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Teramoto K, Nochioka K, Sakata Y, Kato ET, Nishimura K, Shimokawa H, Yasuda S. Growth differentiation factor-15 and metabolic features in chronic heart failure: Insights from the SUPPORT Trial -GDF15 across the BMI spectrum. Int J Cardiol 2024; 407:132093. [PMID: 38663803 DOI: 10.1016/j.ijcard.2024.132093] [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: 02/26/2024] [Revised: 04/08/2024] [Accepted: 04/22/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND GDF15 plays pivotal metabolic roles in nutritional stress and serves as a physiological regulator of energy balance. However, the patterns of GDF15 levels in underweight or obese patients with chronic heart failure (CHF) are not well-understood. METHODS We assessed serum GDF15 levels at baseline and 3 years and the temporal changes in 940 Japanese patients (642 paired samples), as a sub-analysis of the SUPPORT trial (age 65.9 ± 10.1 years). The GDF15 levels were analyzed across BMI groups (underweight [<18.5 kg/m2; n = 50], healthy weight [18.5-22.9; n = 27 5], overweight [23-24.9; n = 234], and obese [≥25; n = 381]), following WHO recommendations for the Asian-Pacific population. Landmark analysis at 3 years assessed the association between GDF15 levels and HF hospitalization or all-cause death. RESULTS Compared to the healthy weight group, the underweight group included more females (54.0%) with advanced HF (NYHA class III; 20.0%) and exhibited increased GDF15 level (1764 pg/mL [IQR 1067-2633]). Obese patients, younger (64.2 years) and diabetic (53%), had a similar GDF15 level to the healthy weight group. A higher baseline GDF15 level was associated with worse outcomes across the BMI spectrum. GDF15 increased by 208 [21-596] pg/mL over 3 years, with the most substantial increase observed in the underweight group (by +28.9% [6.2-81.0]). Persistently high GDF15 levels (≥1800 pg/mL) was independently associated with worse outcomes after 3 years (adjusted HR 1.8 [95%CI 1.1-2.9]). CONCLUSIONS In underweight patients with CHF, GDF15 level was elevated at baseline and experienced the most significant increase over 3 years. Its consistent elevation suggested a worse outcome.
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Affiliation(s)
- Kanako Teramoto
- Department of Biostatistics, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kotaro Nochioka
- Division of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Yasuhiko Sakata
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Eri Toda Kato
- Department of Cardiovascular Medicine and Department of Clinical Laboratory, Kyoto University Hospital, Kyoto, Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroaki Shimokawa
- Division of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan; International University of Health and Welfare Graduate School, Narita, Japan
| | - Satoshi Yasuda
- Division of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Teramoto K, Nochioka K, Sakata Y, Nishimura K, Shimokawa H, Yasuda S. Prognostic significance of growth differentiation factor-15 across age in chronic heart failure. ESC Heart Fail 2024; 11:1666-1676. [PMID: 38426613 PMCID: PMC11098632 DOI: 10.1002/ehf2.14738] [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: 07/26/2023] [Revised: 01/11/2024] [Accepted: 02/11/2024] [Indexed: 03/02/2024] Open
Abstract
AIMS Growth differentiation factor-15 (GDF15), a cytokine in the transforming growth factor family, is up-regulated in stress and inflammatory conditions and is elevated in patients with heart failure (HF). However, the age-specific attributes and prognostic significance of GDF15 across age remain unknown in chronic HF (CHF). METHODS AND RESULTS Serum levels of GDF15 were examined in 942 hypertensive patients (median 68 years) with CHF from the SUPPORT trial across the four age groups [under 50 (n = 73), 51-59 (n = 158), 60-69 (n = 296), and 70-79 years (n = 415)] and in the continuous spectrum. Clinical correlates of GDF15 were explored using the classic stepwise and LASSO (least absolute shrinkage and selection operator) regression approaches. Interaction terms with age were tested in the LASSO regression approach. The associations with the composite outcome of HF hospitalization or all-cause death were investigated across