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RAAS: A Convergent Player in Ischemic Heart Failure and Cancer. Int J Mol Sci 2021; 22:ijms22137106. [PMID: 34281199 PMCID: PMC8268500 DOI: 10.3390/ijms22137106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 12/12/2022] Open
Abstract
The current global prevalence of heart failure is estimated at 64.34 million cases, and it is expected to increase in the coming years, especially in countries with a medium-low sociodemographic index where the prevalence of risk factors is increasing alarmingly. Heart failure is associated with many comorbidities and among them, cancer has stood out as a contributor of death in these patients. This connection points out new challenges both in the context of the pathophysiological mechanisms involved, as well as in the quality of life of affected individuals. A hallmark of heart failure is chronic activation of the renin-angiotensin-aldosterone system, especially marked by a systemic increase in levels of angiotensin-II, a peptide with pleiotropic activities. Drugs that target the renin-angiotensin-aldosterone system have shown promising results both in the prevention of secondary cardiovascular events in myocardial infarction and heart failure, including a lower risk of certain cancers in these patients, as well as in current cancer therapies; therefore, understanding the mechanisms involved in this complex relationship will provide tools for a better diagnosis and treatment and to improve the prognosis and quality of life of people suffering from these two deadly diseases.
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Singh KD, Karnik SS. Angiotensin Type 1 Receptor Blockers in Heart Failure. Curr Drug Targets 2021; 21:125-131. [PMID: 31433752 DOI: 10.2174/1389450120666190821152000] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/31/2019] [Accepted: 08/07/2019] [Indexed: 11/22/2022]
Abstract
Homeostasis in the cardiovascular system is maintained by physiological functions of the Renin Angiotensin Aldosterone System (RAAS). In pathophysiological conditions, over activation of RAAS leads to an increase in the concentration of Angiotensin II (AngII) and over activation of Angiotensin Type 1 Receptor (AT1R), resulting in vasoconstriction, sodium retention and change in myocyte growth. It causes cardiac remodeling in the heart which results in left ventricular hypertrophy, dilation and dysfunction, eventually leading to Heart Failure (HF). Inhibition of RAAS using angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) has shown to significantly reduce morbidity and mortality due to HF. ACEi have been shown to have higher drug withdrawal rates due to discomfort when compared to ARBs; therefore, ARBs are the preferred choice of physicians for the treatment of HF in combination with other anti-hypertensive agents. Currently, eight ARBs have been approved by FDA and are clinically used. Even though they bind to the same site of AT1R displacing AngII binding but clinical outcomes are significantly different. In this review, we described the clinical significance of each ARB in the treatment of HF and their clinical outcome.
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Affiliation(s)
- Khuraijam Dhanachandra Singh
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Sadashiva S Karnik
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, United States
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Kim YH, Her AY, Jeong MH, Kim BK, Hong SJ, Kim S, Ahn CM, Kim JS, Ko YG, Choi D, Hong MK, Jang Y. Monotherapy versus combination therapy of statin and renin-angiotensin system inhibitor in ST-segment elevation myocardial infarction. Cardiol J 2020; 29:93-104. [PMID: 32207841 PMCID: PMC8890409 DOI: 10.5603/cj.a2020.0035] [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: 09/17/2019] [Accepted: 03/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background The beneficial effects of statin and renin–angiotensin system inhibitor (RASI) are well-known. In this retrospective cohort study, 2-year clinical outcomes were compared between monotherapy and combination therapy with statin and RASI in ST-segment elevation myocardial infarction (STEMI) patients after stent implantation. Methods A total of 17,414 STEMI patients were enrolled and divided into the three groups (group A: 2448 patients, statin alone; group B: 2431 patients, RASI alone; and group C: 12,535 patients, both statin and RASI). The principal clinical endpoint was the occurrence of major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction, and any repeat revascularization. Results After adjustment, the cumulative incidences of MACEs in group A (adjusted hazard ratio [aHR] 1.337; 95% confidence interval [CI] 1.064–1.679; p = 0.013) and in group B (aHR 1.375; 95% CI 1.149–1.646; p = 0.001) were significantly higher than in group C. The cumulative incidence of all-cause death in group A was significantly higher than that in group C (aHR 1.539; 95% CI 1.014–2.336; p = 0.043). The cumulative incidences of any repeat revascularization (aHR 1.317; 95% CI 1.031–1.681; p = 0.028), target lesion vascularization, and target vessel vascularization in group B were significantly higher than in group C. Conclusions A statin and RASI combination therapy significantly reduced the cumulative incidence of MACEs compared with a monotherapy of these drugs. Moreover, the combination therapy showed a reduced all-cause death rate compared with statin monotherapy, and a decreased repeat revascularization rate compared with RASI monotherapy.
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Affiliation(s)
- Yong Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Myung-Ho Jeong
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seunghwan Kim
- Division of Cardiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
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Docherty KF, Ferreira JP, Sharma A, Girerd N, Gregson J, Duarte K, Petrie MC, Jhund PS, Dickstein K, Pfeffer MA, Pitt B, Rossignol P, Zannad F, McMurray JJV. Predictors of sudden cardiac death in high-risk patients following a myocardial infarction. Eur J Heart Fail 2020; 22:848-855. [PMID: 31944496 DOI: 10.1002/ejhf.1694] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 12/21/2022] Open
Abstract
AIMS To develop a risk model for sudden cardiac death (SCD) in high-risk acute myocardial infarction (AMI) survivors. METHODS AND RESULTS Data from the Effect of Carvedilol on Outcome After Myocardial Infarction in Patients With Left Ventricular Dysfunction trial (CAPRICORN) and the Valsartan in Acute Myocardial Infarction Trial (VALIANT) were used to create a SCD risk model (with non-SCD as a competing risk) in 13 202 patients. The risk model was validated in the Eplerenone Post-AMI Heart Failure Efficacy and Survival Study (EPHESUS). The rate of SCD was 3.3 (95% confidence interval 3.0-3.5) per 100 person-years over a median follow-up of 2.0 years. Independent predictors of SCD included age > 70 years; heart rate ≥ 70 bpm; smoking; Killip class III/IV; left ventricular ejection fraction ≤30%; atrial fibrillation; history of prior myocardial infarction, heart failure or diabetes; estimated glomerular filtration rate < 60 mL/min/1.73 m2 ; and no coronary reperfusion or revascularisation therapy for index AMI. The model was well calibrated and showed good discrimination (C-statistic = 0.72), including in the early period after AMI. The observed 2-year event rates increased steeply with each quintile of risk score (1.9%, 3.6%, 6.2%, 9.0%, 13.4%, respectively). CONCLUSION An easy to use SCD risk score developed from routinely collected clinical variables in patients with heart failure, left ventricular systolic dysfunction or both, early after AMI was superior to left ventricular ejection fraction. This score might be useful in identifying patients for future trials testing treatments to prevent SCD early after AMI.
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Affiliation(s)
- Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - João Pedro Ferreira
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France.,Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, Montreal, Canada
| | - Nicolas Girerd
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Kevin Duarte
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Kenneth Dickstein
- Department of Cardiology, University of Bergan, Stavanger University Hospital, Stavanger, Norway
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Patrick Rossignol
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Hall TS, von Lueder TG, Zannad F, Rossignol P, Duarte K, Chouihed T, Solomon SD, Dickstein K, Atar D, Agewall S, Girerd N. Left ventricular ejection fraction and adjudicated, cause-specific hospitalizations after myocardial infarction complicated by heart failure or left ventricular dysfunction. Am Heart J 2019; 215:83-90. [PMID: 31291604 DOI: 10.1016/j.ahj.2019.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 06/01/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Reduced left ventricular ejection fraction (LVEF) after acute myocardial infarction (MI) increases risk of cardiovascular (CV) hospitalizations, but evidence regarding its association with non-CV outcome is scarce. We investigated the association between LVEF and adjudicated cause-specific hospitalizations following MI complicated with low LVEF or overt heart failure (HF). METHODS In an individual patient data meta-analysis of 19,740 patients from 3 large randomized trials, Fine and Gray competing risk modeling was performed to study the association between LVEF and hospitalization types. RESULTS The most common cause of hospitalization was non-CV (n = 2,368 for HF, n = 1,554 for MI, and n = 3,703 for non-CV). All types of hospitalizations significantly increased with decreasing LVEF. The absolute risk increase associated with LVEF ≪25% (vs LVEF ≫35%) was 15.5% (95% CI 13.4-17.5) for HF, 4.7% (95% CI 3.0-6.4) for MI, and 10.4% (95% CI 8.0-12.8) for non-CV hospitalization. On a relative scale, after adjusting for confounders, each 5-point decrease in LVEF was associated with an increased risk of HF (hazard ratio [HR] 1.15, 95% CI 1.12-1.18), MI (HR 1.06, 95% CI 1.03-1.10), and non-CV hospitalization (HR 1.03, 95% CI 1.01-1.05). CONCLUSIONS In a high-risk population with complicated acute MI, the absolute risk increase in non-CV hospitalizations associated with LVEF ≪25% was two thirds of the absolute risk increase in HF hospitalizations and twice the absolute risk increase in MI hospitalizations. LVEF was an independent predictor of all types of hospitalization and appears as an integrative marker of sicker patient status.
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Ferreira JP, Girerd N, Gregson J, Latar I, Sharma A, Pfeffer MA, McMurray JJV, Abdul-Rahim AH, Pitt B, Dickstein K, Rossignol P, Zannad F. Stroke Risk in Patients With Reduced Ejection Fraction After Myocardial Infarction Without Atrial Fibrillation. J Am Coll Cardiol 2019; 71:727-735. [PMID: 29447733 DOI: 10.1016/j.jacc.2017.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/05/2017] [Accepted: 12/06/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Stroke can occur after myocardial infarction (MI) in the absence of atrial fibrillation (AF). OBJECTIVES This study sought to identify risk factors (excluding AF) for the occurrence of stroke and to develop a calibrated and validated stroke risk score in patients with MI and heart failure (HF) and/or systolic dysfunction. METHODS The datasets included in this pooling initiative were derived from 4 trials: CAPRICORN (Effect of Carvedilol on Outcome After Myocardial Infarction in Patients With Left Ventricular Dysfunction), OPTIMAAL (Optimal Trial in Myocardial Infarction With Angiotensin II Antagonist Losartan), VALIANT (Valsartan in Acute Myocardial Infarction Trial), and EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study); EPHESUS was used for external validation. A total of 22,904 patients without AF or oral anticoagulation were included in this analysis. The primary outcome was stroke, and death was treated as a "competing risk." RESULTS During a median follow-up of 1.9 years (interquartile range: 1.3 to 2.7 years), 660 (2.9%) patients had a stroke. These patients were older, more often female, smokers, and hypertensive; they had a higher Killip class; a lower estimated glomerular filtration rate; and a higher proportion of MI, HF, diabetes, and stroke histories. The final stroke risk model retained older age, Killip class 3 or 4, estimated glomerular filtration rate ≤45 ml/min/1.73 m2, hypertension history, and previous stroke. The models were well calibrated and showed moderate to good discrimination (C-index = 0.67). The observed 3-year event rates increased steeply for each sextile of the stroke risk score (1.8%, 2.9%, 4.1%, 5.6%, 8.3%, and 10.9%, respectively) and were in agreement with the expected event rates. CONCLUSIONS Readily accessible risk factors associated with the occurrence of stroke were identified and incorporated in an easy-to-use risk score. This score may help in the identification of patients with MI and HF and a high risk for stroke despite their not presenting with AF.
