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Lee TC, Qian M, Liu Y, Graham S, Mann DL, Nakanishi K, Teerlink JR, Lip GYH, Freudenberger RS, Sacco RL, Mohr JP, Labovitz AJ, Ponikowski P, Lok DJ, Matsumoto K, Estol C, Anker SD, Pullicino PM, Buchsbaum R, Levin B, Thompson JLP, Homma S, Di Tullio MR. Cognitive Decline Over Time in Patients With Systolic Heart Failure: Insights From WARCEF. JACC Heart Fail 2020; 7:1042-1053. [PMID: 31779926 DOI: 10.1016/j.jchf.2019.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/28/2019] [Accepted: 09/10/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study sought to characterize cognitive decline (CD) over time and its predictors in patients with systolic heart failure (HF). BACKGROUND Despite the high prevalence of CD and its impact on mortality, predictors of CD in HF have not been established. METHODS This study investigated CD in the WARCEF (Warfarin versus Aspirin in Reduced Ejection Fraction) trial, which performed yearly Mini-Mental State Examinations (MMSE) (higher scores indicate better cognitive function; e.g., normal score: 24 or higher). A longitudinal time-varying analysis was performed among pertinent covariates, including baseline MMSE and MMSE scores during follow-up, analyzed both as a continuous variable and a 2-point decrease. To account for a loss to follow-up, data at the baseline and at the 12-month visit were analyzed separately (sensitivity analysis). RESULTS A total of 1,846 patients were included. In linear regression, MMSE decrease was independently associated with higher baseline MMSE score (p < 0.0001), older age (p < 0.0001), nonwhite race/ethnicity (p < 0.0001), and lower education (p < 0.0001). In logistic regression, CD was independently associated with higher baseline MMSE scores (odds ratio [OR]: 1.13; 95% confidence interval [CI]: 1.07 to 1.20]; p < 0.001), older age (OR: 1.37; 95% CI: 1.24 to 1.50; p < 0.001), nonwhite race/ethnicity (OR: 2.32; 95% CI: 1.72 to 3.13 for black; OR: 1.94; 95% CI: 1.40 to 2.69 for Hispanic vs. white; p < 0.001), lower education (p < 0.001), and New York Heart Association functional class II or higher (p = 0.03). Warfarin and other medications were not associated with CD. Similar trends were seen in the sensitivity analysis (n = 1,439). CONCLUSIONS CD in HF is predicted by baseline cognitive status, demographic variables, and NYHA functional class. The possibility of intervening on some of its predictors suggests the need for the frequent assessment of cognitive function in patients with HF. (Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction [WARCEF]; NCT00041938).
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Affiliation(s)
- Tetz C Lee
- Columbia University Medical Center, New York, NY
| | - Min Qian
- Columbia University Medical Center, New York, NY
| | - Yutong Liu
- Columbia University Medical Center, New York, NY
| | - Susan Graham
- Department of Medicine, State University of New York at Buffalo, Buffalo, New York
| | - Douglas L Mann
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, California
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Ralph L Sacco
- Department of Neurology, University of Miami, Miami, Florida
| | - Jay P Mohr
- Columbia University Medical Center, New York, NY
| | | | | | - Dirk J Lok
- Deventer Hospital, Deventer, the Netherlands
| | | | - Conrado Estol
- Stroke Unit, Sanatorio Guemes, Buenos Aires, Argentina
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology, and Berlin-Brandenburg Center for Regenerative Therapies, Deutsches Zentrum für Herz-Kreislauf-Forschung partner site Berlin; Charité Universitätsmedizin Berlin, Germany; Department of Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
| | | | | | - Bruce Levin
- Columbia University Medical Center, New York, NY
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Shah N, Qian M, Di Tullio MR, Graham S, Mann DL, Sacco RL, Lip GYH, Labovitz AJ, Ponikowski P, Lok DJ, Anker SD, Teerlink JR, Thompson JLP, Homma S, Freudenberger RS. Pulse pressure and prognosis in patients with heart failure with reduced ejection fraction. Eur J Clin Invest 2019; 49:e13092. [PMID: 30801690 DOI: 10.1111/eci.13092] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/25/2019] [Accepted: 02/21/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND A high pulse pressure (PP) is associated with adverse cardiovascular (CV) outcomes; however, this relationship may be reversed in patients with heart failure with reduced ejection fraction (HFREF). METHODS Patients from the WARCEF trial with left ventricular ejection fraction ≤35% were included. PP was divided into tertiles: ≤42, 42-54 and >54 mm Hg. Age and ejection fraction adjusted Kaplan-Meier curves were generated to evaluate the relationship between PP and outcomes [mortality, CV mortality, stroke and HF hospitalizations (HFH)]. Cox proportional hazards models were created incorporating PP as a continuous variable. The interaction of PP with New York Heart Association (NYHA) functional class was examined. Linear and restricted cubic splines were used to study nonlinear association between PP and outcomes. RESULTS We included 2,299 patients with a mean(±SD) follow-up of 3.5 ± 1.8 years. The lowest tertile of PP (≤42 mm Hg) was associated with significantly higher CV mortality and HFH. Cox proportional hazards models showed a reduction in CV death and HFH with higher PP, with adjusted hazard ratios (HR) of 0.91 (P = 0.02) and 0.93 (P = 0.04) per 10 mm Hg increase in PP. This relationship was more pronounced in subjects with NYHA functional class III-IV. Spline analysis showed that the association between PP and CV mortality and HFH was only seen at PP values lower than 40 mm Hg. CONCLUSIONS In patients with advanced HFREF, a low PP (<40 mm Hg) portends a worse prognosis, whereas a high PP (>50 mm Hg) predicts a relatively favourable prognosis.