ages. Median GDF15 levels (pg/mL) increased along with aging, from 691 in under 50 years to 855 in 51-59 years, 1114 in 60-69 years, and 1516 in 70-79 years (trend P < 0.001). Age, sex, systolic blood pressure, history of diabetes, ischaemic heart disease, left ventricular (LV) end-systolic dimension, LV ejection fraction, estimated glomerular filtration rate, haemoglobin, N-terminal pro-brain natriuretic peptide (NT-proBNP), troponin, C-reactive protein, and the use of angiotensin-converting enzyme inhibitors, diuretics, and statins were mutually selected as clinical covariates of GDF15. The LASSO regression analysis identified significant interactions between age and the history of diabetes and NT-proBNP, with particularly robust associations in patients aged between 60 and 70 years. During the mean follow-up of 8.6 years, 474 composite endpoints of HF hospitalization or death occurred. GDF15 was associated with a higher risk of HF hospitalization or all-cause death [adjusted hazard ratio 1.84 (95% confidence interval 1.45-2.33)], with a particularly heightened risk in patients aged around 70 years (Pinteraction = 0.0008). The model with GDF15 on top of other established risk factors yielded marginally higher C-statistics compared with the model without GDF15 (0.803 and 0.796, P = 0.045). The additive value of GDF15 on top of other established risk factors appeared similar across ages. A universal cut-off value of 1400 pg/mL performed well in discriminating between those with and without HF hospitalization or death. CONCLUSIONS Some clinical correlates of GDF15 have an interaction with age. GDF15 is an important determinant of cardiovascular endpoints, particularly in patients aged around 70 years. The additive value of GDF15 appeared consistent across ages, suggesting the use of a universal cut-off value.
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Affiliation(s)
- Kanako Teramoto
- Department of BiostatisticsNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Kotaro Nochioka
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine1‐1 Seiryomachi, Aoba‐kuSendaiJapan
| | - Yasuhiko Sakata
- Department of Clinical Medicine and DevelopmentNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and EpidemiologyNational Cerebral and Cardiovascular CenterOsakaJapan
| | - Hiroaki Shimokawa
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine1‐1 Seiryomachi, Aoba‐kuSendaiJapan
- International University of Health and Welfare Graduate SchoolNaritaJapan
| | - Satoshi Yasuda
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine1‐1 Seiryomachi, Aoba‐kuSendaiJapan
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Leache L, Gutiérrez-Valencia M, Finizola RM, Infante E, Finizola B, Pardo Pardo J, Flores Y, Granero R, Arai KJ. Pharmacotherapy for hypertension-induced left ventricular hypertrophy. Cochrane Database Syst Rev 2021; 10:CD012039. [PMID: 34628642 PMCID: PMC8502530 DOI: 10.1002/14651858.cd012039.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension-induced LVH. OBJECTIVES To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension-induced LVH. SEARCH METHODS Cochrane Hypertension's Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) with at least 12 months' follow-up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension-induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all-cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. DATA COLLECTION AND ANALYSIS Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. MAIN RESULTS We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow-up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention-to-treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add-on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low-certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low-certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low-certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low-certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low-certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. AUTHORS' CONCLUSIONS We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low-certainty evidence requires that caution be used when interpreting the findings. High-quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension-induced LVH are warranted.
