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Oristrell G, Ribera A. [Evolution of the prognosis of acute myocardial infarction]. Med Clin (Barc) 2023; 160:118-120. [PMID: 36049971 DOI: 10.1016/j.medcli.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Gerard Oristrell
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, España; Centro de Investigación Biomédica en Red - Enfermedades Cardiovasculares (CIBER CV), Madrid, España.
| | - Aida Ribera
- Grupo de Investigación en Envejecimiento, Fragilidad y Transiciones (REFiT), Parc Sanitari Pere Virgili e Instituto de Investigación Vall d'Hebron (VHIR), Barcelona, España; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), España
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Sanchis J, García Acuña JM, Raposeiras S, Barrabés JA, Cordero A, Martínez-Sellés M, Bardají A, Díez-Villanueva P, Marín F, Ruiz-Nodar JM, Vicente-Ibarra N, Alonso Salinas GL, Rigueiro P, Abu-Assi E, Formiga F, Núñez J, Núñez E, Ariza-Solé A. Carga de comorbilidad y beneficio de la revascularización en ancianos con síndrome coronario agudo. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.06.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Prognostic Utility of the Combination of Platelet Count with Neutrophil-to-Lymphocyte Ratio in Aged Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Emerg Med Int 2021; 2021:4023472. [PMID: 33981459 PMCID: PMC8088355 DOI: 10.1155/2021/4023472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 01/02/2023] Open
Abstract
Method This was a study recording 637 patients who were diagnosed with acute myocardial infarction. Our patients were grouped according to the combination of platelet count and neutrophil-to-lymphocyte ratio. The prognostic role of the combination of platelet count and neutrophil-to-lymphocyte ratio on mortality was assessed by the univariate and multivariate Cox regression analysis. Result Our study population was divided into three parts according to the median values of platelet count and neutrophil-to-lymphocyte ratio. It was indicated that platelet count and neutrophil-to-lymphocyte ratio were correlative mutually to a certain degree (p=0.010). The Kaplan–Meier analysis showed that the combination of high platelet count and high neutrophil-to-lymphocyte ratio had a greater risk of death in short- and long-term endpoints (log-rank p=0.046, p < 0.001, respectively). Moreover, by multivariate analysis, both high platelet count and high neutrophil-to-lymphocyte ratio groups were an independent predictor (hazard ratio: 2.132, 95% confidence interval: 1.020–4.454, p=0.044) and long-term mortality (hazard ratio: 2.791, 95% confidence interval: 1.406–5.538, p=0.003). Conclusion The combination of platelet count and neutrophil-to-lymphocyte ratio could be a useful predictor for the prediction of in-hospital and long-term mortality in aged patients with acute myocardial infarction.
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Ilagan-Ying YC, Xu J, Lim JK, Do A. Low real-world eligibility rates for nonalcoholic steatohepatitis patients for phase 3 clinical trial criteria application in a large academic health system. Eur J Gastroenterol Hepatol 2021; 33:424-429. [PMID: 32433419 PMCID: PMC7674230 DOI: 10.1097/meg.0000000000001758] [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] [Indexed: 12/10/2022]
Abstract
OBJECTIVE Nonalcoholic steatohepatitis (NASH) is the most common liver disease in the USA. Clinical trials have stringent study criteria which may limit real-world generalizability. Thus, we studied whether a real-world, university-based cohort of patients could be eligible for a pivotal phase 3 NASH clinical trial. METHODS We queried Yale-New Haven Health System electronic medical records for patients with a diagnosis of NASH from 2013 to 2017. Of those who received liver biopsy, we extracted demographic, clinical, laboratory, and biopsy data. We compared patient characteristics to enrollment criteria of the Randomized Global Phase 3 Study to Evaluate the Impact on NASH with Fibrosis of Obeticholic Acid Treatment. RESULTS Of 14 403 patients with NASH, 478 (3.3%) completed liver biopsy, of whom 237 (49.6%) had histological confirmation by a gastrointestinal pathologist. Histologically-confirmed NASH patients were 51.1 ± 13.2 years old, 56.5% female, 69.6% white race, and 24.6% had cirrhosis. In this group, 68 (28.7%) patients met all inclusion criteria, 87 (36.7%) had no exclusions, and 34 (14.4%) met all enrollment criteria. Other than cirrhosis, common reasons for ineligibility were presence of medical comorbidity (n = 83) or laboratory abnormalities (n = 47). Multiple logistic regression did not reveal significant predictors of eligibility. CONCLUSION Within a university-based cohort of NASH patients, few met phase 3 clinical trial enrollment criteria, mostly due to low rates of liver biopsy. Of those with histologic confirmation, 14.4% met enrollment criteria. Validation of generalizability for safety and efficacy of NASH investigational agents in real-world populations is needed.
