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Reynolds HR, Cyr DD, Merz CNB, Shaw LJ, Chaitman BR, Boden WE, Alexander KP, Rosenberg YD, Bangalore S, Stone GW, Held C, Spertus J, Goetschalckx K, Bockeria O, Newman JD, Berger JS, Elghamaz A, Lopes RD, Min JK, Berman DS, Picard MH, Kwong RY, Harrington RA, Thomas B, O'Brien SM, Maron DJ, Hochman JS. Sex Differences in Revascularization, Treatment Goals, and Outcomes of Patients With Chronic Coronary Disease: Insights From the ISCHEMIA Trial. J Am Heart Assoc 2024; 13:e029850. [PMID: 38410945 PMCID: PMC10944079 DOI: 10.1161/jaha.122.029850] [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: 02/22/2023] [Accepted: 11/09/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Women with chronic coronary disease are generally older than men and have more comorbidities but less atherosclerosis. We explored sex differences in revascularization, guideline-directed medical therapy, and outcomes among patients with chronic coronary disease with ischemia on stress testing, with and without invasive management. METHODS AND RESULTS The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial randomized patients with moderate or severe ischemia to invasive management with angiography, revascularization, and guideline-directed medical therapy, or initial conservative management with guideline-directed medical therapy alone. We evaluated the primary outcome (cardiovascular death, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest) and other end points, by sex, in 1168 (22.6%) women and 4011 (77.4%) men. Invasive group catheterization rates were similar, with less revascularization among women (73.4% of invasive-assigned women revascularized versus 81.2% of invasive-assigned men; P<0.001). Women had less coronary artery disease: multivessel in 60.0% of invasive-assigned women and 74.8% of invasive-assigned men, and no ≥50% stenosis in 12.3% versus 4.5% (P<0.001). In the conservative group, 4-year catheterization rates were 26.3% of women versus 25.6% of men (P=0.72). Guideline-directed medical therapy use was lower among women with fewer risk factor goals attained. There were no sex differences in the primary outcome (adjusted hazard ratio [HR] for women versus men, 0.93 [95% CI, 0.77-1.13]; P=0.47) or the major secondary outcome of cardiovascular death/myocardial infarction (adjusted HR, 0.93 [95% CI, 0.76-1.14]; P=0.49), with no significant sex-by-treatment-group interactions. CONCLUSIONS Women had less extensive coronary artery disease and, therefore, lower revascularization rates in the invasive group. Despite lower risk factor goal attainment, women with chronic coronary disease experienced similar risk-adjusted outcomes to men in the ISCHEMIA trial. REGISTRATION URL: http://wwwclinicaltrials.gov. Unique identifier: NCT01471522.
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Affiliation(s)
| | | | | | - Leslee J. Shaw
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research FoundationNew YorkNYUSA
| | | | | | | | | | | | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research FoundationNew YorkNYUSA
| | - Claes Held
- Dept of Medical Sciences, CardiologyUppsala University and Uppsala Clinical Research CenterUppsalaSweden
| | - John Spertus
- Saint Luke’s Mid America Heart Institute/University of Missouri ‐ Kansas City (UMKC)Kansas CityMOUSA
| | | | - Olga Bockeria
- National Research Center for Cardiovascular SurgeryMoscowRussia
| | | | | | - Ahmed Elghamaz
- Northwick Park Hospital‐Royal Brompton HospitalLondonUnited Kingdom
| | | | | | | | - Michael H. Picard
- Massachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | | | | | | | | | - David J. Maron
- Department of MedicineStanford University School of MedicineStanfordCAUSA
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Cho SMJ, Koyama S, Honigberg MC, Surakka I, Haidermota S, Ganesh S, Patel AP, Bhattacharya R, Lee H, Kim HC, Natarajan P. Genetic, sociodemographic, lifestyle, and clinical risk factors of recurrent coronary artery disease events: a population-based cohort study. Eur Heart J 2023; 44:3456-3465. [PMID: 37350734 PMCID: PMC10516626 DOI: 10.1093/eurheartj/ehad380] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 05/07/2023] [Accepted: 05/25/2023] [Indexed: 06/24/2023] Open
Abstract
AIMS Complications of coronary artery disease (CAD) represent the leading cause of death among adults globally. This study examined the associations and clinical utilities of genetic, sociodemographic, lifestyle, and clinical risk factors on CAD recurrence. METHODS AND RESULTS Data were from 7024 UK Biobank middle-aged adults with established CAD at enrolment. Cox proportional hazards regressions modelled associations of age at enrolment, age at first CAD diagnosis, sex, cigarette smoking, physical activity, diet, sleep, Townsend Deprivation Index, body mass index, blood pressure, blood lipids, glucose, lipoprotein(a), C reactive protein, estimated glomerular filtration rate (eGFR), statin prescription, and CAD polygenic risk score (PRS) with first post-enrolment CAD recurrence. Over a median [interquartile range] follow-up of 11.6 [7.2-12.7] years, 2003 (28.5%) recurrent CAD events occurred. The hazard ratio (95% confidence interval [CI]) for CAD recurrence was the most pronounced with current smoking (1.35, 1.13-1.61) and per standard deviation increase in age at first CAD (0.74, 0.67-0.82). Additionally, age at enrolment, CAD PRS, C-reactive protein, lipoprotein(a), glucose, low-density lipoprotein cholesterol, deprivation, sleep quality, eGFR, and high-density lipoprotein (HDL) cholesterol also significantly associated with recurrence risk. Based on C indices (95% CI), the strongest predictors were CAD PRS (0.58, 0.57-0.59), HDL cholesterol (0.57, 0.57-0.58), and age at initial CAD event (0.57, 0.56-0.57). In addition to traditional risk factors, a comprehensive model improved the C index from 0.644 (0.632-0.654) to 0.676 (0.667-0.686). CONCLUSION Sociodemographic, clinical, and laboratory factors are each associated with CAD recurrence with genetic risk, age at first CAD event, and HDL cholesterol concentration explaining the most.