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Affiliation(s)
- Leire Leache
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
| | | | - Rosa M Finizola
- Unit of Special Projects, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Elizabeth Infante
- Unit of Systems, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Bartolome Finizola
- General Coordination, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Jordi Pardo Pardo
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada
| | - Yris Flores
- Echocardiography Department and Cardiac Tomography Department, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | | | - Kaduo J Arai
- Coronary Care Unit, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
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A.S. Murad H, S. Al-Kayy S, A. Alkaabi T. Are the Newest Angiotensin Receptor Blockers Preferred than the Old Members in COVID-19 Patients with Cardiovascular Comorbidity? INT J PHARMACOL 2021. [DOI: 10.3923/ijp.2021.435.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Nochioka K, Sakata Y, Miura M, Shiroto T, Takahashi J, Saga C, Ikeno Y, Shiba N, Shinozaki T, Sugi M, Nakagawa M, Komaru T, Kato A, Nozaki E, Iwabuchi K, Hiramoto T, Inoue K, Ohe M, Tamaki K, Tsuji I, Shimokawa H. Impaired glucose tolerance and albuminuria in patients with chronic heart failure: a subanalysis of the SUPPORT trial. ESC Heart Fail 2019; 6:1252-1261. [PMID: 31647614 PMCID: PMC6989294 DOI: 10.1002/ehf2.12516] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 06/30/2019] [Accepted: 08/16/2019] [Indexed: 01/14/2023] Open
Abstract
AIMS The study aims to evaluate the prognostic significance of impaired glucose tolerance (IGT) with reference to albuminuria in patients with chronic heart failure (CHF). METHODS AND RESULTS We examined 535 CHF patients (mean 66 years, women 25%) in the control arm of our SUPPORT trial, in which we examined additive impact of olmesartan in hypertensive patients with symptomatic CHF treated with β-blockers and/or angiotensin-converting enzyme inhibitors. We examined the association between glycaemic abnormality (assessed by 75 g of oral glucose tolerance test) and albuminuria for a composite outcome of all-cause death, myocardial infarction, stroke, and HF hospitalization. IGT patients (N = 113, mean 67.2 years) were older and more frequently treated with β-blockers compared with those with normal glucose regulation (N = 142, mean 64.0 years) and those with diabetes mellitus (N = 280, mean 65.7 years). Multivariable Cox proportional hazard models revealed that, as compared with normal glucose regulation (NGR), IGT was associated with increased risk of the outcome when complicated by albuminuria [hazard ratio (HR) 2.25; 95% confidence interval (CI) 1.14-4.42; P = 0.019] but not when uncomplicated by albuminuria (HR 0.76; 95% CI 0.35-1.60, P = 0.47) (P for interaction = 0.041). This was also the case for diabetes mellitus and albuminuria (HR 2.06; 95% CI 1.17-3.61; P = 0.012). Among IGT patients without albuminuria, 21 (29%) developed albuminuria at 1-year visit, which was again associated with poor prognosis (HR 7.36; 95% CI 1.39-38.98, P = 0.019). CONCLUSIONS These results indicate that IGT is associated with poor prognosis when complicated by albuminuria in CHF patients, demonstrating the importance of combined early stages of glucose intolerance and renal dysfunction in the management of CHF.
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Grants
- Ministry of Health, Labour and Welfare, Japan
- Ministry of Education, Culture, Sports, Science and Technology
- Ministry of Health, Labour and Welfare, Japan
- Ministry of Education, Culture, Sports, Science and Technology
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Affiliation(s)
- Kotaro Nochioka
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSeiryo‐machi 1–1SendaiMiyagi980–8574Japan
| | - Yasuhiko Sakata
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSeiryo‐machi 1–1SendaiMiyagi980–8574Japan
| | - Masanobu Miura
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSeiryo‐machi 1–1SendaiMiyagi980–8574Japan
| | - Takashi Shiroto
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSeiryo‐machi 1–1SendaiMiyagi980–8574Japan
| | - Jun Takahashi
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSeiryo‐machi 1–1SendaiMiyagi980–8574Japan
| | - Chie Saga