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Affiliation(s)
- João Pedro Ferreira
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France; Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Nicolas Girerd
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - John Gregson
- Department of Biostatistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Ichraq Latar
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Abhinav Sharma
- Duke Clinical Research Institute, Duke University, Durham, North Carolina; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Azmil H Abdul-Rahim
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Kenneth Dickstein
- Department of Cardiology, University of Bergan, Stavanger University Hospital, Stavanger, Norway
| | - Patrick Rossignol
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Faiez Zannad
- National Institute of Health and Medical Research (INSERM), Center for Clinical Multidisciplinary Research 1433, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network (F-CRIN) Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France.
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Mean BMI, visit-to-visit BMI variability and BMI changes during follow-up in patients with acute myocardial infarction with systolic dysfunction and/or heart failure: insights from the High-Risk Myocardial Infarction Initiative. Clin Res Cardiol 2019; 108:1215-1225. [PMID: 30953180 DOI: 10.1007/s00392-019-01453-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 03/13/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND In patients with acute myocardial infarction (MI), BMI < 18.5 kg/m2 and a decrease in BMI during follow-up have been associated with poor prognosis. For BMI ≥ 25 kg/m2, an "obesity paradox" has been suggested. Recently, high visit-to-visit BMI variability has also been associated with poor prognosis in patients with coronary artery disease. AIMS To simultaneously evaluate several BMI measurements and study their association with cardiovascular (CV) outcomes in a large cohort of patients with acute myocardial infarction (MI) and left ventricular (LV) systolic dysfunction, heart failure (HF) or both. METHODS The high-risk MI dataset is pooled from four trials: CAPRICORN, EPHESUS, OPTIMAAL and VALIANT. Mean BMI, change from baseline, and variability were assessed during follow-up. The primary outcome was CV death. Cox-proportional hazard models were performed to study the association between the various BMI parameters and outcomes (median follow-up = 1.8 years). RESULTS A total of 12,719 patients were included (72% male, mean age 65 ± 11 years). Mean, change and visit-to-visit variability in BMI had a non-linear association with CV death (P < 0.001). Mean BMI < 26 kg/m2 (vs. ≥ 26-35 kg/m2) and BMI decrease during follow-up were independently associated with CV death (adjusted HR 1.32, 95% CI 1.16-1.51, P < 0.001 and adjusted HR 1.57, 95% CI 1.40-1.76, P < 0.001, respectively). Low and high BMI variability (< 2% and > 4%) were associated with increased event-rates, but lost statistical significance in sensitivity analysis including patients with ≥ 5 measurements or excluding patients with HF hospitalization, suggesting that BMI variability may be particularly associated with HF hospitalizations. CONCLUSION Mean BMI < 26 kg/m2 and a BMI decrease during follow-up were independently associated with CV death in patients with MI and LV systolic dysfunction, HF or both. These associations likely reflect poorer patient status and causality cannot be inferred.
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Comparison Between Beta-Blockers with Angiotensin-Converting Enzyme Inhibitors and Beta-Blockers with Angiotensin II Type I Receptor Blockers in ST-Segment Elevation Myocardial Infarction After Successful Percutaneous Coronary Intervention with Drug-Eluting Stents. Cardiovasc Drugs Ther 2019; 33:55-67. [DOI: 10.1007/s10557-018-6841-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Hall TS, von Lueder TG, Zannad F, Rossignol P, Duarte K, Chouihed T, Dickstein K, Atar D, Agewall S, Girerd N. Relationship between left ventricular ejection fraction and mortality after myocardial infarction complicated by heart failure or left ventricular dysfunction. Int J Cardiol 2018; 272:260-266. [PMID: 30144995 DOI: 10.1016/j.ijcard.2018.07.137] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 07/18/2018] [Accepted: 07/27/2018] [Indexed: 01/04/2023]
Abstract
BACKGROUND Identifying risk factors for specific modes of death in patients with heart failure (HF) or left ventricular (LV) dysfunction after acute myocardial infarction (MI) may help to avert events. We sought to evaluate LV ejection fraction (LVEF) as a prognosticator of specific death modes. METHODS AND RESULTS In an individual patient data meta-analysis of four merged trials (CAPRICORN, EPHESUS, OPTIMAAL, and VALIANT), Cox modelling was performed to study the association between baseline LVEF from 19,740 patients and types of death during follow-up. Over a median follow-up of 707 days 3419 deaths occurred. The distribution pattern for mode of death was similar across categories (LVEF < 25%, LVEF 25-35%, and LVEF > 35%). In multivariable models, the risk of all types of death increased with decreasing LVEF. If compared to LVEF > 35%, LVEF < 25% was associated with a 113% increased risk of sudden death (hazard ratio (HR) 2.13, 95% confidence interval (CI) 1.53-2.98), a 170% increased risk of HF death (HR 2.70, 95% CI 1.83-3.98), a 66% increased risk of other cardiovascular (CV) death (HR 1.66, 95% CI 1.14-2.42), and a 90% increased risk of non CV death (HR 1.90, 95% CI 1.15-3.14). CONCLUSION In patients with HF or LV dysfunction after acute MI, low LVEF is a ubiquitous risk marker associated with death regardless of type. The different modes of death are fairly equally represented throughout the categories of LVEF and sudden death remains a significant mode of death also in patients with LVEF > 35%.
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Affiliation(s)
- Trygve S Hall
- Department of Cardiology B, Oslo University Hospital, Oslo, Norway.
| | | | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique - 1433 and Unité 1116, Nancy, France; CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France; Université de Lorraine, Nancy, France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) Network, Nancy, France
| | - Patrick Rossignol
- INSERM, Centre d'Investigation Clinique - 1433 and Unité 1116, Nancy, France; CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France; Université de Lorraine, Nancy, France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) Network, Nancy, France
| | - Kevin Duarte
- INSERM, Centre d'Investigation Clinique - 1433 and Unité 1116, Nancy, France; CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France; Université de Lorraine, Nancy, France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) Network, Nancy, France
| | - Tahar Chouihed
- INSERM, Centre d'Investigation Clinique - 1433 and Unité 1116, Nancy, France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) Network, Nancy, France; Emergency Department, CHU Nancy, Nancy, France
| | - Kenneth Dickstein
- Division of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Stefan Agewall
- Department of Cardiology B, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nicolas Girerd
- INSERM, Centre d'Investigation Clinique - 1433 and Unité 1116, Nancy, France; CHU Nancy, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France; Université de Lorraine, Nancy, France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) Network, Nancy, France
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11
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Relation of High Serum Bilirubin to Short-Term Mortality Following a Myocardial Infarction Complicated by Left Ventricular Systolic Dysfunction (from the High-Risk Myocardial Infarction Database Initiative). Am J Cardiol 2018; 121:1015-1020. [PMID: 29631805 DOI: 10.1016/j.amjcard.2018.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 01/09/2018] [Accepted: 01/15/2018] [Indexed: 11/21/2022]
Abstract
Higher serum bilirubin has been associated with poorer prognosis in patients with heart failure (HF). We examined the association between serum bilirubin and clinical outcomes in patients with clinical signs of HF and/or left ventricular systolic dysfunction after acute myocardial infarction (MI). A total of 7,467 patients from the High-Risk Myocardial Infarction Database Initiative with an available baseline total bilirubin concentration were studied. The association between baseline bilirubin concentrations and the composite outcome of cardiovascular mortality (CVM), nonfatal stroke, nonfatal MI or hospitalization for HF, CVM, and all-cause mortality were assessed using Cox proportional hazards models. An interaction with time was observed with associations present only in the first 90 days after randomization. The median (percentile25-75) baseline total bilirubin concentration was 11 (8 to 14) µmol/L and was above the "normal" range (>17.1 µmol/L) in 1,053 (14.1%) patients. In multivariable analysis, with adjustment for baseline characteristics (demographic, co-morbidities, Killip score, left ventricular ejection fraction, and laboratory variables), patients with a bilirubin concentration of >17.1 µmol/L had a significantly higher risk of all the studied outcomes at 90 days (e.g., CVM: adjusted hazard ratio 1.45, 95% confidence interval 1.14 to 1.86, p = 0.003). The addition of bilirubin to a validated survival model modestly improved the risk reclassification to predict 90-day events (continuous net reclassification improvement for CVM 6.4%, 95% confidence interval 0.7% to 9.6%, p = 0.04). In patients with MI complicated with HF and/or systolic dysfunction, bilirubin concentration is an independent predictor of mortality and may improve risk stratification.
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12
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Ferreira JP, Duarte K, Pfeffer MA, McMurray JJV, Pitt B, Dickstein K, Zannad F, Rossignol P. Association between mean systolic and diastolic blood pressure throughout the follow-up and cardiovascular events in acute myocardial infarction patients with systolic dysfunction and/or heart failure: an analysis from the High-Risk Myocardial Infarction Database Initiative. Eur J Heart Fail 2018; 20:323-331. [PMID: 29314455 DOI: 10.1002/ejhf.1131] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/28/2017] [Accepted: 11/30/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Observational data have described the association of blood pressure (BP) with mortality as 'J-shaped', meaning that mortality rates increase below a certain BP threshold. We aimed to analyse the associations between BP and prognosis in a population of acute myocardial infarction (MI) patients with heart failure (HF) and/or systolic dysfunction. METHODS AND RESULTS The datasets included in this pooling initiative are derived from four trials: CAPRICORN, EPHESUS, OPTIMAAL, and VALIANT. A total of 28 771 patients were included in this analysis. Arithmetic means of all office BP values measured throughout follow-up were used. The primary outcome was cardiovascular death. The mean age was 65 ± 11.5 years and 30% were female. Patients in the lower systolic BP (SBP) quintiles had higher rates of cardiovascular death (reference: SBP 121-128 mmHg) [adjusted hazard ratio (HR) 2.49, 95% confidence interval (CI) 2.26-2.74 for SBP ≤112 mmHg, and HR 1.29, 95% CI 1.16-1.43 for SBP 113-120 mmHg]. The findings for HF hospitalization and MI were similar. However, stroke rates were higher in patients within the highest SBP quintile (reference: SBP 121-128 mmHg) (HR 1.38, 95% CI 1.11-1.72). Patients who died had a much shorter follow-up (0.7 vs. 2.1 years), less BP measurements (4.6 vs. 9.8) and lower mean BP (-8 mmHg in the last SBP measurement compared with patients who remained alive during the follow-up), suggesting that the associations of low BP and increased cardiovascular death represent a reverse causality phenomenon. CONCLUSION Systolic BP values <125 mmHg were associated with increased cardiovascular death, but these findings likely represent a reverse causality phenomenon.
