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Tombor LS, Dimmeler S. Why is endothelial resilience key to maintain cardiac health? Basic Res Cardiol 2022; 117:35. [PMID: 35834003 PMCID: PMC9283358 DOI: 10.1007/s00395-022-00941-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/10/2022] [Accepted: 06/13/2022] [Indexed: 02/01/2023]
Abstract
Myocardial injury as induced by myocardial infarction results in tissue ischemia, which critically incepts cardiomyocyte death. Endothelial cells play a crucial role in restoring oxygen and nutrient supply to the heart. Latest advances in single-cell multi-omics, together with genetic lineage tracing, reveal a transcriptional and phenotypical adaptation to the injured microenvironment, which includes alterations in metabolic, mesenchymal, hematopoietic and pro-inflammatory signatures. The extent of transition in mesenchymal or hematopoietic cell lineages is still debated, but it is clear that several of the adaptive phenotypical changes are transient and endothelial cells revert back to a naïve cell state after resolution of injury responses. This resilience of endothelial cells to acute stress responses is important for preventing chronic dysfunction. Here, we summarize how endothelial cells adjust to injury and how this dynamic response contributes to repair and regeneration. We will highlight intrinsic and microenvironmental factors that contribute to endothelial cell resilience and may be targetable to maintain a functionally active, healthy microcirculation.
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Affiliation(s)
- Lukas S. Tombor
- Institute of Cardiovascular Regeneration, Goethe University Frankfurt, Frankfurt, Germany ,Faculty for Biological Sciences, Goethe University Frankfurt, Frankfurt, Germany
| | - Stefanie Dimmeler
- Institute of Cardiovascular Regeneration, Goethe University Frankfurt, Frankfurt, Germany ,Faculty for Biological Sciences, Goethe University Frankfurt, Frankfurt, Germany
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Thomas KH, Dalili MN, López-López JA, Keeney E, Phillippo D, Munafò MR, Stevenson M, Caldwell DM, Welton NJ. Smoking cessation medicines and e-cigarettes: a systematic review, network meta-analysis and cost-effectiveness analysis. Health Technol Assess 2021; 25:1-224. [PMID: 34668482 DOI: 10.3310/hta25590] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cigarette smoking is one of the leading causes of early death. Varenicline [Champix (UK), Pfizer Europe MA EEIG, Brussels, Belgium; or Chantix (USA), Pfizer Inc., Mission, KS, USA], bupropion (Zyban; GlaxoSmithKline, Brentford, UK) and nicotine replacement therapy are licensed aids for quitting smoking in the UK. Although not licensed, e-cigarettes may also be used in English smoking cessation services. Concerns have been raised about the safety of these medicines and e-cigarettes. OBJECTIVES To determine the clinical effectiveness, safety and cost-effectiveness of smoking cessation medicines and e-cigarettes. DESIGN Systematic reviews, network meta-analyses and cost-effectiveness analysis informed by the network meta-analysis results. SETTING Primary care practices, hospitals, clinics, universities, workplaces, nursing or residential homes. PARTICIPANTS Smokers aged ≥ 18 years of all ethnicities using UK-licensed smoking cessation therapies and/or e-cigarettes. INTERVENTIONS Varenicline, bupropion and nicotine replacement therapy as monotherapies and in combination treatments at standard, low or high dose, combination nicotine replacement therapy and e-cigarette monotherapies. MAIN OUTCOME MEASURES Effectiveness - continuous or sustained abstinence. Safety - serious adverse events, major adverse cardiovascular events and major adverse neuropsychiatric events. DATA SOURCES Ten databases, reference lists of relevant research articles and previous reviews. Searches were performed from inception until 16 March 2017 and updated on 19 February 2019. REVIEW METHODS Three reviewers screened the search results. Data were extracted and risk of bias was assessed by one reviewer and checked by the other reviewers. Network meta-analyses were conducted for effectiveness and safety outcomes. Cost-effectiveness was evaluated using an amended version of the Benefits of Smoking Cessation on Outcomes model. RESULTS Most monotherapies and combination treatments were more effective than placebo at achieving sustained abstinence. Varenicline standard plus nicotine replacement therapy standard (odds ratio 5.75, 95% credible interval 2.27 to 14.90) was ranked first for sustained abstinence, followed by e-cigarette low (odds ratio 3.22, 95% credible interval 0.97 to 12.60), although these estimates have high uncertainty. We found effect modification for counselling and dependence, with a higher proportion of smokers who received counselling achieving sustained abstinence than those who did not receive counselling, and higher odds of sustained abstinence among participants with higher average dependence scores. We found that bupropion standard increased odds of serious adverse events compared with placebo (odds ratio 1.27, 95% credible interval 1.04 to 1.58). There were no differences between interventions in terms of major adverse cardiovascular events. There was evidence of increased odds of major adverse neuropsychiatric events for smokers randomised to varenicline standard compared with those randomised to bupropion standard (odds ratio 1.43, 95% credible interval 1.02 to 2.09). There was a high level of uncertainty about the most cost-effective intervention, although all were cost-effective compared with nicotine replacement therapy low at the £20,000 per quality-adjusted life-year threshold. E-cigarette low appeared to be most cost-effective in the base case, followed by varenicline standard plus nicotine replacement therapy standard. When the impact of major adverse neuropsychiatric events was excluded, varenicline standard plus nicotine replacement therapy standard was most cost-effective, followed by varenicline low plus nicotine replacement therapy standard. When limited to licensed interventions in the UK, nicotine replacement therapy standard was most cost-effective, followed by varenicline standard. LIMITATIONS Comparisons between active interventions were informed almost exclusively by indirect evidence. Findings were imprecise because of the small numbers of adverse events identified. CONCLUSIONS Combined therapies of medicines are among the most clinically effective, safe and cost-effective treatment options for smokers. Although the combined therapy of nicotine replacement therapy and varenicline at standard doses was the most effective treatment, this is currently unlicensed for use in the UK. FUTURE WORK Researchers should examine the use of these treatments alongside counselling and continue investigating the long-term effectiveness and safety of e-cigarettes for smoking cessation compared with active interventions such as nicotine replacement therapy. STUDY REGISTRATION This study is registered as PROSPERO CRD42016041302. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 59. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kyla H Thomas
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael N Dalili
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - José A López-López
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - David Phillippo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marcus R Munafò
- Faculty of Life Sciences, School of Psychological Science, University of Bristol, Bristol, UK.,MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.,UK Centre for Tobacco and Alcohol Studies, University of Bristol, Bristol, UK
| | - Matt Stevenson
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Deborah M Caldwell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Dharmayat K, Woringer M, Mastellos N, Cole D, Car J, Ray S, Khunti K, Majeed A, Ray KK, Seshasai SRK. Investigation of Cardiovascular Health and Risk Factors Among the Diverse and Contemporary Population in London (the TOGETHER Study): Protocol for Linking Longitudinal Medical Records. JMIR Res Protoc 2020; 9:e17548. [PMID: 33006568 PMCID: PMC7568219 DOI: 10.2196/17548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 07/20/2020] [Accepted: 07/26/2020] [Indexed: 11/25/2022] Open
Abstract
Background Global trends in cardiovascular disease (CVD) exhibit considerable interregional and interethnic differences, which in turn affect long-term CVD risk across diverse populations. An in-depth understanding of the interplay between ethnicity, socioeconomic status, and CVD risk factors and mortality in a contemporaneous population is crucial to informing health policy and resource allocation aimed at mitigating long-term CVD risk. Generating bespoke large-scale and reliable data with sufficient numbers of events is expensive and time-consuming but can be circumvented through utilization and linkage of data routinely collected in electronic health records (EHR). Objective We aimed to characterize the burden of CVD risk factors across different ethnicities, age groups, and socioeconomic groups, and study CVD incidence and mortality by EHR linkage in London. Methods The proposed study will initially be a cross-sectional observational study unfolding into prospective CVD ascertainment through longitudinal follow-up involving linked data. The government-funded National Health System (NHS) Health Check program provides an opportunity for the systematic collation of CVD risk factors on a large scale. NHS Health Check data on approximately 200,000 individuals will be extracted from consenting general practices across London that use the Egton Medical Information Systems (EMIS) EHR software. Data will be analyzed using appropriate statistical techniques to (1) determine the cross-sectional burden of CVD risk factors and their prospective association with CVD outcomes, (2) validate existing prediction tools in diverse populations, and (3) develop bespoke risk prediction tools across diverse ethnic groups. Results Enrollment began in January 2019 and is ongoing with initial results to be published mid-2021. Conclusions There is an urgent need for more real-life population health studies based on analyses of routine health data available in EHRs. Findings from our study will help quantify, on a large scale, the contemporaneous burden of CVD risk factors by geography and ethnicity in a large multiethnic urban population. Such detailed understanding (especially interethnic and sociodemographic variations) of the burden of CVD risk and its determinants, including heredity, environment, diet, lifestyle, and socioeconomic factors, in a large population sample, will enable the development of tailored and dynamic (continuously learning from new data) risk prediction tools for diverse ethnic groups, and thereby enable the personalized provision of prevention strategies and care. We anticipate that this systematic approach of linking routinely collected data from EHRs to study CVD can be conducted in other settings as EHRs are being implemented worldwide. International Registered Report Identifier (IRRID) PRR1-10.2196/17548
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Affiliation(s)
- Kanika Dharmayat
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, United Kingdom
| | - Maria Woringer
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, United Kingdom
| | - Nikolaos Mastellos
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, United Kingdom
| | - Della Cole
- Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom
| | - Josip Car
- Global eHealth Unit, Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Sumantra Ray
- NNEdPro Global Centre for Nutrition and Health in Cambridge, University of Cambridge, Cambridge, United Kingdom.,Humanities and Social Science, University of Cambridge, Cambridge, United Kingdom
| | - Kamlesh Khunti
- Primary Care Diabetes and Vascular Medicine, University of Leicester, Leicester, United Kingdom
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, United Kingdom
| | - Kausik K Ray
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, Imperial College London, London, United Kingdom
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Abram SGF, Judge A, Beard DJ, Price AJ. Rates of Adverse Outcomes and Revision Surgery After Anterior Cruciate Ligament Reconstruction: A Study of 104,255 Procedures Using the National Hospital Episode Statistics Database for England, UK. Am J Sports Med 2019; 47:2533-2542. [PMID: 31348862 DOI: 10.1177/0363546519861393] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND After an anterior cruciate ligament (ACL) injury, ACL reconstruction is an elective procedure, and therefore, an understanding of the attributable risk from undergoing ACL reconstruction is necessary for patients to make a fully informed treatment decision. PURPOSE To determine the absolute risk of adverse outcomes including reoperation after ACL reconstruction with comparison, where possible, to the rate of adverse events reported in the general population. STUDY DESIGN Descriptive epidemiology study. METHODS National hospital data on all ACL reconstructions performed in England between April 1, 1997, and March 31, 2017, were analyzed. Revision cases, bilateral procedures within 6 months, and cases with concurrent cartilage or multiple ligament surgery were excluded. The primary outcome was the occurrence of at least 1 serious complication (myocardial infarction, stroke, pulmonary embolism, infection requiring surgery, fasciotomy, neurovascular injury, or death) within 90 days. Additionally, 5-year rates of revision ACL reconstruction, contralateral ACL reconstruction, and meniscal surgery were investigated. RESULTS There were 133,270 ACL reconstructions performed, of which 104,255 were eligible for analysis. Within 90 days, serious complications occurred in 675 (0.65% [95% CI, 0.60-0.70]), including 494 reoperations for infections (0.47% [95% CI, 0.43-0.52]) and 129 for pulmonary embolism (0.12% [95% CI, 0.10-0.15]). Of 54,275 procedures with at least 5 years' follow-up, 1746 (3.22% [95% CI, 3.07-3.37]) underwent revision ACL reconstruction in the same knee, 1553 underwent contralateral ACL reconstruction (2.86% [95% CI, 2.72-3.01]), and 340 underwent meniscal surgery (0.63% [95% CI, 0.56-0.70]). The overall risk of serious complications fell over time (adjusted odds ratio [OR], 0.96 per year [95% CI, 0.95-0.98]); however, older patients (adjusted OR, 1.11 per 5 years [95% CI, 1.07-1.16]) and patients with a greater modified Charlson Comorbidity Index (adjusted OR, 2.41 per 10 units [95% CI, 1.65-3.51]) were at a higher risk. For every 850 (95% CI, 720-1039) ACL reconstructions, 1 pulmonary embolism could be provoked. For every 213 (95% CI, 195-233), 1 native knee joint infection could be provoked. CONCLUSION The overall risk of adverse events after ACL reconstruction is low; however, some rare but serious complications, including infections or pulmonary embolism, may occur. Around 3% of patients undergo further ipsilateral or contralateral ACL reconstruction within 5 years. These data will inform shared decision making between clinicians and patients considering their treatment options.