- Department of Evidence‐based Cardiovascular MedicineTohoku University Graduate School of MedicineMiyagiJapan
| | - Yasuko Ikeno
- Department of Evidence‐based Cardiovascular MedicineTohoku University Graduate School of MedicineMiyagiJapan
| | - Nobuyuki Shiba
- Department of Cardiovascular MedicineInternational University of Health and Welfare HospitalTochigiJapan
| | - Tsuyoshi Shinozaki
- Cardiovascular Division, Sendai Medical CenterNational Hospital OrganizationMiyagiJapan
| | - Masafumi Sugi
- Cardiovascular Division, Iwaki City Medical CenterFukushimaJapan
| | - Makoto Nakagawa
- Department of Cardiovascular MedicineIwate Prefectural Isawa HospitalIwateJapan
| | - Tatsuya Komaru
- Department of Cardiovascular MedicineTohoku Medical and Pharmaceutical UniversityMiyagiJapan
| | - Atsushi Kato
- Department of Cardiovascular MedicineSendai Open HospitalMiyagiJapan
| | - Eiji Nozaki
- Department of Cardiovascular MedicineIwate Prefectural Central HospitalIwateJapan
| | - Kaoru Iwabuchi
- Cardiovascular DivisionOsaki Citizen HospitalMiyagiJapan
| | | | - Kanichi Inoue
- Cardiovascular DivisionSenen Rifu HospitalMiyagiJapan
| | - Masatoshi Ohe
- Cardiovascular DivisionKojirakawa Shieido HospitalMiyagiJapan
| | - Kenji Tamaki
- Cardiology DepartmentIwate Health Service AssociationIwateJapan
| | - Ichiro Tsuji
- Division of Epidemiology, Department of Public Health and Forensic MedicineTohoku University Graduate School of MedicineMiyagiJapan
| | - Hiroaki Shimokawa
- Department of Cardiovascular MedicineTohoku University Graduate School of MedicineSeiryo‐machi 1–1SendaiMiyagi980–8574Japan
- Department of Evidence‐based Cardiovascular MedicineTohoku University Graduate School of MedicineMiyagiJapan
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Taylor KS, Mclellan J, Verbakel JY, Aronson JK, Lasserson DS, Pidduck N, Roberts N, Fleming S, O'Callaghan CA, Bankhead CR, Banerjee A, Hobbs FR, Perera R. Effects of antihypertensives, lipid-modifying drugs, glycaemic control drugs and sodium bicarbonate on the progression of stages 3 and 4 chronic kidney disease in adults: a systematic review and meta-analysis. BMJ Open 2019; 9:e030596. [PMID: 31542753 PMCID: PMC6756484 DOI: 10.1136/bmjopen-2019-030596] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To evaluate the effects of drug interventions that may modify the progression of chronic kidney disease (CKD) in adults with CKD stages 3 and 4. DESIGN Systematic review and meta-analysis. METHODS Searching MEDLINE, EMBASE, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, International Clinical Trials Registry Platform, Health Technology Assessment, Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index and Clinical Trials Register, from March 1999 to July 2018, we identified randomised controlled trials (RCTs) of drugs for hypertension, lipid modification, glycaemic control and sodium bicarbonate, compared with placebo, no drug or a drug from another class, in ≥40 adults with CKD stages 3 and/or 4, with at least 2 years of follow-up and reporting renal function (primary outcome), proteinuria, adverse events, maintenance dialysis, transplantation, cardiovascular events, cardiovascular mortality or all-cause mortality. Two reviewers independently screened citations and extracted data. For continuous outcomes, we used the ratio of means (ROM) at the end of the trial in random-effects meta-analyses. We assessed methodological quality with the Cochrane Risk of Bias Tool and confidence in the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. RESULTS We included 35 RCTs and over 51 000 patients. Data were limited, and heterogeneity varied. Final renal function (estimated glomerular filtration rate) was 6% higher in those taking glycaemic control drugs (ROM 1.06, 95% CI 1.02 to 1.10, I2=0%, low GRADE confidence) and 4% higher in those taking lipid-modifying drugs (ROM 1.04, 95% CI 1.00 to 1.08, I2=88%, very low GRADE confidence). For RCTs of antihypertensive drugs, there were no significant differences in renal function. Treatment with lipid-modifying drugs led to a 36% reduction in cardiovascular disease and 26% reduction in all-cause mortality. CONCLUSIONS Glycaemic control and lipid-modifying drugs may slow the progression of CKD, but we found no pooled evidence of benefit nor harm from antihypertensive drugs. However, given the data limitations, further research is needed to confirm these findings. PROSPERO REGISTRATION NUMBER CRD42015017501.
