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Li X, Yu C, Lei L, Liu X, Chen Y, Wang Y, Qiu S, Xiu J. Association of Pre-PCI Blood Pressure and No-Reflow in Patients with Acute ST-Elevation Coronary Infarction. Glob Heart 2024; 19:28. [PMID: 38464557 PMCID: PMC10921965 DOI: 10.5334/gh.1309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 02/12/2024] [Indexed: 03/12/2024] Open
Abstract
Background Previous studies have established blood pressure (BP) as a pivotal factor influencing no-reflow following primary percutaneous coronary intervention (PCI) in patients with ST-elevation acute coronary infarction (STEMI). However, no relevant study has been conducted to investigate the optimal range of BP associated with the lowest risk of no-reflow among STEMI patients so far. Therefore, our objective was to evaluate the association between pre-PCI BP and the occurrence of no-reflow in patients with STEMI. Method We included 1025 STEMI patients undergoing primary PCI. The BP pre-PCI was categorized into 20-mmHg increments. Logistic models were employed to assess the association of no-reflow with systolic blood pressure (SBP) or diastolic blood pressure (DBP). Three sensitivity analyses were conducted to further confirm the robustness of the association between blood pressure and no-reflow. Results SBP or DBP exhibited a U-shaped curve association with no-reflow. No-reflow was higher in patients with lower SBP (<100 mmHg) (adjusted hazard ratio (OR) 3.64, 95% confidence interval (CI) 1.84,7.21; p < 0.001) and lower DBP (<60 mmHg) (OR 3.28, 95% CI 1.63,6.49; p < 0.001) [reference: 120 ≤SBP <140; 80 ≤DBP <100 mmHg], respectively. Furthermore, no-reflow was higher in patients with higher SBP (≥160 mmHg) (OR 2.07, 95% CI 1.27,3.36; p = 0.003) and DBP (≥100 mmHg) (OR 3.36, 95% CI 2.07,5.46; p < 0.001), respectively. The results of sensitivity analyses were consistent with the above findings. Conclusion Maintaining a pre-PCI SBP within the range of 120 to 140 mmHg and a DBP within the range of 80 to 100 mmHg may be confer benefits to patients with STEMI in no-reflow.
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Affiliation(s)
- Xiaobo Li
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- Department of Cardiology, Xiangdong Hospital, Hunan Normal University, Liling, Hunan, China
| | - Chen Yu
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Li Lei
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xuewei Liu
- The Tenth Affiliated Hospital of Southern Medical University (Dongguan People’s Hospital), Southern Medical University, Dongguan, Guangdong, China
| | - Yejia Chen
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yutian Wang
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - ShiFeng Qiu
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jiancheng Xiu
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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Manolis AJ, Kallistratos MS, Koutsaki M, Doumas M, Poulimenos LE, Parissis J, Polyzogopoulou E, Pittaras A, Muiesan ML, Mancia G. The diagnostic approach and management of hypertension in the emergency department. Eur J Intern Med 2024; 121:17-24. [PMID: 38087668 DOI: 10.1016/j.ejim.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 03/08/2024]
Abstract
Hypertension urgency and emergency represents a challenging condition in which clinicians should determine the assessment and/or treatment of these patients. Whether the elevation of blood pressure (BP) levels is temporary, in need of treatment, or reflects a chronic hypertensive state is not always easy to unravel. Unfortunately, current guidelines provide few recommendations concerning the diagnostic approach and treatment of emergency department patients presenting with severe hypertension. Target organ damage determines: the timeframe in which BP should be lowered, target BP levels as well as the drug of choice to use. It's important to distinguish hypertensive emergency from hypertensive urgency, usually a benign condition that requires more likely an outpatient visit and treatment.
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Affiliation(s)
- A J Manolis
- Metropolitan Hospital, 2nd Department of Cardiology, Ethnarchou Makariou 9, Praeus, Greece
| | - M S Kallistratos
- Metropolitan Hospital, 2nd Department of Cardiology, Ethnarchou Makariou 9, Praeus, Greece.
| | - M Koutsaki
- Asklepeion General Hospital, Cardiology Department, Vasileos Pavlou 1 street, Voula Greece
| | - M Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - L E Poulimenos
- Asklepeion General Hospital, Cardiology Department, Vasileos Pavlou 1 street, Voula Greece
| | - J Parissis
- Second Department of Cardiology, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - E Polyzogopoulou
- Second Department of Cardiology, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - A Pittaras
- Metropolitan Hospital, 2nd Department of Cardiology, Ethnarchou Makariou 9, Praeus, Greece
| | - M L Muiesan
- Department of Clinical and Experimental Sciences, University of Brescia & 2a Medicina ASST Spedali Civili di Brescia, 25121 Brescia, Italy
| | - G Mancia
- University of Milano-Bicocca (Emeritus Professor), Milan, Italy
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Mazimba S, Jeukeng C, Ondigi O, Mwansa H, Johnson AE, Elumogo C, Breathett K, Kwon Y, Mubanga M, Mwansa V, Baldeo C, Ibrahim S, Selinski C, Mehta N, Bilchick K. Coronary perfusion pressure is associated with adverse outcomes in advanced heart failure. Perfusion 2023; 38:1492-1500. [PMID: 35947883 DOI: 10.1177/02676591221118693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Myocardial perfusion is an important determinant of cardiac function. We hypothesized that low coronary perfusion pressure (CPP) would be associated with adverse outcomes in heart failure. Myocardial perfusion impacts the contractile efficiency thus a low CPP would signal low myocardial perfusion in the face of increased cardiac demand as a result of volume overload. METHODS We analyzed patients with complete hemodynamic data in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial using Cox Proportional Hazards regression for the primary outcome of the composite risk of death, heart transplantation, or left ventricular assist device [(LVAD). DT × LVAD] and the secondary outcome of the composite risk of DT × LVAD and heart failure hospitalization (DT × LVADHF). CPP was calculated as the difference between diastolic blood pressure and pulmonary artery wedge pressure. Heart failure categories (ischemic vs non-ischemic) were also stratified based on CPP strata. RESULTS The 158 patients (56.7 ± 13.6 years, 28.5% female) studied had a median CPP of 40 mmHg (IQR 35-52 mmHg). During 6 months of follow-up, 35 (22.2%) had the composite primary outcome and 109 (69.0%) had the composite secondary outcome. When these outcomes were then stratified based on the median, CPP was associated with these outcomes. Increasing CPP was associated with lower risk of both the primary outcome of DT × LVAD (HR 0.96, 95% CI 0.94-0.99 p = .002) and as well as the secondary outcome of DT × LVADHF (p = .0008) There was significant interaction between CPP and ischemic etiology (p = .04). CONCLUSION A low coronary artery perfusion pressure below (median) 40mmHg in patients with advanced heart failure undergoing invasive hemodynamic monitoring with a pulmonary artery catheter was associated with adverse outcomes. CPP could useful in guiding risk stratification of advanced heart failure patients and timely evaluation of advanced heart failure therapies.
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Affiliation(s)
- Sula Mazimba
- University of Virginia Health System, Charlottesville, VA, USA
| | | | - Olivia Ondigi
- University of Virginia Health System, Charlottesville, VA, USA
| | | | | | - Comfort Elumogo
- University of Virginia Health System, Charlottesville, VA, USA
| | | | | | | | | | - Cherisse Baldeo
- University of Virginia Health System, Charlottesville, VA, USA
| | - Sami Ibrahim
- University of Virginia Health System, Charlottesville, VA, USA
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Gao JQ, Xu YL, Ye J, Hou SX, Yang W, Li M, Fa JJ, Yang CH, Jin HG, He RQ, Liu ZJ. Effects of renal denervation on cardiac function after percutaneous coronary intervention in patients with acute myocardial infarction. Heliyon 2023; 9:e17591. [PMID: 37483803 PMCID: PMC10362181 DOI: 10.1016/j.heliyon.2023.e17591] [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: 05/15/2023] [Revised: 06/21/2023] [Accepted: 06/21/2023] [Indexed: 07/25/2023] Open
Abstract
Objective To observe the effect of renal artery denervation (RDN) on cardiac function in patients with acute myocardial infarction after percutaneous coronary intervention (AMI-PCI). Methods This is a single-centre, prospective randomized controlled study. A total of 108 AMI-PCI patients were randomly assigned to the RDN group or the control group at 1:1 ratio. All patients received standardized drug therapy after PCI, and patients in the RDN group underwent additional RDN at 4 weeks after the PCI. The follow-up period was 6 months after RDN. Echocardiography-derived parameters, cardiopulmonary exercise testing (CPET) data, Holter electrocardiogram, heart rate variability (HRV) at baseline and at the 6 months-follow up were analyzed. Results Baseline indexes were similar between the two groups (all P > 0.05). After 6 months of follow-up, the echocardiography-derived left ventricular ejection fraction was significantly higher in the RDN group than those in the control group. Cardiopulmonary exercise test indicators VO2Max, metabolic equivalents were significantly higher in the RDN group than in the control group. HRV analysis showed that standard deviation of the normal-to-normal R-R intervals, levels of square root of the mean squared difference of successive RR intervals were significantly higher in the RDN group than those in the control group. Conclusions RDN intervention after PCI in AMI patients is associated with improved cardiac function, improved exercise tolerance in AMI patients post PCI. The underlying mechanism of RDN induced beneficial effects may be related to the inhibition of sympathetic nerve activity and restoration of the sympathetic-vagal balance in these patients.