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Affiliation(s)
- Simon G F Abram
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK.,Musculoskeletal Research Unit, University of Bristol, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre, Bristol, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Andrew J Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
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Abram SGF, Judge A, Beard DJ, Price AJ. Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England. Lancet 2018; 392:2194-2202. [PMID: 30262336 PMCID: PMC6238020 DOI: 10.1016/s0140-6736(18)31771-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/22/2018] [Accepted: 07/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Arthroscopic partial meniscectomy is one of the most common orthopaedic procedures worldwide. Clinical trial evidence published in the past 6 years, however, has raised questions about the effectiveness of the procedure in some patient groups. In view of concerns about potential overuse, we aimed to establish the true risk of serious complications after arthroscopic partial meniscectomy. METHODS We analysed national Hospital Episode Statistics data for all arthroscopic partial meniscectomies done in England between April 1, 1997, and March 31, 2017. Simultaneous or staged (within 6 months) bilateral cases were excluded. We identified complications occurring in the 90 days after the index procedure. The primary outcome was the occurrence of at least one serious complication within 90 days, which was defined as either myocardial infarction, stroke, pulmonary embolism, infection requiring surgery, fasciotomy, neurovascular injury, or death. Logistic regression modelling was used to identify factors associated with complications and, when possible, risk was compared with general population data. FINDINGS During the study period 1 088 782 arthroscopic partial meniscectomies were done, 699 965 of which were eligible for analysis. Within 90 days, serious complications occurred in 2218 (0·317% [95% CI 0·304-0·330]) cases, including 546 pulmonary embolisms (0·078% [95% CI 0·072-0·085]) and 944 infections necessitating further surgery (0·135% [95% CI 0·126-0·144]). Increasing age (adjusted odds ratio [OR] 1·247 per decade [95% CI 1·208-1·288) and modified Charlson comorbidity index (adjusted OR 1·860 per 10 units [95% CI 1·708-2·042]) were associated with an increased risk of serious complications. Female sex was associated with a reduced risk of serious complications (adjusted OR 0·640 [95% CI 0·580-0·705). The risk of mortality fell over time (adjusted OR 0·965 per year [95% CI 0·937-0·994]). Mortality, myocardial infarction, and stroke occurred less frequently in the study cohort than in the general population. The risks of infection and pulmonary embolism did not change during the study, and were significantly higher in the study cohort than in the general population. For every 1390 (95% CI 1272-1532) fewer knee arthroscopies done, one pulmonary embolism could be prevented. For every 749 (95% CI 704-801) fewer procedures done, one native knee joint infection could be prevented. INTERPRETATION Overall, the risk associated with undergoing arthroscopic partial meniscectomy was low. However, some rare but serious complications (including pulmonary embolism and infection) are associated with the procedure, and the risks have not fallen with time. In view of uncertainty about the effectiveness of arthroscopic partial meniscectomy, an appreciation of relative risks is crucial for patients and clinicians. Our data provide a basis for decision making and consent. FUNDING UK National Institute for Health Research.
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Affiliation(s)
- Simon G F Abram
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Boulanger M, Béjot Y, Rothwell PM, Touzé E. Long-Term Risk of Myocardial Infarction Compared to Recurrent Stroke After Transient Ischemic Attack and Ischemic Stroke: Systematic Review and Meta-Analysis. J Am Heart Assoc 2018; 7:e007267. [PMID: 29348322 PMCID: PMC5850155 DOI: 10.1161/jaha.117.007267] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 11/17/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Uncertainties remain about the current risk of myocardial infarction (MI) after ischemic stroke or transient ischemic attack. METHODS AND RESULTS We undertook a systematic review to estimate the long-term risk of MI, compared to recurrent stroke, with temporal trends in ischemic stroke/transient ischemic attack patients. Annual risks and 95% confidence intervals (95% CI) of MI and recurrent stroke were estimated using random-effect meta-analyses. We calculated incidence ratios of MI/recurrent stroke, for fatal and nonfatal events, using similar analyses. Rate ratios for MI in patients with potential risk factors compared to those without were calculated using Poisson regression.A total of 58 studies (131 299 patients) with a mean (range) follow-up of 3.5 (1.0-10.0) years were included. The risk of MI was 1.67%/y (95% CI 1.36-1.98, Phet<0.001 for heterogeneity) and decreased over time (Pint=0.021); 96% of the heterogeneity between studies was explained by study design, study period, follow-up duration, mean age, proportion of patients on antithrombotic therapy, and incident versus combined ischemic stroke/transient ischemic attack. The risk of recurrent stroke was 4.26%/y (95% CI 3.43-5.09, Phet<0.001), with no change over time (Pint=0.63). The risk of fatal MI was half the risk of recurrent strokes ending in fatality (incidence ratio=0.51, 95% CI 0.14-0.89, Phet=0.58). The risk of nonfatal MI was 75% smaller than the risk of recurrent nonfatal stroke (incidence ratio=0.25, 95%CI 0.02-0.50, Phet=0.68). Male sex, hypertension, coronary and peripheral artery diseases were associated with a doubled risk of MI. CONCLUSIONS After ischemic stroke/transient ischemic attack, the risk of MI is currently <2%/y, and recurrent stroke is a more common cause of death than MI.
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Affiliation(s)
- Marion Boulanger
- Normandie Université UNICAEN, Inserm U1237 CHU Caen, Caen, France
- Stroke Prevention Research Unit, University Department of Clinical Neurology, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Yannick Béjot
- Department of Neurology, Dijon Stroke Registry, Pathophysiology and Epidemiology of Cerebro-Cardiovascular Diseases (PEC2) Team, EA7460, CHU Dijon, University of Burgundy, Dijon, France
| | - Peter M Rothwell
- Stroke Prevention Research Unit, University Department of Clinical Neurology, John Radcliffe Hospital, University of Oxford, United Kingdom
| | - Emmanuel Touzé
- Normandie Université UNICAEN, Inserm U1237 CHU Caen, Caen, France
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Torabi A, Cleland JGF, Sherwi N, Atkin P, Panahi H, Kilpatrick E, Thackray S, Hoye A, Alamgir F, Goode K, Rigby A, Clark AL. Influence of case definition on incidence and outcome of acute coronary syndromes. Open Heart 2016; 3:e000487. [PMID: 28123755 PMCID: PMC5237751 DOI: 10.1136/openhrt-2016-000487] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/29/2016] [Accepted: 10/18/2016] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Acute coronary syndromes (ACS) are common, but their incidence and outcome might depend greatly on how data are collected. We compared case ascertainment rates for ACS and myocardial infarction (MI) in a single institution using several different strategies. METHODS The Hull and East Yorkshire Hospitals serve a population of ∼560 000. Patients admitted with ACS to cardiology or general medical wards were identified prospectively by trained nurses during 2005. Patients with a death or discharge code of MI were also identified by the hospital information department and, independently, from Myocardial Infarction National Audit Project (MINAP) records. The hospital laboratory identified all patients with an elevated serum troponin-T (TnT) by contemporary criteria (>0.03 µg/L in 2005). RESULTS The prospective survey identified 1731 admissions (1439 patients) with ACS, including 764 admissions (704 patients) with MIs. The hospital information department reported only 552 admissions (544 patients) with MI and only 206 admissions (203 patients) were reported to the MINAP. Using all 3 strategies, 934 admissions (873 patients) for MI were identified, for which TnT was >1 µg/L in 443, 0.04-1.0 µg/L in 435, ≤0.03 µg/L in 19 and not recorded in 37. A further 823 patients had TnT >0.03 µg/L, but did not have ACS ascertained by any survey method. Of the 873 patients with MI, 146 (16.7%) died during admission and 218 (25.0%) by 1 year, but ranging from 9% for patients enrolled in the MINAP to 27% for those identified by the hospital information department. CONCLUSIONS MINAP and hospital statistics grossly underestimated the incidence of MI managed by our hospital. The 1-year mortality was highly dependent on the method of ascertainment.
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Affiliation(s)
- Azam Torabi
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School, University of Hull, Kingston upon Hull, UK; Department of Cardiovascular and Respiratory Studies, Castle Hill Hospital, Kingston upon Hull, UK
| | | | - Nasser Sherwi
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
| | - Paul Atkin
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
| | - Hossein Panahi
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
| | - Eric Kilpatrick
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
| | - Simon Thackray
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
| | - Angela Hoye
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
| | - Farqad Alamgir
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
| | - Kevin Goode
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
| | - Alan Rigby
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
| | - Andrew L Clark
- Department of Cardiology , Castle Hill Hospital, Hull York Medical School, University of Hull , Kingston upon Hull , UK
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Rosengren A, Wilhelmsen L, Lappas G, Johansson S. Body mass index, coronary heart disease and stroke in Swedish women. A prospective 19-year follow-up in the BEDA study. ACTA ACUST UNITED AC 2016; 10:443-50. [PMID: 14671467 DOI: 10.1097/01.hjr.0000085253.65733.ef] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although obesity is an important determinant of an unfavourable risk factor pattern reported associations between cardiovascular disease and obesity in women have been remarkably inconsistent. DESIGN Longitudinal observational population study. METHODS 1408 Göteborg women without prior cardiovascular disease aged 39 to 65 years at baseline were examined with respect to cardiovascular risk factors, including body mass index (BMI), in 1979 to 1981. Quartiles of BMI were formed of <22 (reference), 22 to 24, 24 to 27, and >27 kg/m(-2). Follow-up was conducted by use of the Swedish patient and cause-specific death registers. RESULTS All trends with respect to incident coronary heart disease (CHD--myocardial infarction or revascularization), stroke and all cardiovascular disease were positive and significant (P<0.05). No significant increase in risk was noted in women with BMI 22-24, compared with women below 22. After adjustment for smoking, women with BMI 24 to 27 had a doubled risk of CHD [hazard ratio(HR) 2.41 (1.06-5.50)] and of any cardiovascular disease [HR 1.89 (1.05-3.37)] whereas the increase in stroke risk was non-significant [HR 1.80 (0.81-4.01)]. Hazard ratios in the heaviest women, with BMI >27, were 3.75 (1.68-8.37) for CHD, 2.84 (1.32-6.12) for stroke, and 2.98 (1.70-5.21) for any cardiovascular disease, after adjustment for smoking. After further adjustment for other cardiovascular risk factors, all trends became non-significant. However, women with BMI >27 still displayed a statistically independent association with respect to coronary disease [adjusted HR 2.67 (1.10-6.47)] and all cardiovascular disease [HR 2.23 (1.23-4.04)], but not stroke [HR 2.08 (0.94-4.61)]. CONCLUSION The influence of BMI on cardiovascular disease in women may be greater than previously thought and, although to a great extent explained by the influence of obesity on other risk factors, associated with adverse outcomes already at moderately increased body weight.