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Affiliation(s)
- Kathryn S Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie Mclellan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Y Verbakel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jeffrey K Aronson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Daniel S Lasserson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Nicola Pidduck
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Susannah Fleming
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Clare R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amitava Banerjee
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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7
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Kasahara S, Sakata Y, Nochioka K, Miura M, Abe R, Sato M, Aoyanagi H, Fujihashi T, Yamanaka S, Shiroto T, Sugimura K, Takahashi J, Miyata S, Shimokawa H. Conversion formula from B-type natriuretic peptide to N-terminal proBNP values in patients with cardiovascular diseases. Int J Cardiol 2019; 280:184-189. [DOI: 10.1016/j.ijcard.2018.12.069] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/07/2018] [Accepted: 12/24/2018] [Indexed: 01/03/2023]
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8
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Nochioka K, Sakata Y, Shimokawa H. Combination Therapy of Renin Angiotensin System Inhibitors and β-Blockers in Patients with Heart Failure. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018. [DOI: 10.1007/5584_2018_179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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9
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Wang Q, Chen Z, Huang X, Chen L, Chen B, Zhu Y, Cao S, Liao W, Bin J, Kitakaze M, Liao Y. Olmesartan attenuates pressure-overload- or post-infarction-induced cardiac remodeling in mice. Oncotarget 2017; 9:24601-24618. [PMID: 29872491 PMCID: PMC5973849 DOI: 10.18632/oncotarget.23628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 12/11/2017] [Indexed: 01/10/2023] Open
Abstract
Either angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor 1 blocker (ARB) attenuates cardiac remodeling. However, the overall molecular modulation of the reversing remodeling process in response to the ACEI or ARB treatment is not yet well determined. In this study, we examined whether gene expressions are modulated by ACEI (temocapril), ARB (olmesartan) or both in a murine model with transverse aortic constriction (TAC) and confirm whether periostin is a target gene of olmesartan in mice with myocardial infarction (MI). We detected 109 genes that were significantly up-regulated in TAC mice and a majority of these were down-regulated in response to temocapril, olmesartan or their combination which significantly attenuated cardiac remodeling at one or four weeks. Real-time RT-PCR demonstrated that olmesartan, temocapril or their combination down-regulated the expression of periostin. In MI mice treated with olmesartan for 4 weeks, the left ventricular end-diastolic and systolic dimensions measured with echocardiography were lower, whereas maximum rate of rise and fall rate of LV pressure (±dp/dt max) were greater, and Azan-staining cardiac fibrotic area was smaller. Furthermore, periostin was upregulated in response to MI, whereas olmesartan blocked this upregulation. Post-MI fibrosis was smaller in periostin knockout adult mice than in wildtype mice, while glycogen synthase kinase 3β was increased and cyclin D1 was decreased in periostin knockout mice. These findings indicate that periostin is a target gene of ARB and olmesartan reverses cardiac remodeling at least partially through the downregulation of periostin.
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Affiliation(s)
- Qiancheng Wang
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.,Department of Cardiology, Jiaozuo People's Hospital of Henan Province, Jiaozuo 454000, China
| | - Zhenhuan Chen
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Xiaobo Huang
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Lin Chen
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Baihe Chen
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Yingqi Zhu
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Shiping Cao
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Wangjun Liao
- Department of Oncology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Jianping Bin
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Masafumi Kitakaze
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China.,Cardiovascular Division of the Department of Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka 565-8565, Japan
| | - Yulin Liao
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
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Avaldi VM, Lenzi J, Urbinati S, Molinazzi D, Descovich C, Campagna A, Taglioni M, Fioritti A, Fantini MP. Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: results from an observational study based on administrative data. BMJ Open 2017; 7:e018243. [PMID: 29101146 PMCID: PMC5695401 DOI: 10.1136/bmjopen-2017-018243] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/08/2017] [Accepted: 09/29/2017] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES To evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF). DESIGN Retrospective observational study based on administrative data. SETTING Local Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants. PARTICIPANTS All patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015. PRIMARY AND SECONDARY OUTCOME MEASURES Multivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge. RESULTS The study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/angiotensin receptor blockers (ACEIs/ARBs), β-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or β-blockers (-53% and -28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (-28%). CONCLUSIONS Compared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF.
