1
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Sur NB, Kozberg M, Desvigne-Nickens P, Silversides C, Bushnell C. Improving Stroke Risk Factor Management Focusing on Health Disparities and Knowledge Gaps. Stroke 2024; 55:248-258. [PMID: 38134258 DOI: 10.1161/strokeaha.122.040449] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Stroke is a leading cause of death and disability in the United States and worldwide, necessitating comprehensive efforts to optimize stroke risk factor management. Health disparities in stroke incidence, prevalence, and risk factor management persist among various race/ethnic, geographic, and socioeconomic populations and negatively impact stroke outcomes. This review highlights existing literature and guidelines for stroke risk factor management, emphasizing health disparities among certain populations. Moreover, stroke risk factors for special groups, including the young, the very elderly, and pregnant/peripartum women are outlined. Strategies for stroke risk factor improvement at every level of the health care system are discussed, from the individual patient to providers, health care systems, and policymakers. Improving stroke risk factor management in the context of the social determinants of health, and with the goal of eliminating inequities and disparities in stroke prevention strategies, are critical steps to reducing the burden of stroke and equitably improving public health.
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Affiliation(s)
- Nicole B Sur
- Department of Neurology, University of Miami Miller School of Medicine, FL (N.B.S.)
| | - Mariel Kozberg
- Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston (M.K.)
| | | | | | - Cheryl Bushnell
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC (C.B.)
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2
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Qian W, Ye Y, Zuo L, Song T, Xu Q, Wang Y, Qian J, Tian Y. Immune checkpoint inhibitors use and effects on prognosis of COVID-19 infection: a systematic review and meta-analysis. Immunotherapy 2021; 13:1271-1282. [PMID: 34431319 PMCID: PMC8388614 DOI: 10.2217/imt-2021-0007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/29/2021] [Indexed: 12/18/2022] Open
Abstract
Aim: We aimed to quantify the effects of immune checkpoint inhibitors (ICIs) on the prognosis of COVID-19. Materials & methods: A meta-analysis was conducted and the hospitalization, severe disease and mortality rates were assessed. Thirteen studies comprising of 4614 cancer patients with COVID-19 were included. Results: When compared with cancer patients without prior ICI exposure, patients with prior ICI treatment exhibited a higher rate of hospitalization (odds ratio [OR] 2.0, 95% CI 1.19-3.38, p = 0.01). However, the OR of severe disease and mortality in ICI exposed cases was similar to non-ICI exposed patients (OR 1.55, 95% CI 0.69-3.51, p = 0.29; OR 1.12, 95% CI 0.85-1.48, p = 0.42, respectively). Conclusion: It is uncertain whether prior exposure to ICIs increases the risk of severe disease and death, however the observed OR suggest a higher rate of hospitalization.
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Affiliation(s)
- Wenwei Qian
- Department of General Surgery, Jinling Hospital, Medical School of Southeast University, No. 305 East Zhongshan Road, Nanjing, PR China
| | - Ying Ye
- Emergency Center, Affiliated Hospital of Xuzhou Medical College. 99 Huaihaixi Road, Xuzhou, Jiangsu, 221002, China
| | - Lugen Zuo
- Department of Gastrointestinal Surgery, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, 233004, China
| | - Ting Song
- Department of Infectious Diseases, The Sixth People’s Hospital of Qingdao, No. 9 Fushun Road, Qingdao, Shandong, 266033, China
| | - Qing Xu
- Department of Oncology, Tongji University Cancer Center, The Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology & Nutrition, The University of MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jun Qian
- Department of Oncology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, China
| | - Yun Tian
- Department of Oncology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, China
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3
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Patel M, Wei X, Weigel K, Gertz ZM, Kron J, Robinson AA, Trankle CR. Diagnosis and Treatment of Intracardiac Thrombus. J Cardiovasc Pharmacol 2021; 78:361-371. [PMID: 34074905 DOI: 10.1097/fjc.0000000000001064] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/01/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Intracardiac thrombi can occur in a variety of locations and are frequently encountered in clinical practice. Yet evidence-based guidance for clinicians managing patients with intracardiac thrombi is often limited. This review summarizes what is known regarding the prevalence of intracardiac thrombus, diagnostic strategies, clinical relevance, and treatment options, focusing on four specific types of thrombus for which recent research has shifted clinical understanding and treatment decisions: (1) left atrial appendage thrombus, (2) cardiac implantable electronic device lead thrombus, (3) bioprosthetic aortic valve thrombus, and (4) left ventricular thrombus. Additional studies, ideally prospective, randomized, and head-to-head in design, are needed to better inform best practices in patients with intracardiac thrombi.