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Affiliation(s)
- Annika Rosengren
- The Cardiovascular Institute, Department of Medicine, Sahlgrenska University Hospital/Ostra, Göteborg, Sweden
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Warren E, Brennan A, Akehurst R. Cost-Effectiveness of Sibutramine in the Treatment of Obesity. Med Decis Making 2016; 24:9-19. [PMID: 15005950 DOI: 10.1177/0272989x03261565] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. This study reports incremental cost-utility of sibutramine compared to diet and lifestyle advice for the treatment of obesity. Method. The model estimates the costs and quality of life benefits associated with weight loss itself and the reduced incidence of coronary heart disease (CHD) and diabetes in the “healthy obese.” The key source of effectiveness data is 2 randomized controlled trials over 12 months. Utility gain per kilogram lost is analyzed using Short Form–36 data from sibutramine trials. The impact on CHD is estimated using the Framingham risk equation, which relates age/sex/body mass index to risk of heart disease. The reduced incidence of diabetes due to weight loss is estimated from published literature. A life tables approach was used to calculate the cost per quality-adjusted life year (QALY) of 1 year’s treatment with sibutramine compared to diet and lifestyle advice. Results. The incremental cost per QALY of sibutramine is £4780. Sensitivity analyses show that this result is sensitive to utility associated with weight loss and the frequency of monitoring.Conclusions. Sibutramine is a costeffective treatment for obesity when combined with diet and lifestyle advice.
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Affiliation(s)
- Emma Warren
- Operational Research, ScHARR, 30 Regent Street, Sheffield, S1 4DA, UK
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Ortiz R, Morales JM, Ruiz-Espana S, Bodi V, Monleon D, Moratal D. Magnetic resonance microimaging of a swine infarcted heart: Performing cardiac virtual histologies. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:1584-7. [PMID: 26736576 DOI: 10.1109/embc.2015.7318676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study is to develop a computer-aided intuitive software tool based on MATLAB to reproduce the functions of a virtual histology over Magnetic Resonance (MR) microimages of small samples of swine's infarcted hearts. The basic characterization consists of selecting regions of interest (ROIs) of that MR microimage and extracting the most important information of these regions. The software tool will implement intuitive and sophisticated tools that allow the user to define ROIs on the different types of images provided by the MR scanner. The final purpose of this tool will be to analyze the acquired data in order to characterize some aspects of the later possible events after a myocardial infarction in swine's hearts and expand the study to human cases.
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Pietzsch JB, Liu S, Garner AM, Kezirian EJ, Strollo PJ. Long-Term Cost-Effectiveness of Upper Airway Stimulation for the Treatment of Obstructive Sleep Apnea: A Model-Based Projection Based on the STAR Trial. Sleep 2015; 38:735-44. [PMID: 25348126 DOI: 10.5665/sleep.4666] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 10/05/2014] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Upper airway stimulation (UAS) is a new approach to treat moderate-to-severe obstructive sleep apnea. Recently, 12-month data from the Stimulation Treatment for Apnea Reduction (STAR) trial were reported, evaluating the effectiveness of UAS in patients intolerant or non-adherent to continuous positive airway pressure therapy. Our objective was to assess the cost-effectiveness of UAS from a U.S. payer perspective. DESIGN A 5-state Markov model was used to predict cardiovascular endpoints (myocardial infarction [MI], stroke, hypertension), motor vehicle collisions (MVC), mortality, quality-adjusted life years (QALYs), and costs. We computed 10-year relative event risks and the lifetime incremental cost-effectiveness ratio (ICER) in $/QALY, comparing UAS therapy to no treatment under the assumption that the STAR trial-observed reduction in mean apnea-hypopnea index from 32.0 to 15.3 events/h was maintained. Costs and effects were discounted at 3% per year. SETTING U.S. healthcare system; third-party payer perspective. PARTICIPANTS 83% male cohort with mean age of 54.5 years. INTERVENTIONS UAS vs. no treatment. MEASUREMENTS AND RESULTS UAS substantially reduced event probabilities over 10 years (relative risks: MI 0.63; stroke 0.75; MVC 0.34), and was projected to add 1.09 QALYs over the patient's lifetime. Costs were estimated to increase by $42,953, resulting in a lifetime ICER of $39,471/QALY. CONCLUSIONS Relative to the acknowledged willingness-to-pay threshold of $50,000-$100,000/QALY, our results indicate upper airway stimulation is a cost-effective therapy in the U.S. healthcare system.
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Affiliation(s)
| | - Shan Liu
- Wing Tech Inc., Menlo Park, CA.,University of Washington, Seattle, WA
| | | | - Eric J Kezirian
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
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Wardlaw J, Brazzelli M, Miranda H, Chappell F, McNamee P, Scotland G, Quayyum Z, Martin D, Shuler K, Sandercock P, Dennis M. An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation. Health Technol Assess 2014; 18:1-368, v-vi. [PMID: 24791949 DOI: 10.3310/hta18270] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment. OBJECTIVES Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention? DATA SOURCES Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion. REVIEW METHODS Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios. RESULTS The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective. LIMITATIONS Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity. CONCLUSIONS Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Miriam Brazzelli
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hector Miranda
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zahid Quayyum
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Duncan Martin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsten Shuler
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Yao HM, Wan YD, Zhang XJ, Shen DL, Zhang JY, Li L, Zhao LS, Sun TW. Long-term follow-up results in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents: results from a single high-volume PCI centre. BMJ Open 2014; 4:e004892. [PMID: 25113554 PMCID: PMC4127920 DOI: 10.1136/bmjopen-2014-004892] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To assess both short-term and long-term prognosis in consecutive patients with coronary heart disease treated with drug-eluting stents in a high-volume percutaneous coronary intervention (PCI) centre. DESIGN Observational cohort study. SETTING A hospital in the Henan province, China, between 2009 and 2011. PARTICIPANTS A total of 2533 patients were enrolled. Patients with ST-elevation myocardial infarction (STEMI) treated with urgent PCI accounted for 3.9% of cases; patients with STEMI treated with delayed PCI accounted for 20.5% of cases; patients with stable angina accounted for 16.5% of cases; and patients with non-ST elevation acute coronary syndrome (NSTE-ACS) accounted for 58.6% of cases. PRIMARY OUTCOMES Death, major adverse cardiac and cerebrovascular events (MACCE: death/myocardial infarction/stroke), and target vessel revascularisation. RESULTS Follow-up after a median of 29.8 months was obtained for 2533 patients (92.6%). The mortality rate during hospitalisation was highest in the urgent PCI group (p<0.001). During follow-up, although the incidences of death and MACCE were highest in the urgent PCI group, no significant differences were observed among the different groups. The incidences of cardiac death and myocardial infarction were significantly higher in the paclitaxel-eluting stent (PES) group than in the sirolimus-eluting stent (SES) group. Independent predictors of death during follow-up were age, left ventricular ejection function <40%, diabetes mellitus, prior coronary artery bypass graft and chronic total occlusion. CONCLUSIONS PCI patients with STEMI had the worst hospital and long-term prognosis. The mortality rate after hospital increased markedly in patients with NSTE-ACS. SESs seem to be more effective than PESs.
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Affiliation(s)
- Hai-Mu Yao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - You-Dong Wan
- Department of Integrated ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Xiao-Juan Zhang
- Department of Integrated ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - De-Liang Shen
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Jin-Ying Zhang
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Ling Li
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Luo-Sha Zhao
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Tong-Wen Sun
- Department of Integrated ICU, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
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Silva Marques J, Pinto FJ. The vulnerable plaque: current concepts and future perspectives on coronary morphology, composition and wall stress imaging. Rev Port Cardiol 2014; 33:101-10. [PMID: 24513090 DOI: 10.1016/j.repc.2013.07.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 07/22/2013] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular imaging plays an important role in the identification and characterization of the vulnerable plaque. A major goal is the ability to identify individuals at risk of plaque rupture and developing an acute coronary syndrome. Early recognition of rupture-prone atherosclerotic plaques may lead to the development of pharmacologic and interventional strategies to reduce acute coronary events. We review state-of-the-art cardiovascular imaging for identification of the vulnerable plaque. There is ample evidence of a close relationship between plaque morphology and patient outcome, but molecular imaging can add significant information on tissue characterization, inflammation and subclinical thrombosis. Additionally, identifying arterial wall exposed to high shear stress may further identify rupture-prone arterial segments. These new modalities may help reduce the individual, social and economic burden of cardiovascular disease.
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Affiliation(s)
- João Silva Marques
- University Hospital Santa Maria, Department of Cardiology I, Lisbon Academic Medical Centre, CCUL, Lisbon, Portugal.
| | - Fausto J Pinto
- University Hospital Santa Maria, Department of Cardiology I, Lisbon Academic Medical Centre, CCUL, Lisbon, Portugal
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The vulnerable plaque: Current concepts and future perspectives on coronary morphology, composition and wall stress imaging. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2013.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Mohammadian-Hafshejani A, Sarrafzadegan N, Hosseini S, Baradaran HR, Roohafza H, Sadeghi M, Asadi-Lari M. Seasonal pattern in admissions and mortality from acute myocardial infarction in elderly patients in Isfahan, Iran. ARYA ATHEROSCLEROSIS 2014; 10:46-54. [PMID: 24963314 PMCID: PMC4063513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 12/21/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Seasonal variation in admissions and mortality due to acute myocardial infarction has been observed in different countries. Since there are scarce reports about this variation in Iran, this study was carried out to determine the existence of seasonal rhythms in hospital admissions for acute myocardial infarction, and in mortality due to acute myocardial infarction (AMI) in elderly patients in Isfahan city. METHODS This prospective hospital-based study included a total of 3990 consecutive patients with acute myocardial infarction admitted to 13 hospitals from January 2002 to December 2007. Seasonal variations were analyzed with the Kaplan-Meier table, log rank test, and Cox regression model. RESULTS There was a statistically significant relationship between the occurrence of heart disease based on season and type of acute myocardial infarction anatomical (P < 0.001). The relationship between the occurrence of death and season and type of AMI according to International Classification of Diseases code 10 (ICD) was also observed and it was statistically significant (P = 0.026). Hazard ratio for death from acute myocardial infarction were 0.96 [Confidence interval of 95% (95% CI) = 0.78-1.18], 0.9 (95%CI = 0.73-1.11), and 1.04 (95%CI = 0.85-1.26) during spring, summer, and winter, respectively. CONCLUSION There is seasonal variation in hospital admission and mortality due to AMI; however, after adjusting in the model only gender and age were significant predictor factors.