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Affiliation(s)
- João Pedro Ferreira
- INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France.,Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Kevin Duarte
- Université de Lorraine, Institut Elie Cartan de Lorraine, UMR 7502, Vandoeuvre-lès-Nancy, France.,CNRS, Institut Elie Cartan de Lorraine, UMR 7502, Vandoeuvre-lès-Nancy, France.,Team BIGS, INRIA, Villers-lès-Nancy, France
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Kenneth Dickstein
- Department of Cardiology, University of Bergan, Stavanger University Hospital, Stavanger, Norway
| | - Faiez Zannad
- INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Patrick Rossignol
- INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
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13
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Dahlöf B. Valsartan and the renin-angiotensin-aldosterone system: Blood pressure control and beyond. J Renin Angiotensin Aldosterone Syst 2017; 1:S14-6. [PMID: 17199213 DOI: 10.3317/jraas.2000.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Patients treated for hypertension are still at significantly elevated risk for cardiovascular complications when compared with normotensive patients, even when on antihypertensive therapy. In all fairness though, a majority of these patients have uncontrolled blood pressure. Blocking the renin-angiotensin-aldosterone system (RAAS) prevents or reverses cardiac remodelling and improves prognosis in cardiovascular disease beyond the effects on blood pressure (BP). Valsartan acts by selectively blocking the AT1-receptor and shows similar efficacy and improved tolerability compared with ACE inhibitors. This drug may provide additional benefits in controlling the cardiovascular complications of hypertension. Results of large clinical trials with valsartan, such as VALUE, Val-HEFT, VALIANT and ABCD-2V, are eagerly awaited.
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Affiliation(s)
- B Dahlöf
- Göteborg University, Göteborg, Sweden.
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14
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Pfeffer MA. Will more complete inhibition of the RAAS with angiotensin receptor blockade improve survival following myocardial infarction? J Renin Angiotensin Aldosterone Syst 2017; 1:S41-3. [PMID: 17199221 DOI: 10.3317/jraas.2000.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Angiotensin-converting enzyme (ACE) inhibitors have a well-established role in the management of patients with hypertension, diabetes, heart failure and myocardial infarction (MI). ACE inhibitors have been particularly well studied in acute and chronic MI with consistent and substantial survival benefits demonstrated, particularly in the higher risk groups. The recent development of angiotensin II (Ang II) receptor blockers (ARBs) as a well tolerated pharmacological therapy to more completely inhibit the actions of Ang II at the AT1-receptor level raises questions concerning comparative efficacy with the proven ACE inhibitor experience. Two major trials will provide a direct comparison of ARBs with an ACE inhibitor. The Valsartan in Acute Myocardial Infarction (VALIANT) trial is specifically designed to compare and contrast the ARB, valsartan, used both alone as well as in combination with a proven ACE inhibitor regimen, in a high risk MI population. VALIANT, with its three arms targetting 14,500 patients, is uniquely poised to determine whether the pharmacological advance in the development of ARBs confers additional clinical (survival) value in high risk MI patients.
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Affiliation(s)
- M A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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15
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Ferreira JP, Girerd N, Pellicori P, Duarte K, Girerd S, Pfeffer MA, McMurray JJV, Pitt B, Dickstein K, Jacobs L, Staessen JA, Butler J, Latini R, Masson S, Mebazaa A, Rocca HPBL, Delles C, Heymans S, Sattar N, Jukema JW, Cleland JG, Zannad F, Rossignol P. Renal function estimation and Cockroft-Gault formulas for predicting cardiovascular mortality in population-based, cardiovascular risk, heart failure and post-myocardial infarction cohorts: The Heart 'OMics' in AGEing (HOMAGE) and the high-risk myocardial infarction database initiatives. BMC Med 2016; 14:181. [PMID: 27829460 PMCID: PMC5103492 DOI: 10.1186/s12916-016-0731-2] [Citation(s) in RCA: 40] [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: 06/30/2016] [Accepted: 10/26/2016] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Renal impairment is a major risk factor for mortality in various populations. Three formulas are frequently used to assess both glomerular filtration rate (eGFR) or creatinine clearance (CrCl) and mortality prediction: body surface area adjusted-Cockcroft-Gault (CG-BSA), Modification of Diet in Renal Disease Study (MDRD4), and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. The CKD-EPI is the most accurate eGFR estimator as compared to a "gold-standard"; however, which of the latter is the best formula to assess prognosis remains to be clarified. This study aimed to compare the prognostic value of these formulas in predicting the risk of cardiovascular mortality (CVM) in population-based, cardiovascular risk, heart failure (HF) and post-myocardial infarction (MI) cohorts. METHODS Two previously published cohorts of pooled patient data derived from the partners involved in the HOMAGE-consortium and from four clinical trials - CAPRICORN, EPHESUS, OPTIMAAL and VALIANT - the high risk MI initiative, were used. A total of 54,111 patients were included in the present analysis: 2644 from population-based cohorts; 20,895 from cardiovascular risk cohorts; 1801 from heart failure cohorts; and 28,771 from post-myocardial infarction cohorts. Participants were patients enrolled in the respective cohorts and trials. The primary outcome was CVM. RESULTS All formulas were strongly and independently associated with CVM. Lower eGFR/CrCl was associated with increasing CVM rates for values below 60 mL/min/m2. Categorical renal function stages diverged in a more pronounced manner with the CG-BSA formula in all populations (higher χ2 values), with lower stages showing stronger associations. The discriminative improvement driven by the CG-BSA formula was superior to that of MDRD4 and CKD-EPI, but remained low overall (increase in C-index ranging from 0.5 to 2 %) while not statistically significant in population-based cohorts. The integrated discrimination improvement and net reclassification improvement were higher (P < 0.05) for the CG-BSA formula compared to MDRD4 and CKD-EPI in CV risk, HF and post-MI cohorts, but not in population-based cohorts. The CKD-EPI formula was superior overall to MDRD4. CONCLUSIONS The CG-BSA formula was slightly more accurate in predicting CVM in CV risk, HF, and post-MI cohorts (but not in population-based cohorts). However, the CG-BSA discriminative improvement was globally low compared to MDRD4 and especially CKD-EPI, the latter offering the best compromise between renal function estimation and CVM prediction.
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Affiliation(s)
- João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Pierpaolo Pellicori
- Academic Cardiology Unit, University of Hull, Castle Hill Hospital, Kingston upon Hull, UK
| | - Kevin Duarte
- Université de Lorraine, Institut Elie Cartan de Lorraine, UMR 7502,, Vandoeuvre-lès-Nancy, F-54506, France.,CNRS, Institut Elie Cartan de Lorraine, UMR 7502,, Vandoeuvre-lès-Nancy, F-54506, France.,Team BIGS, INRIA, Villers-lès-Nancy, F-54600, France
| | - Sophie Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, 02115, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MA, USA.,ASH Comprehensive Hypertension Center, Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The University of Chicago, Chicago, IL, USA
| | - Kenneth Dickstein
- Department of Cardiology, University of Bergan, Stavanger University Hospital, Stavanger, Norway
| | - Lotte Jacobs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Jan A Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, NY, USA
| | - Roberto Latini
- Laboratory of Cardiovascular Clinical Pharmacology, IRCCS - Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - Serge Masson
- Laboratory of Cardiovascular Clinical Pharmacology, IRCCS - Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - Alexandre Mebazaa
- Hôpital Lariboisière, Université Paris Diderot, Inserm 942, Paris, France
| | - Hans Peter Brunner-La Rocca
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Christian Delles
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Stephane Heymans
- Department of Cardiology, Maastricht University Medical Center, Postbox 5800, 6202, AZ, Maastricht, The Netherlands
| | - Naveed Sattar
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - J Wouter Jukema
- Department of Cardiology and Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands
| | - John G Cleland
- National Heart and Lung Institute, Imperial College London (Royal Brompton and Harefield Hospitals) Department of Cardiology, Castle Hill Hospital, University of Hull, Hull, UK
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France. .,Centre d'Investigations Cliniques-INSERM CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500, Vandoeuvre lès Nancy, France.
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16
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Lopes RD, Pieper KS, Stevens SR, Solomon SD, McMurray JJV, Pfeffer MA, Leimberger JD, Velazquez EJ. Predicting Outcomes Over Time in Patients With Heart Failure, Left Ventricular Systolic Dysfunction, or Both Following Acute Myocardial Infarction. J Am Heart Assoc 2016; 5:JAHA.115.003045. [PMID: 27353607 PMCID: PMC4937254 DOI: 10.1161/jaha.115.003045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Most studies of risk assessment or stratification in patients with myocardial infarction (MI) have been static and fail to account for the evolving nature of clinical events and care processes. We sought to identify predictors of mortality, cardiovascular death or nonfatal MI, and cardiovascular death or nonfatal heart failure (HF) over time in patients with HF, left ventricular systolic dysfunction, or both post‐MI. Methods and Results Using data from the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial, we developed models to estimate the association between patient characteristics and the likelihood of experiencing an event from the time of a follow‐up visit until the next visit. The intervals are: hospital arrival to discharge or 14 days, whichever occurs first; hospital discharge to 30 days; 30 days to 6 months; and 6 months to 3 years. Models were also developed to predict the entire 3‐year follow‐up period using baseline information. Multivariable Cox proportional hazards modeling was used throughout with Wald chi‐squares as the comparator of strength for each predictor. For the baseline model of overall mortality, the 3 strongest predictors were age (adjusted hazard ratio [HR], 1.35; 95% CI, 1.28–1.42; P<0.0001), baseline heart rate (adjusted HR, 1.17; 95% CI, 1.14–1.21; P<0.0001), and creatinine clearance (≤100 mL/min; adjusted HR, 0.86; 95% CI, 0.84–0.89; P<0.0001). According to the integrated discrimination improvement (IDI) and net reclassification improvement (NRI) indices, the updated model had significant improvement over the model with baseline covariates only in all follow‐up periods and with all outcomes. Conclusions Patient information assessed closest to the time of the outcome was more valuable in predicting death when compared with information obtained at the time of the index hospitalization. Using updated patient information improves prognosis over using only the information available at the time of the index event.