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Affiliation(s)
- Murti Patel
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Xin Wei
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Kylie Weigel
- School of Pharmacy, Virginia Commonwealth University, Richmond, VA; and
| | - Zachary M Gertz
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Jordana Kron
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | | | - Cory R Trankle
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
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4
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Gusdon AM, Farrokh S, Grotta JC. Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease. Semin Neurol 2021; 41:365-387. [PMID: 33851394 DOI: 10.1055/s-0041-1726331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.
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Affiliation(s)
- Aaron M Gusdon
- Department of Neurosurgery, UTHealth Neurosciences, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas
| | - Salia Farrokh
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James C Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Texas Medical Center, Houston
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5
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Nygaard MH, Hvas AM, Grove EL. Efficacy and Safety of Oral Anticoagulants in Patients with Systolic Heart Failure in Sinus Rhythm: A Systematic Review and Meta-analysis of Randomized Controlled Trials and Cohort Studies. TH OPEN 2020; 4:e383-e392. [PMID: 33274311 PMCID: PMC7704246 DOI: 10.1055/s-0040-1720961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 10/05/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction
There is conflicting evidence on the risk–benefit ratio of oral anticoagulants (OAC) in heart failure (HF) patients without atrial fibrillation. We aimed to evaluate the efficacy and safety of OAC in HF patients in sinus rhythm.
Methods
A systematic literature search was conducted using PubMed and Embase. We included randomized controlled trials (RCT) and cohort studies, comparing OAC with antiplatelet or no treatment/placebo in patients with HF. Outcomes evaluated were stroke, myocardial infarction (MI), all-cause mortality, and major bleeding.
Results
Five RCTs and three cohort studies were included. OAC was associated with a reduced risk of ischemic stroke when compared with no treatment/placebo (odds ratio [OR] = 0.67, 95% confidence interval [CI]: [0.47, 0.94]) and antiplatelet therapy (OR = 0.55, 95% CI: [0.37, 0.81]). No significant reduction was found in MI, when OAC was compared with no treatment/placebo (OR = 0.82, 95% CI: [0.63, 1.07]) or antiplatelet therapy (OR = 1.04, 95% CI: [0.60, 1.81]). The all-cause mortality analysis showed no significant reduction when comparing OAC with no treatment/placebo (OR = 0.99, 95% CI: [0.87, 1.12]) or antiplatelet therapy (OR = 1.00, 95% CI: [0.86, 1.16]). The nonsignificant effect of OAC on all-cause mortality was supported by a meta-analysis of the three cohort studies (OR = 1.02, 95% CI: [0.75, 1.38]). Patients treated with OAC had a significantly higher risk of major bleeding than patients receiving antiplatelet therapy (OR = 2.16, 95% CI: [1.55, 3.00]) and a numerically higher risk when compared with no treatment/placebo (OR = 2.38, 95% CI: [0.87, 6.49]).
Conclusion
The present study does not support the routine use of OAC in patients with HF in sinus rhythm.
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Affiliation(s)
- Marie H Nygaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Biochemistry, Thrombosis and Hemostasis Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
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6
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Saw Y, Yap SY, Tan YH. Evaluation of the clinical and safety outcomes of
face‐to‐face
vs a telephonic model of a
pharmacist‐led
outpatient anticoagulation service. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Yashi Saw
- National University Hospital Singapore Singapore
| | - Shi Yin Yap
- National University Hospital Singapore Singapore
| | - Yu Heng Tan
- National Healthcare Group Woodlands Health Campus Yishun Singapore
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7
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Li X, Yang J, Xu D. Anticoagulation in Patients with Heart Failure and Sinus Rhythm. Int Heart J 2020; 61:1204-1211. [PMID: 33191346 DOI: 10.1536/ihj.20-248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The risk of thromboembolic events is significantly increased among patients with heart failure, even in those without atrial fibrillation. However, it is still unclear whether patients with heart failure and sinus rhythm can benefit from prophylactic anticoagulant therapy.This was a retrospective review of the pathophysiological mechanisms, epidemiological studies, and clinical trials on anticoagulation in patients with heart failure and sinus rhythm.Some subgroup analyses of clinical trials found that prophylactic anticoagulant therapy could reduce the incidence of stroke in patients with heart failure and sinus rhythm, and the risk of bleeding was significantly increased. Regarding the incidence of primary endpoint outcomes, all results from clinical trials were negative.Prophylactic anticoagulation did not improve the clinical outcome in patients with heart failure and sinus rhythm.
