Potentially harmful drug prescription in elderly patients with heart failure with reduced ejection fraction

Aims

This study aimed to evaluate the prescription frequency of potentially harmful prescription drugs as defined in current heart failure guidelines among elderly patients with a diagnosis of heart failure with reduced ejection fraction and their association with clinical outcomes.

Methods and results

We used the Centers for Medicare & Medicaid Services data from a nationally representative 5% sample for the years 2014–2016 to identify patients admitted to acute care hospitals with a primary diagnosis of heart failure with reduced ejection fraction. The primary exposure was filling a prescription for a potentially harmful drug. Potentially harmful drug fills were treated as a time‐dependent covariate to examine their association on readmission and mortality. A total of 8993 patients met study criteria. Potentially harmful drugs were prescribed in 1077 (11.9%) patients within 90 days of discharge from the heart failure hospitalization. Non‐steroidal anti‐inflammatory agents were the most frequently prescribed potentially harmful drug (6.7%) followed by calcium channel blockers (4.7%), thiazolidinedione (0.59%), and select antiarrhythmic (0.33%). Factors independently associated with potentially harmful drug prescription were female gender, Hispanic ethnicity, severe obesity, among others. In the multivariable Cox model, the prescription of a potentially harmful drug was associated with an increased risk of readmission (hazard ratio 1.14; 95% confidence interval 1.05–1.23, P < 0.001). Among drug subgroups, only calcium channel blockers were associated with an increased risk of readmission (hazard ratio 1.225; 95% confidence interval 1.085–1.382, P = 0.0011).

Conclusions

In elderly patients discharged with a primary diagnosis of heart failure with reduced ejection fraction on guideline‐directed medical therapy, prescription of a potentially harmful drug was frequent. Calcium channel blockers were associated with an increased risk of readmission.

New insights to the mechanisms underlying atherosclerosis in rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory circumstance, which has been associated with increased risk of cardiovascular disease (CVD). Although RA management has been promoted, mortality rate due to CVD remains remarkable. Approximately, 50% of premature death cases in RA are attributable to CVD. RA patients develop atherosclerosis in a greater amount than the general population. Moreover, atherosclerotic lesions develop rapidly in RA patients and might be more susceptible to rupture. The inflammatory condition of RA, such as cytokines, abnormally activated immune cells, play a role in the initiation, perpetuation and exacerbation of atherosclerosis. RA and CVD have genetic and environmental contributing risk factors in common, implying to potential coincidence of both disorders. Accelerated atherosclerosis in RA is attributed to inflammation, which carries its role out both through modulation of traditional risk factors and direct effect on the vessel wall. Hence, anti-inflammatory medications in RA like tumor necrosis factor blockers might have a beneficial effect on preventing cardiovascular development. Increasing age, smoking, hypertension, male gender, hypercholesterolemia and diabetes are enumerated as traditional CVD risk factors. Hopefully, further understanding of the cardiovascular risk factors by perceiving the disease conditions behind CVD, will improve management of cardiovascular risks in patients with RA.

Chemical composition and anti-inflammatory activities of essential oil from Trachydium roylei

Chemical composition, anti-inflammatory activity, and cytotoxicity of essential oils obtained from the aerial parts of Trachydium roylei were investigated in this study. The chemical composition of T. roylei essential oil was analyzed using gas chromatography mass spectrometry. Fifty-nine components, representing 98.87% of the oils, were characterized. The oils were predominated by aromatic compounds and monoterpene hydrocarbons, and the main components were myristicin (25.35%), β-phellandrene (22.95%), elemicine (7.69%), isoelemicin (5.48%), and cedrol (5.26%). The anti-inflammatory activity of the oil in lipopolysaccharide-stimulated murine RAW 264.7 cells was evaluated. The oils downregulated the production of proinflammatory cytokines, including tumor necrosis factor-α, interleukin (IL)-1β, and IL-6, and significantly increased the anti-inflammatory cytokine IL-10 levels. Results indicated that the oils effectively inhibited the secretion of nitric oxide and prostaglandin E2 in lipopolysaccharide-stimulated macrophages. Western blot analyses were performed to determine whether the inhibitory effects of the oils on proinflammatory mediators (nitric oxide and prostaglandin E2) were related to the modulation of inducible nitric oxide synthase and cyclooxygenase-2 expression. These findings suggest that T. roylei essential oils exert an anti-inflammatory effect by regulating the expression of inflammatory cytokines.