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Affiliation(s)
- Jun-Qing Gao
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
- Institute of Translational Cardiovascular Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - You-Long Xu
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
- Institute of Translational Cardiovascular Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Jian Ye
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
- Institute of Translational Cardiovascular Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Shu-Xin Hou
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Wei Yang
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Min Li
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Jing-Jing Fa
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
- Institute of Translational Cardiovascular Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Cheng-Hao Yang
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
- Institute of Translational Cardiovascular Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Hui-Gen Jin
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
- Institute of Translational Cardiovascular Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Rui-Qing He
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
| | - Zong-Jun Liu
- Department of Cardiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
- Institute of Translational Cardiovascular Medicine, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200062, China
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Hu Y, Gu Z, Xu M, He W, Wu L, Xu Z, Guo L. Body mass index and clinical outcomes in patients with heart failure with preserved ejection fraction mediated by diastolic blood pressure status? Heliyon 2023; 9:e16515. [PMID: 37274719 PMCID: PMC10238725 DOI: 10.1016/j.heliyon.2023.e16515] [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: 12/16/2022] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/06/2023] Open
Abstract
Background The "obesity paradox" has been elucidated in patients with heart failure (HF). Current guidelines introduce a target diastolic blood pressure (DBP) < 80 mmHg but >70 mmHg in HF patients. Due to reduced coronary perfusion, low DBP has a deleterious impact on cardiovascular outcomes. This present study aimed to assess the relationship between BMI and adjudicated clinical outcomes in HFpEF patients according to the status of DBP. Methods We analyzed the data in 1749 HFpEF patients from the Americas of the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) Trial. The population was stratified by DBP (<70 mmHg, and ≥70 mmHg) and BMI strata (normal weight, overweight, and obesity). Cox proportional hazards models and competing-risks regression analysis were performed. Results At baseline, the median BMI and DBP were 32.9 kg/m2 (interquartile range 28.0-38.5 kg/m2) and 70 mmHg (interquartile range 62-80 mmHg), respectively. In the multivariable analysis, obesity was associated with better survival rates in the total HFpEF population (all-cause death: HR = 0.439, 95% CI 0.256-0.750; and cardiovascular death: HR = 0.378, 95% CI 0.182-0.787). In patients with DBP<70 mmHg, obesity was not significantly associated with reduced risks for all-cause death (HR = 0.531, 95% CI: 0.263-1.704) and cardiovascular death (HR = 0.680, 95% CI: 0.254-1.819). However, multivariate analyses for cardiovascular death (HR = 0.339, 95% CI: 0.117-0.983) and all-cause death (HR = 0.389, 95% CI: 0.156-0.969) were significant in patients with DBP≥70 mmHg. Nevertheless, there were no interactions between DBP and BMI. Conclusions The obesity paradox was observed in patients with HFpEF, regardless of DBP strata (<70 mmHg, and ≥70 mmHg).
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Affiliation(s)
- YingQiu Hu
- Emergency Department of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - ZhenBang Gu
- Medical School of Nanchang University, Nanchang, Jiangxi, China
| | - MeiLing Xu
- Urology Department of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - WenFeng He
- Department of Medical Genetics, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - LiDong Wu
- Emergency Department of the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - ZhiCheng Xu
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
| | - LinJuan Guo
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, Jiangxi, China
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Wang X, Hu J, Wang P, Pei H, Wang Z. Impact of pre-procedural diastolic blood pressure on major adverse cardiovascular events in non ST-segment elevation myocardial infarction patients following revascularization. Heliyon 2023; 9:e17542. [PMID: 37416683 PMCID: PMC10320243 DOI: 10.1016/j.heliyon.2023.e17542] [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: 01/07/2023] [Revised: 06/13/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023] Open
Abstract
Previous reports have observed a consistent J-shaped relationship between cardiac events and diastolic blood pressure (DBP). However, the EPHESUS study clearly showed that myocardial reperfusion abolished the J-shaped association, suggesting a different association pattern after revascularization. Therefore, in this study, we investigated the different patterns in which DBP affects cardiovascular risk in non ST-segment elevation myocardial infarction (NSTEMI) patients after revascularization, which may benefit the risk stratification for NSTEMI patients. We obtained the NSTEMI database from the Dryad data repository and analyzed the association between preprocedural DBP and long-term major adverse cardiovascular events (MACEs) in 1486 patients with NSTEMI following percutaneous coronary intervention (PCI). Multivariate regression models were used to assess the impact of DBP on outcomes in an adjusted fashion according to DBP tertiles. The p value for the trend was calculated using linear regression. When examined as a continuous variable, a multivariate regression analysis was repeated. Pattern stability was verified by interaction and stratified analyses. The median (interquartile range) age of the patients was 61.00 (53.00-68.00) years, and 63.32% were male. Cardiac death showed a graded increase as the DBP tertile increased (p for trend = 0.0369). When examined as a continuous variable, a 1 mmHg increase in DBP level was associated with an 18% higher risk of long-term cardiac death (95% CI: 1.01-1.36, p = 0.0311) and a 2% higher risk of long-term all-cause death (95% CI: 1.01-1.04; p = 0.0178). The association pattern remained stable when stratified by sex, age, diabetes, hypertension, and smoking status. An association between low DBP and higher cardiovascular risk was not observed in our study. We showed that higher preprocedural DBP increased the risk of long-term cardiac death and all-cause death in patients with NSTEMI following PCI.
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Zhou C, Yi Q, Luo Y, Wei H, Ge H, Liu H, Li X, Zhang J, Pan P, Yi M, Cheng L, Liu L, Zhang J, Peng L, Aili A, Liu Y, Pu J, Zhou H. Low diastolic blood pressure and adverse outcomes in inpatients with acute exacerbation of chronic obstructive pulmonary disease: A multicenter cohort study. Chin Med J (Engl) 2023; 136:941-950. [PMID: 37192019 PMCID: PMC10278704 DOI: 10.1097/cm9.0000000000002666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Although intensively studied in patients with cardiovascular diseases (CVDs), the prognostic value of diastolic blood pressure (DBP) has little been elucidated in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This study aimed to reveal the prognostic value of DBP in AECOPD patients. METHODS Inpatients with AECOPD were prospectively enrolled from 10 medical centers in China between September 2017 and July 2021. DBP was measured on admission. The primary outcome was all-cause in-hospital mortality; invasive mechanical ventilation and intensive care unit (ICU) admission were secondary outcomes. Least absolute shrinkage and selection operator (LASSO) and multivariable Cox regressions were used to identify independent prognostic factors and calculate the hazard ratio (HR) and 95% confidence interval (CI) for adverse outcomes. RESULTS Among 13,633 included patients with AECOPD, 197 (1.45%) died during their hospital stay. Multivariable Cox regression analysis showed that low DBP on admission (<70 mmHg) was associated with increased risk of in-hospital mortality (HR = 2.16, 95% CI: 1.53-3.05, Z = 4.37, P <0.01), invasive mechanical ventilation (HR = 1.65, 95% CI: 1.32-2.05, Z = 19.67, P <0.01), and ICU admission (HR = 1.45, 95% CI: 1.24-1.69, Z = 22.08, P <0.01) in the overall cohort. Similar findings were observed in subgroups with or without CVDs, except for invasive mechanical ventilation in the subgroup with CVDs. When DBP was further categorized in 5-mmHg increments from <50 mmHg to ≥100 mmHg, and 75 to <80 mmHg was taken as reference, HRs for in-hospital mortality increased almost linearly with decreased DBP in the overall cohort and subgroups of patients with CVDs; higher DBP was not associated with the risk of in-hospital mortality. CONCLUSION Low on-admission DBP, particularly <70 mmHg, was associated with an increased risk of adverse outcomes among inpatients with AECOPD, with or without CVDs, which may serve as a convenient predictor of poor prognosis in these patients. CLINICAL TRIAL REGISTRATION Chinese Clinical Trail Registry, No. ChiCTR2100044625.