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Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Karen S Pieper
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Susanna R Stevens
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Scott D Solomon
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Marc A Pfeffer
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Eric J Velazquez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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17
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Abstract
BACKGROUND In hypertension, changes in small arterial structure are characterized by an increased wall-to-lumen ratio (WLR). These adaptive processes are modulated by the rennin-angiotensin system. It is unclear whether direct renin inhibitors exert protective effects on small arteries in hypertensive patients. METHODS In this double-blind, randomized, placebo-controlled study (http://www.clinicaltrials.gov: NCT01318395), 114 patients with primary hypertension were randomized to additional therapy with either placebo or aliskiren 300 mg for 8 weeks after 4 weeks of standardized open-label treatment with valsartan 320 mg (run-in phase). Parameter of arteriolar remodelling was WLR of retinal arterioles (80 - 140 μm) assessed noninvasively and in vivo by scanning laser Doppler flowmetry (Heidelberg Engineering, Germany). In addition, pulse wave analysis (SphygmoCor, AtCor Medical, Australia) and pulse pressure (PP) amplification were determined. RESULTS In the whole study population, no clear effect of additional therapy with aliskiren on vascular parameters was documented. When analyses were restricted to patients with vascular remodelling, defined by a median of WLR more than 0.3326 (n = 57), WLR was reduced after 8 weeks by the treatment with aliskiren compared with placebo (-0.044 ± 0.07 versus 0.0043 ± 0.07, P = 0.015). Consistently, after 8 weeks of on-top treatment with aliskiren, there was an improvement of PP amplification compared with placebo (0.025 ± 0.07 versus -0.034 ± 0.08, P = 0.013), indicative of less stiff arteries in the peripheral circulation. CONCLUSION Thus, our data indicate that treatment with aliskiren, given on top of valsartan therapy, improves altered vascular remodelling in hypertensive patients.
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18
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Matsushita K, Ballew SH, Coresh J. Influence of chronic kidney disease on cardiac structure and function. Curr Hypertens Rep 2015; 17:581. [PMID: 26194332 DOI: 10.1007/s11906-015-0581-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Chronic kidney disease (CKD), the presence of kidney dysfunction and/or damage, is a worldwide public health issue. Although CKD is independently associated with various subtypes of cardiovascular diseases, a recent international collaborative meta-analysis demonstrates that CKD is particularly strongly associated with heart failure, suggesting its critical impact on cardiac structure and function. Although numerous studies have investigated the association of CKD and cardiac structure and function, these studies substantially vary regarding source populations and methodology (e.g., measures of CKD and/or parameters of cardiac structure and function), making it difficult to reach universal conclusions. Nevertheless, in this review, we comprehensively examine relevant studies, discuss potential mechanisms linking CKD to alteration of cardiac structure and function, and demonstrate clinical implications as well as potential future research directions. We exclusively focus on studies investigating both CKD measures, kidney function (i.e., glomerular filtration rate [GFR], creatinine clearance, or levels of filtration markers), and kidney damage represented by albuminuria, since current international clinical guidelines of CKD recommend staging CKD and assessing its clinical risk based on both GFR and albuminuria.
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Affiliation(s)
- Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Suite 2-600, Baltimore, MD, USA,
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Complete inhibition of the renin-angiotensin-aldosterone system; where do we stand? Curr Opin Nephrol Hypertens 2015; 23:449-55. [PMID: 25014549 DOI: 10.1097/mnh.0000000000000043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE OF REVIEW This review presents the role of combination therapy of renin-angiotensin-aldosterone system blockade on cardiovascular and kidney disease. RECENT FINDINGS Three large randomized controlled trials comparing combination therapy of renin-angiotensin-aldosterone system blockade to monotherapy in individuals with increased cardiovascular risk, chronic kidney disease, or diabetic nephropathy have been reported. These trials - ONTARGET, ALTITUDE, and VA NEPHRON-D - demonstrated an excess risk of adverse effects [especially acute kidney injury (AKI) and hyperkalemia] with combination therapy, without significant benefit in reducing cardiovascular and renal morbidity. SUMMARY Current evidence supports avoiding dual renin-angiotensin-aldosterone system blockade in patients with chronic kidney disease. Subsequent studies of dual renin-angiotensin-aldosterone system blockade should examine adverse event risks and renal progression endpoints.
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20
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Lewis EF, Li Y, Pfeffer MA, Solomon SD, Weinfurt KP, Velazquez EJ, Califf RM, Rouleau JL, Kober L, White HD, Schulman KA, Reed SD. Impact of Cardiovascular Events on Change in Quality of Life and Utilities in Patients After Myocardial Infarction. JACC-HEART FAILURE 2014; 2:159-65. [DOI: 10.1016/j.jchf.2013.12.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 10/08/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
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21
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Thune JJ, Signorovitch JE, Kober L, McMurray JJ, Swedberg K, Rouleau J, Maggioni A, Velazquez E, Califf R, Pfeffer MA, Solomon SD. Predictors and prognostic impact of recurrent myocardial infarction in patients with left ventricular dysfunction, heart failure, or both following a first myocardial infarction. Eur J Heart Fail 2014; 13:148-53. [DOI: 10.1093/eurjhf/hfq194] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Jens Jakob Thune
- Cardiovascular Division; Brigham and Women's Hospital; 75 Francis Street Boston MA 02115 USA
- Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - James E. Signorovitch
- Cardiovascular Division; Brigham and Women's Hospital; 75 Francis Street Boston MA 02115 USA
| | - Lars Kober
- Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | | | | | | | | | | | | | - Marc A. Pfeffer
- Cardiovascular Division; Brigham and Women's Hospital; 75 Francis Street Boston MA 02115 USA
| | - Scott D. Solomon
- Cardiovascular Division; Brigham and Women's Hospital; 75 Francis Street Boston MA 02115 USA
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Azadpour M, Lamas GA. AT1 receptor blockade for the prevention of cardiovascular events after myocardial infarction. Expert Rev Cardiovasc Ther 2014; 2:891-902. [PMID: 15500434 DOI: 10.1586/14779072.2.6.891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Myocardial infarction is associated with high morbidity and mortality. Multiple therapeutic modalities have been shown to be effective in reducing adverse postmyocardial infarction outcomes. The most prominent drugs that have been used in this group of patients are those that oppose the effects of the renin-angiotensin-aldosterone system. These drugs include beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and aldosterone blockers. Following initial success with angiotensin-converting enzyme inhibitors in reducing mortality and cardiac remodeling in postmyocardial infarction patients, recent focus has been on adjunctive or alternative use of angiotensin II-receptor antagonists. Multiple large-scale, randomized trials have been conducted in order to compare angiotensin II-receptor antagonists with a combination of angiotensin II-receptor antagonists and angiotensin-converting enzyme inhibitors, and with angiotensin-converting enzyme inhibitors alone in postmyocardial infarction patients and also in heart failure. Although some results are conflicting, the weight of evidence is towards equivalency of these two groups of medicines, provided that the maximum effective dose of the angiotensin II-receptor antagonists is used. The combination of an angiotensin-converting enzyme inhibitor and an angiotensin II-receptor antagonist may have additional benefits for some, but not all, patients; for example, reducing morbidity and mortality in patients with chronic heart failure but not in postmyocardial infarction patients. Indeed, in the postmyocardial infarction setting, the combination appears simply to increase the side effects, without conferring additional benefits. Use of aldosterone antagonists as adjunctive therapy in postmyocardial infarction patients is associated with added benefits in terms of mortality reduction and will become the standard of care in this group of patients.
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Affiliation(s)
- Maziar Azadpour
- Mount Sinai Medical Center and Miami Heart Institute, Miami Beach, FL 33140, USA.
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Abstract
Current practice guidelines provide recommendations for the secondary prevention of coronary heart disease. Following the publication of clinical trials in recent years, this review will highlight some controversial issues: the role of angiotensin and aldosterone antagonists after acute myocardial infarction; the effects of angiotensin-converting enzyme inhibitors in patients with stable coronary heart disease and preserved left ventricular ejection fraction; high-intensity lowering of low-density lipoprotein cholesterol; use of 3-hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitors in the elderly; and the targeting of high-density lipoprotein cholesterol with niacin.
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Affiliation(s)
- Angie Veverka
- Wingate University School of Pharmacy, Campus Box 3087, Wingate, NC 28174 0157, USA.
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24
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Moukarbel GV, Yu ZF, Dickstein K, Hou YR, Wittes JT, McMurray JJV, Pitt B, Zannad F, Pfeffer MA, Solomon SD. The impact of kidney function on outcomes following high risk myocardial infarction: findings from 27 610 patients. Eur J Heart Fail 2013; 16:289-99. [DOI: 10.1002/ejhf.11] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/27/2013] [Accepted: 08/30/2013] [Indexed: 11/09/2022] Open
Affiliation(s)
- George V. Moukarbel
- Division of Cardiovascular Medicine, Department of Internal Medicine; University of Toledo Medical Center; 3000 Arlington Avenue, Toledo OH 43614 USA
| | - Zi-Fan Yu
- Statistics Collaborative, Inc.; Washington DC USA
| | | | | | | | | | - Bertram Pitt
- University of Michigan School of Medicine; Ann Arbor MI USA
| | - Faiez Zannad
- Centre d'Investigation Clinique Pierre Drouin; INSERM; CHU de Nancy France
| | - Marc A. Pfeffer
- Division of Cardiovascular Medicine, Department of Internal Medicine; Brigham and Women's Hospital; Boston MA USA
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Department of Internal Medicine; Brigham and Women's Hospital; Boston MA USA
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25
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McClendon J, Smith TR, Thompson SE, Sugrue PA, Sauer AJ, O'Shaughnessy BA, Carabini L, Koski TR. Renin-angiotensin system inhibitors and troponin elevation in spinal surgery. J Clin Neurosci 2013; 21:1133-40. [PMID: 24424247 DOI: 10.1016/j.jocn.2013.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 10/30/2013] [Indexed: 11/25/2022]
Abstract
Renin-angiotensin system (RAS) inhibition by angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB) has been shown to reduce cardiovascular mortality and non-fatal myocardial infarction (MI) in high-risk surgical patients. However, their effect in spinal surgery has not been explored. Our objective was to determine the effect of RAS inhibitors on postoperative troponin elevation in spinal fusions, and to examine their correlation with hospital stay. We retrospectively analyzed 208 consecutive patients receiving spinal fusions ⩾5 levels between 2007-2010 with a mean follow-up of 1.7 years. Inclusion criteria were age ⩾18 years, elective fusions for kyphoscoliosis, and semi-elective fusions for tumor or infection. Exclusion criteria were trauma and follow-up <1 year. Descriptives, frequencies, and logistic and linear regression were used to analyze troponin elevation (⩾0.04 ng/mL), peak troponin level, and hospital stay. The results featured 208 patients with a mean body mass index (BMI) 28.5 kg/m(2) who underwent 345 spinal fusions. ACEI/ARB were withheld the day prior to surgery in 121 patients with 11 patients noteworthy for intra-operative electrocardiogram changes, 126 patients with troponin elevation, and 14 MI identified prior to discharge. Multivariate logistic regression identified BMI (p=0.04), estimated blood loss (p=0.015), and preoperative ACEI/ARB (p=0.015, odds ratio=2.7) as significant independent predictors for postoperative troponin elevation. Multivariate linear regression showed preoperative Oswestry Disability Index (p=0.002), unplanned return to operating room (p=0.007), pneumonia prior to hospital discharge (p<0.01), and preoperative ACEI/ARB to be associated with hospital stay. In patients with spinal fusions ⩾5 levels, ACEI/ARB are independently associated with postoperative troponin elevation and increased hospital stay.