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Affiliation(s)
- Ysabel C. Ilagan-Ying
- Yale University School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale University School of Medicine
| | - Jin Xu
- Department of Internal Medicine, Yale University School of Medicine
| | - Joseph K. Lim
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Albert Do
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
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Gündoğmuş PD, Ölçü EB, Öz A, Tanboğa İH, Orhan AL. The effects of percutaneous coronary intervention on mortality in elderly patients with non-ST-segment elevation myocardial infarction undergoing coronary angiography. Scott Med J 2020; 65:81-88. [PMID: 32772677 DOI: 10.1177/0036933020919931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Although it is recommended that elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) should undergo an assessment for invasive revascularization, these patients undergo fewer coronary interventions despite the current guidelines. The aim of the study is to evaluate the effectiveness of percutaneous coronary intervention on all-cause mortalities monthly and annually in the population. METHODS Three hundred and twenty-four patients with NSTEMI aged 65 years or older who underwent coronary angiography and treated with conservative strategy or percutaneous coronary intervention were included in the study. All demographic and clinical characteristics of the patients were recorded and one-month and one-year follow-up results were analysed. RESULTS Two hundred eight cases (64.19%) were treated with percutaneous coronary intervention and 116 cases (35.81%) of the participant were treated with conservative methods. The mean age of the participants was 75.41 ± 6.65 years. The treatment strategy was an independent predictor for the mortality of one-year (HR: 1.965). Furthermore, Killip class ≥2 (HR:2.392), Left Ventricular Ejection Fraction (HR:2.637) and renal failure (HR: 3.471) were independent predictors for one-year mortality. CONCLUSION The present study has revealed that percutaneous coronary intervention was effective on one-year mortality in NSTEMI patients over the age of 65. It is considered that percutaneous coronary intervention would decrease mortality in these patients but it should be addressed in larger population studies.
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Affiliation(s)
- Pınar D Gündoğmuş
- Medical Doctor, Department of Cardiology, 29 Mayıs State Hospital, Ankara/Turkey
| | - Emrah B Ölçü
- Medical Doctor, Department of Cardiology, Sultan Abdulhamid Han Training and Research Hospital, Istanbul/Turkey
| | - Ahmet Öz
- Medical Doctor, Department of Cardiology, Sultan Abdulhamid Han Training and Research Hospital, Istanbul/Turkey
| | - İbrahim H Tanboğa
- Medical Doctor, Department of Cardiology, Hisar Hospital, Istanbul/Turkey
| | - Ahmet L Orhan
- Medical Doctor, Department of Cardiology, Sultan Abdulhamid Han Training and Research Hospital, Istanbul/Turkey
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Sanchis J, García Acuña JM, Raposeiras S, Barrabés JA, Cordero A, Martínez-Sellés M, Bardají A, Díez-Villanueva P, Marín F, Ruiz-Nodar JM, Vicente-Ibarra N, Alonso Salinas GL, Rigueiro P, Abu-Assi E, Formiga F, Núñez J, Núñez E, Ariza-Solé A. Comorbidity burden and revascularization benefit in elderly patients with acute coronary syndrome. ACTA ACUST UNITED AC 2020; 74:765-772. [PMID: 32778402 DOI: 10.1016/j.rec.2020.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/11/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND OBJECTIVES To evaluate the interaction between comorbidity burden and the benefits of in-hospital revascularization in elderly patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). METHODS This retrospective study included 7211 patients aged ≥ 70 years from 11 Spanish NSTEACS registries. Six comorbidities were evaluated: diabetes, peripheral artery disease, cerebrovascular disease, chronic pulmonary disease, renal failure, and anemia. A propensity score was estimated to enable an adjusted comparison of in-hospital revascularization and conservative management. The end point was 1-year all-cause mortality. RESULTS In total, 1090 patients (15%) died. The in-hospital revascularization rate was 60%. Revascularization was associated with lower 1-year mortality; the strength of the association was unchanged by the addition of comorbidities to the model (HR, 0.61; 95%CI, 0.53-0.69; P=.0001). However, the effects