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Loeb M, Roy A, Dokainish H, Dans A, Palileo-Villanueva LM, Karaye K, Zhu J, Liang Y, Goma F, Damasceno A, Alhabib KF, Yonga G, Mondo C, Almahmeed W, Al Mulla A, Thanabalan V, Rao-Melacini P, Grinvalds A, McCready T, Bangdiwala SI, Yusuf S. Influenza vaccine to reduce adverse vascular events in patients with heart failure: a multinational randomised, double-blind, placebo-controlled trial. Lancet Glob Health 2022; 10:e1835-e1844. [PMID: 36400089 DOI: 10.1016/s2214-109x(22)00432-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/22/2022] [Accepted: 09/29/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Influenza increases the risk of cardiovascular events and deaths. We aimed to see whether influenza vaccination reduces death and vascular events in patients with heart failure. METHODS We did a pragmatic, randomised, double-blind, placebo-controlled trial in 30 centres (mostly hospitals affliated with universities or a research institute) in ten countries in Asia, the Middle East, and Africa (7 in India, 4 in Philippines, 4 in Nigeria, 6 in China, 1 in Zambia, 2 in Mozambique, 3 in Saudi Arabia, 1 in Kenya, 1 in Uganda, and 1 in Zambia). Participants (aged ≥18 years; 52·1% female; not disaggregated by race or ethnicity) with heart failure (New York Heart Association class II, III, or IV) were randomly assigned (1:1) by a centralised web-based system with block randomisation stratified by site, to receive 0·5 ml intramuscularly once a year for up to 3 years of either inactivated standard dose influenza vaccine or placebo (saline). We excluded people who had received influenza vaccine in 2 of the previous 3 years, and those likely to require valve repair or replacement. Those who administered assigned treatments were not masked and had no further role in the study. Investigators, study coordinators, outcome adjudicators, and participants were masked to group assignment. The first of two co-primary outcomes was a first-event composite for cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke, and the second was a recurrent-events composite for cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalisation for heart failure. Outcomes were assessed every 6 months in the intention-to-treat population. Secondary outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, all-cause hospitalisation, hospitalisation for heart failure, and pneumonia, both overall and during periods of peak influenza exposure. This study is registered with ClinicalTrials.gov, NCT02762851. FINDINGS Between June 2, 2015, and Nov 21, 2021, we enrolled 5129 participants and randomly assigned (1:1) 2560 (50·0%) to influenza vaccine and 2569 (50·0%) to placebo. The first co-primary outcome occurred in 380 (14·8%) of 2560 participants in the vaccine group and 410 (16·0%) of 2569 participants in the placebo group (hazard ratio [HR] 0·93 [95% CI 0·81-1·07]; p=0·30). The second co-primary outcome occurred in 754 (29·5%) of 2560 participants in the vaccine group and 819 (31·9%) of 2569 participants in the placebo group; HR 0·92 [95% CI 0·84-1·02]; p=0·12). The secondary outcomes of all-cause hospitalisations (HR 0·84 [95% CI 0·74-0·97]; p=0·013) and pneumonia (HR 0·58 [0·42-0·80]; p=0·0006) were significantly reduced in the vaccine group compared with in the placebo group but there was no significant difference between groups for all-cause death, cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalisation for heart failure. In a prespecified analysis, in which events were limited to periods of peak influenza circulation, the first co-primary outcome, and the secondary outcomes of all-cause death, cardiovasular death, and pneumonia were significantly lower in the vaccinated group than in the placebo group, whereas the second co-primary outcome and the secondary outcomes of non-fatal myocardial infarction, non-fatal stroke, all-cause hospitalisation, and hospitalisation for heart failure were not significantly lower. INTERPRETATION Although the prespecified co-primary outcomes during the entire period of observation were not statistically significant, the reduction during the peak influenza circulating period suggests that there is likely to be a clinical benefit of giving influenza vaccine, given the clear reduction in pneumonia, a moderate reduction in hospitalisations, and a reduction in cardiovascular events and deaths during periods of peak circulation of influenza. Taken in conjunction with previous trials and the observational studies, the collective data suggest benefit. FUNDING UK Joint Global Health Trials Scheme and Canadian Institutes for Health Research Foundation.