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Affiliation(s)
- Chen Zhou
- West China School of Medicine, Sichuan University, Chengdu, Sichuan 610041, China
| | - Qun Yi
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
- Sichuan Cancer Hospital and Institution, Sichuan Cancer Center, Cancer Hospital Affiliated to School of Medicine, UESTC, Chengdu, Sichuan 610041, China
| | - Yuanming Luo
- State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, Guangdong 510120, China
| | - Hailong Wei
- Department of Respiratory and Critical Care Medicine, People's Hospital of Leshan, Leshan, Sichuan 614000, China
| | - Huiqing Ge
- Department of Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310016, China
| | - Huiguo Liu
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Xianhua Li
- Department of Respiratory and Critical Care Medicine, The First People's Hospital of Neijiang City, Neijiang, Sichuan 641000, China
| | - Jianchu Zhang
- Department of Respiratory and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Pinhua Pan
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Mengqiu Yi
- Department of Emergency, the First People's Hospital of Jiujiang, Jiujiang, Jiangxi 332000, China
| | - Lina Cheng
- Department of Emergency, the First People's Hospital of Jiujiang, Jiujiang, Jiangxi 332000, China
| | - Liang Liu
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Chengdu University, Chengdu, Sichuan 610041, China
| | - Jiarui Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Lige Peng
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Adila Aili
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yu Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jiaqi Pu
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Haixia Zhou
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Fu G, Zhou Z, Jian B, Huang S, Feng Z, Liang M, Liu Q, Huang Y, Liu K, Chen G, Wu Z. Systolic blood pressure time in target range and long-term outcomes in patients with ischemic cardiomyopathy. Am Heart J 2023; 258:177-185. [PMID: 36925271 DOI: 10.1016/j.ahj.2022.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/13/2022] [Accepted: 12/25/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND The relationship between the degree of systolic blood pressure (SBP) control and outcomes remains unclear in patients with ischemic cardiomyopathy (ICM). Current control metrics may not take into account the potential effects of SBP fluctuations over time on patients. METHODS This study was a post-hoc analysis of the surgical treatment of ischemic heart failure trial which enrolled 2,136 participants with ICM. Our SBP target range was defined as 110 to 130 mm Hg and the time in target range (TTR) was calculated by linear interpolation. RESULTS A total of 1,194 patients were included. Compared with the quartile 4 group (TTR 77.87%-100%), the adjusted hazard ratios and 95% confidence intervals of all-cause mortality were 1.32 (0.98-1.78) for quartile 3 group (TTR 54.81%-77.63%), 1.40 (1.03-1.90) for quartile 2 group (TTR 32.59%-54.67%), and 1.53 (1.14-2.04) for quartile 1 group (TTR 0%-32.56%). Per 29.28% (1-SD) decrement in TTR significantly increased the risk of all-cause mortality (1.15 [1.04-1.26]). Similar results were observed in the cardiovascular (CV) mortality and the composite outcome of all-cause mortality plus CV rehospitalization, and in the subgroup analyses of either coronary artery bypass grafting or medical therapy, and different baseline SBP. CONCLUSIONS In patients with ICM, the higher TTR was significantly associated with decreased risk of all-cause mortality, CV mortality and the composite outcome of all-cause mortality plus CV rehospitalization, regardless of whether the patient received coronary artery bypass grafting or medical therapy, and the level of baseline SBP. TTR may be a surrogate metric of long-term SBP control in patients with ICM.
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Affiliation(s)
- Guangguo Fu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhuoming Zhou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Bohao Jian
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Suiqing Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zicong Feng
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mengya Liang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Quan Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yang Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Kaizheng Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Guangxian Chen
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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Akkermansia muciniphila ameliorates chronic kidney disease interstitial fibrosis via the gut-renal axis. Microb Pathog 2023; 174:105891. [PMID: 36427659 DOI: 10.1016/j.micpath.2022.105891] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/17/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022]
Abstract
CONTEXT Chronic kidney disease (CKD) affects approximately 10% of the global population. The abundance of Akkermansia muciniphila (AKK) is significantly reduced in CKD patients. OBJECTIVE This study investigated the effects of AKK bacteria on kidney damage and the renal interstitium in rats with CKD. MATERIALS AND METHODS CKD model 5/6 nephrectomy rats were used. CKD rats were supplemented with AKK (2 × 108 cfu/0.2 mL) for 8 weeks. RESULTS AKK administration significantly suppressed epithelial-mesenchymal transition (EMT), and high-throughput 16S rRNA pyrosequencing showed that AKK supplementation restored the disordered intestinal microecology in CKD rats. AKK also enhanced the intestinal mucosal barrier function. AKK may regulate the intestinal microecology and reduce renal interstitial fibrosis by enhancing the abundance of probiotics and reducing damage to the intestinal mucosal barrier. CONCLUSION The results suggest that AKK administration could be a novel therapeutic strategy for treating renal fibrosis and CKD.
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Siński M, Berka P, Lewandowski J, Sobieraj P, Piechocki K, Paleczny B, Siennicka A. Answering Clinical Questions Using Machine Learning: Should We Look at Diastolic Blood Pressure When Tailoring Blood Pressure Control? J Clin Med 2022; 11:jcm11247454. [PMID: 36556072 PMCID: PMC9785044 DOI: 10.3390/jcm11247454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Background: The guidelines recommend intensive blood pressure control. Randomized trials have focused on the relevance of the systolic blood pressure (SBP) lowering, leaving the safety of the diastolic blood pressure (DBP) reduction unresolved. There are data available which show that low DBP should not stop clinicians from achieving SBP targets; however, registries and analyses of randomized trials present conflicting results. The purpose of the study was to apply machine learning (ML) algorithms to determine, whether DBP is an important risk factor to predict stroke, heart failure (HF), myocardial infarction (MI), and primary outcome in the SPRINT trial database. Methods: ML experiments were performed using decision tree, random forest, k-nearest neighbor, naive Bayesian, multi-layer perceptron, and logistic regression algorithms, including and excluding DBP as the risk factor in an unselected and selected (DBP < 70 mmHg) study population. Results: Including DBP as the risk factor did not change the performance of the machine learning models evaluated using accuracy, AUC, mean, and weighted F-measure, and was not required to make proper predictions of stroke, MI, HF, and primary outcome. Conclusions: Analyses of the SPRINT trial data using ML algorithms imply that DBP should not be treated as an independent risk factor when intensifying blood pressure control.