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Affiliation(s)
- So Mi Jemma Cho
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Satoshi Koyama
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
| | - Michael C Honigberg
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
| | - Ida Surakka
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Division of Cardiology, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Sara Haidermota
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
| | - Shriienidhie Ganesh
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
| | - Aniruddh P Patel
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
| | - Romit Bhattacharya
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
| | - Hokyou Lee
- Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Hyeon Chang Kim
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
- Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
- Institute for Innovation in Digital Healthcare, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Pradeep Natarajan
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, 415 Main St., Cambridge, MA 02142, USA
- Cardiovascular Research Center and Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge St., Boston, MA 02114, USA
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA
- Department of Medicine, Harvard Medical School, 25 Shattuck St., Boston, MA 02114, USA
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Tsaban G, Zahger D, Abramowitz Y. Editorial Commentary: The COURAGE to face ISCHEMIA: Applying data from randomized studies to real-life. Trends Cardiovasc Med 2023; 33:131-132. [PMID: 34801663 DOI: 10.1016/j.tcm.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Gal Tsaban
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Yigal Abramowitz
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.
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Hochman JS, Anthopolos R, Reynolds HR, Bangalore S, Xu Y, O’Brien SM, Mavromichalis S, Chang M, Contreras A, Rosenberg Y, Kirby R, Bhargava B, Senior R, Banfield A, Goodman SG, Lopes RD, Pracoń R, López-Sendón J, Maggioni AP, Newman JD, Berger JS, Sidhu MS, White HD, Troxel AB, Harrington RA, Boden WE, Stone GW, Mark DB, Spertus JA, Maron DJ. Survival After Invasive or Conservative Management of Stable Coronary Disease. Circulation 2023; 147:8-19. [PMID: 36335918 PMCID: PMC9797439 DOI: 10.1161/circulationaha.122.062714] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) compared an initial invasive versus an initial conservative management strategy for patients with chronic coronary disease and moderate or severe ischemia, with no major difference in most outcomes during a median of 3.2 years. Extended follow-up for mortality is ongoing. METHODS ISCHEMIA participants were randomized to an initial invasive strategy added to guideline-directed medical therapy or a conservative strategy. Patients with moderate or severe ischemia, ejection fraction ≥35%, and no recent acute coronary syndromes were included. Those with an unacceptable level of angina were excluded. Extended follow-up for vital status is being conducted by sites or through central death index search. Data obtained through December 2021 are included in this interim report. We analyzed all-cause, cardiovascular, and noncardiovascular mortality by randomized strategy, using nonparametric cumulative incidence estimators, Cox regression models, and Bayesian methods. Undetermined deaths were classified as cardiovascular as prespecified in the trial protocol. RESULTS Baseline characteristics for 5179 original ISCHEMIA trial participants included median age 65 years, 23% women, 16% Hispanic, 4% Black, 42% with diabetes, and median ejection fraction 0.60. A total of 557 deaths accrued during a median follow-up of 5.7 years, with 268 of these added in the extended follow-up phase. This included a total of 343 cardiovascular deaths, 192 noncardiovascular deaths, and 22 unclassified deaths. All-cause mortality was not different between randomized treatment groups (7-year rate, 12.7% in invasive strategy, 13.4% in conservative strategy; adjusted hazard ratio, 1.00 [95% CI, 0.85-1.18]). There was a lower 7-year rate cardiovascular mortality (6.4% versus 8.6%; adjusted hazard ratio, 0.78 [95% CI, 0.63-0.96]) with an initial invasive strategy but a higher 7-year rate of noncardiovascular mortality (5.6% versus 4.4%; adjusted hazard ratio, 1.44 [95% CI, 1.08-1.91]) compared with the conservative strategy. No heterogeneity of treatment effect was evident in prespecified subgroups, including multivessel coronary disease. CONCLUSIONS There was no difference in all-cause mortality with an initial invasive strategy compared with an initial conservative strategy, but there was lower risk of cardiovascular mortality and higher risk of noncardiovascular mortality with an initial invasive strategy during a median follow-up of 5.7 years. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04894877.