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Affiliation(s)
- Abdollah Mohammadian-Hafshejani
- Deputy of Health, Isfahan University of Medical Sciences, Isfahan AND PhD Candidates, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Nizal Sarrafzadegan
- Professor, Isfahan Cardiovascular Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shidokht Hosseini
- Researcher, Hypertension Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamid Reza Baradaran
- Associate Professor, Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Roohafza
- Assistant Professor, Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masoumeh Sadeghi
- Associate Professor, Cardiac Rehabilitation Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Asadi-Lari
- Associate Professor, Department of Epidemiology, School of Health AND Oncopathology Research Center, Iran University of Medical Sciences, Tehran, Iran,Correspondence to: Mohsen Asadi-Lari,
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Tekin K, Cagliyan CE, Tanboga IH, Balli M, Uysal OK, Ozkan B, Arik OZ, Cayli M. Influence of the Timing of Percutaneous Coronary Intervention on Clinical Outcomes in Non-ST-Elevation Myocardial Infarction. Korean Circ J 2013; 43:725-30. [PMID: 24363747 PMCID: PMC3866311 DOI: 10.4070/kcj.2013.43.11.725] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 08/19/2013] [Accepted: 09/10/2013] [Indexed: 11/11/2022] Open
Abstract
Background and Objectives We have intended to investigate the influence of the timing of invasive procedures on all-cause mortality, recurrent myocardial infarction (MI), re-hospitalization due to cardiac causes and left ventricular function over a 3-month period among patients with Non-ST-elevation myocardial infarction (NSTEMI). Subjects and Methods A total of 131 NSTEMI patients with moderate-high Thrombolysis in Myocardial Infarction risk scores, who had been admitted to our department between July 2011-December 2011 were included in our study. They had been randomized into 2 groups according to the timing of the percutaneous coronary intervention (PCI). Patient undergoing PCI in the first 24 hours of hospitalization were named the "Early Invasive Group" and those undergoing PCI between 24-72 hours of hospitalization were named the "Delayed Invasive Group". All patients were followed up for 3 months. Results Third month left ventricular ejection fraction (LVEF) values were higher in the early invasive group (59.9±6.0% vs. 54.1±8.7%; p<0.001). Recurrent MI rates were lower in the early invasive group (2.9% vs. 14.5%; p=0.016). Similarly, hospitalization rates due to cardiac events were lower in the early invasive group (8.7% vs. 30.6%; p=0.001). All cause mortality appeared to be lower in the early invasive group, although not to a statistically significant degree (0% vs. 4.8%; p=0.065). Conclusion The early invasive strategy appears to be more effective for the reduction of recurrent MI, re-hospitalization due to cardiac events, and the preservation of 3rd month LVEF in patients with moderate-high risk NSTEMI when compared to a delayed invasive strategy.
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Affiliation(s)
- Kamuran Tekin
- Department of Cardiology, Batman State Hospital, Batman, Turkey
| | - Caglar Emre Cagliyan
- Department of Cardiology, Adanana Numune Education and Research Hospital, Istanbul, Turkey
| | - Ibrahim Halil Tanboga
- Department of Cardiology, Adanana Numune Education and Research Hospital, Istanbul, Turkey
| | - Mehmet Balli
- Department of Cardiology, Adanana Numune Education and Research Hospital, Istanbul, Turkey
| | - Onur Kadir Uysal
- Department of Cardiology, Adanana Numune Education and Research Hospital, Istanbul, Turkey
| | - Bugra Ozkan
- Department of Cardiology, Adanana Numune Education and Research Hospital, Istanbul, Turkey
| | - Osman Ziya Arik
- Department of Cardiology, Adanana Numune Education and Research Hospital, Istanbul, Turkey
| | - Murat Cayli
- Department of Cardiology, Adanana Numune Education and Research Hospital, Istanbul, Turkey
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Akkus O, Sahin DY, Bozkurt A, Nas K, Ozcan KS, Illyés M, Molnár F, Demir S, Tüfenk M, Acarturk E. Evaluation of arterial stiffness for predicting future cardiovascular events in patients with ST segment elevation and non-ST segment elevation myocardial infarction. ScientificWorldJournal 2013; 2013:792693. [PMID: 24294138 PMCID: PMC3833000 DOI: 10.1155/2013/792693] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 09/15/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Arterial stiffness parameters in patients who experienced MACE after acute MI have not been studied sufficiently. We investigated arterial stiffness parameters in patients with ST segment elevation (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI). METHODS Ninety-four patients with acute MI (45 STEMI and 49 NSTEMI) were included in the study. Arterial stiffness was assessed noninvasively by using TensioMed Arteriograph. RESULTS Arterial stiffness parameters were found to be higher in NSTEMI group but did not achieve statistical significance apart from pulse pressure (P = 0.007). There was no significant difference at MACE rates between two groups. Pulse pressure and heart rate were also significantly higher in MACE observed group. Aortic pulse wave velocity (PWV), aortic augmentation index (AI), systolic area index (SAI), heart rate, and pulse pressure were higher; ejection fraction, the return time (RT), diastolic reflex area (DRA), and diastolic area index (DAI) were significantly lower in patients with major cardiovascular events. However, PWV, heart rate, and ejection fraction were independent indicators at development of MACE. CONCLUSIONS Parameters of arterial stiffness and MACE rates were similar in patients with STEMI and NSTEMI in one year followup. The independent prognostic indicator aortic PWV may be an easy and reliable method for determining the risk of future events in patients hospitalized with acute MI.
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Affiliation(s)
- Oguz Akkus
- Sanliurfa Siverek State Hospital, 63600 Sanliurfa, Turkey
| | - Durmus Yildiray Sahin
- Department of Cardiology, Adana Numune Training and Research Hospital, Adana, Turkey
| | - Abdi Bozkurt
- Department of Cardiology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Kamil Nas
- Department of Radiology, Szent János Hospital, Budapest, Hungary
| | | | - Miklós Illyés
- Heart Institute, Faculty of Medicine, University of Pécs, Pécs, Hungary
| | - Ferenc Molnár
- Department of Hydrodynamic Systems, Budapest University of Technology and Economics, Budapest, Hungary
| | | | - Mücahit Tüfenk
- Department of Cardiology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Esmeray Acarturk
- Department of Cardiology, Faculty of Medicine, Cukurova University, Adana, Turkey
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Rasoul S, Roolvink V, Ottervanger JP, Gosselink AM, Dambrink JHE, de Boer MJ, Hoorntje JC, Suryapranata H, van 't Hof AW. Angiography guided therapy in an all comer acute coronary syndrome patient population. Int J Cardiol 2013; 168:4900-2. [DOI: 10.1016/j.ijcard.2013.07.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
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Kaambwa B, Bryan S, Jowett S, Mant J, Bray EP, Hobbs FDR, Holder R, Jones MI, Little P, Williams B, McManus RJ. Telemonitoring and self-management in the control of hypertension (TASMINH2): a cost-effectiveness analysis. Eur J Prev Cardiol 2013; 21:1517-30. [PMID: 23990660 DOI: 10.1177/2047487313501886] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIMS Self-monitoring and self-titration of antihypertensives (self-management) is a novel intervention which improves blood pressure control. However, little evidence exists regarding the cost-effectiveness of self-monitoring of blood pressure in general and self-management in particular. This study aimed to evaluate whether self-management of hypertension was cost-effective. DESIGN AND METHODS A cohort Markov model-based probabilistic cost-effectiveness analysis was undertaken extrapolating to up to 35 years from cost and outcome data collected from the telemonitoring and self-management in hypertension trial (TASMINH2). Self-management of hypertension was compared with usual care in terms of lifetime costs, quality adjusted life years and cost-effectiveness using a UK Health Service perspective. Sensitivity analyses examined the effect of different time horizons and reduced effectiveness over time from self-management. RESULTS In the long-term, when compared with usual care, self-management was more effective by 0.24 and 0.12 quality adjusted life years (QALYs) gained per patient for men and women, respectively. The resultant incremental cost-effectiveness ratio for self-management was £1624 per QALY for men and £4923 per QALY for women. There was at least a 99% chance of the intervention being cost-effective for both sexes at a willingness to pay threshold of £20,000 per QALY gained. These results were robust to sensitivity analyses around the assumptions made, provided that the effects of self-management lasted at least two years for men and five years for women. CONCLUSION Self-monitoring with self-titration of antihypertensives and telemonitoring of blood pressure measurements not only reduces blood pressure, compared with usual care, but also represents a cost-effective use of health care resources.
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Affiliation(s)
- Billingsley Kaambwa
- Flinders Health Economics Group, School of Medicine, Flinders University, Repatriation General Hospital, Daw Park, Australia
| | - Stirling Bryan
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute and School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Sue Jowett
- Health Economics Unit, Division of Health and Population Sciences, University of Birmingham, UK
| | - Jonathan Mant
- Primary Care Unit, Institute of Public Health, University of Cambridge, UK
| | - Emma P Bray
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, UK
| | - F D Richard Hobbs
- Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, UK
| | - Roger Holder
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, UK
| | - Miren I Jones
- Primary Care Clinical Sciences, NIHR School for Primary Care Research, University of Birmingham, UK
| | - Paul Little
- School of Medicine, University of Southampton, UK
| | - Bryan Williams
- Institute of Cardiovascular Sciences, University College London, UK
| | - Richard J McManus
- Primary Care Health Sciences, NIHR School for Primary Care Research, University of Oxford, UK
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Cardiovascular Disease in the Developing World. J Am Coll Cardiol 2012; 60:1207-16. [DOI: 10.1016/j.jacc.2012.03.074] [Citation(s) in RCA: 302] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 02/29/2012] [Accepted: 03/06/2012] [Indexed: 12/18/2022]
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Miners A, Harris J, Felix L, Murray E, Michie S, Edwards P. An economic evaluation of adaptive e-learning devices to promote weight loss via dietary change for people with obesity. BMC Health Serv Res 2012; 12:190. [PMID: 22769737 PMCID: PMC3438094 DOI: 10.1186/1472-6963-12-190] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 06/11/2012] [Indexed: 11/16/2022] Open
Abstract
Background The prevalence of obesity is over 25 % in many developed countries. Obesity is strongly associated with an increased risk of fatal and chronic conditions such as cardiovascular disease and type 2 diabetes. Therefore it has become a major public health concern for many economies. E-learning devices are a relatively novel approach to promoting dietary change. The new generation of devices are ‘adaptive’ and use interactive electronic media to facilitate teaching and learning. E-Learning has grown out of recent developments in information and communication technology, such as the Internet, interactive computer programmes, interactive television and mobile phones. The aim of this study is to assess the cost-effectiveness of e-learning devices as a method of promoting weight loss via dietary change. Methods An economic evaluation was performed using decision modelling techniques. Outcomes were expressed in terms of Quality-Adjusted Life-Years (QALYs) and costs were estimated from a health services perspective. All parameter estimates were derived from the literature. A systematic review was undertaken to derive the estimate of relative treatment effect. Results The base case results from the e-Learning Economic Evaluation Model (e-LEEM) suggested that the incremental cost-effectiveness ratio was approximately £102,000 per Quality-Adjusted Life-Year (QALY) compared to conventional care. This finding was robust to most alternative assumptions, except a much lower fixed cost of providing e-learning devices. Expected value of perfect information (EVPI) analysis showed that while the individual level EVPI was arguably negligible, the population level value was between £37 M and £170 M at a willingness to pay between £20,000 to £30,000 per additional QALY. Conclusion The current economic evidence base suggests that e-learning devices for managing the weight of obese individuals are unlikely to be cost-effective unless their fixed costs are much lower than estimated or future devices prove to be much more effective.