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Affiliation(s)
- Mark Loeb
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Ambuj Roy
- All India Institute of Medical Sciences, Delhi, India
| | | | - Antonio Dans
- Department of Medicine, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Lia M Palileo-Villanueva
- Department of Medicine, College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Kamilu Karaye
- Department of Medicine, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Jun Zhu
- Department of Cardiovascular Medicine, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Liang
- Department of Cardiovascular Medicine, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fastone Goma
- Department of Physiological Sciences, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Albertino Damasceno
- Department of Medicine, Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Khalid F Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Gerald Yonga
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya
| | | | - Wael Almahmeed
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Arif Al Mulla
- Division of Cardiology, Cardiac Sciences Institute, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Vitheya Thanabalan
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Alex Grinvalds
- Population Health Research Institute, Hamilton, ON, Canada
| | - Tara McCready
- Population Health Research Institute, Hamilton, ON, Canada
| | - Shrikant I Bangdiwala
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Salim Yusuf
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
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Jan RK, Alsheikh-Ali A, Mulla AA, Sulaiman K, Panduranga P, Al-Mahmeed W, Bazargani N, Al-Suwaidi J, Al-Jarallah M, Al-Motarreb A, Salam A, Al-Zakwani I. Outcomes of guideline-based medical therapy in patients with acute heart failure and reduced left ventricular ejection fraction: Observations from the Gulf acute heart failure registry (Gulf CARE). Medicine (Baltimore) 2022; 101:e29452. [PMID: 35687781 PMCID: PMC9276384 DOI: 10.1097/md.0000000000029452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/22/2022] [Indexed: 01/04/2023] Open
Abstract
This study aimed to report on the use, predictors and outcomes of guideline-based medical therapy (GBMT) in patients with acute heart failure (HF) with reduced ejection fraction of <40% (HFrEF), from seven countries in the Arabian Gulf.Patients with acute HFrEF (N = 2680), aged 18 years or older, and hospitalized February-November 2012 were recruited and data were collected post discharge at 3 months (n = 2477) and 1 year (n = 2418). The use and doses of GBMT were evaluated as per European, American and Canadian HF guidelines. Analyses were performed using multivariate logistic regression. This study was registered at clinicaltrials.gov (NCT01467973).The majority of patients were on dual (39%) and triple (39%) GBMT modalities, 14% received one GBMT medication, while 7.2% were not on any GBMT medications. On admission, 80% of patients were on renin-angiotensin system (RAS) blockers, 75% on b-blockers and 56% on mineralocorticoid receptor antagonists (MRAs), with a small proportion of these patients were taking target doses (RAS blockers 13%, b-blockers 7.3%, MRAs 14%). Patients taking triple GBMT were younger (P < .001), less likely to have comorbidities such as diabetes mellitus (P < .001) and CKD/dialysis (P < .001), less likely to receive in-hospital invasive treatments (P < .001), and more likely to be treated by a cardiologist (P < .001), than patients on a single medication. Patients taking triple GBMT showed significantly reduced all-cause mortality both at 3-months (P = .048), and at 12-months (P = .003), compared to patients taking no GBMT.Triple GBMT prescribing and dosing in patients with HFrEF were suboptimal in the Arabian Gulf. Further studies are required to investigate GBMT utilization and dosing in the outpatient setting.