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Affiliation(s)
- Xiao Li
- Department of Internal Cardiovascular Medicine, Second Xiangya Hospital, Central South University
| | - Jingmin Yang
- Department of Internal Cardiovascular Medicine, Second Xiangya Hospital, Central South University
| | - Danyan Xu
- Department of Internal Cardiovascular Medicine, Second Xiangya Hospital, Central South University
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8
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Friebel J, Weithauser A, Witkowski M, Rauch BH, Savvatis K, Dörner A, Tabaraie T, Kasner M, Moos V, Bösel D, Gotthardt M, Radke MH, Wegner M, Bobbert P, Lassner D, Tschöpe C, Schutheiss HP, Felix SB, Landmesser U, Rauch U. Protease-activated receptor 2 deficiency mediates cardiac fibrosis and diastolic dysfunction. Eur Heart J 2020; 40:3318-3332. [PMID: 31004144 DOI: 10.1093/eurheartj/ehz117] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/11/2018] [Accepted: 04/05/2019] [Indexed: 02/06/2023] Open
Abstract
AIMS Heart failure with preserved ejection fraction (HFpEF) and pathological cardiac aging share a complex pathophysiology, including extracellular matrix remodelling (EMR). Protease-activated receptor 2 (PAR2) deficiency is associated with EMR. The roles of PAR1 and PAR2 have not been studied in HFpEF, age-dependent cardiac fibrosis, or diastolic dysfunction (DD). METHODS AND RESULTS Evaluation of endomyocardial biopsies from patients with HFpEF (n = 14) revealed that a reduced cardiac PAR2 expression was associated with aggravated DD and increased myocardial fibrosis (r = -0.7336, P = 0.0028). In line, 1-year-old PAR2-knockout (PAR2ko) mice suffered from DD with preserved systolic function, associated with an increased age-dependent α-smooth muscle actin expression, collagen deposition (1.7-fold increase, P = 0.0003), lysyl oxidase activity, collagen cross-linking (2.2-fold increase, P = 0.0008), endothelial activation, and inflammation. In the absence of PAR2, the receptor-regulating protein caveolin-1 was down-regulated, contributing to an augmented profibrotic PAR1 and transforming growth factor beta (TGF-β)-dependent signalling. This enhanced TGF-β/PAR1 signalling caused N-proteinase (ADAMTS3) and C-proteinase (BMP1)-related increased collagen I production from cardiac fibroblasts (CFs). PAR2 overexpression in PAR2ko CFs reversed these effects. The treatment with the PAR1 antagonist, vorapaxar, reduced cardiac fibrosis by 44% (P = 0.03) and reduced inflammation in a metabolic disease model (apolipoprotein E-ko mice). Patients with HFpEF with upstream PAR inhibition via FXa inhibitors (n = 40) also exhibited reduced circulating markers of fibrosis and DD compared with patients treated with vitamin K antagonists (n = 20). CONCLUSIONS Protease-activated receptor 2 is an important regulator of profibrotic PAR1 and TGF-β signalling in the heart. Modulation of the FXa/FIIa-PAR1/PAR2/TGF-β-axis might be a promising therapeutic approach to reduce HFpEF.
