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Abdin A, Böhm M, Shahim B, Karlström P, Kulenthiran S, Skouri H, Lund LH. Heart failure with preserved ejection fraction epidemiology, pathophysiology, diagnosis and treatment strategies. Int J Cardiol 2024; 412:132304. [PMID: 38944348 DOI: 10.1016/j.ijcard.2024.132304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 06/11/2024] [Accepted: 06/26/2024] [Indexed: 07/01/2024]
Abstract
The prevalence of HF with preserved ejection raction (HFpEF, with EF ≥50%) is increasing across all populations with high rates of hospitalization and mortality, reaching up to 80% and 50%, respectively, within a 5-year timeframe. Comorbidity-driven systemic inflammation is thought to cause coronary microvascular dysfunction and increased epicardial adipose tissue, leading to downstream friborsis and molecular changes in the cardiomyocyte, leading to increased stiffness and diastolic dynsfunction. HFpEF poses unique challenges in terms of diagnosis due to its complex and diverse nature. The diagnosis of HFpEF relies on a combination of clinical assessment, imaging studies, and biomarkers. An additional important step in diagnosing HFpEF involves excluding certain cardiac diagnoses that may be specific underlying causes of HFpEF or may be masquerading as HFpEF and require specific alternative treatment approaches. In addition to administering sodium-glucose cotransporter 2 inhibitors to all patients, the most effective approach to enhance clinical outcomes may involve tailored therapy based on each patient's unique clinical profile. Exercise should be recommended for all patients to improve the quality of life. Glucagon-like peptide-1 1 agonists are a promising treatment option in obese HFpEF patients. Novel approaches targeting inflammation are also in early phase trials.
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Affiliation(s)
- Amr Abdin
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Bahira Shahim
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Patric Karlström
- Department of Internal Medicine, Ryhov County Hospital, Jönköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Saarraaken Kulenthiran
- Klinik für Innere Medizin III-Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hadi Skouri
- Division of Cardiology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
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Chen DQ, Xu WB, Xiao KY, Que ZQ, Feng JY, Sun NK, Cai DX, Rui G. PCSK9 inhibitors and osteoporosis: mendelian randomization and meta-analysis. BMC Musculoskelet Disord 2024; 25:548. [PMID: 39010016 PMCID: PMC11251371 DOI: 10.1186/s12891-024-07674-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 07/08/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors represent an effective strategy for reducing cardiovascular disease risk. Yet, PCSK9's impact on osteoporosis remains unclear. Hence, we employed Mendelian randomization (MR) analysis for examining PCSK9 inhibitor effects on osteoporosis. METHODS Single nucleotide polymorphisms (SNPs) for 3-hydroxy-3-methylglutaryl cofactor A reductase (HMGCR) and PCSK9 were gathered from available online databases for European pedigrees. Four osteoporosis-related genome-wide association studies (GWAS) data served as the main outcomes, and coronary artery disease (CAD) as a positive control for drug-targeted MR analyses. The results of MR analyses examined by sensitivity analyses were incorporated into a meta-analysis for examining causality between PCSK9 and HMGCR inhibitors and osteoporosis. RESULTS The meta-analysis involving a total of 1,263,102 subjects, showed that PCSK9 inhibitors can increase osteoporosis risk (P < 0.05, I2, 39%). However, HMGCR inhibitors are not associated with osteoporosis risk. Additionally, a replication of the analysis was conducted with another exposure-related GWAS dataset, which led to similar conclusions. CONCLUSION PCSK9 inhibitors increase osteoporosis risk. However, HMGCR inhibitors are unremarkably linked to osteoporosis.
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Affiliation(s)
- Ding-Qiang Chen
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, Xiamen, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Wen-Bin Xu
- Department of Orthopedics, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Ke-Yi Xiao
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, Xiamen, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
| | - Zhi-Qiang Que
- Department of Orthopedics, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Jin-Yi Feng
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, Xiamen, China
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China
- Department of Orthopedics, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Nai-Kun Sun
- Department of Orthopedics, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Di-Xin Cai
- Department of Orthopedics, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China
| | - Gang Rui
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, Xiamen, China.
- The School of Clinical Medicine, Fujian Medical University, Fuzhou, China.
- Department of Orthopedics, School of Medicine, The First Affiliated Hospital of Xiamen University, Xiamen University, Xiamen, China.
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Ovchinnikov A, Potekhina A, Arefieva T, Filatova A, Ageev F, Belyavskiy E. Use of Statins in Heart Failure with Preserved Ejection Fraction: Current Evidence and Perspectives. Int J Mol Sci 2024; 25:4958. [PMID: 38732177 PMCID: PMC11084261 DOI: 10.3390/ijms25094958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
Systemic inflammation and coronary microvascular endothelial dysfunction are essential pathophysiological factors in heart failure (HF) with preserved ejection fraction (HFpEF) that support the use of statins. The pleiotropic properties of statins, such as anti-inflammatory, antihypertrophic, antifibrotic, and antioxidant effects, are generally accepted and may be beneficial in HF, especially in HFpEF. Numerous observational clinical trials have consistently shown a beneficial prognostic effect of statins in patients with HFpEF, while the results of two larger trials in patients with HFrEF have been controversial. Such differences may be related to a more pronounced impact of the pleiotropic properties of statins on the pathophysiology of HFpEF and pro-inflammatory comorbidities (arterial hypertension, diabetes mellitus, obesity, chronic kidney disease) that are more common in HFpEF. This review discusses the potential mechanisms of statin action that may be beneficial for patients with HFpEF, as well as clinical trials that have evaluated the statin effects on left ventricular diastolic function and clinical outcomes in patients with HFpEF.
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Affiliation(s)
- Artem Ovchinnikov
- Laboratory of Myocardial Fibrosis and Heart Failure with Preserved Ejection Fraction, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Academician Chazov St., 15a, 121552 Moscow, Russia; (A.P.); (A.F.)
- Department of Clinical Functional Diagnostics, A.I. Yevdokimov Moscow State University of Medicine and Dentistry, Delegatskaya St., 20, p. 1, 127473 Moscow, Russia
| | - Alexandra Potekhina
- Laboratory of Myocardial Fibrosis and Heart Failure with Preserved Ejection Fraction, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Academician Chazov St., 15a, 121552 Moscow, Russia; (A.P.); (A.F.)
| | - Tatiana Arefieva
- Laboratory of Cell Immunology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Academician Chazov St., 15a, 121552 Moscow, Russia;
- Faculty of Basic Medicine, Lomonosov Moscow State University, Leninskie Gory, 1, 119991 Moscow, Russia
| | - Anastasiia Filatova
- Laboratory of Myocardial Fibrosis and Heart Failure with Preserved Ejection Fraction, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Academician Chazov St., 15a, 121552 Moscow, Russia; (A.P.); (A.F.)
- Laboratory of Cell Immunology, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Academician Chazov St., 15a, 121552 Moscow, Russia;
| | - Fail Ageev
- Out-Patient Department, National Medical Research Center of Cardiology Named after Academician E.I. Chazov, Academician Chazov St., 15a, 121552 Moscow, Russia;
| | - Evgeny Belyavskiy
- Medizinisches Versorgungszentrum des Deutsches Herzzentrum der Charite, Augustenburger Platz 1, 13353 Berlin, Germany;
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Ju C, Lau WCY, Chambers P, Man KKC, Forster MD, Mackenzie IS, Manisty C, Wei L. Effect of statin treatment on the risk of cancer in patients with heart failure: A target trial emulation study. Pharmacoepidemiol Drug Saf 2024; 33:e5775. [PMID: 38450806 DOI: 10.1002/pds.5775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/01/2023] [Accepted: 02/15/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE A recent observational study suggested statins could reduce cancer diagnosis in patients with heart failure (HF). The findings need to be validated using robust epidemiological methods. This study aimed to evaluate the effect of statin treatment on the risk of cancer in patients with HF. METHODS We conducted two target trial emulations using primary care data from IQVIA Medical Research Database-UK (2000 to 2019) with a clone-censor-weight design. The first emulated trial addressed the treatment initiation effect: initiating within 1 year versus not initiating a statin after the HF diagnosis. The second emulated trial addressed the cumulative exposure effect: continuing a statin for ≤3 years, 3-6 years, and >6 years after initiation. The study outcomes were any incident cancer and site-specific cancer diagnoses. Weighted pooled logistic regression models were used to estimate 10-year risk ratios (RR). 95% confidence intervals (CIs) were estimated using non-parametric bootstrapping. RESULTS The first emulated trial showed that, compared to no statin, statins did not reduce the cancer risk in patients with HF (RR, 1.05; 95% CI, 0.94-1.15). The second emulated trial showed that, compared to treatment ≤3 years, statins with longer durations did not reduce the cancer risk (3-6 years: RR, 0.94; 95% CI, 0.70-1.33. >6 years: RR, 0.97; 95% CI, 0.79-1.26). No significant risk difference was observed on any site-specific cancer diagnoses. CONCLUSIONS The results from the target trial emulations suggest that statin treatment is not associated with cancer risk in patients with HF.
