1
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Heidenreich PA, McMurray JJV. Should Beta-Blockers Be Used in Heart Failure If the LVEF Is Not Reduced? JACC. HEART FAILURE 2023; 11:901-902. [PMID: 37452802 DOI: 10.1016/j.jchf.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Paul A Heidenreich
- Department of Medicine, Stanford University School of Medicine, VA Palo Alto Health Care System, Palo Alto, California, USA.
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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2
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Van der Linden L. Navigating the twilight zone of DOAC plasma monitoring. Thromb Res 2023; 225:101-102. [PMID: 37060730 DOI: 10.1016/j.thromres.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 04/04/2023] [Indexed: 04/17/2023]
Affiliation(s)
- Lorenz Van der Linden
- Clinical Pharmacology and Pharmacotherapy Unit, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven-University of Leuven, Leuven, Belgium; Hospital Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.
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3
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Abensur Vuillaume L, Lefebvre F, Benhamed A, Schnee A, Hoffmann M, Godoy Falcao F, Haber N, Sabah J, Lavoignet CE, Le Borgne P. Lymphocyte-to-C-Reactive Protein (LCR) Ratio Is Not Accurate to Predict Severity and Mortality in Patients with COVID-19 Admitted to the ED. Int J Mol Sci 2023; 24:ijms24065996. [PMID: 36983064 PMCID: PMC10051361 DOI: 10.3390/ijms24065996] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Health care systems worldwide have been battling the ongoing COVID-19 pandemic. Since the beginning of the COVID-19 pandemic, Lymphocytes and CRP have been reported as markers of interest. We chose to investigate the prognostic value of the LCR ratio as a marker of severity and mortality in COVID-19 infection. Between 1 March and 30 April 2020, we conducted a multicenter, retrospective cohort study of patients with moderate and severe coronavirus disease 19 (COVID-19), all of whom were hospitalized after being admitted to the Emergency Department (ED). We conducted our study in six major hospitals of northeast France, one of the outbreak's epicenters in Europe. A total of 1035 patients with COVID-19 were included in our study. Around three-quarters of them (76.2%) presented a moderate form of the disease, while the remaining quarter (23.8%) presented a severe form requiring admission to the ICU. At ED admission, the median LCR was significantly lower in the group presenting severe disease compared to that with moderate disease (versus 6.24 (3.24-12) versus 12.63 ((6.05-31.67)), p < 0.001). However, LCR was neither associated with disease severity (OR: 0.99, CI 95% (0.99-1)), p = 0.476) nor mortality (OR: 0.99, CI 95% (0.99-1)). In the ED, LCR, although modest, with a threshold of 12.63, was a predictive marker for severe forms of COVID-19.
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Affiliation(s)
| | - François Lefebvre
- Department of Public Health, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, 69000 Lyon, France
| | - Amandine Schnee
- Emergency Department, CHR Metz-Thionville, 57000 Metz, France
| | | | | | - Nathan Haber
- Emergency Department, CHR Metz-Thionville, 57000 Metz, France
| | - Jonathan Sabah
- Department of Gynecologic Surgery, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | | | - Pierrick Le Borgne
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS), 67000 Strasbourg, France
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4
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Liu Y, Tan Y, Cao G, Shi L, Song Y, Shan W, Zhang M, Li P, Zhou H, Zhang B, Sun Y, Yi W. Bergenin alleviates myocardial ischemia-reperfusion injury via SIRT1 signaling. Biomed Pharmacother 2023; 158:114100. [PMID: 36538860 DOI: 10.1016/j.biopha.2022.114100] [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: 10/04/2022] [Revised: 11/25/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022] Open
Abstract
Myocardial ischemia-reperfusion (MI/R) is a major risk factor for cardiovascular disease. At present, reducing oxidative stress and apoptosis is a crucial therapeutic strategy for ameliorating MI/R injury. However, there is a lack of drugs targeting oxidative stress and apoptosis for the clinical therapy of MI/R. Bergenin is a reportedly effective agent with antioxidative and antiapoptotic activity against acute injury. Nevertheless, the roles and potential mechanisms of bergenin against MI/R injury remain unknown. Here, we hypothesized that bergenin attenuated MI/R-induced apoptosis and reactive oxygen species (ROS) production via SIRT1. Mice were subjected to MI/R and treated with bergenin, after which the cardiac function, cardiomyocyte apoptosis, LDH release, and MDA content were evaluated. In vitro, myocardial injury model of H9c2 cells was induced by simulated ischemia/reperfusion (SI/R), apoptosis and oxidative stress was decreased after treated with bergenin. Bergenin significantly reduced myocardial apoptosis and ROS generation in vitro and improved cardiac function in vivo. Intriguingly, bergenin remarkably decreased apoptosis in cardiac tissue accompanied by SIRT1 upregulation following MI/R injury. Further studies showed that inhibiting SIRT1 blocked bergenin's beneficial impact against apoptosis following SI/R injury through excessive oxidative stress and depression of the Bcl2 to Bax ratio. Collectively, these findings indicate that bergenin alleviates MI/R injury by ameliorating myocardial apoptosis and oxidative damage via the SIRT1 signaling pathway.
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Affiliation(s)
- Yingying Liu
- College of Life Science, Northwest University, Xi'an 710069, China; Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Yanzhen Tan
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Guojie Cao
- Department of general medical, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Lei Shi
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Yujie Song
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Wenju Shan
- Department of general medical, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Miao Zhang
- Department of general medical, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Panpan Li
- Department of general medical, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Haitao Zhou
- Department of general medical, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Bing Zhang
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Yang Sun
- Department of general medical, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Wei Yi
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
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5
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Yang Y, Feng K, Yuan L, Liu Y, Zhang M, Guo K, Yin Z, Wang W, Zhou S, Sun H, Yan K, Yan X, Wang X, Duan Y, Hu Y, Han J. Compound Danshen Dripping Pill inhibits hypercholesterolemia/atherosclerosis-induced heart failure in ApoE and LDLR dual deficient mice via multiple mechanisms. Acta Pharm Sin B 2022; 13:1036-1052. [PMID: 36970211 PMCID: PMC10031343 DOI: 10.1016/j.apsb.2022.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/19/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Heart failure is the leading cause of death worldwide. Compound Danshen Dripping Pill (CDDP) or CDDP combined with simvastatin has been widely used to treat patients with myocardial infarction and other cardiovascular diseases in China. However, the effect of CDDP on hypercholesterolemia/atherosclerosis-induced heart failure is unknown. We constructed a new model of heart failure induced by hypercholesterolemia/atherosclerosis in apolipoprotein E (ApoE) and LDL receptor (LDLR) dual deficient (ApoE-/-LDLR-/-) mice and investigated the effect of CDDP or CDDP plus a low dose of simvastatin on the heart failure. CDDP or CDDP plus a low dose of simvastatin inhibited heart injury by multiple actions including anti-myocardial dysfunction and anti-fibrosis. Mechanistically, both Wnt and lysine-specific demethylase 4A (KDM4A) pathways were significantly activated in mice with heart injury. Conversely, CDDP or CDDP plus a low dose of simvastatin inhibited Wnt pathway by markedly up-regulating expression of Wnt inhibitors. While the anti-inflammation and anti-oxidative stress by CDDP were achieved by inhibiting KDM4A expression and activity. In addition, CDDP attenuated simvastatin-induced myolysis in skeletal muscle. Taken together, our study suggests that CDDP or CDDP plus a low dose of simvastatin can be an effective therapy to reduce hypercholesterolemia/atherosclerosis-induced heart failure.
