlund
- School of Health Sciences, Jönköping University, Jönköping, Sweden
| | - Bjarne M Hardig
- Physio-Control Sweden/Jolife AB, Sweden; Department of Cardiology, Lund University, Sweden
| | - Romy Mahrer-Imhof
- Institute of Nursing, Zurich University of Applied Sciences, Switzerland
| | - Philip Moons
- Department of Public Health and Primary Care, University of Leuven, Belgium; The Heart Centre, Copenhagen University Hospital, Denmark
| | - Samar Noureddine
- Hariri School of Nursing, American University of Beirut, Lebanon
| | | | - Susanne S Pedersen
- Department of Medical and Clinical Psychology, Tilburg University, The Netherlands; Thorax Center, Erasmus Medical Center, The Netherlands; Institute of Psychology, University of Southern Denmark, Denmark; Department of Cardiology, Odense University Hospital, Denmark
| | - Simon Stewart
- National Health and Medical Research Council (NHMRC) Centre of Research Excellence to Reduce Inequality in Heart Disease & Preventative Health, Baker IDI Heart and Diabetes Institute, Australia
| | - Anna Strömberg
- Department of Medicine and Health Sciences, Linköping University, Sweden; Department of Cardiology, County Council of Östergötland, Sweden
| | - David R Thompson
- Cardiovascular Research Centre, Australian Catholic University, Australia
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Henry TD, Satran D, Hodges JS, Johnson RK, Poulose AK, Campbell AR, Garberich RF, Bart BA, Olson RE, Boisjolie CR, Harvey KL, Arndt TL, Traverse JH. Long-term survival in patients with refractory angina. Eur Heart J 2013; 34:2683-8. [DOI: 10.1093/eurheartj/eht165] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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McGillion M, Arthur HM, Natarajan M, Cook A, Gunn E, Watt-Watson J, Thorpe K, Cosman T. Nonischemic Chest Pain Following Successful Percutaneous Coronary Intervention at a Regional Referral Centre in Southern Ontario. Can J Cardiol 2012; 28:S60-9. [DOI: 10.1016/j.cjca.2011.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 10/18/2011] [Accepted: 10/25/2011] [Indexed: 12/14/2022] Open
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Losordo DW, Henry TD, Davidson C, Sup Lee J, Costa MA, Bass T, Mendelsohn F, Fortuin FD, Pepine CJ, Traverse JH, Amrani D, Ewenstein BM, Riedel N, Story K, Barker K, Povsic TJ, Harrington RA, Schatz RA. Intramyocardial, autologous CD34+ cell therapy for refractory angina. Circ Res 2011; 109:428-36. [PMID: 21737787 DOI: 10.1161/circresaha.111.245993] [Citation(s) in RCA: 392] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
RATIONALE A growing number of patients with coronary disease have refractory angina. Preclinical and early-phase clinical data suggest that intramyocardial injection of autologous CD34+ cells can improve myocardial perfusion and function. OBJECTIVE Evaluate the safety and bioactivity of intramyocardial injections of autologous CD34+ cells in patients with refractory angina who have exhausted all other treatment options. METHODS AND RESULTS In this prospective, double-blind, randomized, phase II study (ClinicalTrials.gov identifier: NCT00300053), 167 patients with refractory angina received 1 of 2 doses (1×10(5) or 5×10(5) cells/kg) of mobilized autologous CD34+ cells or an equal volume of diluent (placebo). Treatment was distributed into 10 sites of ischemic, viable myocardium with a NOGA mapping injection catheter. The primary outcome measure was weekly angina frequency 6 months after treatment. Weekly angina frequency was significantly lower in the low-dose group than in placebo-treated patients at both 6 months (6.8±1.1 versus 10.9±1.2, P=0.020) and 12 months (6.3±1.2 versus 11.0±1.2, P=0.035); measurements in the high-dose group were also lower, but not significantly. Similarly, improvement in exercise tolerance was significantly greater in low-dose patients than in placebo-treated patients (6 months: 139±151 versus 69±122 seconds, P=0.014; 12 months: 140±171 versus 58±146 seconds, P=0.017) and greater, but not significantly, in the high-dose group. During cell mobilization and collection, 4.6% of patients had cardiac enzyme elevations consistent with non-ST segment elevation myocardial infarction. Mortality at 12 months was 5.4% in the placebo-treatment group with no deaths among cell-treated patients. CONCLUSIONS Patients with refractory angina who received intramyocardial injections of autologous CD34+ cells (10(5) cells/kg) experienced significant improvements in angina frequency and exercise tolerance. The cell-mobilization and -collection procedures were associated with cardiac enzyme elevations, which will be addressed in future studies.