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Affiliation(s)
- Chengsheng Ju
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Wallis C Y Lau
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, SAR, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, SAR, China
| | - Pinkie Chambers
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Pharmacy Department, University College London Hospital NHS Trust, London, UK
| | - Kenneth K C Man
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, SAR, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, SAR, China
| | | | - Isla S Mackenzie
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Charlotte Manisty
- Department of Cardiology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
- Institute of Cardiovascular Science, University College London, London, UK
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, SAR, China
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Poloczková H, Krejčí J. Heart Failure Treatment in 2023: Is There a Place for Lipid Lowering Therapy? Curr Atheroscler Rep 2023; 25:957-964. [PMID: 38048006 DOI: 10.1007/s11883-023-01166-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 12/05/2023]
Abstract
PURPOSE OF REVIEW An evidence for lipid lowering therapy in heart failure is briefly summarized in this review. RECENT FINDINGS Heart failure therapy is based on recent guidelines for diagnosis and treatment of acute and chronic heart failure. The question of the importance of hypolipidemic treatment in heart failure remains insufficiently answered. We still rely only on results of two randomized controlled trials that did not show significant benefit of statins on mortality in these patients. In contrast, some meta-analysis, prospective or retrospective cohorts, found some positive effects of this therapy. Recently, the role of inflammation and the possibility of its influence by hypolipidemics have been discussed. PCSK9 inhibitors, new lipid lowering drugs, are very effective in LDL-cholesterol lowering and atherosclerotic cardiovascular diseases prevention. The role of PCSK9 inhibitors in heart failure treatment is investigated. Based on current knowledge, hypolipidemics are not generally recommended in heart failure therapy, unless there is another indication for their use.
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Affiliation(s)
- Hana Poloczková
- Department of Cardiovascular Diseases, St Anne's University Hospital and Masaryk, University Brno, Brno, Czech Republic
| | - Jan Krejčí
- Department of Cardiovascular Diseases, St Anne's University Hospital and Masaryk, University Brno, Brno, Czech Republic.
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Ma L, Du Y, Ma C, Liu M. Association of HMGCR inhibition with rheumatoid arthritis: a Mendelian randomization and colocalization study. Front Endocrinol (Lausanne) 2023; 14:1272167. [PMID: 38047111 PMCID: PMC10691537 DOI: 10.3389/fendo.2023.1272167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/25/2023] [Indexed: 12/05/2023] Open
Abstract
Objective The objective of this study was to investigate the association between hydroxymethylglutaryl coenzyme A reductase (HMGCR) inhibition and rheumatoid arthritis (RA) using drug-target Mendelian randomization (MR) and genetic colocalization analyses. Methods Two sets of genetic instruments were employed to proxy HMGCR inhibitors: expression quantitative trait loci (eQTLs) of target genes from the eQTLGen Consortium and genetic variants associated with low-density lipoprotein cholesterol (LDL-C) levels with HMGCR locus from open genome-wide association studies (GWAS). Positive control analyses were conducted on type 2 diabetes and coronary heart disease, and multiple sensitivity analyses were performed. Results Genetically proxied expression of eQTL was associated with a lower risk of RA (OR=0.996, 95% CI =0.992-0.999, p= 0.032). Similarly, hydroxymethylglutaryl coenzyme A reductase (HMGCR)-mediated low-density lipoprotein cholesterol was negatively associated with risk of RA (OR=0.995, 95% CI =0.991-0.998, p= 0.007) in the inverse variance weighted (IVW) method. Colocalization analysis suggested a 74.6% posterior probability of sharing a causal variant within the SNPs locus (PH4 = 74.6%). A causal relationship also existed between HMGCR-mediated LDL and RA risk factors. The results were also confirmed by multiple sensitivity analyses. The results in positive control were consistent with the previous study. Conclusion Our study suggested that HMGCR inhibition was associated with an increased risk of RA while also highlighting an increased risk of current smoking and obesity. These findings contribute to a growing body of evidence regarding the adverse effects of HMGCR inhibition on RA risk, calling for further research on alternative approaches using HMGCR inhibitors in RA management.
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Affiliation(s)
- Li Ma
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
- Department of General Practice, Heze Municiple Hospital, Heze, Shandong, China
| | - Yufei Du
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao Ma
- Department of Urology, Heze Municiple Hospital, Heze, Shandong, China
| | - Ming Liu
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
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Pitt B, Rosenson RS. Statins in Patients With Established Heart Failure: Time for Reflection. J Cardiovasc Pharmacol 2023; 82:345-346. [PMID: 37656993 DOI: 10.1097/fjc.0000000000001475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Affiliation(s)
- Bertram Pitt
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI; and
| | - Robert S Rosenson
- Metabolism and Lipids Unit, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
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Nowak MM, Niemczyk M, Florczyk M, Kurzyna M, Pączek L. Effect of Statins on All-Cause Mortality in Adults: A Systematic Review and Meta-Analysis of Propensity Score-Matched Studies. J Clin Med 2022; 11:jcm11195643. [PMID: 36233511 PMCID: PMC9572734 DOI: 10.3390/jcm11195643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/15/2022] [Accepted: 09/20/2022] [Indexed: 11/25/2022] Open
Abstract
Statins are lipid-lowering medications used for the prevention of cardiovascular disease (CVD), but the pleiotropic effects of statins might be beneficial in other chronic diseases. This meta-analysis investigated the association between statin use and mortality in different chronic conditions. Eligible studies were real-world studies that compared all-cause mortality over at least 12 months between propensity score-matched statin users and non-users. Overall, 54 studies were included: 21 in CVD, 6 in chronic kidney disease, 6 in chronic inflammatory diseases, 3 in cancer, and 18 in other diseases. The risk of all-cause mortality was significantly reduced in statin users (hazard ratio: 0.72, 95% confidence interval: 0.66−0.76). The reduction in mortality risk was similar in CVD studies (0.73, 0.66−0.76) and non-CVD studies (0.70, 0.67−0.79). There were no significant differences in the risk reduction between cohorts with different diseases (p = 0.179). The greatest mortality reduction was seen in studies from Asia (0.61, 0.61−0.73) and the lowest in studies from North America (0.78, 0.73−0.83) and Australia (0.78, 0.62−0.97). There was a significant heterogeneity (I2 = 95%, tau2 = 0.029, p < 0.01). In conclusion, statin use was associated with a significantly reduced risk of all-cause mortality in real-world cohorts with CVD and non-CVD.
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Affiliation(s)
- Marcin M. Nowak
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology at the European Health Center, 05-400 Otwock, Poland
- Correspondence:
| | - Mariusz Niemczyk
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland
| | - Michał Florczyk
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology at the European Health Center, 05-400 Otwock, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology at the European Health Center, 05-400 Otwock, Poland
| | - Leszek Pączek
- Department of Immunology, Transplant Medicine and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland
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Silverdal J, Sjöland H, Pivodic A, Dahlström U, Fu M, Bollano E. Prognostic differences in long-standing vs. recent-onset dilated cardiomyopathy. ESC Heart Fail 2022; 9:1294-1303. [PMID: 35132793 PMCID: PMC8934954 DOI: 10.1002/ehf2.13816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 12/23/2021] [Accepted: 01/11/2022] [Indexed: 11/24/2022] Open
Abstract
Aims This study aimed to evaluate the outcome and prognostic factors in patients with dilated cardiomyopathy (DCM) and long‐standing heart failure (LDCM) vs. recent‐onset heart failure (RODCM). Methods and results We compared 2019 patients with RODCM (duration <6 months, mean age 58.6 years, 70.7% male) with 1714 patients with LDCM (duration ≥6 months, median duration 3.5 years, mean age 62.5 years, 73.7% male) included in the Swedish Heart Failure Registry in the years 2003–16. Outcome measures were all‐cause, cardiovascular (CV), and non‐CV death and hospitalizations; heart transplantation; and a combined outcome of all‐cause death, heart transplantation, or heart failure (HF) hospitalization. Multivariable risk factor analyses were performed for the combined endpoint. All outcomes were more frequent in LDCM than in RODCM. The multivariable‐adjusted hazard ratios (HRs) (95% confidence interval) for LDCM vs. RODCM were 1.56 (1.34–1.82), P < 0.0001, for all‐cause death over a median follow‐up of 4.2 and 5.0 years, respectively; 1.67 (1.36–2.05), P < 0.0001, for CV death; 2.12 (1.14–3.91), P < 0.0001, for heart transplantation; 1.36 (1.21–1.53), P < 0.0001, for HF hospitalization; and 1.37 (1.24–1.52), P < 0.0001, for the combined outcome. A propensity score‐matched analysis yielded similar results. CV death was the main cause of mortality in LDCM and was higher in LDCM than in RODCM (P < 0.0001). Almost all co‐morbidities were significantly more frequent in LDCM than in RODCM, and the mean number of co‐morbidities increased significantly with increased duration of disease, also after age adjustment. Age, New York Heart Association functional class, ejection fraction, and left bundle branch block were prognostically adverse. The only co‐morbidity associated with the combined outcome regardless of HF duration was diabetes, in LDCM [HR 1.34 (1.15–1.56), P = 0.0002] and in RODCM [HR 1.29 (1.04–1.59), P = 0.018]. Male sex [HR 1.38 (1.18–1.63), P < 0.0001] and aspirin use [HR 1.33 (1.14–1.55), P = 0.0004] carried increased risk only in RODCM. Heart rate ≥75 b.p.m. [HR 1.20 (1.04–1.37), P = 0.01], atrial fibrillation [HR 1.24 (1.08–1.42), P = 0.0024], musculoskeletal or connective tissue disorder [HR 1.36 (1.13–1.63), P = 0.0014], and diuretic therapy [HR 1.40 (1.17–1.67), P = 0.0002] were prognostically adverse only in LDCM. Conclusions This nationwide study of patients with DCM demonstrates that longer disease duration is associated with worse prognosis. Co‐morbidities are more common in long‐standing HF than in recent‐onset HF and are associated with worse outcome. With the increased survival seen in the last decades, our results highlight the importance of careful attention to co‐morbid conditions in patients with DCM.