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Affiliation(s)
- Jamal McClendon
- Department of Neurological Surgery, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 2210, Chicago, IL 60611, USA.
| | - Timothy R Smith
- Department of Neurological Surgery, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 2210, Chicago, IL 60611, USA
| | - Sara E Thompson
- Department of Neurological Surgery, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 2210, Chicago, IL 60611, USA
| | - Patrick A Sugrue
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Andrew J Sauer
- Department of Internal Medicine, Division of Cardiology, Northwestern Memorial Hospital, Chicago, IL, USA
| | | | - Louanne Carabini
- Department of Anesthesiology, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Tyler R Koski
- Department of Neurological Surgery, Northwestern Memorial Hospital, 676 N. St. Clair, Suite 2210, Chicago, IL 60611, USA
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26
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Peripheral artery disease and outcomes after myocardial infarction: An individual-patient meta-analysis of 28,771 patients in CAPRICORN, EPEHESUS, OPTIMAAL and VALIANT. Int J Cardiol 2013. [DOI: 10.1016/j.ijcard.2012.11.033] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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27
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Friedrich S, Schmieder RE. Review of direct renin inhibition by aliskiren. J Renin Angiotensin Aldosterone Syst 2013; 14:193-6. [PMID: 23873285 DOI: 10.1177/1470320313497328] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Numerous clinical studies have been conducted to analyse the ability of renin-angiotensin system blockade to lower blood pressure and to reduce end-organ damage. In addition to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, direct renin inhibitors emerged as an attractive option to inhibit the renin-angiotensin system and thus to prevent cardiovascular damage. Based on the publication of the most recent available results of ALTITUDE and ASTRONAUT, we review the data with respect to the direct renin inhibitor aliskiren given as an antihypertensive drug, in monotherapy and combination therapy, and the most recent publication analysing the effects of aliskiren on end-organ protection.
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Affiliation(s)
- Stefanie Friedrich
- Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
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28
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Measuring comorbidity in cardiovascular research: a systematic review. Nurs Res Pract 2013; 2013:563246. [PMID: 23956853 PMCID: PMC3730163 DOI: 10.1155/2013/563246] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 06/24/2013] [Indexed: 11/18/2022] Open
Abstract
Background. Everything known about the roles, relationships, and repercussions of comorbidity in cardiovascular disease is shaped by how comorbidity is currently measured. Objectives. To critically examine how comorbidity is measured in randomized controlled trials or clinical trials and prospective observational studies in acute myocardial infarction (AMI), heart failure (HF), or stroke. Design. Systematic review of studies of hospitalized adults from MEDLINE CINAHL, PsychINFO, and ISI Web of Science Social Science databases. At least two reviewers screened and extracted all data. Results. From 1432 reviewed abstracts, 26 studies were included (AMI n = 8, HF n = 11, stroke n = 7). Five studies used an instrument to measure comorbidity while the remaining used the presence or absence of an unsubstantiated list of individual diseases. Comorbidity data were obtained from 1-4 different sources with 35% of studies not reporting the source. A year-by-year analysis showed no changes in measurement. Conclusions. The measurement of comorbidity remains limited to a list of conditions without stated rationale or standards increasing the likelihood that the true impact is underestimated.
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Wang H, Eitzman DT. Acute myocardial infarction leads to acceleration of atherosclerosis. Atherosclerosis 2013; 229:18-22. [PMID: 23631842 DOI: 10.1016/j.atherosclerosis.2013.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 03/07/2013] [Accepted: 04/01/2013] [Indexed: 01/25/2023]
Abstract
Patients who experience acute myocardial infarction (AMI) are at increased risk of recurrent events in the weeks to months following the initial event. The underlying etiology for this vulnerable period following MI is unclear but could be related to the same underlying triggers responsible for the initial MI. Alternatively, the recurrent cardiac event could be promoted by the incident event. For example, several biomarkers reflecting inflammatory activity have been shown to be elevated for weeks to months following MI and this inflammatory response could aggravate existing atherosclerotic lesions by accelerating their growth and/or promoting plaque instability. The purpose of this review is to highlight recent preclinical and clinical studies supporting links between AMI and atherosclerosis and to consider potential therapeutic interventions.
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Affiliation(s)
- Hui Wang
- University of Michigan, Department of Internal Medicine, Cardiovascular Research Center, 7301A MSRB III, 1150 West Medical Center Drive, Ann Arbor, MI 48109-0644, USA
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30
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Lim TM, Ibrahim MI. Evaluation of angiotensin II receptor blockers for drug formulary using objective scoring analytical tool. Pharm Pract (Granada) 2012; 10:136-42. [PMID: 24155829 PMCID: PMC3780493 DOI: 10.4321/s1886-36552012000300003] [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: 01/16/2012] [Accepted: 09/08/2012] [Indexed: 11/24/2022] Open
Abstract
Drug selection methods with scores have been developed and used worldwide for
formulary purposes. These tools focus on the way in which the products are
differentiated from each other within the same therapeutic class. Scoring
Analytical Tool (SAT) is designed based on the same principle with score and
is able to assist formulary committee members in evaluating drugs either to
add or delete in a more structured, consistent and reproducible manner. Objective To develop an objective SAT to facilitate evaluation of drug selection for
formulary listing purposes. Methods A cross-sectional survey was carried out. The proposed SAT was developed to
evaluate the drugs according to pre-set criteria and sub-criteria that were
matched to the diseases concerned and scores were then assigned based on
their relative importance. The main criteria under consideration were
safety, quality, cost and efficacy. All these were converted to
questionnaires format. Data and information were collected through
self-administered questionnaires that were distributed to medical doctors
and specialists from the established public hospitals. A convenient sample
of 167 doctors (specialists and non-specialists) were taken from various
disciplines in the outpatient clinics such as Medical, Nephrology and
Cardiology units who prescribed ARBs hypertensive drugs to patients. They
were given a duration of 4 weeks to answer the questionnaires at their
convenience. One way ANOVA, Kruskal Wallis and post hoc comparison tests
were carried out at alpha level 0.05. Results Statistical analysis showed that the descending order of ARBs preference was
Telmisartan or Irbesartan or Losartan, Valsartan or Candesartan, Olmesartan
and lastly Eprosartan. The most cost saving ARBs for hypertension in public
hospitals was Irbesartan. Conclusions SAT is a tool which can be used to reduce the number of drugs and retained
the most therapeutically appropriate drugs in the formulary, to determine
most cost saving drugs and has the potential to complement the conventional
method of drug selection as it is effective in aiding decision making
process through the pre-established criteria and increasing scientific
ground of decisions and transparency.
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Affiliation(s)
- Tsuey M Lim
- Hospital Sultanah Aminah Johor Bahru. Johor ( Malaysia )
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31
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Shah AM, Hung CL, Shin SH, Skali H, Verma A, Ghali JK, Køber L, Velazquez EJ, Rouleau JL, McMurray JJV, Pfeffer MA, Solomon SD. Cardiac structure and function, remodeling, and clinical outcomes among patients with diabetes after myocardial infarction complicated by left ventricular systolic dysfunction, heart failure, or both. Am Heart J 2011; 162:685-91. [PMID: 21982661 DOI: 10.1016/j.ahj.2011.07.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 07/20/2011] [Indexed: 01/07/2023]
Abstract
AIMS The mechanisms responsible for the increased risk of heart failure (HF) post-myocardial infarction (MI) may differ between patients with versus without diabetes. We hypothesized that after high-risk MI, patients with diabetes would demonstrate patterns of remodeling that are suggestive of reduced ventricular compliance and that are associated with an increased risk of death or HF. METHODS AND RESULTS We performed quantitative echocardiographic analysis in 153 patients with diabetes and 451 patients without diabetes enrolled in the VALIANT Echo study. Diabetes was associated with a higher risk of death or HF in age-adjusted models (hazard ratio 1.44, 95% CI 1.04-2.00, P = .028). Diabetic patients were similar to nondiabetic patients with respect to left ventricular (LV) volume and ejection fraction but had higher LV mass index (104.1 ± 27.5 vs 97.1 ± 28.6 g/m(2), P = .009), relative wall thickness (0.41 ± 0.08 vs 0.38 ± 0.07, P < .0001), and left atrial volume index (LAVi) (26.2 ± 8.1 vs 24.0 ± 8.2 mL/m(2), P = .008)-all parameters that were significantly related to the risk of death or HF hospitalization. Changes in LV volume and ejection fraction from baseline to 20 months were not different, although diabetic patients demonstrated greater increase in LAVi (4.4 ± 7.7 vs 2.2 ± 6.7 mL/m(2), P = .01). CONCLUSIONS After high-risk MI, diabetic patients were at higher risk of death or HF and demonstrated greater baseline LV mass index, relative wall thickness, and LAVi as well as greater left atrial enlargement at 20-month follow-up. These findings suggest greater baseline concentric remodeling and long-term elevation in LV diastolic pressure post-MI among diabetic patients, which may partially mediate this risk.
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Affiliation(s)
- Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA 02445, USA.
