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Berwanger O, de Barros E Silva PGM, Barbosa RR, Precoma DB, Figueiredo EL, Hajjar LA, Kruel CDP, Alboim C, Almeida AP, Dracoulakis MDA, Filho HV, Carmona MJC, Maia LN, de Oliveira Filho JB, Saraiva JFK, Soares RM, Damiani L, Paisani D, Kodama AA, Gonzales B, Ikeoka DT, Devereaux PJ, Lopes RD. Atorvastatin for high-risk statin-naïve patients undergoing noncardiac surgery: The Lowering the Risk of Operative Complications Using Atorvastatin Loading Dose (LOAD) randomized trial. Am Heart J 2017; 184:88-96. [PMID: 27892891 DOI: 10.1016/j.ahj.2016.11.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/04/2016] [Indexed: 02/06/2023]
Abstract
Preliminary evidence suggests that statins may prevent major perioperative vascular complications. METHODS We randomized 648 statin-naïve patients who were scheduled for noncardiac surgery and were at risk for a major vascular complication. Patients were randomized to a loading dose of atorvastatin or placebo (80 mg anytime within 18hours before surgery), followed by a maintenance dose of 40 mg (or placebo), started at least 12hours after the surgery, and then 40 mg/d (or placebo) for 7days. The primary outcome was a composite of all-cause mortality, nonfatal myocardial injury after noncardiac surgery, and stroke at 30days. RESULTS The primary outcome was observed in 54 (16.6%) of 326 patients in the atorvastatin group and 59 (18.7%) of 316 patients in the placebo group (hazard ratio [HR] 0.87, 95% CI 0.60-1.26, P=.46). No significant effect was observed on the 30-day secondary outcomes of all-cause mortality (4.3% vs 4.1%, respectively; HR 1.14, 95% CI 0.53-2.47, P=.74), nonfatal myocardial infarction (3.4% vs 4.4%, respectively; HR 0.76, 95% CI 0.35-1.68, P=.50), myocardial injury after noncardiac surgery (13.2% vs 16.5%; HR 0.79, 95% CI 0.53-1.19, P=.26), and stroke (0.9% vs 0%, P=.25). CONCLUSION In contrast to the prior observational and trial data, the LOAD trial has neutral results and did not demonstrate a reduction in major cardiovascular complications after a short-term perioperative course of statin in statin-naïve patients undergoing noncardiac surgery. We demonstrated, however, that a large multicenter blinded perioperative statin trial for high-risk statin-naïve patients is feasible and should be done to definitely establish the efficacy and safety of statin in this patient population.
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Affiliation(s)
- Otavio Berwanger
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil.
| | - Pedro G M de Barros E Silva
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil; Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil
| | | | | | | | - Ludhmila Abrahão Hajjar
- Instituto do Câncer do estado de São Paulo (ICESP), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | | | - Carolina Alboim
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Hugo Vargas Filho
- Hospital São Vicente de Paulo, Passo Fundo, Rio Grande do Sul, Brazil
| | - Maria José Carvalho Carmona
- Divisão de Anestesia Instituto Central-Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Rafael M Soares
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | - Lucas Damiani
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | - Denise Paisani
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | | | - Beatriz Gonzales
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | - Dimas T Ikeoka
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | | | - Renato D Lopes
- Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil; Duke Clinical Research Institute, Durham, NC
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Bernardez-Pereira S, Lopes RD, Carrion MJM, Santucci EV, Soares RM, de Oliveira Abreu M, Laranjeira LN, Ikeoka DT, Zazula AD, Moreira FR, Cavalcanti AB, Mesquita ET, Peterson ED, Califf RM, Berwanger O. Prevalence, characteristics, and predictors of early termination of cardiovascular clinical trials due to low recruitment: insights from the ClinicalTrials.gov registry. Am Heart J 2014; 168:213-9.e1. [PMID: 25066561 DOI: 10.1016/j.ahj.2014.04.