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Affiliation(s)
- Jonas Silverdal
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helen Sjöland
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Entela Bollano
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Napoli C, Bontempo P, Palmieri V, Coscioni E, Maiello C, Donatelli F, Benincasa G. Epigenetic Therapies for Heart Failure: Current Insights and Future Potential. Vasc Health Risk Manag 2021; 17:247-254. [PMID: 34079271 PMCID: PMC8164213 DOI: 10.2147/vhrm.s287082] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/29/2021] [Indexed: 12/20/2022] Open
Abstract
Despite the current reductionist approach providing an optimal indication for diagnosis and treatment of patients with heart failure with reduced ejection fraction (HFrEF), there are no standard pharmacological therapies for heart failure with preserved ejection fraction (HFpEF). Although in its infancy in cardiovascular diseases, the epigenetic-based therapy ("epidrugs") is capturing the interest of physician community. In fact, an increasing number of controlled clinical trials is evaluating the putative beneficial effects of: 1) direct epigenetic-oriented drugs, eg, apabetalone, and 2) repurposed drugs with a possible indirect epigenetic interference, eg, metformin, statins, sodium glucose transporter inhibitors 2 (SGLT2i), and omega 3 polyunsaturated fatty acids (PUFAs) in both HFrEF and HFpEF, separately. Apabetalone is the first and unique direct epidrug tested in cardiovascular patients to date, and the BETonMACE trial has reported a reduction in first HF hospitalization (any EF value) and cardiovascular death in patients with type 2 diabetes and recent acute coronary syndrome, suggesting a possible role in secondary prevention. Patients with HFpEF seem to benefit from supplementation to the standard therapy with statins, metformin, and SGLT2i owing to their ability in reducing mortality. In contrast, the vasodilator hydralazine, with or without isosorbide dinitrate, did not provide beneficial effects. In HFrEF, metformin and SGLT2i could reduce the risk of incident HF and mortality in affected patients whereas clinical trials based on statins provided mixed results. Furthermore, PUFAs diet supplementation was significantly associated with reduced cardiovascular risk in both HFpEF and HFrEF. Future large trials will reveal whether direct and indirect epitherapy will remain a work in progress or become a useful way to customize the therapy in the real-world management of HFpEF and HFrEF. Our goal is to discuss the recent advancement in the epitherapy as a possible way to improve personalized therapy of HF.
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Affiliation(s)
- Claudio Napoli
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, 80138, Italy
| | - Paola Bontempo
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, 80138, Italy
| | - Vittorio Palmieri
- Department of Cardiac Surgery and Transplantation, Heart Transplantation Unit in Adults of the 'Ospedali dei Colli Monaldi-Cotugno-CTO', Naples, Italy
| | - Enrico Coscioni
- Department of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Ciro Maiello
- Department of Cardiovascular Surgery and Transplants, Monaldi Hospital, Azienda dei Colli, Naples, Italy
| | - Francesco Donatelli
- Chair of Cardiac Surgery, Department of Cardiothoracic Center, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Giuditta Benincasa
- Department of Advanced Medical and Surgical Sciences (DAMSS), University of Campania "Luigi Vanvitelli", Naples, 80138, Italy
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Techorueangwiwat C, Kanitsoraphan C, Hansrivijit P. Therapeutic implications of statins in heart failure with reduced ejection fraction and heart failure with preserved ejection fraction: a review of current literature. F1000Res 2021; 10:16. [PMID: 36873456 PMCID: PMC9982192 DOI: 10.12688/f1000research.28254.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 11/20/2022] Open
Abstract
Statins are one of the standard treatments to prevent cardiovascular events such as coronary artery disease and heart failure (HF). However, data on the use of statins to improve clinical outcomes in patients with established HF remains controversial. We summarized available clinical studies which investigated the effects of statins on clinical outcomes in patients with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Statins possess many pleiotropic effects in addition to lipid-lowering properties that positively affect the pathophysiology of HF. In HFrEF, data from two large randomized placebo-controlled trials did not show benefits of statins on mortality of patients with HFrEF. However, more recent prospective cohort studies and meta-analyses have shown decreased risk of mortality as well as cardiovascular hospitalization with statins treatment. In HFpEF, most prospective and retrospective cohort studies as well as meta analyses have consistently reported positive effects of statins, including reducing mortality and improving other clinical outcomes. Current evidence also suggests better outcomes with lipophilic statins in patients with HF. In summary, statins might be effective in improving survival and other clinical outcomes in patients with HF, especially for patients with HFpEF. Lipophilic statins might also be more beneficial for HF patients. Based on current evidence, statins did not cause harm and should be continued in HF patients who are already taking the medication. Further randomized controlled trials are needed to clarify the benefits of statins in HF patients.
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12
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Packer M, Lam CS, Lund LH, Maurer MS, Borlaug BA. Characterization of the inflammatory-metabolic phenotype of heart failure with a preserved ejection fraction: a hypothesis to explain influence of sex on the evolution and potential treatment of the disease. Eur J Heart Fail 2020; 22:1551-1567. [PMID: 32441863 PMCID: PMC7687188 DOI: 10.1002/ejhf.1902] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/05/2020] [Accepted: 05/17/2020] [Indexed: 12/11/2022] Open
Abstract
Accumulating evidence points to the existence of an inflammatory-metabolic phenotype of heart failure with a preserved ejection fraction (HFpEF), which is characterized by biomarkers of inflammation, an expanded epicardial adipose tissue mass, microvascular endothelial dysfunction, normal-to-mildly increased left ventricular volumes and systolic blood pressures, and possibly, altered activity of adipocyte-associated inflammatory mediators. A broad range of adipogenic metabolic and systemic inflammatory disorders - e.g. obesity, diabetes and metabolic syndrome as well as rheumatoid arthritis and psoriasis - can cause this phenotype, independent of the presence of large vessel coronary artery disease. Interestingly, when compared with men, women are both at greater risk of and may suffer greater cardiac consequences from these systemic inflammatory and metabolic disorders. Women show disproportionate increases in left ventricular filling pressures following increases in central blood volume and have greater arterial stiffness than men. Additionally, they are particularly predisposed to epicardial and intramyocardial fat expansion and imbalances in adipocyte-associated proinflammatory mediators. The hormonal interrelationships seen in inflammatory-metabolic phenotype may explain why mineralocorticoid receptor antagonists and neprilysin inhibitors may be more effective in women than in men with HFpEF. Recognition of the inflammatory-metabolic phenotype may improve an understanding of the pathogenesis of HFpEF and enhance the ability to design clinical trials of interventions in this heterogeneous syndrome.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical CenterDallasTXUSA
- Imperial College LondonLondonUK
| | - Carolyn S.P. Lam
- National Heart Centre Singapore and Duke‐National University of SingaporeSingapore
- University Medical Centre GroningenGroningenThe Netherlands
- The George Institute for Global HealthSydneyAustralia
| | - Lars H. Lund
- Department of Medicine, Karolinska Institutet and Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
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Vieira JL, Pfeffer M, Claggett BL, Stewart GC, Givertz MM, Coakley L, Mallidi HR, Mehra MR. The impact of statin therapy on neurological events following left ventricular assist system implantation in advanced heart failure. J Heart Lung Transplant 2020; 39:582-592. [DOI: 10.1016/j.healun.2020.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 11/28/2022] Open
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Bielecka-Dabrowa A, Bytyçi I, Von Haehling S, Anker S, Jozwiak J, Rysz J, Hernandez AV, Bajraktari G, Mikhailidis DP, Banach M. Association of statin use and clinical outcomes in heart failure patients: a systematic review and meta-analysis. Lipids Health Dis 2019; 18:188. [PMID: 31672151 PMCID: PMC6822388 DOI: 10.1186/s12944-019-1135-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/16/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The role of statins in patients with heart failure (HF) of different levels of left ventricular ejection fraction (LVEF) remains unclear especially in the light of the absence of prospective data from randomized controlled trials (RCTs) in non-ischemic HF, and taking into account potential statins' prosarcopenic effects. We assessed the association of statin use with clinical outcomes in patients with HF. METHODS We searched PubMed, EMBASE, Scopus, Google Scholar and Cochrane Central until August 2018 for RCTs and prospective cohorts comparing clinical outcomes with statin vs non-statin use in patients with HF at different LVEF levels. We followed the guidelines of the 2009 PRISMA statement for reporting and applied independent extraction by multiple observers. Meta-analyses of hazard ratios (HRs) of effects of statins on clinical outcomes used generic inverse variance method and random model effects. Clinical outcomes were all-cause mortality, cardiovascular (CV) mortality and CV hospitalization. RESULTS Finally we included 17 studies (n = 88,100; 2 RCTs and 15 cohorts) comparing statin vs non-statin users (mean follow-up 36 months). Compared with non-statin use, statin use was associated with lower risk of all-cause mortality (HR 0.77, 95% confidence interval [CI], 0.72-0.83, P < 0.0001, I2 = 63%), CV mortality (HR 0.82, 95% CI: 0.76-0.88, P < 0.0001, I2 = 63%), and CV hospitalization (HR 0.78, 95% CI: 0.69-0.89, P = 0.0003, I2 = 36%). All-cause mortality was reduced on statin therapy in HF with both EF < 40% and ≥ 40% (HR: 0.77, 95% Cl: 0.68-0.86, P < 0.00001, and HR 0.75, 95% CI: 0.69-0.82, P < 0.00001, respectively). Similarly, CV mortality (HR 0.86, 95% CI: 0.79-0.93, P = 0.0003, and HR 0.83, 95% CI: 0.77-0.90, P < 0.00001, respectively), and CV hospitalizations (HR 0.80 95% CI: 0.64-0.99, P = 0.04 and HR 0.76 95% CI: 0.61-0.93, P = 0.009, respectively) were reduced in these EF subgroups. Significant effects on all clinical outcomes were also found in cohort studies' analyses; the effect was also larger and significant for lipophilic than hydrophilic statins. CONCLUSIONS In conclusion, statins may have a beneficial effect on CV outcomes irrespective of HF etiology and LVEF level. Lipophilic statins seem to be much more favorable for patients with heart failure.