of revascularization were attenuated in patients with renal failure, peripheral artery disease, and chronic pulmonary disease (P for interaction=.004, .007, and .03, respectively) but were not modified by diabetes, anemia, and previous stroke (P=.74, .51, and .28, respectively). Revascularization benefits gradually decreased as the number of comorbidities increased (from a HR of 0.48 [95%CI, 0.39-0.61] with 0 comorbidities to 0.83 [95%CI, 0.62-1.12] with ≥ 5 comorbidities; omnibus P=.016). The results were similar for the propensity score model. The same findings were obtained when invasive management was considered the exposure variable. CONCLUSIONS In-hospital revascularization improves 1-year mortality regardless of comorbidities in elderly patients with NSTEACS. However, the revascularization benefit is progressively reduced with an increased comorbidity burden. Renal failure, peripheral artery disease, and chronic lung disease were the comorbidities with the most detrimental effects on revascularization benefits.
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Affiliation(s)
- Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Jose María García Acuña
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - Sergio Raposeiras
- Servicio de Cardiología. Hospital Álvaro Cunqueiro de Vigo, Vigo, Pontevedra, Spain
| | - Jose A Barrabés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Alberto Cordero
- Servicio de Cardiología, Hospital Clínico Universitario de San Juan, Alicante, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Alfredo Bardají
- Servicio de Cardiología, Hospital Universitario de Tarragona Joan XXIII, IISPV, Universitat Rovira i Virgili, Tarragona, Spain
| | | | - Francisco Marín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, El Palmar, Murcia, Spain
| | - Juan M Ruiz-Nodar
- Servicio de Cardiología, Hospital General Universitario de Alicante, Alicante, Spain
| | | | - Gonzalo L Alonso Salinas
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain
| | - Pedro Rigueiro
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - Emad Abu-Assi
- Servicio de Cardiología. Hospital Álvaro Cunqueiro de Vigo, Vigo, Pontevedra, Spain
| | - Frances Formiga
- Servicio de Medicina Interna, Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Eduardo Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Albert Ariza-Solé
- Servicio de Cardiología, Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Bardaji A, Barrabés JA, Ribera A, Bueno H, Fernández-Ortiz A, Marrugat J, Oristrell G, Ferreira-González I. Revascularisation in older adult patients with non-ST-segment elevation acute coronary syndrome: effect and impact on 6-month mortality. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:358-366. [PMID: 31084380 DOI: 10.1177/2048872619849922] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although revascularisation in non-ST-segment elevation acute coronary syndrome (NSTEACS) is associated with better outcomes, its impact in older adult patients is unclear. This is a retrospective analyses of three national NSTEACS registries conducted during the past decade in Spain. Patients aged 75 years and older were included: DESCARTES (DES; year 2002; n=534), MASCARA (MAS; 2005; n=1736) and DIOCLES (DIO; 2012; n=593). The adjusted association between revascularisation and total (inhospital and 6-month) mortality was estimated by two-stage meta-analysis (pooled effect across the three registries with inverse-variability weights) and one-stage meta-analysis (multilevel model with random effects across studies). The impact of revascularisation was assessed comparing the observed and the expected mortality based on a logistic regression model in the pooled database. Although revascularisation was associated with a lower risk of mortality in meta-analyses (two-stage: odds ratio 0.44, 95% confidence interval 0.29-0.67; one-stage: odds ratio 0.54, 95% confidence interval 0.36-0.81) and the revascularisation rate increased steadily from 2002 (DES 14.2%) to 2012 (DIO 43.7%), its impact was not patent across registries, probably because this increase was concentrated in low and medium-risk GRACE strata (tertile 1, 2 and 3: MAS 59%, 20% and 6%; DIO 64%, 39% and 19%, respectively). In conclusion, a consistent increase of revascularisation in NSTEACS in older adults was not followed by a decrease in mortality at 6 months, probably because the impact of this strategy is limited to the higher risk population, the stratum with the lowest revascularisation rate in real life.