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Affiliation(s)
| | | | | | | | - Yifan Xu
- NYU Grossman School of Medicine, New York, NY, USA
| | | | | | | | | | | | - Ruth Kirby
- National Institutes of Health, Bethesda, MD, USA
| | | | - Roxy Senior
- Northwick Park Hospital, Harrow, London, UK
- Imperial College London and Royal Brompton Hospital, London, UK
| | | | - Shaun G. Goodman
- St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - José López-Sendón
- IdiPaz Research Institute and Hospital Universitario La Paz, Madrid, Spain
| | | | | | | | | | - Harvey D. White
- Te Whatu Ora Health New Zealand, Te Toki Tumai, Green Lane Cardiovascular Services and University of Auckland, Auckland, NZ
| | | | | | - William E. Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John A. Spertus
- Saint Luke’s Mid America Heart Institute and the University of Missouri, Kansas City, Kansas City, MO, USA
| | - David J. Maron
- Stanford University Department of Medicine, Stanford, CA, USA
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5
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Achievement of Low-Density Lipoprotein Cholesterol Targets in Cardiac Rehabilitation: Impact of the 2019 ESC/EAS Dyslipidaemia Guidelines. J Clin Med 2022; 11:jcm11237057. [PMID: 36498631 PMCID: PMC9740039 DOI: 10.3390/jcm11237057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/20/2022] [Accepted: 11/24/2022] [Indexed: 12/05/2022] Open
Abstract
In 2019 the European Society of Cardiology (ESC) lowered the target values for low-density lipoprotein cholesterol (LDL-C) from <1.8 mmol/L to <1.4 mmol/L for secondary prevention of cardiovascular disease (CVD). The aim of this study was to determine the clinical impact of the 2019 ESC/EAS dyslipidaemia guidelines on lipid-lowering therapies and achievement rates of LDL-C targets in a contemporary cohort of CAD patients participating in an ambulatory cardiac rehabilitation (CR) program.We conducted a retrospective analysis of prospectively collected data from the Swiss Secondary Prevention Registry (SwissPR) in patients with Coronary Artery Disease (CAD), who completed the ambulatory cardiovascular rehabilitation program (CR) of the University Hospital Basel, Switzerland from January 2017 to April 2021. To evaluate the impact of the guideline publication, the cohort was split into a pre-Guideline 2019 group (A) and a post-Guideline 2019 group (B). In total 1320 patients were screened leaving 875 patients for analysis. At discharge, more patients in group B were on maximal statin doses (20% vs. 9%, p < 0.0001) and on combination therapy with ezetimibe (51% vs. 17%, p < 0.0001) than in group A, which resulted in 53% of patients reaching the LDL-C target of <1.4 mmol/L in group B. Regression analysis revealed that dyslipidaemia and positive smoking history represent independent predictors for intensified lipid-lowering medication, whereas absolving CR after publication of the 2019 guidelines was the only significant predictor for reduced LDL-C at CR discharge. We found a significant difference in prescription rates of lipid-lowering medication, especially combination therapies and statin doses, after publication of the 2019 ESC/EAS dyslipidaemia guidelines resulting in an achievement rate of >50% of the LDL-C target <1.4 mmol/L in CAD patients participating in ambulatory CR.
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Mathew RO, Maron DJ, Anthopolos R, Fleg JL, O’Brien SM, Rockhold FW, Briguori C, Roik MF, Mazurek T, Demkow M, Malecki R, Ye Z, Kaul U, Miglinas M, Stone GW, Wald R, Charytan DM, Sidhu MS, Hochman JS, Bangalore S. Guideline-Directed Medical Therapy Attainment and Outcomes in Dialysis-Requiring Versus Nondialysis Chronic Kidney Disease in the ISCHEMIA-CKD Trial. Circ Cardiovasc Qual Outcomes 2022; 15:e008995. [PMID: 36193750 PMCID: PMC9588677 DOI: 10.1161/circoutcomes.122.008995] [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: 02/03/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) on dialysis (CKD G5D) have worse cardiovascular outcomes than patients with advanced nondialysis CKD (CKD G4-5: estimated glomerular filtration rate <30 mL/[min·1.73m2]). Our objective was to evaluate the relationship between achievement of cardiovascular guideline-directed medical therapy (GDMT) goals and clinical outcomes for CKD G5D versus CKD G4-5. METHODS This was a subgroup analysis of ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease) participants with CKD G4-5 or CKD G5D and moderate-to-severe myocardial ischemia on stress testing. Exposures included dialysis requirement at randomization and GDMT goal achievement during follow-up. The composite outcome was all-cause mortality or nonfatal myocardial infarction. Individual GDMT goal (smoking cessation, systolic blood pressure <140 mm Hg, low-density lipoprotein cholesterol <70 mg/dL, statin use, aspirin use) trajectory was modeled. Percentage point difference was estimated for each GDMT goal at 24 months between CKD G5D and CKD G4-5, and for association with key predictors. Probability of survival free from all-cause mortality or nonfatal myocardial infarction by GDMT goal achieved was assessed for CKD G5D versus CKD G4-5. RESULTS A total of 415 CKD G5D and 362 CKD G4-5 participants were randomized. Participants with CKD G5D were less likely to receive statin (-6.9% [95% CI, -10.3% to -3.7%]) and aspirin therapy (-3.0% [95% CI, -5.6% to -0.6%]), with no difference in other GDMT goal attainment. Cumulative exposure to GDMT achieved during follow-up was associated with reduction in all-cause mortality or nonfatal myocardial infarction (hazard ratio, 0.88 [95% CI, 0.87-0.90]; per each GDMT goal attained over 60 days), irrespective of dialysis status. CONCLUSIONS CKD G5D participants received statin or aspirin therapy less often. Cumulative exposure to GDMT goals achieved was associated with lower incidence of all-cause mortality or nonfatal myocardial infarction in participants with advanced CKD and chronic coronary disease, regardless of dialysis status. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01985360.
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Affiliation(s)
- Roy O. Mathew
- Department of Medicine, Loma Linda VA Health Care System, Loma Linda, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - David J. Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Jerome L. Fleg
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Sean M. O’Brien
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, SC, USA
| | - Frank W. Rockhold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, SC, USA
| | | | - Marek F. Roik
- Department of Internal Medicine and Cardiology, Infant Jesus Teaching Hospital, Medical University of Warsaw, POL
| | | | | | | | - Zhiming Ye
- Guangdong Provincial People’s Hospital, Guangdong, CHN
| | - Upendra Kaul
- Batra Hospital and Medical Research Center, New Delhi, IND
| | - Marius Miglinas
- Vilnius University, Nephrology Center, Santaros Klinikos Hospital, Vilnius, LTU
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ron Wald
- St. Michael’s Hospital, Toronto, ON, CAN
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Underberg J, Toth PP, Rodriguez F. LDL-C target attainment in secondary prevention of ASCVD in the United States: barriers, consequences of nonachievement, and strategies to reach goals. Postgrad Med 2022; 134:752-762. [PMID: 36004573 DOI: 10.1080/00325481.2022.2117498] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death in the United States. Elevated low-density lipoprotein cholesterol (LDL-C) is a major causal risk factor for ASCVD. Current evidence overwhelmingly demonstrates that lowering LDL-C reduces the risk of secondary cardiovascular events in patients with previous myocardial infarction or stroke. There is no lower limit for LDL-C: large, randomized studies and meta-analyses have found continuous benefit and no safety concerns in patients achieving LDL-C levels <25 mg/dL. As 'Time is plaque' in patients with ASCVD, early, sustained reductions in LDL-C are critical to slow or halt disease progression. However, despite use of lipid-lowering medications, <30% of patients with ASCVD achieve guideline-recommended reductions in LDL-C, resulting in a substantial societal burden of preventable cardiovascular events and early mortality. LDL-C goals are not met due to several factors: lipid-lowering therapy is not initiated and intensified as directed by clinical guidelines (clinical inertia); most patients do not adhere to prescribed medications; and high-risk patients are frequently denied access to add-on therapies by their insurance providers. Promoting patient and clinician education, multidisciplinary collaboration, and other interventions may help to overcome these barriers. Ultimately, achieving population-level guideline-recommended reductions in LDL-C will require a collaborative effort from patients, clinicians, relevant professional societies, drug manufacturers, and payers.