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Affiliation(s)
- Agata Bielecka-Dabrowa
- Department of Hypertension, Medical University of Lodz, Rzgowska, 281/289; 93-338, Łódź, Poland
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland
| | - Ibadete Bytyçi
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Republic of Kosovo
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Stephan Von Haehling
- Department of Cardiology and Pneumology, University Medical Center Gottingen (UMG), Gottingen, Germany
| | - Stefan Anker
- Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jacek Jozwiak
- Department of Family Medicine and Public Health, Institute of Medicine, University of Opole, Opole, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, Lodz, Poland
| | - Adrian V Hernandez
- Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, University of Connecticut School of Pharmacy, Storrs, CT, USA
- School of Medicine, Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru
| | - Gani Bajraktari
- Clinic of Cardiology, University Clinical Centre of Kosovo, Prishtina, Republic of Kosovo
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Campus, University College London Medical School, University College London (UCL), London, UK
| | - Maciej Banach
- Department of Hypertension, Medical University of Lodz, Rzgowska, 281/289; 93-338, Łódź, Poland.
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute (PMMHRI), Lodz, Poland.
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Al-Gobari M, Agrinier N, Soudant M, Burnand B, Thilly N. Effects of Statins to Reduce All-Cause Mortality in Heart Failure Patients: Findings from the EPICAL2 Cohort Study. Am J Cardiovasc Drugs 2019; 19:497-508. [PMID: 30972619 DOI: 10.1007/s40256-019-00346-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The addition of statins to standard care in heart failure (HF) patients remains controversial in clinical practice. Large-scale clinical trials failed to show mortality benefits, but uncertainty persists in real-world settings. OBJECTIVE We evaluated whether the prescription of statins at hospital discharge is associated with a reduction in all-cause mortality at up to 1 year of follow-up in HF patients. METHODS We analyzed data from Epidémiologie et Pronostic de l'Insuffisance Cardiaque Aiguë en Lorraine (EPICAL2) cohort study of 2254 hospitalized acute HF patients who were admitted to 21 hospitals located in northeast France for acute HF between October 2011 and October 2012 and who received statins at discharge compared with patients who did not. We used propensity score matching and instrumental variable analyses to estimate the treatment effects of statins, and a multivariable Cox proportional-hazards model to examine survival with statin use, adjusting for patient demographics, HF characteristics, medical history, comorbidities, drug treatment and other known potential confounders. We plotted Kaplan-Meier survivor curves, and used log-rank test to determine the equality of survivor functions. RESULTS We included 2032 patients in this investigation: 919 (45%) in the statin-treated group and 1113 (55%) in the control group. The estimated average statin-treatment effects for all-cause mortality in HF failed to demonstrate a significant effect on mortality [Z = - 1.73, 95% confidence interval (CI) - 0.11 to 0.007, p value = 0.083, and Z = - 0.95, 95% CI - 1.34 to 0.46, p value = 0.34] for propensity score matching and instrumental variable analyses, respectively. Moreover, the Cox proportional-hazards model showed that statin prescription was not significantly associated with the rate of death (hazard ratio = 0.85, 95% CI 0.66-1.11, p value = 0.26), adjusted for all confounders. CONCLUSION In patients with HF (and reduced or preserved ejection fraction), the prescription of statins did not appear to be associated with better survival after 1 year of follow-up in the EPICAL2 cohort. We cannot exclude that a subpopulation of HF patients may have some benefits compared with the whole HF population or that there might be a lack of power to show such effect. CLINICAL TRIAL REGISTRATION NCT02880358.
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Affiliation(s)
- Muaamar Al-Gobari
- Center for Primary Care and Public Health (Unisanté) and Cochrane Switzerland, University of Lausanne, Biopôle 2 SV-A, Route de la Corniche 10, 1010, Lausanne, Switzerland.
- Institute of Family Medicine, University of Fribourg, Fribourg, Switzerland.
| | - Nelly Agrinier
- Inserm, CHRU Nancy, Université de Lorraine, CIC-1433, Epidémiologie Clinique, 54000, Nancy, France
- Université de Lorraine, APEMAC, 54000, Nancy, France
| | - Marc Soudant
- Inserm, CHRU Nancy, Université de Lorraine, CIC-1433, Epidémiologie Clinique, 54000, Nancy, France
- Université de Lorraine, APEMAC, 54000, Nancy, France
| | - Bernard Burnand
- Center for Primary Care and Public Health (Unisanté) and Cochrane Switzerland, University of Lausanne, Biopôle 2 SV-A, Route de la Corniche 10, 1010, Lausanne, Switzerland
| | - Nathalie Thilly
- CHRU Nancy, Université de Lorraine, Plateforme d'Aide à la Recherche Clinique, 54000, Nancy, France
- Université de Lorraine, APEMAC, 54000, Nancy, France
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Zvizdić F, Godinjak A, Durak-Nalbantic A, Rama A, Iglica A, Vucijak-Grgurevic M, Sokolovic S. Impact of Different Types of Statins on Clinical Outcomes in Patients Hospitalized for Ischemic Heart Failure. Med Arch 2019; 72:401-405. [PMID: 30814769 PMCID: PMC6340614 DOI: 10.5455/medarh.2018.72.401-405] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction: The effect of statins on risk of heart failure (HF) hospitalization and lethal outcome remains dubious. Aim: To investigate whether statin therapy improves clinical outcomes in patients hospitalized for ischemic heart failure (HF), to compare the efficacy of lipophilic and hydrophilic statins and to investigate which statin subtype provides better survival and other outcome benefits. Material and Methods: Total amount of 155 patients in the study were admitted to the Clinic for Cardiology, Rheumatology and Vascular diseases in Clinical Center University of Sarajevo in the period from January 2014- December 2017. Inclusion criteria was HF caused by ischemic coronary artery disease upon admission. For each patient the following data were obtained: gender, age, comorbidities and medications on discharge. New York Heart Association (NYHA) class for heart failure was determined by physician evaluation and left ventricle ejection fraction (LVEF) was determined by echocardiography. The patients were followed for a period of two years. Outcome points were: rehospitalization, in-hospital death, mortality after 6 months, 1 year and 2 years. All-cause mortality included cardiovascular events or worsening heart failure. Results: Overall, 58.9% of HF patients received statin therapy, with 33.9% patients receiving atorvastatin and 25.0% rosuvastatin therapy. The most frequent rehospitalization was in patients without statin therapy (66.7%), followed by patients on rosuvastatin (64.1%), and atorvastatin (13.2%), with statistically significant difference p = 0.001 between the groups. Mortality after 6 months, 1 year and 2 years was the most frequent in patients without statin therapy with a statistically significant difference (p = 0.001). Progression of HF accounted for 31.7% of mortality in patients without statin therapy, 12.8% in patients on rosuvastatin therapy and 3.8% in patients on atorvastatin therapy (p = 0.004). Conclusion: Lipophilic statin therapy is associated with substantially better long-term outcomes in patients with HF.
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Affiliation(s)
- Faris Zvizdić
- Department for Cardiology, Clinic for Heart, Vascular Diseases and Rheumatology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Amina Godinjak
- Department for Emergency Medicine, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Azra Durak-Nalbantic
- Department for Cardiology, Clinic for Heart, Vascular Diseases and Rheumatology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Admir Rama
- Bahceci IVF Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Amer Iglica
- Department for Cardiology, Clinic for Heart, Vascular Diseases and Rheumatology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Marina Vucijak-Grgurevic
- Department for Cardiology, Clinic for Heart, Vascular Diseases and Rheumatology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Sekib Sokolovic
- Department for Cardiology, Clinic for Heart, Vascular Diseases and Rheumatology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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Arnold SV, Yap J, Lam CSP, Tang F, Tay WT, Teng THK, McGuire DK, Januzzi JL, Fonarow GC, Masoudi FA, Kosiborod M. Management of patients with diabetes and heart failure with reduced ejection fraction: An international comparison. Diabetes Obes Metab 2019; 21:261-266. [PMID: 30136348 DOI: 10.1111/dom.13511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/14/2018] [Accepted: 08/18/2018] [Indexed: 12/01/2022]
Abstract
AIMS To compare the management of patients with diabetes and heart failure with reduced ejection fraction (HFrEF) in the United States and Asia to understand variations in treatment patterns across different healthcare systems. MATERIALS AND METHODS Our cohort included patients with diabetes and HFrEF (ejection fraction <40%) from a US-based registry of adults with diabetes (2013-2016, electronic health records) and a multi-national Asian registry of adults with heart failure (2010-2016, prospective registry). Asian countries were categorized as high income (HI) or low income (LI), according to the United Nations classification. Rates of use of guideline-directed medical therapies (determined through review of active medication lists) were compared across regions. RESULTS Patients with diabetes and HFrEF in the United States (n = 28 877) were older, had higher body mass indices, and were more likely to have coronary disease than those in Asia (n = 2235). Compared with US patients, the use of guideline-directed medical therapy for HFrEF was lower in patients in LI Asian countries (angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers: patients in the United States, 77% vs. patients in HI Asian countries, 76% vs patients in LI Asian countries, 69%; β-blockers: patients in the United States, 91% vs. patients in HI Asian countries, 87% vs. patients in LI Asian countries, 69%; P < 0.001 for both). Insulin was used more commonly in the United States (44% vs. 24% vs. 25%, respectively; P < 0.001), whereas sulphonylureas were more often prescribed in Asian countries (42% vs. 52% vs. 54%; respectively, P < 0.001). Thiazolidinediones were prescribed in 6% of US patients compared with <1% of patients in Asia. The use of newer diabetes medications was <5% in all. CONCLUSION In both the United States and Asia, opportunities for improvement in the use of evidence-based therapies exist for patients with both diabetes and HFrEF. Effective tools to guide medication choices for these complex, high-risk patients could have substantial impact on quality and outcomes.