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Affiliation(s)
- Alfredo Bardaji
- Servicio de Cardiología, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - José A Barrabés
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Aida Ribera
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Héctor Bueno
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Jaume Marrugat
- Grupo de Epidemiología y Genética Cardiovascular, Instituto Hospital del Mar de Investigaciones Médicas, Barcelona, Spain
| | - Gerard Oristrell
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Adamski P, Adamska U, Ostrowska M, Navarese EP, Kubica J. Evaluating current and emerging antithrombotic therapy currently available for the treatment of acute coronary syndrome in geriatric populations. Expert Opin Pharmacother 2018; 19:1415-1425. [PMID: 30132731 DOI: 10.1080/14656566.2018.1510487] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Acute coronary syndromes (ACS) represent one of the most perilous presentations of ischemic heart disease. Temporal trends clearly demonstrate that ACS occur later and later in life. Elderly patients with ACS comprise a populous and growing group, with more than half of individuals presenting with myocardial infarction being 75 years or older. Nevertheless, geriatric patients are greatly underrepresented in the landmark ACS trials evaluating innovative pharmacological strategies. AREAS COVERED The authors critically summarize recently published research on contemporary and emerging antithrombotic therapy for the treatment of ACS in geriatric patients. EXPERT OPINION Elderly ACS patients are characterized by simultaneously increased risk of cardiovascular events and bleeding. Very few studies assessing the efficacy and safety of novel ACS pharmacotherapy in geriatric patients are currently available. Guidelines on the treatment of ACS are based on the overall results of major randomized clinical trials (RCTs), and data supporting the recommended therapy in elderly mainly derive from subanalyses of these RCTs. Properly designed and powered RCTs are necessary to properly evaluate the net effect of current and emerging pharmacotherapy in geriatric patients. Until such data are available, elderly ACS patients should receive treatment according to the general recommendations.
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Affiliation(s)
- Piotr Adamski
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Urszula Adamska
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | | | - Eliano Pio Navarese
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland.,b Interventional Cardiology and Cardiovascular Medicine Research, Inova Center for Thrombosis Research and Drug Development , Inova Heart and Vascular Institute , Falls Church , VA , USA.,c SIRIO MEDICINE Research Network, Inova Heart and Vascular Institute, Inova Center for Thrombosis Research and Drug Development , Fairfax , VA , USA
| | - Jacek Kubica
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
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Rymer JA, Tempelhof MW, Clare RM, Pieper KS, Granger CB, Van de Werf F, Moliterno DJ, Harrington RA, White HD, Armstrong PW, Lopes RD, Mahaffey KW, Newby LK. Discharge timing and outcomes after uncomplicated non-ST-segment elevation acute myocardial infarction. Am Heart J 2018; 201:103-110. [PMID: 29910048 DOI: 10.1016/j.ahj.2018.