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Suebsaicharoen T, Chunekamrai P, Yingchoncharoen T, Tansawet A, Issarawattana T, Numthavaj P, Thakkinstian A. Comparative cardiovascular outcomes of novel drugs as an addition to conventional triple therapy for heart failure with reduced ejection fraction (HFrEF): a network meta-analysis of randomised controlled trials. Open Heart 2023; 10:e002364. [PMID: 37940331 PMCID: PMC10632908 DOI: 10.1136/openhrt-2023-002364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/02/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Currently, there is no head-to-head comparison of novel pharmacological treatments for heart failure with reduced ejection fraction (HFrEF). A network meta-analysis aimed to compare effects of both conventional and alternative drug combinations on time to develop primary composite outcome of cardiovascular death or heart failure hospitalisation (PCO). METHODS Randomised controlled trials (RCTs) were identified from Medline, Scopus up to June 2021. The RCTs were included if comparing any single or combination of drugs, that is, ACE inhibitors (ACEI), angiotensin receptor blockers, beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), ivabradine (IVA), angiotensin receptor blocker/neprilysin inhibitors (ARNI) and sodium-glucose cotransporter-2 inhibitors (SGLT2i), soluble guanylyl cyclase and omecamtiv mecarbil and reporting PCO. Data were extracted from Kaplan-Meier curves, individual patient data were generated. A mixed-effect Weibull regression was applied. Median time to PCO, HRs with 95% CI were estimated accordingly. Our findings suggested that ACEI+BB+MRA+SGLT2i, BB+MRA+ARNI, and ACEI+BB+MRA+IVA had lower probability of PCOs than the conventional triple therapy (ACEI+BB+MRA). RESULTS Median time to PCOs of ACEI+BB+MRA was 57.7 months whereas median times to those new combinations were longer than 57.7 months. In addition, the three new regimens had a significantly lower PCO risks than ACEI+BB+MRA, with the HRs (95% CI) of 0.51 (0.43 to 0.61), 0.55 (0.46 to 0.65) and 0.56 (0.47 to 0.67), accordingly. CONCLUSION This study suggested that SGLT2i, ARNI and IVA in addition to ACEI+BB+MRA may be better in prolonging time to develop PCO in HFrEF patients.
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Affiliation(s)
| | - Puri Chunekamrai
- Faculty of Medicine, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Teerapat Yingchoncharoen
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Amarit Tansawet
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanaphruet Issarawattana
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pawin Numthavaj
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Akhtar H, Al Sudani H, Hussein M, Farhan MUN, Elkholy K. Effects of Renin-Angiotensin-Aldosterone System Inhibition on Left Ventricular Hypertrophy, Diastolic Function, and Functional Status in Patients With Hypertrophic Cardiomyopathy: A Systematic Review. Cureus 2022; 14:e26642. [PMID: 35949750 PMCID: PMC9356743 DOI: 10.7759/cureus.26642] [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: 07/07/2022] [Indexed: 11/25/2022] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) plays a vital role in cardiovascular homeostasis by regulating blood pressure, salt, and water balance. The kidneys produce renin which converts angiotensinogen to angiotensin-1 (AT-I) and angiotensin-converting enzyme (ACE) to angiotensin-II (AT-II). AT-II binds to receptors in the adrenal cortex to release aldosterone. AT-II and aldosterone promote water and salt retention, vascular tone, and myocardial contractility. These physiological changes raise blood pressure and circulation. Reduced renal perfusion pressure sensed by baroreceptors and the sympathetic nervous system’s β-adrenergic receptors trigger renin release and RAAS activation. RAAS restores hemodynamic stability in pathological states associated with low perfusion. This adaptive response is important for restoring perfusion and hemodynamic stability, but prolonged RAAS activation has deleterious effects on the cardiovascular system. Long-term mineralocorticoid exposure has been linked to left ventricular hypertrophy (LVH) and remodeling. AT-II activates fibroblasts and cardiac myocytes to promote cardiac remodeling. Blocking RAAS can eliminate the long-term negative effects of RAAS activation. Direct renin inhibitors, ACE inhibitors, angiotensin receptor blockers, and aldosterone antagonists are RAAS blockers. RAAS blockade improves mortality and hospitalization in systolic heart failure and acute myocardial infarction. RAAS blockade has not demonstrated the same benefits in other cardiac populations, such as those with preserved ejection fraction. Hypertrophic cardiomyopathy (HCM) causes LVH and asymmetric septal hypertrophy. When the outflow tract gradient exceeds 30 mmHg and is associated with septal hypertrophy, it is known as obstructive HCM. Dyspnea on exertion, syncope, and exertional angina are symptoms of HCM. RAAS activation worsens LVH by increasing blood pressure and by directly affecting cardiac myocytes with AT-II and aldosterone. RAAS blockade reverses myocardial fibrosis and slows HCM progression in animal models. We performed a meta-analysis of randomized clinical trials to further investigate the potential benefit of RAAS blockade in HCM patients. Although our findings included significant results for some of the RAAS blockade agents, these findings were not consistent throughout all the studies. Mavacamten, one of the newest treatments, has shown promising outcomes.
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3
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Mayer O, Bruthans J, Bilkova S, Seidlerova J, Jirak J, Filipovsky J. The prognosis and therapeutic management of patients hospitalized for heart failure in 2010-2020. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2022; 166:312-321. [PMID: 35444330 DOI: 10.5507/bp.2022.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 04/06/2022] [Indexed: 01/11/2023] Open
Abstract
AIMS We analyzed the mortality risk and its predictors in patients hospitalized for heart failure (HF). METHODS Patients discharged from hospitalization for acute decompensation of HF in 2010- 2020 and younger than 86 years were followed (n=4097). We assessed the incidence and trends of all-cause death, its main predictors, and the pharmacotherapy recommended at discharge from the hospital. RESULTS The 30 days all-cause mortality was in discharged patients 3.2%, while 1-year 20.4% and 5-years 55.4%. We observed a modest trend to decreased 1-year mortality risk over time. Any increase of year of hospitalization by one was associated with about 5% lower risk in the fully adjusted model. Regarding predictors of 1-year mortality risk, a positive association was found for age over 65, history of malignancy, and peak brain natriuretic peptide during hospitalization ≥10times higher than normal concentration. In contrast, as protective factors, we identified LDL ≥1.8 mmol/L, treatment with beta-blockers, renin-angiotensin axis blockers, statins, and implanted cardioverter in the same regression model. The ejection fraction category and primary etiology of HF (coronary artery disease vs. others) did not significantly affect the mortality risk in a fully adjusted model. CONCLUSIONS Despite advances in cardiovascular disease management over the last two decades, the prognosis of patients hospitalized for heart failure remained highly unfavorable.