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Affiliation(s)
- Alec Miners
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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Movahed MR, John J, Hashemzadeh M, Hashemzadeh M. Mortality trends for non-ST-segment elevation myocardial infarction (NSTEMI) in the United States from 1988 to 2004. Clin Cardiol 2012; 34:689-92. [PMID: 22095658 DOI: 10.1002/clc.20968] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Non-ST-segment myocardial infarction (NSTEMI) is one of the major causes of hospital admissions. Mortality trend in patients with NSTEMI over the years has not been studied well. The goal of this study is to explore age-adjusted long-term mortality trends from NSTEMI in the United States using a very large database. METHODS We used the National Inpatient Sample (NIS) database, a component of the Health Care Cost and Utilization (HCUP) project, for this study. International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes were used to identify NSTEMI cases in patients >40 years old. Age-adjusted mortality rates for NSTEMI cases were calculated by multiplying the age-specific mortality rates of NSTEMI by age-specific weights. RESULTS A total of 1,400,234 patients above the age of 40 years were identified. The mean age of this cohort was 77.1±10.7 years, with a total of 179,361 deaths being reported over this 16-year period. Among patients who died, 51.2% were men and 48.8% were women. The age-adjusted mortality from NSTEMI declined from 1988 (727 per 100,000) to 2004 (305 per 100,000) until the middle of the decade when mortality from NSTEMI started leveling off. Total mortality decreased from 29.6% in 1988 to 11.3% in 2004. CONCLUSIONS Our analysis showed a significant reduction in the age-adjusted and total mortality for NSTEMI over the years studied. The cause of this trend is not known but most likely reflects advancement in the treatment of patients with acute coronary syndrome.
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Affiliation(s)
- Mohammed Reza Movahed
- Section of Cardiology, Department of Medicine, The Southern Arizona VA Health Care System, Tucson, Arizona 85721, USA.
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Smolina K, Wright FL, Rayner M, Goldacre MJ. Incidence and 30-day case fatality for acute myocardial infarction in England in 2010: national-linked database study. Eur J Public Health 2012; 22:848-53. [PMID: 22241758 PMCID: PMC3505446 DOI: 10.1093/eurpub/ckr196] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: There are limited national population-based epidemiological data on acute myocardial infarction (AMI) in England, making the current burden of disease, and clinical prognosis, difficult to quantify. The aim of this study was to provide national estimates of incidence and 30-day case fatality rate (CFR) for first and recurrent AMI in England. Methods: Population-based study using person-linked routine hospital and mortality data on 79 896 individuals of any age, who were admitted to hospital for AMI or who died suddenly from AMI in 2010. Results: Of 82 252 AMI events in 2010, 83% were first. Age-standardized incidence of first AMI per 100 000 population was 130 (95% CI 129–131) in men and 55.9 (95% CI 55.3–56.6) in women. Age-standardized 30-day overall CFRs including sudden AMI deaths for men and women, respectively, were 32.4% (95% CI 32.0–32.9) and 30.3% (95% CI 29.8–30.9) for first AMI and 29.7% (95% CI 28.7–30.7) and 26.7% (95% CI 25.5–27.9) for recurrent AMI. Age-standardized hospitalized 30-day CFR was 12.0% (95% CI 11.6–12.3) for men and 12.3% (95% CI 11.9–12.7) for women. Conclusions: While the majority of AMIs are not fatal, of those that are, two-thirds occur as sudden AMI deaths. About one in six of all AMIs are recurrent events. These findings reinforce the importance of primary and secondary prevention in reducing AMI morbidity and mortality.
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Affiliation(s)
- Kate Smolina
- Department of Public Health, University of Oxford, Headington, Oxford, OX3 7LF, UK
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Early and long-term prognosis of patients with coronary artery disease treated with percutaneous coronary interventions in 2005. Experience of single large-volume PCI center. Adv Med Sci 2011; 56:222-30. [PMID: 21940265 DOI: 10.2478/v10039-011-0029-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE The progress which has been made in interventional cardiology contributes to the gradual improvement of the results of CHD (coronary heart disease) therapy. The aim of the study was the assessment of early and long-term prognosis in all the patients with CHD treated invasively in one large-volume PCI center in 2005. MATERIAL AND METHODS 1390 consecutive patients with CHD treated with PCI in 2005 were included in the analysis. Patients with ST-elevation myocardial infarction (STEMI) accounted for 50% of cases, patients with stable angina (SA) amounted to 25%, and patients with non-ST elevation acute coronary syndromes (NSTE-ACS) constituted 25%. Mean follow-up was 738 (±237) days. RESULTS The highest mortality during the hospitalization was noted within the STEMI group(SA vs. NSTE-ACS vs. STEMI; 0% vs. 0.3% vs. 4.1%, respectively; p<0.001). The highest mortality during a 2-year follow-up was also observed in the STEMI group (SA vs. NSTE-ACS vs. STEMI, 6.3% vs. 8.5% vs. 13.8%, respectively; p<0.001). Multiple regression model showed that independent risk factors for death during the follow-up were: age, glycaemia at admission, heart rate, blood pressure, ejection fraction, STEMI, ineffective PCI (R=0.3613; F(10.131)=19.672; p<0.0001 for the model). CONCLUSIONS The highest relative increase of mortality after the discharge of patients with CHD undergoing PCI referred to the patients with NSTE-ACS. However, in the real life PCI practice STEMI patients have the worst hospital and long-term prognosis. Well recognized risk factors for death in patients with CHD are still of great importance in negative prognosis of patients undergoing PCI.
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Sicras-Mainar A, Fernández de Bobadilla J, Navarro-Artieda R, Martín I, Varela-Moreno C. [Morbi-mortality and use of recourses after acute coronary syndrome in a Spanish population]. Rev Clin Esp 2011; 211:560-71. [PMID: 22088667 DOI: 10.1016/j.rce.2011.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Revised: 06/15/2011] [Accepted: 07/02/2011] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the management of patients suffering acute coronary syndrome (ACS) and to determine its clinical and economic consequences in a Spanish population. METHODS A multicenter, retrospective claim database study including patient medical records from 6 primary care centers, two hospitals and two years of follow-up was carried out. Patients ≥30 years, suffering a first acute coronary syndrome (ACS), between 2003 and 2007, were included. Groups: acute coronary syndrome with and without ST segment elevation. VARIABLES socio-demographic, co-morbidities, metabolic syndrome (MS), biochemical parameters, drugs, cumulative incidence (total mortality and cardiovascular events (CVE: including myocardial infarction, stroke and peripheral artery disease) and total costs. STATISTICAL ANALYSIS logistic regression, Kaplan-Meier curves and ANCOVA; (P<.05). RESULTS A total of 1020 patients were included. Mean age: 69 years; males: 65%. Groups: ST segment elevation ACS (N=632; 62%). Co-morbidities: hypertension (56%), dyslipidemia (46%) and diabetes (38%). Prevalence of MS: 59% (CI 95%: 56-62%). All biochemical parameters had improved after two years of follow-up. The average total cost per patient was €14,069 (87% direct costs; 13% productivity loss costs). Direct costs: primary care (20%), specialty care (67%); hospitalization costs represented 63% of total costs. The average total cost for patients presenting more than one CVE was 22,750€ vs 12,380€ for those patients who suffered only one (P<.001). Cumulative incidence: total mortality 14%; CVE: 16%. CONCLUSIONS In the current clinical practice, and despite the clinical efforts carried out, patients with an ACS are still at a high risk of suffering further CVE, representing a high cost burden to the health care system.
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Affiliation(s)
- A Sicras-Mainar
- Dirección de Planificación, Badalona Serveis Assistencials SA, Barcelona, España.
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Pietzsch JB, Garner A, Cipriano LE, Linehan JH. An integrated health-economic analysis of diagnostic and therapeutic strategies in the treatment of moderate-to-severe obstructive sleep apnea. Sleep 2011; 34:695-709. [PMID: 21629357 DOI: 10.5665/sleep.1030] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is a common disorder associated with substantially increased cardiovascular risks, reduced quality of life, and increased risk of motor vehicle collisions due to daytime sleepiness. This study evaluates the cost-effectiveness of three commonly used diagnostic strategies (full-night polysomnography, split-night polysomnography, unattended portable home-monitoring) in conjunction with continuous positive airway pressure (CPAP) therapy in patients with moderate-to-severe OSA. DESIGN A Markov model was created to compare costs and effectiveness of different diagnostic and therapeutic strategies over a 10-year interval and the expected lifetime of the patient. The primary measure of cost-effectiveness was incremental cost per quality-adjusted life year (QALY) gained. PATIENTS OR PARTICIPANTS Baseline computations were performed for a hypothetical average cohort of 50-year-old males with a 50% pretest probability of having moderate-to-severe OSA (apnea-hypopnea index [AHI] ≥ 15 events per hour). MEASUREMENTS AND RESULTS For a patient with moderate-to-severe OSA, CPAP therapy has an incremental cost-effectiveness ratio (ICER) of $15,915 per QALY gained for the lifetime horizon. Over the lifetime horizon in a population with 50% prevalence of OSA, full-night polysomnography in conjunction with CPAP therapy is the most economically efficient strategy at any willingness-to-pay greater than $17,131 per-QALY gained because it dominates all other strategies in comparative analysis. CONCLUSIONS Full-night polysomnography (PSG) is cost-effective and is the preferred diagnostic strategy for adults suspected to have moderate-to-severe OSA when all diagnostic options are available. Split-night PSG and unattended home monitoring can be considered cost-effective alternatives when full-night PSG is not available.
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Anderson CD, Nalls MA, Biffi A, Rost NS, Greenberg SM, Singleton AB, Meschia JF, Rosand J. The effect of survival bias on case-control genetic association studies of highly lethal diseases. ACTA ACUST UNITED AC 2011; 4:188-96. [PMID: 21292865 DOI: 10.1161/circgenetics.110.957928] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Survival bias is the phenomenon by which individuals are excluded from analysis of a trait because of mortality related to the expression of that trait. In genetic association studies, variants increasing risk for disease onset as well as risk of disease-related mortality (lethality) could be difficult to detect in genetic association case-control designs, possibly leading to underestimation of a variant's effect on disease risk. METHODS AND RESULTS We modeled cohorts for 3 diseases of high lethality (intracerebral hemorrhage, ischemic stroke, and myocardial infarction) using existing longitudinal data. Based on these models, we simulated case-control genetic association studies for genetic risk factors of varying effect sizes, lethality, and minor allele frequencies. For each disease, erosion of detected effect size was larger for case-control studies of individuals of advanced age (age >75 years) and/or variants with very high event-associated lethality (genotype relative risk for event-related death >2.0). We found that survival bias results in no more than 20% effect size erosion for cohorts with mean age <75 years, even for variants that double lethality risk. Furthermore, we found that increasing effect size erosion was accompanied by depletion of minor allele frequencies in the case population, yielding a "signature" of the presence of survival bias. CONCLUSIONS Our simulation provides formulas to allow estimation of effect size erosion given a variant's odds ratio of disease, odds ratio of lethality, and minor allele frequencies. These formulas will add precision to power calculation and replication efforts for case-control genetic studies. Our approach requires validation using prospective data.
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Affiliation(s)
- Christopher D Anderson
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA
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Flachskampf FA, Schmid M, Rost C, Achenbach S, DeMaria AN, Daniel WG. Cardiac imaging after myocardial infarction. Eur Heart J 2010; 32:272-83. [PMID: 21163851 DOI: 10.1093/eurheartj/ehq446] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
After myocardial infarction, optimal clinical management depends critically on cardiac imaging. Remodelling and heart failure, presence of inducible ischaemia, presence of dysfunctional viable myocardium, future risk of adverse events including risk of ventricular arrhythmias, need for anticoagulation, and other questions should be addressed by cardiac imaging. Strengths and weaknesses, recent developments, choice, and timing of the different non-invasive techniques are reviewed for this frequent clinical scenario.