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Affiliation(s)
- Douglas W Losordo
- Division of Cardiology, Northwestern Memorial Hospital, Northwestern University, Chicago, IL 60611, USA.
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22
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Williams B, Menon M, Satran D, Hayward D, Hodges JS, Burke MN, Johnson RK, Poulose AK, Traverse JH, Henry TD. Patients with coronary artery disease not amenable to traditional revascularization: prevalence and 3-year mortality. Catheter Cardiovasc Interv 2010; 75:886-91. [PMID: 20432394 DOI: 10.1002/ccd.22431] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To determine the contemporary prevalence of and mortality in patients with coronary artery disease (CAD) not amenable to revascularization. BACKGROUND A growing number of patients have severe CAD with ongoing angina despite optimal medical therapy which is not amenable to traditional revascularization. Limited data exist on contemporary prevalence and outcome for these patients. METHODS Clinical and angiographic data were reviewed for 493 consecutive patients undergoing coronary angiography and revascularization if indicated. Patients were categorized into six groups: (1) normal coronary arteries, (2) CAD <70%, (3) CAD >70% with complete revascularization by percutaneous intervention or coronary artery bypass grafting, (4) CAD >70% with partial revascularization, (5) CAD >70% treated medically, and (6) CAD >70% on optimal medical therapy with no revascularization option. All-cause mortality at 3 years was determined. RESULTS Prevalence for groups 1-6 was 14.8, 19.5, 36.9, 12.8, 9.3, and 6.7%, respectively. Three-year mortality increased with angiographic severity of CAD: 2.7, 6.3, 8.2, 12.7, 17.4, and 15.2%, respectively. Patients with incomplete revascularization (groups 4-6, n = 142) had higher mortality than completely revascularized patients (groups 1-3, n = 351): 14.8 vs. 6.6% (P = 0.004). CONCLUSIONS In a contemporary series of patients undergoing coronary angiography, 28.8% (142/493) of patients had significant CAD and did not undergo complete revascularization, including 12.8% partially revascularized, 9.3% managed medically, and 6.7% with "no-option." These patients had higher mortality at 3 years (14.8 vs. 6.6%, P = 0.004) when compared with completely revascularized patients.
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Affiliation(s)
- Benjamin Williams
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota 55407, USA
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23
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Dyer MTD, Goldsmith KA, Sharples LS, Buxton MJ. A review of health utilities using the EQ-5D in studies of cardiovascular disease. Health Qual Life Outcomes 2010; 8:13. [PMID: 20109189 PMCID: PMC2824714 DOI: 10.1186/1477-7525-8-13] [Citation(s) in RCA: 278] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2009] [Accepted: 01/28/2010] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The EQ-5D has been extensively used to assess patient utility in trials of new treatments within the cardiovascular field. The aims of this study were to review evidence of the validity and reliability of the EQ-5D, and to summarise utility scores based on the use of the EQ-5D in clinical trials and in studies of patients with cardiovascular disease. METHODS A structured literature search was conducted using keywords related to cardiovascular disease and EQ-5D. Original research studies of patients with cardiovascular disease that reported EQ-5D results and its measurement properties were included. RESULTS Of 147 identified papers, 66 met the selection criteria, with 10 studies reporting evidence on validity or reliability and 60 reporting EQ-5D responses (VAS or self-classification). Mean EQ-5D index-based scores ranged from 0.24 (SD 0.39) to 0.90 (SD 0.16), while VAS scores ranged from 37 (SD 21) to 89 (no SD reported). Stratification of EQ-5D index scores by disease severity revealed that scores decreased from a mean of 0.78 (SD 0.18) to 0.51 (SD 0.21) for mild to severe disease in heart failure patients and from 0.80 (SD 0.05) to 0.45 (SD 0.22) for mild to severe disease in angina patients. CONCLUSIONS The published evidence generally supports the validity and reliability of the EQ-5D as an outcome measure within the cardiovascular area. This review provides utility estimates across a range of cardiovascular subgroups and treatments that may be useful for future modelling of utilities and QALYs in economic evaluations within the cardiovascular area.