Nonaspirin Nonsteroidal Anti-Inflammatory Drugs and Risk of Hemorrhagic Stroke

Background and Purpose—

The association between hemorrhagic stroke and use of nonsteroidal anti-inflammatory drugs (NSAIDs) is not well established. We conducted a systematic review and meta-analysis of observation studies to further characterize this possible association.

Methods—

Case–control and cohort studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing risk of hemorrhagic stroke among NSAIDs users versus nonusers were systematically searched. Point estimates from each study were extracted. Pooled risk ratios (RR) and 95% confidence intervals (CI) for all NSAIDs and individual NSAIDs were calculated using random-effect, generic inverse variance method.

Results—

Ten studies were identified and included in our data analysis. As a single group, NSAIDs use was associated with a small but insignificant risk of hemorrhagic stroke with the pooled RR of 1.09 (95% CI, 0.98–1.22). Individual NSAIDs analysis revealed a significantly increased risk among diclofenac and meloxicam users (RR 1.27; 95% CI, 1.02–1.59 and RR 1.27; 95% CI, 1.08–1.50, respectively). The risk estimate for rofecoxib users was higher, but statistically nonsignificant (RR 1.35; 95% CI, 0.88–2.06).

Conclusions—

Overall, the use of NSAIDs is not associated with an increased risk of hemorrhagic stroke, although this risk was modestly significantly elevated in diclofenac and meloxicam users.

Nonsteroidal Anti-inflammatory Drugs and Risk of Incident Heart Failure: A Systematic Review and Meta-analysis of Observational Studies

BACKGROUND

The association between the development of heart failure (HF) and use of nonsteroidal anti-inflammatory drugs (NSAIDs) is not well established.

HYPOTHESIS

Use of NSAIDs may increase the risk of incident HF.

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing risk of incident HF in NSAID users vs nonusers. Pooled risk ratios (RR) and 95% confidence intervals (CI) for all NSAIDs and both subclasses (conventional NSAIDs and highly selective cyclooxygenase-2 inhibitors [COXIBs]) were calculated using a random-effect, generic inverse variance method.

RESULTS

Seven studies with 7,543,805 participants were identified and included in our data analysis. Use of NSAIDs was associated with a significantly higher risk of developing HF, with a pooled RR of 1.17 (95% CI: 1.01-1.36). Subgroup analysis showed a significantly elevated risk among users of conventional NSAIDs (RR: 1.35, 95% CI: 1.15-1.57) but not users of COXIBs (RR: 1.03, 95% CI: 0.92-1.16).

CONCLUSIONS

A significantly elevated risk of incident HF was observed among users of NSAIDs.

Non-steroidal anti-inflammatory drugs and risk of heart failure exacerbation: A systematic review and meta-analysis

BACKGROUND

The association between exacerbation of heart failure (HF) and use of non-steroidal anti-inflammatory drugs (NSAIDs) has long been recognized but the data on this adverse effect are limited.

METHODS

To further characterize this possible association, we conducted a systematic review and meta-analysis of observation studies that reported odds ratio, relative risk, hazard ratio or standardized incidence ratio comparing risk of exacerbation of HF in patients with pre-existing HF who took NSAIDs versus non-users. Pooled risk ratios (RR) and 95% confidence intervals for conventional NSAIDs, celecoxib and rofecoxib were calculated using random-effect, generic inverse variance method.