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Affiliation(s)
- Otto Mayer
- 2nd Department of Internal Medicine, Faculty of Medicine, Charles University and University Hospital, Pilsen, Czech Republic.,Biomedical Center, Faculty of Medicine, Charles University Pilsen, Czech Republic
| | - Jan Bruthans
- 2nd Department of Internal Medicine, Faculty of Medicine, Charles University and University Hospital, Pilsen, Czech Republic.,Centre for Cardiovascular Prevention, First Faculty of Medicine, Charles, University and Thomayer's Hospital, Prague, Czech Republic
| | - Simona Bilkova
- 2nd Department of Internal Medicine, Faculty of Medicine, Charles University and University Hospital, Pilsen, Czech Republic.,Biomedical Center, Faculty of Medicine, Charles University Pilsen, Czech Republic
| | - Jitka Seidlerova
- 2nd Department of Internal Medicine, Faculty of Medicine, Charles University and University Hospital, Pilsen, Czech Republic.,Biomedical Center, Faculty of Medicine, Charles University Pilsen, Czech Republic
| | - Josef Jirak
- Department of Informatics, University Hospital Pilsen, Czech Republic
| | - Jan Filipovsky
- 2nd Department of Internal Medicine, Faculty of Medicine, Charles University and University Hospital, Pilsen, Czech Republic.,Biomedical Center, Faculty of Medicine, Charles University Pilsen, Czech Republic
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Guo L, Meng S, Lv H, Zhong L, Wu J, Ding H, Xu J, Zhang X, Huang R. Long-Term Outcomes of Successful Recanalization Compared With Optimal Medical Therapy for Coronary Chronic Total Occlusions in Patients With and Without Left Ventricular Systolic Dysfunction. Front Cardiovasc Med 2021; 8:654730. [PMID: 33959643 PMCID: PMC8093409 DOI: 10.3389/fcvm.2021.654730] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The number of coronary chronic total occlusion (CTO) patients with left ventricular (LV) systolic dysfunction is significant, but the clinical outcomes of these patients are rarely reported. The present retrospective cohort study aimed to investigate the long-term outcomes of successful recanalization vs. optimal medical therapy (MT) for CTOs in patients with preserved and impaired LV systolic function. Methods: A total of 1,895 patients with CTOs were stratified according to LV function. Of these, 1,420 patients (74.9%) with LV ejection fraction (LVEF) >45% and 475 patients (25.1%) with LVEF ≤45% were treated with optimal MT or successful CTO percutaneous coronary intervention (PCI). A 1:1 propensity score matching (PSM) was conducted to reduce the impact of potential confounding on the outcomes. The primary outcome was the frequency of major adverse cardiac events (MACEs). Results: Throughout a 2.6-year follow-up and after adjusting for confounders, among patients with preserved LV function, successful CTO PCI was associated with reduced incidence of MACE (14.2 vs. 23.9%, adjusted HR 0.63, 95% CI 0.48–0.83, p = 0.001) compared to MT. There was no significant difference in MACE occurrence (29.6 vs. 28.9%, adjusted HR 1.05, 95% CI: 0.71–1.56, p = 0.792) between successful recanalization and MT in patients with LV systolic dysfunction. The primary outcome among patients with impaired and preserved LV systolic function after PSM was similar to that from earlier findings before PSM was conducted. A significant interaction between LV function and therapeutic strategy for MACE was observed (interaction p = 0.038). Conclusions: Compared to MT alone for management of patients with CTOs, successful CTO PCI may reduce the risk of MACE in patients with preserved LV systolic function, but not in patients with LV dysfunction.
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Affiliation(s)
- Lei Guo
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Shaoke Meng
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Haichen Lv
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lei Zhong
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jian Wu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Huaiyu Ding
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jiaying Xu
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Xiaoyan Zhang
- Department of Radiology, Fuyang Hospital of Anhui Medical University, Fuyang, China
| | - Rongchong Huang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China.,Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Topf A, Mirna M, Ohnewein B, Jirak P, Kopp K, Fejzic D, Haslinger M, Motloch LJ, Hoppe UC, Berezin A, Lichtenauer M. The Diagnostic and Therapeutic Value of Multimarker Analysis in Heart Failure. An Approach to Biomarker-Targeted Therapy. Front Cardiovasc Med 2020; 7:579567. [PMID: 33344515 PMCID: PMC7746655 DOI: 10.3389/fcvm.2020.579567] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Heart failure is a pathophysiological state, which is still associated with high morbidity and mortality despite established therapies. Diverse well-known biomarkers fail to assess the variety of individual pathophysiology in the context of heart failure. Methods: An analysis of prospective, multimarker-specific therapeutic approaches to heart failure based on studies in current literature was performed. A total of 159 screened publications in the field of biomarkers in heart failure were hand-selected and found to be eligible for this study by a team of experts. Results: Established biomarkers of the inflammatory axis, matrix remodeling, fibrosis and oxidative stress axis, as well as potential therapeutic interventions were investigated. Interaction with end organs, such as cardio-hepatic, cardio-renal and cardio-gastrointestinal interactions show the complexity of the syndrome and could be of further therapeutic value. MicroRNAs are involved in a wide variety of physiologic and pathophysiologic processes in heart failure and could be useful in diagnostic as well as therapeutic setting. Conclusion: Based on our analysis by a biomarker-driven approach in heart failure therapy, patients could be treated more specifically in long term with a consideration of different aspects of heart failure. New studies evaluating a multimarker – based therapeutic approach could lead in a decrease in the morbidity and mortality of heart failure patients.