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Affiliation(s)
- Maciej Siński
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Petr Berka
- Department of Information and Knowledge Engineering, Faculty of Informatics and Statistics, Prague University of Economics and Business, W. Churchill Sq. 4, 120 00 Prague, Czech Republic
| | - Jacek Lewandowski
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
- Correspondence: ; Tel./Fax: +48-22-5991828
| | - Piotr Sobieraj
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Kacper Piechocki
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Banacha 1a, 02-097 Warsaw, Poland
| | - Bartłomiej Paleczny
- Department of Physiology and Pathophysiology, Wroclaw Medical University, Chałubińskiego 10, 50-368 Wroclaw, Poland
| | - Agnieszka Siennicka
- Department of Physiology and Pathophysiology, Wroclaw Medical University, Chałubińskiego 10, 50-368 Wroclaw, Poland
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11
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Zhang M, Yan XN, Hong LF, Jin JL, Dong Q, Qian J, Li JJ. Clinical impact of blood pressure on cardiovascular death in patients 80 years and older following acute myocardial infarction: a prospective cohort study. Hypertens Res 2022; 45:1882-1890. [PMID: 36123399 DOI: 10.1038/s41440-022-01030-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 08/17/2022] [Accepted: 08/23/2022] [Indexed: 12/15/2022]
Abstract
Numerous trials have shown that lowering blood pressure (BP) reduces cardiovascular risk and mortality, yet data about the impact of BP on cardiovascular death risk in patients aged ≥80 years with acute myocardial infarction (AMI) are sparse. This study explored the prognostic value of BP for cardiovascular death during the first 48 h after admission following AMI among patients aged ≥80 years. A total of 1005 patients ≥80 years with AMI were enrolled. Average BP parameters, including systolic, diastolic, and pulse BP, over the first 48 h after admission were calculated. The end point was cardiovascular death. Receiver operating curve (ROC) analysis was used to identify whether BP was relevant to cardiovascular death. The relationship between BP levels and cardiovascular death was evaluated by Cox regression models. ROC analysis showed that average diastolic blood pressure (aDBP), but not systolic and pulse BP, was relevant to cardiovascular death, and the optimal cutoff was 65 mmHg. During the 2.9-year follow-up, patients who died from a cardiovascular cause had lower aDBP levels than those who did not (p = 0.002). Patients with aDBP <65 mmHg had a 1.5-fold higher incidence of cardiovascular death than those with aDBP ≥65 mmHg (35.9% vs. 24.0%; p < 0.001). In multivariable regression analysis, low aDBP remained a strong and independent predictor of cardiovascular death (adjusted hazard ratio 1.907; 95% CI 1.303-2.792). aDBP was independently associated with cardiovascular death in patients aged ≥80 years with AMI, suggesting that aDBP may be a useful index to predict worse outcome in these patients.
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Affiliation(s)
- Meng Zhang
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xiao-Ni Yan
- Division of Cardiology, The Fifth Hospital of Wuhan & Cardiovascular Institute of Jianghan University, Wuhan, China
| | - Li-Feng Hong
- Division of Cardiology, The Fifth Hospital of Wuhan & Cardiovascular Institute of Jianghan University, Wuhan, China
| | - Jing-Lu Jin
- Department of Endocrinology, Genetics and Metabolism, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qian Dong
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jie Qian
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
| | - Jian-Jun Li
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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12
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Lauder L, Mahfoud F, Azizi M, Bhatt DL, Ewen S, Kario K, Parati G, Rossignol P, Schlaich MP, Teo KK, Townsend RR, Tsioufis C, Weber MA, Weber T, Böhm M. Hypertension management in patients with cardiovascular comorbidities. Eur Heart J 2022:6808663. [DOI: 10.1093/eurheartj/ehac395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/23/2022] [Accepted: 07/08/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Michel Azizi
- Université Paris Cité, INSERM CIC1418 , F-75015 Paris , France
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department, DMU CARTE , F-75015 Paris , France
- FCRIN INI-CRCT , Nancy , France
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School , Boston, MA , USA
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine , Tochigi , Japan
| | - Gianfranco Parati
- Department of Medicine and Surgery, Cardiology Unit, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS , Milan , Italy
| | - Patrick Rossignol
- FCRIN INI-CRCT , Nancy , France
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques - Plurithématique 14-33 and INSERM U1116 , Nancy , France
- CHRU de Nancy , Nancy , France
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School—Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia , Perth, WA , Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital , Perth, WA , Australia
| | - Koon K Teo
- Population Health Research Institute, McMaster University , Hamilton, ON , Canada
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
| | - Costas Tsioufis
- National and Kapodistrian University of Athens, 1st Cardiology Clinic, Hippocratio Hospital , Athens , Greece
| | | | - Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen , Wels , Austria
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
- Cape Heart Institute (CHI), Faculty of Health Sciences, University of Cape Town , Cape Town , South Africa
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13
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Controversies in Hypertension II: The Optimal Target Blood Pressure. Am J Med 2022; 135:1168-1177.e3. [PMID: 35636475 DOI: 10.1016/j.amjmed.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022]
Abstract
The optimal target blood pressure in the treatment of hypertension is undefined. Whether more intense therapy is better than standard, typically <140/90 mm Hg, is controversial. The most recent American guidelines recommend ≤130/80 mm Hg for essentially all adults. There have been at least 28 trials targeting more versus less intensive therapy, including 13 aimed at reducing cardiovascular events and mortality, 11 restricted to patients with chronic kidney disease, and 4 with surrogate endpoints. We review these trials in a narrative fashion due to significant heterogeneity in targets chosen, populations studied, and primary endpoints. Most were negative, although some showed significant benefit to more intense therapy. When determining the optimal pressure for an individual patient, additional factors should be considered, including age, frailty, polypharmacy, baseline blood pressure, and the diastolic blood pressure J-curve. We discuss these modifying factors in detail. Whereas the tenet "lower is better" is generally true, one size does not fit all, and blood pressure control must be individualized.
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14
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Van Minh H, Van Huy T, Long DPP, Tien HA. Highlights of the 2022 Vietnamese Society of Hypertension guidelines for the diagnosis and treatment of arterial hypertension: The collaboration of the Vietnamese Society of Hypertension (VSH) task force with the contribution of the Vietnam National Heart Association (VNHA): The collaboration of the Vietnamese Society of Hypertension (VSH) task force with the contribution of the Vietnam National Heart Association (VNHA). J Clin Hypertens (Greenwich) 2022; 24:1121-1138. [PMID: 36196473 PMCID: PMC9532930 DOI: 10.1111/jch.14580] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/29/2022] [Accepted: 09/04/2022] [Indexed: 11/19/2022]
Abstract
Hypertension is uncontrolled in over 50% hypertensive population in Vietnam which indicated a compelling need for new hypertension guidelines. The highlights were composed of three parts: the diagnosis of arterial hypertension, the recommendation of home blood pressure monitoring, and the treatment of hypertension. Our guideline applied flexibility based upon the "essential" and "optimal" concepts in the diagnosis and management of hypertensive patients according to the socio-economic status of Vietnam. Hypertension is defined as an office systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg which is equivalent to a 24-hr ambulatory blood pressure monitoring average of ≥130/80 mmHg or home blood pressure monitoring average of ≥135/85 mmHg. We established an integrated hypertensive diagnostic algorithm for adults with the optimal option by the role of out-of-office blood pressure measurement, especially home blood pressure monitoring, which is fully recommended in this guideline. The threshold and target of hypertension treatment were individualized in safety range and effective evidence-based medicine. We also update for the management of resistant hypertension, hypertension in diabetic patients, hypertension with heart failure, and with other comorbidities. Vietnam has tried on the best strategy for improving the control of hypertension and recently received several achievements in the world, especially in the Asian region. Because the conditions for conducting our national data have not been fully conducted, we have to adapt from existing guidelines so there are still certain limitations that need to be supplemented and adjusted in the upcoming version.
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Affiliation(s)
- Huynh Van Minh
- Department of Internal MedicineUniversity of Medicine and PharmacyHue UniversityHue CityVietnam
| | - Tran Van Huy
- Department of Internal MedicineFaculty of MedicineBan Me Thuot UniversityVietnam
| | - Doan Pham Phuoc Long
- Department of Internal MedicineUniversity of Medicine and PharmacyHue UniversityHue CityVietnam
| | - Hoang Anh Tien
- Department of Internal MedicineUniversity of Medicine and PharmacyHue UniversityHue CityVietnam
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15
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Hsieh MJ, Chen CC, Chen DY, Lee CH, Ho MY, Yeh JK, Huang YC, Lu YY, Chang CY, Wang CY, Chang SH, Hsieh IC. Risk Stratification by Coronary Perfusion Pressure in Left Ventricular Systolic Dysfunction Patients Undergoing Revascularization: A Propensity Score Matching Analysis. Front Cardiovasc Med 2022; 9:860346. [PMID: 35498029 PMCID: PMC9046789 DOI: 10.3389/fcvm.2022.860346] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background Coronary perfusion pressure (CPP) and coronary artery stenosis are responsible for myocardial perfusion. However, how CPP-related survival outcome affects revascularization is unclear. Objective The aim of this study is to investigate the prognostic role of CPP in patients with left ventricular systolic dysfunction (LVSD) undergoing percutaneous coronary intervention (PCI) with complete revascularization (CR) or reasonable incomplete revascularization (RIR). Methods We retrospectively screened 6,076 consecutive patients in a registry. The residual synergy between percutaneous coronary intervention with Taxus and cardiac surgery (SYNTAX) score (rSS) was used to define CR (rSS = 0) and RIR (0<rSS≤8). Propensity score matching was performed to reduce bias between RIR and CR. The primary endpoint was all-cause mortality. Results In total, 816 patients with LVSD who underwent CR or RIR were enrolled. After a mean follow-up of 4.6 years, 134 patients died. Both CPP and RIR independently predicted mortality in the total population. After 1:1 matching, 175 pairs of RIR and CR were found in patients with CPP > 42 mmHg. Moreover, 101 pairs of RIR and CR were present in patients with CPP ≤ 42 mmHg. In patients with CPP > 42 mmHg, RIR was not significantly different from CR in long-term mortality [hazard ratio (HR) 1.20; 95% confidence interval (CI):0.70–2.07; p = 0.513]; However, in patients with CPP≤42 mmHg, RIR had a significantly higher mortality risk than CR (HR 2.39; 95% CI: 1.27–4.50; p = 0.007). Conclusions The CPP had a risk stratification role in selecting different revascularization strategies in patients with LVSD. When patients with LVSD had CPP > 42 mmHg, RIR was equivalent to CR in survival. However, when patients with LVSD had CPP ≤ 42 mmHg, RIR had a significantly higher mortality risk than CR.