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Affiliation(s)
- Vera Maria Avaldi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Stefano Urbinati
- Department of Cardiology, Bellaria Hospital, Bologna, Emilia-Romagna, Italy
| | - Dario Molinazzi
- Department of Management Control and Administrative Data, Bologna Local Healthcare Authority, Bologna, Emilia-Romagna, Italy
| | - Carlo Descovich
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Emilia-Romagna, Italy
| | - Anselmo Campagna
- Regional Agency for Health and Social Care of Emilia-Romagna, Bologna, Emilia-Romagna, Italy
| | - Martina Taglioni
- Department of Clinical Governance and Quality, St Orsola-Malpighi Hospital, Bologna, Emilia-Romagna, Italy
| | - Angelo Fioritti
- Medical Directorate, Bologna Local Healthcare Authority, Bologna, Emilia-Romagna, Italy
| | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum - University of Bologna, Bologna, Emilia-Romagna, Italy
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11
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The Role of Cardiologists in the Management of Patients with Heart Failure. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1067:133-144. [PMID: 29188455 DOI: 10.1007/5584_2017_120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Heart failure is a complex clinical syndrome with a remarkable impact on health care systems in terms of patients' morbidity and mortality, as well as direct and indirect costs. It is essential to redesign models of care for patients with heart failure that are tailored on personalized health care needs and carried out in the most appropriate setting. There is some debate about the role of cardiologists in the management of patients with heart failure. Indeed, results regarding the inclination of cardiologists' patients to achieve better outcomes are controversial, given the heterogeneity of studies in terms of study design, population, setting and variables considered. The aim of this chapter is to describe and synthesize the current state of knowledge about the role of specialists in the management of patient with heart failure, and to assess whether there is a type of patients for which cardiologists demonstrate the greatest value or a setting of care where they add more benefit.
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12
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Miura M, Sakata Y, Miyata S, Shiba N, Takahashi J, Nochioka K, Takada T, Saga C, Shinozaki T, Sugi M, Nakagawa M, Sekiguchi N, Komaru T, Kato A, Fukuchi M, Nozaki E, Hiramoto T, Inoue K, Goto T, Ohe M, Tamaki K, Ibayashi S, Ishide N, Maruyama Y, Tsuji I, Shimokawa H. Influence of Left Ventricular Ejection Fraction on the Effects of Supplemental Use of Angiotensin Receptor Blocker Olmesartan in Hypertensive Patients With Heart Failure. Circ J 2016; 80:2155-64. [DOI: 10.1253/circj.cj-16-0577] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masanobu Miura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Satoshi Miyata
- Department of Evidence-based Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Nobuyuki Shiba
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Kotaro Nochioka
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tsuyoshi Takada
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital
| | - Chiharu Saga
- Department of Evidence-based Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tsuyoshi Shinozaki
- Cardiovascular Division, Sendai Medical Center, National Hospital Organization
| | | | | | | | - Tatsuya Komaru
- Department of Cardiology, Miyagi Cardiovascular and Respiratory Center
| | | | | | - Eiji Nozaki
- Department of Cardiology, Iwate Prefectural Central Hospital
| | | | - Kanichi Inoue
- Cardiovascular Division, South Miyagi Medical Center
| | - Toshikazu Goto
- Department of Cardiology, Yamagata Prefectural Central Hospital
| | - Masatoshi Ohe
- Cardiovascular Division, Kojirakawa Shieido Hospital
| | - Kenji Tamaki
- Cardiology Department, Iwate Health Service Association
| | | | | | | | - Ichiro Tsuji
- Division of Epidemiology, Department of Public Health and Forensic Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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13
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Short- and long-term mortality and hospital readmissions among patients with new hospitalization for heart failure: A population-based investigation from Italy. Int J Cardiol 2015; 181:81-7. [DOI: 10.1016/j.ijcard.2014.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/28/2014] [Accepted: 12/01/2014] [Indexed: 11/21/2022]