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Affiliation(s)
- Yanfang Yang
- College of Life Sciences, State Key Laboratory of Medicinal Chemical Biology, Key Laboratory of Bioactive Materials of Ministry of Education, Nankai University, Tianjin 300071, China
| | - Ke Feng
- Department of Physiology, Binzhou Medical University, Yantai 264003, China
| | - Liying Yuan
- College of Life Sciences, State Key Laboratory of Medicinal Chemical Biology, Key Laboratory of Bioactive Materials of Ministry of Education, Nankai University, Tianjin 300071, China
| | - Yuxin Liu
- College of Life Sciences, State Key Laboratory of Medicinal Chemical Biology, Key Laboratory of Bioactive Materials of Ministry of Education, Nankai University, Tianjin 300071, China
| | - Mengying Zhang
- Cloudphar Pharmaceuticals Co., Ltd., Shenzhen 518000, China
| | - Kaimin Guo
- Cloudphar Pharmaceuticals Co., Ltd., Shenzhen 518000, China
| | - Zequn Yin
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei 230009, China
| | - Wenjia Wang
- Cloudphar Pharmaceuticals Co., Ltd., Shenzhen 518000, China
| | - Shuiping Zhou
- The State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China
- Tasly Pharmaceutical Group Co., Ltd., Tianjin 300410, China
| | - He Sun
- Cloudphar Pharmaceuticals Co., Ltd., Shenzhen 518000, China
- The State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China
- Tasly Pharmaceutical Group Co., Ltd., Tianjin 300410, China
| | - Kaijing Yan
- Cloudphar Pharmaceuticals Co., Ltd., Shenzhen 518000, China
- The State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China
- Tasly Pharmaceutical Group Co., Ltd., Tianjin 300410, China
| | - Xijun Yan
- The State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China
- Tasly Pharmaceutical Group Co., Ltd., Tianjin 300410, China
| | - Xuerui Wang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei 230009, China
| | - Yajun Duan
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei 230009, China
- Department of Cardiology, the First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei 230001, China
- Corresponding authors. Tel.: +86 17352916451 (Yajun Duan); +86 18522755110 (Yunhui Hu); +86 13920545670 (Jihong Han).
| | - Yunhui Hu
- Cloudphar Pharmaceuticals Co., Ltd., Shenzhen 518000, China
- Corresponding authors. Tel.: +86 17352916451 (Yajun Duan); +86 18522755110 (Yunhui Hu); +86 13920545670 (Jihong Han).
| | - Jihong Han
- College of Life Sciences, State Key Laboratory of Medicinal Chemical Biology, Key Laboratory of Bioactive Materials of Ministry of Education, Nankai University, Tianjin 300071, China
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei 230009, China
- Corresponding authors. Tel.: +86 17352916451 (Yajun Duan); +86 18522755110 (Yunhui Hu); +86 13920545670 (Jihong Han).
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6
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Kytö V, Saraste A, Rautava P, Tornio A. Digoxin use and outcomes after myocardial infarction in patients with atrial fibrillation. Basic Clin Pharmacol Toxicol 2022; 130:655-665. [PMID: 35420260 PMCID: PMC9321089 DOI: 10.1111/bcpt.13733] [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: 02/07/2022] [Revised: 03/27/2022] [Accepted: 04/11/2022] [Indexed: 12/04/2022]
Abstract
Digoxin is used for rate control in atrial fibrillation (AF), but evidence for its efficacy and safety after myocardial infarction (MI) is scarce and mixed. We studied post‐MI digoxin use effects on AF patient outcomes in a nationwide registry follow‐up study in Finland. Digoxin was used by 18.6% of AF patients after MI, with a decreasing usage trend during 2004–2014. Baseline differences in digoxin users (n = 881) and controls (n = 3898) were balanced with inverse probability of treatment weight adjustment. The median follow‐up was 7.4 years. Patients using digoxin after MI had a higher cumulative all‐cause mortality (77.4% vs. 72.3%; hazard ratio [HR]: 1.19; confidence interval [CI]: 1.07–1.32; p = 0.001) during a 10‐year follow‐up. Mortality differences were detected in a subgroup analysis of patients without baseline heart failure (HF) (HR: 1.23; p = 0.019) but not in patients with baseline HF (HR: 1.05; p = 0.413). Cumulative incidences of HF hospitalizations, stroke and new MI were similar between digoxin group and controls. In conclusion, digoxin use after MI is associated with increased mortality but not with HF hospitalizations, new MI or stroke in AF patients. Increased mortality was detected in patients without baseline HF. Results suggest caution with digoxin after MI in AF patients, especially in the absence of HF.
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Affiliation(s)
- Ville Kytö
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Administrative Center, Hospital District of Southwest Finland, Turku, Finland.,Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Antti Saraste
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Päivi Rautava
- Department of Public Health, University of Turku, Turku, Finland.,Turku Clinical Research Centre, Turku University Hospital, Turku, Finland
| | - Aleksi Tornio
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland.,Unit of Clinical Pharmacology, Turku University Hospital, Turku, Finland
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7
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D'Amario D, Rodolico D, Rosano GM, Dahlström U, Crea F, Lund LH, Savarese G. Association between dosing and combination use of medications and outcomes in heart failure with reduced ejection fraction: data from the Swedish Heart Failure Registry. Eur J Heart Fail 2022; 24:871-884. [PMID: 35257446 PMCID: PMC9315143 DOI: 10.1002/ejhf.2477] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/04/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS To assess the association between combination, dose and use of current guideline-recommended target doses (TD) of renin-angiotensin system inhibitors (RASi), angiotensin receptor-neprilysin inhibitors (ARNi) and β-blockers, and outcomes in a large and unselected contemporary cohort of patients with heart failure (HF) and reduced ejection fraction. METHODS AND RESULTS Overall, 17 809 outpatients registered in the Swedish Heart Failure Registry (SwedeHF) from May 2000 to December 2018, with ejection fraction <40% and duration of HF ≥90 days were selected. Primary outcome was a composite of time to cardiovascular death and first HF hospitalization. Compared with no use of RASi or ARNi, the adjusted hazard ratio (HR) (95% confidence interval [CI]) was 0.83 (0.76-0.91) with <50% of TD, 0.78 (0.71-0.86) with 50%-99%, and 0.73 (0.67-0.80) with ≥100% of TD. Compared with no use of β-blockers, the adjusted HR (95% CI) was 0.86 (0.76-0.91), 0.81 (0.74-0.89) and 0.74 (0.68-0.82) with <50%, 50%-99% and ≥100% of TD, respectively. Patients receiving both an angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB)/ARNi and a β-blocker at 50%-99% of TD had a lower adjusted risk of the primary outcome compared with patients only receiving one drug, i.e. ACEi/ARB/ARNi or β-blocker, even if this was at ≥100% of TD. CONCLUSION Heart failure with reduced ejection fraction patients using higher doses of RASi or ARNi and β-blockers had lower risk of cardiovascular death or HF hospitalization. Use of two drug classes at 50%-99% of TD dose was associated with lower risk than one drug class at 100% of TD.
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Affiliation(s)
- Domenico D'Amario
- Division of Cardiology, Department of MedicineKarolinska InstitutetStockholmSweden
- Department of Cardiovascular SciencesFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Daniele Rodolico
- Division of Cardiology, Department of MedicineKarolinska InstitutetStockholmSweden
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | | | - Ulf Dahlström
- Department of Cardiology and the Department of Health, Medicine and Caring SciencesLinkoping UniversityLinkopingSweden
| | - Filippo Crea
- Department of Cardiovascular SciencesFondazione Policlinico Universitario Agostino Gemelli IRCCSRomeItaly
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Lars H. Lund
- Division of Cardiology, Department of MedicineKarolinska InstitutetStockholmSweden
- Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of MedicineKarolinska InstitutetStockholmSweden
- Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
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8
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Krogh J, Hjorthøj C, Kristensen SL, Selmer C, Haugaard SB. The effect of sodium-glucose transport protein 2 inhibitors on mortality and heart failure in randomized trials versus observational studies. Diabet Med 2021; 38:e14600. [PMID: 33991127 DOI: 10.1111/dme.14600] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 05/10/2021] [Indexed: 12/26/2022]
Abstract
AIM Randomized clinical trials (RCTs) allocating type 2 diabetes patients to treatment with sodium-glucose transport protein 2 (SGLT-2) inhibitors or placebo have found significant effects on the risk of heart failure and modest effects on mortality. In the wake of the first trials, a number of observational studies have been conducted, some of these reporting a mortality reduction of 50% compared to active comparators. In this review, we systematically assess and compare the results on all-cause mortality, cardiovascular mortality and heart failure hospitalization observed in RCTs with the results obtained in observational studies. METHOD We performed a systematic bibliographical search including cardiovascular outcome trials and observational studies assessing the effect of SGLT-2 inhibitors on mortality and heart failure. RESULTS Seven RCTs and 23 observational studies were included in the current review. The observed heterogeneity between study results for all-cause mortality (p-interaction < 0.001) and cardiovascular mortality (p-interaction < 0.001) was explained by study type, whereas this was not the case for heart failure (p-interaction = 0.18). CONCLUSION Methodological considerations such as the omission of important confounders, immortal-time bias and residual confounding such as unmeasured social economic inequality may be the cause of the inflated results observed in observational studies and that calls for caution when observational studies are used to guide treatment of patients with type 2 diabetes.