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Affiliation(s)
- Ming-Jer Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- *Correspondence: Ming-Jer Hsieh
| | - Chun-Chi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Dong-Yi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lee
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Yun Ho
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jih-Kai Yeh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chang Huang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Ying Lu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chieh-Yu Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chao-Yung Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shang-Hung Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Center for Big Data Analytics and Statistics, Department of Medical Research and Development, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- I-Chang Hsieh
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16
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Birrane JP, Foschi M, Sacco S, McEvoy JW. Another Nail in the Coffin of Causality for the Diastolic Blood Pressure J Curve. Hypertension 2022; 79:794-797. [PMID: 35263158 DOI: 10.1161/hypertensionaha.122.18997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John P Birrane
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway School of Medicine, Galway, Ireland (J.P.B., J.W.M.)
| | - Matteo Foschi
- Department of Neuroscience, Neurology Unit, S. Maria delle Croci Hospital of Ravenna, AUSL Romagna, Italy (M.F.).,Department of Medical and Surgical Sciences, University of Bologna, Italy (M.F.)
| | - Simona Sacco
- Neuroscience Section, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, Italy (S.S.)
| | - John W McEvoy
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway School of Medicine, Galway, Ireland (J.P.B., J.W.M.).,Division of Cardiology, Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Medical Institutions, Baltimore, MD (J.W.M.)
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17
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Hara T, Kasahara Y, Nakagawa T. Pre-dialysis diastolic blood pressure and intradialytic hypotension in patients undergoing maintenance haemodialysis. J Nephrol 2022; 35:1419-1426. [PMID: 35247180 DOI: 10.1007/s40620-022-01292-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intradialytic hypotension is a clinically relevant complication in haemodialysis patients. Pre-dialysis diastolic blood pressure is routinely measured. However, the association between pre-dialysis diastolic blood pressure and intradialytic hypotension is not well understood. METHODS Patient-level (N = 545) and haemodialysis session-level (N = 3261) data were collected; the exposure variable was pre-dialysis diastolic blood pressure. The primary outcome of interest was the development of intradialytic hypotension, defined as any nadir < 100 mmHg if the pre-dialysis systolic blood pressure was ≥ 160 mmHg, or any nadir < 90 mmHg if the pre-dialysis systolic blood pressure was < 160 mmHg. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using mixed-effects logistic regression for the association between pre-dialysis diastolic blood pressure and intradialytic hypotension, after adjusting for potential confounders. RESULTS Intradialytic hypotension occurred in 14.4% of the sessions. All sessions were divided into five categories according to pre-dialysis diastolic blood pressure. The adjusted ORs for intradialytic hypotension were 2.72 (95% CI 1.64-4.51), 1.07 (95% CI 0.68-1.66), 1.68 (95% CI 1.08-2.62), and 1.81 (95% CI 1.05-3.14) in sessions with pre-dialysis diastolic blood pressure of < 60 mmHg, ≥ 60 to < 70 mmHg, ≥ 80 to < 90 mmHg, and ≥ 90 mmHg, respectively, compared with the reference pre-dialysis diastolic blood pressure of ≥ 70 to < 80 mmHg. Cubic spline analyses revealed a reverse J-shaped association between pre-dialysis diastolic blood pressure and intradialytic hypotension. CONCLUSIONS Low and high pre-dialysis diastolic blood pressure levels were associated with intradialytic hypotension. This may help identify patients at a high risk of developing intradialytic hypotension.
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Affiliation(s)
- Takashi Hara
- Department of Nephrology, Rakuwakai Otowa Hospital, 2 Otowa-Chinji-cho, Yamashina-ku, Kyoto, 607-8062, Japan.
| | - Yuto Kasahara
- Department of Nephrology, Rakuwakai Otowa Hospital, 2 Otowa-Chinji-cho, Yamashina-ku, Kyoto, 607-8062, Japan
| | - Takahiko Nakagawa
- Department of Nephrology, Rakuwakai Otowa Hospital, 2 Otowa-Chinji-cho, Yamashina-ku, Kyoto, 607-8062, Japan.,Department of Biochemistry, Shiga University of Medical Science, Shiga, Japan
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18
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Do recent meta-analyses truly prove that treatment with blood pressure-lowering drugs is beneficial at any blood pressure value, no matter how low? A critical review. J Hypertens 2022; 40:839-846. [PMID: 35191413 DOI: 10.1097/hjh.0000000000003056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Current European guidelines for the management of hypertension and on cardiovascular disease prevention place the threshold for pharmacological treatment at a SBP level of 140 mmHg or above, with the exception of patients at very high risk (mainly because of coronary heart disease). This is in agreement with the current definition of hypertension, that is, the level of blood pressure at which the benefits of treatment outweigh the risks of treatment, as documented by clinical trials. This rationale and definition was recently challenged by meta-analyses using individual participant-level data from 48 randomized trials by the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC). The authors calculated for a fixed 5 mmHg pharmacological reduction of SBP an overall 10% risk reduction for major cardiovascular events. It was concluded that there was no reliable evidence of heterogeneity of treatment effects by baseline SBP categories; that the effect was independent from the presence of cardiovascular disease; applied also to old and very old individuals up to 84 years or beyond; and that BP-lowering was also beneficial in individuals with normal or high-normal SBP down to a baseline SBP less than 120 mmHg. In this report, we identify and discuss a number of shortcomings of the BPLTTC meta-analyses. In our view, the conclusions by the BPLTTC must be - together with accompanying suggestions to abandon the definition of hypertension - strongly rejected as they are not justified and may be harmful for cardiovascular health in individuals without hypertension.
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19
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Gaffney B, Jacobsen AP, Pallippattu AW, Leahy N, McEvoy JW. The Diastolic Blood Pressure J-Curve in Hypertension Management: Links and Risk for Cardiovascular Disease. Integr Blood Press Control 2021; 14:179-187. [PMID: 34938115 PMCID: PMC8685549 DOI: 10.2147/ibpc.s286957] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/03/2021] [Indexed: 12/14/2022] Open
Abstract
Purpose of Review The treatment of hypertension has changed dramatically over the last century, with recent trials informing clinical guidelines that recommend aiming for lower blood pressure (BP) targets than ever before. However, a “J”- or “U-shaped curve” in the association between diastolic BP and cardiovascular events has been observed in epidemiological studies, suggesting that both high diastolic BPs and diastolic BPs below a certain nadir are associated with higher risk of cardiovascular disease (CVD) events. Despite the potential for confounding and reverse causation, this association may caution against overly intensive BP lowering in some hypertensive adults who also have a low baseline diastolic BP. Recent Findings Recent post-hoc analyses of the landmark Systolic Blood Pressure Intervention Trial (SPRINT) appear to contradict these J-curve concerns, finding that the benefit of more intensive BP treatment did not differ based on baseline blood pressure. Similarly, sensitivity analyses of The Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients (STEP) randomized controlled trial found that patients experienced similar benefits from an intensive BP goal, regardless of whether their diastolic BP was above or below 60 mm Hg. Finally, several Mendelian randomization analyses, which are less susceptible to confounding and reverse causation, demonstrated a clear linear relationship between diastolic BP and cardiovascular events. These studies indicate that a potential reduction in CVD risk is possible, irrespective of baseline diastolic BP values. Summary Sufficient recent evidence indicates that low diastolic BP is not causal of worse cardiovascular outcomes but rather represents confounding or reverse causation. Therefore, while low diastolic BP can be considered a marker of CVD risk, this risk is not expected to increase with further BP lowering when necessary to control concomitant elevations of systolic BP. Indeed, BP reduction in this setting appears beneficial.