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Affiliation(s)
- Frank A Flachskampf
- Uppsala University, Akademiska sjukhuset, Ingång 40, plan 5, 75185 Uppsala, Sweden.
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Uren N. Acute coronary syndromes: assessing risk and choosing optimal pharmacological regimens for a superior outcome. Eur Heart J Suppl 2010. [DOI: 10.1093/eurheartj/suq020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Ruiz-Nodar JM, Cequier Á, Lozano T, Fernández Vázquez F, Möller I, Abán S, Marqués JT, González Llopis F, Álvarez P, Bethencourt A, Zarauza J, de la Villa BG, Burgos V, Ferreiro JL, García JM, Rodríguez AG, de la Tassa CM. Impacto del tipo de hospital en el tratamiento y evolución de los pacientes con síndrome coronario agudo sin elevación del ST. Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70059-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vemer P, Rutten-van Mölken MPMH. Crossing borders: factors affecting differences in cost-effectiveness of smoking cessation interventions between European countries. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2010; 13:230-41. [PMID: 19804435 DOI: 10.1111/j.1524-4733.2009.00612.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
OBJECTIVES Many different factors affect the transferability of cost-effectiveness results between countries. The objective is to quantify the impact of nine potential causes of variation in cost-effectiveness of pharmacological smoking cessation therapies (SCTs) between The Netherlands (reference case), Germany, Sweden, UK, Belgium, and France. METHODS The life-time benefits of smoking cessation were calculated using the Benefits of Smoking Cessation on Outcomes model, following a cohort of smokers making an unaided quit attempt, or using nicotine replacement therapy (NRT), bupropion, or varenicline. We investigated the impact of between-country differences in nine factors-demography, smoking prevalence, mortality, epidemiology and costs of smoking-related diseases, resource use and unit costs of SCTs, utility weights and discount rates-on the incremental net monetary benefit (INMB), using a willingness-to-pay (WTP) of euro20,000 per quality adjusted life year (QALY). RESULTS The INMB of 1000 quit attempts with NRT versus unaided, varies from euro0.39 million (Germany) to euro1.47 million (France). The differences between the countries were primarily due to differences in discount rates, causing the INMB to change between -65% to +62%, incidence and mortality rates (epidemiology) of smoking-related diseases (-43% to +35%) and utility weights. Impact also depended on the WTP for a QALY and time horizon: at a low WTP or a short time horizon, the resource use and unit costs of SCTs had the highest impact on INMB. CONCLUSIONS Although all INMBs were positive, there were significant differences across countries. These were primarily related to choice of discount rate and epidemiology of diseases.
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Affiliation(s)
- Pepijn Vemer
- Institute for Medical Technology Assessment (iMTA), Erasmus MC, Rotterdam, The Netherlands.
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Sicras-Mainar A, Fernández de Bobadilla J, Navarro-Artieda R, Rejas-Gutiérrez J. [All-cause mortality and incidence of major cardiovascular events in hypertensive patients with ASCOT-type profile in a Spanish population setting]. Aten Primaria 2010; 42:420-30. [PMID: 20116891 DOI: 10.1016/j.aprim.2009.09.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 09/25/2009] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Mediterranean populations are traditionally considered to be associated with lower incidence of cardiovascular events (CVE). However, this might not be homogeneous throughout different patient strata. The goal was to compare the incidence of CVE and all-causes mortality in hypertensive patients with an ASCOT-type profile with that of the rest hypertensive subjects. METHODS A retrospective analysis was carried out using a claim database. Hypertensive patients without known cardiovascular disease on antihypertensive therapy included during year 2006 were followed up for two consecutive years to ascertain the incidence of all-causes mortality and any CVE. CVE included any of the following: coronary heart disease, acute myocardial infarction (AMI), angina, stroke, transient ischemic attack (TIA) and peripheral artery disease. Patients with ASCOT and ASCOT-LLA type profiles were identified and compared with non-ASCOT-type profile hypertensive subjects. RESULTS A total of 11,104 were included in the analysis; 68.0+/-11.4 years, 41.6% males. More than 73% of subjects fulfilled criteria for ASCOT-type profile. All-causes mortality were numerically higher in ASCOT and ASCOT-LLA subjects compared with non-ASCOT-type; hazard ratio (95% CI)=1.3 (0.8-1.9) and 1.6 (0.9-2.8), respectively. However, any-coronary event rate was significantly higher in ASCOT-type [2.3 (1.8-2.8), p<0.001], as well as in ASCOT-LLA subjects [1.8 (1.3-2.4), p<0.001]. CONCLUSIONS Hypertensive patients on treatment with ASCOT-type profile are more likely to have any cardiovascular event than those hypertensive patients without ASCOT profile in a Mediterranean setting in Spain.
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Affiliation(s)
- Antoni Sicras-Mainar
- Dirección de Planificación, Badalona Serveis Assistencials SA, Badalona, Barcelona, España.
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Manari A, Albiero R, De Servi S. High-risk non-ST-segment elevation myocardial infarction versus ST-segment elevation myocardial infarction: same behaviour and outcome? J Cardiovasc Med (Hagerstown) 2010; 10 Suppl 1:S13-6. [PMID: 19851215 DOI: 10.2459/01.jcm.0000362039.48638.92] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Despite advances in the treatment of acute coronary syndromes (ACS) a large proportion of patients do not receive adequate treatment. In most cases, myocardial infarction with ST-segment elevation myocardial infarction (STEMI) is associated with thrombotic occlusion of a major coronary artery, and 30-day mortality is higher than for patients with non-ST-segment elevation myocardial infarction (NSTEMI). In patients with NSTEMI, however, the mortality rate increases after discharge, becoming close to that seen in STEMI patients at 6 months. Whereas patients with STEMI usually undergo emergent revascularization, the clinical scenario in NSTEMI is extremely variable and, in most cases, high-risk patients do not undergo coronary angiography at the times recommended in the European Society of Cardiology guidelines. Unlike NSTEMI, STEMI is associated with a very high risk of mortality in 30% of cases, whereas the remaining 70% of cases have a short-term mortality risk of less than 5%. The application of accurate models for risk prediction may significantly improve survival in these patients, thus avoiding emergent revascularization in low to medium-risk patients. This approach may lead to a redistribution of care across the spectrum of ACS, thus giving priority when the risk/benefit ratio is higher, independent of electrocardiogram results at presentation.
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Affiliation(s)
- Antonio Manari
- U.O. Cardiologia Interventistica, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy.
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Wardlaw JM, Stevenson MD, Chappell F, Rothwell PM, Gillard J, Young G, Thomas SM, Roditi G, Gough MJ. Carotid Artery Imaging for Secondary Stroke Prevention. Stroke 2009; 40:3511-7. [DOI: 10.1161/strokeaha.109.557017] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Patients with transient ischemic attack require carotid imaging to diagnose carotid stenosis. The differing sensitivity/specificity and availability of carotid imaging methods have created uncertainty over which noninvasive method is best and whether intra-arterial angiography is still required. We evaluated the influence of carotid imaging methods on secondary stroke prevention.
Methods—
We modeled the effect of different carotid imaging strategies and timing on endarterectomy workload, stroke, and death at 1 and 5 years. We used all available data on stroke prevention after transient ischemic attack from systematic reviews (carotid imaging, medical and surgical interventions), population-based transient ischemic attack/stroke studies, government statistics, and stroke prevention clinics.
Results—
Choice of imaging strategy affected speed of assessment, strokes prevented, and endarterectomy workload. The number of strokes prevented at 5 years varied by up to 22 per 1000 patients between imaging strategies for a given time to assessment. Delaying endarterectomy from 14 to approximately 30 days would fail to prevent up to 11 strokes per 1000 patients depending on the imaging strategy. Sensitive fast imaging (eg, ultrasound) was best for patients seen early; specific imaging (eg, CT angiography or contrast-enhanced MR angiography) was best for patients seen late after transient ischemic attack. Intra-arterial angiography conferred no advantage over noninvasive imaging.
Conclusions—
Rapid access to sensitive noninvasive carotid imaging prevents most strokes. However, imaging strategies differ in their effect on stroke prevention by as much as 22 per 1000 patients and optimal imaging varies with time after transient ischemic attack TIA. Routine intra-arterial angiography should be avoided.