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Affiliation(s)
- Jesper Krogh
- Department of Endocrinology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health-Core, Mental Health Centre Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Søren L Kristensen
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Christian Selmer
- Department of Endocrinology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Steen B Haugaard
- Department of Endocrinology, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
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9
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Cleland JGF, Lyon AR, McDonagh T, McMurray JJV. The year in cardiology: heart failure. Eur Heart J 2021; 41:1232-1248. [PMID: 31901936 DOI: 10.1093/eurheartj/ehz949] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
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Affiliation(s)
- John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow G12 8QQ, UK.,National Heart & Lung Institute, Imperial College, London, UK.,British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8QQ, UK
| | - Alexander R Lyon
- National Heart & Lung Institute, Imperial College, London, UK.,Royal Brompton Hospital, London, UK
| | - Theresa McDonagh
- King's College Hospital, London, UK.,King's College London, London, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8QQ, UK
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10
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The Future of Meat: Health Impact Assessment with Randomized Evidence. Am J Med 2021; 134:569-575. [PMID: 33316249 DOI: 10.1016/j.amjmed.2020.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 11/12/2020] [Accepted: 11/18/2020] [Indexed: 01/07/2023]
Abstract
Massive animal farming for meat production poses major problems in terms of resource use, environmental impact, and biodiversity. Furthermore, excessive meat consumption has been associated with multiple deleterious health consequences. However, more and better-designed randomized trials are needed to increase the level of evidence on the health impacts of meat. Novel meat alternatives, such as plant- and cell-based meat, are much less impactful to the environment and might replace traditional animal meat in the future, but, despite promising early data, the health consequences of these novel products need further study. This manuscript focuses on the health impacts of meat over 3 main sections: 1) overview of the evidence highlighting the association of meat consumption with health; 2) novel alternatives to meat, including plant-based and cell-based alternatives; and 3) examine the rationale for randomized studies to evaluate the effects of the novel meat alternatives compared with the standard animal meat.
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11
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Mullen L, Meah MN, Elamin A, Aggarwal S, Shahzad A, Shaw M, Hasara J, Rashid M, Fisher M, Ali T, Patel B, Ding WY, Grainger R, Heseltine T, Kirmani BH, Obeidat M, Kasolo Y, Thatchil J, Khand A. Risk of Major Bleeding With Potent Antiplatelet Agents After an Acute Coronary Event: A Comparison of Ticagrelor and Clopidogrel in 5116 Consecutive Patients in Clinical Practice. J Am Heart Assoc 2021; 10:e019467. [PMID: 33834845 PMCID: PMC8174168 DOI: 10.1161/jaha.120.019467] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Major bleeding after acute coronary syndrome predicts a poor outcome but is challenging to define. The choice of antiplatelet influences bleeding risk. Methods and Results Major bleeding, subsequent myocardial infarction (MI), and all‐cause mortality to 1 year were compared in consecutive patients with acute coronary syndrome treated with clopidogrel (n=2491 between 2011 and 2013) and ticagrelor (n=2625 between 2012 and 2015) in 5 English hospitals. Clinical outcomes were identified from national hospital episode statistics. Bleeding and MI events were independently adjudicated by 2 experienced clinicians, blinded to drug, sequence, and year. Bleeding events were categorized using Bleeding Academic Research Consortium 3 to 5 and PLATO (Platelet Inhibition and Patient Outcomes) criteria and MI by the Third Universal Definition. Multivariable regression analysis was used to adjust outcomes for case mix. The median age was 68 years and 34% were women. 39% underwent percutaneous coronary intervention and 13% coronary artery bypass graft surgery. Clinical outcome data were 100% complete for bleeding and 99.7% for MI. No statistically significant difference was seen in crude or adjusted major bleeding for ticagrelor compared with clopidogrel (Bleeding Academic Research Consortium 3–5, hazard ratio [HR], 1.23; 95% CI, 0.90–1.68; P=0.2, PLATO major adjusted HR, 1.30; 95% CI, 0.98–1.74; P=0.07) except in the non‐coronary artery bypass graft cohort (n=4464), where bleeding was more frequent with ticagrelor (Bleeding Academic Research Consortium 3–5, adjusted HR, 1.58; 95% CI, 1.09–2.31; P=0.017; and PLATO major HR, 1.67; 95% CI, 1.18–2.37; P=0.004). There was no difference in crude or adjusted subsequent MI (adjusted HR, 1.20; 95% CI, 0.87–1.64; P=0.27). Crude mortality was higher in the clopidogrel group but not after adjustment, using either Cox proportional hazards or propensity matched population (HR, 0.90; 95% CI, 0.76–1.10; P=0.21) as was the case for stroke (HR, 0.82; 95% CI, 0.52–1.32; P=0.42). Conclusions This observational study indicates that the apparent benefit of ticagrelor demonstrated in a clinical trial population may not be observed in the broader population encountered in clinical practice. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02484924.
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Affiliation(s)
- Liam Mullen
- Liverpool University Hospitals NHS Foundation Trust Liverpool United Kingdom.,Liverpool Heart and Chest Hospital Liverpool United Kingdom
| | | | - Ahmed Elamin
- Liverpool University Hospitals NHS Foundation Trust Liverpool United Kingdom
| | | | - Adeel Shahzad
- Manchester University Hospitals NHS Trust Manchester United Kingdom
| | - Matthew Shaw
- Liverpool Heart and Chest Hospital Liverpool United Kingdom
| | - Jaroslav Hasara
- Liverpool University Hospitals NHS Foundation Trust Liverpool United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke- on-Trent United Kingdom
| | - Michael Fisher
- Liverpool University Hospitals NHS Foundation Trust Liverpool United Kingdom
| | - Turab Ali
- Liverpool Heart and Chest Hospital Liverpool United Kingdom.,Arrowe Park Hospital Wirral United Kingdom
| | - Billal Patel
- Blackpool & Fylde University Hospital NHS Trust Blackpool United Kingdom
| | - Wern Y Ding
- Liverpool Heart and Chest Hospital Liverpool United Kingdom
| | - Ruth Grainger
- North-West Coast Strategic Clinical Networks Warrington United Kingdom
| | - Thomas Heseltine
- Liverpool University Hospitals NHS Foundation Trust Liverpool United Kingdom
| | | | | | - Yande Kasolo
- Warrington and Halton NHS Trust Warrington United Kingdom
| | - Jecko Thatchil
- Manchester University Hospitals NHS Trust Manchester United Kingdom
| | - Aleem Khand
- Liverpool University Hospitals NHS Foundation Trust Liverpool United Kingdom.,Liverpool Heart and Chest Hospital Liverpool United Kingdom.,Department of Ageing and Chronic Diseases University of Liverpool United Kingdom
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12
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Schuemie MJ, Ryan PB, Pratt N, Chen R, You SC, Krumholz HM, Madigan D, Hripcsak G, Suchard MA. Large-scale evidence generation and evaluation across a network of databases (LEGEND): assessing validity using hypertension as a case study. J Am Med Inform Assoc 2021; 27:1268-1277. [PMID: 32827027 PMCID: PMC7481033 DOI: 10.1093/jamia/ocaa124] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/02/2020] [Accepted: 06/01/2020] [Indexed: 01/12/2023] Open
Abstract
Objectives To demonstrate the application of the Large-scale Evidence Generation and
Evaluation across a Network of Databases (LEGEND) principles described in
our companion article to hypertension treatments and assess internal and
external validity of the generated evidence. Materials and Methods LEGEND defines a process for high-quality observational research based on 10
guiding principles. We demonstrate how this process, here implemented
through large-scale propensity score modeling, negative and positive control
questions, empirical calibration, and full transparency, can be applied to
compare antihypertensive drug therapies. We assess internal validity through
covariate balance, confidence-interval coverage, between-database
heterogeneity, and transitivity of results. We assess external validity
through comparison to direct meta-analyses of randomized controlled trials
(RCTs). Results From 21.6 million unique antihypertensive new users, we generate
6 076 775 effect size estimates for 699 872 research
questions on 12 946 treatment comparisons. Through propensity score
matching, we achieve balance on all baseline patient characteristics for
75% of estimates, observe 95.7% coverage in our
effect-estimate 95% confidence intervals, find high between-database
consistency, and achieve transitivity in 84.8% of triplet
hypotheses. Compared with meta-analyses of RCTs, our results are consistent
with 28 of 30 comparisons while providing narrower confidence intervals. Conclusion We find that these LEGEND results show high internal validity and are
congruent with meta-analyses of RCTs. For these reasons we believe that
evidence generated by LEGEND is of high quality and can inform medical
decision-making where evidence is currently lacking. Subsequent publications
will explore the clinical interpretations of this evidence.