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Affiliation(s)
- Brian Gaffney
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, School of Medicine, Galway, Ireland
| | - Alan P Jacobsen
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Abhishek W Pallippattu
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, School of Medicine, Galway, Ireland
| | - Niall Leahy
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, School of Medicine, Galway, Ireland
| | - John W McEvoy
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, School of Medicine, Galway, Ireland
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20
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Thompson B, McEvoy JW. Establishing target systolic and diastolic blood pressure in diabetic patients with hypertension: what do we need to consider? Expert Rev Cardiovasc Ther 2021; 19:993-1003. [PMID: 34878361 DOI: 10.1080/14779072.2021.2013814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The optimum target for systolic and diastolic blood pressure remains divisive. In particular, the conflicting outcomes of the SPRINT and ACCORD trials have led to a divergence of guideline-recommended blood pressure targets for adults with diabetes. AREAS COVERED Here, we review the existing recommendations for blood pressure targets in diabetes, discussing the evidence base behind them and their limitations. We start by outlining the risks and benefits of lower systolic blood pressure targets among diabetics. We then follow with a separate appraisal of diastolic blood pressure targets, which necessitates examination of the 'J curve' and isolated diastolic hypertension. EXPERT OPINION Current and emerging evidence supports, on balance, a blood pressure therapeutic target of < 130/90 mmHg in adults at increased risk for cardiovascular disease, including diabetics. Whether certain diabetics with systolic BPs of 120-130 and/or diastolic BPs 80-90 mmHg require drug treatment to a target of <120/80 mmHg is less clear and requires more research.
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Affiliation(s)
- Brian Thompson
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - John W McEvoy
- School of Medicine, National University of Ireland Galway, Galway, Ireland.,Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Filippone EJ, Foy AJ, Naccarelli GV. The diastolic blood pressure J-curve revisited: An update. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2021; 12:100065. [PMID: 38559601 PMCID: PMC10978147 DOI: 10.1016/j.ahjo.2021.100065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/04/2021] [Accepted: 10/15/2021] [Indexed: 04/04/2024]
Abstract
Hypertension remains a leading cause of morbidity and mortality. Recent treatment guidelines stress more strict systolic blood pressure (SBP) targets without regard for abnormally low achieved diastolic blood pressures (DBP). However, as DBP falls below a critical level, adverse events increase, the so-called J-shaped curve. Proponents argue that the low DBP is causative due to reduced coronary perfusion during diastole with obstructive coronary artery disease (CAD), whereas others postulate the J-curve represents reverse causality from underlying comorbidity. Most data are observational, derived from population-based cohorts or post-hoc analyses of randomized controlled trials (RCT) conducted for other reasons. The purpose of this review is to analyze the observational studies performed over the last decade addressing the J-curve, with consideration of earlier data. Overall, a J-curve exists, but it remains uncertain whether low DBP is causative or instead reflects reverse causation from either diseased vasculature (widened pulse pressure) or severe underlying comorbidity. The most convincing data for causation come from studies restricted to patients with documented CAD, with evidence suggesting revascularization may mitigate risk. RCTs are needed to determine if a low DBP should preclude intensification of therapy, especially with documented CAD. Firm recommendations cannot be made with contemporary data.
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Affiliation(s)
- Edward J. Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew J. Foy
- Department of Medicine, Penn State University Heart and Vascular Institute, Penn State M.S Hershey Medical Center and College of Medicine, Hershey, PA, USA
| | - Gerald V. Naccarelli
- Department of Medicine, Penn State University Heart and Vascular Institute, Penn State M.S Hershey Medical Center and College of Medicine, Hershey, PA, USA
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22
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Association of blood pressure in the first-week of hospitalization and long-term mortality in patients with acute left ventricular myocardial infarction. Int J Cardiol 2021; 349:18-26. [PMID: 34838680 DOI: 10.1016/j.ijcard.2021.11.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/13/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Previous studies have shown that optimal blood pressure (BP) control is necessary to outcomes in patients with acute myocardial infarction (AMI). Acute left ventricular MI is a prevalent type of AMI with poor prognosis. We aimed to analyze the associations between BP control in the first 7 days of hospitalization and long-term mortality specific to patients with isolated left ventricular MI. METHODS A total of 3108 acute left ventricular MI patients were included in this analysis. The average BP on the first seven days of hospitalization was categorized into 10-mmHg increments. The primary and secondary outcomes were all-cause death and cardiac death, respectively. Cox models were used to assess the association of outcomes with BP during hospitalization. RESULTS The median length-of-stay was 7 (IQR 6-10) days. The relationship between systolic BP (SBP) or diastolic BP (DBP) followed a U-shaped curve association with outcomes. All-cause mortality was higher in patients with lower SBP (≤90 mmHg) (adjusted hazard ratios (HRs) 7.12, 95% confidence interval (CI) 3.13-16.19; p < 0.001) and DBP (<60 mmHg) (HR 1.76, 95% CI 1.14-2.71; p = 0.011) [reference: 110 < SBP ≤120 mmHg; 70 < DBP ≤ 80 mmHg], respectively. Furthermore, primary outcome was higher in patients with higher SBP (>130 mmHg) (HR 1.51, 95% CI 1.12-2.03; p = 0.007) and DBP (>80 mmHg) (HR 1.61, 95% CI 1.20-2.18; p = 0.002), respectively. CONCLUSION Maintaining a SBP from 90 to 130 mmHg and a DBP from 60 to 80 mmHg may be beneficial to patients with acute left ventricular MI in the long run.
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23
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Messerli FH, Shalaeva EV, Rexhaj E. Optimal BP Targets to Prevent Stroke and MI: Is There a Lesser of 2 Evils? J Am Coll Cardiol 2021; 78:1679-1681. [PMID: 34674812 DOI: 10.1016/j.jacc.2021.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Franz H Messerli
- Swiss Cardiovascular Center, Inselspital, University of Bern, Bern, Switzerland.
| | | | - Emrush Rexhaj
- Departments of Cardiology and Biomedical Research, University Hospital, Bern, Switzerland
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24
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Guide de Pratique Clinique. Prise en charge de l’hypertension artérielle chez l’adulte en Tunisie. LA TUNISIE MÉDICALE 2021. [PMCID: PMC9003593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ce document a été réalisé dans le cadre d'une collaboration entre l'Instance Nationale de l’Évaluation et de l'Accréditation en Santé (INEAS), la Société Tunisienne de Cardiologie et de Chirurgie Cardiovasculaire (STCCCV) et la Caisse Nationale d’Assurance Maladie (CNAM).
