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Jamil YA, Cohen R, Alameddine DK, Deo SV, Kumar M, Orkaby AR. Cholesterol Lowering in Older Adults: Should We Wait for Further Evidence? Curr Atheroscler Rep 2024; 26:521-536. [PMID: 38958924 DOI: 10.1007/s11883-024-01224-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW Current guidelines for primary and secondary prevention of cardiovascular events in adults up to age 75 years are well-established. However, recommendations for lipid-lowering therapies (LLT), particularly for primary prevention, are inconclusive after age 75. In this review, we focus on adults ≥ 75 years to assess low-density lipoprotein-cholesterol (LDL-C) as a marker for predicting atherosclerotic cardiovascular disease (ASCVD) risk, review risk assessment tools, highlight guidelines for LLT, and discuss benefits, risks, and deprescribing strategies. RECENT FINDINGS The relationship between LDL-C and all-cause mortality and cardiovascular outcomes in older adults is complex and confounded. Current ASCVD risk estimators heavily depend on age and lack geriatric-specific variables. Emerging tools may reclassify individuals based on biologic rather than chronologic age, with coronary artery calcium scores gaining popularity. After initiating LLT for primary or secondary prevention, target LDL-C levels for older adults are lacking, and non-statin therapy thresholds remain unknown, relying on evidence from younger populations. Shared decision-making is crucial, considering therapy's time to benefit, life expectancy, adverse events, and geriatric syndromes. Deprescribing is recommended in end-of-life care but remains unclear in fit or frail older adults. After an ASCVD event, LLT is appropriate for most older adults, and deprescribing can be considered for those approaching the last months of life. Ongoing trials will guide statin prescription and deprescribing among older adults free of ASCVD. In the interim, for adults ≥ 75 years without a limited life expectancy who are free of ASCVD, an LLT approach that includes both lifestyle and medications, specifically statins, may be considered after shared decision-making.
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Affiliation(s)
- Yasser A Jamil
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Dana K Alameddine
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Salil V Deo
- Cleveland VA Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Manish Kumar
- Albert Einstien College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Ariela R Orkaby
- New England GRECC (Geriatric Research, Education, and Clinical Center), VA Boston Healthcare System, 150 S Huntington St, Boston, MA, 02130, USA.
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Abrignani MG, Lucà F, Abrignani V, Pelaggi G, Aiello A, Colivicchi F, Fattirolli F, Gulizia MM, Nardi F, Pino PG, Parrini I, Rao CM. A Look at Primary and Secondary Prevention in the Elderly: The Two Sides of the Same Coin. J Clin Med 2024; 13:4350. [PMID: 39124617 PMCID: PMC11312802 DOI: 10.3390/jcm13154350] [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: 05/08/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 08/12/2024] Open
Abstract
The global population is experiencing an aging trend; however, this increased longevity is not necessarily accompanied by improved health in older age. A significant consequence of this demographic shift is the rising prevalence of multiple chronic illnesses, posing challenges to healthcare systems worldwide. Aging is a major risk factor for multimorbidity, which marks a progressive decline in resilience and a dysregulation of multisystem homeostasis. Cardiovascular risk factors, along with aging and comorbidities, play a critical role in the development of heart disease. Among comorbidities, age itself stands out as one of the most significant risk factors for cardiovascular disease, with its prevalence and incidence notably increasing in the elderly population. However, elderly individuals, especially those who are frail and have multiple comorbidities, are under-represented in primary and secondary prevention trials aimed at addressing traditional cardiovascular risk factors, such as hypercholesterolemia, diabetes mellitus, and hypertension. There are concerns regarding the optimal intensity of treatment, taking into account tolerability and the risk of drug interactions. Additionally, uncertainty persists regarding therapeutic targets across different age groups. This article provides an overview of the relationship between aging and cardiovascular disease, highlighting various cardiovascular prevention issues in the elderly population.
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Affiliation(s)
| | - Fabiana Lucà
- O.U. Interventional Cardiology, Bianchi Melacrino Morelli Hospital, 89124 Reggio Calabria, Italy; (F.L.)
| | - Vincenzo Abrignani
- Internal Medicine and Stroke Care Ward, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, 90141 Palermo, Italy
| | - Giuseppe Pelaggi
- O.U. Interventional Cardiology, Bianchi Melacrino Morelli Hospital, 89124 Reggio Calabria, Italy; (F.L.)
| | | | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, 00135 Rome, Italy
| | - Francesco Fattirolli
- Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, 50121 Firenze, Italy
| | | | - Federico Nardi
- O.U. Cardiology, Santo Spirito Hospital, 15033 Casale Monferrato, Italy;
| | | | - Iris Parrini
- Cardiology Department, Mauriziano Umberto I Hospital, 10128 Turin, Italy
| | - Carmelo Massimiliano Rao
- O.U. Interventional Cardiology, Bianchi Melacrino Morelli Hospital, 89124 Reggio Calabria, Italy; (F.L.)
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Nabuchi M, Doi T, Hatano R, Tsuzuki T, Komuro K, Iwano H, Nagahara D, Yuda S, Hashimoto A, Nakata T. Impairment of Cognitive Function Increases Mortality Risk in Relation to Cardiac Sympathetic Denervation and Renal Dysfunction in Patients With Systolic Heart Failure. Circ J 2024:CJ-24-0124. [PMID: 38972736 DOI: 10.1253/circj.cj-24-0124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
BACKGROUND In contrast to the well-known prognostic values of the cardiorenal linkage, it remains unclear whether impaired cognitive function affects cardiac prognosis in relation to cardiac sympathetic innervation and renal function in patients with heart failure (HF).Methods and Results: A total of 433 consecutive HF patients with left ventricular ejection fraction (LVEF) <50% underwent the Mini-Mental State Examination (MMSE) and a neuropsychological test for screening of cognition impairment or subclinical dementia. Following metaiodobenzylguanidine (MIBG) scintigraphy, patient outcomes with a primary endpoint of lethal cardiac events (CEs) were evaluated for a mean period of 14.8 months. CEs were documented in 84 HF patients during follow-up. MMSE score, estimated glomerular filtration rate (eGFR) and standardized heart-to-mediastinum ratio of MIBG activity (sHMR) were significantly reduced in patients with CEs compared with patients without CEs. Furthermore, overall multivariate analysis revealed that these parameters were significant independent determinants of CEs. The cutoff values of MMSE score (<26), sHMR (<1.80) and eGFR (<47.0 mL/min/1.73 m2) determined by receiver operating characteristic (ROC) analysis successfully differentiated HF patients at more increased risk for CEs from other HF patients. CONCLUSIONS Impairment of cognitive function is not only independently related to but also synergistically increases cardiac mortality risk in association with cardiac sympathetic function and renal function in patients with HF.
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Affiliation(s)
| | - Takahiro Doi
- Department of Cardiology, Teine Keijinkai Hospita
| | | | - Taro Tsuzuki
- Department of Cardiology, Teine Keijinkai Hospita
| | - Kaoru Komuro
- Department of Cardiology, Teine Keijinkai Hospita
| | | | | | - Satoshi Yuda
- Department of Cardiology, Teine Keijinkai Hospita
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University Hospital
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Iankov S, Sikand A, Chowdhury J, Spence JD, Jang SA, Sohrevardi SM, Hackam DG, Azarpazhooh MR. Effect of lipid-lowering therapy on carotid plaque burden in older adults. J Neurol Sci 2024; 461:123023. [PMID: 38718551 DOI: 10.1016/j.jns.2024.123023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 04/02/2024] [Accepted: 04/28/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Little is known about the benefits of lipid-lowering medications in those age ≥ 75 years. We assessed the effect of lipid-lowering medications on progression to severe atherosclerosis in patients age > 75. METHODS Data was retrospectively obtained from the Stroke Prevention & Atherosclerosis Research Centre, Canada. Atherosclerosis burden was measured as carotid total plaque area (TPA), a powerful predictor of cardiovascular risk. Survival time free of severe atherosclerosis (SFSA) was defined as the period when TPA remained <1.19 cm2. Kaplan-Meier, multiple Cox proportional hazard and hierarchical mixed-effect models were used to determine the effects of lipid-lowering medications on progression to severe atherosclerosis. RESULTS In total 1404 cases (mean age 81 ± 4 years; women 52%) were included. Those taking lipid-lowering medications were more likely to have a history of diabetes and a higher burden of atherosclerosis at baseline. In Kaplan-Meier analysis, the SFSA was significantly longer in those receiving lipid-lowering therapy. In multivariable-adjusted analyses, those not receiving lipid lowering therapy (irrespective of their vascular disease at baseline) were more likely to have TPA > 1.19 cm2 (hazard ratio (HR) = 1.37, 95% confidence interval (CI): 1.09,0.71). Similar findings were observed in mixed effects models when plaque progression was defined as any change >0.05 cm2 per year (odds ratio (OR):2.17, 95% CI:1.38,3.57). CONCLUSION Lipid-lowering therapy is effective in controlling the burden of atherosclerosis among older adults with and without vascular disease. The measurement of plaque burden can guide selection and follow-up of those who may benefit from treatment.