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Affiliation(s)
- Suzanne V Arnold
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | | | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
- Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | - Wan T Tay
- National Heart Centre Singapore, Singapore
| | | | | | | | - Gregg C Fonarow
- University of California, Los Angeles, California, Los Angeles
| | | | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
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18
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Marume K, Takashio S, Nagai T, Tsujita K, Saito Y, Yoshikawa T, Anzai T. Effect of Statins on Mortality in Heart Failure With Preserved Ejection Fraction Without Coronary Artery Disease - Report From the JASPER Study. Circ J 2018; 83:357-367. [PMID: 30416189 DOI: 10.1253/circj.cj-18-0639] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Statins might be associated with improved survival in patients with heart failure with preserved ejection fraction (HFpEF). The effect of statins in HFpEF without coronary artery disease (CAD), however, remains unclear. Methods and Results: From the JASPER registry, a multicenter, observational, prospective cohort with Japanese patients aged ≥20 years requiring hospitalization with acute HF and LVEF ≥50%, 414 patients without CAD were selected for outcome analysis. Based on prescription of statins at admission, we divided patients into the statin group (n=81) or no statin group (n=333). We followed them for 25 months. The association between statin use and primary (all-cause mortality) and secondary (non-cardiac death, cardiac death, or rehospitalization for HF) endpoints was assessed in the entire cohort and in a propensity score-matched cohort. In the propensity score-matched cohort, 3-year mortality was lower in the statin group (HR, 0.21; 95% CI: 0.06-0.72; P=0.014). The statin group had a significantly lower incidence of non-cardiac death (P=0.028) and rehospitalization for HF (P<0.001), but not cardiac death (P=0.593). The beneficial effect of statins on mortality did not have any significant interaction with cholesterol level or HF severity. CONCLUSIONS Statin use has a beneficial effect on mortality in HFpEF without CAD. The present findings should be tested in an adequately powered randomized clinical trial.
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Affiliation(s)
- Kyohei Marume
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine.,Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Yoshihiko Saito
- First Department of Internal Medicine, Nara Medical University
| | | | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine.,Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Tsai TH, Lin CJ, Chua S, Chung SY, Chen SM, Lee CH, Hang CL. Deletion of RasGRF1 Attenuated Interstitial Fibrosis in Streptozotocin-Induced Diabetic Cardiomyopathy in Mice through Affecting Inflammation and Oxidative Stress. Int J Mol Sci 2018; 19:ijms19103094. [PMID: 30308936 PMCID: PMC6213028 DOI: 10.3390/ijms19103094] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/30/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023] Open
Abstract
Background: Diabetic cardiomyopathy (DCM) is characterized by cardiac fibrosis and stiffness, which often develops into heart failure. This study investigated the role of Ras protein-specific guanine nucleotide releasing factor 1 (RasGRF1) in the development of DCM. Methods: Forty-eight mice were divided into four groups (n = 12 per group): Group 1: Wild-type (WT) mice, Group 2: RasGRF1 deficiency (RasGRF1−/−) mice. Group 3: Streptozotocin (STZ)-induced diabetic WT mice, Group 4: STZ-induced diabetic RasGRF1−/− mice. Myocardial functions were assessed by cardiac echography. Heart tissues from all of the mice were investigated for cardiac fibrosis, inflammation, and oxidative stress markers. Results: Worse impaired diastolic function with elevation serum interleukin (IL)-6 was found in the diabetic group compared with the non-diabetic groups. Serum IL-6 levels were found to be elevated in the diabetic compared with the non-diabetic groups. However, the diabetic RasGRF1−/− mice exhibited lower serum IL-6 levels and better diastolic function than the diabetic WT mice. The diabetic RasGRF1−/− mice were associated with reduced cardiac inflammation, which was shown by lower invading inflammation cells, lower expression of matrix metalloproteinase 9, and less chemokines compared to the diabetic WT mice. Furthermore, less oxidative stress as well as extracellular matrix deposition leading to a reduction in cardiac fibrosis was also found in the diabetic RasGRF1−/− mice compared with the diabetic WT mice. Conclusion: The deletion of RasGRF1 attenuated myocardial fibrosis and improved cardiac function in diabetic mice through inhibiting inflammation and oxidative stress.
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Affiliation(s)
- Tzu-Hsien Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan.
| | - Cheng-Jei Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Sarah Chua
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Sheng-Ying Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Shyh-Ming Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Chien-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
| | - Chi-Ling Hang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan.
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Rush CJ, Campbell RT, Jhund PS, Petrie MC, McMurray JJV. Association is not causation: treatment effects cannot be estimated from observational data in heart failure. Eur Heart J 2018; 39:3417-3438. [PMID: 30085087 PMCID: PMC6166137 DOI: 10.1093/eurheartj/ehy407] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/01/2018] [Accepted: 06/27/2018] [Indexed: 12/21/2022] Open
Abstract
Aims Treatment 'effects' are often inferred from non-randomized and observational studies. These studies have inherent biases and limitations, which may make therapeutic inferences based on their results unreliable. We compared the conflicting findings of these studies to those of prospective randomized controlled trials (RCTs) in relation to pharmacological treatments for heart failure (HF). Methods and results We searched Medline and Embase to identify studies of the association between non-randomized drug therapy and all-cause mortality in patients with HF until 31 December 2017. The treatments of interest were: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists (MRAs), statins, and digoxin. We compared the findings of these observational studies with those of relevant RCTs. We identified 92 publications, reporting 94 non-randomized studies, describing 158 estimates of the 'effect' of the six treatments of interest on all-cause mortality, i.e. some studies examined more than one treatment and/or HF phenotype. These six treatments had been tested in 25 RCTs. For example, two pivotal RCTs showed that MRAs reduced mortality in patients with HF with reduced ejection fraction. However, only one of 12 non-randomized studies found that MRAs were of benefit, with 10 finding a neutral effect, and one a harmful effect. Conclusion This comprehensive comparison of studies of non-randomized data with the findings of RCTs in HF shows that it is not possible to make reliable therapeutic inferences from observational associations. While trials undoubtedly leave gaps in evidence and enrol selected participants, they clearly remain the best guide to the treatment of patients.
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Affiliation(s)
- Christopher J Rush
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Ross T Campbell
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
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Keller SF, Rai SK, Lu N, Oza A, Jorge AM, Zhang Y, Choi HK. Statin use and mortality in gout: A general population-based cohort study. Semin Arthritis Rheum 2018; 48:449-455. [PMID: 29801703 DOI: 10.1016/j.semarthrit.2018.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 03/02/2018] [Accepted: 03/14/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Gout is associated with a higher risk of cardiovascular disease and premature mortality. We examined the potential survival benefit of statin use among gout patients in the general population. METHODS We performed an incident user cohort study with time-stratified propensity score matching using a database representative of the UK general population between January 1999 and December 2014. To account for potential confounders, we compared propensity score-matched cohorts of statin initiators and non-initiators within 1-year cohort accrual blocks. We estimated the hazard ratio (HR) for mortality using a Cox proportional hazard model and the mortality rate difference using an additive hazard model. We examined potential subgroup effects stratified by key factors, including circulatory disease history. RESULTS Among 17,018 statin initiators, 2025 deaths occurred during the follow-up (mean = 5.0 years) with a mortality rate of 24.0/1000 person-years (PY). The number of deaths and all-cause mortality rate among matched comparators during the follow-up (mean = 4.6 years) were 2503 and 31.7/1000 PY respectively. Compared with non-initiators, statin initiators experienced a 16% lower relative risk of all-cause mortality (HR = 0.84, 95% CI: 0.79-0.89) and 7.7 (95% CI: 6.1-9.3) fewer deaths per 1000 PY. This protective association was stronger among those without prior circulatory disease (HRs = 0.65 vs. 0.85; p for interaction = 0.02). CONCLUSION In this general population-based cohort study, statin initiation was associated with a lower risk of mortality in gout, potentially with greater benefits among those without prior circulatory disease. The proper use of statins may help to substantially improve the premature mortality in gout.