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Affiliation(s)
- Julian Friebel
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | - Alice Weithauser
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | - Marco Witkowski
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | - Bernhard H Rauch
- Institute of Pharmacology, Center of Drug Absorption and Transport, University Medicine Greifswald, Felix-Hausdorff-Str. 3, Greifswald, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, Ferdinand-Sauerbruch-Str., Greifswald, Germany
| | - Konstantinos Savvatis
- Inherited Cardiovascular Diseases Unit, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK.,William Harvey Research Institute, Queen Mary University London, Charterhouse Square, London, UK
| | - Andrea Dörner
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | - Termeh Tabaraie
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | - Mario Kasner
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | - Verena Moos
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | - Diana Bösel
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | - Michael Gotthardt
- Neuromuscular and Cardiovascular Cell Biology, Max Delbrück Center for Molecular Medicine, Berlin, Robert-Rössle-Str. 10, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Oudenarder Straße 16, Berlin, Germany
| | - Michael H Radke
- Neuromuscular and Cardiovascular Cell Biology, Max Delbrück Center for Molecular Medicine, Berlin, Robert-Rössle-Str. 10, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Oudenarder Straße 16, Berlin, Germany
| | - Max Wegner
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | - Peter Bobbert
- Department of Internal Medicine and Angiology, Hubertus Hospital, Berlin, Spanische Allee 10-14, Berlin, Germany
| | - Dirk Lassner
- Institute for Cardiac Diagnostics and Therapy (IKDT), Moltkestr. 31, Berlin, Germany
| | - Carsten Tschöpe
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany
| | | | - Stephan B Felix
- German Centre for Cardiovascular Research (DZHK), Partner Site Greifswald, Ferdinand-Sauerbruch-Str., Greifswald, Germany.,Department of Internal Medicine B, Cardiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., Greifswald, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Oudenarder Straße 16, Berlin, Germany
| | - Ursula Rauch
- Department of Cardiology, Charité Center 11, Charité-University Medicine Berlin, Hindenburgdamm 30, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Oudenarder Straße 16, Berlin, Germany
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9
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Salazar-Mendiguchía J, González-Costello J, Oliveras T, Gual F, Lupón J, Manito N. Seguimiento a largo plazo de pacientes sintomáticos adultos con miocardiopatía no compactada. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2017.11.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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10
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Kadam UT, Roberts I, White S, Bednall R, Khunti K, Nilsson PM, Lawson CA. Conceptualizing multiple drug use in patients with comorbidity and multimorbidity: proposal for standard definitions beyond the term polypharmacy. J Clin Epidemiol 2018; 106:98-107. [PMID: 30385327 DOI: 10.1016/j.jclinepi.2018.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/28/2018] [Accepted: 10/24/2018] [Indexed: 12/22/2022]
Abstract
With older and aging populations, patients experience multiple chronic diseases at the same time. Individual chronic disease guidelines often recommend pharmacological therapies as a key intervention, resulting in patients being prescribed multiple regular medications for their different diseases. Although the term "polypharmacy" has been applied to the use of multiple medications, there is no consistent definition, and this term is now being used all inclusively. To improve both scientific rigor and optimal patient care, it is crucial that a standard terminology is used, which reclassifies the term "polypharmacy" into distinct phenotypes relating to the index chronic disease, additional conditions to the index (comorbidity), or the experience of multiple chronic conditions at the same time (multimorbidity). Using three exemplar index conditions; heart failure, type 2 diabetes, and breast cancer, we propose the reclassification of the term "polypharmacy" into three distinct phenotypes. First, index drug or multi-index drug therapy, where each index condition creates multiple drug use for that condition; second, codrug therapy, where addition of other comorbid conditions increases the multiple drug use and may influence the management of the index disease and third, multidrug therapy, where adult population with multimorbidity may be on many drugs. This article reviews guidelines for the individual exemplars to develop the basis for the new terms and then develops the pharmacoepidemiology of multiple drug use further by reviewing the evidence on the relationship between the phenotypic classification and important outcomes. The importance of standardizing "polypharmacy" terminology for the scientific agenda and clinical practice is that it relates to an index condition or disease safety outcomes including drug interactions, adverse side effects in hospital admissions, and related "polypill" concept.
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Affiliation(s)
- Umesh T Kadam
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK; Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK.