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Affiliation(s)
- Stella Iankov
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
| | - Aditya Sikand
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
| | - Joy Chowdhury
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - J David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; Division of Clinical Pharmacology, Department of Medicine, Western University, London, Ontario, Canada.
| | - Shahram Arsang Jang
- Department of Biostatistics and Epidemiology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Seyed Mojtaba Sohrevardi
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Daniel G Hackam
- Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Shahid Sadoughi University of Medical Sciences, Yazd, Iran..
| | - M Reza Azarpazhooh
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; Department of Neuroscience, Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
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Walker AJ, Zhu J, Thoma F, Marroquin O, Makani A, Gulati M, Gianos E, Virani SS, Rodriguez F, Reis SE, Ballantyne C, Mulukutla S, Saeed A. Statin utilization and cardiovascular outcomes in a real-world primary prevention cohort of older adults. Am J Prev Cardiol 2024; 18:100664. [PMID: 38665251 PMCID: PMC11043821 DOI: 10.1016/j.ajpc.2024.100664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/25/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Background Statins are a cost-effective therapy for prevention of atherosclerotic cardiovascular disease (ASCVD). Guidelines on statins for primary prevention are unclear for older adults (>75 years). Objective Investigate statin utility in older adults without ASCVD events, by risk stratifying in a large healthcare network. Methods We included 8,114 older adults, without CAD, PVD or ischemic stroke. Statin utilization based on ACC/AHA 10-year ASCVD risk calculation, was evaluated in intermediate (7.5%-19.9%) and high-risk patients (≥ 20%); and categorized using low and 'moderate or high' intensity statins with a follow up period of ∼7 years. Cox regression models were used to calculate hazard ratios for incident ASCVD and mortality across risk categories stratified by statin utilization. Data was adjusted for competing risk using Elixhauser Comorbidity Index. Results Compared with those on moderate or high intensity statins, high-risk older patients not on any statin had a significantly increased risk of MI [HR 1.51 (1.17-1.95); p<0.01], stroke [HR 1.47 (1.14-1.90); p<0.01] and all-cause mortality [HR 1.37 (1.19-1.58); p<0.001] in models adjusted for Elixhauser Comorbidity Index. When comparing the no statin group versus the moderate or high intensity statin group in the intermediate risk cohort, although a trend for increased risk was seen, it did not meet statistical significance thresholds for MI, stroke or all-cause mortality. Conclusion Lack of statin use was associated with increased cardiovascular events and mortality in high-risk older adults. Given the benefits appreciated, statin use may need to be strongly considered for primary ASCVD prevention among high-risk older adults. Future studies will assess the risk-benefit ratio of statin intervention in older adults.
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Affiliation(s)
- Aaron J. Walker
- Florida State University College of Medicine, Tallahassee, FL, United States
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jianhui Zhu
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Floyd Thoma
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Oscar Marroquin
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Amber Makani
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Martha Gulati
- Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | | | | | | | - Steven E. Reis
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | | | - Suresh Mulukutla
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Anum Saeed
- University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Sergeant M, Ly O, Kandasamy S, Anand SS, de Souza RJ. Managing greenhouse gas emissions in the terminal year of life in an overwhelmed health system: a paradigm shift for people and our planet. Lancet Planet Health 2024; 8:e327-e333. [PMID: 38729672 DOI: 10.1016/s2542-5196(24)00048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/14/2024] [Accepted: 03/22/2024] [Indexed: 05/12/2024]
Abstract
Health care contributes 4·4% of global net carbon emissions. Hospitals are resource-intensive settings, using a large amount of supplies in patient care and have high energy, ventilation, and heating needs. This Viewpoint investigates emissions related to health care in a patient's last year of life. End of life (EOL) is a period when health-care use and associated emissions production increases exponentially due primarily to hospital admissions, which are often at odds with patients' values and preferences. Potential solutions detailed within this Viewpoint are facilitating advanced care plans with patients to ensure their EOL wishes are clear, beginning palliative care interventions earlier when treating a life-limiting illness, deprescribing unnecessary medications because medications and their supply chains make up a significant portion of health-care emissions, and, enhancing access to low-intensity community care settings (eg, hospices) within the last year of life if home care is not available. Our analysis was done using Canadian data, but the findings can be applied to other high-income countries.
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Affiliation(s)
- Myles Sergeant
- Department of Family Medicine, Michael G DeGroote School of Medicine, Hamilton, ON, Canada
| | - Olivia Ly
- Department of Family Medicine, Michael G DeGroote School of Medicine, Hamilton, ON, Canada
| | - Sujane Kandasamy
- Department of Child and Youth Studies, Brock University, St Catherine's, ON, Canada
| | - Sonia S Anand
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada.
| | - Russell J de Souza
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
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7
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Gjyriqi G, Gross A, Burns E, Gianos E, Sidhu MS, Mathew RO. Patterns of Statin Therapy Use and Associated Outcomes in Older Veterans Across Kidney Function. Am J Med 2024:S0002-9343(24)00173-6. [PMID: 38574795 DOI: 10.1016/j.amjmed.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 03/05/2024] [Accepted: 03/09/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Despite significant morbidity and mortality related to atherosclerotic cardiovascular disease, to date, most major clinical trials studying the effects of statin therapy have excluded older adults. The objective of this analysis was to evaluate the effect of initiating statin therapy on incident dementia and mortality among individuals 75 years of age or older across the complete spectrum of kidney function. METHODS We conducted a retrospective cohort study of 640,191 VA health system patients who turned 75 years of age between 2000 and 2018. Patients on statin therapy received the medication for an average of 6.3 years (standard deviation 4.6 years). The primary outcome of interest included incident dementia diagnosis during the study period. The secondary outcome was all-cause mortality. Cox proportional hazard analysis was used to evaluate the adjusted association of statin initiation with these outcomes. RESULTS There was a higher rate of incident dementia in the No Statin group (4.7%) vs the Statin group (3.2%). Additionally, we observed a 22% all-cause mortality benefit associated with statin therapy. We did not observe a treatment effect with respect to primary or secondary outcomes across varying levels of kidney function. CONCLUSION This large cohort study did not reveal an association between the initiation of statin therapy and incident dementia. A survival benefit was seen in statin users compared with nonusers. Prospective studies in more diverse populations including older adults will be needed to verify these findings.
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Affiliation(s)
- Grenita Gjyriqi
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | | | - Edith Burns
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Eugenia Gianos
- Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Mandeep S Sidhu
- Division of Cardiology, Department of Medicine and Department of Medical Education, Albany Medical College, Albany Med Health System, NY
| | - Roy O Mathew
- Department of Medicine, Loma Linda VA Health Care System, Calif
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Mésidor M, Sirois C, Guertin JR, Schnitzer ME, Candas B, Blais C, Cossette B, Poirier P, Brophy JM, Lix L, Tadrous M, Diop A, Hamel D, Talbot D. Effect of statin use for the primary prevention of cardiovascular disease among older adults: a cautionary tale concerning target trials emulation. J Clin Epidemiol 2024; 168:111284. [PMID: 38367659 DOI: 10.1016/j.jclinepi.2024.111284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 02/19/2024]
Abstract
OBJECTIVES Evidence concerning the effect of statins in primary prevention of cardiovascular disease (CVD) among older adults is lacking. Using Quebec population-wide administrative data, we emulated a hypothetical randomized trial including older adults >65 years on April 1, 2013, with no CVD history and no statin use in the previous year. STUDY DESIGN AND SETTING We included individuals who initiated statins and classified them as exposed if they were using statin at least 3 months after initiation and nonexposed otherwise. We followed them until March 31, 2018. The primary outcome was the composite endpoint of coronary events (myocardial infarction, coronary bypass, and percutaneous coronary intervention), stroke, and all-cause mortality. The intention-to-treat (ITT) effect was estimated with adjusted Cox models and per-protocol effect with inverse probability of censoring weighting. RESULTS A total of 65,096 individuals were included (mean age = 71.0 ± 5.5, female = 55.0%) and 93.7% were exposed. Whereas we observed a reduction in the composite outcome (ITT-hazard ratio (HR) = 0.75; 95% CI: 0.68-0.83) and mortality (ITT-HR = 0.69; 95% CI: 0.61-0.77) among exposed, coronary events increased (ITT-HR = 1.46; 95% CI: 1.09-1.94). All multibias E-values were low indicating that the results were not robust to unmeasured confounding, selection, and misclassification biases simultaneously. CONCLUSION We cannot conclude on the effectiveness of statins in primary prevention of CVD among older adults. We caution that an in-depth reflection on sources of biases and careful interpretation of results are always required in observational studies.