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Affiliation(s)
| | - Peter P Toth
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
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Garcia RA, Spertus JA, Benton MC, Jones PG, Mark DB, Newman JD, Bangalore S, Boden WE, Stone GW, Reynolds HR, Hochman JS, Maron DJ. Association of Medication Adherence With Health Outcomes in the ISCHEMIA Trial. J Am Coll Cardiol 2022; 80:755-765. [PMID: 35981820 PMCID: PMC10548342 DOI: 10.1016/j.jacc.2022.05.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/27/2022] [Accepted: 05/16/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial randomized participants with chronic coronary disease (CCD) to guideline-directed medical therapy with or without angiography and revascularization. The study examined the association of nonadherence with health status outcomes. OBJECTIVES The study sought to compare 12-month health status outcomes of adherent and nonadherent participants with CCD with an a priori hypothesis that nonadherent patients would have better health status if randomized to invasive management. METHODS Self-reported medication-taking behavior was assessed at randomization with a modified 4-item Morisky-Green-Levine Adherence Scale, and participants were classified as adherent or nonadherent. Twelve-month health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ-7) summary score (SS), which ranges from 0 to 100 (higher score = better). The association of adherence with outcomes was evaluated using Bayesian proportional odds models, including an interaction by study arm (conservative vs invasive). RESULTS Among 4,480 randomized participants, 1,245 (27.8%) were nonadherent at baseline. Nonadherent participants had worse baseline SAQ-7 SS in both conservative (72.9 ± 19.3 vs 75.6 ± 18.4) and invasive (71.0 ± 19.8 vs 74.2 ± 18.7) arms. In adjusted analyses, adherence was associated with higher 12-month SAQ-7 SS in both treatment groups (mean difference in SAQ-7 SS with conservative treatment = 1.6 [95% credible interval: 0.3-2.9] vs with invasive management = 1.9 [95% credible interval: 0.8-3.1]), with no interaction by treatment. CONCLUSIONS More than 1 in 4 participants reported medication nonadherence, which was associated with worse health status in both conservative and invasive treatment strategies at baseline and 12 months. Strategies to improve medication adherence are needed to improve health status outcomes in CCD, regardless of treatment strategy. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- R Angel Garcia
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John A Spertus
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA.
| | - Mary C Benton
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Philip G Jones
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan D Newman
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Sripal Bangalore
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - William E Boden
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Gregg W Stone
- Department of Medicine (Cardiology) and Population Health Science and Policy, Mount Sinai Hospital, New York, New York, USA
| | - Harmony R Reynolds
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Judith S Hochman
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Rodriguez F, Hochman JS, Xu Y, Reynolds HR, Berger JS, Mavromichalis S, Newman JD, Bangalore S, Maron DJ. Screening for participants in the ISCHEMIA trial: Implications for clinical research. J Clin Transl Sci 2022; 6:e90. [PMID: 36003207 PMCID: PMC9389278 DOI: 10.1017/cts.2022.428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/28/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022] Open
Abstract
The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) found that there was no statistical difference in cardiovascular events with an initial invasive strategy as compared with an initial conservative strategy of guideline-directed medical therapy for patients with moderate to severe ischemia on noninvasive testing. In this study, we describe the reasons that potentially eligible patients who were screened for participation in the ISCHEMIA trial did not advance to enrollment, the step prior to randomization. Of those who preliminarily met clinical inclusion criteria on screening logs submitted during the enrollment period, over half did not participate due to physician or patient refusal, a potentially modifiable barrier. This analysis highlights the importance of physician equipoise when advising patients about participation in randomized controlled trials.