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 04/28/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Early termination of clinical trials due to low recruitment represents an understudied challenge for clinical research. We aimed to describe characteristics of cardiovascular trials terminated because of low recruitment and identify the major predictors of such early termination. METHODS We reviewed all cardiovascular clinical trials (7,042 studies) registered in ClinicalTrials.gov from February 29, 2000, to January 17, 2013, and assessed information about trials that were completed and those that were terminated early. Logistic regression models were developed to identify independent predictors of early termination due to low recruitment. RESULTS Our search strategy identified 6,279 cardiovascular clinical trials, of which 684 (10.9%) were terminated prematurely. Of these halted trials, the main reason for termination was lower than expected recruitment (278 trials; 53.6%). When comparing trials that terminated early because of low recruitment with those that were completed, we found that studies funded by the National Institutes of Health or other US federal agencies (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.14-0.89), studies of behavior/diet intervention (OR 0.35, 95% CI 0.19-0.65), and single-arm design studies (OR 0.57, 95% CI 0.42-0.78) were associated with a lower risk of early termination. University/hospital-funded (OR 1.52, 95% CI 1.10-2.10) and mixed-source-funded studies (OR 2.14, 95% CI 1.52-3.01) were associated with a higher likelihood of early termination due to lower than expected recruitment rates. CONCLUSIONS Low recruitment represents the main cause of early termination of cardiovascular clinical trials. Funding source, type of intervention, and study design are factors associated with early termination due to low recruitment and might be good targets for improving enrollment into cardiovascular clinical trials.
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Affiliation(s)
- Sabrina Bernardez-Pereira
- Research Institute, HCOR-Hospital do Coração, Sao Paulo, Brazil; Fluminense Federal University, Niteroi, Rio de Janeiro, Brazil
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Brazilian Clinical Research Institute, Sao Paulo, Brazil
| | | | | | | | | | | | - Dimas T Ikeoka
- Research Institute, HCOR-Hospital do Coração, Sao Paulo, Brazil
| | | | | | | | | | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Robert M Califf
- Duke Translational Medicine Institute, Duke University Medical Center, Durham, NC
| | - Otavio Berwanger
- Research Institute, HCOR-Hospital do Coração, Sao Paulo, Brazil.
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Baruzzi ACDA, Ikeoka DT. End of life and palliative care in intensive care. Rev Assoc Med Bras (1992) 2013; 59:528-30. [PMID: 24246448 DOI: 10.1016/j.ramb.2013.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 04/25/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022] Open
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Ikeoka DT, Pachler C, Mader JK, Bock G, Neves AL, Svehlikova E, Feichtner F, Koehler G, Wrighton CJ, Pieber TR, Ellmerer M. Lipid-heparin infusion suppresses the IL-10 response to trauma in subcutaneous adipose tissue in humans. Obesity (Silver Spring) 2011; 19:715-21. [PMID: 21088675 DOI: 10.1038/oby.2010.227] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
An imbalance between pro- and anti-inflammatory cytokine productions in adipose tissue is thought to contribute to chronic, systemic, low-grade inflammation and consequently to an increased risk of cardiovascular complications in obese and type 2 diabetic patients. Nonesterified fatty acids (NEFA), whose serum levels are elevated in such patients, have been shown to interfere with cytokine production in vitro. In order to evaluate the effects of elevated NEFA levels on cytokine production in adipose tissue in vivo we used an 18-gauge open-flow microperfusion (OFM) catheter to induce local inflammation in the subcutaneous adipose tissue (SAT) of healthy volunteers and to sample interstitial fluid (IF) specifically from the inflamed tissue. In two crossover studies, nine subjects received either an intravenous lipid-heparin infusion to elevate circulating NEFA levels or saline over a period of 28 h. The former increased the circulating levels of triglycerides (TGs), NEFA, glucose, and insulin over the study period. NEFA effects on locally induced inflammation were estimated by measuring the levels of a panel adipokines in the OFM probe effluent. Interleukin-6 (IL-6), IL-8, tumor necrosis factor-α (TNF-α) and monocyte chemoattractant protein-1 (MCP-1) levels increased during the study period but were not affected by lipid-heparin infusion. In contrast, the level of IL-10, an anti-inflammatory cytokine, was significantly reduced during the final hour of lipid-heparin infusion (saline: 449.2 ± 105.9 vs. lipid-heparin: 65.4 ± 15.4 pg/ml; P = 0.02). These data provide the first in vivo evidence that elevated NEFA can modulate cytokine production by adipose tissue.