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Affiliation(s)
- Miceline Mésidor
- Département de médecine sociale et préventive, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec, Université Laval, Québec, Canada.
| | - Caroline Sirois
- Centre de recherche du CHU de Québec, Université Laval, Québec, Canada; Faculté de pharmacie, Université Laval, Québec, Canada; Institut national de santé publique du Québec, Québec, Canada
| | - Jason Robert Guertin
- Département de médecine sociale et préventive, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec, Université Laval, Québec, Canada
| | - Mireille E Schnitzer
- Faculté de pharmacie et Département de médecine sociale et préventive, Université de Montréal, Montréal, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada
| | - Bernard Candas
- Département de médecine sociale et préventive, Université Laval, Québec, Canada
| | - Claudia Blais
- Faculté de pharmacie, Université Laval, Québec, Canada; Institut national de santé publique du Québec, Québec, Canada
| | - Benoit Cossette
- Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Montréal, Canada
| | - Paul Poirier
- Faculté de pharmacie, Université Laval, Québec, Canada; Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Canada
| | - James M Brophy
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada; McGill University Hospital Center, Centre for Health Outcomes Research, Montréal, Canada
| | - Lisa Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Mina Tadrous
- University of Toronto, Leslie Dan Faculty of Pharmacy, Toronto, Canada
| | - Awa Diop
- Département de médecine sociale et préventive, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec, Université Laval, Québec, Canada
| | - Denis Hamel
- Institut national de santé publique du Québec, Québec, Canada
| | - Denis Talbot
- Département de médecine sociale et préventive, Université Laval, Québec, Canada; Centre de recherche du CHU de Québec, Université Laval, Québec, Canada
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9
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Zhou Z, Tonkin AM, Curtis AJ, Murray A, Zhu C, Reid CM, Williamson JD, Ryan J, McNeil JJ, Beilin LJ, Ernst ME, Stocks N, Lacaze P, Shah RC, Woods RL, Wolfe R, Gall S, Zoungas S, Orchard SG, Nelson MR. Low-Density-Lipoprotein Cholesterol and Mortality Outcomes Among Healthy Older Adults: A Post Hoc Analysis of ASPREE Trial. J Gerontol A Biol Sci Med Sci 2024; 79:glad268. [PMID: 38038339 PMCID: PMC10960624 DOI: 10.1093/gerona/glad268] [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] [Received: 08/21/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND The prognostic implication of cholesterol levels in older adults remains uncertain. This study aimed to examine the relationship between low-density-lipoprotein cholesterol (LDL-c) and mortality outcomes in older individuals. METHODS This post hoc analysis examined the associations of LDL-c levels with mortality risks from all-cause, cardiovascular disease (CVD), cancer, and combined non-CVD/noncancer conditions in a cohort of individuals aged ≥65 years from the ASPirin in Reducing Events in the Elderly trial (NCT01038583). At baseline, participants had no diagnosed dementia, physical disability, or CVD, and were not taking lipid-lowering agents. Outcome analyses were performed using multivariable Cox models. RESULTS We analyzed 12 334 participants (mean age: 75.2 years). Over a median 7-year follow-up, 1 250 died. Restricted cubic splines found a U-shaped relation for LDL-c and all-cause mortality, cancer mortality, and noncancer/non-CVE mortality (nadir: 3.3-3.4 mmol/L); the risk of CVD mortality was similar at LDL-c below 3.3 mmol/L and increased above 3.3 mmol/L. Similar trends were observed in analyses modeling LDL-c by quartiles. When modeling LDL-c as a continuous variable, the risk of all-cause mortality, cancer mortality, and noncancer/non-CVD mortality was decreased by 9%, 16%, and 18%, respectively, per 1-mmol/L higher LDL-c, and the risk of CVD mortality was increased by 19% per 1-mmol/L higher LDL-c. Reduced all-cause and non-CVD/noncancer mortality risks were only significant in males but not females (pinteraction < .05). CONCLUSIONS There were U-shaped relationships between LDL-c and all-cause mortality, cancer mortality, and noncancer/non-CVD mortality in healthy older adults. Higher LDL-c levels were associated with an increased risk of CVD mortality. Future studies are warranted to confirm our results.
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Affiliation(s)
- Zhen Zhou
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Andrew M Tonkin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrea J Curtis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anne Murray
- Berman Center for Outcomes and Clinical Research, Hennepin Healthcare Research Institute, Division of Geriatrics, Department of Medicine Hennepin HealthCare, Minneapolis, Minnesota, USA
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Chao Zhu
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Christopher M Reid
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Jeff D Williamson
- Sticht Center on Aging and Alzheimer’s Prevention, Section on Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Joanne Ryan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - John J McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lawrence J Beilin
- School of Medicine, Royal Perth Hospital, University of Western Australia, Perth, Western Australia, Australia
| | - Michael E Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA
- Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Nigel Stocks
- Discipline of General Practice, University of Adelaide, Adelaide, South Australia, Australia
| | - Paul Lacaze
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Raj C Shah
- Department of Family Medicine and Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Robyn L Woods
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Suzanne G Orchard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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10
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Zafari Z, Park JE, Shah CH, dosReis S, Gorman EF, Hua W, Ma Y, Tian F. The State of Use and Utility of Negative Controls in Pharmacoepidemiologic Studies. Am J Epidemiol 2024; 193:426-453. [PMID: 37851862 DOI: 10.1093/aje/kwad201] [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] [Received: 12/16/2022] [Revised: 07/27/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
Uses of real-world data in drug safety and effectiveness studies are often challenged by various sources of bias. We undertook a systematic search of the published literature through September 2020 to evaluate the state of use and utility of negative controls to address bias in pharmacoepidemiologic studies. Two reviewers independently evaluated study eligibility and abstracted data. Our search identified 184 eligible studies for inclusion. Cohort studies (115, 63%) and administrative data (114, 62%) were, respectively, the most common study design and data type used. Most studies used negative control outcomes (91, 50%), and for most studies the target source of bias was unmeasured confounding (93, 51%). We identified 4 utility domains of negative controls: 1) bias detection (149, 81%), 2) bias correction (16, 9%), 3) P-value calibration (8, 4%), and 4) performance assessment of different methods used in drug safety studies (31, 17%). The most popular methodologies used were the 95% confidence interval and P-value calibration. In addition, we identified 2 reference sets with structured steps to check the causality assumption of the negative control. While negative controls are powerful tools in bias detection, we found many studies lacked checking the underlying assumptions. This article is part of a Special Collection on Pharmacoepidemiology.
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11
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Domingo E, Marques P, Francisco V, Piqueras L, Sanz MJ. Targeting systemic inflammation in metabolic disorders. A therapeutic candidate for the prevention of cardiovascular diseases? Pharmacol Res 2024; 200:107058. [PMID: 38218355 DOI: 10.1016/j.phrs.2024.107058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/11/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
Cardiovascular disease (CVD) remains the leading cause of death and disability worldwide. While many factors can contribute to CVD, atherosclerosis is the cardinal underlying pathology, and its development is associated with several metabolic risk factors including dyslipidemia and obesity. Recent studies have definitively demonstrated a link between low-grade systemic inflammation and two relevant metabolic abnormalities: hypercholesterolemia and obesity. Interestingly, both metabolic disorders are also associated with endothelial dysfunction/activation, a proinflammatory and prothrombotic phenotype of the endothelium that involves leukocyte infiltration into the arterial wall, one of the earliest stages of atherogenesis. This article reviews the current literature on the intricate relationship between hypercholesterolemia and obesity and the associated systemic inflammation and endothelial dysfunction, and discusses the effectiveness of present, emerging and in-development pharmacological therapies used to treat these metabolic disorders with a focus on their effects on the associated systemic inflammatory state and cardiovascular risk.
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Affiliation(s)
- Elena Domingo
- Institute of Health Research INCLIVA, University Clinic Hospital of Valencia, Valencia, Spain; Department of Pharmacology, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | - Patrice Marques
- Institute of Health Research INCLIVA, University Clinic Hospital of Valencia, Valencia, Spain; Department of Pharmacology, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain
| | - Vera Francisco
- Institute of Health Research INCLIVA, University Clinic Hospital of Valencia, Valencia, Spain; Endocrinology and Nutrition Service, University Clinic Hospital of Valencia, Valencia, Spain
| | - Laura Piqueras
- Institute of Health Research INCLIVA, University Clinic Hospital of Valencia, Valencia, Spain; Department of Pharmacology, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; CIBERDEM, Spanish Biomedical Research Center in Diabetes and Associated Metabolic Disorders, Carlos III Health Institute (ISCIII), Spain.
| | - Maria-Jesus Sanz
- Institute of Health Research INCLIVA, University Clinic Hospital of Valencia, Valencia, Spain; Department of Pharmacology, Faculty of Medicine and Odontology, University of Valencia, Valencia, Spain; CIBERDEM, Spanish Biomedical Research Center in Diabetes and Associated Metabolic Disorders, Carlos III Health Institute (ISCIII), Spain.
