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Abel AAI, Clark AL. Long-Term Pharmacological Management of Reduced Ejection Fraction Following Acute Myocardial Infarction: Current Status and Future Prospects. Int J Gen Med 2021; 14:7797-7805. [PMID: 34795500 PMCID: PMC8593493 DOI: 10.2147/ijgm.s294896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/26/2021] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) with reduced ejection fraction is common following acute myocardial infarction (MI), and active medical management can have a profound impact on prognosis. Reviewing relevant clinical trials, we focus on the pharmacological management of left ventricular systolic dysfunction (LVSD) following an acute MI, although there is overlap with the pharmacological management of chronic HF due to reduced ejection fraction. Angiotensin converting enzyme (ACE) inhibitors, beta-blockers, and mineralocorticoid receptor antagonists are the mainstay of medical management in patients with LVSD post MI; there may also be a role for anticoagulation. Sacubitril-valsartan (angiotensin receptor neprilysin inhibitor) has not yet been shown to be superior to an ACE inhibitor in reducing cardiovascular mortality and HF events in patients with LVSD post MI. Large randomised trials evaluating sodium glucose transporter 2 (SGLT-2) inhibitors in LVSD post MI are ongoing.
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Affiliation(s)
- Alexandra A I Abel
- Department of Academic Cardiology, Castle Hill Hospital, Kingston Upon Hull, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Castle Hill Hospital, Kingston Upon Hull, UK
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Raman M, Green D, Middleton RJ, Kalra PA. Comparing the impact of older age on outcome in chronic kidney disease of different etiologies: a prospective cohort study. J Nephrol 2018; 31:931-939. [PMID: 30187380 PMCID: PMC6244557 DOI: 10.1007/s40620-018-0529-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 08/22/2018] [Indexed: 11/30/2022]
Abstract
Background In older patients with chronic kidney disease (CKD), the risk of progression to end stage renal disease and cardiovascular death both differ compared to younger patients. This likely reflects differences in case mix and co-morbid burdens. We sought to establish the extent to which age itself is an independent biomarker of adverse outcome in CKD. Methods This was an analysis of the Salford Kidney Study, a prospective, longitudinal, observational study of 2,667 patients with eGFR < 60 ml/min/1.73 m2. Patients were divided into four age groups (< 55, 55–65, 65–75 and > 75 years). Within group adjusted hazard ratios for death in older compared to younger patients were calculated for different primary renal diseases. A competing risk model of death and renal replacement therapy (RRT) as outcomes was performed. Results The median age of the cohort was 67.1 years [interquartile range (IQR): 55.6–75.3] and median eGFR 30.8 ml/min/1.73 m2 (IQR: 20.6–43.2). Follow up was 3.5 ± 2.9 years. Overall, the adjusted HR for death in patients aged > 75 years compared to those < 55 years was 4.4 (95% CI 3.4–5.9), p < 0.001. The HR for death differed between primary renal diseases and CKD stages. In diabetic nephropathy, the HR was 3.0 (1.8–5.3, p < 0.001), in glomerulonephritis the HR was 12.2 (5.6–25.5, p < 0.001). The cumulative incidence of RRT was < 0.1 at 10 years for patients > 75 years, compared with 0.50 in those < 55 years. Death was more likely at 20 months in those aged 75 years or older (0.17) than at 10 years in those aged < 55 years (0.10). Conclusion This study demonstrates that the risk associated with older age shows significant variability between primary renal diseases. This is whilst acknowledging that observational studies carry the risk of hidden bias not adjusted for in the statistical model. Electronic supplementary material The online version of this article (10.1007/s40620-018-0529-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maharajan Raman
- Vascular Research Group, Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Darren Green
- Vascular Research Group, Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK. .,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Rachel J Middleton
- Vascular Research Group, Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Philip A Kalra