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Affiliation(s)
- Dimas T Ikeoka
- Department of Internal Medicine, Medical University of Graz, Graz, Austria.
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Feitosa ACR, Marques AC, Caramelli B, Ayub B, Polanczyk CA, Jardim C, Vieira CLZ, Pinho C, Calderaro D, Gualandro DM, Iezzi D, Ikeoka DT, Schreen D, D'Amico EA, Pfeferman E, Lima EQD, Burdmann EDA, Pachon E, Machado FS, Galas FRBG, Paula FJD, Carvalho FCD, Feitosa-Filho GS, Prado GF, Lopes HF, Lima JJGD, Marchini JFM, Fornari LS, Drager LF, Vacanti LJ, Hajjar LA, Rohde LEP, Gowdak LH, Cardoso LF, Vieira MLC, Monachini MC, Macatrão M, Yu PC, Villaça PR, Farsky PS, Lopes RD, Bagnatori RS, Heinisch RH, Gualandro SFM, Accorsi TAD, Ávila WS, Mathias Jr. W. II Diretriz de Avaliação Perioperatória da Sociedade Brasileira de Cardiologia. Arq Bras Cardiol 2011. [DOI: 10.1590/s0066-782x2011000800001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Gualandro DM, Yu PC, Calderaro D, Marques AC, Pinho C, Caramelli B, Feitosa ACR, Ayub B, Polanczyk CA, Jardim C, Vieira CLZ, lezzi D, Ikeoka DT, Schreen D, D'Amico EA, Pfeferman E, de Lima EQ, Burdmann EDA, Pachon E, Machado FS, Galas FRBG, Paula FJD, Carvalho FCD, Feitosa-Filho GS, Prado GF, Lopes HF, Lima JJGD, Marchini JFM, Fornari LS, Drager LF, Vacanti LJ, Hajjar LA, Rohde LEP, Gowdak LH, Cardoso LF, Vieira MLC, Monachini MC, Macatrão M, Villaça PR, Farsky PS, Lopes RD, Bagnatori RS, Heinisch RH, Gualandro SFM, Accorsi TAD, Avila WS, Mathias W. II Guidelines for perioperative evaluation of the Brazilian Society of Cardiology. Arq Bras Cardiol 2011; 96:1-68. [PMID: 21655875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Affiliation(s)
- Danielle Menosi Gualandro
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Dr Eneas de Carvalho Aguiar 44 - andar AB - bloco 2, setor C6, 05403-000 São Paulo
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Ikeoka DT, Vieira CZ, Lemos PA, Strabelli TV, da Silva EER, Perin MA, Groselj-Strele A, Tiran B, Tiran A, Caramelli B. Azithromycin does not prevent six-month myointimal proliferation but attenuates the transient systemic inflammation occurring after coronary stenting. Clin Res Cardiol 2008; 98:44-51. [PMID: 18853090 DOI: 10.1007/s00392-008-0722-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2007] [Accepted: 09/09/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Stent implantation produces a systemic increase of inflammatory markers that correlates with Chlamydophila pneumoniae infection in atherosclerotic plaque. We performed a clinical intervention study to investigate the effect of antibiotic treatment on 6-month follow-up angiographic minimal luminal diameter after stenting. METHODS Ninety patients were randomly assigned to oral azithromycin or placebo in a double-blinded and randomized fashion. Medication was initiated 2 weeks before a pre-scheduled stenting procedure and maintained 12 weeks thereafter. Angiographic outcomes were evaluated by a six-month follow-up angiography and laboratorial parameters were accessed by blood sampling 2 weeks before stenting, within the first 24 h after procedure and additional samples after four weeks and 6 months. RESULTS Minimal luminal diameter (1.76 +/- 0.56 mm Vs. 1.70 +/- 0.86 mm; P = 0.7), restenosis rate, diameter stenosis, late loss, and binary restenosis rates were comparable in placebo and azithromycin group in the 6 months follow-up. Serum levels of C-reactive protein presented a three fold significant increase in the control group one day after stenting but did not change in the azithromycin group (8.5 [3.0;16.4] Vs. 2.9 [1.7;6.6]-median [25;75 percentile] P < 0.01). CONCLUSIONS Azithromycin does not improve late angiographic outcomes but attenuates the elevation of C-reactive protein levels after stenting, indicating an anti-inflammatory effect.