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12
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Alif SM, Benke GP, Kromhout H, Vermeulen R, Tran C, Ronaldson K, Walker-Bone K, Woods R, Beilin L, Tonkin A, Owen AJ, McNeil JJ. Long-term occupational exposures on disability-free survival and mortality in older adults. Occup Med (Lond) 2023; 73:492-499. [PMID: 37948123 PMCID: PMC10756660 DOI: 10.1093/occmed/kqad105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND The impact of long-term occupational exposures on health in older adults is increasingly relevant as populations age. To date, no studies have reported their impact on survival free of disability in older adults. AIMS We aimed to investigate the association between long-term occupational exposure and disability-free survival (DFS), all-cause mortality and cause-specific mortality in initially healthy older adults. METHODS We analysed data from 12 215 healthy participants in the ASPirin in Reducing Events in the Elderly (ASPREE) study whose mean age was 75 years. Their work history was collated with the 'ALOHA-plus JEM' (Job Exposure Matrix) to assign occupational exposures. The primary endpoint, DFS, was a composite measure of death, dementia or persistent physical disability. The secondary endpoint, mortality, was classified according to the underlying cause. Cox proportional hazard models were used to calculate hazard ratios and 95% confidence intervals, adjusted for confounders. RESULTS A total of 1835 individuals reached the DFS endpoint during the median 4.7 years follow-up period. Both ever-high and cumulative exposure to all dusts and all pesticides during a person's working years were associated with reduced DFS. Compared to no exposure, men with high exposure to dusts and pesticides had a reduced DFS. Neither of these exposures were significantly associated with all-cause mortality. Men with high occupational exposure to solvents and women exposed to dusts experienced higher all-cause and cancer-related mortality. CONCLUSIONS Long-term occupational exposure to all dusts and pesticides was associated with a reduced DFS and increased mortality in community-dwelling healthy older adults.
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Affiliation(s)
- S M Alif
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
- School of Health Sciences, The University of Melbourne, Melbourne, Victoria 3000, Australia
- Institute of Health and Wellbeing, Federation University Australia, Berwick, Victoria 3806, Australia
| | - G P Benke
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
| | - H Kromhout
- Environmental Epidemiology Division, Institute for Risk Assessment Sciences, Utrecht University, 3584 CS Utrecht, The Netherlands
| | - R Vermeulen
- Environmental Epidemiology Division, Institute for Risk Assessment Sciences, Utrecht University, 3584 CS Utrecht, The Netherlands
| | - C Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
| | - K Ronaldson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
| | - K Walker-Bone
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
| | - R Woods
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
| | - L Beilin
- School of Medicine, The University of Western Australia, Perth, Western Australia 6009, Australia
| | - A Tonkin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
| | - A J Owen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
| | - J J McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria 3004, Australia
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13
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Cacciatore S, Spadafora L, Bernardi M, Galli M, Betti M, Perone F, Nicolaio G, Marzetti E, Martone AM, Landi F, Asher E, Banach M, Hanon O, Biondi-Zoccai G, Sabouret P. Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence. J Clin Med 2023; 12:5233. [PMID: 37629275 PMCID: PMC10455820 DOI: 10.3390/jcm12165233] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.
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Affiliation(s)
- Stefano Cacciatore
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy
| | - Matteo Betti
- University of Milan, 20122, Milan, Italy
- Monzino IRCCS Cardiological Center, 20137 Milan, Italy
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic “Villa delle Magnolie”, 81020 Castel Morrone, Caserta, Italy
| | - Giulia Nicolaio
- Department of Experimental and Clinical Medicine and Geriatrics, University of Florence, Azienda Ospedaliero Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, 50134 Florence, Italy
| | - Emanuele Marzetti
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Anna Maria Martone
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Francesco Landi
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Elad Asher
- The Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, P.O. Box 12271, Jerusalem 9112102, Israel
| | - Maciej Banach
- Department of Preventive Cardiology, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Medical University of Lodz (MUL), 93-338 Lodz, Poland
| | - Olivier Hanon
- Assistance Publique Hôpitaux de Paris, Geriatric Department, Broca Hospital, University of Paris Cité, 54–56 Rue Pascal, 75013 Paris, France
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100 Latina, Italy
- Mediterranea Cardiocentro, Via Orazio 2, 80122 Naples, Italy
| | - Pierre Sabouret
- Heart Institute, Pitié-Salpétrière Hospital, ACTION-Group, Sorbonne University, 47–83 Bd de l’Hôpital, 75013 Paris, France
- Department of Cardiology, National College of French Cardiologists, 13 Rue Niépce, 75014 Paris, France
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14
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Nanna MG, Sutton NR, Kochar A, Rymer JA, Lowenstern AM, Gackenbach G, Hummel SL, Goyal P, Rich MW, Kirkpatrick JN, Krishnaswami A, Alexander KP, Forman DE, Bortnick AE, Batchelor W, Damluji AA. A Geriatric Approach to Percutaneous Coronary Interventions in Older Adults, Part II: A JACC: Advances Expert Panel. JACC. ADVANCES 2023; 2:100421. [PMID: 37575202 PMCID: PMC10419335 DOI: 10.1016/j.jacadv.2023.100421] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/07/2023] [Indexed: 08/15/2023]
Abstract
We review a comprehensive risk assessment approach for percutaneous coronary interventions in older adults and highlight the relevance of geriatric syndromes within that broader perspective to optimize patient-centered outcomes in interventional cardiology practice. Reflecting the influence of geriatric principles in older adults undergoing percutaneous coronary interventions, we propose a "geriatric" heart team to incorporate the expertise of geriatric specialists in addition to the traditional heart team members, facilitate uptake of the geriatric risk assessment into the preprocedural risk assessment, and address ways to mitigate these geriatric risks. We also address goals of care in older adults, highlighting common priorities that can impact shared decision making among older patients, as well as frequently encountered pharmacotherapeutic considerations in the older adult population. Finally, we clarify gaps in current knowledge and describe crucial areas for future investigation.
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Affiliation(s)
| | - Nadia R. Sutton
- Department of Internal Medicine, Division of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Internal Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA
| | - Ajar Kochar
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Grace Gackenbach
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Scott L. Hummel
- University of Michigan School of Medicine and VA Ann Arbor Health System, Ann Arbor, Michigan, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Michael W. Rich
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - James N. Kirkpatrick
- Division of Cardiology, Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ashok Krishnaswami
- Division of Cardiology, Kaiser Permanente San Jose Medical Center, San Jose, California, USA
| | | | - Daniel E. Forman
- Divisions of Geriatrics and Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh GRECC, Pittsburgh, Pennsylvania, USA
| | - Anna E. Bortnick
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Abdulla A. Damluji
- Inova Center of Outcomes Research, Fairfax, Virginia, USA
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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15
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Zoungas S, Curtis A, Spark S, Wolfe R, McNeil JJ, Beilin L, Chong TTJ, Cloud G, Hopper I, Kost A, Nelson M, Nicholls SJ, Reid CM, Ryan J, Tonkin A, Ward SA, Wierzbicki A. Statins for extension of disability-free survival and primary prevention of cardiovascular events among older people: protocol for a randomised controlled trial in primary care (STAREE trial). BMJ Open 2023; 13:e069915. [PMID: 37012015 PMCID: PMC10083753 DOI: 10.1136/bmjopen-2022-069915] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
INTRODUCTION The world is undergoing a demographic transition to an older population. Preventive healthcare has reduced the burden of chronic illness at younger ages but there is limited evidence that these advances can improve health at older ages. Statins are one class of drug with the potential to prevent or delay the onset of several causes of incapacity in older age, particularly major cardiovascular disease (CVD). This paper presents the protocol for the STAtins in Reducing Events in the Elderly (STAREE) trial, a randomised double-blind placebo-controlled trial examining the effects of statins in community dwelling older people without CVD, diabetes or dementia. METHODS AND ANALYSIS We will conduct a double-blind, randomised placebo-controlled trial among people aged 70 years and over, recruited through Australian general practice and with no history of clinical CVD, diabetes or dementia. Participants will be randomly assigned to oral atorvastatin (40 mg daily) or matching placebo (1:1 ratio). The co-primary endpoints are disability-free survival defined as survival-free of dementia and persistent physical disability, and major cardiovascular events (cardiovascular death or non-fatal myocardial infarction or stroke). Secondary endpoints are all-cause death, dementia and other cognitive decline, persistent physical disability, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, heart failure, atrial fibrillation, fatal and non-fatal cancer, all-cause hospitalisation, need for permanent residential care and quality of life. Comparisons between assigned treatment arms will be on an intention-to-treat basis with each of the co-primary endpoints analysed separately in time-to-first-event analyses using Cox proportional hazards regression models. ETHICS AND DISSEMINATION STAREE will address uncertainties about the preventive effects of statins on a range of clinical outcomes important to older people. Institutional ethics approval has been obtained. All research outputs will be disseminated to general practitioner co-investigators and participants, published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT02099123.