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Affiliation(s)
- Matthew TD Dyer
- Health Economics Research Group, Brunel University, Uxbridge, UK
- National Collaborating Centre for Mental Health, The Royal College of Psychiatrists, London, UK
| | - Kimberley A Goldsmith
- Papworth Hospital NHS Trust, Cambridge UK
- MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Linda S Sharples
- Papworth Hospital NHS Trust, Cambridge UK
- MRC Biostatistics Unit, Institute of Public Health, Cambridge, UK
| | - Martin J Buxton
- Health Economics Research Group, Brunel University, Uxbridge, UK
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Ara R, Pandor A, Tumur I, Paisley S, Duenas A, Williams R, Rees A, Wilkinson A, Durrington P, Chilcott J. Cost effectiveness of ezetimibe in patients with cardiovascular disease and statin intolerance or contraindications: a Markov model. Am J Cardiovasc Drugs 2009; 8:419-27. [PMID: 19159125 DOI: 10.2165/0129784-200808060-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the cost effectiveness of long-term ezetimibe monotherapy in patients with established cardiovascular disease (CVD) who do not tolerate statins or in whom they are contraindicated. METHODS A Markov model was used to estimate the potential costs and benefits associated with ezetimibe monotherapy compared with no treatment. The benefits associated with ezetimibe treatment were informed by a systematic review of clinical evidence and a published relationship linking changes in low-density lipoprotein cholesterol (LDL-C) levels to cardiovascular events. RESULTS In the absence of data from clinical outcome trials, surrogate endpoints such as changes in lipid levels were used as indicators of clinical outcomes. A meta-analysis of seven placebo-controlled trials included in the review showed that ezetimibe was associated with a statistically significant mean reduction (from baseline to endpoint) in LDL-C of 18.56% (95% CI -19.68, -17.44; p < 0.00001) compared with placebo. Using 10,000 Monte Carlo simulations, it is estimated that ezetimibe monotherapy would prevent an average of 49 nonfatal myocardial infarctions, 11 nonfatal strokes, and 37 cardiovascular deaths in a cohort of 1,000 patients aged 55 years with a baseline LDL-C concentration of 4.0 mmol/L. Events avoided provide an additional 211 quality-adjusted life-years (QALYs) over the 45 years modeled. With a mean incremental cost of pound 4,861,000 (year 2006 value), the discounted cost per QALY is pound 23,026 (Jackknife CI 22 979, 23 074). The model is reasonably robust to variations in key parameters. Incremental cost-effectiveness ratios fall below pound 20,000 per QALY for cohorts with baseline LDL-C values >4.5 mmol/L. CONCLUSION Ezetimibe monotherapy compared with no treatment is a cost-effective alternative for individuals with a history of CVD and high LDL-C levels, who do not tolerate statins or in whom they are contraindicated.
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Affiliation(s)
- Roberta Ara
- Health Economics and Decision Science, ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
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Abstract
PURPOSE OF REVIEW Refractory angina pectoris is a common clinical condition associated with significant morbidity and mortality. This review aims to provide a systematic approach to the assessment and treatment of patients with this condition, focusing particularly on recent data. RECENT FINDINGS Recent registry-based data have confirmed that a significant proportion of patients referred to cardiologists are suffering from refractory angina pectoris and that this is associated with poor quality of life and increased mortality. A number of novel antianginal drugs have been developed, although there has been little consensus on their use in the treatment of refractory angina. In addition, multiple interventional treatments are available but detailed evaluation is sparse. More recent studies have begun to address some of the major concerns associated with the use of these technologies, including the placebo effect. Studies comparing the different techniques are now beginning to emerge, allowing clinicians and patients to make informed choices. SUMMARY A systematic approach is needed for the assessment and treatment of patients with refractory angina pectoris. Further research must include carefully designed randomized placebo-controlled trials to enable the role and application of the different techniques to be defined.