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Affiliation(s)
- Reem K. Jan
- College of Medicine, Mohammed Bin Rashid University of Medicine & Health Sciences, Dubai, UAE
| | - Alawi Alsheikh-Ali
- College of Medicine, Mohammed Bin Rashid University of Medicine & Health Sciences, Dubai, UAE
| | - Arif Al Mulla
- Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, UAE
| | - Kadhim Sulaiman
- Department of Cardiology, Royal Hospital, Muscat, Oman
- Director General of Specialized Medical Care, Ministry of Health, Muscat, Oman
| | | | - Wael Al-Mahmeed
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, UAE
| | | | - Jassim Al-Suwaidi
- Department of Adult Cardiology, Hamad Medical Corporation, Doha, Qatar
- Qatar Cardiovascular Research Centre, Doha, Qatar
| | - Mohammed Al-Jarallah
- Department of Cardiology, Sabah Al Ahmed Cardiac Centre, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Ahmed Al-Motarreb
- Department of Internal Medicine, Faculty of Medicine, Sana’a University, Sana’a, Yemen
| | - Amar Salam
- Department of Adult Cardiology, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, QU Health, Qatar University, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Ibrahim Al-Zakwani
- Department of Pharmacology & Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
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Loeb M, Dokainish H, Dans A, Palileo-Villanueva LM, Roy A, Karaye K, Zhu J, Liang Y, Goma F, Damasceno A, AlHabib KF, Yonga G, Mondo C, Almahmeed W, Al Mulla A, Yusuf S. Corrigendum to "Randomized controlled trial of influenza vaccine in patients with heart failure to reduce adverse vascular events (IVVE): Rationale and design" [212 (2019) 36-44]. Am Heart J 2020; 221:180. [PMID: 31839177 PMCID: PMC7184954 DOI: 10.1016/j.ahj.2019.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Zubaid M, Rashed W, Ridha M, Bazargani N, Hamad A, Banna RA, Asaad N, Sulaiman K, Al-Jarallah M, Mulla AA, Baslaib F, AlMahmeed W. Implementation of Guideline-Recommended Therapies for Patients With Heart Failure and Reduced Ejection Fraction: A Regional Arab Middle East Experience. Angiology 2020; 71:431-437. [PMID: 32066246 DOI: 10.1177/0003319720905742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We describe the characteristics of ambulatory patients with heart failure with reduced ejection fraction (HFrEF) in the Gulf region (Middle East) and the implementation of guideline-recommended treatments. We included 2427 HFrEF outpatients (mean age 59 ± 13 years, 75% males and median left ventricular ejection fraction [LVEF] of 30%). A high proportion of patients received guideline-recommended medications (angiotensin-converting enzyme inhibitor [ACEI]/angiotensin receptor blocker [ARB]/angiotensin receptor-neprilysin inhibitor [ARNI] 87%, β-blocker 91%, mineralocorticoid antagonist [MRA] 64%). However, only a minority of patients received guideline-recommended target doses (ACEI/ARB/ARNI 13%, β-blocker 27%, and MRA 4.4%). Old age was a significant independent predictor for not prescribing treatment (P < .001 for ACEI/ARB/ARNI and MRA; and P = .002 for β-blockers). Other independent predictors were chronic kidney disease (for both ACEI/ARB/ARNI and MRA, P < .001) and higher LVEF (P = .014 for β-blockers and P < .001 for MRA). Patients with HFrEF managed by heart failure specialists more often received recommended target doses of ACEI/ARB/ARNI (40% vs 11%, P < .001) and β-blockers (56% vs 26%, P < .001) compared to those treated by general cardiologists. Although the majority of our patients with HFrEF received guideline-recommended medications, the doses they were prescribed were suboptimal. Understanding the reasons behind this is important for improved practice.
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Affiliation(s)
- Mohammad Zubaid
- Faculty of Medicine, Department of Medicine, Kuwait University, Kuwait
| | - Wafa Rashed
- Department of Medicine, Mubarak Al-Kabeer Hospital, Kuwait
| | - Mustafa Ridha
- Department of Cardiology, Al Dabbous Cardiac Centre, Kuwait
| | - Nooshin Bazargani
- Department of Cardiology, Dubai Hospital, Dubai, United Arab Emirates
| | - Adel Hamad
- Mohammed bin Salman Al Khalifa Cardiac Centre, Bahrain Defense Force Hospital, Manama, Bahrain
| | - Rashed Al Banna
- Department of Cardiology, Salmaniya Medical Complex, Manama, Bahrain
| | - Nidal Asaad
- Department of Cardiology, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Arif Al Mulla
- Department of Cardiology, Cardiac Sciences Institute, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Fahad Baslaib
- Department of Cardiology, Rashid Hospital, Dubai, United Arab Emirates
| | - Wael AlMahmeed
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
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Zubaid M, Rashed W, Ridha M, Al-Jarallah M, Hamad A, Al Banna R, Sulaiman K, Bazargani N, Almahmeed W, Al Mulla A, Baslaib F, Asaad N, Attur S. Design and Rationale of Gulf Documentation of Ambulatory Sick Patients with Heart Failure (Gulf DYSPNEA) Registry. Heart Views 2019; 19:81-84. [PMID: 31007855 PMCID: PMC6448477 DOI: 10.4103/heartviews.heartviews_9_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Aim: The aim of this study is to describe the clinical characteristics of ambulatory patients with chronic heart failure (HF) in the Arabian Gulf and to examine several aspects including types of HF, causes, and adherence to management guidelines. Methods: Gulf documentation of ambulatory sick patients with HF (Gulf DYSPNEA) registry is a multicenter, cross-sectional study, recruiting adult ambulatory HF patients from 24 hospitals in five Arabian Gulf countries. Consecutive patients are recruited prospectively from participating clinics with no follow-up data collection. Recruitment started on November 07, 2016 and will stop when 3,500 patients are enrolled in this study. Collected data explore demographics, baseline patient characteristics, symptoms, previous medical history, comorbidities, physical signs, presenting electrocardiogram, echocardiographic findings, types of HF, and management. Conclusion: This registry is expected to provide useful data on several important aspects and features of ambulatory patients with chronic HF in Arabian Gulf countries. The trial registration number is “ClinicalTrials.gov number, NCT02793180”.