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Affiliation(s)
- Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrea Curtis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Simone Spark
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - John J McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lawrence Beilin
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Trevor T-J Chong
- Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
| | - Geoffrey Cloud
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Ingrid Hopper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology and General Medicine Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Alissia Kost
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Nelson
- Menzies Research Institute, University of Tasmania, Hobart, Tasmania, Australia
| | - Stephen J Nicholls
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Victorian Heart Institute, Monash University, Clayton, Victoria, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
| | - Joanne Ryan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Tonkin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephanie A Ward
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
| | - Anthony Wierzbicki
- Metabolic Medicine/Chemical Pathology, Guy's and St Thomas' Hospitals, London, UK
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16
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Zhou K, Xiao J, Wang H, Ni B, Huang J, Long X. Estradiol regulates oxidative stress and angiogenesis of myocardial microvascular endothelial cells via the CDK1/CDK2 pathway. Heliyon 2023; 9:e14305. [PMID: 36942258 PMCID: PMC10023923 DOI: 10.1016/j.heliyon.2023.e14305] [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: 09/01/2022] [Revised: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 03/07/2023] Open
Abstract
Cardiovascular diseases remain the leading cause of death, morbidity, and disability. Recently, it has been reported that gonadal hormones such as estradiol can act on membrane receptors and activate intracellular signaling mechanisms, thereby altering cellular function. This study aims to explore the function and molecular mechanism of estradiol on cardiac microvascular endothelial cells (CMVECs). Estradiol had low toxicity to CMVECs. Hypoxia/reoxygenation (H/R) stimulation inhibited the proliferation and migration of CMVECs, while estradiol significantly promoted proliferation and migration. Estradiol inhibited il-1, IL6, and TNF-α secretion levels after H/R stimulation. Meanwhile, estradiol inhibits oxidative stress and promotes angiogenesis. Further, estradiol upregulated the gene and protein levels of cyclin-dependent kinases 1 (CDK1) and CDK2 after H/R stimulation. When knocking down CDK1 and CDK2 of CMVECs, estradiol did not affect the protein expression of Cyclin E1 and Cyclin D1. Meanwhile, the regulatory effect of estradiol on oxidative stress, angiogenesis, and inflammatory response was significantly weakened or even disappeared. In conclusion, estradiol mediates oxidative stress and angiogenesis of myocardial microvascular endothelial cells by regulating the CDK/cyclin signaling pathway.
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Affiliation(s)
- Ke Zhou
- Vasculocardiology Department, Chongqing University Central Hospital, Chongqing, 400014, China
| | - Jun Xiao
- Vasculocardiology Department, Chongqing University Central Hospital, Chongqing, 400014, China
- Corresponding author.
| | - Hao Wang
- Vasculocardiology Department, Chongqing University Central Hospital, Chongqing, 400014, China
| | - Bing Ni
- Institute of Immunology of Army Medical University, Chongqing, 400014, China
| | - Jietao Huang
- Vasculocardiology Department, Chongqing University Central Hospital, Chongqing, 400014, China
| | - Xueyuan Long
- Vasculocardiology Department, Chongqing University Central Hospital, Chongqing, 400014, China
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17
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Marcellaud E, Jost J, Tchalla A, Magne J, Aboyans V. Statins in Primary Prevention in People Over 80 Years. Am J Cardiol 2023; 187:62-73. [PMID: 36459749 DOI: 10.1016/j.amjcard.2022.10.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/24/2022] [Accepted: 10/06/2022] [Indexed: 11/30/2022]
Abstract
In the much older population (≥80 years), the management of cardiovascular diseases requires specific research to avoid a plain transposition of medical practice from younger populations. Whether statins are useful in primary prevention in this population is not clear. The 3 intricate issues requiring attention are (1) the impact of hypercholesterolemia on mortality and major adverse cardiovascular events in subjects >80 years, (2) the efficacy of statins to prevent cardiovascular events at this age, and (3) the safety and tolerance of statins in this population. Three systematic reviews were performed using a search on EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases including publication until January 2021. Among the 7,617 references identified, 29 were finally retained. Regarding the first objective (16 studies, 121,250 participants), 7 studies (10,241 participants) did not find total cholesterol and low-density lipoprotein levels associated with an increased rate of major cardiovascular events in octogenarians. A total of 6 studies (14,493 participants) found increased levels associated with events, whereas 3 studies (96,516 participants) found the opposite, with increased risk of major adverse cardiovascular events with lower levels of cholesterol. In 8 studies (436,005 participants) addressing the efficacy of statins, most did not indicate a significant decrease in the rate of major cardiovascular events in these subjects. Finally, regarding tolerance (9 studies, 217,088 participants), the most important side effects in this population were muscular, hepatic, and gastrointestinal disorders. These events were more frequent than in the younger population. In conclusion, in the absence of convincing evidence, the benefit of statins in primary prevention for much older patients is not certain. Their prescription in this setting should only be considered case by case, taking into consideration physiological status, co-morbidities, level of risk, and expected life expectancy. Specific trials are mandatory.
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Affiliation(s)
- Elodie Marcellaud
- Inserm U1094, IRD U270, University of Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, U1094 Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France; Unit of Clinical Pharmacy, Division of Hospital Pharmacy, Limoges Hospital Center, Limoges, France.
| | - Jeremy Jost
- Inserm U1094, IRD U270, University of Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, U1094 Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France; Unit of Clinical Pharmacy, Division of Hospital Pharmacy, Limoges Hospital Center, Limoges, France
| | - Achille Tchalla
- Division of Geriatrics, Limoges Hospital Center, Limoges, France; VIESANTE, UR 24134 Ageing Frailty Prevention e-Health, OmegaHealth Institute, University of Limoges, Limoges, France
| | - Julien Magne
- Inserm U1094, IRD U270, University of Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, U1094 Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France; Division of Cardiology, Limoges Hospital Center, Limoges, France
| | - Victor Aboyans
- Inserm U1094, IRD U270, University of Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases in Tropical Zone, U1094 Institute of Epidemiology and Tropical Neurology, Omega Health, Limoges, France; Division of Cardiology, Limoges Hospital Center, Limoges, France
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18
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Nowak MM, Niemczyk M, Florczyk M, Kurzyna M, Pączek L. Effect of Statins on All-Cause Mortality in Adults: A Systematic Review and Meta-Analysis of Propensity Score-Matched Studies. J Clin Med 2022; 11:jcm11195643. [PMID: 36233511 PMCID: PMC9572734 DOI: 10.3390/jcm11195643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/25/2022] Open
Abstract
Statins are lipid-lowering medications used for the prevention of cardiovascular disease (CVD), but the pleiotropic effects of statins might be beneficial in other chronic diseases. This meta-analysis investigated the association between statin use and mortality in different chronic conditions. Eligible studies were real-world studies that compared all-cause mortality over at least 12 months between propensity score-matched statin users and non-users. Overall, 54 studies were included: 21 in CVD, 6 in chronic kidney disease, 6 in chronic inflammatory diseases, 3 in cancer, and 18 in other diseases. The risk of all-cause mortality was significantly reduced in statin users (hazard ratio: 0.72, 95% confidence interval: 0.66−0.76). The reduction in mortality risk was similar in CVD studies (0.73, 0.66−0.76) and non-CVD studies (0.70, 0.67−0.79). There were no significant differences in the risk reduction between cohorts with different diseases (p = 0.179). The greatest mortality reduction was seen in studies from Asia (0.61, 0.61−0.73) and the lowest in studies from North America (0.78, 0.73−0.83) and Australia (0.78, 0.62−0.97). There was a significant heterogeneity (I2 = 95%, tau2 = 0.029, p < 0.01). In conclusion, statin use was associated with a significantly reduced risk of all-cause mortality in real-world cohorts with CVD and non-CVD.
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Affiliation(s)
- Marcin M. Nowak
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology at the European Health Center, 05-400 Otwock, Poland
- Correspondence:
| | - Mariusz Niemczyk
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland
| | - Michał Florczyk
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology at the European Health Center, 05-400 Otwock, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology at the European Health Center, 05-400 Otwock, Poland
| | - Leszek Pączek
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland
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Zhao M, Ren L, Zhou Z, Wang T, Li J. The Association Between Statin Use and Risk of Chronic Kidney Disease in Community-Dwelling Older People in Shanghai, China. Clin Epidemiol 2022; 14:779-788. [PMID: 35782995 PMCID: PMC9242432 DOI: 10.2147/clep.s360395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose The effects of statins on renal outcomes have already been studied in patients with chronic kidney disease (CKD); however, data on the general population are limited. We evaluated the association between statin use and risk of CKD in community-dwelling older people in Shanghai, China. Patients and Methods This registry-based cohort study was conducted in four communities in four districts in Shanghai. Participants with an estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73 m2 in 2016 were eligible for the study, and new-onset CKD in 2017, 2018, and 2019 was recorded. Poisson generalized linear models were conducted to examine the relationships among statin therapy, dyslipidemia, and CKD; linear mixed-effects models were conducted to examine the relationships between statin therapy and changes in eGFR. All analyses were performed with both conventional adjustment and propensity score-matching methods. Results Of the study cohort of 2455 participants (41.1% men; average age, 68.06 years), 624 (25.4%) were treated with stains. Two propensity score-matched cohorts of 604 participants each were analyzed (statin users and nonusers). Statin use was significantly associated with a decreased risk of new-onset CKD with hazard ratios (HRs) and 95% confidence intervals (CIs) of 0.73 (0.59 to 0.91) (p<0.01) in the unmatched cohort and 0.75 (0.59 to 0.97) (p=0.02) in the matched cohort. There were significant differences in the eGFR decline between statin users and nonusers from baseline to 3 years in the unmatched and matched cohorts (both p<0.05). In addition, both statin users and nonusers with dyslipidemia experienced more new-onset CKD (both p<0.05). Conclusion Statin use was significantly associated with a decreased risk of new-onset CKD and a slower decline in eGFR in community-dwelling older people. Meanwhile, dyslipidemia was a risk factor for CKD progression among both statin users and nonusers.