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Affiliation(s)
- Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Stanford Prevention Research Center, Department of Medicine, Stanford University, School of Medicine, Stanford, CA, USA
| | | | - Yifan Xu
- New York University, Grossman School of Medicine, New York, NY, USA
| | | | | | | | | | - Sripal Bangalore
- New York University, Grossman School of Medicine, New York, NY, USA
| | - David J. Maron
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Stanford Prevention Research Center, Department of Medicine, Stanford University, School of Medicine, Stanford, CA, USA
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10
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Sidhu MS, Alexander KP, Huang Z, O'Brien SM, Chaitman BR, Stone GW, Newman JD, Boden WE, Maggioni AP, Steg PG, Ferguson TB, Demkow M, Peteiro J, Wander GS, Phaneuf DC, De Belder MA, Doerr R, Alexanderson-Rosas E, Polanczyk CA, Henriksen PA, Conway DS, Miro V, Sharir T, Lopes RD, Min JK, Berman DS, Rockhold FW, Balter S, Borrego D, Rosenberg YD, Bangalore S, Reynolds HR, Hochman JS, Maron DJ. Causes of cardiovascular and noncardiovascular death in the ISCHEMIA trial. Am Heart J 2022; 248:72-83. [PMID: 35149037 DOI: 10.1016/j.ahj.2022.01.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial demonstrated no overall difference in the composite primary endpoint and the secondary endpoints of cardiovascular (CV) death/myocardial infarction or all-cause mortality between an initial invasive or conservative strategy among participants with chronic coronary disease and moderate or severe myocardial ischemia. Detailed cause-specific death analyses have not been reported. METHODS We compared overall and cause-specific death rates by treatment group using Cox models with adjustment for pre-specified baseline covariates. Cause of death was adjudicated by an independent Clinical Events Committee as CV, non-CV, and undetermined. We evaluated the association of risk factors and treatment strategy with cause of death. RESULTS Four-year cumulative incidence rates for CV death were similar between invasive and conservative strategies (2.6% vs 3.0%; hazard ratio [HR] 0.98; 95% CI [0.70-1.38]), but non-CV death rates were higher in the invasive strategy (3.3% vs 2.1%; HR 1.45 [1.00-2.09]). Overall, 13% of deaths were attributed to undetermined causes (38/289). Fewer undetermined deaths (0.6% vs 1.3%; HR 0.48 [0.24-0.95]) and more malignancy deaths (2.0% vs 0.8%; HR 2.11 [1.23-3.60]) occurred in the invasive strategy than in the conservative strategy. CONCLUSIONS In International Study of Comparative Health Effectiveness with Medical and Invasive Approaches, all-cause and CV death rates were similar between treatment strategies. The observation of fewer undetermined deaths and more malignancy deaths in the invasive strategy remains unexplained. These findings should be interpreted with caution in the context of prior studies and the overall trial results.
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11
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Opportunità cliniche e impatto sul sistema sanitario di un trattamento ottimale del paziente post-sindrome coronarica acuta. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2022; 9:17-26. [PMID: 36628067 PMCID: PMC9796606 DOI: 10.33393/grhta.2022.2391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/23/2022] [Indexed: 01/13/2023] Open
Abstract
Despite the improvement of revascularization procedures, patients with acute coronary syndrome often develop recurrent ischemic events, suggesting a high residual cardiovascular risk in these patients, which requires a strict clinical monitoring as well as an optimal control of modifiable risk factors. To this aim, an optimal management of index event and appropriate preventive measures are equally important. Hospital care by cardiologists should be followed by outpatient management by general practitioners, as established by specific diagnostic and therapeutic pathways, which should warrant an optimal support to the patient. A strict collaboration between hospital and primary care is crucial to monitor and adapt drug therapy after the acute event and improve adherence of the patients to prescribed treatments and implementation of life-style modifications, with benefits also in term of cost-effectiveness. In this context, individualized rehabilitation programs should also be offered to patients with acute coronary syndromes, in order to improve survival and quality of life.
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12
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Cardoso R, Abovich A, Boden WE, Arbab-Zadeh A, Blankstein R, Blumenthal RS. The 2021 AHA/ACC/SCAI Coronary Artery Revascularization Recommendations: Need for Emphasis on Prevention and Future Considerations. JACC. ADVANCES 2022; 1:100006. [PMID: 38939089 PMCID: PMC11198690 DOI: 10.1016/j.jacadv.2022.100006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 06/29/2024]
Affiliation(s)
- Rhanderson Cardoso
- Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Arielle Abovich
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William E. Boden
- VA New England Health Care System, Massachusetts Veterans Epidemiology, Research, and Informatics Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Armin Arbab-Zadeh
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ron Blankstein
- Cardiovascular Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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13
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OUP accepted manuscript. Eur J Prev Cardiol 2022; 29:1465-1475. [DOI: 10.1093/eurjpc/zwac079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/06/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022]
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14
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Newman JD, Anthopolos R, Mancini GBJ, Bangalore S, Reynolds HR, Kunichoff DF, Senior R, Peteiro J, Bhargava B, Garg P, Escobedo J, Doerr R, Mazurek T, Gonzalez-Juanatey J, Gajos G, Briguori C, Cheng H, Vertes A, Mahajan S, Guzman LA, Keltai M, Maggioni AP, Stone GW, Berger JS, Rosenberg YD, Boden WE, Chaitman BR, Fleg JL, Hochman JS, Maron DJ. Outcomes of Participants With Diabetes in the ISCHEMIA Trials. Circulation 2021; 144:1380-1395. [PMID: 34521217 DOI: 10.1161/circulationaha.121.054439] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among patients with diabetes and chronic coronary disease, it is unclear if invasive management improves outcomes when added to medical therapy. METHODS The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trials (ie, ISCHEMIA and ISCHEMIA-Chronic Kidney Disease) randomized chronic coronary disease patients to an invasive (medical therapy + angiography and revascularization if feasible) or a conservative approach (medical therapy alone with revascularization if medical therapy failed). Cohorts were combined after no trial-specific effects were observed. Diabetes was defined by history, hemoglobin A1c ≥6.5%, or use of glucose-lowering medication. The primary outcome was all-cause death or myocardial infarction (MI). Heterogeneity of effect of invasive management on death or MI was evaluated using a Bayesian approach to protect against random high or low estimates of treatment effect for patients with versus without diabetes and for diabetes subgroups of clinical (female sex and insulin use) and anatomic features (coronary artery disease severity or left ventricular function). RESULTS Of 5900 participants with complete baseline data, the median age was 64 years (interquartile range, 57-70), 24% were female, and the median estimated glomerular filtration was 80 mL·min-1·1.73-2 (interquartile range, 64-95). Among the 2553 (43%) of participants with diabetes, the median percent hemoglobin A1c was 7% (interquartile range, 7-8), and 30% were insulin-treated. Participants with diabetes had a 49% increased hazard of death or MI (hazard ratio, 1.49 [95% CI, 1.31-1.70]; P<0.001). At median 3.1-year follow-up the adjusted event-free survival was 0.54 (95% bootstrapped CI, 0.48-0.60) and 0.66 (95% bootstrapped CI, 0.61-0.71) for patients with diabetes versus without diabetes, respectively, with a 12% (95% bootstrapped CI, 4%-20%) absolute decrease in event-free survival among participants with diabetes. Female and male patients with insulin-treated diabetes had an adjusted event-free survival of 0.52 (95% bootstrapped CI, 0.42-0.56) and 0.49 (95% bootstrapped CI, 0.42-0.56), respectively. There was no difference in death or MI between strategies for patients with diabetes versus without diabetes, or for clinical (female sex or insulin use) or anatomic features (coronary artery disease severity or left ventricular function) of patients with diabetes. CONCLUSIONS Despite higher risk for death or MI, chronic coronary disease patients with diabetes did not derive incremental benefit from routine invasive management compared with initial medical therapy alone. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.