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 04/14/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Length of stay after non-ST-segment elevation myocardial infarction (NSTEMI) continues to decrease, but information to guide duration of hospitalization is limited. METHODS We used landmark analyses, in which the landmark defined potential days of discharge, to estimate complication rates on the first day the patient would have been out of the hospital, and estimated associations between timing of discharge and 30-day and 1-year event-free survival after discharge among NSTEMI patients. RESULTS Among 20,410 NSTEMI patients, median length of stay was 7 (4, 12) days; 3,209 (15.7%) experienced a cardiac complication on days 0 to 2 and 1,322 (6.5%) were discharged without complications during hospital days 0 to 2. At the start of day 3, 15,879 patients (77.8%) were still hospitalized without complications. Of these, 1,689 (10.6%) were discharged event-free on day 3. Adjusted event-free survival rates of death or myocardial infarction from day 4 to 30 days after among the 1,689 patients was 99.1% compared with 93.1% for the 14,190 who remained hospitalized at the end of day 3. For 1-year mortality, these rates were 98.1% and 96.4%, respectively. Among 13,334 patients hospitalized without complications at the start of day 4, 1,706 were discharged event-free that day. Adjusted survival rates among these patients, compared with those still hospitalized at the end of day 4, were 98.0% versus 93.7% for 30-day death or myocardial infarction and 97.8% versus 96.1% for 1-year mortality. CONCLUSIONS Patients with NSTEMI who had no serious complications during the first 2 hospital days were at low risk of subsequent short- and intermediate-term death or ischemic events.
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Patel KK, Arnold SV, Jones PG, Qintar M, Alexander KP, Spertus JA. Relation of Age and Health-Related Quality of Life to Invasive Versus Ischemia-Guided Management of Patients with Non-ST Elevation Myocardial Infarction. Am J Cardiol 2018; 121:789-795. [PMID: 29397885 DOI: 10.1016/j.amjcard.2017.12.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 12/14/2017] [Accepted: 12/27/2017] [Indexed: 01/30/2023]
Abstract
In older patients with non-ST-elevation myocardial infarction, an initial invasive strategy reduces cardiovascular events compared with an ischemia-guided approach; however its association with health status outcomes is unknown. Among patients with non-ST-elevation myocardial infarction from 2 multicenter US acute myocardial infarction (AMI) registries, health status was assessed at baseline and at 1, 6, and 12 months after AMI using the Seattle Angina Questionnaire (SAQ) and the 12-item Short-Form Health Survey (SF-12). Routine invasive management was defined as coronary angiography within 72 hours of admission without a preceding stress test. Among 3,559 patients with NSTEMI, 2,455 (69.0%) were treated with routine invasive treatment, which was more common in younger patients. In propensity-adjusted analyses, invasive treatment was associated with higher SAQ physical limitation, angina frequency, and summary scores over the year after AMI; however, the differences were small (<5 points, all p <0.05). Although there was a trend toward worse health status in patients aged ≥85 years treated with an initial invasive treatment, the interaction between age and treatment for any health status measure (all p ≥0.09) was not significant, except for SF-12 physical component score (p = 0.02), where worse scores were observed with invasive treatment in patients 85 years or older. In conclusion, an initial invasive treatment for patients with NSTEMI is associated with a small benefit in health status of marginal clinical significance, mainly in younger patients. The oldest old group trended toward less health status benefit from a routine invasive strategy-results that will need to be confirmed in a larger study.
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Affiliation(s)
- Krishna K Patel
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri.