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Spronk S, Bosch JL, Ryjewski C, Rosenblum J, Kaandorp GC, White JV, Hunink MGM. Cost-effectiveness of new cardiac and vascular rehabilitation strategies for patients with coronary artery disease. PLoS One 2008; 3:e3883. [PMID: 19065259 PMCID: PMC2587698 DOI: 10.1371/journal.pone.0003883] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 10/29/2008] [Indexed: 12/31/2022] Open
Abstract
Objective Peripheral arterial disease (PAD) often hinders the cardiac rehabilitation program. The aim of this study was evaluating the relative cost-effectiveness of new rehabilitation strategies which include the diagnosis and treatment of PAD in patients with coronary artery disease (CAD) undergoing cardiac rehabilitation. Data Sources Best-available evidence was retrieved from literature and combined with primary data from 231 patients. Methods We developed a Markov decision model to compare the following treatment strategies: 1. cardiac rehabilitation only; 2. ankle-brachial index (ABI) if cardiac rehabilitation fails followed by diagnostic work-up and revascularization for PAD if needed; 3. ABI prior to cardiac rehabilitation followed by diagnostic work-up and revascularization for PAD if needed. Quality-adjusted-life years (QALYs), life-time costs (US $), incremental cost-effectiveness ratios (ICER), and gain in net health benefits (NHB) in QALY equivalents were calculated. A threshold willingness-to-pay of $75 000 was used. Results ABI if cardiac rehabilitation fails was the most favorable strategy with an ICER of $44 251 per QALY gained and an incremental NHB compared to cardiac rehabilitation only of 0.03 QALYs (95% CI: −0.17, 0.29) at a threshold willingness-to-pay of $75 000/QALY. After sensitivity analysis, a combined cardiac and vascular rehabilitation program increased the success rate and would dominate the other two strategies with total lifetime costs of $30 246 a quality-adjusted life expectancy of 3.84 years, and an incremental NHB of 0.06 QALYs (95%CI:−0.24, 0.46) compared to current practice. The results were robust for other different input parameters. Conclusion ABI measurement if cardiac rehabilitation fails followed by a diagnostic work-up and revascularization for PAD if needed are potentially cost-effective compared to cardiac rehabilitation only.
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Affiliation(s)
- Sandra Spronk
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands.
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Norekvål TM, Wahl AK, Fridlund B, Nordrehaug JE, Wentzel-Larsen T, Hanestad BR. Quality of life in female myocardial infarction survivors: a comparative study with a randomly selected general female population cohort. Health Qual Life Outcomes 2007; 5:58. [PMID: 17971206 PMCID: PMC2174935 DOI: 10.1186/1477-7525-5-58] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 10/30/2007] [Indexed: 12/18/2022] Open
Abstract
Background A substantial burden associated with MI has been reported. Thus, how survivors experience their quality of life (QOL) is now being given increasing attention. However, few studies have involved women and a comparison with the general population. The aims of this study were to determine the QOL of female MI survivors, to investigate whether their QOL differed from that of the general population, and to evaluate the clinical significance of the findings. Methods Two cross-sectional surveys were performed; on female MI survivors and the general Norwegian population. The MI survey included women aged 62–80 years, three months to five years after their MI. One hundred and forty-five women responded, yielding a response rate of 60%. A subset of women in the same age range (n = 156) was drawn from a study of 1893 randomly selected Norwegian citizens. QOL was measured in both groups with the World Health Organization Quality of Life Instrument Abbreviated (WHOQOL-BREF). Results The majority (54%) of the female MI survivors presented with ST-elevation in their ECG, 31% received thrombolysis, and 38% had reduced left ventricular ejection fraction. Female MI survivors reported significantly lower satisfaction with general health (p = 0.020) and overall QOL (p = 0.017) than women from the general population. This was also the case for the physical and environmental QOL domains (p < 0.001), but not for the psychological and social relationship domains. Estimated effect sizes between the two groups of participants ranged from 0.1 to -0.6. Conclusion The burden of MI significantly affects the physical health of elderly women. Still, female MI survivors fare as well as the general female population on psychosocial QOL domains. Action should be taken not only to support women's physical needs but also to reinforce their strengths in order to maintain optimal QOL.