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Affiliation(s)
- Albert Topf
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Moritz Mirna
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Bernhard Ohnewein
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Peter Jirak
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Kristen Kopp
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Dzeneta Fejzic
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Michael Haslinger
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Lukas J Motloch
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Uta C Hoppe
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Alexander Berezin
- Internal Medicine Department, State Medical University, Zaporozhye, Ukraine
| | - Michael Lichtenauer
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
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Heo JH, Park C, Ghosh S, Park SK, Zivkovic M, Rascati KL. A network meta-analysis of efficacy and safety of first-line and second-line therapies for the management of metastatic renal cell carcinoma. J Clin Pharm Ther 2020; 46:35-49. [PMID: 33112003 DOI: 10.1111/jcpt.13282] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 08/29/2020] [Accepted: 09/15/2020] [Indexed: 12/20/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Metastatic renal cell carcinoma (mRCC) is the most common type of kidney cancers. Disease-specific survival for mRCC has been significantly improved with the introduction of new targeted agents since 2005. However, there is a lack of head-to-head clinical trials comparing the efficacy between therapies. This study compared indirectly progression-free survival (PFS) and overall survival (OS) among first-line and second-line therapies in patients with mRCC using network meta-analysis (NMA). METHODS The PubMed, MEDLINE, Cochrane Library and Web of Science were searched to identify phase II or phase III randomized controlled trials (RCTs) of targeted and biological therapies in patients with mRCC published between January 2000 and June 2020. The Bayesian fixed-effect NMA was performed to evaluate relative PFS and OS of first-line and second-line therapies of axitinib, bevacizumab, cabozantinib, everolimus, lenvatinib, nivolumab, ipilimumab, pazopanib, sorafenib, sunitinib, temsirolimus, tivozanib, avelumab and pembrolizumab, which were approved by the Food and Drug Administration or European Medicines Agency. End points were compared using hazard ratio (HR) and 95% credible interval (CrI). The surface under the cumulative ranking curve (SUCRA) was estimated to assess the probability of being the best treatment. RESULTS AND DISCUSSION A total of 26 RCTs (first line: 19, second line: 9) with 13 893 patients were included in the NMA. For the first-line therapy, cabozantinib was associated with the highest improved PFS (HR = 0.26, 95% CrI = 0.14-0.44) followed by avelumab + axitinib and pembrolizumab + axitinib (HR = 0.27, SUCRA = 90%). Pembrolizumab + axitinib had a high likelihood of being the preferred treatment when using OS as the outcome measure (HR = 0.41, 95% CrI = 0.16-0.85). Avelumab + axitinib had the lowest HR compared with placebo + interferon on discontinuations due to AE (HR = 1.04, 95% CrI = 0.54-1.86). For second-line therapy, cabozantinib was identified as the most effective treatment option when assessing PFS (HR = 0.17, 95% CrI = 0.12-0.24). Axitinib had the lowest HR of OS and discontinuation due to AE (HR = 0.54, 95% CrI = 0.40-0.71; HR = 0.98, 95% CrI = 0.42-1.97, respectively). Pazopanib was the second choice in terms of OS (HR = 0.56, 95% CrI = 0.28-1.00; SUCRA = 76%) compared with placebo. WHAT IS NEW AND CONCLUSION With respect to PFS and OS improvement, cabozantinib, avelumab + axitinib and pembrolizumab + axitinib are likely to be the preferred options for the first-line therapy and cabozantinib and axitinib for the second-line therapy in the management of mRCC. Regarding safety, avelumab + axitinib and temsirolimus were considered preferred treatment options in first-line and second-line therapies. More future research is needed to establish subgroup analyses, allowing evaluation of the impact of some of the differences in patient characteristics, including treatment effect modifiers.
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Affiliation(s)
- Ji Haeng Heo
- Genesis Research, LLC, Hoboken, NJ, USA.,The University of Texas at Austin, Austin, TX, USA
| | | | - Somraj Ghosh
- The University of Texas at Austin, Austin, TX, USA
| | - Sun-Kyeong Park
- College of Pharmacy, The Catholic University of Korea, Bucheon, South Korea
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Benefits and adverse effects of ACE inhibitors in patients with heart failure with reduced ejection fraction: a systematic review and meta-analysis. Eur J Clin Pharmacol 2020; 77:321-329. [PMID: 33070218 DOI: 10.1007/s00228-020-03018-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Angiotensin-converting enzyme (ACE) inhibitors are part of first-line treatment for reduced ejection fraction heart failure (HFrEF). The aim was to assess the benefits and adverse effects of ACE inhibitors in HFrEF with a focus on important patient outcomes. METHODS A systematic review of double-blind randomized clinical trials (RCTs) and comparison of ACE inhibitors versus placebo, in HFrEF patients published in French or English. Searches were undertaken of Medline, Cochrane Central, and Embase. The primary outcomes were all-cause mortality and adverse events. RESULTS From 636 articles analysed, 11 were included (13,882 patients). For all-cause mortality (5 RCTs, 9277 patients), the number needed to treat (NNT) to avoid one death at 6 months was 50 (33-107). The NNT to prevent one death at 12 months (6 RCTs, 13,016 patients) was 63 (35-314). Under the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the evidence was of moderate quality. The number needed to harm was 12 (10-15) for cough, 20 (14-31) for hypotension, 23 (17-36) for dizziness, 31 (23-47) for hyperkalaemia, and 49 (30-121) for increased creatinine levels. The quality of evidence was moderate for these criteria except for cough (low quality of evidence). CONCLUSION This review focuses on clinical elements necessary in a shared decision-making process. In practice, general practitioners will be able to use these data to discuss ACE inhibitor treatment with HFrEF patients. This study was registered in the PROSPERO registry under the reference number CRD42018096930.