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Affiliation(s)
- Martijn J Schuemie
- Epidemiology Analytics, Janssen Research and Development, Titusville, New Jersey, USA.,Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA
| | - Patrick B Ryan
- Epidemiology Analytics, Janssen Research and Development, Titusville, New Jersey, USA.,Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide, Australia
| | - RuiJun Chen
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Seng Chan You
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea
| | - Harlan M Krumholz
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David Madigan
- Department of Statistics, Columbia University, New York, New York, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA.,Medical Informatics Services, New York-Presbyterian Hospital, New York, New York, USA
| | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, USA.,Department of Biomathematics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California, USA
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13
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Ferreira JP, Epstein M, Zannad F. The Decline of the Experimental Paradigm During the COVID-19 Pandemic: A Template for the Future. Am J Med 2021; 134:166-175. [PMID: 32950502 PMCID: PMC7499175 DOI: 10.1016/j.amjmed.2020.08.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022]
Abstract
The current Coronavirus Disease 2019 (COVID-19) pandemic has exerted an unprecedented impact across the globe. As a consequence of this overwhelming catastrophe, long-established prevailing medical and scientific paradigms have been disrupted. The response of the scientific community, medical journals, media, and some politicians has been far from ideal. The present manuscript discusses the failure of the scientific enterprise in its initiatives to address the COVID-19 outbreak as a consequence of the disarray attributable to haste and urgency. To enhance conveying our message, this manuscript is organized into 3 interrelated sections: 1) the accelerated pace of publications coupled with a dysfunctional review process; 2) failure of the clinical trial enterprise; 3) propagation of misleading information by the media. In response we propose a template comprising a focus on randomized controlled clinical trials, and an insistence on responsible journal publication, and enumeration of policies to deal with social media-propagated news. We conclude with a reconsideration of the appropriate role of academic medicine and journals.
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Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique Inserm 1433, Université de Lorraine, Nancy, France; Centre Hospitalier Régional Universitaire (CHRU) de Nancy, Inserm U1116, Nancy, France; French Clinical Research Infrastructure Network (FCRIN INI-CRCT), Nancy, France.
| | - Murray Epstein
- Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Fla
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique Inserm 1433, Université de Lorraine, Nancy, France; Centre Hospitalier Régional Universitaire (CHRU) de Nancy, Inserm U1116, Nancy, France; French Clinical Research Infrastructure Network (FCRIN INI-CRCT), Nancy, France
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14
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Fanaroff AC, Califf RM, Harrington RA, Granger CB, McMurray JJV, Patel MR, Bhatt DL, Windecker S, Hernandez AF, Gibson CM, Alexander JH, Lopes RD. Randomized Trials Versus Common Sense and Clinical Observation: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 76:580-589. [PMID: 32731936 PMCID: PMC7384793 DOI: 10.1016/j.jacc.2020.05.069] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/11/2022]
Abstract
Concerns about the external validity of traditional randomized clinical trials (RCTs), together with the widespread availability of real-world data and advanced data analytic tools, have led to claims that common sense and clinical observation, rather than RCTs, should be the preferred method to generate evidence to support clinical decision-making. However, over the past 4 decades, results from well-done RCTs have repeatedly contradicted practices supported by common sense and clinical observation. Common sense and clinical observation fail for several reasons: incomplete understanding of pathophysiology, biases and unmeasured confounding in observational research, and failure to understand risks and benefits of treatments within complex systems. Concerns about traditional RCT models are legitimate, but randomization remains a critical tool to understand the causal relationship between treatments and outcomes. Instead, development and promulgation of tools to apply randomization to real-world data are needed to build the best evidence base in cardiovascular medicine. Well-conducted RCTs have repeatedly contradicted practices supported by common sense and clinical observation. Common sense and clinical observation fail because of the inability to fully understand complex biopsychosocial systems. RCTs must be integrated into clinical practice to improve the evidence base in cardiology.
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Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, Pennsylvania. https://twitter.com/ACFanaroff
| | - Robert M Califf
- Verily Life Sciences (Alphabet), South San Francisco, California
| | | | - Christopher B Granger
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
| | - Manesh R Patel
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Adrian F Hernandez
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - C Michael Gibson
- Cardiovascular Division, Beth Israel Deaconess Medical, Harvard Medical School, Boston, Massachusetts
| | - John H Alexander
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Renato D Lopes
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina.
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15
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He L, Dong ZJ, Du X, Jiang C, Chen N, Xia SJ, Hou XX, Yu HR, Lv Q, Yu RH, Long DY, Bai R, Liu N, Sang CH, Jiang CX, Li SN, Huffman MD, Dong JZ, Ma CS. Healthcare quality and mortality among patients hospitalized for heart failure by hospital level in Beijing, China. ESC Heart Fail 2021; 8:1186-1194. [PMID: 33403776 PMCID: PMC8006727 DOI: 10.1002/ehf2.13178] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/18/2020] [Accepted: 12/03/2020] [Indexed: 01/14/2023] Open
Abstract
Aims This study sought to compare healthcare quality and 30 day, 90 day, and 1 year mortality rates among patients admitted to secondary and tertiary hospitals for heart failure (HF) in Beijing. Methods and results This study retrospectively enrolled patients hospitalized with a primary discharge diagnosis of HF during January 2014 to December 2015, from five tertiary and four secondary hospitals, in Beijing, China. Mortality data were extracted from Beijing Death Surveillance Database. HF healthcare quality indices were used to evaluate in‐hospital care. Associations between hospital level and mortality rates were assessed using generalized linear mixed models, adjusting for patients' baseline characteristics and intra‐hospital correlation. Data from 1413 patients (median [interquartile range] age = 74 [65–80] years, 52.7% female) from secondary hospitals and 1250 patients (median [interquartile range] age = 72 [61–79] years, 43.3% female) from tertiary hospitals were collected. Rates of left ventricular ejection fraction assessment (73.2% vs. 90.1%) and combined use of β‐blockers and angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers (30.1% vs. 49.3%) were lower in secondary hospitals than those in tertiary hospitals, respectively. Patients admitted to secondary hospitals had a higher 90 day mortality [10.8% vs. 5.0%; adjusted odds ratio (OR): 2.06; 95% confidence interval (CI): 1.10–3.84, P = 0.024 and a higher 1 year mortality rate [21.0% vs. 12.1%; adjusted OR: 1.64; 95% CI: 1.02–2.62, P = 0.039], but 30 day mortality rates were not significantly different (5.5% vs. 3.0%; adjusted OR: 1.49; 95% CI: 0.63–3.52, P = 0.368). Conclusions Worse quality of care for patients with HF in secondary hospitals was associated with higher 90 day and 1 year mortality rates. Improving care quality in secondary hospitals is crucial to improve prognosis of patients they served.