| | - Isobel Roberts
- Pharmacy Directorate, University Hospitals of North Staffordshire, Stoke-on-Trent ST4 6QG, UK
| | - Simon White
- School of Pharmacy, Keele University, Keele ST5 5BG, UK
| | - Ruth Bednall
- Pharmacy Directorate, University Hospitals of North Staffordshire, Stoke-on-Trent ST4 6QG, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK
| | - Peter M Nilsson
- Department of Clinical Sciences, Lund University, Malmö S-205 02, Sweden
| | - Claire A Lawson
- Diabetes Research Centre, University of Leicester, Leicester LE5 4PW, UK
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11
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Lee TC, Qian M, Lip GY, Di Tullio MR, Graham S, Mann DL, Nakanishi K, Teerlink JR, Freudenberger RS, Sacco RL, Mohr J, Labovitz AJ, Ponikowski P, Lok DJ, Estol C, Anker SD, Pullicino PM, Buchsbaum R, Levin B, Thompson JL, Homma S, Ye S. Heart Failure Severity and Quality of Warfarin Anticoagulation Control (From the WARCEF Trial). Am J Cardiol 2018; 122:821-827. [PMID: 30037426 DOI: 10.1016/j.amjcard.2018.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/07/2018] [Accepted: 05/07/2018] [Indexed: 01/06/2023]
Abstract
Previous studies in patients with atrial fibrillation showed that a history of heart failure (HF) could negatively impact anticoagulation quality, as measured by the average time in therapeutic range (TTR). Whether additional markers of HF severity are associated with TTR has not been investigated thoroughly. We aimed to examine the potential role of HF severity in the quality of warfarin control in patients with HF with reduced ejection fraction. Data from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction Trial were used to investigate the association between TTR and HF severity. Multivariable logistic regression models were used to examine the association of markers of HF severity, including New York Heart Association (NYHA) class, Minnesota Living with HF (MLWHF) score, and frequency of HF hospitalization, with TTR ≥70% (high TTR). We included 1,067 participants (high TTR, N = 413; low TTR, N = 654) in the analysis. In unadjusted analysis, patients with a high TTR were older and less likely to have had strokes or receive other antiplatelet agents. Those patients also had lower NYHA class, better MLWHF scores, greater 6-minute walk distance, and lower frequency of HF hospitalizations. Multivariable analysis showed that NYHA class III and/or IV (Odds ratio [OR] 0.68 [95% confidence intervals [CIs] 0.49 to 0.94]), each 10-point increase in MLWHF score (i.e., worse health-related quality of life) (OR 0.92 [0.86 to 0.99]), and higher number of HF hospitalization per year (OR0.45 [0.30 to 0.67]) were associated with decreased likelihood of having high TTR. In HF patients with systolic dysfunction, NYHA class III and/or IV, poor health-related quality of life, and a higher rate of HF hospitalization were independently associated with suboptimal quality of warfarin anticoagulation control. These results affirm the need to assess the new approaches, such as direct oral anticoagulants, to prevent thromboembolism in this patient population.
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12
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Salazar-Mendiguchía J, González-Costello J, Oliveras T, Gual F, Lupón J, Manito N. Long-term Follow-up of Symptomatic Adult Patients With Noncompaction Cardiomyopathy. ACTA ACUST UNITED AC 2017; 72:169-171. [PMID: 29289512 DOI: 10.1016/j.rec.2017.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Joel Salazar-Mendiguchía
- Área de Enfermedades del Corazón, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Departamento de Genética, Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Barcelona, Spain.
| | - José González-Costello
- Área de Enfermedades del Corazón, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Teresa Oliveras
- Servicio de Cardiología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Francisco Gual
- Servicio de Cardiología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Josep Lupón
- Servicio de Cardiología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Nicolás Manito
- Área de Enfermedades del Corazón, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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13
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Feingold B, Mahle WT, Auerbach S, Clemens P, Domenighetti AA, Jefferies JL, Judge DP, Lal AK, Markham LW, Parks WJ, Tsuda T, Wang PJ, Yoo SJ. Management of Cardiac Involvement Associated With Neuromuscular Diseases: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e200-e231. [DOI: 10.1161/cir.0000000000000526] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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14
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Patient-Specific Tailored Intervention Improves INR Time in Therapeutic Range and INR Variability in Heart Failure Patients. Am J Med 2017; 130:982-989. [PMID: 28344144 DOI: 10.1016/j.amjmed.2017.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 01/31/2017] [Accepted: 02/01/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND Many patients with heart failure need anticoagulants, including warfarin. Good control is particularly challenging in heart failure patients, with <60% of international normalized ratio (INR) measurements in the therapeutic range, thereby increasing the risk of complications. This study aimed to evaluate the effect of a patient-specific tailored intervention on anticoagulation control in patients with heart failure. METHODS Patients with heart failure taking warfarin therapy (n = 145) were randomized to either standard care or a 1-time intervention assessing potential risk factors for lability of INR, in which they received patient-specific instructions. Time in therapeutic range (TTR) using Rosendaal's linear model was assessed 3 months before and after the intervention. RESULTS The patient-tailored intervention significantly increased anticoagulation control. The median TTR levels before intervention were suboptimal in the interventional and control groups (53% vs 45%, P = .14). After intervention the median TTR increased significantly in the interventional group compared with the control group (80% [interquartile range, 62%-93%] vs 44% [29%-61%], P <.0001). The intervention resulted in a significant improvement in the interventional group before versus after intervention (53% vs 80%, P <.0001) but not in the control group (45% vs 44%, P = .95). The percentage of patients with a TTR ≥60%, considered therapeutic, was substantially higher in the interventional group: 79% versus 25% (P <.0001). The INR variability (standard deviation of each patient's INR measurements) decreased significantly in the interventional group, from 0.53 to 0.32 (P <.0001) after intervention but not in the control group. CONCLUSIONS Patient-specific tailored intervention significantly improves anticoagulation therapy in patients with heart failure.