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Vecchi AL, Abete R, Marazzato J, Iacovoni A, Mortara A, De Ponti R, Senni M. Ventricular arrhythmias and ARNI: is it time to reappraise their management in the light of new evidence? Heart Fail Rev 2020; 27:103-110. [PMID: 32556671 DOI: 10.1007/s10741-020-09991-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The remarkable scientific progress in the treatment of patients with heart failure (HF) and reduced ejection fraction (HFrEF) has more than halved the risk of sudden cardiac death (SCD) in this setting. However, SCD remains one of the major causes of death in this patient population. Beyond the acknowledged role of beta blockers and inhibitors of the renin-angiotensin-aldosterone system (RAAS), a new class of drugs, the angiotensin receptor neprilysin inhibitors (ARNI), proved to reduce the overall cardiovascular mortality and, more specifically, the risk of SCD in HFrEF patients. The mechanism by which ARNI may reduce the mortality connected with harmful ventricular arrhythmias is not utterly clear. A variety of direct and indirect mechanisms have been suggested, but a favorable left ventricular reverse remodeling seems to play a key role in this setting. Furthermore, the well-known protective effect of implantable cardioverter-defibrillator (ICD) has been debated in HFrEF patients with non-ischemic cardiomyopathy (NICM) arguing against the role of primary prevention ICD in this setting, particularly when ARNI therapy is considered. The purpose of this review was to provide insights into the SCD mechanisms involved in HFrEF patients together with the current role of electrical therapies and new drug agents in this setting. Graphical abstract.
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Affiliation(s)
- Andrea Lorenzo Vecchi
- Department of Heart and Vessels, Ospedale di Circolo and Macchi Foundation, University of Insubria, Varese, Italy.
| | - Raffaele Abete
- Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Jacopo Marazzato
- Department of Heart and Vessels, Ospedale di Circolo and Macchi Foundation, University of Insubria, Varese, Italy
| | - Attilio Iacovoni
- Cardiovascular Department & Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| | - Andrea Mortara
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo and Macchi Foundation, University of Insubria, Varese, Italy
| | - Michele Senni
- Cardiovascular Department & Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
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Mazzetti S, Scifo C, Abete R, Margonato D, Chioffi M, Rossi J, Pisani M, Passafaro G, Grillo M, Poggio D, Mortara A. Short-term echocardiographic evaluation by global longitudinal strain in patients with heart failure treated with sacubitril/valsartan. ESC Heart Fail 2020; 7:964-972. [PMID: 32233080 PMCID: PMC7261528 DOI: 10.1002/ehf2.12656] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 01/26/2020] [Accepted: 02/06/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS The angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan reduces mortality and hospitalizations in patients with heart failure and reduced ejection fraction (HFrEF). Favourable effects on haemodynamic and functional parameters have been observed in patients with HFrEF undergoing ARNI therapy, using standard transthoracic echocardiography. Global longitudinal strain (GLS) assessment uses a semi-automatic procedure to provide a reliable and repeatable method that improves the detection of early changes of contractile function. We aimed to assess the effects of ARNI on GLS and myocardial mechanics in patients with HFrEF. METHODS AND RESULTS Thirty patients with New York Heart Association class II-III HFrEF were treated with ARNI and monitored using standard echocardiographic examination and GLS measurements at baseline, 3 months, and 6 months. ARNI therapy resulted in a significant reduction of ventricular volumes and a significant increase in left ventricular ejection fraction at 6 months but not 3 months by standard transthoracic echocardiography (left ventricular ejection fraction from 28 ± 8% at baseline to 34 ± 12% at 6 months, P < 0.001). Non-significant differences in the size of the left atrium, right ventricular function, and pulmonary pressures were found at 6 months. By using GLS, there was a progressive improvement of all strain parameters by 3 months. The improvement showed a progressive trend over time and maintained significance at 6 months: GLS 4ch -7.2 ± 4.8% at baseline vs. -7.5 ± 3.9% at 3 months (P = 0.025) and - 9.2 ± 5.2% at 6 months (P = 0.0001); AVG GLS -6.9 ± 4.3 at baseline vs. -7.9 ± 4.2 at 3 months (P = 0.04) and - 8.8 ± 4.4 at 6 months (P = 0.035); GLS endo 8.2 ± 4.8 at baseline vs. -9.0 ± 4.8 at 3 months (P = 0.05) and - 10.1 ± 5.1 at 6 months (P = 0.001). CONCLUSIONS Sacubitril/valsartan induces an early benefit on left ventricular remodelling, which is captured by myocardial strain and not by standard echocardiography. Strain method represents a practical tool to assess early and minimal variations of left ventricular systolic function.
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Affiliation(s)
- Simone Mazzetti
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy
| | - Chiara Scifo
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy
| | - Raffaele Abete
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy.,Department of Cardiology, University of Pavia, Pavia, Italy
| | - Davide Margonato
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy.,Department of Cardiology, University of Pavia, Pavia, Italy
| | - Margherita Chioffi
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy
| | - Jessica Rossi
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy.,Department of Cardiology, University of Pavia, Pavia, Italy
| | - Matteo Pisani
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy
| | - Giovanni Passafaro
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy
| | - Massimiliano Grillo
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy
| | - Daniele Poggio
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy
| | - Andrea Mortara
- Department of Clinical Cardiology, Policlinico di Monza, Via Amati, 111, 20900, Monza, MB, Italy
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AlHabeeb W, Al-Ayoubi F, AlGhalayini K, Al Ghofaili F, Al Hebaishi Y, Al-Jazairi A, Al-Mallah MH, AlMasood A, Al Qaseer M, Al-Saif S, Chaudhary A, Elasfar A, Tash A, Arafa M, Hassan W. Saudi Heart Association (SHA) guidelines for the management of heart failure. J Saudi Heart Assoc 2019; 31:204-253. [PMID: 31371908 PMCID: PMC6660461 DOI: 10.1016/j.jsha.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/31/2019] [Accepted: 06/18/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is the leading cause of morbidity and mortality worldwide and negatively impacts quality of life, healthcare costs, and longevity. Although data on HF in the Arab population are scarce, recently developed regional registries are a step forward to evaluating the quality of current patient care and providing an overview of the clinical picture. Despite the burden of HF in Saudi Arabia, there are currently no standardized protocols or guidelines for the management of patients with acute or chronic heart failure. Therefore, the Heart Failure Expert Committee, comprising 13 local specialists representing both public and private sectors, has developed guidelines to address the needs and challenges for the diagnosis and treatment of HF in Saudi Arabia. The ultimate aim of these guidelines is to assist healthcare professionals in delivering optimal care and standardized clinical practice across Saudi Arabia.