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Skali H, Uno H, Levey AS, Inker LA, Pfeffer MA, Solomon SD. Prognostic assessment of estimated glomerular filtration rate by the new Chronic Kidney Disease Epidemiology Collaboration equation in comparison with the Modification of Diet in Renal Disease Study equation. Am Heart J 2011; 162:548-54. [PMID: 21884875 DOI: 10.1016/j.ahj.2011.06.006] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 06/10/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Systematic reporting of estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) Study equation is recommended for detection of chronic kidney disease and prediction of cardiovascular (CV) risk. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is a newly developed and validated formula for eGFR that is more accurate at normal or near-normal eGFR. We aimed to assess the incremental prognostic accuracy of eGFR(CKD-EPI) versus eGFR(MDRD) in subjects at increased risk for CV disease. METHODS We performed a post hoc analysis of the VALIANT trial that enrolled 14,527 patients with acute myocardial infarction with signs and symptoms of heart failure and/or left ventricular systolic dysfunction. The eGFR(MDRD) and eGFR(CKD-EPI) were computed using age, gender, race, and baseline creatinine level. Patients were categorized according to their eGFR using each equation. To assess the incremental prognostic value of eGFR(CKD-EPI), the net reclassification improvement was calculated for the composite end point of CV death, recurrent myocardial infarction, heart failure, or stroke. RESULTS Twenty-four percent of the subjects were reclassified into a different eGFR category using eGFR(CKD-EPI). The composite end point occurred in 33% of the subjects in this cohort. Based on eGFR(CKD-EPI), subjects reclassified into a higher eGFR experienced fewer events than those reclassified into a lower eGFR (21% vs 43%). In unadjusted analyses, the composite end point risk in subjects with eGFR between 75 and 90 mL/min per 1.73 m(2) was comparable with the referent group (eGFR between 90 and 105) using eGFR(MDRD) (hazard ratio 1.1, 95% CI 0.9-1.2) but was significantly higher using eGFR(CKD-EPI) (hazard ratio 1.2, 95% CI 1.1-1.4). The net reclassification improvement for eGFR(CKD-EPI) over eGFR(MDRD) was 8.7%. CONCLUSION The CKD-EPI equation provides more accurate risk stratification than the MDRD Study equation in patients at high risk for CV disease, including identification of increased risk at mildly decreased eGFR.
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Nantel P, René de Cotret P. The evolution of angiotensin blockade in the management of cardiovascular disease. Can J Cardiol 2011; 26 Suppl E:7E-13E. [PMID: 21620285 DOI: 10.1016/s0828-282x(10)71168-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 10/07/2010] [Indexed: 01/01/2023] Open
Abstract
Dysregulation of the renin-angiotensin system is implicated in many cardiovascular and renal pathologies. Discovery of the renin-angiotensin system represents a major advance in the understanding of hypertension and cardiovascular disease, leading to the development of the anti-angiotensin medications: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and direct renin inhibitors. Clinical trials have shown that drugs in each of these classes have a protective effect on vascular organs that surpass the protection associated with the lowering of blood pressure alone.
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Affiliation(s)
- Pierre Nantel
- Hotel-Dieu de Sorel, 130 St Nicholas, Sorel-Tracy, Québec.
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Use of the Aortoatrial Continuity as Means of Providing Left Ventricular Assist Support Without Entering the Ventricle: A Feasibility Study. J Card Fail 2011; 17:511-8. [DOI: 10.1016/j.cardfail.2011.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 01/11/2011] [Accepted: 01/28/2011] [Indexed: 11/18/2022]
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Shah AM, Uno H, Køber L, Velazquez EJ, Maggioni AP, MacDonald MR, Petrie MC, McMurray JJV, Califf RM, Pfeffer MA, Solomon SD. The inter-relationship of diabetes and left ventricular systolic function on outcome after high-risk myocardial infarction. Eur J Heart Fail 2011; 12:1229-37. [PMID: 20965879 DOI: 10.1093/eurjhf/hfq179] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
AIMS Diabetes is a potent risk factor for death and heart failure (HF) hospitalization following myocardial infarction (MI). Whether diabetes modifies the relationship between left ventricular ejection fraction (LVEF) and outcomes in the post-MI population is unknown. METHODS AND RESULTS The Valsartan in Acute Myocardial Infarction trial (VALIANT) enrolled 14 703 patients with acute MI complicated by HF, systolic dysfunction, or both. We compared the risk of death, HF hospitalization, and/or recurrent MI among patients with and without diabetes using Cox proportional hazards models. To assess the relationship between diabetes, LVEF and outcomes, we assessed the relative influence of baseline LVEF on outcomes in diabetic and non-diabetic patients. Totally, 11 325 subjects (3095 diabetics) with site-reported LVEF and known diabetes status were included. At any given LVEF, diabetes was associated with a higher risk of all-cause mortality [adjusted hazard ratio (HR) 1.37, 95% CI 1.25-1.51], death or HF hospitalization (adjusted HR 1.42, 95% CI 1.31-1.51), and death or recurrent MI (adjusted HR 1.36, 95% CI 1.24-1.48). Diabetes modified the relationship between LVEF and death or HF hospitalization (P for interaction = 0.0109), such that the association between diabetes and increased risk was greater in magnitude at higher LVEF. No interaction was noted between diabetes and LVEF on risk of all-cause mortality or death or recurrent MI. CONCLUSION Diabetes is associated with a higher risk of death or HF hospitalization across the spectrum of LVEF in high-risk post-MI patients. The magnitude of reduction in risk of death or HF hospitalization associated with increasing LVEF is significantly attenuated among patients with diabetes when compared to patients without diabetes.
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Affiliation(s)
- Amil M Shah
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02445, USA
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36
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Piérard LA, Lancellotti P. Risk Stratification After Myocardial Infarction. J Am Coll Cardiol 2010; 56:1823-5. [DOI: 10.1016/j.jacc.2010.06.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 06/15/2010] [Indexed: 01/01/2023]
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Strauer BE, Yousef M, Schannwell CM. The acute and long-term effects of intracoronary Stem cell Transplantation in 191 patients with chronic heARt failure: the STAR-heart study. Eur J Heart Fail 2010; 12:721-9. [PMID: 20576835 DOI: 10.1093/eurjhf/hfq095] [Citation(s) in RCA: 180] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
AIMS Despite accumulated evidence that intracoronary bone marrow cell (BMC) therapy may be beneficial in acute myocardial infarction, there are only limited data available on the effectiveness of BMC's in chronic heart failure. The aim of this study was to quantitatively investigate ventricular haemodynamics, geometry, and contractility as well as the long-term clinical outcome of BMC treated patients with reduced left ventricular ejection fraction (LVEF) due to chronic ischaemic cardiomyopathy. METHODS AND RESULTS Patients with chronic heart failure (n = 391 LVEF <or=35%) due to ischaemic cardiomyopathy were enrolled in the present study. Of these, 191 patients (mean NYHA class 3.22) underwent intracoronary BMC therapy. The control group (mean NYHA class 3.06) consisted of 200 patients with comparable LVEF. Assessments of haemodynamics at rest and exercise, quantitative ventriculography, spiroergometry, 24 h Holter ECG, late potentials, and heart rate variability were analysed. Over 3 months to 5 years after intracoronary BMC therapy there was a significant improvement in haemodynamics (e.g. LVEF, cardiac index), exercise capacity, oxygen uptake, and LV contractility. Importantly, there was a significant decrease in long-term mortality in the BMC treated patients compared with the control group. CONCLUSION Intracoronary BMC therapy improves ventricular performance, quality of life and survival in patients with heart failure. These effects were present when BMC were administered in addition to standard therapeutic regimes. No side effects were observed.
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Affiliation(s)
- Bodo-Eckehard Strauer
- Department of Medicine, Division of Cardiology, Pneumology and Angiology, Heinrich-Heine-University of Düsseldorf, Moorenstr 5, 40225 Düsseldorf, Germany.
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Shamshad F, Kenchaiah S, Finn PV, Soler-Soler J, McMurray JJ, Velazquez EJ, Maggioni AP, Califf RM, Swedberg K, Kober L, Belenkov Y, Varshavsky S, Pfeffer MA, Solomon SD. Fatal myocardial rupture after acute myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: the VALsartan In Acute myocardial iNfarcTion Trial (VALIANT). Am Heart J 2010; 160:145-51. [PMID: 20598985 DOI: 10.1016/j.ahj.2010.02.037] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2009] [Accepted: 02/24/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Myocardial rupture is a relatively rare and usually fatal complication of myocardial infarction (MI). Early recognition of patients at greatest risk of myocardial rupture provides an opportunity for early intervention. METHODS VALIANT was a double-blind, randomized, controlled trial comparing valsartan, captopril, and their combination in high-risk patients post-MI. Myocardial rupture was identified by autopsy (available in 138/589 patients dying within 30 days of index MI), echocardiography, direct surgical visualization, or presence of hemopericardium. An independent clinical end points committee reviewed medical records for all deaths or suspected nonfatal cardiovascular events. RESULTS Rupture was identified in 45 (0.31%) patients enrolled in VALIANT, occurring 9.8 +/- 6.0 days after the qualifying MI. Rupture accounted for 7.6% (45/589) of all deaths occurring in the first 30 days of follow-up and 24% (33/138) of deaths in which autopsies were obtained. Compared with survivors, rupture was associated with increased age, hypertension, increased Killip class, lower estimated glomerular filtration rate, and Q wave MI, and inversely related to beta-blocker and diuretic use. Compared with patients who died of other causes within 30 days, patients with myocardial rupture were more likely to have had an inferior MI, Q wave MI, or hypertension; to have used oral anticoagulants; or to have received thrombolytic therapy. CONCLUSIONS Although rare, myocardial rupture accounted for nearly one fourth of all deaths within the first 30 days after high-risk MI, suggesting an estimated incidence of approximately 1% within the first 30 days. A number of clinical characteristics may identify post-MI patients at higher risk of myocardial rupture.