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14
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Sakata Y, Shiba N, Takahashi J, Miyata S, Nochioka K, Miura M, Takada T, Saga C, Shinozaki T, Sugi M, Nakagawa M, Sekiguchi N, Komaru T, Kato A, Fukuchi M, Nozaki E, Hiramoto T, Inoue K, Goto T, Ohe M, Tamaki K, Ibayashi S, Ishide N, Maruyama Y, Tsuji I, Shimokawa H. Clinical impacts of additive use of olmesartan in hypertensive patients with chronic heart failure: the supplemental benefit of an angiotensin receptor blocker in hypertensive patients with stable heart failure using olmesartan (SUPPORT) trial. Eur Heart J 2015; 36:915-23. [PMID: 25637937 PMCID: PMC4466154 DOI: 10.1093/eurheartj/ehu504] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 12/16/2014] [Indexed: 12/12/2022] Open
Abstract
We examined whether an additive treatment with an angiotensin receptor blocker, olmesartan, reduces the mortality and morbidity in hypertensive patients with chronic heart failure (CHF) treated with angiotensin-converting enzyme (ACE) inhibitors, β-blockers, or both. In this prospective, randomized, open-label, blinded endpoint study, a total of 1147 hypertensive patients with symptomatic CHF (mean age 66 years, 75% male) were randomized to the addition of olmesartan (n = 578) to baseline therapy vs. control (n = 569). The primary endpoint was a composite of all-cause death, non-fatal acute myocardial infarction, non-fatal stroke, and hospitalization for worsening heart failure. During a median follow-up of 4.4 years, the primary endpoint occurred in 192 patients (33.2%) in the olmesartan group and in 166 patients (29.2%) in the control group [hazard ratio (HR) 1.18; 95% confidence interval (CI), 0.96–1.46, P = 0.112], while renal dysfunction developed more frequently in the olmesartan group (16.8 vs. 10.7%, HR 1.64; 95% CI 1.19–2.26, P = 0.003). Subgroup analysis revealed that addition of olmesartan to combination of ACE inhibitors and β-blockers was associated with increased incidence of the primary endpoint (38.1 vs. 28.2%, HR 1.47; 95% CI 1.11–1.95, P = 0.006), all-cause death (19.4 vs. 13.5%, HR 1.50; 95% CI 1.01–2.23, P = 0.046), and renal dysfunction (21.1 vs. 12.5%, HR 1.85; 95% CI 1.24–2.76, P = 0.003). Additive use of olmesartan did not improve clinical outcomes but worsened renal function in hypertensive CHF patients treated with evidence-based medications. Particularly, the triple combination therapy with olmesartan, ACE inhibitors and β-blockers was associated with increased adverse cardiac events. This study is registered at clinicaltrials.gov-NCT00417222.
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Affiliation(s)
- Yasuhiko Sakata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Nobuyuki Shiba
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Jun Takahashi
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Satoshi Miyata
- Department of Evidence-based Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Kotaro Nochioka
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Masanobu Miura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Tsuyoshi Takada
- Department of Cardiovascular Medicine, International University of Health and Welfare Hospital, Nasushiobara, Japan
| | - Chiharu Saga
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
| | - Tsuyoshi Shinozaki
- Cardiovascular Division, Sendai Medical Center, National Hospital Organization, Sendai, Japan
| | - Masafumi Sugi
- Cardiovascular Division, Iwaki Kyouritsu Hospital, Iwaki, Japan
| | - Makoto Nakagawa
- Department of Cardiology, Iwate Prefectural Isawa Hospital, Oshu, Japan
| | | | - Tatsuya Komaru
- Department of Cardiology, Miyagi Cardiovascular and Respiratory Center, Kurihara, Japan
| | - Atsushi Kato
- Cardiovascular Division, Sendai Open Hospital, Sendai, Japan
| | | | - Eiji Nozaki
- Department of Cardiology, Iwate Prefectural Central Hospital, Morioka, Japan
| | | | - Kanichi Inoue
- Cardiovascular Division, South Miyagi Medical Center, Ogawara, Japan
| | - Toshikazu Goto
- Department of Cardiology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Masatoshi Ohe
- Cardiovascular Division, Kojirakawa Shiseido Hospital, Yamagata, Japan
| | - Kenji Tamaki
- Department of Cardiology, Iwate Prefectural Miyako Hospital, Miyako, Japan
| | | | | | | | - Ichiro Tsuji