RESULTS

Six studies were identified and included in our data analysis. Use of conventional NSAIDs was associated with a significantly higher risk of development of exacerbation of HF with the pooled RR of 1.39 (95% CI 1.20-1.62). Elevated risk was also observed among celecoxib and rofecoxib users (RR 1.34, 95% CI 0.98-1.85 and RR 2.04, 95% CI 1.68-2.48). The pooled RR of rofecoxib was significantly higher than conventional NSAIDs (p=0.02).

CONCLUSION

Use of NSAIDs is associated with an increased risk of HF exacerbation among patients with pre-existing HF. The excess risk was approximately 40% for conventional NSAIDs and celecoxib. The highest risk was observed among rofecoxib users.

Mechanism of QSYQ on anti-apoptosis mediated by different subtypes of cyclooxygenase in AMI induced heart failure rats

Background

Qi-shen-yi-qi (QSYQ), one of the most well-known traditional Chinese medicine (TCM) formulas, has been shown to have cardioprotective effects in rats with heart failure (HF) induced by acute myocardial infarction (AMI). However, the mechanisms of its therapeutic effects remain unclear. In this study, we aim to explore the mechanisms of QSYQ in preventing left ventricular remodelling in rats with HF. The anti-apoptosis an anti-inflammation effects of QSYQ were investigated.

Methods

Sprague–Dawley (SD) rats were randomly divided into 4 groups: sham group, model group, QSYQ treatment group and aspirin group. Heart failure model was induced by ligation of left anterior descending (LAD) coronary artery. 28 days after surgery, hemodynamics were detected. Echocardiography was adopted to evaluate heart function. TUNEL assay was applied to assess myocardial apoptosis rates. Protein expressions of cyclooxygenase1 and 2 (COX1and COX2), Fas ligand (FasL), P53 and MDM2 were measured by western-blot. RT-PCR was applied to detect expressions of our subtype receptors of PGE2 (EP1, 2, 3, and 4).

Results

Ultrasonography showed that EF and FS values decreased significantly and abnormal hemodynamic alterations were observed in model group compared to sham group. These indications illustrated that HF models were successfully induced. Levels of inflammatory cytokines (TNF-α and IL-6) in myocardial tissue were up-regulated in the model group as compared to those in sham group. Western-blot analysis showed that cyclooxygenase 2, which is highly inducible by inflammatory cytokines, increased significantly. Moreover, RT-PCR showed that expressions of EP2 and EP4, which are the receptors of PGE2, were also up-regulated. Increased expressions of apoptotic pathway factors, including P53 and FasL, might be induced by the binding of PGE2 with EP2/4. MDM2, the inhibitor of P53, decreased in model group. TUNEL results manifested that apoptosis rates of myocardial cells increased in the model group. After treatment with QSYQ, expressions of inflammatory factors, including TNF-α, IL-6 and COX2, were reduced. Expressions of EP2 and EP4 receptors also decreased, suggesting that PGE2-mediated apoptosis was inhibited by QSYQ. MDM2 was up-regulated and P53 and FasL in the apoptotic pathway were down-regulated. Apoptosis rates in myocardial tissue in the QSYQ group decreased compared with those in the model group.

Conclusions

QSYQ exerts cardiac protective efficacy mainly through inhibiting the inflammatory response and down-regulating apoptosis. The anti-inflammatory and anti-apoptosis efficacies of QSYQ are probably achieved by inhibition of COXs-induced P53/FasL pathway. These findings provide experimental evidence for the beneficial effects of QSYQ in the clinical application for treating patients with HF.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-015-0869-z) contains supplementary material, which is available to authorized users.