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Affiliation(s)
- Sarah F Keller
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Bulfinch 165, Boston, MA 02114.
| | - Sharan K Rai
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Bulfinch 165, Boston, MA 02114
| | - Na Lu
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Bulfinch 165, Boston, MA 02114; Clinical Epidemiology Unit, Boston University School of Medicine, 650 Albany Street, Suite X-200, Boston, MA 02118
| | - Amar Oza
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Bulfinch 165, Boston, MA 02114
| | - April M Jorge
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Bulfinch 165, Boston, MA 02114
| | - Yuqing Zhang
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Bulfinch 165, Boston, MA 02114; Clinical Epidemiology Unit, Boston University School of Medicine, 650 Albany Street, Suite X-200, Boston, MA 02118
| | - Hyon K Choi
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Bulfinch 165, Boston, MA 02114
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22
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Cho J, Park IB, Lee K, Ahn TH, Park WB, Kim JH, Ahn Y, Jeong MH, Lee DH. Statin has more protective effects in AMI patients with higher plasma BNP or NT-proBNP level, but not with lower left ventricular ejection fraction. J Cardiol 2017; 71:375-381. [PMID: 29158023 DOI: 10.1016/j.jjcc.2017.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/04/2017] [Accepted: 10/13/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND The benefit of statin therapy in patients with higher grades of heart failure has yet to be determined. The present study investigated whether statin therapy affects major composite outcomes (MCOs) and all-cause mortality in patients with acute myocardial infarction (AMI) within 1 year after AMI, according to their plasma natriuretic peptide (NP) levels and left ventricular ejection fraction (LVEF). METHODS A total of 11,492 patients with AMI from two nationwide registry databases in Korea were analyzed. AMI patients were divided into quartiles by plasma levels of B-type NP (BNP) or N-terminal pro-BNP (NT-proBNP) at admission. Patients with LVEF <40% on initial echocardiography were also evaluated. Total mortality and MCOs within 12 months of AMI, including death, nonfatal MI, and revascularization, were assessed. RESULTS Among AMI patients, statin therapy was included in the discharge medications for 9075 (79.0%) patients, but not for the remaining 2417 patients (21.0%), and statin therapy was associated with a 27.8% lower risk of MCOs. After adjusting for risk factors, statin therapy was associated with lower hazard ratios for MCOs and all-cause mortality in only the third and fourth NP quartile subgroups, being effective only with moderate- to high-intensity statin therapy. However, statins did not modify the outcomes in patients with LVEF <40%. CONCLUSIONS Our results show that moderate- to high-intensity statin therapy was associated with a lower risk of major clinical outcomes and all-cause mortality in AMI patients with higher plasma NP, but not in AMI patients with decreased LVEF.
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Affiliation(s)
- Jaelim Cho
- Department of Occupational and Environmental Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Ie Byung Park
- Department of Internal Medicine, Gachon University College of Medicine, Incheon, Republic of Korea; Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Kiyoung Lee
- Department of Internal Medicine, Gachon University College of Medicine, Incheon, Republic of Korea; Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Tae Hoon Ahn
- Department of Internal Medicine, Gachon University College of Medicine, Incheon, Republic of Korea; Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Won Bin Park
- Deparment of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea; Department of Emergency Medical Service, College of Health Science, Gachon University, Incheon, Republic of Korea
| | - Ju Han Kim
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Youngkeun Ahn
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Myung Ho Jeong
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Dae Ho Lee
- Department of Internal Medicine, Gachon University College of Medicine, Incheon, Republic of Korea; Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea; Lee Gil Ya Cancer and Diabetes Institute, Incheon, Gachon University, Incheon, Republic of Korea.
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23
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Catapano AL, Pirillo A, Norata GD. Targeting Cholesterol in Non-ischemic Heart Failure: A Role for LDLR Gene Therapy? Mol Ther 2017; 25:2435-2437. [PMID: 29056399 DOI: 10.1016/j.ymthe.2017.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Affiliation(s)
- Alberico Luigi Catapano
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy; IRCCS Multimedica Hospital, Sesto San Giovanni, Milan, Italy
| | - Angela Pirillo
- IRCCS Multimedica Hospital, Sesto San Giovanni, Milan, Italy; Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Giuseppe Danilo Norata
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Milan, Italy; Center for the Study of Atherosclerosis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy; School of Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia.
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24
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Vedin O, Lam CSP, Koh AS, Benson L, Teng THK, Tay WT, Braun OÖ, Savarese G, Dahlström U, Lund LH. Significance of Ischemic Heart Disease in Patients With Heart Failure and Preserved, Midrange, and Reduced Ejection Fraction: A Nationwide Cohort Study. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.003875. [PMID: 28615366 DOI: 10.1161/circheartfailure.117.003875] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pathogenic role of ischemic heart disease (IHD) in heart failure (HF) with reduced ejection fraction (HFrEF; EF <40%) is well established, but its pathogenic and prognostic significance in HF with midrange (HFmrEF; EF 40%-50%) and preserved EF (HFpEF; EF ≥50%) has been much less explored. METHODS AND RESULTS We evaluated 42 987 patients from the Swedish Heart Failure Registry with respect to baseline IHD, outcomes (IHD, HF, cardiovascular events, and all-cause death), and EF change during a median follow-up of 2.2 years. Overall, 23% had HFpEF (52% IHD), 21% had HFmrEF (61% IHD), and 55% had HFrEF (60% IHD). After multivariable adjustment, associations with baseline IHD were similar for HFmrEF and HFrEF and lower in HFpEF (risk ratio, 0.91 [0.89-0.93] versus HFmrEF and risk ratio, 0.90 [0.88-0.92] versus HFrEF). The adjusted risk of IHD events was similar for HFmrEF versus HFrEF and lower in HFpEF (hazard ratio, 0.89 [0.84-0.95] versus HFmrEF and hazard ratio, 0.84 [0.80-0.90] versus HFrEF). After adjustment, prevalent IHD was associated with increased risk of IHD events and all other outcomes in all EF categories except all-cause mortality in HFpEF. Those with IHD, particularly new IHD events, were also more likely to change to a lower EF category and less likely to change to a higher EF category over time. CONCLUSIONS HFmrEF resembled HFrEF rather than HFpEF with regard to both a higher prevalence of IHD and a greater risk of new IHD events. Established IHD was an important prognostic factor across all HF types.
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Affiliation(s)
- Ola Vedin
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden.
| | - Carolyn S P Lam
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Angela S Koh
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Lina Benson
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Tiew Hwa Katherine Teng
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Wan Ting Tay
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Oscar Ö Braun
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Gianluigi Savarese
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Ulf Dahlström
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Lars H Lund
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
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25
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Abstract
Most elderly patients, particularly women, who have heart failure, have a preserved ejection fraction. Patients with this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. Despite the importance of heart failure with preserved ejection fraction (HFpEF), the understanding of its pathophysiology is incomplete, and optimal treatment remains largely undefined. Unlike the management of HFrEF, there is a paucity of large evidence-based trials demonstrating morbidity and mortality benefit for the treatment of HFpEF. An update is presented on information regarding pathophysiology, diagnosis, management, and future directions in this important and growing disorder.
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Affiliation(s)
- Bharathi Upadhya
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA
| | - Dalane W Kitzman
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC 27101, USA.
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26
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Bonsu KO, Owusu IK, Buabeng KO, Reidpath DD, Kadirvelu A. Statin Treatment and Clinical Outcomes of Heart Failure Among Africans: An Inverse Probability Treatment Weighted Analysis. J Am Heart Assoc 2017; 6:JAHA.116.004706. [PMID: 28365564 PMCID: PMC5532994 DOI: 10.1161/jaha.116.004706] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Randomized control trials of statins have not demonstrated significant benefits in outcomes of heart failure (HF). However, randomized control trials may not always be generalizable. The aim was to determine whether statin and statin type–lipophilic or –hydrophilic improve long‐term outcomes in Africans with HF. Methods and Results This was a retrospective longitudinal study of HF patients aged ≥18 years hospitalized at a tertiary healthcare center between January 1, 2009 and December 31, 2013 in Ghana. Patients were eligible if they were discharged from first admission for HF (index admission) and followed up to time of all‐cause, cardiovascular, and HF mortality or end of study. Multivariable time‐dependent Cox model and inverse‐probability‐of‐treatment weighting of marginal structural model were used to estimate associations between statin treatment and outcomes. Adjusted hazard ratios were also estimated for lipophilic and hydrophilic statin compared with no statin use. The study included 1488 patients (mean age 60.3±14.2 years) with 9306 person‐years of observation. Using the time‐dependent Cox model, the 5‐year adjusted hazard ratios with 95% CI for statin treatment on all‐cause, cardiovascular, and HF mortality were 0.68 (0.55–0.83), 0.67 (0.54–0.82), and 0.63 (0.51–0.79), respectively. Use of inverse‐probability‐of‐treatment weighting resulted in estimates of 0.79 (0.65–0.96), 0.77 (0.63–0.96), and 0.77 (0.61–0.95) for statin treatment on all‐cause, cardiovascular, and HF mortality, respectively, compared with no statin use. Conclusions Among Africans with HF, statin treatment was associated with significant reduction in mortality.
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Affiliation(s)
- Kwadwo Osei Bonsu
- School of Medicine and Health Sciences, Monash University, Bandar Sunway, Malaysia .,Accident and Emergency Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Isaac Kofi Owusu
- Directorate of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Medicine, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kwame Ohene Buabeng
- Department of Pharmacy Practice, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Daniel D Reidpath
- School of Medicine and Health Sciences, Monash University, Bandar Sunway, Malaysia
| | - Amudha Kadirvelu
- School of Medicine and Health Sciences, Monash University, Bandar Sunway, Malaysia
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27
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Fröhlich H, Raman N, Täger T, Schellberg D, Goode KM, Kazmi S, Grundtvig M, Hole T, Cleland JGF, Katus HA, Agewall S, Clark AL, Atar D, Frankenstein L. Statins attenuate but do not eliminate the reverse epidemiology of total serum cholesterol in patients with non-ischemic chronic heart failure. Int J Cardiol 2017; 238:97-104. [PMID: 28342630 DOI: 10.1016/j.ijcard.2017.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 03/01/2017] [Accepted: 03/08/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND In patients with chronic heart failure (CHF) increasing levels of total serum cholesterol are associated with improved survival - while statin usage is not. The impact of statin treatment on the "reverse epidemiology" of cholesterol is unclear. METHODS 2992 consecutive patients with non-ischemic CHF due to left ventricular systolic dysfunction from the Norwegian CHF Registry and the CHF Registries of the Universities of Hull, UK, and Heidelberg, Germany, were studied. 1736 patients were individually double-matched on both cholesterol levels and the individual propensity scores for statin treatment. All-cause mortality was analyzed as a function of baseline cholesterol and statin use in both the general and the matched sample. RESULTS 1209 patients (40.4%) received a statin. During a follow-up of 13,740 patient-years, 360 statin users (29.8%) and 573 (32.1%) statin non-users died. When grouped according to total cholesterol levels as low (≤3.6mmol/L), moderate (3.7-4.9mmol/L), high (4.8-6.2mmol/L), and very high (>6.2mmol/L), we found improved survival with very high as compared with low cholesterol levels. This association was present in statin users and non-users in both the general and matched sample (p<0.05 for each group comparison). The negative association of total cholesterol and mortality persisted when cholesterol was treated as a continuous variable (HR 0.83, 95%CI 0.77-0.90, p<0.001 for matched patients), but it was less pronounced in statin users than in non-users (F-test p<0.001). CONCLUSIONS Statins attenuate but do not eliminate the reverse epidemiological association between increasing total serum cholesterol and improved survival in patients with non-ischemic CHF.