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Affiliation(s)
- Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Zhao-Jie Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China.,Heart Health Research Center, Beijing, China.,The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Ning Chen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Shi-Jun Xia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Xiao-Xia Hou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Hai-Rong Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Qiang Lv
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Rong-Hui Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - De-Yong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Rong Bai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Cai-Hua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Chen-Xi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Song-Nan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Mark D Huffman
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia.,Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Advanced Innovation Center for Big Data-Based Precision Medicine for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing, 100029, China
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16
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Kruik-Kollöffel WJ, van der Palen J, Doggen CJM, van Maaren MC, Kruik HJ, Heintjes EM, Movig KLL, Linssen GCM. Heart failure medication after a first hospital admission and risk of heart failure readmission, focus on beta-blockers and renin-angiotensin-aldosterone system medication: A retrospective cohort study in linked databases. PLoS One 2020; 15:e0244231. [PMID: 33351823 PMCID: PMC7755181 DOI: 10.1371/journal.pone.0244231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/05/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND This study assessed the association between heart failure (HF) medication (angiotensin-converting-enzyme inhibitors (ACEI)/angiotensin-receptor blockers (ARB), beta-blockers (BB), mineralocorticoid-receptor antagonists (MRA) and diuretics) and HF readmissions in a real-world unselected group of patients after a first hospital admission for HF. Furthermore we analysed readmission rates for ACEI versus ARB and for carvedilol versus β1-selective BB and we investigated the effect of HF medication in relation to time since discharge. METHODS AND FINDINGS Medication at discharge was determined with dispensing data from the Dutch PHARMO Database Network including 22,476 patients with HF between 2001 and 2015. After adjustment for age, gender, number of medications and year of admission no associations were found for users versus non-users of ACEI/ARB (hazard ratio, HR = 1.01; 95%CI 0.96-1.06), BB (HR = 1.00; 95%CI 0.95-1.05) and readmissions. The risk of readmission for patients prescribed MRA (HR = 1.11; 95%CI 1.05-1.16) or diuretics (HR = 1.17; 95%CI 1.09-1.25) was higher than for non-users. The HR for ARB relative to ACEI was 1.04 (95%CI 0.97-1.12) and for carvedilol relative to β1-selective BB 1.33 (95%CI 1.20-1.46). Post-hoc analyses showed a protective effect shortly after discharge for most medications. For example one month post discharge the HR for ACEI/ARB was 0.77 (95%CI 0.69-0.86). Although we did try to adjust for confounding by indication, probably residual confounding is still present. CONCLUSIONS Patients who were prescribed carvedilol have a higher or at least a similar risk of HF readmission compared to β1-selective BB. This study showed that all groups of HF medication -some more pronounced than others- were more effective immediately following discharge.
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Affiliation(s)
- Willemien J. Kruik-Kollöffel
- Department of Clinical Pharmacy, Ziekenhuisgroep Twente (Hospital Group Twente), Almelo and Hengelo, the Netherlands
| | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, the Netherlands
- Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, the Netherlands
| | - Carine J. M. Doggen
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
| | - Marissa C. van Maaren
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, the Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - H. Joost Kruik
- Department of Cardiology, Ziekenhuisgroep Twente (Hospital Group Twente), Almelo and Hengelo, the Netherlands
| | | | - Kris L. L. Movig
- Department of Clinical Pharmacy, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Gerard C. M. Linssen
- Department of Cardiology, Ziekenhuisgroep Twente (Hospital Group Twente), Almelo and Hengelo, the Netherlands
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17
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Nabeta T, Ishii S, Ikeda Y, Maemura K, Oki T, Yazaki M, Fujita T, Naruke T, Inomata T, Ako J. Late gadolinium enhancement for re-worsening left ventricular ejection fraction in patients with dilated cardiomyopathy. ESC Heart Fail 2020; 8:615-624. [PMID: 33270357 PMCID: PMC7835548 DOI: 10.1002/ehf2.13133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 11/02/2020] [Accepted: 11/11/2020] [Indexed: 01/14/2023] Open
Abstract
Aims This study aimed to evaluate the clinical parameters including late gadolinium enhancement (LGE) of cardiovascular magnetic resonance to predict re‐worsening of left ventricular ejection fraction (LVEF) in patients with dilated cardiomyopathy (DCM). Methods and results We included 138 patients with recent‐onset DCM who had an LVEF <45% and underwent LGE of cardiovascular magnetic resonance imaging at diagnosis and echocardiography at the yearly follow‐up [median 6 (4–8.3) years]. Initial LVEF recovery was defined as LVEF increase >10% from baseline, resulting in LVEF ≧45% after treatment. The patients were divided into three groups: (i) improved (n = 83, 60%), defined as those with sustained LVEF ≧45%; (ii) re‐worsening (n = 39, 28%), those with >5% decrease and LVEF <45% after the initial LVEF recovery; and (iii) not‐improved (n = 16, 12%), those without initial LVEF recovery. The primary endpoint was a composite of hospitalization for heart failure or sudden cardiac death. In baseline, LGE was observed in 70 patients. The LGE area was significantly larger in the re‐worsening and not‐improved groups than that in the improved group (P < 0.001). Loess curves of long‐term LVEF trajectories showed that LVEF in the re‐worsening group increased in the first 2 years and slowly declined thereafter. Multivariate logistic regression analysis demonstrated that LGE area [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.03–1.16, P = 0.004], B‐type natriuretic peptide (OR 1.49, 95% CI 1.05–2.21, P = 0.030) level at the initial recovery, and LVEF (OR 0.91, 95% CI 0.86–0.97, P = 0.004) at the initial LVEF recovery were independent predictors of re‐worsening of LVEF. During a median follow‐up of 2273 (interquartile range: 1634–3191) days, the primary endpoint was observed in 31 (22%) patients. Univariate Cox proportional hazards analysis demonstrated that the risk of experiencing the primary event in the re‐worsening group was significantly higher (hazard ratio: 4.30, 95% CI 1.63–11.31, P = 0.003) than that in the improved group and was lower than that in the not‐improved group (hazard ratio: 0.33, 95% CI 0.15–0.72, P = 0.006). Conclusions Re‐worsening of LVEF was observed in 28% of patients with recent‐onset DCM who showed an initial improvement in LVEF. High LGE burden, higher B‐type natriuretic peptide level, and lower LVEF at the initial LVEF recovery were independent predictors of re‐worsening of LVEF in patients with DCM. Careful observation is recommended for patients with a high risk for re‐worsening of LVEF, even in those with an initial LVEF recovery.
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Affiliation(s)
- Takeru Nabeta
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan
| | - Shunsuke Ishii
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan
| | - Yuki Ikeda
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan
| | - Kenji Maemura
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan
| | - Takumi Oki
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan
| | - Mayu Yazaki
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan
| | - Teppei Fujita
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan
| | - Takashi Naruke
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0329, Japan
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18
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Aguirre Dávila L, Weber K, Bavendiek U, Bauersachs J, Wittes J, Yusuf S, Koch A. Digoxin-mortality: randomized vs. observational comparison in the DIG trial. Eur Heart J 2020; 40:3336-3341. [PMID: 31211324 PMCID: PMC6801940 DOI: 10.1093/eurheartj/ehz395] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 03/18/2019] [Accepted: 06/03/2019] [Indexed: 11/12/2022] Open
Abstract
AIMS The Digitalis Investigation Group (DIG) trial, the only large randomized trial of digoxin in heart failure, reported a neutral effect on mortality and a significant reduction in heart failure hospitalizations. Recent observational studies reported increased mortality with digoxin treatment. We present further analyses of the DIG trial displaying the inability to control bias in observational treatment comparisons despite extensive statistical adjustments. METHODS AND RESULTS Forty-four percent of the 6800 patients in the DIG trial had been treated with digoxin before randomization, and half of them were randomly withdrawn from digoxin treatment. We contrast the main randomization-based result of the DIG trial with the observational non-randomized comparison of patients pre-treated or not pre-treated with digoxin. Mortality [hazard ratio (HR) 1.22, 95% confidence interval (CI) 1.12-1.34; P < 0.001] and heart failure hospitalizations (HR 1.47, 95% CI 1.33-1.61; P < 0.001) were significantly higher in patients pre-treated with digoxin even after adjustment for baseline population differences. The higher risks for both outcomes in those who had previously received digoxin persisted even if they received placebo during the trial (HR 1.24, 95% CI 1.10-1.40; P < 0.001). This sharply contradicts the neutral effect on mortality and the significant reduction in heart failure hospitalizations observed in the randomized comparison. CONCLUSION Prescription of digoxin is an indicator of disease severity and worse prognosis, which cannot be fully accounted for by covariate adjustments in the DIG trial where patients were well-characterized. It is unlikely that weaker research approaches (observational studies of administrative data or registries) can provide more reliable estimates of the effects of cardiac glycosides.