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Califf RM, Lokhnygina Y, Velazquez EJ, McMurray JJ, Leimberger JD, Lewis EF, Diaz R, Murin J, Pfeffer MA. Usefulness of beta blockers in high-risk patients after myocardial infarction in conjunction with captopril and/or valsartan (from the VALsartan In Acute Myocardial Infarction [VALIANT] trial). Am J Cardiol 2009; 104:151-7. [PMID: 19576338 DOI: 10.1016/j.amjcard.2009.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Revised: 03/03/2009] [Accepted: 03/03/2009] [Indexed: 10/20/2022]
Abstract
Concern has been raised about combining beta blockers with angiotensin-receptor blockers in patients with heart failure. The VALsartan In Acute myocardial infarction (VALIANT) trial enrolled 14,703 patients with myocardial infarction complicated by heart failure or documented left ventricular systolic dysfunction. These patients were randomly allocated to treatment with valsartan, captopril, or both. Physicians were also encouraged to prescribe beta blockers because of previous evidence of benefit. The baseline characteristics, treatments, and outcomes were compared among 4 groups: patients taking beta blockers at admission only, at discharge only, at both admission and discharge, and neither. Patients treated with beta blockers were at lower risk than those not treated at any period. Those treated with beta blockers at both intervals had a lower 3-year mortality rate (17.7%) than those treated only at randomization (30.7%) or only at discharge (25.9%). The greatest mortality (35.1%) occurred in patients not treated at either point. No statistically significant interaction with prognosis was observed between beta-blocker use and treatment with valsartan or valsartan plus captopril. Patients discharged with a beta blocker had a significant survival advantage after adjustment for differences in baseline characteristics and intervening complications (hazard ratio 0.89, 95% confidence interval 0.81 to 0.98, p = 0.02). This association was most pronounced in patients prescribed consistent beta blockers at randomization and discharge and was present in both patients with impaired and those with preserved systolic left ventricular function. These results have further confirmed that beta blockers reduce the risk of death and nonfatal cardiovascular events in patients with heart failure or systolic left ventricular dysfunction after myocardial infarction. In conclusion, no evidence was found of adverse interactions between the angiotensin-receptor blocker valsartan and beta blockers or of a negative effect of the combination of valsartan, captopril, and beta blockers.
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Moukarbel GV, Signorovitch JE, Pfeffer MA, McMurray JJV, White HD, Maggioni AP, Velazquez EJ, Califf RM, Scheiman JM, Solomon SD. Gastrointestinal bleeding in high risk survivors of myocardial infarction: the VALIANT Trial. Eur Heart J 2009; 30:2226-32. [PMID: 19556260 DOI: 10.1093/eurheartj/ehp256] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AIMS The risk of gastrointestinal (GI) bleeding limits the use of antiplatelet and anticoagulant drugs. Risk factors for GI bleeding in post- myocardial infarction (MI) patients have not been well defined. We sought to identify risk factors for GI bleeding in patients following MI. METHODS AND RESULTS The VALsartan In Acute myocardial iNfarcTion trial (VALIANT) enrolled 14 703 post-MI patients with left ventricular dysfunction and/or heart failure and followed them for a median of 24.7 months. In the present secondary analysis, times from baseline to first GI bleeding were identified from the VALIANT serious adverse event database. Potential risk factors were explored from medical history, demographics, clinical profile, and medications, both at baseline and during follow-up. We also explored the relationship between the occurrence of GI bleeding and subsequent mortality. During follow-up, 98 (0.7%) patients had a serious GI bleeding event. These patients were older, had more comorbidities, were more likely to be taking additional antiplatelet drugs, and had worse left ventricular systolic and renal function. The Kaplan-Meier estimated rate of GI bleeding at 6 months was 0.37% (95% CI 0.27-0.47). In a multivariable Cox model, dual antiplatelet therapy was the most powerful predictor of GI bleeding, with an adjusted hazard ratio of 3.18 (95% CI 1.91-5.29). Other predictors were non-white race, history of alcohol abuse, increasing age, worse New York Heart Association class, anticoagulant therapy, diabetes, lower estimated glomerular filtration rate, and male sex. Gastrointestinal bleeding was associated with increased risk of death [adjusted hazard ratio 2.54 (95% CI 1.66-3.89)]. CONCLUSION Following MI, clinical characteristics can identify patients with increased risk of GI bleeding. The use of dual antiplatelet agents appears to be the most profound risk factor. Whether these patients would benefit from GI prophylaxis therapy remains unknown.
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Affiliation(s)
- George V Moukarbel
- Division of Cardiovascular Diseases, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
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González GE, Seropian IM, Krieger ML, Palleiro J, Lopez Verrilli MA, Gironacci MM, Cavallero S, Wilensky L, Tomasi VH, Gelpi RJ, Morales C. Effect of early versus late AT(1) receptor blockade with losartan on postmyocardial infarction ventricular remodeling in rabbits. Am J Physiol Heart Circ Physiol 2009; 297:H375-86. [PMID: 19429818 DOI: 10.1152/ajpheart.00498.2007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To characterize the temporal activation of the renin-angiotensin system after myocardial infarction (MI) in rabbits, we examined cardiac ANG II type 1 receptor (AT(1)R) expression and ANG II levels from 3 h to 35 days. The effects of losartan (12.5 mg.kg(-1).day(-1)) on functional and histomorphometric parameters when treatment was initiated early (3 h) and late (day 15) post-MI and maintained for different periods of time [short term (4 days), midterm (20 days), and long term (35 days)] were also studied. AT(1)R expression increased in the MI zone at 15 and 35 days (P < 0.05). ANG II levels increased (P < 0.05) in the non-MI zone at 24 h and in the MI zone as well as in plasma at 4 days and then progressively decreased until 35 days. The survival rate was significantly lower in untreated MI and early long-term-treated animals. Diastolic pressure-volume curves in MI at 35 and 56 days shifted to the right (P < 0.05). This shift was even more pronounced in long-term-treated groups (P < 0.05). Contractility decreased (P < 0.05 vs. sham) in the untreated and long-term-treated groups and was attenuated in the midterm-treated group. The early administration of losartan reduced RAM 11-positive macrophages from 4.15 +/- 0.05 to 3.05 +/- 0.02 cells/high-power field (HPF; P < 0.05) and CD45 RO-positive lymphocytes from 2.23 +/- 0.05 to 1.48 +/- 0.01 cells/HPF (P < 0.05) in the MI zone at 4 days. Long-term treatment reduced the scar collagen (MI: 70.50 +/- 2.35% and MI + losartan: 57.50 +/- 2.48, P < 0.05), determined the persistency of RAM 11-positive macrophages (3.02 +/- 0.13 cells/HPF) and CD45 RO-positive lymphocytes (2.77 +/- 0.58 cells/HPF, P < 0.05 vs. MI), and reduced the scar thinning ratio at 35 days (P < 0.05). Consequently, the temporal expressions of cardiac AT(1)R and ANG II post-MI in rabbits are different from those described in other species. Long-term treatment unfavorably modified post-MI remodeling, whereas midterm treatment attenuated this harmful effect. The delay in wound healing (early reduction and late persistency of inflammatory infiltrate) and adverse remodeling observed in long-term-treated animals might explain the unfavorable effect observed in rabbits.
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Affiliation(s)
- Germán E González
- Institute of Cardiovascular Physiopathology, Department of Pathology, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
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Berry C, Pieper KS, White HD, Solomon SD, Van de Werf F, Velazquez EJ, Maggioni AP, Califf RM, Pfeffer MA, McMurray JJ. Patients with prior coronary artery bypass grafting have a poor outcome after myocardial infarction: an analysis of the VALsartan in acute myocardial iNfarcTion trial (VALIANT). Eur Heart J 2009; 30:1450-6. [DOI: 10.1093/eurheartj/ehp102] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Hawkins NM, Huang Z, Pieper KS, Solomon SD, Kober L, Velazquez EJ, Swedberg K, Pfeffer MA, McMurray JJV, Maggioni AP. Chronic obstructive pulmonary disease is an independent predictor of death but not atherosclerotic events in patients with myocardial infarction: analysis of the Valsartan in Acute Myocardial Infarction Trial (VALIANT). Eur J Heart Fail 2009; 11:292-8. [PMID: 19176539 PMCID: PMC2645058 DOI: 10.1093/eurjhf/hfp001] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 11/02/2008] [Accepted: 11/20/2008] [Indexed: 11/12/2022] Open
Abstract
AIMS Chronic obstructive pulmonary disease is an independent predictor of mortality in patients with myocardial infarction (MI). However, the impact on mode of death and risk of atherosclerotic events is unknown. METHODS AND RESULTS We assessed the risk of death and major cardiovascular (CV) events associated with chronic obstructive pulmonary disease in 14 703 patients with acute MI enrolled in the Valsartan in Acute Myocardial Infarction (VALIANT) trial. Cox proportional hazards models were used to evaluate the relationship between chronic obstructive pulmonary disease and CV outcomes. A total of 1258 (8.6%) patients had chronic obstructive pulmonary disease. Over a median follow-up period of 24.7 months, all-cause mortality was 30% in patients with chronic obstructive pulmonary disease, compared with 19% in those without. The adjusted hazard ratio (HR) for mortality was 1.14 (95% confidence interval 1.02-1.28). This reflected increased incidence of both non-CV death [HR 1.86 (1.43-2.42)] and sudden death [HR 1.26 (1.03-1.53)]. The unadjusted risk of all pre-specified CV outcomes was increased. However, after multivariate adjustment, chronic obstructive pulmonary disease was not an independent predictor of atherosclerotic events [MI or stroke: HR 0.98 (0.77-1.23)]. Mortality was significantly lower in patients receiving beta-blockers, irrespective of airway disease. CONCLUSION In high-risk patients with acute MI, chronic obstructive pulmonary disease is associated with increased mortality and non-fatal clinical events (both CV and non-CV). However, patients with chronic obstructive pulmonary disease did not experience a higher rate of atherosclerotic events.
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Affiliation(s)
- Nathaniel M Hawkins
- Aintree Cardiac Centre, University Hospital Aintree, Longmoor Lane, Liverpool L9 7AL, UK.
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Schmitt J, Duray G, Gersh BJ, Hohnloser SH. Atrial fibrillation in acute myocardial infarction: a systematic review of the incidence, clinical features and prognostic implications. Eur Heart J 2008; 30:1038-45. [DOI: 10.1093/eurheartj/ehn579] [Citation(s) in RCA: 378] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Meris A, Amigoni M, Uno H, Thune JJ, Verma A, Køber L, Bourgoun M, McMurray JJ, Velazquez EJ, Maggioni AP, Ghali J, Arnold JMO, Zelenkofske S, Pfeffer MA, Solomon SD. Left atrial remodelling in patients with myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: the VALIANT Echo study. Eur Heart J 2008; 30:56-65. [PMID: 19001474 DOI: 10.1093/eurheartj/ehn499] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS To assess the relationship between left atrial (LA) size and outcome after high-risk myocardial infarction (MI) and to study dynamic changes in LA size during long-term follow-up. METHODS AND RESULTS The VALIANT Echocardiography study prospectively enrolled 610 patients with left ventricular (LV) dysfunction, heart failure (HF), or both following MI. We assessed LA volume indexed to body surface area (LAVi) at baseline, 1 month, and 20 months after MI. Baseline LAVi was an independent predictor of all-cause death or HF hospitalization (P = 0.004). In patients who survived to 20 months, LAVi increased a mean of 3.00 +/- 7.08 mL/m(2) from baseline. Hypertension, lower estimated glomerular filtration rate, and LV mass were the only baseline independent predictors of LA remodelling. Changes in LA size were related to worsening in MR and increasing in LV volumes. LA enlargement during the first month was significantly greater in patients who subsequently died or were hospitalized for HF than in patients without events. CONCLUSION Baseline LA size is an independent predictor of death or HF hospitalization following high-risk MI. Moreover, LA remodelling during the first month after infarction is associated with adverse outcome.