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Affiliation(s)
- Miaomiao Zhao
- School of Clinical Medicine, Shanghai University of Medicine and Health Sciences, Shanghai, People’s Republic of China
- Department of Epidemiology, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Longbing Ren
- Institute of Clinical Epidemiology and Evidence-Based Medicine, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Zhitong Zhou
- Institute of Clinical Epidemiology and Evidence-Based Medicine, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Tao Wang
- Institute of Clinical Epidemiology and Evidence-Based Medicine, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Jue Li
- Department of Epidemiology, Tongji Hospital Affiliated to Tongji University School of Medicine, Shanghai, People’s Republic of China
- Correspondence: Jue Li, Department of Epidemiology, Tongji Hospital Affiliated to Tongji University School of Medicine, 389 Xincun Road, Shanghai, 200442, People’s Republic of China, Tel +86-21-65986735, Fax +86-21-65980448, Email
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20
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Jung HN, Kim M, Kim HS, Lee WJ, Min SH, Kim Y, Jung CH. Age‐Related Associations of Low‐Density Lipoprotein Cholesterol and Atherosclerotic Cardiovascular Disease: A Nationwide Population‐Based Cohort Study. J Am Heart Assoc 2022; 11:e024637. [PMID: 35492003 PMCID: PMC9238630 DOI: 10.1161/jaha.121.024637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background The relationship between low‐density lipoprotein cholesterol (LDL‐C) and atherosclerotic cardiovascular disease (ASCVD) according to age remains undetermined. Thus, this study aimed to investigate the age‐related association of LDL‐C and ASCVD. Methods and Results Data from the Korean NHIS‐HEALS (National Health Insurance Service‐National Health Screening Cohort) were analyzed. Individuals previously diagnosed with cardiovascular disease or taking lipid‐lowering drugs were excluded. Age‐specific association between LDL‐C and ASCVD was calculated using adjusted Cox proportional hazards models. During a median follow‐up of 6.44 years for 285 119 adults, ASCVD developed in 8996 (3.2%). All age groups showed positive associations between LDL‐C and ASCVD risk, mostly with statistical significance from LDL‐C of 160 mg/dL onward. ASCVD risk did not differ significantly between the age groups (P for interaction=0.489). Correspondingly, subgroup analysis in type 2 diabetes exhibited no difference in the age‐specific association of LDL‐C and ASCVD (P for interaction=0.784). Conclusions The study demonstrated that people aged ≥75 years with higher LDL‐C at baseline still presented increased ASCVD risk, which was not significantly different from the younger groups. These findings support the importance of managing LDL‐C for the prevention of primary ASCVD in the growing elderly population.
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Affiliation(s)
- Han Na Jung
- Department of Internal Medicine Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
- Asan Diabetes Center Asan Medical Center Seoul Republic of Korea
| | - Min‐Ju Kim
- Department of Clinical Epidemiology and Biostatistics Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
| | - Hwi Seung Kim
- Department of Internal Medicine Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
- Asan Diabetes Center Asan Medical Center Seoul Republic of Korea
| | - Woo Je Lee
- Department of Internal Medicine Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
- Asan Diabetes Center Asan Medical Center Seoul Republic of Korea
| | - Se Hee Min
- Department of Internal Medicine Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
- Asan Diabetes Center Asan Medical Center Seoul Republic of Korea
| | - Ye‐Jee Kim
- Department of Clinical Epidemiology and Biostatistics Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
| | - Chang Hee Jung
- Department of Internal Medicine Asan Medical CenterUniversity of Ulsan College of Medicine Seoul Republic of Korea
- Asan Diabetes Center Asan Medical Center Seoul Republic of Korea
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21
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Long DE, Kosmac K, Dungan CM, Bamman MM, Peterson CA, Kern PA. Potential Benefits of Combined Statin and Metformin Therapy on Resistance Training Response in Older Individuals. Front Physiol 2022; 13:872745. [PMID: 35492586 PMCID: PMC9047873 DOI: 10.3389/fphys.2022.872745] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/24/2022] [Indexed: 12/24/2022] Open
Abstract
Metformin and statins are currently the focus of large clinical trials testing their ability to counter age-associated declines in health, but recent reports suggest that both may negatively affect skeletal muscle response to exercise. However, it has also been suggested that metformin may act as a possible protectant of statin-related muscle symptoms. The potential impact of combined drug use on the hypertrophic response to resistance exercise in healthy older adults has not been described. We present secondary statin analyses of data from the MASTERS trial where metformin blunted the hypertrophy response in healthy participants (>65 years) following 14 weeks of progressive resistance training (PRT) when compared to identical placebo treatment (n = 94). Approximately one-third of MASTERS participants were taking prescribed statins. Combined metformin and statin resulted in rescue of the metformin-mediated impaired growth response to PRT but did not significantly affect strength. Improved muscle fiber growth may be associated with medication-induced increased abundance of CD11b+/CD206+ M2-like macrophages. Sarcopenia is a significant problem with aging and this study identifies a potential interaction between these commonly used drugs which may help prevent metformin-related blunting of the beneficial effects of PRT.Trial Registration: ClinicalTrials.gov, NCT02308228, Registered on 25 November 2014.
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Affiliation(s)
- Douglas E. Long
- Department of Physical Therapy and Center for Muscle Biology, College of Health Sciences, University of Kentucky, Lexington, KY, United States
| | - Kate Kosmac
- Department of Physical Therapy and Center for Muscle Biology, College of Health Sciences, University of Kentucky, Lexington, KY, United States
| | - Cory M. Dungan
- Department of Physical Therapy and Center for Muscle Biology, College of Health Sciences, University of Kentucky, Lexington, KY, United States
| | - Marcas M. Bamman
- Florida Institute for Human and Machine Cognition, Pensacola, FL, United States
- Center for Exercise Medicine and Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Charlotte A. Peterson
- Department of Physical Therapy and Center for Muscle Biology, College of Health Sciences, University of Kentucky, Lexington, KY, United States
| | - Philip A. Kern
- Department of Internal Medicine, Division of Endocrinology, Barnstable Brown Diabetes and Obesity Center, University of Kentucky, Lexington, KY, United States
- *Correspondence: Philip A. Kern,
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22
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Hongo T, Yamamoto R, Liu K, Yaguchi T, Dote H, Saito R, Masuyama T, Nakatsuka K, Watanabe S, Kanaya T, Yamaguchi T, Yumoto T, Naito H, Nakao A. Association between timing of speech and language therapy initiation and outcomes among post-extubation dysphagia patients: a multicenter retrospective cohort study. Crit Care 2022; 26:98. [PMID: 35395802 PMCID: PMC8991938 DOI: 10.1186/s13054-022-03974-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/31/2022] [Indexed: 02/07/2023] Open
Abstract
Background Post-extubation dysphagia (PED) is recognized as a common complication in the intensive care unit (ICU). Speech and language therapy (SLT) can potentially help improve PED; however, the impact of the timing of SLT initiation on persistent PED has not been well investigated. This study aimed to examine the timing of SLT initiation and its effect on patient outcomes after extubation in the ICU. Methods We conducted this multicenter, retrospective, cohort study, collecting data from eight ICUs in Japan. Patients aged ≥ 20 years with orotracheal intubation and mechanical ventilation for longer than 48 h, and those who received SLT due to PED, defined as patients with modified water swallowing test scores of 3 or lower, were included. The primary outcome was dysphagia at hospital discharge, defined as functional oral intake scale score < 5 or death after extubation. Secondary outcomes included dysphagia or death at the seventh, 14th, or 28th day after extubation, aspiration pneumonia, and in-hospital mortality. Associations between the timing of SLT initiation and outcomes were determined using multivariable logistic regression. Results A total of 272 patients were included. Of them, 82 (30.1%) patients exhibited dysphagia or death at hospital discharge, and their time spans from extubation to SLT initiation were 1.0 days. The primary outcome revealed that every day of delay in SLT initiation post-extubation was associated with dysphagia or death at hospital discharge (adjusted odds ratio (AOR), 1.09; 95% CI, 1.02–1.18). Similarly, secondary outcomes showed associations between this per day delay in SLT initiation and dysphagia or death at the seventh day (AOR, 1.28; 95% CI, 1.05–1.55), 14th day (AOR, 1.34; 95% CI, 1.13–1.58), or 28th day (AOR, 1.21; 95% CI, 1.07–1.36) after extubation and occurrence of aspiration pneumonia (AOR, 1.09; 95% CI, 1.02–1.17), while per day delay in post-extubation SLT initiation did not affect in-hospital mortality (AOR, 1.04; 95% CI, 0.97–1.12). Conclusions Delayed initiation of SLT in PED patients was associated with persistent dysphagia or death. Early initiation of SLT may prevent this complication post-extubation. A randomized controlled study is needed to validate these results. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03974-6.