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25
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Messerli FH, Brguljan J, Rexhaj E, Sever P, Pocock S, Taddei S. Lowering systolic blood pressure to 120 mmHg or The Lancet's true grit. Eur Heart J 2021; 42:2052-2059. [PMID: 34062560 DOI: 10.1093/eurheartj/ehab013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/11/2021] [Indexed: 12/16/2022] Open
Affiliation(s)
- Franz H Messerli
- Swiss Cardiovascular Center, University of Bern, Inselspital, Freiburgstrasse, Bern 3010, Switzerland.,Departement for BioMedical Research, University of Bern, 3008 Bern, Switzerland
| | - Jana Brguljan
- University Medical Centre Ljubljana, Department of Hypertension, University of Ljubljana, Faculty of Medicine, Vodnikova 62, 1000 Ljubljana, Slovenia
| | - Emrush Rexhaj
- Swiss Cardiovascular Center, University of Bern, Inselspital, Freiburgstrasse, Bern 3010, Switzerland.,University Medical Centre Ljubljana, Department of Hypertension, University of Ljubljana, Faculty of Medicine, Vodnikova 62, 1000 Ljubljana, Slovenia
| | - Peter Sever
- Imperial College London, National Heart & Lung Institute, ICTEM Building, Du Cane Road, London W12 0NN, UK
| | | | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, Pisa 56126, Italy
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26
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Chang HCH, Tsai MS, Kuo LK, Hsu HH, Huang WC, Lai CH, Shih MC, Huang CH. Factors affecting outcomes in patients with cardiac arrest who receive target temperature management: The multi-center TIMECARD registry. J Formos Med Assoc 2021; 121:294-303. [PMID: 33934947 DOI: 10.1016/j.jfma.2021.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/12/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Target temperature management (TTM) is a recommended therapy for patients after cardiac arrest (PCA). The TaIwan Network of Targeted Temperature ManagEment for CARDiac Arrest (TIMECARD) registry was established for PCA who receive TTM therapy in Taiwan. We aim to determine the variables that may affect neurologic outcomes in PCA who undergo TTM. METHODS We retrieved demographic variables, resuscitation variables, and cerebral performance category (CPC) scale score at hospital discharge from the TIMECARD registry. The primary outcome was a favorable neurologic outcome, defined as a CPC scale of 1 or 2 at discharge. A total of 540 PCA treated between January 2014 and September 2019 were identified from the registry. Univariate and multivariate analyses were performed to identify significant variables. RESULTS The mortality rate was 58.1% (314/540). Favorable neurologic outcomes were noted in 117 patients (21.7%). The factors significantly influencing the neurologic outcome (p < 0.05) were the presence of an initial shockable rhythm or pulseless electric activity, a witnessed cardiac-arrest event, bystander cardiopulmonary resuscitation, a smaller total dose of epinephrine, the diastolic blood pressure value at return of spontaneous circulation, a pre-arrest CPC score of 1, coronary angiography, new-onset seizure, and new-onset serious infection. Older patients and those with premorbid diabetes mellitus, chronic kidney disease, malignancy, obstructive lung disease, or cerebrovascular accident were more likely to have an unfavorable neurologic outcome. CONCLUSIONS In the TIMECARD registry, some PCA baseline characteristics, cardiac arrest events, cardiopulmonary resuscitation characteristics, and post-arrest management characteristics were significantly associated with neurologic outcomes.
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Affiliation(s)
- Herman Chih-Heng Chang
- Department of Emergency and Critical Care Medicine, Fu-Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kuo Kuo
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei Branch, Taipei, Taiwan
| | - Hsin-Hui Hsu
- Department of Critical Care Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chih-Hung Lai
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Chieh Shih
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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27
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Ferreira JP, Gregson J, Böhm M, Rossignol P, Zannad F, Pocock SJ. Blood pressure reduction and anti-hypertensive treatment choice: A post-hoc analysis of the SPRINT trial. Clin Cardiol 2021; 44:665-674. [PMID: 33822396 PMCID: PMC8119807 DOI: 10.1002/clc.23591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Uncontrolled blood pressure (BP) increases the risk of major adverse cardiovascular events. In SPRINT an intensive versus standard BP lowering strategy resulted in a lower rate of cardiovascular events and death. Whether BP reduction only or also the choice of anti-hypertensive drugs is associated with outcomes remains to be elucidated. AIMS We aim to study the association of BP and different anti-hypertensive drugs with several cardiovascular outcomes. METHODS Time-updated Cox and mixed-effects models. The primary outcome was a composite of first myocardial infarction, acute coronary syndrome, stroke, heart failure, or cardiovascular death. RESULTS A total of 9361 patients were included. The anti-hypertensive agents most frequently used were ACEi/ARBs, with an almost 20% higher prescription rate in the intensive arm (80% vs. 61%), followed by thiazide-type diuretics (65% vs. 42%), calcium-channel blockers (57% vs. 39%), and beta-blockers (52% vs. 26%). Mineralocorticoid receptor antagonists were rarely used (≤7% of the observations). In multivariate analysis, the use of ACEi/ARBs, especially in combination with thiazides, were independently associated with a lower primary outcome event-rate (HR [95%CI] 0.75 [0.61-0.92], p = .006), whereas a DBP <60 mmHg was independently associated with a higher event-rate (HR [95%CI] 1.36 [1.07-1.71], p = .011). SBP <120 mmHg was associated with lower rate of cardiovascular and all-cause death on intensive treatment but not on the standard arm (interaction p < .05 for both). CONCLUSIONS In SPRINT, an intensive therapy strategy achieving SBP <120 mmHg with a DBP ≥60 mmHg, and using ACEi/ARBs plus thiazides was associated with a lower event-rate.
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Affiliation(s)
- João Pedro Ferreira
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique Inserm 1433, CHRU de Nancy Inserm U1116, FCRIN INI-CRCT, Nancy, France
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Böhm
- Klinik für Innere Medizin III, Saarland University Medical Center, Homburg, Germany
| | - Patrick Rossignol
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique Inserm 1433, CHRU de Nancy Inserm U1116, FCRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique Inserm 1433, CHRU de Nancy Inserm U1116, FCRIN INI-CRCT, Nancy, France
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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Cardiovascular outcomes in patients at high cardiovascular risk with previous myocardial infarction or stroke. J Hypertens 2021; 39:1602-1610. [PMID: 34188004 DOI: 10.1097/hjh.0000000000002822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Guidelines recommend to start blood pressure (BP)-lowering drugs also according to cardiovascular risk including history of cardiovascular events. We hypothesized that in patients with a history of myocardial infarction (MI), stroke, both or none of those, the index events predict the next event and have different SBP risk associations to different cardiovascular outcomes. DESIGN AND MEASUREMENTS In this pooled posthoc, nonprespecified analysis, we assessed outcome data from high-risk patients aged 55 years or older with a history of cardiovascular events or proven cardiovascular disease, randomized to the Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial and to Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease Trial investigating telmisartan, ramipril and their combination with a median follow-up of 56 months. Standardized office BP was measured every 6 months. Associations of mean achieved BP on treatment were investigated on MI, stroke and cardiovascular death. We identified patients with previous MI (N = 13 487), stroke (N = 4985), both (N = 1509) or none (N = 10 956) of these index events. Analyses were done by Cox regression, analysis of variance and Chi2-test. 30 937 patients with complete data were enrolled between 1 December 2001 and 31 July 2003, and followed until 31 July 2008. Data of both trials were pooled as the outcomes were similar. RESULTS Patients with MI as index event had a higher risk to experience a second MI [hazard ratio 1.42 (confidence interval (CI) 1.20-1.69), P < 0.0001] compared with patients with no events but no increased risk for a stroke as a next event [hazard ratio 0.95 (CI 0.73-1.23), n.s.]. The risk was roughly doubled when they had both, MI and stroke before [hazard ratio 2.07 (CI 1.58-2.71), P < 0.0001]. Patients with a stroke history had a roughly three-fold higher likelihood to experience a second stroke [hazard ratio 2.89 (CI 2.37-3.53) P < 0.0001] but not MI [hazard ratio 1.07 (CI 0.88-1.32), n.s.]. Both types of index events increased roughly three-fold the risk of a second stroke compared with no previous events. The SBP-risk relationship was not meaningfully altered by the event history. After MI and stroke the risk for subsequent events and cardiovascular death was increased over the whole SBP spectrum. A J-shape relationship between BP and outcome was only observed for cardiovascular death. CONCLUSION Previous MI and previous stroke are associated with increased risk for the same event in the future, independent of achieved SBP. Thus, secondary prevention may also be chosen according to the event history of patients. CLINICAL TRIAL REGISTRATION http://clinicaltrials.gov. Unique identifier: NCT00153101.