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Affiliation(s)
- Waleed AlHabeeb
- Cardiac Sciences Department, King Saud University, Riyadh, Saudi ArabiaSaudi Arabia
- Corresponding author at: Cardiac Sciences Department, King Saud University, P.O. Box 7805, Riyadh 11472, Saudi Arabia.
| | - Fakhr Al-Ayoubi
- King Fahad Cardiac Center, King Saud University, Riyadh, Saudi ArabiaSaudi Arabia
| | - Kamal AlGhalayini
- King Abdulaziz University Hospital, Jeddah, Saudi ArabiaSaudi Arabia
| | - Fahad Al Ghofaili
- King Salman Heart Center, King Fahad Medical City, Riyadh, Saudi ArabiaSaudi Arabia
| | | | - Abdulrazaq Al-Jazairi
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi ArabiaSaudi Arabia
| | - Mouaz H. Al-Mallah
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Cardiac Center, Ministry of National Guard, Health Affairs, Riyadh, Saudi ArabiaSaudi Arabia
| | - Ali AlMasood
- Riyadh Care Hospital, Riyadh, Saudi ArabiaSaudi Arabia
| | - Maryam Al Qaseer
- King Fahad Specialist Hospital, Dammam, Saudi ArabiaSaudi Arabia
| | - Shukri Al-Saif
- Saud Al-Babtain Cardiac Center, Dammam, Saudi ArabiaSaudi Arabia
| | - Ammar Chaudhary
- King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi ArabiaSaudi Arabia
| | - Abdelfatah Elasfar
- Madina Cardiac Center, AlMadina AlMonaoarah, Saudi ArabiaSaudi Arabia
- Cardiology Department, Tanta University, EgyptEgypt
| | - Adel Tash
- Ministry of Health, Riyadh, Saudi ArabiaSaudi Arabia
| | - Mohamed Arafa
- Cardiac Sciences Department, King Saud University, Riyadh, Saudi ArabiaSaudi Arabia
| | - Walid Hassan
- International Medical Center, Jeddah, Saudi ArabiaSaudi Arabia
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11
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Pisano A, Bolignano D, Mallamaci F, D’Arrigo G, Halimi JM, Persu A, Wuerzner G, Sarafidis P, Watschinger B, Burnier M, Zoccali C. Comparative effectiveness of different antihypertensive agents in kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant 2019; 35:878-887. [DOI: 10.1093/ndt/gfz092] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/11/2019] [Indexed: 12/19/2022] Open
Abstract
Abstract
Background
We conducted a systematic review and meta-analysis to compare benefits and harms of different antihypertensive drug classes in kidney transplant recipients, as post-transplant hypertension (HTN) associates with increased cardiovascular (CV) morbidity and mortality.
Methods
The Ovid-MEDLINE, PubMed and CENTRAL databases were searched for randomized controlled trials (RCTs) comparing all main antihypertensive agents versus placebo/no treatment, routine treatment.
Results
The search identified 71 RCTs. Calcium channel blockers (CCBs) (26 trials) reduced the risk for graft loss {risk ratio [RR] 0.58 [95% confidence interval (CI) 0.38–0.89]}, increased glomerular filtration rate (GFR) [mean difference (MD) 3.08 mL/min (95% CI 0.38–5.78)] and reduced blood pressure (BP). Angiotensin-converting enzyme inhibitors (ACEIs) (13 trials) reduced the risk for graft loss [RR 0.62 (95% CI 0.40–0.96)] but decreased renal function and increased the risk for hyperkalaemia. Angiotensin receptor blockers (ARBs) (10 trials) did not modify the risk of death, graft loss and non-fatal CV events and increased the risk for hyperkalaemia. When pooling ACEI and ARB data, the risk for graft failure was lower in renin–angiotensin system (RAS) blockade as compared with control treatments. In direct comparison with ACEIs or ARBs (11 trials), CCBs increased GFR [MD 11.07 mL/min (95% CI 6.04–16.09)] and reduced potassium levels but were not more effective in reducing BP. There are few available data on mortality, graft loss and rejection. Very few studies performed comparisons with other active drugs.
Conclusions
CCBs could be the preferred first-step antihypertensive agents in kidney transplant patients, as they improve graft function and reduce graft loss. No definite patient or graft survival benefits were associated with RAS inhibitor use over conventional treatment.
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Affiliation(s)
- Anna Pisano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Davide Bolignano
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Graziella D’Arrigo
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Jean-Michel Halimi
- Service de Néphrologie et Immunologie clinique, CHRU de Tours—Hôpital Bretonneau, Tours, France
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | | | - Bruno Watschinger
- Department of Internal Medicine III, Division of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | - Carmine Zoccali
- CNR-Institute of Clinical Physiology, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension, Reggio Calabria, Italy
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12
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Njoroge JN, Cheema B, Ambrosy AP, Greene SJ, Collins SP, Vaduganathan M, Mebazaa A, Chioncel O, Butler J, Gheorghiade M. Expanded algorithm for managing patients with acute decompensated heart failure. Heart Fail Rev 2019; 23:597-607. [PMID: 29611010 DOI: 10.1007/s10741-018-9697-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure is a complex disease process, the manifestation of various cardiac and noncardiac abnormalities. General treatment approaches for heart failure have remained the same over the past decades despite the advent of novel therapies and monitoring modalities. In the same vein, the readmission rates for heart failure patients remain high and portend a poor prognosis for morbidity and mortality. In this context, development and implementation of improved algorithms for assessing and treating HF patients during hospitalization remains an unmet need. We propose an expanded algorithm for both monitoring and treating patients admitted for acute decompensated heart failure with the goal to improve post-discharge outcomes and decrease rates of rehospitalizations.