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Affiliation(s)
- Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
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Fukuoka Y, Lindgren TG, Rankin SH, Cooper BA, Carroll DL. Cluster analysis: a useful technique to identify elderly cardiac patients at risk for poor quality of life. Qual Life Res 2007; 16:1655-63. [PMID: 17955345 DOI: 10.1007/s11136-007-9272-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 10/03/2007] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The purposes of this study are (1) to examine the frequency of cardiac symptoms in elderly people one year after acute myocardial infarction (AMI) and/or coronary artery bypass surgery (CABG); (2) to identify patient subgroups (cluster solutions) based on cardiac symptoms after cardiac events and (3) to determine if these subgroups vary based on health related quality of life and psychological distress. METHODS A sample of 206 elderly, unpartnered, patients (age > or = 65) were interviewed one year after AMI and/or CABG by telephone. Cardiac symptoms, SF-36, POMS, and QOL-I were measured. A hierarchical cluster analysis was used to identify patient subgroups based on cardiac symptoms, using a combination of dendrograms and stopping rules. RESULTS Three subgroups were identified: (1) the Weary (19.4%), (2) the Diffuse symptom (68.4%), and (3) the Breathless groups (12.2%). The Weary group had significantly lower scores on all of SF-36 subscales (except for social functioning) and higher scores on all of POMS subscales (except for Anger/hostility and Confusion/Bewilderment) compared to the Diffuse symptom group. CONCLUSIONS The cluster analysis was useful to identify the subgroup with poorer recovery. Patients in the Weary group need more attention and intervention strategies to improve their health.
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Affiliation(s)
- Yoshimi Fukuoka
- School of Nursing, University of California San Francisco, San Francisco, CA 94143, USA.
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Komorovsky R, Desideri A, Rozbowsky P, Sabbadin D, Celegon L, Gregori D. Quality of life and behavioral compliance in cardiac rehabilitation patients: a longitudinal survey. Int J Nurs Stud 2007; 45:979-85. [PMID: 17673241 DOI: 10.1016/j.ijnurstu.2007.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 06/06/2007] [Accepted: 06/08/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Few data regarding inter-relations between health-related quality of life (HRQoL) and compliance are available. The aim of present study was to assess which aspects of HRQoL might predict patients' behavioral compliance to medical suggestions and whether questionnaires might be useful for patients undergoing cardiac rehabilitation. METHODS HRQoL and compliance were measured in 52 consecutive patients undergoing cardiovascular rehabilitation. The measurements were performed at the beginning, at the end of rehabilitation, and after 6 months follow-up. Baseline, demographic and HRQoL characteristics were linked to compliance by multiple regression modelling. RESULTS Over time no significant differences between HRQoL and compliance scores were observed. Age (odds ratio (OR) 1.37, 95% confidence interval (CI) 1.08-2.45), number of taken drugs (OR=1.45; 95% CI: 1.02-2.11), anxiety score (OR=0.32; 95% CI: 0.15-1.02), depression score (OR=0.48; 95% CI: 0.06-0.78), and social health score (OR=1.09; 95% CI: 1.01-1.24), appeared to be independent predictors of compliance. CONCLUSION Older age, higher number of drugs, high social health score, and low anxiety and depression scores predict better behavioral compliance in cardiac rehabilitation patients.
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Affiliation(s)
- Roman Komorovsky
- Cardiovascular Research Foundation, S. Giacomo Hospital, Castelfranco Veneto, Italy
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Norekvål TM, Deaton C, Scholte op Reimer WJM. The European Council on Cardiovascular Nursing and Allied Professions: toward promoting excellence in cardiovascular care. PROGRESS IN CARDIOVASCULAR NURSING 2007; 22:217-220. [PMID: 18059200 DOI: 10.1111/j.0889-7204.2007.07467.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.
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