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Affiliation(s)
- Hanna Fröhlich
- University Hospital Heidelberg, Department of Cardiology, Angiology and Pulmology. Im Neuenheimer Feld 410, 69221 Heidelberg, Germany
| | - Nandita Raman
- University Hospital Heidelberg, Department of Cardiology, Angiology and Pulmology. Im Neuenheimer Feld 410, 69221 Heidelberg, Germany
| | - Tobias Täger
- University Hospital Heidelberg, Department of Cardiology, Angiology and Pulmology. Im Neuenheimer Feld 410, 69221 Heidelberg, Germany
| | - Dieter Schellberg
- University Hospital Heidelberg, Department of Cardiology, Angiology and Pulmology. Im Neuenheimer Feld 410, 69221 Heidelberg, Germany
| | - Kevin M Goode
- Castle Hill Hospital, Hull York Medical School in the University of Hull, Cottingham HU165JQ, United Kingdom
| | - Syed Kazmi
- Castle Hill Hospital, Hull York Medical School in the University of Hull, Cottingham HU165JQ, United Kingdom
| | - Morten Grundtvig
- Medical Department, Innlandet Hospital Trust Division Lillehammer, Anders Sandvigs gate 17, 2609 Lillehammer, Norway
| | - Torstein Hole
- Medical Faculty, Norwegian University of Science and Technology (NTNU), Trondheim, Norway & Medical Clinic, Helse Møre and Romsdal CHF, Åsehaugen 1, 6017 Ålesund, Norway
| | - John G F Cleland
- National Heart & Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, SW72AZ London, United Kingdom
| | - Hugo A Katus
- University Hospital Heidelberg, Department of Cardiology, Angiology and Pulmology. Im Neuenheimer Feld 410, 69221 Heidelberg, Germany
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Andrew L Clark
- Castle Hill Hospital, Hull York Medical School in the University of Hull, Cottingham HU165JQ, United Kingdom
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital, Ulleval and Institute of Clinical Sciences, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Lutz Frankenstein
- University Hospital Heidelberg, Department of Cardiology, Angiology and Pulmology. Im Neuenheimer Feld 410, 69221 Heidelberg, Germany.
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28
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Lund LH, Carrero JJ, Farahmand B, Henriksson KM, Jonsson Å, Jernberg T, Dahlström U. Association between enrolment in a heart failure quality registry and subsequent mortality-a nationwide cohort study. Eur J Heart Fail 2017; 19:1107-1116. [DOI: 10.1002/ejhf.762] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/28/2016] [Indexed: 12/28/2022] Open
Affiliation(s)
- Lars H. Lund
- Department of Medicine, Karolinska Institute; Stockholm Sweden
- Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
| | - Juan-Jesus Carrero
- Department of Clinical Science; Intervention and Technology, Karolinska Institute; Stockholm Sweden
| | | | - Karin M. Henriksson
- Department of Medical Sciences; Uppsala University; Uppsala Sweden
- AstraZeneca RD; Mölndal Sweden
| | - Åsa Jonsson
- Department of Medicine, Division of Cardiology; County Hospital Ryhov; Jönköping Sweden
| | - Tomas Jernberg
- Department of Cardiology; Karolinska University Hospital; Stockholm Sweden
- Department of Medical Epidemiology and Biostatistics; Karolinska Institute; Stockholm Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Medical and Health Sciences; Linköping University; Linköping Sweden
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29
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Abstract
Comorbidities frequently accompany chronic heart failure (HF), contributing to increased morbidity and mortality, and an impaired quality of life. We describe the prevalence of several high-impact comorbidities in chronic HF patients and their impact on morbidity and mortality. Furthermore, we try to explain the underlying pathophysiological processes and the complex interaction between chronic HF and specific comorbidities. Although common risk factors are likely to contribute, it is reasonable to believe that factors associated with HF might cause other comorbidities and vice versa. Potential factors are inflammation, neurohormonal activation, and hemodynamic changes.
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30
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Schoenfeld SR, Lu L, Rai SK, Seeger JD, Zhang Y, Choi HK. Statin use and mortality in rheumatoid arthritis: a general population-based cohort study. Ann Rheum Dis 2016; 75:1315-20. [PMID: 26245753 PMCID: PMC5399680 DOI: 10.1136/annrheumdis-2015-207714] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 07/20/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Dual lipid-lowering and anti-inflammatory properties of statins may lead to survival benefits in patients with rheumatoid arthritis (RA). However, data on this topic are limited, and the role of statins in RA remains unclear. OBJECTIVES To examine the association of statin use with overall mortality among patients with RA in a general population context. METHODS We conducted an incident user cohort study with time-stratified propensity score matching using a UK general population database. The study population included individuals aged ≥20 years who had a diagnosis of RA and had used at least one disease-modifying antirheumatic drug (DMARD) between January 2000 and December 2012. To closely account for potential confounders, we compared propensity score matched cohorts of statin initiators and comparators (non-initiators) within 1-year cohort accrual blocks. RESULTS 432 deaths occurred during follow-up (mean 4.51 years) of the 2943 statin initiators for an incidence rate of 32.6/1000 person-years (PY), while the 513 deaths among 2943 matched comparators resulted in an incidence rate of 40.6/1000 PY. Baseline characteristics were well-balanced across the two groups. Statin initiation was associated with a 21% lower risk of all-cause mortality (HR=0.79, 95% CI 0.68 to 0.91). When we defined RA by its diagnosis code alone (not requiring DMARD use), the corresponding HR was 0.81 (95% CI 0.74 to 0.90). CONCLUSIONS Statin initiation is associated with a lower risk of mortality among patients with RA. The magnitude of association is similar to that seen in previous randomised trials among the general population.
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Affiliation(s)
- Sara R. Schoenfeld
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Leo Lu
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Clinical Epidemiology Unit, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Sharan K. Rai
- Arthritis Research Centre of Canada, University of British Columbia, Vancouver, Canada
| | - John D. Seeger
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Yuqing Zhang
- Clinical Epidemiology Unit, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Hyon K. Choi
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
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31
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Bonsu KO, Owusu IK, Buabeng KO, Reidpath DD, Kadirvelu A. Review of novel therapeutic targets for improving heart failure treatment based on experimental and clinical studies. Ther Clin Risk Manag 2016; 12:887-906. [PMID: 27350750 PMCID: PMC4902145 DOI: 10.2147/tcrm.s106065] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is a major public health priority due to its epidemiological transition and the world's aging population. HF is typified by continuous loss of contractile function with reduced, normal, or preserved ejection fraction, elevated vascular resistance, fluid and autonomic imbalance, and ventricular dilatation. Despite considerable advances in the treatment of HF over the past few decades, mortality remains substantial. Pharmacological treatments including β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and aldosterone antagonists have been proven to prolong the survival of patients with HF. However, there are still instances where patients remain symptomatic, despite optimal use of existing therapeutic agents. This understanding that patients with chronic HF progress into advanced stages despite receiving optimal treatment has increased the quest for alternatives, exploring the roles of additional pathways that contribute to the development and progression of HF. Several pharmacological targets associated with pathogenesis of HF have been identified and novel therapies have emerged. In this work, we review recent evidence from proposed mechanisms to the outcomes of experimental and clinical studies of the novel pharmacological agents that have emerged for the treatment of HF.
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Affiliation(s)
- Kwadwo Osei Bonsu
- School of Medicine and Health Sciences, Monash University Sunway Campus, Jalan Lagoon Selatan, Bandar Sunway, Subang Jaya, Selangor, Malaysia
- Accident and Emergency Directorate, Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Isaac Kofi Owusu
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kwame Ohene Buabeng
- Department of Clinical and Social Pharmacy, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Daniel Diamond Reidpath
- School of Medicine and Health Sciences, Monash University Sunway Campus, Jalan Lagoon Selatan, Bandar Sunway, Subang Jaya, Selangor, Malaysia
| | - Amudha Kadirvelu
- School of Medicine and Health Sciences, Monash University Sunway Campus, Jalan Lagoon Selatan, Bandar Sunway, Subang Jaya, Selangor, Malaysia
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32
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Won J, Hong YJ, Jeong MH, Park HJ, Kim MC, Kim WJ, Kim HK, Sim DS, Kim JH, Ahn Y, Cho JG, Park JC. Comparative Effects of Statin Therapy versus Renin-Angiotensin System Blocking Therapy in Patients with Ischemic Heart Failure Who Underwent Percutaneous Coronary Intervention. Chonnam Med J 2016; 52:128-35. [PMID: 27231678 PMCID: PMC4880578 DOI: 10.4068/cmj.2016.52.2.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 03/16/2016] [Accepted: 03/23/2016] [Indexed: 11/29/2022] Open
Abstract
Statins and renin-angiotensin system (RAS) blockers are key drugs for treating patients with an acute myocardial infarction (AMI). This study was designed to show the association between treatment with statins or RAS blockers and clinical outcomes and the efficacy of two drug combination therapies in patients with ischemic heart failure (IHF) who underwent revascularization for an AMI. A total of 804 AMI patients with a left ventricular ejection fraction <40% who undertook percutaneous coronary interventions (PCI) were analyzed using the Korea Acute Myocardial Infarction Registry (KAMIR). They were divided into four groups according to the use of medications [Group I: combination of statin and RAS blocker (n=611), Group II: statin alone (n=112), Group III: RAS blocker alone (n=53), Group IV: neither treatment (n=28)]. The cumulative incidence of major adverse cardiac and cerebrovascular events (MACCEs) and independent predictors of MACCEs were investigated. Over a median follow-up study of nearly 1 year, MACCEs had occurred in 48 patients (7.9%) in Group I, 16 patients (14.3%) in Group II, 3 patients (5.7%) in Group III, 7 patients (21.4%) in Group IV (p=0.013). Groups using RAS blocker (Group I and III) showed better clinical outcomes compared with the other groups. By multivariate analysis, use of RAS blockers was the most powerful independent predictor of MACCEs in patients with IHF who underwent PCI (odds ratio 0.469, 95% confidence interval 0.285-0.772; p=0.003), but statin therapy was not found to be an independent predictor. The use of RAS blockers, but not statins, was associated with better clinical outcomes in patients with IHF who underwent PCI.