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Affiliation(s)
- Lukas Aguirre Dávila
- Institute for Biostatistics, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany
| | - Kristina Weber
- Institute for Biostatistics, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Janet Wittes
- Statistics Collaborative, Inc., Washington, DC, USA
| | - Salim Yusuf
- Population Health Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - Armin Koch
- Institute for Biostatistics, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 299] [Impact Index Per Article: 74.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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Schuemie MJ, Ryan PB, Pratt N, Chen R, You SC, Krumholz HM, Madigan D, Hripcsak G, Suchard MA. Principles of Large-scale Evidence Generation and Evaluation across a Network of Databases (LEGEND). J Am Med Inform Assoc 2020; 27:1331-1337. [PMID: 32909033 PMCID: PMC7481029 DOI: 10.1093/jamia/ocaa103] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/27/2020] [Accepted: 05/16/2020] [Indexed: 01/13/2023] Open
Abstract
Evidence derived from existing health-care data, such as administrative claims and electronic health records, can fill evidence gaps in medicine. However, many claim such data cannot be used to estimate causal treatment effects because of the potential for observational study bias; for example, due to residual confounding. Other concerns include P hacking and publication bias. In response, the Observational Health Data Sciences and Informatics international collaborative launched the Large-scale Evidence Generation and Evaluation across a Network of Databases (LEGEND) research initiative. Its mission is to generate evidence on the effects of medical interventions using observational health-care databases while addressing the aforementioned concerns by following a recently proposed paradigm. We define 10 principles of LEGEND that enshrine this new paradigm, prescribing the generation and dissemination of evidence on many research questions at once; for example, comparing all treatments for a disease for many outcomes, thus preventing publication bias. These questions are answered using a prespecified and systematic approach, avoiding P hacking. Best-practice statistical methods address measured confounding, and control questions (research questions where the answer is known) quantify potential residual bias. Finally, the evidence is generated in a network of databases to assess consistency by sharing open-source analytics code to enhance transparency and reproducibility, but without sharing patient-level information. Here we detail the LEGEND principles and provide a generic overview of a LEGEND study. Our companion paper highlights an example study on the effects of hypertension treatments, and evaluates the internal and external validity of the evidence we generate.
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Affiliation(s)
- Martijn J Schuemie
- Epidemiology Analytics, Janssen Research and Development, Titusville, New Jersey, USA
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Patrick B Ryan
- Epidemiology Analytics, Janssen Research and Development, Titusville, New Jersey, USA
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide, South Australia, Australia
| | - RuiJun Chen
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Seng Chan You
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea
| | - Harlan M Krumholz
- Department of Medicine, Yale University School of Medicine, New Haven, California, USA
| | - David Madigan
- Department of Statistics, Columbia University, New York, New York, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Medical Center, New York, New York, USA
- Medical Informatics Services, New York-Presbyterian Hospital, New York, New York, USA
| | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, California, USA
- Department of Biomathematics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California, USA
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22
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Medical treatment of octogenarians with chronic heart failure: data from CHECK-HF. Clin Res Cardiol 2020; 109:1155-1164. [PMID: 32030498 DOI: 10.1007/s00392-020-01607-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/20/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Elderly heart failure (HF) patients are underrepresented in clinical trials, though are a large proportion of patients in real-world practice. We investigated practice-based, secondary care HF management in a large group of chronic HF patients aged ≥ 80 years (octogenarians). METHODS We analyzed electronic health records of 3490 octogenarians with chronic HF at 34 Dutch outpatient clinics in the period between 2013 and 2016 , 49% women. Study patients were divided into HFpEF [LVEF ≥ 50%; n = 911 (26.1%)], HFrEF [LVEF < 40%; n = 2009 (57.6%)] and HF with mid-range EF [HFmrEF: LVEF 40-49%; n = 570 (16.3%)]. RESULTS Most HFrEF patients aged ≥ 80 years received a beta blocker and a renin-angiotensin system (RAS) inhibitor (angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker), i.e. 78.3% and 72.8% respectively, and a mineralocorticoid receptor antagonist (MRA) was prescribed in 52.0% of patients. All three of these guideline-recommended medications (triple therapy) were given in only 29.9% of octogenarians with HFrEF, and at least 50% of target doses of triple therapy, beta blockers, RAS inhibitor and MRA, were prescribed in 43.8%, 62.2% and 53.5% of the total group of HFrEF patients. Contraindications or intolerance for beta blockers was present in 3.5% of the patients, for RAS inhibitors and MRAs in, 7.2% and 6.1% CONCLUSIONS: The majority of octogenarians with HFrEF received one or more guideline-recommended HF medications. However, triple therapy or target doses of the medications were prescribed in a minority. Comorbidities and reported contraindications and tolerances did not fully explain underuse of recommended HF therapies.
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Schuemie MJ, Cepeda MS, Suchard MA, Yang J, Tian Y, Schuler A, Ryan PB, Madigan D, Hripcsak G. How Confident Are We about Observational Findings in Healthcare: A Benchmark Study. HARVARD DATA SCIENCE REVIEW 2020; 2. [PMID: 33367288 DOI: 10.1162/99608f92.147cc28e] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Healthcare professionals increasingly rely on observational healthcare data, such as administrative claims and electronic health records, to estimate the causal effects of interventions. However, limited prior studies raise concerns about the real-world performance of the statistical and epidemiological methods that are used. We present the "OHDSI Methods Benchmark" that aims to evaluate the performance of effect estimation methods on real data. The benchmark comprises a gold standard, a set of metrics, and a set of open source software tools. The gold standard is a collection of real negative controls (drug-outcome pairs where no causal effect appears to exist) and synthetic positive controls (drug-outcome pairs that augment negative controls with simulated causal effects). We apply the benchmark using four large healthcare databases to evaluate methods commonly used in practice: the new-user cohort, self-controlled cohort, case-control, case-crossover, and self-controlled case series designs. The results confirm the concerns about these methods, showing that for most methods the operating characteristics deviate considerably from nominal levels. For example, in most contexts, only half of the 95% confidence intervals we calculated contain the corresponding true effect size. We previously developed an "empirical calibration" procedure to restore these characteristics and we also evaluate this procedure. While no one method dominates, self-controlled methods such as the empirically calibrated self-controlled case series perform well across a wide range of scenarios.
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Affiliation(s)
- Martijn J Schuemie
- Observational Health Data Sciences and Informatics.,Epidemiology Analytics, Janssen Research and Development.,Department of Biostatistics, University of California, Los Angeles
| | - M Soledad Cepeda
- Observational Health Data Sciences and Informatics.,Epidemiology Analytics, Janssen Research and Development
| | - Marc A Suchard
- Observational Health Data Sciences and Informatics.,Department of Biostatistics, University of California, Los Angeles.,Department of Biomathematics, University of California, Los Angeles.,Department of Human Genetics, University of California, Los Angeles
| | - Jianxiao Yang
- Observational Health Data Sciences and Informatics.,Department of Biomathematics, University of California, Los Angeles
| | - Yuxi Tian
- Observational Health Data Sciences and Informatics.,Department of Biomathematics, University of California, Los Angeles
| | - Alejandro Schuler
- Observational Health Data Sciences and Informatics.,Center for Biomedical Informatics Research, Stanford University
| | - Patrick B Ryan
- Observational Health Data Sciences and Informatics.,Epidemiology Analytics, Janssen Research and Development.,Department of Biomedical Informatics, Columbia University
| | - David Madigan
- Observational Health Data Sciences and Informatics.,Department of Statistics, Columbia University
| | - George Hripcsak
- Observational Health Data Sciences and Informatics.,Department of Biomedical Informatics, Columbia University.,Medical Informatics Services, New York-Presbyterian Hospital
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Enzan N, Matsushima S, Ide T, Kaku H, Higo T, Tsuchihashi-Makaya M, Tsutsui H. Spironolactone use is associated with improved outcomes in heart failure with mid-range ejection fraction. ESC Heart Fail 2020; 7:339-347. [PMID: 31951680 PMCID: PMC7083406 DOI: 10.1002/ehf2.12571] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/22/2019] [Accepted: 11/11/2019] [Indexed: 12/28/2022] Open
Abstract
Aims Spironolactone has been shown to improve outcomes in patients with heart failure (HF) with reduced ejection fraction (EF). We investigated whether the discharge use of spironolactone could be associated with better long‐term outcomes among patients with HF with mid‐range EF (HFmrEF). Methods and results We analysed HFmrEF (left ventricular EF 40–49%) patients enrolled in the Japanese Cardiac Registry of Heart Failure in Cardiology, which prospectively studied the clinical characteristics, treatments, and long‐term outcomes of patients hospitalized due to HF. Patients were divided into two groups according to the use of spironolactone at discharge. The primary outcome was a composite of all‐cause death or HF rehospitalization. A total of 457 patients had HFmrEF. The mean age was 69.3 years and 286 (62.6%) were male. Among them, spironolactone was prescribed at discharge in 158 patients (34.6%). Chronic kidney disease (7.6% vs. 16.8%, P = 0.007) was less prevalent and loop diuretics (89.2% vs. 70.2%, P < 0.001) were more often prescribed in patients with spironolactone. During a mean follow‐up of 2.2 years, patients with spironolactone had a lower incidence rate of the primary outcome than those without it (171.5 vs. 278.8 primary outcome per 1000 patient‐years, incidence rate ratio 0.61, 95% confidence interval 0.44–0.86; P = 0.004). After multivariable adjustment, spironolactone use at discharge was associated with a significant reduction in the composite of all‐cause death or HF rehospitalization (adjusted hazard ratio 0.63, 95% confidence interval 0.44–0.90, P = 0.010). Conclusions Among patients with HF hospitalized for HFmrEF, spironolactone use at discharge was associated with better long‐term outcomes.