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29
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Renal outcomes and blood pressure patterns in diabetic and nondiabetic individuals at high cardiovascular risk. J Hypertens 2021; 39:766-774. [PMID: 33560052 DOI: 10.1097/hjh.0000000000002697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Diabetes and hypertension are risk factors for renal and cardiovascular outcomes. Data on the association of achieved blood pressure (BP) with renal outcomes in patients with and without diabetes are sparse. We investigated the association of achieved SBP, DBP with renal outcomes and urinary albumin excretion (UAE) in people with vascular disease. METHODS In this pooled analysis, we assessed renal outcome data from high-risk patients aged 55 years or older with a history of cardiovascular disease, 70% of whom had hypertension, randomized to The Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial and to Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease trials investigating telmisartan, ramipril and their combination with a median follow-up of 56 months. Standardized office BP was measured every 6 months, estimated glomerular filtration rate (eGFR) and UAE at baseline, 2 years and study end. Associations of mean achieved BP on treatment were investigated on major renal outcomes including end-stage renal disease (ESRD), decline of eGFR by at least 40%, doubling of creatinine and the composites thereof and on UAE. Analyses were by Cox regression analysis, analysis of variance and Chi2-test. Of 30 937 patients with complete data, 19 450 patients without and 11 487 with diabetes were enrolled between 1 December 2001 and 31 July 2003 and followed until 31 July 2008. Data were pooled as the outcomes for telmisartan 80 mg/day (n = 2903) or placebo (n = 2907) for Telmisartan Randomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease and ramipril 10 mg/day (n = 8407), telmisartan 80 mg/day (n = 8386) or the combination of both (n = 8334) were similar. RESULTS For both those with and without diabetes, the hazard ratios for the composites ESRD or doubling of serum creatinine (707 events overall) and ESRD or 40% eGFR loss (2371 events overall) reached a nadir at achieved SBP of 120 to less than 140 mmHg, and increased with higher and lower SBP with similar relative risk with or without diabetes. For example, risk for the former composite reached a hazard ratios 3.06 (confidence interval 1.90-4.92) with a mean achieved SBP more than 160 mmHg compared with 120 to less than 130 mmHg with diabetes and hazard ratios 2.14 (1.09-4.26) without diabetes. In contrast, the development of new microalbuminuria and macroalbuminuria (3002 and 846 events overall) associated linearly over the whole range of achieved SBP (apart from a slight increase in risk at SBP less than 120 mmHg only in those without diabetes). Absolute risks for the composite and albuminuria outcomes were consistently greater in those with diabetes as compared with without diabetes with high event rates over the whole SBP spectrum. The increased renal risk at low SBP was not related to a meaningful reduction of mandated study drugs or open label renin-angiotensin-aldosterone system inhibition. CONCLUSION In patients at high cardiovascular risk, SBP levels more than 140 mmHg and less than 120 are associated with increased risk for renal outcomes. Renal risk was greater in diabetes across the whole range of achieved SBP and DBP. These data suggest similar target BP range in patients with and without diabetes to prevent renal outcomes, a frequent complication in high-risk vascular patients. CLINICAL TRIAL REGISTRATION Clinical Trial registration: http://clinicaltrials.gov.Unique identifier: NCT00153101.
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30
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Li J, Somers VK, Gao X, Chen Z, Ju J, Lin Q, Mohamed EA, Karim S, Xu H, Zhang L. Evaluation of Optimal Diastolic Blood Pressure Range Among Adults With Treated Systolic Blood Pressure Less Than 130 mm Hg. JAMA Netw Open 2021; 4:e2037554. [PMID: 33595663 PMCID: PMC7890449 DOI: 10.1001/jamanetworkopen.2020.37554] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE Extremely low diastolic blood pressure has been reported to be associated with increased adverse cardiovascular events (ie, the diastolic J-shape phenomenon); however, current US guidelines recommend an intensive blood pressure target of less than 130/80 mm Hg without mentioning the lower limits of diastolic blood pressure. OBJECTIVES To evaluate whether there is a diastolic J-shape phenomenon for patients with an treated systolic blood pressure of less than 130 mm Hg and to explore the safe and optimal diastolic blood pressure ranges for this patient population. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed outcome data of patients at high cardiovascular risk who were randomized to intensive or standard blood pressure control and achieved treated systolic blood pressure of less than 130 mm Hg in the Systolic Blood Pressure Intervention Trial (SPRINT) and Action to Control Cardiovascular Risk in Diabetes-Blood Pressure (ACCORD-BP) trial. Data were collected from October 2010 to August 2015 (SPRINT) and from September 1999 to June 2009 (ACCORD-BP). Data were analyzed from January to May 2020. EXPOSURE Treated diastolic blood pressure, divided in intervals of less than 60, 60 to less than 70, 70 to less than 80, and 80 mm Hg and greater. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of all-cause death, nonfatal myocardial infarction, and nonfatal stroke. A composite cardiovascular outcome, including cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke, was among the key secondary outcomes. RESULTS A total of 7515 patients (mean [SD] age, 65.6 [8.7] years; 4553 [60.6%] men) were included in this analysis. The nominally lowest risk was observed at a diastolic blood pressure between 70 and 80 mm Hg for the primary outcome, the composite cardiovascular outcome, nonfatal myocardial infarction, and cardiovascular death. A mean diastolic blood pressure of less than 60 mm Hg was associated with significantly increased risk of the primary outcome (hazard ratio [HR], 1.46; 95% CI, 1.13-1.90; P = .004), the composite cardiovascular outcome (HR, 1.74; 95% CI, 1.26-2.41; P = .001), nonfatal myocardial infarction (HR, 1.73; 95% CI, 1.15-2.59; P = .008), and nonfatal stroke (HR, 2.67; 95% CI, 1.26-5.63; P = .01). CONCLUSIONS AND RELEVANCE This cohort study found that lowering diastolic blood pressure to less than 60 mm Hg was associated with increased risk of cardiovascular events in patients with high cardiovascular risk and an treated systolic blood pressure less than 130 mm Hg. The finding that a diastolic blood pressure value between 70 and 80 mm Hg was an optimum target for this patient population merits further study.
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Affiliation(s)
- Jingen Li
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Virend K. Somers
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Xiang Gao
- Internal Medicine Division, Tieying Hospital of Fengtai District, Beijing, China
| | - Zhuo Chen
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
| | - Jianqing Ju
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
| | - Qian Lin
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
| | - Essa A. Mohamed
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shahid Karim
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Hao Xu
- Cardiovascular Diseases Center, Xiyuan Hospital, China Academy of Chinese Medical Sciences, National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
| | - Lijing Zhang
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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31
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Liew CH, McEvoy JW. The diastolic blood pressure J-curve remains an observational research phenomenon that has not yet been proven as causal and should not be used to make invasive treatment decisions. Eur Heart J 2020; 41:4284-4285. [PMID: 33155014 DOI: 10.1093/eurheartj/ehaa627] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Chee H Liew
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, Moyola Lane, Newcastle, Galway H91 FF68, Ireland
| | - John W McEvoy
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, Moyola Lane, Newcastle, Galway H91 FF68, Ireland.,Department of Medicine, Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Baltimore, MD 21287, USA
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32
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Crea F. The complex biology of the arterial wall: much more than endothelial dysfunction and atherosclerosis. Eur Heart J 2020; 41:4215-4218. [PMID: 33295616 DOI: 10.1093/eurheartj/ehaa926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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33
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Böhm M, Mahfoud F. J-curve revisited. Eur Heart J 2020; 41:4283. [PMID: 33245321 DOI: 10.1093/eurheartj/ehaa834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael Böhm
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III, Saarland University, Kirrberger Straße 100, 66421 Homburg/Saar, Germany
| | - Felix Mahfoud
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III, Saarland University, Kirrberger Straße 100, 66421 Homburg/Saar, Germany
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34
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Lüscher TF. Optimizing management of atrial fibrillation: integrated care, blood pressure control, ablation, and left atrial appendix occlusion. Eur Heart J 2020; 41:2821-2825. [PMID: 33216915 DOI: 10.1093/eurheartj/ehaa676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, 8032 Zurich, Switzerland
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35
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Niedriger diastolischer Blutdruck gefährlich bei stenosierender KHK. AKTUELLE KARDIOLOGIE 2020. [DOI: 10.1055/a-1200-5369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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36
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Lüscher TF. Chronic coronary syndromes: perfusion pressure, FFR, and secondary prevention. Eur Heart J 2020; 41:1611-1614. [PMID: 33216867 DOI: 10.1093/eurheartj/ehaa380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, 8032 Zurich, Switzerland
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37
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Messerli FH, Bangalore S, Messerli AW, Räber L. The muddy waters of the J-curve and coronary revascularization. Eur Heart J 2020; 41:1684-1686. [PMID: 32118261 DOI: 10.1093/eurheartj/ehaa054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | | | - Lorenz Räber
- Inselspital University of Bern, Bern, Switzerland
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