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Affiliation(s)
- Dimas T Ikeoka
- Center for Medical Research and Clinical Institute for Medical and Chemical Laboratory Diagnostics, Medical University Graz, Stiftingtalstrasse, 24, 8010, Graz, Austria
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Feitosa ACR, Ayub B, Caramelli B, Polanczyk CA, Vieira CLZ, Pinho C, Calderaro D, Gualandro DM, Iezzi D, Schreen D, Ikeoka DT, D'Amico EA, Pfeferman E, de Lima EQ, Burdmann EDA, Machado FS, Galas FRBG, Feitosa-Filho GS, Lopes HF, Pachón H, Sbano JCN, Filho JASB, Andrade JL, Heinisch RH, dos Santos LM, Fornari LS, Hajjar LA, Rohde LEP, Cardoso LF, Vieira MLC, Monachini MC, Yu PC, Villaça PR, Grandini P, Bagnatori RS, Rodrigues RDR, Gualandro SFM, Avila WS, Mathias W. I Diretriz de avaliação perioperatória. Arq Bras Cardiol 2007; 88:e139-78. [PMID: 17589621 DOI: 10.1590/s0066-782x2007000500030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Vasconcelos CPD, Ikeoka DT. Como fazer o controle glicêmico em UTI? Rev Assoc Med Bras (1992) 2005. [DOI: 10.1590/s0104-42302005000200005] [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] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Durazzo AES, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leão P, Caramelli B. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized trial. J Vasc Surg 2004; 39:967-75; discussion 975-6. [PMID: 15111846 DOI: 10.1016/j.jvs.2004.01.004] [Citation(s) in RCA: 360] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This prospective, randomized, placebo-controlled, double-blind clinical trial was performed to analyze the effect of atorvastatin compared with placebo on the occurrence of a 6-month composite of cardiovascular events after vascular surgery. Cardiovascular complications are the most important cause of perioperative morbidity and mortality among patients undergoing vascular surgery. Statin therapy may reduce perioperative cardiac events through stabilization of coronary plaques. METHODS One hundred patients were randomly assigned to receive 20 mg atorvastatin or placebo once a day for 45 days, irrespective of their serum cholesterol concentration. Vascular surgery was performed on average 30 days after randomization, and patients were prospectively followed up over 6 months. The cardiovascular events studied were death from cardiac cause, nonfatal myocardial infarction, unstable angina, and stroke. RESULTS Fifty patients received atorvastatin, and 50 received placebo. During the 6-month follow-up primary end points occurred in 17 patients, 4 in the atorvastatin group and 13 in the placebo group. The incidence of cardiac events was more than three times higher with placebo (26.0%) compared with atorvastatin (8.0%; P =.031). The risk for an event was compared between the groups with the Kaplan-Meier method, as event-free survival after vascular surgery. Patients given atorvastatin exhibited a significant decrease in the rate of cardiac events, compared with the placebo group, within 6 months after vascular surgery (P =.018). CONCLUSION Short-term treatment with atorvastatin significantly reduces the incidence of major adverse cardiovascular events after vascular surgery.
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Affiliation(s)
- Anai E S Durazzo
- Heart Institute and Vascular Surgery Department, University of São Paulo Medical School, São Paulo, Brazil.
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