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
| | - Mohammed Qintar
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
| | - Karen P Alexander
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
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Liu E, Hsueh L, Kim H, Vidovich MI. Global geographical variation in patient characteristics in percutaneous coronary intervention clinical trials: A systematic review and meta-analysis. Am Heart J 2018; 195:39-49. [PMID: 29224645 DOI: 10.1016/j.ahj.2017.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 09/02/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND We sought to determine whether there are differences in enrolled patients' risk factors in published percutaneous coronary intervention (PCI) trials between various continents. METHODS We systematically identified clinical trials evaluating PCI interventions through PubMed. We reviewed 701 studies between 1990 and 2014 from North America (N=135), Europe (N=403), and Asia (N=163), examining the prevalence of cardiovascular risk factors-hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HL), smoking, sex, and body mass index. We performed meta-regression with random- and mixed-effects models to compare patient baseline characteristics between continents and linear meta-regression analysis to test trends over time. RESULTS In meta-regression with random-effects model, North American trials recruited the lowest proportion of male participants (71.32%), followed by Asian (74.41%) and European trials (76.47%; P<.0001). North American trials enrolled the highest proportion of patients with HTN (63.17%, P=.0035) and HL (63.72%, P<.0001), whereas Asia enrolled the highest proportion of DM patients (29.64%, P<.0001) and smoking (38.41%, P=.0144). When adjusting for other moderators such as publication date, body mass index, and sex in meta-regression with mixed-effects model, age was significantly positively correlated with HTN, HL, DM, and smoking (P<.001). Body mass index was significantly higher in Europe and North America than in Asia. All enrollment risk factors demonstrated (β<0.02) statistically significant temporal trends over time, except for sex. CONCLUSIONS There are major continental differences in risk factors among patients enrolled in PCI trials from various continents. Clinical trial results may not be applicable to patient populations from another region.
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Yang Q, Wang Y, Liu J, Liu J, Hao Y, Smith SC, Huo Y, Fonarow GC, Ma C, Ge J, Taubert KA, Morgan L, Guo Y, Wang W, Zhou Y, Zhao D. Invasive Management Strategies and Antithrombotic Treatments in Patients With Non–ST-Segment–Elevation Acute Coronary Syndrome in China. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004750. [DOI: 10.1161/circinterventions.116.004750] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 05/12/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Qing Yang
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Ying Wang
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Jing Liu
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Jun Liu
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Yongchen Hao
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Sidney C. Smith
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Yong Huo
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Gregg C. Fonarow
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Changsheng Ma
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Junbo Ge
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Kathryn A. Taubert
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Louise Morgan
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Yang Guo
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Wei Wang
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Yujie Zhou
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
| | - Dong Zhao
- From the Department of Epidemiology (Q.Y., Y.W., Jing Liu, Jun Liu, Y.H., Y.G., W.W., D.Z.) and Department of Cardiology (Q.Y., C.M., Y.Z.), Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, China; Department of Cardiology, University of North Carolina, Chapel Hill (S.C.S.); Department of Cardiology, Peking University First Hospital, China (Y.H.); Department of Cardiology, University of California, Los Angeles (G.C.F.); Department of
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13
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Bourgeois FT, Orenstein L, Ballakur S, Mandl KD, Ioannidis JPA. Exclusion of Elderly People from Randomized Clinical Trials of Drugs for Ischemic Heart Disease. J Am Geriatr Soc 2017; 65:2354-2361. [PMID: 28306144 DOI: 10.1111/jgs.14833] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To measure exclusion of elderly adults from randomized trials studying drug interventions for ischemic heart disease (IHD) and describe the characteristics of these trials. DESIGN Cross-sectional analysis. SETTING Interventional clinical trials studying a drug intervention for IHD that started in 2006 and after were identified in ClinicalTrials.gov. Data were extracted on study features, including age-based inclusion criteria. Data on participants and their age distribution were collected from trial publications, investigator inquiry, and result data in ClinicalTrials.gov. PARTICIPANTS Individuals aged 65 and older. MEASUREMENTS Proportion of trials excluding individuals based on age, mean age of trial participants, and proportion of enrolled participants aged 65 and older and 75 and older. RESULTS Of 839 identified trials, 446 (53%) explicitly excluded elderly adults. The most-frequent upper age limits were 80 (n = 164) and 75 (n = 114), with a median upper age limit of 80 (interquartile range 75-80). Trials with upper age limit exclusions tended to be smaller (median number of participants 100 vs 201, P < .001) and were more likely to be funded primarily by nonindustry sources (78.3% vs 70.0%, P = .006). The overall mean age of trial participants was 62.7 (mean maximum age 74). The estimated proportion of participants aged 65 and older was 42.5% and the estimated proportion aged 75 and older was 12.3%. CONCLUSION Despite the high burden of IHD in elderly adults, the majority of drug trials do not enroll participants reflective of age-related prevalence of the disease.