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Affiliation(s)
- Joanna M. Wardlaw
- From the University of Edinburgh (J.M.W., F.C.), Edinburgh, UK; the University of Sheffield (M.S., S.T.), Sheffield, UK; the University of Cambridge (J.G.), Cambridge, UK; Leeds Teaching Hospital NHS Trust and University of Leeds (M.G.), St James Hospital and Leeds General Hospital, Leeds, UK; The James Cook University Hospital (G.Y.), Middlesbrough, UK; University of Oxford (P.M.R.), Oxford, UK; and Glasgow Royal Infirmary (G.R.), Glasgow, UK
| | - Matt D. Stevenson
- From the University of Edinburgh (J.M.W., F.C.), Edinburgh, UK; the University of Sheffield (M.S., S.T.), Sheffield, UK; the University of Cambridge (J.G.), Cambridge, UK; Leeds Teaching Hospital NHS Trust and University of Leeds (M.G.), St James Hospital and Leeds General Hospital, Leeds, UK; The James Cook University Hospital (G.Y.), Middlesbrough, UK; University of Oxford (P.M.R.), Oxford, UK; and Glasgow Royal Infirmary (G.R.), Glasgow, UK
| | - Francesca Chappell
- From the University of Edinburgh (J.M.W., F.C.), Edinburgh, UK; the University of Sheffield (M.S., S.T.), Sheffield, UK; the University of Cambridge (J.G.), Cambridge, UK; Leeds Teaching Hospital NHS Trust and University of Leeds (M.G.), St James Hospital and Leeds General Hospital, Leeds, UK; The James Cook University Hospital (G.Y.), Middlesbrough, UK; University of Oxford (P.M.R.), Oxford, UK; and Glasgow Royal Infirmary (G.R.), Glasgow, UK
| | - Peter M. Rothwell
- From the University of Edinburgh (J.M.W., F.C.), Edinburgh, UK; the University of Sheffield (M.S., S.T.), Sheffield, UK; the University of Cambridge (J.G.), Cambridge, UK; Leeds Teaching Hospital NHS Trust and University of Leeds (M.G.), St James Hospital and Leeds General Hospital, Leeds, UK; The James Cook University Hospital (G.Y.), Middlesbrough, UK; University of Oxford (P.M.R.), Oxford, UK; and Glasgow Royal Infirmary (G.R.), Glasgow, UK
| | - Jonathan Gillard
- From the University of Edinburgh (J.M.W., F.C.), Edinburgh, UK; the University of Sheffield (M.S., S.T.), Sheffield, UK; the University of Cambridge (J.G.), Cambridge, UK; Leeds Teaching Hospital NHS Trust and University of Leeds (M.G.), St James Hospital and Leeds General Hospital, Leeds, UK; The James Cook University Hospital (G.Y.), Middlesbrough, UK; University of Oxford (P.M.R.), Oxford, UK; and Glasgow Royal Infirmary (G.R.), Glasgow, UK
| | - Gavin Young
- From the University of Edinburgh (J.M.W., F.C.), Edinburgh, UK; the University of Sheffield (M.S., S.T.), Sheffield, UK; the University of Cambridge (J.G.), Cambridge, UK; Leeds Teaching Hospital NHS Trust and University of Leeds (M.G.), St James Hospital and Leeds General Hospital, Leeds, UK; The James Cook University Hospital (G.Y.), Middlesbrough, UK; University of Oxford (P.M.R.), Oxford, UK; and Glasgow Royal Infirmary (G.R.), Glasgow, UK
| | - Steven M. Thomas
- From the University of Edinburgh (J.M.W., F.C.), Edinburgh, UK; the University of Sheffield (M.S., S.T.), Sheffield, UK; the University of Cambridge (J.G.), Cambridge, UK; Leeds Teaching Hospital NHS Trust and University of Leeds (M.G.), St James Hospital and Leeds General Hospital, Leeds, UK; The James Cook University Hospital (G.Y.), Middlesbrough, UK; University of Oxford (P.M.R.), Oxford, UK; and Glasgow Royal Infirmary (G.R.), Glasgow, UK
| | - Giles Roditi
- From the University of Edinburgh (J.M.W., F.C.), Edinburgh, UK; the University of Sheffield (M.S., S.T.), Sheffield, UK; the University of Cambridge (J.G.), Cambridge, UK; Leeds Teaching Hospital NHS Trust and University of Leeds (M.G.), St James Hospital and Leeds General Hospital, Leeds, UK; The James Cook University Hospital (G.Y.), Middlesbrough, UK; University of Oxford (P.M.R.), Oxford, UK; and Glasgow Royal Infirmary (G.R.), Glasgow, UK
| | - Michael J. Gough
- From the University of Edinburgh (J.M.W., F.C.), Edinburgh, UK; the University of Sheffield (M.S., S.T.), Sheffield, UK; the University of Cambridge (J.G.), Cambridge, UK; Leeds Teaching Hospital NHS Trust and University of Leeds (M.G.), St James Hospital and Leeds General Hospital, Leeds, UK; The James Cook University Hospital (G.Y.), Middlesbrough, UK; University of Oxford (P.M.R.), Oxford, UK; and Glasgow Royal Infirmary (G.R.), Glasgow, UK
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Gabriel R, Alonso M, Reviriego B, Muñiz J, Vega S, López I, Novella B, Suárez C, Rodríguez-Salvanés F. Ten-year fatal and non-fatal myocardial infarction incidence in elderly populations in Spain: the EPICARDIAN cohort study. BMC Public Health 2009; 9:360. [PMID: 19778417 PMCID: PMC2761893 DOI: 10.1186/1471-2458-9-360] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 09/24/2009] [Indexed: 11/24/2022] Open
Abstract
Background In Spain, more than 85% of coronary heart disease deaths occur in adults older than 65 years. However, coronary heart disease incidence and mortality in the Spanish elderly have been poorly described. The aim of this study is to estimate the ten-year incidence and mortality rates of myocardial infarction in a population-based large cohort of Spanish elders. Methods A population-based cohort of 3729 people older than 64 years old, free of previous myocardial infarction, was established in 1995 in three geographical areas of Spain. Any case of fatal and non-fatal myocardial infarction was investigated until December 2004 using the "cold pursuit method", previously used and validated by the the WHO-MONICA project. Results Men showed a significantly (p < 0.001) higher cumulative incidence of myocardial infarction (7.2%; 95%CI: 5.94-8.54) than women (3.8%; 95%CI: 3.06-4.74). Although cumulative incidence increased with age (p < 0.05), gender-differences tended to narrow. Adjusted incidence rates were higher in men (957 per 100 000 person-years) than in women (546 per 100 000 person-years) (p < 0.001) and increased with age (p < 0.001). The increase was progressive in women but not in men. Adjusted mortality rates were also higher in men than in women (p < 0.001), being three times higher in the age group of ≥ 85 years old than in the age group of 65-74 years old (p < 0.001). Conclusion Incidence of fatal and non-fatal myocardial infarction is high in the Spanish elderly population. Men show higher rates than women, but gender differences diminish with age.
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Affiliation(s)
- Rafael Gabriel
- Unidad de Investigación, Red RECAVA, Hospital Universitario La Paz, Madrid, Spain.
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Mortality from cardiovascular and cerebrovascular diseases in Europe and other areas of the world: an update. ACTA ACUST UNITED AC 2009; 16:333-50. [PMID: 19369880 DOI: 10.1097/hjr.0b013e328325d67d] [Citation(s) in RCA: 178] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To update trends in mortality from coronary heart diseases (CHD) and cerebrovascular diseases (CVD) over the period 1981-2004 in Europe, the USA, Latin America, Japan and other selected areas of the world. METHODS Age-standardized mortality rates were derived from the World Health Organization database. Joinpoint analysis was used to identify significant changes in trends. RESULTS In the European Union (27 countries), CHD mortality in men declined from 139/100,000 in 1985-1989 to 93/100,000 in 2000-2004 (-33%). In women, the fall was from 61/100,000 to 44/100,000 (-27%). In this area, a decline by over 30% was also registered in CVD mortality for both sexes. In the Russian Federation and other countries of the former Soviet Union, CHD rates in 2000-2004 were exceedingly high, around 380/100,000 men and 170/100,000 women in Russia, 430 for men and 240 for women in Ukraine, 420 and 200 in Belarus. For CVD, a similar situation was registered, with mortality rates of 226/100,000 for men and 159/100,000 for women in 2004 in the Russian Federation, and more than 24% increase since the late 1980s for men and 15% for women. CHD and CVD mortality continued to decline in most Latin American countries, Australia and other areas considered, including Asia (even if with marked differences). CONCLUSION Although mortality from CHD and CVD continues to decline in several areas of the world including most countries of Europe and of the America providing data and Australia, unfavourable trends were still observed in the Russian Federation and other countries of the former Soviet Union, whose recent rates remain exceedingly high.
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Hardman SMR, Gebbie AE. Hormonal contraceptive regimens in the perimenopause. Maturitas 2009; 63:204-12. [PMID: 19524378 DOI: 10.1016/j.maturitas.2009.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022]
Abstract
Perimenopausal women have low fertility but still need contraception if they are sexually active. They often have co-existing menstrual problems and menopausal symptoms. No method of contraception is contraindicated by age alone. In addition to highly effective contraception, hormonal methods offer non-contraceptive benefits which can improve quality of life for perimenopausal women. Combined hormonal oral contraception has been available for many decades. The combined vaginal ring and transdermal patch are newer methods offering alternative delivery systems but similar risk profiles to oral preparations. New combinations containing naturally occurring estrogens in place of the synthetic hormone ethinylestradiol are now available and, in theory, could be safer. The progestogen-only methods have an excellent safety profile and have a range of delivery systems and dosages to suit all. Concerns regarding loss of bone mineral density with the injectable depot medroxyprogesterone acetate continue but to date there is no evidence that this translates into higher fracture risk. Effective use of any method of contraception is strongly dependent on good counselling and support from healthcare professionals. Risks should be explained in absolute terms for each individual woman, enabling her to make an informed choice on evidence-based medicine and not influenced by ill-informed media publicity.
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Affiliation(s)
- Sarah M R Hardman
- NHS Lothian Family Planning and Well Woman Services, 18 Dean Terrace, Edinburgh, UK
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Novella B, Alonso M, Rodriguez-Salvanés F, Susi R, Reviriego B, Escalante L, Suárez C, Gabriel R. Incidencia a diez años de infarto de miocardio fatal y no fatal en la población anciana de Madrid. Rev Esp Cardiol 2008. [DOI: 10.1157/13127845] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Mulnier HE, Seaman HE, Raleigh VS, Soedamah-Muthu SS, Colhoun HM, Lawrenson RA, de Vries CS. Risk of myocardial infarction in men and women with type 2 diabetes in the UK: a cohort study using the General Practice Research Database. Diabetologia 2008; 51:1639-45. [PMID: 18581091 DOI: 10.1007/s00125-008-1076-y] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Accepted: 05/19/2008] [Indexed: 11/24/2022]
Abstract
AIMS/HYPOTHESIS Our primary aim was to establish reliable and generalisable estimates of the risk of myocardial infarction (MI) for men and women with type 2 diabetes in the UK compared with people without diabetes. Our secondary aim was to investigate how the MI risk associated with diabetes differs between men and women. METHODS A cohort study using the General Practice Research Database (1992-1999) was carried out, selecting 40,727 patients with type 2 diabetes and 194,913 age and sex-matched patients without diabetes. Rates of MI in men and women with and without diabetes were derived, as were hazard ratios for MI adjusted for known risk factors. RESULTS The rate of MI in men with type 2 diabetes was 19.74 (95% CI 18.83-20.69) per 1,000 person-years compared with 16.18 (95% CI 15.33-17.08) per 1,000 person-years in women with type 2 diabetes. The overall adjusted relative risk of MI in diabetes versus no diabetes was 2.13 (95% CI 2.01-2.26) in men and 2.95 (95% CI 2.75-3.17) in women and decreased with age in both sexes. Women with type 2 diabetes aged 35 to 54 years were at almost five times the risk of MI compared with women of the same age without diabetes (HR 4.86 [95% CI 2.78-8.51]). CONCLUSIONS/INTERPRETATION This study has demonstrated that women with type 2 diabetes are at a much greater relative risk of MI than men even when adjusted for risk factors.
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Affiliation(s)
- H E Mulnier
- Postgraduate Medical School, University of Surrey, Daphne Jackson Road, Manor Park, Guildford, Surrey GU2 7WG, UK.
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C-terminal provasopressin (copeptin) is associated with left ventricular dysfunction, remodeling, and clinical heart failure in survivors of myocardial infarction. J Card Fail 2008; 14:739-45. [PMID: 18995178 DOI: 10.1016/j.cardfail.2008.07.231] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 07/02/2008] [Accepted: 07/14/2008] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute myocardial infarction (AMI) is associated with left ventricular (LV) dysfunction and clinical heart failure. Arginine vasopressin is elevated in heart failure and the C-terminal of provasopressin (Copeptin) is associated with adverse outcome post-AMI. The aim of this study was to describe the association between Copeptin with LV dysfunction, volumes, and remodeling and clinical heart failure post-AMI. METHODS AND RESULTS We studied 274 subjects with AMI. Copeptin was measured from plasma at discharge and subjects underwent echocardiography at discharge and follow-up (median 155 days). Subjects were followed for clinical heart failure for a median of 381 days. Remodeling was assessed as the change (Delta) in LV volumes between echo examinations. Copeptin correlated directly with wall motion index score (WMIS) and inversely with LV ejection fraction (LVEF) at discharge (WMIS, r=0.276, P < .001; LVEF, r=-0.188, P=.03) and follow-up (WMIS, r=0.244, P < .001; LVEF, r=-0.270, P < .001) and with ventricular volumes at follow-up (LVEDV, r=0.215, P=.002; LVESV, r=0.299, P < .001). Copeptin was associated with ventricular remodeling; DeltaEDV; r=0.171, P=0.015, DeltaESV; r=0.186, P=.008. Subjects with increasing LVESV had higher levels of Copeptin (median 6.30 vs. 5.75 pmol/L, P=.012). Subjects with clinical heart failure (n=30) during follow-up had higher Copeptin before discharge (median 13.55 vs. 5.80, P < .001). In a Cox proportional hazards model, Copeptin retained association with clinical heart failure. Kaplan-Meier assessment revealed increased risk in subjects with Copeptin >6.31 pmol/L. CONCLUSIONS Copeptin is associated with LV dysfunction, volumes, and remodeling and clinical heart failure post-AMI. Measurement of Copeptin may provide prognostic information and the AVP system may be a therapeutic target in post-MI LV dysfunction.