- Division of Epidemiology, Department of Public Health and Forensic Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan Department of Evidence-based Cardiovascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai 980-8574, Japan
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15
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Padwal R, Lin M, Etminan M, Eurich DT. Comparative Effectiveness of Olmesartan and Other Angiotensin Receptor Blockers in Diabetes Mellitus. Hypertension 2014; 63:977-83. [DOI: 10.1161/hypertensionaha.113.02855] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Olmesartan has been linked with increased risk of cardiovascular mortality and sprue-like enteropathy. We compared outcomes between olmesartan and other angiotensin receptor blockers in a large clinical registry of patients with diabetes mellitus. A retrospective cohort analysis using nationwide US-integrated insurance and laboratory claims was performed in 45 185 incident diabetic angiotensin receptor blocker users, including 10 370 (23%) olmesartan users. Hazard ratios were computed using time-dependant Cox models adjusted for sociodemographic characteristics, comorbidities, laboratory data, drug use, healthcare utilization, and the propensity to receive olmesartan. Blood pressure data were unavailable. Subjects were followed up for 116 721 patient-years. The primary end point was all-cause hospitalization or all-cause mortality and occurred in 10 915 (24%) patients. Average age was 54.3±9.6 years, 52% were men, 17% had cardiovascular disease, and 10% chronic kidney disease. Compared with other angiotensin receptor blockers, the adjusted hazard for olmesartan was 0.99 (95% confidence interval, 0.94–1.05) for all-cause hospitalization and mortality; 0.90 (0.62–1.30) for all-cause mortality; 0.99 (0.94–1.05) for all-cause hospital admission; 0.88 (0.78–1.00) for cardiovascular disease–related admission, and 1.09 (0.98–1.20) for gastrointestinal disease–related hospitalization in the overall cohort. Olmesartan use was associated with an adjusted hazard for the primary outcome of 1.11 (0.99–1.24) in subjects with history of cardiovascular disease and 1.21 (1.04–1.41) in subjects with chronic kidney disease. In conclusion, there is no robust signal for harm with olmesartan use. Risk may be increased in kidney disease; thus, given the widespread availability of alternate agents, olmesartan should be used with caution in this subgroup pending further study.
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Affiliation(s)
- Raj Padwal
- From the Department of Medicine (R.P.), Department of Public Health Sciences, School of Public Health (M.L., D.T.E.), and Alliance for Canadian Health Outcomes Research in Diabetes (D.T.E.), University of Alberta, Edmonton, Alberta, Canada; Alberta Diabetes Institute, Edmonton, Alberta, Canada (R.P., M.L., D.T.E.); and Therapeutic Evaluation Unit, Provincial Health Services Authority of BC, Faculty of Medicine, University of British Columbia, Vancouver, Canada (R.P., M.E.)
| | - Mu Lin
- From the Department of Medicine (R.P.), Department of Public Health Sciences, School of Public Health (M.L., D.T.E.), and Alliance for Canadian Health Outcomes Research in Diabetes (D.T.E.), University of Alberta, Edmonton, Alberta, Canada; Alberta Diabetes Institute, Edmonton, Alberta, Canada (R.P., M.L., D.T.E.); and Therapeutic Evaluation Unit, Provincial Health Services Authority of BC, Faculty of Medicine, University of British Columbia, Vancouver, Canada (R.P., M.E.)
| | - Mahyar Etminan
- From the Department of Medicine (R.P.), Department of Public Health Sciences, School of Public Health (M.L., D.T.E.), and Alliance for Canadian Health Outcomes Research in Diabetes (D.T.E.), University of Alberta, Edmonton, Alberta, Canada; Alberta Diabetes Institute, Edmonton, Alberta, Canada (R.P., M.L., D.T.E.); and Therapeutic Evaluation Unit, Provincial Health Services Authority of BC, Faculty of Medicine, University of British Columbia, Vancouver, Canada (R.P., M.E.)
| | - Dean T. Eurich
- From the Department of Medicine (R.P.), Department of Public Health Sciences, School of Public Health (M.L., D.T.E.), and Alliance for Canadian Health Outcomes Research in Diabetes (D.T.E.), University of Alberta, Edmonton, Alberta, Canada; Alberta Diabetes Institute, Edmonton, Alberta, Canada (R.P., M.L., D.T.E.); and Therapeutic Evaluation Unit, Provincial Health Services Authority of BC, Faculty of Medicine, University of British Columbia, Vancouver, Canada (R.P., M.E.)
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