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Affiliation(s)
- Neeraj Shah
- Department of Cardiology, Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Min Qian
- Columbia University Medical Center, New York, New York
| | | | - Susan Graham
- The State University of New York at Buffalo, Buffalo, New York
| | | | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | | | | | - Dirk J Lok
- Hospital Deventer, Deventer, the Netherlands
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology & Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
| | - John R Teerlink
- University of California San Francisco, San Francisco, California
| | | | | | - Ronald S Freudenberger
- Department of Cardiology, Lehigh Valley Health Network, Allentown, Pennsylvania.,The University of South Florida, Tampa, Florida
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3
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Lee TC, Qian M, Mu L, Di Tullio MR, Graham S, Mann DL, Nakanishi K, Teerlink JR, Lip GYH, Freudenberger RS, Sacco RL, Mohr JP, Labovitz AJ, Ponikowski P, Lok DJ, Estol C, Anker SD, Pullicino PM, Buchsbaum R, Levin B, Thompson JLP, Homma S, Ye S. Association between mortality and implantable cardioverter-defibrillators by aetiology of heart failure: a propensity-matched analysis of the WARCEF trial. ESC Heart Fail 2019; 6:297-307. [PMID: 30816013 PMCID: PMC6437435 DOI: 10.1002/ehf2.12407] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 07/26/2018] [Accepted: 12/12/2018] [Indexed: 12/28/2022] Open
Abstract
Aims There is debate on whether the beneficial effect of implantable cardioverter‐defibrillators (ICDs) is attenuated in patients with non‐ischaemic cardiomyopathy (NICM). We assess whether any ICD benefit differs between patients with NICM and those with ischaemic cardiomyopathy (ICM), using data from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial. Methods and results We performed a post hoc analysis using WARCEF (N = 2293; ICM, n = 991 vs. NICM, n = 1302), where participants received optimal medical treatment. We developed stratified propensity scores for having an ICD at baseline using 41 demographic and clinical variables and created 1:2 propensity‐matched cohorts separately for ICM patients with ICD (N = 223 with ICD; N = 446 matched) and NICM patients (N = 195 with ICD; N = 390 matched). We constructed a Cox proportional hazards model to assess the effect of ICD status on mortality for patients with ICM and those with NICM and tested the interaction between ICD status and aetiology of heart failure. During mean follow‐up of 3.5 ± 1.8 years, 527 patients died. The presence of ICD was associated with a lower risk of all‐cause death among those with ICM (hazard ratio: 0.640; 95% confidence interval: 0.448 to 0.915; P = 0.015) but not among those with NICM (hazard ratio: 0.984; 95% confidence interval: 0.641 to 1.509; P = 0.941). There was weak evidence of interaction between ICD status and the aetiology of heart failure (P = 0.131). Conclusions The presence of ICD is associated with a survival benefit in patients with ICM but not in those with NICM.
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Affiliation(s)
- Tetz C Lee
- Columbia University Irving Medical Center, New York, NY, USA
| | - Min Qian
- Columbia University Irving Medical Center, New York, NY, USA
| | - Lan Mu
- Columbia University Irving Medical Center, New York, NY, USA
| | | | - Susan Graham
- The State University of New York at Buffalo, Buffalo, NY, USA
| | - Douglas L Mann
- Washington University School of Medicine, St. Louis, MO, USA
| | - Koki Nakanishi
- Columbia University Irving Medical Center, New York, NY, USA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | | | - Jay P Mohr
- Columbia University Irving Medical Center, New York, NY, USA
| | | | | | - Dirk J Lok
- Deventer Hospital, Deventer, The Netherlands
| | - Conrado Estol
- Neurological Center for Treatment and Rehabilitation, Buenos Aires, Argentina
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology; and Berlin-Brandenburg Center for Regenerative Therapies; Deutsches Zentrum für Herz-Kreislauf-Forschung partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology and Pneumology, University Medicine Göttingen, Göttingen, Germany
| | | | | | - Bruce Levin
- Columbia University Irving Medical Center, New York, NY, USA
| | | | - Shunichi Homma
- Columbia University Irving Medical Center, New York, NY, USA
| | - Siqin Ye
- Columbia University Irving Medical Center, New York, NY, USA
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Lee TC, Qian M, Lip GY, Di Tullio MR, Graham S, Mann DL, Nakanishi K, Teerlink JR, Freudenberger RS, Sacco RL, Mohr J, Labovitz AJ, Ponikowski P, Lok DJ, Estol C, Anker SD, Pullicino PM, Buchsbaum R, Levin B, Thompson JL, Homma S, Ye S. Heart Failure Severity and Quality of Warfarin Anticoagulation Control (From the WARCEF Trial). Am J Cardiol 2018; 122:821-827. [PMID: 30037426 DOI: 10.1016/j.amjcard.2018.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/07/2018] [Accepted: 05/07/2018] [Indexed: 01/06/2023]
Abstract