- Vascular Research Group, Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Raman M, Green D, Middleton RJ, Kalra PA. OLDER PEOPLE WITH CHRONIC KIDNEY DISEASE: DEFINITION, AND INFLUENCE OF BIOMARKERS AND MEDICATIONS UPON CARDIOVASCULAR AND RENAL OUTCOMES. J Ren Care 2016; 42:150-61. [PMID: 27364740 DOI: 10.1111/jorc.12164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a global problem. With an ageing population the burden on the health services has increased due to the growing number of older people with CKD. This group of individuals is far different to the younger CKD population and their risk of cardiovascular death is far greater than the risk of progressing to end stage kidney disease (ESKD). OBJECTIVE In this review we explore the role of certain biomarkers and medications in predicting the risk of progression to ESKD and death in old people with CKD. METHODS An electronic literature search of EMBASE and MEDLINE databases was performed using Healthcare Databases Advanced Search (HDAS) in December 2014. RESULTS Albuminuria is a key biomarker in predicting the risk of death and progression to ESKD. Cystatin C appears to be superior in predicting the risk of cardiovascular and non-cardiovascular death compared to GFR or creatinine. Several inflammatory biomarkers can be used to predict the risk of death and progression to CKD but measuring and monitoring them in routine clinical practice will be expensive and impractical. The effects of long-term RAAS inhibition in older people are not well established. Older people especially those with CKD receive suboptimal secondary preventive measures. Due to multiple comorbidities older people with CKD are usually receiving a number of medications. This can potentially lead to significant adverse drug events (ADE) due to drug interactions. CONCLUSION Novel non-traditional risk factors like albuminuria, Cystatin C and inflammatory biomarkers play an important role in predicting their risk of death and progression to ESKD. The efficacy and safety of medications in older people with CKD is not well established and requires more extensive, focused study.
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Affiliation(s)
- Maharajan Raman
- Vascular Research Group, Salford Royal NHS Foundation Trust, Salford, UK.,Institute of Population Health, University of Manchester, Manchester, UK
| | - Darren Green
- Vascular Research Group, Salford Royal NHS Foundation Trust, Salford, UK.,Institute of Population Health, University of Manchester, Manchester, UK
| | - Rachel J Middleton
- Vascular Research Group, Salford Royal NHS Foundation Trust, Salford, UK.,Institute of Population Health, University of Manchester, Manchester, UK
| | - Philip A Kalra
- Vascular Research Group, Salford Royal NHS Foundation Trust, Salford, UK.,Institute of Population Health, University of Manchester, Manchester, UK
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Arnold JJ, Hayer M, Sharif A, Begaj I, Tabriez M, Bagnall D, Ray D, Hoye C, Nazir M, Dutton M, Fifer L, Kirkham K, Sims D, Townend JN, Gill PS, Dasgupta I, Cockwell P, Ferro CJ. Acute Care QUAliTy in chronic Kidney disease (ACQUATIK): a prospective cohort study exploring outcomes of patients with chronic kidney disease. BMJ Open 2015; 5:e006987. [PMID: 25941178 PMCID: PMC4420952 DOI: 10.1136/bmjopen-2014-006987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) is common and carries a high risk of morbidity, including hospital admissions and readmissions and mortality. This is largely attributed to an increased risk of cardiovascular disease. Patients with CKD are less likely to receive evidence-based treatments for cardiovascular disease. However, these treatments are based on trials which generally exclude patients with CKD. It is therefore unclear whether this patient group derives the same benefits without an increased risk of adverse effects. METHODS AND ANALYSIS The Acute Care QUAliTy in chronic Kidney disease (ACQUATIK) study is a prospective, observational, multicentre cohort study. Over 4000 patients will be recruited with an enrolment period of 2 years and a follow-up period of 2-4 years. Patients under follow-up by a renal team will be excluded. Data will be obtained from patient and hospital records during the index admission. Preadmission data will be extracted from general practice records based on the Quality and Outcomes Framework. Diagnosis, comorbidities and procedure data pertaining to the index and subsequent admissions will be extracted from the Hospital Episode Statistics database and long-term mortality data will be tracked using the Office of National Statistics. This information will allow us to examine a complete patient journey through primary and secondary care, providing unequalled levels of information on treatment and outcomes of patients with CKD. The combined data set will be used to compare outcomes and treatments among patients with CKD versus patients without CKD. The primary end point is hospital readmission rates. The relationship between age, sex, ethnicity, socioeconomic status and concurrent comorbidities will be analysed to determine their influence on outcomes and treatments. ETHICS AND DISSEMINATION The ACQUATIK study has been approved by the NRES Committee West Midlands-South Birmingham-Reference 13/WM/0317. The results from ACQUATIK will be submitted for publication in peer-reviewed journals and presented at primary and secondary care conferences. TRIAL REGISTRATION NUMBER ISRCTN37237454.