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Prisant LM, Thomas KL, Lewis EF, Huang Z, Francis GS, Weaver WD, Pfeffer MA, McMurray JJV, Califf RM, Velazquez EJ. Racial analysis of patients with myocardial infarction complicated by heart failure and/or left ventricular dysfunction treated with valsartan, captopril, or both. J Am Coll Cardiol 2008; 51:1865-71. [PMID: 18466801 DOI: 10.1016/j.jacc.2007.12.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2006] [Revised: 12/07/2007] [Accepted: 12/11/2007] [Indexed: 01/13/2023]
Abstract
OBJECTIVES African Americans have a high incidence of heart failure (HF). Limited retrospective observational subgroup analyses of patients with left ventricular systolic dysfunction (LVSD) suggest marginal benefit of angiotensin-converting enzyme inhibitors in the prevention of HF hospitalizations or total mortality in African Americans. BACKGROUND Very few data exist concerning the effectiveness of angiotensin receptor blockers in this population. METHODS Baseline characteristics, treatments, and outcomes of patients from the U.S. (3,390 white and 340 African-American patients) in the VALIANT (VALsartan In Acute myocardial iNfarcTion) trial were compared. This trial included patients with an acute myocardial infarction (MI) after initial stabilization and documented LVSD and/or HF. Patients were randomly assigned to receive treatment with valsartan, captopril, or the combination; follow-up continued for up to 3 years (median 24.7 months). RESULTS African Americans had more coronary risk factors, more markers of poor outcome after MI, and were less likely to be revascularized when compared with white patients. After adjusting for treatment assignment, baseline characteristics, and post-infarction parameters, no difference was found in the 3-year rate of all-cause mortality, cardiovascular mortality, rehospitalization for HF, recurrent MI, or stroke between the 2 groups. CONCLUSIONS African Americans sustaining an acute MI with LVSD and/or HF had similar clinical outcomes compared with white Americans. Valsartan, captopril, or the combination had comparable effects on cardiovascular morbidity and mortality in African Americans and white Americans.
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Affiliation(s)
- L Michael Prisant
- Hypertension and Clinical Pharmacology, Medical College of Georgia, Augusta, Georgia 30912, USA.
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Anderson RE, Pfeffer MA, Thune JJ, McMurray JJ, Califf RM, Velazquez E, White HD, Rouleau JL, Skali H, Maggioni A, Solomon SD. High-risk myocardial infarction in the young: the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial. Am Heart J 2008; 155:706-11. [PMID: 18371480 DOI: 10.1016/j.ahj.2007.11.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Accepted: 11/15/2007] [Indexed: 11/25/2022]
Abstract
BACKGROUND Advanced age is a well-established prognostic risk factor after acute myocardial infarction (AMI), yet approximately 10% of MIs occur in patients <45 years. We examined characteristics, cardiovascular outcomes, and the influence of risk factors on outcomes in young survivors of AMI. METHODS Fourteen thousand seven hundred three patients enrolled in the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial were divided into 3 age groups: 18 to < 45 (n = 803), 45 to < 65 (n = 6185), > or = 65 years (n = 7715). Multivariate Cox regression was used to compare cardiovascular event rates and assess the impact of risk factors on outcomes. RESULTS The youngest patients had less diabetes, hypertension, and history of MI and were more likely to be male (18 to < 45 years, 88%; > or = 65 years, 59.1%), nonwhite (18 to < 45 years, 9.6%; > or = 65 years, 5%), current smokers (18 to < 45 years, 73.7%; > or = 65 years, 15.9%), obese (18 to < 45 years, 37.9%; > or = 65 years, 25.1%), and dyslipidemic at randomization (18 to < 45 years, 43.1%; > or = 65 years, 32.7%). Adjusted relative risks of smoking (18 to < 45 years, hazard ratio [HR] 1.6 [95% confidence interval {CI} 1.1-2.5]; > or = 45 years, HR 0.9 [95% CI 0.9-1.1]; P =.014) and hypertension (18 to < 45 years, HR 1.8 [95% CI 1.3-2.6]; > or = 45 years, HR 1.2 [95% CI 1.1-1.3]; P = .044) were higher in the young, with significant interactions observed between age and these risk factors. CONCLUSIONS After AMI, risk factors and outcomes of the young differ substantively from their older counterparts. The influence of hypertension and smoking is more profound in the young, underscoring the need for aggressive risk factor modification post-AMI.
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Thune JJ, Signorovitch J, Kober L, Velazquez EJ, McMurray JJV, Califf RM, Maggioni AP, Rouleau JL, Howlett J, Zelenkofske S, Pfeffer MA, Solomon SD. Effect of antecedent hypertension and follow-up blood pressure on outcomes after high-risk myocardial infarction. Hypertension 2007; 51:48-54. [PMID: 18025296 DOI: 10.1161/hypertensionaha.107.093682] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The influence of blood pressure on outcomes after high-risk myocardial infarction is not well characterized. We studied the relationship between blood pressure and the risk of cardiovascular events in 14 703 patients with heart failure, left ventricular systolic dysfunction, or both after acute myocardial infarction in the Valsartan in Myocardial Infarction Trial. We assessed the relationship between antecedent hypertension and outcomes and the association between elevated (systolic: >140 mm Hg) or low blood pressure (systolic: <100 mm Hg) in 2 of 3 follow-up visits during the first 6 months and subsequent cardiovascular events over a median 24.7 months of follow-up. Antecedent hypertension independently increased the risk of heart failure (hazard ratio [HR]: 1.19; 95% CI: 1.08 to 1.32), stroke (HR: 1.27; 95% CI: 1.02 to 1.58), cardiovascular death (HR: 1.11; 95% CI: 1.01 to 1.22), and the composite of death, myocardial infarction, heart failure, stroke, or cardiac arrest (HR: 1.13; 95% CI: 1.06 to 1.21). While low blood pressure in the postmyocardial infarction period was associated with increased risk of adverse events, patients with elevated blood pressure (n=1226) were at significantly higher risk of stroke (adjusted HR: 1.64; 95% CI: 1.17 to 2.29) and combined cardiovascular events (adjusted HR: 1.14; 95% CI: 1.00 to 1.31). Six months after a high-risk myocardial infarction, elevated systolic blood pressure, a potentially modifiable risk factor, is associated with an increased risk of subsequent stroke and cardiovascular events. Whether aggressive antihypertensive treatment can reduce this risk remains unknown.
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Affiliation(s)
- Jens J Thune
- Brigham and Women's Hospital, Boston, MA 02115, USA
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Weber M, Basile J, Izzo J, Oparil S. Blood Pressure Goal Attainment: Meeting the Challenge of the JNC 7's Blood Pressure Goals and the Role of Renin‐Angiotensin‐Aldosterone System Blockade. J Clin Hypertens (Greenwich) 2007; 6:699-705. [PMID: 15599118 PMCID: PMC8109338 DOI: 10.1111/j.1524-6175.2004.03737.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This roundtable discussion, held in December 2003, was convened to discuss the impact of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure's (JNC 7) challenging blood pressure goal objectives for the clinical management of hypertensive patients. The discussion was moderated by Michael Weber, MD, of the State University of New York Downstate College of Medicine in New York City. Participants included leading experts in the field Joseph Izzo, Jr., MD, of the School of Medicine and Biomedical Sciences at the State University of New York at Buffalo; Suzanne Oparil, MD, of the Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, University of Alabama at Birmingham; and Jan Basile, MD, of the Ralph H. Johnson VA Medical Center and Department of General Internal Medicine/Geriatrics, Medical University of South Carolina in Charleston. The primary intention of this roundtable is to educate physicians about the importance of achieving the blood pressure goals agreed upon by the JNC 7 Committee and to present practical ways for the attainment of such goals in clinical practice.
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Stephenson K, Skali H, McMurray JJV, Velazquez EJ, Aylward PG, Kober L, Van de Werf F, White HD, Pieper KS, Califf RM, Solomon SD, Pfeffer MA. Long-term outcomes of left bundle branch block in high-risk survivors of acute myocardial infarction: The VALIANT experience. Heart Rhythm 2007; 4:308-13. [PMID: 17341394 DOI: 10.1016/j.hrthm.2006.11.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Accepted: 11/16/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND In survivors of myocardial infarction (MI), new left bundle branch block (LBBB) is associated with adverse outcomes, but its impact is not well described in post-MI patients with left ventricular (LV) systolic dysfunction and/or heart failure (HF). OBJECTIVES The aim of this study was to determine if new LBBB is an independent predictor of long-term fatal and nonfatal outcomes in high-risk survivors of MI by reviewing data from the VALsartan In Acute myocardial iNfarcTion (VALIANT) trial. METHODS In VALIANT, 14,703 patients with LV systolic dysfunction and/or HF were randomized to valsartan, captopril, or both a mean of 5 days after MI. Baseline ECG data were available from 14,259 patients. We assessed the predictive value of new LBBB for death and major cardiovascular outcomes after 3 years, adjusting for multiple baseline covariates including LV ejection fraction. RESULTS At follow-up, patients with new LBBB (608 [4.2%]) compared with patients without new LBBB had more comorbidities and increased adjusted risk of death (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.2-1.6), cardiovascular death (HR 1.4, 95% CI 1.2-1.7), HF (HR 1.3, 95% CI 1.1-1.6), MI (HR 1.5, 95% CI 1.2-1.9), and the composite of death, HF, or MI (HR 1.4, 95% CI 1.2-1.6). CONCLUSION In post-MI survivors with LV systolic dysfunction and/or HF, new LBBB was an independent predictor of all major adverse cardiovascular outcomes during long-term follow-up. This readily available ECG marker should be considered a major risk factor for long-term cardiovascular complications in high-risk patients after MI.
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Affiliation(s)
- Kent Stephenson
- Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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