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Affiliation(s)
- Jumin Won
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Young Joon Hong
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Myung Ho Jeong
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Hyuk Jin Park
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Min Chul Kim
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Woo Jin Kim
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Hyun Kuk Kim
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Doo Sun Sim
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Ju Han Kim
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Youngkeun Ahn
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Jeong Gwan Cho
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
| | - Jong Chun Park
- Division of Cardiology, Chonnam National University Hospital, Cardiovascular Convergence Research Center Nominated by Korea Ministry of Health and Welfare, Gwangju, Korea
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Kotecha D, Manzano L, Krum H, Rosano G, Holmes J, Altman DG, Collins PD, Packer M, Wikstrand J, Coats AJS, Cleland JGF, Kirchhof P, von Lueder TG, Rigby AS, Andersson B, Lip GYH, van Veldhuisen DJ, Shibata MC, Wedel H, Böhm M, Flather MD. Effect of age and sex on efficacy and tolerability of β blockers in patients with heart failure with reduced ejection fraction: individual patient data meta-analysis. BMJ 2016; 353:i1855. [PMID: 27098105 PMCID: PMC4849174 DOI: 10.1136/bmj.i1855] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To determine the efficacy and tolerability of β blockers in a broad age range of women and men with heart failure with reduced ejection fraction (HFrEF) by pooling individual patient data from placebo controlled randomised trials. DESIGN Prospectively designed meta-analysis of individual patient data from patients aged 40-85 in sinus rhythm at baseline, with left ventricular ejection fraction <0.45. PARTICIPANTS 13,833 patients from 11 trials; median age 64; 24% women. MAIN OUTCOME MEASURES The primary outcome was all cause mortality; the major secondary outcome was admission to hospital for heart failure. Analysis was by intention to treat with an adjusted one stage Cox proportional hazards model. RESULTS Compared with placebo, β blockers were effective in reducing mortality across all ages: hazard ratios were 0.66 (95% confidence interval 0.53 to 0.83) for the first quarter of age distribution (median age 50); 0.71 (0.58 to 0.87) for the second quarter (median age 60); 0.65 (0.53 to 0.78) for the third quarter (median age 68); and 0.77 (0.64 to 0.92) for the fourth quarter (median age 75). There was no significant interaction when age was modelled continuously (P=0.1), and the absolute reduction in mortality was 4.3% over a median follow-up of 1.3 years (number needed to treat 23). Admission to hospital for heart failure was significantly reduced by β blockers, although this effect was attenuated at older ages (interaction P=0.05). There was no evidence of an interaction between treatment effect and sex in any age group. Drug discontinuation was similar regardless of treatment allocation, age, or sex (14.4% in those give β blockers, 15.6% in those receiving placebo). CONCLUSION Irrespective of age or sex, patients with HFrEF in sinus rhythm should receive β blockers to reduce the risk of death and admission to hospital.Registration PROSPERO CRD42014010012; Clinicaltrials.gov NCT00832442.
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Affiliation(s)
- Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Roma, Italy Cardiovascular and Cell Science Institute, St George's University of London, London, UK
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Peter D Collins
- National Heart and Lung Institute, Imperial College, London, UK
| | | | - John Wikstrand
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Andrew J S Coats
- Monash Warwick Alliance, Monash University, Melbourne, Australia Monash Warwick Alliance, University of Warwick, Warwick, UK
| | | | - Paulus Kirchhof
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | | | - Alan S Rigby
- Academic Cardiology, Castle Hill Hospital, Kingston upon Hull, UK
| | - Bert Andersson
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | | | - Hans Wedel
- Nordic School of Public Health, Gothenburg, Sweden
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
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Zhai XB, Gu ZC, Liu XY. Effectiveness of the clinical pharmacist in reducing mortality in hospitalized cardiac patients: a propensity score-matched analysis. Ther Clin Risk Manag 2016; 12:241-50. [PMID: 26937196 PMCID: PMC4762444 DOI: 10.2147/tcrm.s98300] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Pharmacist-led medication review services have been assessed in the meta-analyses in hospital. Of the 135 relevant articles located, 21 studies met the inclusion criteria; however, there was no statistically significant difference found between pharmacists’ interventions and usual care for mortality (odds ratio 1.50, 95% confidence interval 0.65, 3.46, P=0.34). These analyses may not have found a statistically significant effect because they did not adequately control the wide variation in the delivery of care and patient selection parameters. Additionally, the investigators did not conduct research on the cases of death specifically and did not identify all possible drug-related problems (DRPs) that could cause or contribute to mortality and then convince physicians to correct. So there will be a condition to use a more precise approach to evaluate the effect of clinical pharmacist interventions on the mortality rates of hospitalized cardiac patients. Objective To evaluate the impact of the clinical pharmacist as a direct patient-care team member on the mortality of all patients admitted to the cardiology unit. Methods A comparative study was conducted in a cardiology unit of a university-affiliated hospital. The clinical pharmacists did not perform any intervention associated with improper use of medications during Phase I (preintervention) and consulted with the physicians to address the DRPs during Phase II (postintervention). The two phases were compared to evaluate the outcome, and propensity score (PS) matching was applied to enhance the comparability. The primary endpoint of the study was the composite of all-cause mortality during Phase I and Phase II. Results Pharmacists were consulted by the physicians to correct any drug-related issues that they suspected may cause or contribute to a fatal outcome in the cardiology ward. A total of 1,541 interventions were suggested by the clinical pharmacist in the study group; 1,416 (92.0%) of them were accepted by the cardiology team, and violation of incompatibilities had the highest percentage of acceptance by the cardiology team. All-cause mortality was 1.5% during Phase I (preintervention) and was reduced to 0.9% during Phase II (postintervention), and the difference was statistically significant (P=0.0005). After PS matching, all-cause mortality changed from 1.7% during Phase I down to 1.0% during Phase II, and the difference was also statistically significant (P=0.0074). Conclusion DRPs that were suspected to cause or contribute to a possibly fatal outcome were determined by clinical pharmacist service in patients hospitalized in a cardiology ward. Correction of these DRPs by physicians after pharmacist’s advice caused a significant decrease in mortality as analyzed by PS matching. The significant reduction in the mortality rate in this patient population observed in this study is “hypothesis generating” for future randomized studies.
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Affiliation(s)
- Xiao-Bo Zhai
- Department of Pharmacy, Shanghai East Hospital, Affiliated to Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiao-Yan Liu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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35
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Alehagen U, Benson L, Edner M, Dahlström U, Lund LH. Association Between Use of Statins and Mortality in Patients With Heart Failure and Ejection Fraction of ≥50%. Circ Heart Fail 2015; 8:862-70. [DOI: 10.1161/circheartfailure.115.002143] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 07/29/2015] [Indexed: 11/16/2022]
Abstract
Background—
The pathophysiology of heart failure with preserved ejection fraction is poorly understood, but may involve a systemic proinflammatory state. Therefore, statins might improve outcomes in patients with heart failure with preserved ejection fraction defined as ≥50%.
Methods and Results—
Of 46 959 unique patients in the prospective Swedish Heart Failure Registry, 9140 patients had heart failure and ejection fraction ≥50% (age 77±11 years, 54.0% women), and of these, 3427 (37.5%) were treated with statins. Propensity scores for statin treatment were derived from 40 baseline variables. The association between statin use and primary (all-cause mortality) and secondary (separately, cardiovascular mortality, and combined all-cause mortality or cardiovascular hospitalization) end points was assessed with Cox regressions in a population matched 1:1 based on age and propensity score. In the matched population, 1-year survival was 85.1% for statin-treated versus 80.9% for untreated patients (hazard ratio, 0.80; 95% confidence interval, 0.72–0.89;
P
<0.001). Statins were also associated with reduced cardiovascular death (hazard ratio, 0.86; 95% confidence interval, 0.75–0.98;
P
=0.026) and composite all-cause mortality or cardiovascular hospitalization (hazard ratio, 0.89; 95% confidence interval, 0.82–0.96;
P
=0.003).
Conclusions—
In heart failure with ejection fraction ≥50%, the use of statins was associated with improved outcomes. The mechanisms should be evaluated and the effects tested in a randomized trial.
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Affiliation(s)
- Urban Alehagen
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
| | - Lina Benson
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
| | - Magnus Edner
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
| | - Ulf Dahlström
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
| | - Lars H. Lund
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
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