Defining the COX inhibitor selectivity of NSAIDs: implications for understanding toxicity

The hypothesis that the anti-inflammatory activity of NSAIDs derives from COX inhibition is well established. It also underpins the accepted mechanism of the gastrointestinal and renal toxicity of NSAIDs. However, in terms of NSAID-induced cardiovascular toxicity, is COX inhibition then guilty by association? Multiple experimental models of COX-1/COX-2 inhibition have enabled ranking of the relative inhibitory activity of NSAIDs. Inhibition is expressed as an IC(50) value and the index of COX selectivity as the ratio of the IC(50) value for COX-2 and COX-1. These data informed the 'imbalance hypothesis' that the cardiovascular risk of NSAIDs results from an imbalance in the detrimental actions of COX-1-derived thromboxane A(2) and the beneficial actions of COX-2-derived prostacyclin (PGI(2)). Data derived from in vitro models used to generate NSAID IC(50) values are discussed in the context of the difficulties in defining COX selectivity and hence understanding the toxicity of NSAIDs in current clinical use.

Room for improvement: unmet needs in postoperative pain management

Postoperative pain treatment is an important healthcare issue. However, the management of pain in patients after surgery remains insufficient. In the present review, several key areas important for postoperative pain management are discussed. New findings about efficacy and side effects of nonopioid analgesics, such as paracetamol, NSAIDs and COX-2 inhibitors, are presented and discussed in light of acute, short-term application in the perioperative period. Second, new findings about postoperative pain management in patients with preoperative pain and chronic opioid consumption are reported. Third, feasibility of the transversus abdominal plane block as a new and promising regional anesthesia technique is discussed. Finally, potential predictors, mechanisms and preventive treatment strategies of persistent chronic pain after surgery are presented.

Do the blood pressure effects of nonsteroidal antiinflammatory drugs influence cardiovascular morbidity and mortality?

There are many theories about why selective inhibitors of the second isoform of cyclooxygenase (COX-2) increase cardiovascular risk. Although torcetrapib raises blood pressure and cardiovascular risk, it has been difficult to prove such a link for COX-2 inhibitors in randomized clinical trials. This review shows a significant correlation in placebo-controlled trials between the five agents' elevations in blood pressures and their rate ratios for cardiovascular events. A larger body of evidence arises from randomized clinical trial comparisons of selective versus nonselective inhibitors of COX-2, but these results are heterogeneous for naproxen versus other traditional agents. The best current trial evidence comes from the centrally adjudicated placebo-controlled trials of celecoxib for colonic polyps: If the blood pressure did not rise at 1 or 3 years after randomization, cardiovascular risk did not significantly increase. Many more data will become available in 2013, after the only prospective clinical trial involving cardiovascular end points is completed.

Use of non-steroidal anti-inflammatory drugs and risk of incident myocardial infarction and heart failure, and all-cause mortality in the Australian veteran community

AIMS

We studied the association between either non-selective NSAIDs (ns-NSAIDs), selective COX-2 inhibitors, or any NSAID and risk of incident myocardial infarction (MI) and heart failure (HF), and all-cause mortality in elderly subjects.

METHODS

We conducted a retrospective nested case-control study on Australian veterans using nationwide hospital admission and pharmacy dispensing data. We estimated adjusted odds ratios (OR) with 95% confidence intervals (CI) for the risk of events for three different measures of prescription supply exposure over the last 2 years: (i) supplied at least once, (ii) supply frequency: supplied more than twice within the last 30 days, once or twice within the last 30 days, and once or more 30 days to 2 years and (iii) total supplies.

RESULTS

We identified 83 623 cases and 1 662 099 matched controls (1:20) contributing 3 862 931 persons-years of observation. NSAID use at least once within the last 2 years did not significantly affect the risk of MI (OR 1.00, 95% CI 0.96, 1.04) but was associated with a mildly reduced risk of HF (OR 0.95, 95% CI 0.92, 0.98). There was a reduced all-cause mortality with at least one supply of either ns-NSAIDs (OR 0.94, 95% CI 0.90, 0.97), selective COX-2 inhibitors (OR 0.90, 95% CI 0.88, 0.93), or any NSAID (OR 0.87, 95% CI 0.85, 0.90). Risk of death was also inversely associated with the number of prescription supplies.

CONCLUSIONS

NSAID use is not associated with an increased risk of incident MI and HF but is associated with a reduction in all-cause mortality in Australian veterans.