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Affiliation(s)
- Takashi Hongo
- Department of Emergency, Okayama Saiseikai General Hospital, 2-25 Kokutaityo, Okayama Kita-ku, Okayama, 700-8511, Japan.,Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama, 700-8558, Japan
| | - Ryohei Yamamoto
- Department of Healthcare Epidemiology, School of Public Health, Graduate School of Medicine, Kyoto University, Yoshida-honmachi, Kyoto Sakyo-ku, Kyoto, 606-8501, Japan
| | - Keibun Liu
- Critical Care Research Group, Faculty of Medicine, University of Queensland, The Prince Charles Hospital, 627 Rode Rd, Chermside, Brisbane, QLD, 4032, Australia
| | - Takahiko Yaguchi
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, 296-0041, Japan
| | - Hisashi Dote
- Department of Emergency and Critical Care Medicine, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu Naka-ku, Shizuoka, 430-8558, Japan
| | - Ryusuke Saito
- Department of Emergency and Critical Care Medicine, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi, Hamamatsu Naka-ku, Shizuoka, 430-8558, Japan
| | - Tomoyuki Masuyama
- Department of Emergency, Misato Kenwa Hospital, 4-494-1 Takano, Misato, Saitama, 341-0035, Japan
| | - Kosuke Nakatsuka
- Department of Anesthesiology, Okayama Rosai Hospital, 1-10-25 Chikkomidorimachi, Okayama Minami-ku, Okayama, 702-8055, Japan
| | - Shinichi Watanabe
- Department of Rehabilitation, Nagoya Medical Center, NHO, 4-1-1 Sannomaru, , Nagoya Naka-ku, Aichi, 461-0001, Japan
| | - Takahiro Kanaya
- Department of Rehabilitation, Hokkaido Medical Center, NHO, 7-1-1 Yamanote5jo, Sapporo Nishi-ku, Hokkaido, 063-0005, Japan
| | - Tomoya Yamaguchi
- Division of Critical Care Medicine, Nara Prefecture General Medical Center, 2-897-5 Shichijonishimachi, Nara, Nara, 630-8581, Japan
| | - Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama, 700-8558, Japan.
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama, 700-8558, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama Kita-ku, Okayama, 700-8558, Japan
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23
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Huang H, Zhu H, Ya R. Statin use in older people primary prevention on cardiovascular disease: an updated systematic review and meta-analysis. Rev Cardiovasc Med 2022; 23:114. [PMID: 39076238 PMCID: PMC11273788 DOI: 10.31083/j.rcm2304114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/13/2021] [Accepted: 12/22/2021] [Indexed: 07/31/2024] Open
Abstract
Background Evidence on statin use for primary prevention of cardiovascular disease (CVD) in older people needs to be extended and updated, aiming to provide further guidance for clinical practice. Methods PubMed, EMBASE, Cochrane Library and Web of Science were searched for eligible observational studies comparing statin use vs. no-statin use for primary prevention of CVD in older people (age ≥ 65 years). The primary outcomes were all-cause mortality, CVD mortality, coronary heart disease (CHD)/myocardial infraction (MI), stroke and total CV events. Risk estimates of each relevant outcome were synthesized as a hazard ratio (HR) with 95% confidence interval (95% CI) using in the random-effects model. Results Twelve eligible observational studies (n = 1,627,434) were enrolled. The pooled results suggested that statin use was associated with a significantly decreased risk of all-cause mortality (HR: 0.54, 95% CI: 0.46-0.63), CVD mortality (HR: 0.51, 95% CI: 0.39-0.65), CHD/MI (HR: 0.83, 95% CI: 0.69-1.00), stroke (HR: 0.79, 95% CI: 0.68-0.92) and total CV events (HR: 0.75, 95% CI: 0.66-0.85). The association in all-cause mortality still remained obvious at higher ages ( ≥ 70 years old, HR: 0.56, 95% CI: 0.44-0.71; ≥ 75 years old, HR: 0.70, 95% CI: 0.60-0.80; ≥ 85 years old, HR: 0.85, 95% CI: 0.74-0.97), ≥ 20% (HR: 0.47, 95% CI: 0.35-0.62) and < 20% diabetic populations (HR: 0.50, 95% CI: 0.40-0.64), and ≥ 50% (HR: 0.68, 95% CI: 0.59-0.79) and < 50% hypertensive populations (HR: 0.38, 95% CI: 0.16-0.88). Conclusions Statin use was related to a 46%, 49%, 17%, 21% and 25% risk reduction on all-cause mortality, CVD mortality, CHD/MI, stroke and total CV events in older patients, respectively. The significant association was also addressed in older patients and ≥ 75 years old individuals for CVD primary prevention.
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Affiliation(s)
- Hao Huang
- Department of Critical Rehabilitation, Shanghai Third Rehabilitation Hospital, 200436 Shanghai, China
| | - Hechen Zhu
- Department of Critical Care Medicine, Huashan Hospital, Fudan University, 200031 Shanghai, China
| | - Ru Ya
- Department of Critical Rehabilitation, Shanghai Third Rehabilitation Hospital, 200436 Shanghai, China
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Comparison of statins for primary prevention of cardiovascular disease and persistent physical disability in older adults. Eur J Clin Pharmacol 2022; 78:467-476. [PMID: 34698889 PMCID: PMC9993349 DOI: 10.1007/s00228-021-03239-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 10/19/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Recent epidemiological evidence has suggested that use of lipid-lowering medications, particularly statins, was associated with reduced cardiovascular disease (CVD) events and persistent physical disability in healthy older adults. However, the comparative efficacy of different statins in this group remains unclear. This study aimed to compare different forms of statins in their associations with CVD and physical disability in healthy older adults. METHODS This post hoc analysis included data from 5981 participants aged ≥ 70 years (≥ 65 if US minorities; median age:74.0) followed for a median of 4.7 years, who had no prior CVD events or physical disability and reported using a statin at baseline. The incidence of the composite and components of major adverse cardiovascular events and persistent physical disability were compared across different statins according to their type, potency, and lipophilicity using multivariable Cox proportional-hazards models. RESULTS Atorvastatin was the most used statin type at baseline (37.9%), followed by simvastatin (29.6%), rosuvastatin (25.5%), and other statins (7.0%, predominantly pravastatin). In comparisons of specific statins according to type and lipophilicity (lipophilic vs. hydrophilic statin), observed differences in all outcomes were small and not statistically significant (all p values > 0.05). High-potency statin use (atorvastatin and rosuvastatin) was marginally associated with lower risk of fatal CVD events compared with low-/moderate-potency statin use (hazard ratio: 0.59; 95% confidence interval: 0.35, 1.00). CONCLUSION There were minimal differences in CVD outcomes and no significant difference in persistent physical disability between various forms of statins in healthy older adults. Future investigations are needed to confirm our results.
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Lahoz C, Cárdenas-Valladolid J, Salinero-Fort MÁ, Mostaza JM. Use of statins and associated factors in nonagenarians in the Community of Madrid, Spain. Aging Clin Exp Res 2022; 34:439-444. [PMID: 34363590 PMCID: PMC8349136 DOI: 10.1007/s40520-021-01945-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 07/27/2021] [Indexed: 11/08/2022]
Abstract
Background The role of statins in the management of dyslipidemia in elderly patients with different cardiovascular risks remains unclear. Objective To study use of statins and associated factors in subjects aged 90 or over in the Community of Madrid, Spain. Methods Observational, cross-sectional study that included all people aged 90 or more residing in the Community of Madrid as of December 31, 2015. The clinical information was obtained from the database that contains the electronic medical records collected by family doctors in primary care. Comorbidity data are collected according to the International Classification of Primary Care, Second Edition (ICPC-2). Results The study population comprised 59,423 subjects, with a mean age of 93.3 (2.5) years (25.8% males). Slightly more than one quarter of the population (28.2%) was in treatment with statins, 21.9% were in primary prevention, and 48.1% in secondary prevention. The multivariate analysis revealed the factors independently associated with statin treatment to be younger age, not being institutionalized, a higher Barthel score, a lower Charlson score, a higher body mass index, and a history of diabetes, dyslipidemia, chronic kidney disease, and cardiovascular disease. Conclusions A significant percentage of nonagenarians—mainly less frail patients with more comorbidities—in the Community of Madrid receive statin treatment. No clear efficacy has been demonstrated in reducing cardiovascular events in an age group with such a short life expectancy.
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Moon IT, Kang SH, Lee W, Cho Y, Park JJ, Yoon YE, Oh IY, Yoon CH, Suh JW, Youn TJ, Chae IH, Choi DJ, Cho YS. Impact of statin intensity on adverse cardiac and cerebrovascular events in older adult patients with myocardial infarction. J Geriatr Cardiol 2021; 18:609-622. [PMID: 34527027 PMCID: PMC8390935 DOI: 10.11909/j.issn.1671-5411.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There is insufficient evidence regarding the effect of high-intensity statin therapy in older adults. This study aimed to investigate the effects of high-intensity statin treatment on the clinical outcomes in older adults with myocardial infarction (MI). METHODS Consecutive patients with MI aged at least 75 years were analyzed retrospectively. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of all-cause death, MI, rehospitalization due to unstable angina, repeat revascularization, and ischemic stroke. The high-intensity group was compared to the low-to-moderate intensity group in the propensity score-matched cohort. RESULTS Average age of total 546 patients was 81 years. Among them, 84% of patients underwent percutaneous coronary intervention. The unadjusted seven-year MACCE rate differed by statin intensity (high-intensity statin group: 38%, moderate-intensity statin group: 42%, low-intensity statin group: 56%, and no-statin group: 61%, P = 0.004). However, among these groups, many baseline characteristics were significantly different. Among the 74 propensity score-matched pairs, which lacked any significant differences in all baseline characteristics, the high-intensity group had a significantly lower rate of MACCE than the low-to-moderate intensity group (37% vs. 53%, P = 0.047). Follow-up low-density lipoprotein cholesterol levels were significantly lower in the high-intensity group than that in the low-to-moderate intensity group (69.4 ± 16.0 mg/dL vs. 77.9 ± 25.9 mg/dL, P = 0.026). CONCLUSIONS In older adult patients with MI, the use of high-intensity statin caused significantly less occurrence of MACCE in comparison to that in low-to-moderate intensity for up to seven years of follow-up.