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Affiliation(s)
- Joyce N Njoroge
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Baljash Cheema
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Andrew P Ambrosy
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Stephen J Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Sean P Collins
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, Inserm U942, Hôpitaux Universitaires Saint-Louis-Lariboisière, Paris, France.,University Paris Diderot, Paris, France
| | - Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases "Prof C.C.Iliescu", Bucharest, Romania.,University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Javed Butler
- Department of Medicine, University of Mississippi, Oxford, MS, USA
| | - Mihai Gheorghiade
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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13
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Zeglinski MR, Moghadam AR, Ande SR, Sheikholeslami K, Mokarram P, Sepehri Z, Rokni H, Mohtaram NK, Poorebrahim M, Masoom A, Toback M, Sareen N, Saravanan S, Jassal DS, Hashemi M, Marzban H, Schaafsma D, Singal P, Wigle JT, Czubryt MP, Akbari M, Dixon IM, Ghavami S, Gordon JW, Dhingra S. Myocardial Cell Signaling During the Transition to Heart Failure. Compr Physiol 2018; 9:75-125. [DOI: 10.1002/cphy.c170053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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14
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Bobrovitz N, Heneghan C, Onakpoya I, Fletcher B, Collins D, Tompson A, Lee J, Nunan D, Fisher R, Scott B, O’Sullivan J, Van Hecke O, Nicholson BD, Stevens S, Roberts N, Mahtani KR. Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments. BMC Med 2018; 16:115. [PMID: 30045724 PMCID: PMC6060538 DOI: 10.1186/s12916-018-1104-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/19/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Rates of emergency hospitalisations are increasing in many countries, leading to disruption in the quality of care and increases in cost. Therefore, identifying strategies to reduce emergency admission rates is a key priority. There have been large-scale evidence reviews to address this issue; however, there have been no reviews of medication therapies, which have the potential to reduce the use of emergency health-care services. The objectives of this study were to review systematically the evidence to identify medications that affect emergency hospital admissions and prioritise therapies for quality measurement and improvement. METHODS This was a systematic review of systematic reviews. We searched MEDLINE, PubMed, the Cochrane Database of Systematic Reviews & Database of Abstracts of Reviews of Effects, Google Scholar and the websites of ten major funding agencies and health charities, using broad search criteria. We included systematic reviews of randomised controlled trials that examined the effect of any medication on emergency hospital admissions among adults. We assessed the quality of reviews using AMSTAR. To prioritise therapies, we assessed the quality of trial evidence underpinning meta-analysed effect estimates and cross-referenced the evidence with clinical guidelines. RESULTS We identified 140 systematic reviews, which included 1968 unique randomised controlled trials and 925,364 patients. Reviews contained 100 medications tested in 47 populations. We identified high-to moderate-quality evidence for 28 medications that reduced admissions. Of these medications, 11 were supported by clinical guidelines in the United States, the United Kingdom and Europe. These 11 therapies were for patients with heart failure (angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists and digoxin), stable coronary artery disease (intensive statin therapy), asthma exacerbations (early inhaled corticosteroids in the emergency department and anticholinergics), chronic obstructive pulmonary disease (long-acting muscarinic antagonists and long-acting beta-2 adrenoceptor agonists) and schizophrenia (second-generation antipsychotics and depot/maintenance antipsychotics). CONCLUSIONS We identified 11 medications supported by strong evidence and clinical guidelines that could be considered in quality monitoring and improvement strategies to help reduce emergency hospital admission rates. The findings are relevant to health systems with a large burden of chronic disease and those managing increasing pressures on acute health-care services.
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Affiliation(s)
- Niklas Bobrovitz
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Benjamin Fletcher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - Dylan Collins
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Alice Tompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joseph Lee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - David Nunan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Rebecca Fisher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- The Health Foundation, London, United Kingdom
| | - Brittney Scott
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada
| | - Jack O’Sullivan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Oliver Van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - Brian D. Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - Sarah Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - Nia Roberts
- Bodelian Libraries, University of Oxford, Oxford, UK
| | - Kamal R. Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
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15
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Millen AME, Woodiwiss AJ, Gomes M, Michel F, Norton GR. Systemic Angiotensinogen Concentrations Are Independently Associated With Left Ventricular Diastolic Function in a Community Sample. Am J Hypertens 2018; 31:212-219. [PMID: 28985347 DOI: 10.1093/ajh/hpx156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/16/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Left ventricular (LV) diastolic dysfunction characterizes heart failure with a preserved ejection fraction. Although it is recognized that the renin-angiotensin-aldosterone system (RAAS) decreases LV diastolic function, whether systemic angiotensinogen (AGT) contributes to these effects is uncertain. Hence, the aim was to determine the relationship between systemic AGT concentrations and LV diastolic function. METHODS LV diastolic function was determined from the mean of the lateral and septal wall myocardial tissue lengthening at the mitral annulus (average e') and from the ratio of early transmitral blood flow velocity (E) to average e' (E/e') in 445 Black African participants from a community sample. RESULTS In multivariate regression models with adjustments for age, sex, waist circumference diabetes mellitus, alcohol and tobacco use, hypertension treatment, systolic blood pressure (BP), and relative wall thickness, the square root of serum AGT concentrations was independently associated with E/e' (partial r (95% confidence interval [CI]) = 0.11 (0.02-0.21), P = 0.04), but not with average e' (partial r (95% CI) = -0.06 (-0.15 to 0.04), P = 0.25). There was no association between plasma renin concentrations and markers of diastolic function (all P > 0.05). CONCLUSION Circulating AGT concentrations are associated with LV diastolic function beyond BP and other confounders in an African population. Hence, through circulating AGT, the systemic RAAS may play an important role in contributing to LV diastolic function in Black Africans.
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Affiliation(s)
- Aletta M E Millen
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Angela J Woodiwiss
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Monica Gomes
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Frederic Michel
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Gavin R Norton
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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16
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Jiang YM, Song TR, Qiu Y, Liu JP, Wang XD, Huang ZL, Lin T. Effect of renin-angiotensin system inhibitors on survival in kidney transplant recipients: A systematic review and meta-analysis. Kaohsiung J Med Sci 2018; 34:1-13. [PMID: 29310811 DOI: 10.1016/j.kjms.2017.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 05/10/2017] [Accepted: 07/27/2017] [Indexed: 11/25/2022] Open
Abstract
Renin-angiotensin system inhibitors, specifically angiotensin II converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB), have confirmed renoprotective benefits in patients with proteinuria and hypertension. However, it remains controversial whether these agents are beneficial to kidney recipients. We conducted this meta-analysis to evaluate the effects of ACEI/ARB treatment on patient and allograft survival after kidney transplant. The PubMed, Embase and Cochrane Library databases were searched for eligible articles from before May 2016, and we included 24 articles (9 randomised controlled trials [RCTs] and 15 cohort studies with 54,096 patients), in which patient or graft survival was compared between an ACEI/ARB treatment arm and a control arm. Pooled results showed that ACEI/ARB was associated with decreased risks of patient death (relative risk [RR] = 0.64; 95% confidence interval [CI]:0.49-0.84) and graft loss (RR = 0.59; 95%CI:0.47-0.74). Subgroup analysis of the cohorts revealed significantly reduced patient death (RR = 0.61; 95%CI:0.50-0.74) and graft loss (RR = 0.58; 95%CI:0.46-0.73), but this was not seen in RCTs (patient survival: RR = 0.84, 95%CI:0.39-1.81; graft survival: RR = 0.70, 95%CI:0.17-2.79). Significantly less graft loss was noted among patients with biopsy-proved chronic allograft nephropathy (CAN) (RR = 0.26, 95%CI:0.16-0.44). Furthermore, the benefit of ACEI/ARB on patient survival (RR = 0.62; 95%CI:0.47-0.83) and graft survival (RR = 0.58, 95%CI:0.47-0.71) was limited to those with ≥3years' follow-up. ACEI/ARB decreased proteinuria (P < 0.001) and lowered haemoglobin (P = 0.002), but the haemoglobin change requires no additional treatment (from 119-131 g/L to 107-123 g/L). We therefore concluded that ACEI/ARB treatment may reduce patient death and graft loss, but additional well-designed prospective studies are needed to validate these findings.