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Affiliation(s)
- Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - Liat Orenstein
- Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - Sarita Ballakur
- Faculty of Arts and Sciences, Brown University, Providence, Rhode Island
| | - Kenneth D Mandl
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.,Computational Health Informatics Program, Boston Children's Hospital, Boston, Massachusetts
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, School of Medicine, Stanford University, Stanford, California.,Department of Health Research and Policy, School of Medicine, Stanford University, Stanford, California
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14
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Armaganijan LV, Alexander KP, Huang Z, Tricoci P, Held C, Van de Werf F, Armstrong PW, Aylward PE, White HD, Moliterno DJ, Wallentin L, Chen E, Harrington RA, Strony J, Mahaffey KW, Lopes RD. Effect of age on efficacy and safety of vorapaxar in patients with non-ST-segment elevation acute coronary syndrome: Insights from the Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRACER) trial. Am Heart J 2016; 178:176-84. [PMID: 27502866 DOI: 10.1016/j.ahj.2016.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 05/27/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antithrombotic therapy plays an important role in the treatment of non-ST-segment elevation acute coronary syndromes (NSTE ACS) but is associated with bleeding risk. Advanced age may modify the relationship between efficacy and safety. METHODS Efficacy and safety of vorapaxar (a protease-activated receptor 1 antagonist) was analyzed across ages as a continuous and a categorical variable in the 12,944 patients with NSTE ACS enrolled in the TRACER trial. To evaluate the effect of age, Cox regression models were developed to estimate hazard ratios (HRs) with the adjustment of other baseline characteristics and randomized treatment for the primary efficacy composite of cardiovascular death, myocardial infarction (MI), stroke, recurrent ischemia with rehospitalization, or urgent coronary revascularization, and the primary safety composite of moderate or severe Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) bleeding. RESULTS The median age of the population was 64years (25th, 75th percentiles = 58, 71). Also, 1,791 patients (13.8%) were ≤54years of age, 4,968 (38.4%) were between 55 and 64 years, 3,979 (30.7%) were between 65 and 74 years, and 2,206 (17.1%) were 75years or older. Older patients had higher rates of hypertension, renal insufficiency, and previous stroke and worse Killip class. The oldest age group (≥75years) had substantially higher 2-year rates of the composite ischemic end point and moderate or severe GUSTO bleeding compared with the youngest age group (≤54years). The relationships between treatment assignment (vorapaxar vs placebo) and efficacy outcomes did not vary by age. For the primary efficacy end point, the HRs (95% CIs) comparing vorapaxar and placebo in the 4 age groups were as follows: 1.12 (0.88-1.43), 0.88 (0.76-1.02), 0.89 (0.76-1.04), and 0.88 (0.74-1.06), respectively (P value for interaction = .435). Similar to what was observed for efficacy outcomes, we did not observe any interaction between vorapaxar and age on bleeding outcomes. For the composite of moderate or severe bleeding according to the GUSTO classification, the HRs (95% CIs) comparing vorapaxar and placebo in the 4 age groups were 1.73 (0.89-3.34), 1.39 (1.04-1.86), 1.10 (0.85-1.42), and 1.73 (1.29-2.33), respectively (P value for interaction = .574). CONCLUSION Older patients had a greater risk for ischemic and bleeding events; however, the efficacy and safety of vorapaxar in NSTE ACS were not significantly influenced by age.
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Affiliation(s)
| | | | - Zhen Huang
- Duke Clinical Research Institute, Durham, NC
| | | | - Claes Held
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Frans Van de Werf
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Philip E Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Center, Adelaide, Australia
| | - Harvey D White
- Green Lane Cardiovascular Service, Auckland, New Zealand
| | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Edmond Chen
- Bayer HealthCare Pharmaceuticals Inc, Whippany, NJ
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