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Affiliation(s)
- In Tae Moon
- Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu, South Korea
| | - Si-Hyuck Kang
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Wonjae Lee
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Youngjin Cho
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin Joo Park
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yeonyee E. Yoon
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Il-Young Oh
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Chang-Hwan Yoon
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jung-Won Suh
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Tae-Jin Youn
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In-Ho Chae
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dong-Ju Choi
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Young-Seok Cho
- Department of Cardiology, Incheon Sejong Hospital, Incheon, South Korea
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27
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Association of statin use in older people primary prevention group with risk of cardiovascular events and mortality: a systematic review and meta-analysis of observational studies. BMC Med 2021; 19:139. [PMID: 34154589 PMCID: PMC8218529 DOI: 10.1186/s12916-021-02009-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 05/17/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Current evidence from randomized controlled trials on statins for primary prevention of cardiovascular disease (CVD) in older people, especially those aged > 75 years, is still lacking. We conducted a systematic review and meta-analysis of observational studies to extend the current evidence about the association of statin use in older people primary prevention group with risk of CVD and mortality. METHODS PubMed, Scopus, and Embase were searched from inception until March 18, 2021. We included observational studies (cohort or nested case-control) that compared statin use vs non-use for primary prevention of CVD in older people aged ≥ 65 years; provided that each of them reported the risk estimate on at least one of the following primary outcomes: all cause-mortality, CVD death, myocardial infarction (MI), and stroke. Risk estimates of each relevant outcome were pooled as a hazard ratio (HR) with a 95% confidence interval (CI) using the random-effects meta-analysis model. The quality of the evidence was rated using the GRADE approach. RESULTS Ten observational studies (9 cohorts and one case-control study; n = 815,667) fulfilled our criteria. The overall combined estimate suggested that statin therapy was associated with a significantly lower risk of all-cause mortality (HR: 0.86 [95% CI 0.79 to 0.93]), CVD death (HR: 0.80 [95% CI 0.78 to 0.81]), and stroke (HR: 0.85 [95% CI 0.76 to 0.94]) and a non-significant association with risk of MI (HR 0.74 [95% CI 0.53 to 1.02]). The beneficial association of statins with the risk of all-cause mortality remained significant even at higher ages (> 75 years old; HR 0.88 [95% CI 0.81 to 0.96]) and in both men (HR: 0.75 [95% CI: 0.74 to 0.76]) and women (HR 0.85 [95% CI 0.72 to 0.99]). However, this association with the risk of all-cause mortality remained significant only in those with diabetes mellitus (DM) (HR 0.82 [95% CI 0.68 to 0.98]) but not in those without DM. The level of evidence of all the primary outcomes was rated as "very low." CONCLUSIONS Statin therapy in older people (aged ≥ 65 years) without CVD was associated with a 14%, 20%, and 15% lower risk of all-cause mortality, CVD death, and stroke, respectively. The beneficial association with the risk of all-cause mortality remained significant even at higher ages (> 75 years old), in both men and women, and in individuals with DM, but not in those without DM. These observational findings support the need for trials to test the benefits of statins in those above 75 years of age.
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Talic S, Marquina Hernandez C, Ofori-Asenso R, Liew D, Owen A, Petrova M, Lybrand S, Thomson D, Ilomaki J, Ademi Z, Zomer E. Trends in the Utilization of Lipid-Lowering Medications in Australia: An Analysis of National Pharmacy Claims Data. Curr Probl Cardiol 2021; 47:100880. [PMID: 34108083 DOI: 10.1016/j.cpcardiol.2021.100880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022]
Abstract
Lipid-lowering medications comprise standard of care in the prevention of cardiovascular disease. This study examined the trends in the utilization of statin and non-statin medications in the Australian general population between 2013 and 2019. Pharmacoepidemiological analyses were performed using pharmacy dispensing data from Australian Pharmaceutical Benefits Scheme. One-year prevalence and incidence of statin and non-statin prescribing patterns were reported, and relative variations in prescribing examined via Poisson regression modelling. The one-year prevalence of statins' prescriptions decreased between 2013-2019 by 5.5% (from 25.0%-19.5%). Females were less likely than males to be prescribed statins (rate ratio [RR]=0.90, 95% confidence interval [CI] 0.89-0.91). The one-year prevalence of ezetimibe alone, and in combination with statins, increased consistently from 2013-2019 from 1.5%-3.6% (P<0.01) and 0.1%-1.1% (P<0.01), respectively. The prevalence was higher among those aged 61-80 years (RR=1.20, 95%CI 1.10-1.21) and those aged older than 80 years (RR=1.34, 95%CI 1.22-1.47), when compared to people aged <60 years. The incidence of ezetimibe prescriptions was highest in people aged 61-80 years (RR=1.36, 95%CI 1.31-1.41) compared to those aged <60 years. The one-year prevalence of proprotein convertase subtilisin/kexin type 9 inhibitor prescriptions was highest among those aged 46-60 years (RR=1.24, 95%CI 0.97-4.97) compared to people aged <46 and >60 years. Females were less likely than males to be prescribed a proprotein convertase subtilisin/kexin type 9 inhibitor (RR=0.87, 95%CI 0.75-0.98). Statins remain the most prevalent lipid-lowering medication prescribed in Australia. The prescribing of non-statin medications remains low, but is increasing.
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Affiliation(s)
- Stella Talic
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Richard Ofori-Asenso
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alice Owen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Marjana Petrova
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | - Jenni Ilomaki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Ella Zomer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Masud R, Khan AUH, Anjum AF, Jawwad G, Azeem Z, Baqai HZ, Hashmi SN. The Connotation of Variances in the Risk Predictors, Medications, Homocysteine, and Homocysteine Pathway Gene Polymorphisms with CVA/Stroke. Glob Med Genet 2020; 7:113-120. [PMID: 33693444 PMCID: PMC7938795 DOI: 10.1055/s-0041-1722884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Cerebrovascular accidents (CVAs) are vascular multifactorial, multigenic ailments with intricate genetic, environmental risk influences. The present study aimed to establish affiliation of CVAs/stroke with blood parameters, differences in prescribed drugs consumption, and with differences in homocysteine pathway genes polymorphisms. The participants in study included controls n = 251, transient ischemic attack (TIA) patients n = 16, and stroke cases n = 122, respectively, (total participants, n = 389). The analyzed single nucleotide polymorphisms (SNPs) included C677T(rs1801133), A1298C(rs1801131) of methylene tetrahydrofolate reductase ( MTHFR ), A2756G(rs1805087) of methyl tetrahydrofolate homocysteine methyltransferase/methionine synthase ( MS ), and the A192G(rs662) of paraoxonase 1( PON1 ) genes, all validated by tetra-primer allele refractory mutation system polymerase chain reaction (T-ARMS-PCR). The insertion deletion (I/D; rs4646994) polymorphism in angiotensin converting enzyme ( ACE ) gene was analyzed using routine PCR. All studied traits were scrutinized through analysis of variance (ANOVA), and later through regression analysis. Through ANOVA and multiple comparison, there was association of CVA with serum homocysteine, cholesterol, and with diastolic blood pressure readings. When data was subjected to regression, serum homocysteine and diastolic blood pressure (significant through ANOVA), as well as two additional traits, high-density lipoproteins (HDL), and rs1801133 MTHFR SNP sustained statistical significance and noteworthy odds in relation to CVA and stroke. The ailments affecting cerebral vasculature are mutifactorial, whereby genes, proteins, and environmental cues all exert cumulative effects enhancing CVA risk. The current study emphasizes that SNPs and variation in circulating biomarkers can be used for screening purposes and for reviewing their effects in stroke/CVA-linked risk progression.
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Affiliation(s)
- Rizwan Masud
- Department of Physiology, CMH Kharian Medical College, Kharian, Pakistan
| | - Aleem Ul Haq Khan
- Department of Biochemistry, CMH Kharian Medical College, Kharian, Pakistan
| | - Aiman Farogh Anjum
- Department of Physiology, CMH Kharian Medical College, Kharian, Pakistan
| | - Ghazala Jawwad
- Department of Physiology, Rawal Institute of Health Sciences, Islamabad, Pakistan
| | - Zahid Azeem
- Department of Biochemistry, AJ&K Medical College, Muzaffarabad, AJ&K, Pakistan
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Statine: kein Demenzrisiko und effektiv auch bei Älteren. AKTUELLE KARDIOLOGIE 2020. [DOI: 10.1055/a-1220-9661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kirkpatrick JN, Bernacki GM. Primary Prevention Statins in Older Patients. J Am Coll Cardiol 2020; 76:28-30. [PMID: 32616159 PMCID: PMC7324097 DOI: 10.1016/j.jacc.2020.05.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/14/2020] [Indexed: 10/26/2022]
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