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Affiliation(s)
- Ya-Mei Jiang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tu-Run Song
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yang Qiu
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin-Peng Liu
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xian-Ding Wang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhong-Li Huang
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Lin
- Department of Urology, Urology Institute and Organ Transplantation Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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17
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Leong DP, Joseph PG, McKee M, Anand SS, Teo KK, Schwalm JD, Yusuf S. Reducing the Global Burden of Cardiovascular Disease, Part 2: Prevention and Treatment of Cardiovascular Disease. Circ Res 2017; 121:695-710. [PMID: 28860319 DOI: 10.1161/circresaha.117.311849] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In this second part of a 2-part series on the global burden of cardiovascular disease, we review the proven, effective approaches to the prevention and treatment of cardiovascular disease. We specifically review the management of acute cardiovascular diseases, including acute coronary syndromes and stroke; the care of cardiovascular disease in the ambulatory setting, including medical strategies for vascular disease, atrial fibrillation, and heart failure; surgical strategies for arterial revascularization, rheumatic and other valvular heart disease, and symptomatic bradyarrhythmia; and approaches to the prevention of cardiovascular disease, including lifestyle factors, blood pressure control, cholesterol-lowering, antithrombotic therapy, and fixed-dose combination therapy. We also discuss cardiovascular disease prevention in diabetes mellitus; digital health interventions; the importance of socioeconomic status and universal health coverage. We review building capacity for conduction cardiovascular intervention through strengthening healthcare systems, priority setting, and the role of cost effectiveness.
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Affiliation(s)
- Darryl P Leong
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.).
| | - Philip G Joseph
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Martin McKee
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Sonia S Anand
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Koon K Teo
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Jon-David Schwalm
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
| | - Salim Yusuf
- From the Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada (D.P.L., P.G.J., S.S.A., K.K.T., J.-D.S., S.Y.); and London School of Hygiene and Tropical Medicine, United Kingdom (M.M.)
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18
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Burnett H, Earley A, Voors AA, Senni M, McMurray JJV, Deschaseaux C, Cope S. Thirty Years of Evidence on the Efficacy of Drug Treatments for Chronic Heart Failure With Reduced Ejection Fraction: A Network Meta-Analysis. Circ Heart Fail 2017; 10:e003529. [PMID: 28087688 PMCID: PMC5265698 DOI: 10.1161/circheartfailure.116.003529] [Citation(s) in RCA: 151] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/15/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treatments that reduce mortality and morbidity in patients with heart failure with reduced ejection fraction, including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), β-blockers (BB), mineralocorticoid receptor antagonists (MRA), and angiotensin receptor-neprilysin inhibitors (ARNI), have not been studied in a head-to-head fashion. This network meta-analysis aimed to compare the efficacy of these drugs and their combinations regarding all-cause mortality in patients with heart failure with reduced ejection fraction. METHODS AND RESULTS A systematic literature review identified 57 randomized controlled trials published between 1987 and 2015, which were compared in terms of study and patient characteristics, baseline risk, outcome definitions, and the observed treatment effects. Despite differences identified in terms of study duration, New York Heart Association class, ejection fraction, and use of background digoxin, a network meta-analysis was considered feasible and all trials were analyzed simultaneously. The random-effects network meta-analysis suggested that the combination of ACEI+BB+MRA was associated with a 56% reduction in mortality versus placebo (hazard ratio 0.44, 95% credible interval 0.26-0.66); ARNI+BB+MRA was associated with the greatest reduction in all-cause mortality versus placebo (hazard ratio 0.37, 95% credible interval 0.19-0.65). A sensitivity analysis that did not account for background therapy suggested that ARNI monotherapy is more efficacious than ACEI or ARB monotherapy. CONCLUSIONS The network meta-analysis showed that treatment with ACEI, ARB, BB, MRA, and ARNI and their combinations were better than the treatment with placebo in reducing all-cause mortality, with the exception of ARB monotherapy and ARB plus ACEI. The combination of ARNI+BB+MRA resulted in the greatest mortality reduction.
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Affiliation(s)
- Heather Burnett
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.).
| | - Amy Earley
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Adriaan A Voors
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Michele Senni
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - John J V McMurray
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Celine Deschaseaux
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Shannon Cope
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
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19
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Shireman TI, Mahnken JD, Phadnis MA, Ellerbeck EF, Wetmore JB. Comparative Effectiveness of Renin-Angiotensin System Antagonists in Maintenance Dialysis Patients. Kidney Blood Press Res 2016; 41:873-885. [PMID: 27871075 DOI: 10.1159/000452590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2016] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND/AIMS Whether angiotensin converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) are differentially associated with reductions in cardiovascular events and mortality in patients receiving maintenance dialysis is uncertain. We compared outcomes between ACE and ARB users among hypertensive, maintenance dialysis patients. METHODS National retrospective cohort study of hypertensive, Medicare-Medicaid eligible patients initiating chronic dialysis between 1/1/2000 to 12/31/2005. The exposure of interest was new use of either an ACEI or ARB. Outcomes were all-cause mortality (ACM) and combined cardiovascular hospitalization or death (CV-endpoint). Cox proportion hazards models were used to compare the effect of ACEI vs ARB use on ACM and, separately, CV-endpoint. RESULTS ACM models were based on 3,555 ACEI and 1,442 ARB new users, while CV-endpoint models included 3,289 ACEI and 1,346 ARB new users. After statistical adjustments, ACEI users had higher hazard ratios for ACM (AHR = 1.22, 99% CI 1.05-1.42) and CV-endpoint (AHR = 1.12, 99% CI 0.99-1.27). CONCLUSIONS Patients initiating maintenance dialysis who received an ACEI faced an increased risk for mortality and a trend towards an increased risk for CV-endpoints when compared to patients who received an ARB. Validation of these results in a rigorous clinical trial is warranted.