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Affiliation(s)
- Jonathan D Newman
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Rebecca Anthopolos
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - G B John Mancini
- Center for Cardiovascular Innovation, University of British Columbia, Vancouver, Canada (G.B.J.M.)
| | - Sripal Bangalore
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Harmony R Reynolds
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Dennis F Kunichoff
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, UK (R.S.)
| | - Jesus Peteiro
- Complejo Hospitalario Universitario de A Coruña (CHUAC), Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Universidad de A Coruña, A Coruña, Spain (J.P.)
| | | | - Pallav Garg
- London Health Sciences Center, Western University, Ontario, Canada (P.G.)
| | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City (J.E.)
| | - Rolf Doerr
- Praxisklinik Herz und Gefaesse, Dresden, Germany (R.D.)
| | | | - Jose Gonzalez-Juanatey
- Cardiology Department, Hospital Clínico Universitario, Instituto de Investigación Sanitaria de Santiago de Compostela (IDIS), Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares Institution, Spain (J.G-J.)
| | - Grzegorz Gajos
- Department of Coronary Disease and Heart Failure, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland (G.G.)
| | - Carlo Briguori
- Laboratory of Interventional Cardiology and Department of Cardiology, Mediterranea Cardiocentro, Naples, Italy (C.B.)
| | - Hong Cheng
- Beijing Anzhen Hospital, Capital Medical University, China (H.C.)
| | - Andras Vertes
- Dél-pesti Centrumkóház Hospital, National Institute of Hematology and Infectious Disease, Cardiovascular Department, Budapest, Hungary (A.V.)
| | | | - Luis A Guzman
- Instituto Médico Docencia Asistencia Médica e Investigación Clínica, Cordoba, Argentina (L.A.G.)
| | | | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy (A.P.M.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York (G.W.S.)
| | - Jeffrey S Berger
- New York University Grossman School of Medicine (J.D.N., R.A., S.B., H.R.R., D.F.K., J.S.H.)
| | - Yves D Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (Y.D.R., J.L.F.)
| | - William E Boden
- Veterans Affairs New England Healthcare System, Boston University School of Medicine, MA (W.E.B.)
| | - Bernard R Chaitman
- St Louis University School of Medicine Center for Comprehensive Cardiovascular Care, MO (B.R.C.)
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (Y.D.R., J.L.F.)
| | | | - David J Maron
- Department of Medicine, Stanford University, CA (D.J.M.)
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15
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Lopez-Sendon J, Moreno R, Tamargo J. ISCHEMIA Trial: Key Questions and Answers. Eur Cardiol 2021; 16:e34. [PMID: 34603514 PMCID: PMC8477173 DOI: 10.15420/ecr.2021.16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/26/2021] [Indexed: 12/28/2022] Open
Abstract
A healthy lifestyle, myocardial revascularisation and medical therapy constitute the three pillars for the treatment of ischaemic heart disease. Lifestyle and optimal medical therapy should be used in all cases. However, the selection of cases for revascularisation among stable patients remains controversial. The ISCHEMIA trial compared an early invasive strategy with revascularisation plus optimal medical therapy against initial optimal medical therapy alone with revascularisation reserved for cases in which symptom control was insufficient. The study included over 5,000 patients with stable coronary artery disease and moderate to severe myocardial ischaemia. No differences were found in relevant clinical outcomes, including all-cause mortality, cardiovascular death, MI, heart failure and stroke, over a follow-up of 3.2 years. Conversely, angina control was better in patients with severe symptomatic angina. Following the tradition of all trials comparing medical therapy alone with revascularisation, the ISCHEMIA trial results are controversial, but an analysis of the design and results of the trial offers important information to better understand, evaluate and treat the growing number of patients with stable chronic ischaemic heart disease and moderate to severe myocardial ischaemia.