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Affiliation(s)
- Nobuyuki Enzan
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouji Matsushima
- Department of Cardiovascular Medicine, Kyushu University Hospital, Maidashi 3-1-1, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tomomi Ide
- Department of Experimental and Clinical Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hidetaka Kaku
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Taiki Higo
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
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25
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Docherty KF, Shen L, Castagno D, Petrie MC, Abraham WT, Böhm M, Desai AS, Dickstein K, Køber LV, Packer M, Rouleau JL, Solomon SD, Swedberg K, Vazir A, Zile MR, Jhund PS, McMurray JJ. Relationship between heart rate and outcomes in patients in sinus rhythm or atrial fibrillation with heart failure and reduced ejection fraction. Eur J Heart Fail 2019; 22:528-538. [DOI: 10.1002/ejhf.1682] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/14/2019] [Accepted: 10/27/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Li Shen
- BHF Cardiovascular Research CentreUniversity of Glasgow Glasgow UK
| | - Davide Castagno
- Division of Cardiology, Città della Salute e della Scienza Hospital, Department of Medical SciencesUniversity of Turin Torino Italy
| | - Mark C. Petrie
- BHF Cardiovascular Research CentreUniversity of Glasgow Glasgow UK
| | - William T. Abraham
- Division of Cardiovascular Medicine, Davis Heart and Lung Research InstituteThe Ohio State University Columbus OH USA
| | - Michael Böhm
- Department of Internal Medicine III, University Hospital of SaarlandSaarland University Homburg/Saar Germany
| | - Akshay S. Desai
- Cardiovascular MedicineBrigham and Women's Hospital Boston MA USA
| | - Kenneth Dickstein
- Department of CardiologyUniversity of Bergen, Stavanger University Hospital Stavanger Norway
| | - Lars V. Køber
- Department of Cardiology, The Heart CentreRigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical Center Dallas TX USA
| | - Jean L. Rouleau
- Institut de Cardiologie de MontréalUniversité de Montréal Montréal Canada
| | - Scott D. Solomon
- Cardiovascular MedicineBrigham and Women's Hospital Boston MA USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; National Heart and Lung InstituteImperial College London London UK
| | - Ali Vazir
- Department of Cardiology, Royal Brompton Hospital, National Heart and Lung InstituteImperial College London London UK
| | - Michael R. Zile
- Department of MedicineMedical University of South Carolina Charleston SC USA
| | - Pardeep S. Jhund
- BHF Cardiovascular Research CentreUniversity of Glasgow Glasgow UK
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Tan Q. Harnessing the power of twins in epigenetic association studies: causal inference and more. Epigenomics 2019; 12:1-3. [PMID: 31833395 DOI: 10.2217/epi-2019-0359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Qihua Tan
- Epidemiology & Biostatistics, Department of Public Health, University of Southern Denmark, Odense, Denmark.,Unit of Human Genetics, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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27
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Suchard MA, Schuemie MJ, Krumholz HM, You SC, Chen R, Pratt N, Reich CG, Duke J, Madigan D, Hripcsak G, Ryan PB. Comprehensive comparative effectiveness and safety of first-line antihypertensive drug classes: a systematic, multinational, large-scale analysis. Lancet 2019; 394:1816-1826. [PMID: 31668726 PMCID: PMC6924620 DOI: 10.1016/s0140-6736(19)32317-7] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/02/2019] [Accepted: 08/15/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Uncertainty remains about the optimal monotherapy for hypertension, with current guidelines recommending any primary agent among the first-line drug classes thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers, and non-dihydropyridine calcium channel blockers, in the absence of comorbid indications. Randomised trials have not further refined this choice. METHODS We developed a comprehensive framework for real-world evidence that enables comparative effectiveness and safety evaluation across many drugs and outcomes from observational data encompassing millions of patients, while minimising inherent bias. Using this framework, we did a systematic, large-scale study under a new-user cohort design to estimate the relative risks of three primary (acute myocardial infarction, hospitalisation for heart failure, and stroke) and six secondary effectiveness and 46 safety outcomes comparing all first-line classes across a global network of six administrative claims and three electronic health record databases. The framework addressed residual confounding, publication bias, and p-hacking using large-scale propensity adjustment, a large set of control outcomes, and full disclosure of hypotheses tested. FINDINGS Using 4·9 million patients, we generated 22 000 calibrated, propensity-score-adjusted hazard ratios (HRs) comparing all classes and outcomes across databases. Most estimates revealed no effectiveness differences between classes; however, thiazide or thiazide-like diuretics showed better primary effectiveness than angiotensin-converting enzyme inhibitors: acute myocardial infarction (HR 0·84, 95% CI 0·75-0·95), hospitalisation for heart failure (0·83, 0·74-0·95), and stroke (0·83, 0·74-0·95) risk while on initial treatment. Safety profiles also favoured thiazide or thiazide-like diuretics over angiotensin-converting enzyme inhibitors. The non-dihydropyridine calcium channel blockers were significantly inferior to the other four classes. INTERPRETATION This comprehensive framework introduces a new way of doing observational health-care science at scale. The approach supports equivalence between drug classes for initiating monotherapy for hypertension-in keeping with current guidelines, with the exception of thiazide or thiazide-like diuretics superiority to angiotensin-converting enzyme inhibitors and the inferiority of non-dihydropyridine calcium channel blockers. FUNDING US National Science Foundation, US National Institutes of Health, Janssen Research & Development, IQVIA, South Korean Ministry of Health & Welfare, Australian National Health and Medical Research Council.
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Affiliation(s)
- Marc A. Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, CA, USA
- Department of Biomathematics, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, USA
| | - Martijn J. Schuemie
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles, CA, USA
- Epidemiology Analytics, Janssen Research and Development, Titusville, NJ,, USA
| | - Harlan M. Krumholz
- Department of Medicine, Yale University School of Medicine, New Haven, CA, USA
| | - Seng Chan You
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea
| | - RuiJun Chen
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
- Department of Biomedical Informatics, Columbia University Medical Center, New York, NY, USA
| | - Nicole Pratt
- Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute, University of South Australia, Adelaide, SA, Australia
| | | | - Jon Duke
- Georgia Tech Research Institute, Georgia Tech College of Computing, Atlanta, GA, USA
| | - David Madigan
- Department of Statistics, Columbia University, New York, NY, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University Medical Center, New York, NY, USA
- Medical Informatics Services, New York-Presbyterian Hospital, New York, NY 10032
| | - Patrick B. Ryan
- Epidemiology Analytics, Janssen Research and Development, Titusville, NJ,, USA
- Department of Biomedical Informatics, Columbia University Medical Center, New York, NY, USA
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28
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The epigenome of twins as a perfect laboratory for studying behavioural traits. Neurosci Biobehav Rev 2019; 107:192-195. [PMID: 31536737 DOI: 10.1016/j.neubiorev.2019.09.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/11/2019] [Accepted: 09/13/2019] [Indexed: 01/04/2023]
Abstract
The debate upon the relative importance of nature vs nurture in the development of human behaviour can be traced back to ancient times. Traditional epidemiology and genetic epidemiology have confirmed the association of environmental and genetic factors with behavioural traits. Current genomic studies are identifying genetic variants associated with various behavioural traits. However, exploring the relationship of abundant environmental factors with the complex epigenome that mediates human behaviour is just at its beginning. Identical twins can serve as perfect experiments for studying the environmental impact on behavioural epigenetics advantaged by enriched power in association analysis due to controlling of their genetic make-ups. Recent development in causal inference using twin-based models adds more values in twins. This review briefly introduces the various approaches in making use of twins in studying behavioural epigenetics from experiment design to practical applications. Exploring the epigenome of twins using the powerful twin-based study designs and analytical approaches will help identifying causal epigenetic markers mediating environmental exposures and behavioural traits enabling both pharmaceutical intervention and effective prevention.