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Affiliation(s)
- Julia J Arnold
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Manvir Hayer
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Adnan Sharif
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Irena Begaj
- Department of Informatics, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Mohammed Tabriez
- Department of Informatics, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - David Bagnall
- Department of Informatics, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Daniel Ray
- Department of Informatics, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Ciaron Hoye
- Birmingham Crosscity Clinical Commissioning Group, Birmingham, UK
| | - Masood Nazir
- Birmingham Crosscity Clinical Commissioning Group, Birmingham, UK
| | - Mary Dutton
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Lesley Fifer
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Katie Kirkham
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Don Sims
- Care of the Elderly Medicine, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Department of Cardiology, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Paramjit S Gill
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Indranil Dasgupta
- Department of Nephrology, Heart of England NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Paul Cockwell
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Charles J Ferro
- Department of Nephrology, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
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Kalra PR, García-Moll X, Zamorano J, Kalra PA, Fox KM, Ford I, Ferrari R, Tardif JC, Tendera M, Greenlaw N, Steg PG. Impact of chronic kidney disease on use of evidence-based therapy in stable coronary artery disease: a prospective analysis of 22,272 patients. PLoS One 2014; 9:e102335. [PMID: 25051258 PMCID: PMC4106833 DOI: 10.1371/journal.pone.0102335] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/17/2014] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the frequency of chronic kidney disease (CKD), define the associated demographics, and evaluate its association with use of evidence-based drug therapy in a contemporary global study of patients with stable coronary artery disease. Methods 22,272 patients from the ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease (CLARIFY) were included. Baseline estimated glomerular filtration rate (eGFR) was calculated (CKD-Epidemiology Collaboration formula) and patients categorised according to CKD stage: >89, 60–89, 45–59 and <45 mL/min/1.73 m2. Results Mean (SD) age was 63.9±10.4 years, 77.3% were male, 61.8% had a history of myocardial infarction, 71.9% hypertension, 30.4% diabetes and 75.4% dyslipidaemia. Chronic kidney disease (eGFR<60 mL/min/1.73 m2) was seen in 22.1% of the cohort (6.9% with eGFR<45 mL/min/1.73 m2); lower eGFR was associated with increasing age, female sex, cardiovascular risk factors, overt vascular disease, other comorbidities and higher systolic but lower diastolic blood pressure. High use of secondary prevention was seen across all CKD stages (overall 93.4% lipid-lowering drugs, 95.3% antiplatelets, 75.9% beta-blockers). The proportion of patients taking statins was lower in patients with CKD. Antiplatelet use was significantly lower in patients with CKD whereas oral anticoagulant use was higher. Angiotensin-converting enzyme inhibitor use was lower (52.0% overall) and inversely related to declining eGFR, whereas angiotensin-receptor blockers were more frequently prescribed in patients with reduced eGFR. Conclusions Chronic kidney disease is common in patients with stable coronary artery disease and is associated with comorbidities. Whilst use of individual evidence-based medications for secondary prevention was high across all CKD categories, there remains an opportunity to improve the proportion who take all three classes of preventive therapies. Angiotensin-converting enzyme inhibitors were used less frequently in lower eGRF categories. Surprisingly the reverse was seen for angiotensin-receptor blockers. Further evaluation is required to fully understand these associations. The CLARIFY (ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) Registry is registered in the ISRCTN registry of clinical trials with the number ISRCTN43070564. http://www.controlled-trials.com/ISRCTN43070564.
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Affiliation(s)
- Paul R Kalra
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; NHLI Imperial College, ICMS, London, United Kingdom
| | - Xavier García-Moll
- Unitat Hospitalització, Servei de Cardiologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Philip A Kalra
- Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Kim M Fox
- NHLI Imperial College, ICMS, London, United Kingdom; Royal Brompton Hospital, London, United Kingdom
| | - Ian Ford
- University of Glasgow, Glasgow, United Kingdom
| | - Roberto Ferrari
- Department of Cardiology, Azienda Ospedaliero-Universitaria di Ferrara, Ospedale di Cona, Cona, Italy
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Do patients with chronic kidney disease get optimal cardiovascular risk reduction? Curr Opin Nephrol Hypertens 2014; 23:267-74. [DOI: 10.1097/01.mnh.0000444913.78536.b1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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