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Affiliation(s)
- Jose Lopez-Sendon
- IdiPaz Research Institute, Hospital Universitario La Paz, Universidad Autonoma de Madrid Madrid, Spain
| | - Raúl Moreno
- Interventional Cardiology Unit, Hospital Universitario La Paz, IdiPaz Madrid, Spain
| | - Juan Tamargo
- Pharmacology Department, Universidad Complutense de Madrid Madrid, Spain
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16
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Anderson NN, Gagliardi AR. Medical student exposure to women's health concepts and practices: a content analysis of curriculum at Canadian medical schools. BMC MEDICAL EDUCATION 2021; 21:435. [PMID: 34407817 PMCID: PMC8371837 DOI: 10.1186/s12909-021-02873-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 08/04/2021] [Indexed: 05/12/2023]
Abstract
BACKGROUND Women's health (WH) includes a broad array of concerns and challenges that affect health across the lifespan. Considerable research shows that women continue to experience disparities in access to and quality of care. Apart from surveys of medical trainees and faculty, little research and none in Canada examined medical curriculum for WH. This study assessed how Canadian medical schools integrate WH in their curriculum. METHODS We used deductive and summative content analysis to describe instances and the nature of WH topics in program and course descriptions that were publicly-available on web sites of Canadian medical schools. We reported results using summary statistics and text examples. We employed a framework, tested in our prior research, that included mention of women's health principles and practices relevant to any health concern or condition including factors (e.g. sex, gender, social determinants) that influence health, and access to or quality of care. RESULTS We retrieved 1459 documents from 16 medical schools (median 49.5, range 16 to 301). Few mentioned WH (125, 8.6 %), and the quantity of mentions varied by school (range 0.0-37.5 %). Pre-clerkship course documents more frequently mentioned WH (61/374, 17.3 %, chi square 43.2, p < 0.00001) compared with clerkship course documents (58/1067, 5.4 %). Core course documents more frequently mentioned WH (72/542, 13.3 %, chi square 29.0, p < 0.00001) compared with elective course documents WH (47/899, 5.2 %). Overall, documents more frequently referred to the WH domain of social determinants of health (88, 70.4 %). Few documents addressed women's health (21, 16.8 %), sex or gender (19, 15.2 %), other considerations (15.2 %) or principles/components of women's health (2, 1.6 %). Most documents that mentioned WH provided little detail about what those concepts referred to or how to optimize WH. CONCLUSIONS Based on program and course descriptions, WH may not be well-integrated at Canadian medical schools, and future physicians may not be consistently exposed to the full breadth of WH. This reveals opportunities for enhancing WH in the medical curriculum. Future research is needed to engage stakeholders including women in developing, implementing and evaluating competencies and corresponding curriculum that reflect the full range of WH concepts and practices.
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Affiliation(s)
- Natalie N Anderson
- Toronto General Hospital Research Institute, University Health Network, 200 Elizabeth Street. 13EN-228, M5G2C4, Toronto, Canada
| | - Anna R Gagliardi
- Toronto General Hospital Research Institute, University Health Network, 200 Elizabeth Street. 13EN-228, M5G2C4, Toronto, Canada.
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17
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Abstract
Although technological and procedural advances have resulted in substantial improvements in clinical outcomes following percutaneous coronary interventions (PCI), recurrent coronary events may occur despite achieving optimal procedural results. Beyond myocardial revascularisation failure related to anatomical or stent-related factors, adverse cardiovascular events post PCI often arise from non-culprit lesions not treated during index interventions. While stenting treats a focal manifestation of a systemic, progressive disease, the residual risk following an acute coronary syndrome (ACS) or elective PCI is largely related to the systemic pro-atherogenic effects of suboptimally controlled cardiovascular risk factors. Lowering atherogenic lipid levels, in particular low-density lipoprotein cholesterol (LDL-C), can halt the progression of coronary atherosclerosis and improve cardiovascular outcomes to an extent that is proportional to the magnitude of LDL-C reduction. Early (in-hospital) initiation of intensive statin therapy leads to a very early clinical benefit following ACS, and prolonged adherence to optimised lipid-lowering treatment effectively reduces longer-term cardiovascular events following PCI. Therefore, achieving guideline-recommended treatment goals for LDL-C with statins and, if indicated, with the addition of non-statin lipid-lowering drugs should become a priority for all physicians involved in the treatment of patients with coronary heart disease, including comprehensive strategies initiated during the in-hospital care of patients undergoing coronary interventions. This review article summarises current evidence on the role of LDL-C in the development and progression of coronary atherosclerosis, discusses the clinical benefits of intensive lipid-lowering treatments, and presents current guideline recommendations, with emphasis on patients undergoing PCI.
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Affiliation(s)
- Konstantinos Koskinas
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - François Mach
- Department of Cardiology, Geneva University Hospital, Geneva, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
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18
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Shaya GE, Leucker TM, Jones SR, Martin SS, Toth PP. Coronary heart disease risk: Low-density lipoprotein and beyond. Trends Cardiovasc Med 2021; 32:181-194. [PMID: 33872757 DOI: 10.1016/j.tcm.2021.04.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/30/2021] [Accepted: 04/05/2021] [Indexed: 01/06/2023]
Abstract
Coronary heart disease (CHD) is the leading cause of morbidity and mortality world-wide and has been characterized as a chronic immunoinflammatory, fibroproliferative disease fueled by lipids. Great advances have been made in elucidating the complex mechanistic interactions among risk factors associated with CHD, yielding abundant success towards preventive measures and the development of pharmaceuticals to prevent and treat CHD via attenuation of lipoprotein-mediated risk. However, significant residual risk remains. Several potentially modifiable CHD risk factors ostensibly contributing to this residual risk have since come to the fore, including systemic inflammation, diabetes mellitus, high-density lipoprotein, plasma triglycerides (TG) and remnant lipoproteins (RLP), lipoprotein(a) (Lp[a]), and vascular endothelial dysfunction (ED). Herein, we summarize the body of evidence implicating each of these risk factors in residual CHD risk.
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Affiliation(s)
- Gabriel E Shaya
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Thorsten M Leucker
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Steven R Jones
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Seth S Martin
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Peter P Toth
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA; Community Hospital General Medical Center, Sterling, IL, USA.