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Affiliation(s)
- Mohammad Zubaid
- Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Wafa Rashed
- Department of Medicine, Mubarak Al-Kabeer Hospital, Kuwait City, Kuwait
| | - Mustafa Ridha
- Department of Cardiology, Al Dabbous Cardiac Centre, Kuwait City, Kuwait
| | | | - Adel Hamad
- Mohammed Bin Salman Al Khalifa Cardiac Centre, Bahrain Defence Force Hospital, Manama, Bahrain
| | - Rashed Al Banna
- Department of Cardiology, Salmaniya Medical Complex, Manama, Bahrain
| | | | - Nooshin Bazargani
- Department of Cardiology, Dubai Hospital, Dubai, United Arab Emirates
| | - Wael Almahmeed
- Department of Medicine, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Arif Al Mulla
- Department of Cardiology, Cardiac Sciences Institute, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Fahad Baslaib
- Department of Cardiology, Rashid Hospital, Dubai, United Arab Emirates
| | - Nidal Asaad
- Department of Cardiology, Hamad Medical Corporation, Doha, Qatar
| | - Sreeja Attur
- Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
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Jha NK, Kiraly L, Shah N, Al Mulla A, Mora B. Congenital aneurysmal right coronary artery with a fistula to the left atrium in an adult. J Cardiothorac Surg 2019; 14:33. [PMID: 30736865 PMCID: PMC6367818 DOI: 10.1186/s13019-019-0854-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/03/2019] [Indexed: 11/24/2022] Open
Abstract
Background Congenital coronary artery fistula in association with aneurysm of the involved coronary artery in adults is rare. Moreover, the right coronary artery- left atrial fistula is also uncommon. Most of the cases are asymptomatic. However, symptomatic patients need therapeutic interventions. The potential complications associated with this anomaly are life-threatening, therefore, there is a need to explore more on differential diagnosis, investigations, management strategies and prevention of complications. Case presentation We present herewith a 26-year-old male patient with symptoms of chest pain and dyspnea. He was diagnosed with aneurysmal dilatation of the right coronary artery in its entire course which terminated as a fistulous communication into the left atrium. The closure of the fistula was done using autologous pericardial patch under cardiopulmonary bypass. Currently, the patient is being followed up after surgery and receiving anticoagulants. Conclusion The advancement in the diagnostic imaging modalities have made it possible to find similar abnormalities more frequently. Due to rare nature of this anomaly, there is a need to explore and discuss management strategies that include medical management, surgical intervention or percutaneous interventions for a successful outcome.
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Affiliation(s)
- Neerod Kumar Jha
- Institute of Cardiac Sciences, PO BOX 51900, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates.
| | - Laszlo Kiraly
- Institute of Cardiac Sciences, PO BOX 51900, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Nishant Shah
- Institute of Cardiac Sciences, PO BOX 51900, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Arif Al Mulla
- Institute of Cardiac Sciences, PO BOX 51900, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Bassem Mora
- Institute of Cardiac Sciences, PO BOX 51900, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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