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Huerta C, Johansson S, Wallander MA, Rodríguez LAG. Risk of myocardial infarction and overall mortality in survivors of venous thromboembolism. Thromb J 2008; 6:10. [PMID: 18706117 PMCID: PMC2531082 DOI: 10.1186/1477-9560-6-10] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Accepted: 08/18/2008] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) and thromboembolic arterial diseases are usually considered to be distinct entities, but there is evidence to suggest that these disorders may be linked. The aim of this study was to determine whether a diagnosis of VTE increases the long-term risk of myocardial infarction (MI). METHODS The incidence rate (IR) and relative risk (RR) of MI in a cohort of patients with a diagnosis of VTE (n = 4890) compared with that of a control cohort without prior VTE (n = 43 382) were evaluated in the UK General Practice Research Database (GPRD). Death during follow-up was also determined. Patients were followed for up to 8 years (mean of 3 years). RESULTS The IR of MI per 1000 person-years was 4.1 (95% CI: 3.1-5.3) for the VTE cohort and 3.5 (95% CI: 3.2-3.8) for the control cohort. The IR of MI was highest in the first year after the VTE episode, but overall differences between the two cohorts were not significant (RR of MI associated with VTE: 1.2; 95% CI: 0.9-1.6). The risk of death was higher in the VTE cohort than the control cohort, even after adjustment for cancer, heart failure and ischaemic heart disease (RR: 2.4; 95% CI: 2.2-2.6), particularly during the first year after VTE (RR: 3.8; 95% CI: 3.4-4.3). CONCLUSION A VTE episode does not significantly increase the risk of MI, but does increase the risk of death, particularly in the first year following VTE diagnosis.
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Affiliation(s)
- Consuelo Huerta
- Spanish Centre for Pharmacoepidemiologic Research (CEIFE), Madrid, Spain.
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Allender S, Scarborough P, O'Flaherty M, Capewell S. Patterns of coronary heart disease mortality over the 20th century in England and Wales: Possible plateaus in the rate of decline. BMC Public Health 2008; 8:148. [PMID: 18452595 PMCID: PMC2386471 DOI: 10.1186/1471-2458-8-148] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Accepted: 05/01/2008] [Indexed: 11/12/2022] Open
Abstract
Background Coronary heart disease (CHD) rates in England and Wales between 1950 and 2005 were high and reasonably steady until the mid 1970s, when they began to fall. Recent work suggests that the rate of change in some groups has begun to decrease and may be starting to plateau or even reverse. Methods Data for all deaths between 1931 and 2005 in England and Wales were grouped by year, sex, age at death and contemporaneous ICD code for CHD as cause of death. CHD mortality rates by calendar year and birth cohort were produced for both sexes and rates of change were examined. Results The pattern of increased burden of CHD mortality within older age groups has only recently emerged in men, whereas it has been established in women for far longer. CHD mortality rates among younger people showed little variation by birth cohort. For younger women (49 and under), the rate of change in CHD mortality has reversed in the last 20 years, indicating a future plateau and possible reversal of previous improvement in CHD mortality rates. Among younger men the rate of change in CHD mortality has been consistent for the past 15 years indicating that rates in this group have continued to fall steadily. Conclusion Although CHD mortality rates continue to drop in older age groups the actual burden of coronary heart disease is increasing due to the ageing of the population. The rate of improvement in CHD mortality appears to be beginning to decline and may even be reversing among younger women.
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Affiliation(s)
- Steven Allender
- Division of Public Health and Primary Health Care, University of Oxford, Oxford, UK.
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Usher-Smith J, Ramsbottom T, Pearmain H, Kirby M. Evaluation of the clinical outcomes of switching patients from atorvastatin to simvastatin and losartan to candesartan in a primary care setting: 2 years on. Int J Clin Pract 2008; 62:480-4. [PMID: 18201178 DOI: 10.1111/j.1742-1241.2007.01690.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS This short report was designed to provide 2-year follow-up data from a previous study carried out in a primary care practice in the UK to assess the clinical and practical implications of switching to generic drugs. METHODS All patients previously switched from atorvastatin to simvastatin or losartan to candesartan were reviewed retrospectively 2 years after the switch. Total serum cholesterol and clinic blood pressure readings were used along with records of cardiovascular events occuring during the 2 year period to assess the clinical impact of the switch. RESULTS Of the 69 patients switched from atorvastatin to simvastatin between March and September 2005, 65 are still registered at the practice. Of these, 61 (94%) are still on simvastatin and 58 (89%) on the same dose. There was no significant change in mean total cholesterol over this 2 year period [between 4.04 +/- 0.52 mmol/l prior to the switch and 3.90 +/- 0.63 mmol/l 2 years after the switch (p = 0.06)]. Of the 108 patients switched from losartan to candesartan, 94 are still registered at the practice and taking an angiotensin receptor blocker (ARB), 92 of these (98%) are still on candesartan and there was a significant reduction in blood pressure 2 years post-switch [between 138/79 +/- 12.9/6.6 prior to the switch and 131/77 +/- 13.1/7.6 mmHg 2 years after the switch (p<<0.05)]. No adverse events attributable to the switch were reported in either group. CONCLUSION This small study provides evidence that switching drugs in primary care can be cost effective and safe in the medium term, if care is taken with selection of patients and there is structured follow-up in place.
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Affiliation(s)
- J Usher-Smith
- Department of Medicine, West Suffolk Hospital NHS Trust, Suffolk, UK.
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Moore RA, Derry S, McQuay HJ, Paling J. What do we know about communicating risk? A brief review and suggestion for contextualising serious, but rare, risk, and the example of cox-2 selective and non-selective NSAIDs. Arthritis Res Ther 2008; 10:R20. [PMID: 18257914 PMCID: PMC2374447 DOI: 10.1186/ar2373] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Revised: 12/06/2007] [Accepted: 02/07/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Communicating risk is difficult. Although different methods have been proposed - using numbers, words, pictures or combinations - none has been extensively tested. We used electronic and bibliographic searches to review evidence concerning risk perception and presentation. People tend to underestimate common risk and overestimate rare risk; they respond to risks primarily on the basis of emotion rather than facts, seem to be risk averse when faced with medical interventions, and want information on even the rarest of adverse events. METHODS We identified observational studies (primarily in the form of meta-analyses) with information on individual non-steroidal anti-inflammatory drug (NSAID) or selective cyclooxygenase-2 inhibitor (coxib) use and relative risk of gastrointestinal bleed or cardiovascular event, the background rate of events in the absence of NSAID or coxib, and the likelihood of death from an event. Using this information we present the outcome of additional risk of death from gastrointestinal bleed and cardiovascular event for individual NSAIDs and coxibs alongside information about death from other causes in a series of perspective scales. RESULTS The literature on communicating risk to patients is limited. There are problems with literacy, numeracy and the human tendency to overestimate rare risk and underestimate common risk. There is inconsistency in how people translate between numbers and words. We present a method of communicating information about serious risks using the common outcome of death, using pictures, numbers and words, and contextualising the information. The use of this method for gastrointestinal and cardiovascular harm with NSAIDs and coxibs shows differences between individual NSAIDs and coxibs. CONCLUSION Although contextualised risk information can be provided on two possible adverse events, many other possible adverse events with potential serious consequences were omitted. Patients and professionals want much information about risks of medical interventions but we do not know how best to meet expectations. The impact of contextualised information remains to be tested.
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Affiliation(s)
- R Andrew Moore
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe NHS Trust, The Churchill, Headington, Oxford OX3 7LJ, UK
| | - Sheena Derry
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe NHS Trust, The Churchill, Headington, Oxford OX3 7LJ, UK
| | - Henry J McQuay
- Pain Research and Nuffield Department of Anaesthetics, University of Oxford, Oxford Radcliffe NHS Trust, The Churchill, Headington, Oxford OX3 7LJ, UK
| | - John Paling
- Risk Communication Institute, 5822 NW 91st Boulevard, Gainesville, Florida 32653, USA
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Hernández R, Vale L. The value of myocardial perfusion scintigraphy in the diagnosis and management of angina and myocardial infarction: a probabilistic economic analysis. Med Decis Making 2007; 27:772-88. [PMID: 17989429 DOI: 10.1177/0272989x07306111] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
BACKGROUND AND AIM Coronary heart disease (CHD) is the most common cause of death in the United Kingdom, accounting for more than 120,000 deaths in 2001, among the highest rates in the world. This study reports an economic evaluation of single photon emission computed tomography myocardial perfusion scintigraphy (SPECT) for the diagnosis and management of coronary artery disease (CAD). METHODS Strategies involving SPECT with and without stress electrocardiography (ECG) and coronary angiography (CA) were compared to diagnostic strategies not involving SPECT. The diagnosis decision was modeled with a decision tree model and long-term costs and consequences using a Markov model. Data to populate the models were obtained from a series of systematic reviews. Unlike earlier evaluations, a probabilistic analysis was included to assess the statistical imprecision of the results. The results are presented in terms of incremental cost per quality-adjusted life year (QALY). RESULTS At prevalence levels of CAD of 10.5%, SPECT-based strategies are cost-effective; ECG-CA is highly unlikely to be optimal. At a ceiling ratio of Pound 20,000 per QALY, SPECT-CA has a 90% likelihood of being optimal. Beyond this threshold, this strategy becomes less likely to be cost-effective. At more than Pound 75,000 per QALY, coronary angiography is most likely to be optimal. For higher levels of prevalence (around 50%) and more than a Pound 10,000 per QALY threshold, coronary angiography is the optimal decision. CONCLUSIONS SPECT-based strategies are likely to be cost-effective when risk of CAD is modest (10.5%). Sensitivity analyses show these strategies dominated non-SPECT-based strategies for risk of CAD up to 4%. At higher levels of prevalence, invasive strategies may become worthwhile. Finally, sensitivity analyses show stress echocardiography as a potentially cost-effective option, and further research to assess the relative cost-effectiveness of echocardiography should also be performed.
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Affiliation(s)
- Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland, UK. r.a.hernandez @abdn.ac.uk
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Guía de Práctica Clínica para el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol 2007. [DOI: 10.1157/13111518] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
This paper aims to assess the cost-effectiveness of sibutramine in treating obese patients in the Western countries. The model estimates the costs and quality of life benefits directly associated with weight losses combined with the costs and benefits associated with the reduced incidence of coronary heart disease (CHD) and diabetes. The pivotal effectiveness evidence is derived from a German multicentre, double-blind, randomized clinical trial on obese (body mass index >/= 30 Euro kg m(-2)) patients. The incremental cost per quality-adjusted life year ranges from 10,734 Euro in Switzerland to 13,707 Euro in Germany. The total number of CHD events avoided ranges from 1.96 for the UK to 4.49 for Switzerland. The number of diabetes cases avoided is in the region of 3.0 (ranges from 2.58 for Germany to 3.28 for Switzerland). The majority of costs and benefits are accrued through sibutramine treatment and monitoring. Univariate sensitivity analyses show that results are sensitive to changes in the utility directly attributable to weight losses. The results demonstrate that the benefits associated with sibutramine-induced weight losses are obtained at a reasonable cost in each of the settings explored and suggest that sibutramine treatment could be considered as a viable option for pharmacotherapy treatment alongside diet and exercise.
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Affiliation(s)
- R Ara
- School of Health and Related Research, The University of Sheffield, Sheffield, UK.
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