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Adelborg K, Szépligeti S, Sundbøll J, Horváth-Puhó E, Henderson VW, Ording A, Pedersen L, Sørensen HT. Risk of Stroke in Patients With Heart Failure. Stroke 2017; 48:1161-1168. [DOI: 10.1161/strokeaha.116.016022] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 02/02/2017] [Accepted: 02/10/2017] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The long-term risk of specific stroke subtypes among heart failure patients is largely unknown. We examined short-term and long-term risk of ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) in heart failure patients and in a general population comparison cohort.
Methods—
In this nationwide cohort study (1980−2012), we used Danish population-based medical registries to identify and follow (1) all patients hospitalized for the first time with heart failure and (2) a birth year–, sex-, and calendar year–matched general population comparison cohort. Age-, sex-, and comorbidity-adjusted stroke rate ratios were computed based on Cox regression analysis.
Results—
We included 289 353 patients with heart failure and 1 446 765 individuals from the general population in the analysis. One- and 5-year risks among heart failure patients were 1.4% and 3.9% for ischemic stroke, 0.2% and 0.5% for ICH, and 0.03% and 0.07% for SAH. The 30-day adjusted stroke rate ratio was increased markedly for ischemic stroke (5.08; 95% confidence interval, 4.58–5.63] and was also elevated for ICH (2.13; 95% confidence interval, 1.53–2.97) and SAH (3.52; 95% confidence interval, 1.54–8.08). Between 31 days and 30 years, risk of all stroke subtypes remained positively associated with heart failure (1.5- to 2.1-fold for ischemic stroke, 1.4- to 1.8-fold for ICH, and 1.1- to 1.7-fold for SAH) in comparison with the general population cohort.
Conclusions—
Heart failure was associated with increased short-term and long-term risk of all stroke subtypes, suggesting that heart failure is a potent and persistent risk factor for ischemic stroke, ICH, and SAH.
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Affiliation(s)
- Kasper Adelborg
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Denmark (K.A., S.S., J.S., E.H.-P., V.W.H., A.O., L.P., H.T.S.); and Department of Health Research and Policy (Epidemiology) (V.W.H., H.T.S.) and Department of Neurology and Neurological Sciences (V.W.H.), Stanford University, CA
| | - Szimonetta Szépligeti
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Denmark (K.A., S.S., J.S., E.H.-P., V.W.H., A.O., L.P., H.T.S.); and Department of Health Research and Policy (Epidemiology) (V.W.H., H.T.S.) and Department of Neurology and Neurological Sciences (V.W.H.), Stanford University, CA
| | - Jens Sundbøll
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Denmark (K.A., S.S., J.S., E.H.-P., V.W.H., A.O., L.P., H.T.S.); and Department of Health Research and Policy (Epidemiology) (V.W.H., H.T.S.) and Department of Neurology and Neurological Sciences (V.W.H.), Stanford University, CA
| | - Erzsébet Horváth-Puhó
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Denmark (K.A., S.S., J.S., E.H.-P., V.W.H., A.O., L.P., H.T.S.); and Department of Health Research and Policy (Epidemiology) (V.W.H., H.T.S.) and Department of Neurology and Neurological Sciences (V.W.H.), Stanford University, CA
| | - Victor W. Henderson
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Denmark (K.A., S.S., J.S., E.H.-P., V.W.H., A.O., L.P., H.T.S.); and Department of Health Research and Policy (Epidemiology) (V.W.H., H.T.S.) and Department of Neurology and Neurological Sciences (V.W.H.), Stanford University, CA
| | - Anne Ording
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Denmark (K.A., S.S., J.S., E.H.-P., V.W.H., A.O., L.P., H.T.S.); and Department of Health Research and Policy (Epidemiology) (V.W.H., H.T.S.) and Department of Neurology and Neurological Sciences (V.W.H.), Stanford University, CA
| | - Lars Pedersen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Denmark (K.A., S.S., J.S., E.H.-P., V.W.H., A.O., L.P., H.T.S.); and Department of Health Research and Policy (Epidemiology) (V.W.H., H.T.S.) and Department of Neurology and Neurological Sciences (V.W.H.), Stanford University, CA
| | - Henrik Toft Sørensen
- From the Department of Clinical Epidemiology, Aarhus University Hospital, Denmark (K.A., S.S., J.S., E.H.-P., V.W.H., A.O., L.P., H.T.S.); and Department of Health Research and Policy (Epidemiology) (V.W.H., H.T.S.) and Department of Neurology and Neurological Sciences (V.W.H.), Stanford University, CA
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Boehme AK, Esenwa C, Elkind MSV. Stroke Risk Factors, Genetics, and Prevention. Circ Res 2017; 120:472-495. [PMID: 28154098 PMCID: PMC5321635 DOI: 10.1161/circresaha.116.308398] [Citation(s) in RCA: 822] [Impact Index Per Article: 117.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/05/2017] [Accepted: 01/05/2017] [Indexed: 12/18/2022]