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Boorsma EM, Rienstra M, van Veldhuisen DJ, van der Meer P. Residual confounding in observational studies: new data from the old DIG trial. Eur Heart J 2019; 40:3342-3344. [DOI: 10.1093/eurheartj/ehz527] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Eva M Boorsma
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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30
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Wiggers H. Insulin treatment in heart failure patients: the good, the bad or the ugly? Eur J Heart Fail 2019; 21:985-987. [DOI: 10.1002/ejhf.1556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 06/19/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Henrik Wiggers
- Department of CardiologyAarhus University Hospital Aarhus Denmark
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31
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Law JP, Pickup L, Townend JN, Ferro CJ. Vive les Differences!-A case for optimism in the treatment of patients with heart failure and preserved ejection fraction? Int J Clin Pract 2019; 73:e13307. [PMID: 30582265 DOI: 10.1111/ijcp.13307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Jonathan P Law
- Birmingham Cardio-Renal Group, University Hospitals Birmingham and University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Luke Pickup
- Birmingham Cardio-Renal Group, University Hospitals Birmingham and University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group, University Hospitals Birmingham and University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Charles J Ferro
- Birmingham Cardio-Renal Group, University Hospitals Birmingham and University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
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32
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Bavendiek U, Berliner D, Dávila LA, Schwab J, Maier L, Philipp SA, Rieth A, Westenfeld R, Piorkowski C, Weber K, Hänselmann A, Oldhafer M, Schallhorn S, von der Leyen H, Schröder C, Veltmann C, Störk S, Böhm M, Koch A, Bauersachs J. Rationale and design of the DIGIT-HF trial (DIGitoxin to Improve ouTcomes in patients with advanced chronic Heart Failure): a randomized, double-blind, placebo-controlled study. Eur J Heart Fail 2019; 21:676-684. [PMID: 30892806 PMCID: PMC6607489 DOI: 10.1002/ejhf.1452] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/31/2019] [Accepted: 02/06/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS Despite recent advances in the treatment of chronic heart failure (HF), mortality and hospitalizations still remain high. Additional therapies to improve mortality and morbidity are urgently needed. The efficacy of cardiac glycosides - although regularly used for HF treatment - remains unclear. DIGIT-HF was designed to demonstrate that digitoxin on top of standard of care treatment improves mortality and morbidity in patients with HF and a reduced ejection fraction (HFrEF). METHODS Patients with chronic HF, New York Heart Association (NYHA) functional class III-IV and left ventricular ejection fraction (LVEF) ≤ 40%, or patients in NYHA functional class II and LVEF ≤ 30% are randomized 1:1 in a double-blind fashion to treatment with digitoxin (target serum concentration 8-18 ng/mL) or matching placebo. Randomization is stratified by centre, sex, NYHA functional class (II, III, or IV), atrial fibrillation, and treatment with cardiac glycosides at baseline. A total of 2190 eligible patients will be included in this clinical trial (1095 per group). All patients receive standard of care treatment recommended by expert guidelines upon discretion of the treating physician. The primary outcome is a composite of all-cause mortality or hospital admission for worsening HF (whatever occurs first). Key secondary endpoints are all-cause mortality, hospital admission for worsening HF, and recurrent hospital admission for worsening HF. CONCLUSION The DIGIT-HF trial will provide important evidence, whether the cardiac glycoside digitoxin reduces the risk for all-cause mortality and/or hospital admission for worsening HF in patients with advanced chronic HFrEF on top of standard of care treatment.
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Affiliation(s)
- Udo Bavendiek
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | - Dominik Berliner
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | | | - Johannes Schwab
- Department of Cardiology, Cardiovascular Center, Clinical Center NuernbergParacelsus Medical UniversityNuernbergGermany
| | - Lars Maier
- Department of Internal Medicine IIUniversity Medical Center RegensburgRegensburgGermany
| | - Sebastian A. Philipp
- Department of Cardiology and Intensive Care MedicineElbe Clinic StadeStadeGermany
| | - Andreas Rieth
- Department of Cardiology, Kerckhoff HeartRheuma and Thoracic CenterBad NauheimGermany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical FacultyUniversity DuesseldorfDuesseldorfGermany
| | - Christopher Piorkowski
- Department of Electrophysiology, Heart CenterUniversity of Technology DresdenDresdenGermany
| | - Kristina Weber
- Department of BiostatisticsHannover Medical SchoolHannoverGermany
| | - Anja Hänselmann
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | | | - Sven Schallhorn
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | | | - Christoph Schröder
- Institute of Clinical PharmacologyHannover Medical SchoolHannoverGermany
| | - Christian Veltmann
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
| | - Stefan Störk
- Department of Internal Medicine IUniversity Hospital WuerzburgWuerzburgGermany
| | - Michael Böhm
- Department of Internal Medicine IIIUniversity Hospital of the SaarlandHomburgGermany
| | - Armin Koch
- Department of BiostatisticsHannover Medical SchoolHannoverGermany
| | - Johann Bauersachs
- Department of Cardiology and AngiologyHannover Medical SchoolHannoverGermany
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Digitalis therapy is associated with higher comorbidities and poorer prognosis in patients undergoing ablation of atrial arrhythmias: data from the German Ablation Registry. Clin Res Cardiol 2019; 108:1083-1092. [PMID: 30798346 DOI: 10.1007/s00392-019-01442-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 02/18/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Digitalis glycosides are employed for rate control of atrial fibrillation. Recent studies suggested potential harmful effects of digitalis monotherapy and combination with antiarrhythmic drugs. The aim of the present study was to assess the prevalence and potential impact of digitalis therapy on outcome in patients undergoing catheter ablation of supraventricular arrhythmias. METHODS AND RESULTS The German Ablation Registry is a nationwide, prospective registry with a 1-year follow-up investigating 12,566 patients receiving catheter ablations of supraventricular arrhythmias in 52 German centres. The present analysis focussed on pharmacotherapy in 8608 patients undergoing catheter ablation of atrial tachycardia, atrial fibrillation, or atrial flutter. Patients receiving digitalis therapy (n = 417) were older and presented a significantly increased prevalence of comorbidities including coronary artery disease, heart failure, diabetes, and pulmonary disease. One-year mortality was significantly higher in digitalis-treated patients (4.7% vs. 1.3%, p < 0.001), most strikingly in patients undergoing ablation of atrial flutter. This effect was maintained after adjustment for important risk factors. Similar results were obtained for as the combined endpoint of death, myocardial infarction, stroke and major bleeding (6.6% vs. 2.7%, p < 0.001), and non-fatal rehospitalisations (54.1% vs. 45.1%, p = 0.001). CONCLUSION In the present study of patients undergoing catheter ablation of supraventricular arrhythmias, an association of digitalis therapy with increased mortality and an increased rate of other severe adverse events were observed. The results from this 'real-life' registry are consistent with previously published studies. However, whether digitalis therapy promotes a poorer prognosis or may just serve as a marker for this aspect cannot be thoroughly interpreted.
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Gerstein HC, McMurray J, Holman RR. Real-world studies no substitute for RCTs in establishing efficacy. Lancet 2019; 393:210-211. [PMID: 30663582 DOI: 10.1016/s0140-6736(18)32840-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 11/05/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Hertzel C Gerstein
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON L8S4K1, Canada.
| | - John McMurray
- University of Glasgow, BHF Cardiovascular Research Centre, Glasgow, UK
| | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
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