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19
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Foley M, Rajkumar CA, Shun-Shin M, Ganesananthan S, Seligman H, Howard J, Nowbar AN, Keeble TR, Davies JR, Tang KH, Gerber R, O'Kane P, Sharp ASP, Petraco R, Malik IS, Nijjer S, Sen S, Francis DP, Al-Lamee R. Achieving Optimal Medical Therapy: Insights From the ORBITA Trial. J Am Heart Assoc 2021; 10:e017381. [PMID: 33496201 PMCID: PMC7955412 DOI: 10.1161/jaha.120.017381] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background In stable coronary artery disease, medications are used for 2 purposes: cardiovascular risk reduction and symptom improvement. In clinical trials and clinical practice, medication use is often not optimal. The ORBITA (Objective Randomised Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) trial was the first placebo‐controlled trial of percutaneous coronary intervention. A key component of the ORBITA trial design was the inclusion of a medical optimization phase, aimed at ensuring that all patients were treated with guideline‐directed truly optimal medical therapy. In this study, we report the medical therapy that was achieved. Methods and Results After enrollment into the ORBITA trial, all 200 patients entered a 6‐week period of intensive medical therapy optimization, with initiation and uptitration of risk reduction and antianginal therapy. At the prerandomization stage, the median number of antianginals established was 3 (interquartile range, 2–4). A total of 195 patients (97.5%) reached the prespecified target of ≥2 antianginals; 136 (68.0%) did not stop any antianginals because of adverse effects, and the median number of antianginals stopped for adverse effects per patient was 0 (interquartile range, 0–1). Amlodipine and bisoprolol were well tolerated (stopped for adverse effects in 4/175 [2.3%] and 9/167 [5.4%], respectively). Ranolazine and ivabradine were also well tolerated (stopped for adverse effects in 1/20 [5.0%] and 1/18 [5.6%], respectively). Isosorbide mononitrate and nicorandil were stopped for adverse effects in 36 of 172 (20.9%) and 32 of 141 (22.7%) of patients, respectively. Statins were well tolerated and taken by 191 of 200 (95.5%) patients. Conclusions In the 12‐week ORBITA trial period, medical therapy was successfully optimized and well tolerated, with few drug adverse effects leading to therapy cessation. Truly optimal medical therapy can be achieved in clinical trials, and translating this into longer‐term clinical practice should be a focus of future study. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02062593.
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Affiliation(s)
- Michael Foley
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - Christopher A Rajkumar
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - Matthew Shun-Shin
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | | | - Henry Seligman
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - James Howard
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - Alexandra N Nowbar
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - Thomas R Keeble
- Essex Cardiothoracic Centre Basildon UK.,Anglia Ruskin School of Medicine Chelmsford UK
| | - John R Davies
- Essex Cardiothoracic Centre Basildon UK.,Anglia Ruskin School of Medicine Chelmsford UK
| | | | | | - Peter O'Kane
- Royal Bournemouth and Christchurch NHS Trust Bournemouth UK
| | | | - Ricardo Petraco
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - Iqbal S Malik
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - Sukhjinder Nijjer
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - Sayan Sen
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - Darrel P Francis
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
| | - Rasha Al-Lamee
- National Heart and Lung InstituteImperial College London London UK.,Imperial College Healthcare NHS Trust London UK
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20
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Frank-Tewaag J, Bleek J, Horenkamp-Sonntag D, Marschall U, Zeymer U, Donner-Banzhoff N, Sundmacher L. Use of guideline-recommended drug therapy in patients undergoing percutaneous coronary intervention for stable coronary heart disease in Germany: a multilevel analysis of nationwide routine data. BMJ Open 2020; 10:e042886. [PMID: 33318120 PMCID: PMC7737102 DOI: 10.1136/bmjopen-2020-042886] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To determine the prescription of guideline recommended drug therapy in patients with stable coronary heart disease (sCHD) prior to percutaneous coronary intervention (PCI) in Germany and to examine the role of patient characteristics and features of regional healthcare supply in a multilevel model. DESIGN Secondary data analysis of factors associated with the prescription of guideline recommended drug therapy using a multilevel model to analyse regional-level effects, over and above the effects of patient-level demographic and health status. SETTING Office-based prescriptions in the year prior to the invasive procedure. PARTICIPANTS A linked nationwide dataset from Germany's three largest statutory health insurance funds of all patients receiving PCI in the year 2016. MAIN OUTCOME MEASURES Patients' odds of receiving optimal medical therapy and symptom-oriented therapy within 1 year prior to PCI. RESULTS 68.6% of patients received at least one lipid-lowering drug and one symptom-oriented therapy prior to PCI. 43.6% received at least two agents to control their symptoms. Patients who received treatment in accordance with the recommendations had a greater number of diagnosed risk factors, a more severe history of cardiac disease and used a higher volume of ambulatory office-based physician services. The prescriptions prevalence for the symptom-oriented therapies differed significantly between eastern and western Germany, with a higher prevalence in the eastern districts. CONCLUSIONS Guidelines can only provide decision-making corridors, and the applicability of recommendations must always be assessed on a case by case basis. Nevertheless, our analysis indicates that the prevalence of prescriptions in routine practice is subject to substantial variation and that conservative therapy options are not fully exhausted prior to PCI. This suggests that there might be room for improvement in the care of patients with sCHD.
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Affiliation(s)
- Julia Frank-Tewaag
- Department of Health Services Management, Munich School of Management, Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-University Munich, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
| | | | | | | | - Uwe Zeymer
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice/Family Medicine, Philipps-University Marburg, Marburg, Germany
| | - Leonie Sundmacher
- Chair of Health Economics, Technical University Munich, Munich, Germany
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Rajkumar CA, Foley M, Al-Lamee R. The Goldilocks Guide to Getting Medical Therapy 'Just Right': Insights From the ISCHEMIA Trial. Circ Cardiovasc Qual Outcomes 2019; 12:e006265. [PMID: 31718295 DOI: 10.1161/circoutcomes.119.006265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Christopher A Rajkumar
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.F., R.A.-L.).,Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.F., R.A.-L.)
| | - Michael Foley
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.F., R.A.-L.).,Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.F., R.A.-L.)
| | - Rasha Al-Lamee
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, United Kingdom (C.A.R., M.F., R.A.-L.).,Imperial College Healthcare NHS Trust, London, United Kingdom (C.A.R., M.F., R.A.-L.)
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