Abstract
Stroke is a heterogeneous syndrome, and determining risk factors and treatment depends on the specific pathogenesis of stroke. Risk factors for stroke can be categorized as modifiable and nonmodifiable. Age, sex, and race/ethnicity are nonmodifiable risk factors for both ischemic and hemorrhagic stroke, while hypertension, smoking, diet, and physical inactivity are among some of the more commonly reported modifiable risk factors. More recently described risk factors and triggers of stroke include inflammatory disorders, infection, pollution, and cardiac atrial disorders independent of atrial fibrillation. Single-gene disorders may cause rare, hereditary disorders for which stroke is a primary manifestation. Recent research also suggests that common and rare genetic polymorphisms can influence risk of more common causes of stroke, due to both other risk factors and specific stroke mechanisms, such as atrial fibrillation. Genetic factors, particularly those with environmental interactions, may be more modifiable than previously recognized. Stroke prevention has generally focused on modifiable risk factors. Lifestyle and behavioral modification, such as dietary changes or smoking cessation, not only reduces stroke risk, but also reduces the risk of other cardiovascular diseases. Other prevention strategies include identifying and treating medical conditions, such as hypertension and diabetes, that increase stroke risk. Recent research into risk factors and genetics of stroke has not only identified those at risk for stroke but also identified ways to target at-risk populations for stroke prevention.
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Affiliation(s)
- Amelia K Boehme
- From the Department of Epidemiology, Mailman School of Public Health (A.K.B., M.S.V.E.) and Department of Neurology, College of Physicians and Surgeons (A.K.B., C.E., M.S.V.E.), Columbia University, New York, NY
| | - Charles Esenwa
- From the Department of Epidemiology, Mailman School of Public Health (A.K.B., M.S.V.E.) and Department of Neurology, College of Physicians and Surgeons (A.K.B., C.E., M.S.V.E.), Columbia University, New York, NY
| | - Mitchell S V Elkind
- From the Department of Epidemiology, Mailman School of Public Health (A.K.B., M.S.V.E.) and Department of Neurology, College of Physicians and Surgeons (A.K.B., C.E., M.S.V.E.), Columbia University, New York, NY.
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Raccah BH, Perlman A, Danenberg HD, Pollak A, Muszkat M, Matok I. Major Bleeding and Hemorrhagic Stroke With Direct Oral Anticoagulants in Patients With Renal Failure: Systematic Review and Meta-Analysis of Randomized Trials. Chest 2016; 149:1516-24. [PMID: 26836922 DOI: 10.1016/j.chest.2015.12.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/23/2015] [Accepted: 12/30/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are used as an alternative for traditional antithrombotic therapy. However, the safety profile of DOACs in patients with renal failure (RF) has not been determined. METHODS A systematic review was performed assessing the reported safety of DOACs compared with vitamin K antagonists (VKAs) in patients with RF and estimated creatinine clearance (eCrCL) < 50 mL/min and eCrCL 50 to 80 mL/min. MEDLINE, EMBASE, Cochrane, and the Clinical Trials Registry (ClinicalTrials.gov) were searched for randomized clinical trials up to November 2015. The data were pooled by using both traditional frequentist and Bayesian random effects models. RESULTS Nine trials met the inclusion criteria. Among 94,897 participants, 54,667 (58%) had RF. Compared with VKAs, DOACs were associated with a significantly decreased risk for major bleeding in patients with eCrCL 50 to 80 mL/min (risk ratio, 0.87 [95% CI, 0.81-0.93]) and a nonsignificant decrease in the risk for major bleeding in patients with eCrCL < 50 mL/min (risk ratio, 0.83 [95% CI, 0.68-1.02]); there was evidence of significant heterogeneity. Indirect comparisons, using Bayesian network analysis, indicated that apixaban was associated with a decreased rate of major bleeding compared with other DOACs in patients with eCrCL < 50 mL/min. DOACs were associated with a significant decrease in the risk for hemorrhagic stroke compared with VKAs in patients with eCrCL < 50 mL/min and 50 to 80 mL/min. CONCLUSIONS As a class, DOACs are associated with a reduced risk for hemorrhagic stroke compared with VKAs in patients with RF. However, DOACs may differ from each other in their relative risk for major bleeding in patients with eCrCL < 50 mL/min. TRIAL REGISTRY PROSPERO registry; No.: CRD42014013730; URL: http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014013730.