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Affiliation(s)
- Theresa I Shireman
- Center for Gerontology & Health Care Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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20
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Gromotowicz-Poplawska A, Szoka P, Kolodziejczyk P, Kramkowski K, Wojewodzka-Zelezniakowicz M, Chabielska E. New agents modulating the renin-angiotensin-aldosterone system-Will there be a new therapeutic option? Exp Biol Med (Maywood) 2016; 241:1888-1899. [PMID: 27439538 DOI: 10.1177/1535370216660211] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/22/2016] [Indexed: 12/19/2022] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) is more complex than it was originally regarded. According to the current subject knowledge, there are two main axes of the RAAS: (1) angiotensin-converting enzyme (ACE)-angiotensin II-AT1 receptor axis and (2) ACE2-angiotensin-(1-7)-Mas receptor axis. The activation of the first axis leads to deleterious effects, including vasoconstriction, endothelial dysfunction, thrombosis, inflammation, and fibrosis; therefore, blocking the components of this axis is a highly rational and commonly used therapeutic procedure. The ACE2-Ang-(1-7)-Mas receptor axis has a different role, since it often opposes the effects induced by the classical ACE-Ang II-AT1 axis. Once the positive effects of the ACE2-Ang-(1-7)-Mas axis were discovered, the alternative ways of pharmacotherapy activating this axis of RAAS appeared. This article briefly describes new molecules affecting the RAAS, namely: recombinant human ACE2, ACE2 activators, angiotensin-(1-7) peptide and non-peptide analogs, aldosterone synthase inhibitors, and the third and fourth generation of mineralocorticoid receptor antagonists. The results of the experimental and clinical studies are encouraging, which leads us to believe that these new molecules can support the treatment of cardiovascular diseases as well as cardiometabolic disorders.
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Affiliation(s)
| | - Piotr Szoka
- Department of Biopharmacy, Medical University of Bialystok, 15-089 Bialystok, Poland
| | - Patrycjusz Kolodziejczyk
- Department of Pharmaceutical Analysis, Medical University of Bialystok, 15-522 Bialystok, Poland
| | - Karol Kramkowski
- Department of Biopharmacy, Medical University of Bialystok, 15-089 Bialystok, Poland
| | | | - Ewa Chabielska
- Department of Biopharmacy, Medical University of Bialystok, 15-089 Bialystok, Poland
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21
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DENG FUXUE, XIA YONG, FU MICHAEL, HU YUNFENG, JIA FANG, RAHARDJO YEFFRY, DUAN YINGYI, HE LINJING, CHANG JING. Influence of heart failure on the prognosis of patients with acute myocardial infarction in southwestern China. Exp Ther Med 2016; 11:2127-2138. [PMID: 27284294 PMCID: PMC4887864 DOI: 10.3892/etm.2016.3211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 12/21/2015] [Indexed: 12/13/2022] Open
Abstract
The impact of heart failure (HF) on acute myocardial infarction (AMI) in patients from southwestern China remains unclear. The present study aimed to compare in-hospital cardiovascular events, mortality and clinical therapies in AMI patients with or without HF in southwestern China. In total, 591 patients with AMI hospitalized between February 2009 and December 2012 were examined; those with a history of HF were excluded. The patients were divided into four groups according to AMI type (ST-elevated or non-ST-elevated AMI) and the presence of HF during hospitalization. Clinical characteristics, in-hospital cardiovascular events, mortality, coronary angiography and treatment were compared. Clinical therapies, specifically evidence-based drug use were analyzed in patients with HF during hospitalization, including angiotensin converting enzyme inhibitors (ACEIs) and β-blockers (BBs). AMI patients with HF had a higher frequency of co-morbidities, lower left ventricular ejection fraction, longer length of hospital stay and a greater risk of in-hospital mortality compared with AMI patients without HF. AMI patients with HF were less likely to be examined by cardiac angiography or treated with reperfusion therapy or recommended medications. AMI patients with HF co-treated with ACEIs and BBs had a significantly higher survival rate (94.4 vs. 67.5%; P<0.001) compared with untreated patients or patients treated with either ACEIs or BBs alone. Logistic regression analysis revealed that HF and cardiogenic shock in patients with AMI were the strongest predictors of in-hospital mortality. AMI patients with HF were at a higher risk of adverse outcomes. Cardiac angiography and timely standard recommended medications were associated with improved clinical outcomes.
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Affiliation(s)
- FUXUE DENG
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 404100, P.R. China
| | - YONG XIA
- Heart & Lung Research Institute, The Ohio State University College of Medicine, Columbus, OH 43210, USA
| | - MICHAEL FU
- Section of Cardiology, Sahlgrenska University Hospital/Östra Hospital, Gothenburg 40530, Sweden
| | - YUNFENG HU
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 404100, P.R. China
| | - FANG JIA
- Department of Internal Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 404100, P.R. China
| | - YEFFRY RAHARDJO
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 404100, P.R. China
| | - YINGYI DUAN
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 404100, P.R. China
| | - LINJING HE
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 404100, P.R. China
| | - JING CHANG
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 404100, P.R. China
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22
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Guo WQ, Li L. Angiotensin converting enzyme inhibitors for heart failure with reduced ejection fraction or left ventricular dysfunction: A complementary network meta-analyses. Int J Cardiol 2016; 214:10-2. [PMID: 27055158 DOI: 10.1016/j.ijcard.2016.03.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/20/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Wen-Qin Guo
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lang Li
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China.
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