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Affiliation(s)
- Bruria Hirsh Raccah
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Cardiology, Hadassah University Hospital, Jerusalem, Israel
| | - Amichai Perlman
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel; Department of Medicine, Hadassah University Hospital, Jerusalem, Israel
| | - Haim D Danenberg
- Department of Cardiology, Hadassah University Hospital, Jerusalem, Israel
| | - Arthur Pollak
- Department of Cardiology, Hadassah University Hospital, Jerusalem, Israel
| | - Mordechai Muszkat
- Department of Medicine, Division of Clinical Pharmacology, Hadassah University Hospital, Jerusalem, Israel
| | - Ilan Matok
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Xiong Q, Lau YC, Senoo K, Lane DA, Hong K, Lip GYH. Non-vitamin K antagonist oral anticoagulants (NOACs) in patients with concomitant atrial fibrillation and heart failure: a systemic review and meta-analysis of randomized trials. Eur J Heart Fail 2015; 17:1192-200. [PMID: 26335355 DOI: 10.1002/ejhf.343] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/26/2015] [Accepted: 07/09/2015] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND No pooled analysis has been undertaken to assess the efficacy and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) compared with warfarin in the subgroup of patients with atrial fibrillation (AF) and heart failure (HF), including edoxaban data from recent randomized controlled trials (RCTs). METHODS Comprehensive literature searches were conducted using the Cochrane Library, MEDLINE, and Scopus databases from inception to April 2015. Statistical analyses were performed using RevMan 5.3 software. RESULTS Four RCTs were included: 19 122 of 32 512 AF patients with HF were allocated to a NOAC (13 384 receiving single-/high-dose NOAC regimens), and 13 390 to warfarin. Among AF patients with HF, single/high-dose NOACs significantly reduced the risk of stroke/systemic embolic (SE) events by 14% [odds ratio0.86, 95% confidence interval (CI) 0.76-0.98), and had a 24% lower risk of major bleeding(OR 0.76, 95% CI 0.67-0.86). For low-dose NOAC regimens, comparable efficacy to warfarin for stroke or SE events (OR 1.02, 95% CI 0.86-1.21) and a non-significant trend for lower major bleeding was observed. Regardless of high- or low-dose NOAC, the incidences of both major bleeding and stroke/SE in AF patients with HF were similar to those without HF. Atrial fibrillation patients with HF on NOACs had a 41% lower risk of intracranial haemorrhage compared with those without HF (OR 0.59, 95% CI 0.40-0.87). CONCLUSION Among AF patients with HF, single-/high-dose NOAC regimens have a better efficacy and safety profile, but low-dose regimens had similar efficacy and safety to warfarin. NOACs were similarly effective or even safer (less intracranial haemorrhage) in AF patients with HF compared with those without HF.
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Affiliation(s)
- Qinmei Xiong
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital NHS Trust, Birmingham, B18 7QH, UK
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yee Cheng Lau
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital NHS Trust, Birmingham, B18 7QH, UK
| | - Keitaro Senoo
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital NHS Trust, Birmingham, B18 7QH, UK
| | - Deirdre A Lane
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital NHS Trust, Birmingham, B18 7QH, UK
| | - Kui Hong
- Cardiovascular Department, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital NHS Trust, Birmingham, B18 7QH, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Homma S, Ye S. Stroke and anticoagulation in heart failure without atrial fibrillation: from risk to opportunity. Circulation 2015; 131:1465-7. [PMID: 25810335 DOI: 10.1161/circulationaha.115.016329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Shunichi Homma
- From Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY.
| | - Siqin Ye
- From Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY
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