Previous studies in patients with atrial fibrillation showed that a history of heart failure (HF) could negatively impact anticoagulation quality, as measured by the average time in therapeutic range (TTR). Whether additional markers of HF severity are associated with TTR has not been investigated thoroughly. We aimed to examine the potential role of HF severity in the quality of warfarin control in patients with HF with reduced ejection fraction. Data from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction Trial were used to investigate the association between TTR and HF severity. Multivariable logistic regression models were used to examine the association of markers of HF severity, including New York Heart Association (NYHA) class, Minnesota Living with HF (MLWHF) score, and frequency of HF hospitalization, with TTR ≥70% (high TTR). We included 1,067 participants (high TTR, N = 413; low TTR, N = 654) in the analysis. In unadjusted analysis, patients with a high TTR were older and less likely to have had strokes or receive other antiplatelet agents. Those patients also had lower NYHA class, better MLWHF scores, greater 6-minute walk distance, and lower frequency of HF hospitalizations. Multivariable analysis showed that NYHA class III and/or IV (Odds ratio [OR] 0.68 [95% confidence intervals [CIs] 0.49 to 0.94]), each 10-point increase in MLWHF score (i.e., worse health-related quality of life) (OR 0.92 [0.86 to 0.99]), and higher number of HF hospitalization per year (OR0.45 [0.30 to 0.67]) were associated with decreased likelihood of having high TTR. In HF patients with systolic dysfunction, NYHA class III and/or IV, poor health-related quality of life, and a higher rate of HF hospitalization were independently associated with suboptimal quality of warfarin anticoagulation control. These results affirm the need to assess the new approaches, such as direct oral anticoagulants, to prevent thromboembolism in this patient population.
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Di Tullio MR, Qian M, Thompson JLP, Labovitz AJ, Mann DL, Sacco RL, Pullicino PM, Freudenberger RS, Teerlink JR, Graham S, Lip GYH, Levin B, Mohr JP, Buchsbaum R, Estol CJ, Lok DJ, Ponikowski P, Anker SD, Homma S. Left atrial volume and cardiovascular outcomes in systolic heart failure: effect of antithrombotic treatment. ESC Heart Fail 2018; 5:800-808. [PMID: 30015405 PMCID: PMC6165930 DOI: 10.1002/ehf2.12331] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 12/27/2017] [Revised: 05/24/2018] [Accepted: 06/14/2018] [Indexed: 01/20/2023] Open
Abstract
AIMS Left atrium (LA) dilation is associated with adverse cardiovascular (CV) outcomes. Blood stasis, thrombus formation and atrial fibrillation may occur, especially in heart failure (HF) patients. It is not known whether preventive antithrombotic treatment may decrease the incidence of CV events in HF patients with LA enlargement. We investigated the relationship between LA enlargement and CV outcomes in HF patients and the effect of different antithrombotic treatments. METHODS AND RESULTS Two-dimensional echocardiography with LA volume index (LAVi) measurement was performed in 1148 patients with systolic HF from the Warfarin versus Aspirin in Reduced Ejection Fraction (WARCEF) trial. Patients were randomized to warfarin or aspirin and followed for 3.4 ± 1.7 years. While the primary aim of the trial was a composite of ischaemic stroke, death, and intracerebral haemorrhage, the present report focuses on the individual CV events, whose incidence was compared across different LAVi and treatment subgroups. After adjustment for demographics and clinical covariates, moderate or severe LA enlargement was significantly associated with total death (hazard ratio 1.6 and 2.7, respectively), CV death (HR 1.7 and 3.3), and HF hospitalization (HR 2.3 and 2.6) but not myocardial infarction (HR 1.0 and 1.4) or ischaemic stroke (1.1 and 1.5). The increased risk was observed in both patients treated with warfarin or aspirin. In warfarin-treated patients, a time in therapeutic range >60% was associated with lower event rates, and an interaction between LAVi and time in therapeutic range was observed for death (P = 0.034). CONCLUSIONS In patients with systolic HF, moderate or severe LA enlargement is associated with death and HF hospitalization despite treatment with antithrombotic medications. The possibility that achieving a more consistent therapeutic level of anticoagulation may decrease the risk of death requires further investigation.
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Affiliation(s)
- Marco R Di Tullio
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Min Qian
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | | | | | | | | | | | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - Susan Graham
- SUNY Upstate Medical University, Syracuse, NY, USA
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK
| | - Bruce Levin
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Jay P Mohr
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Richard Buchsbaum
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Conrado J Estol
- Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina
| | - Dirk J Lok
- Deventer Hospital, Deventer, The Netherlands
| | | | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Göttingen, Germany
| | - Shunichi Homma
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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6
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Teerlink JR, Qian M, Bello NA, Freudenberger RS, Levin B, Di Tullio MR, Graham S, Mann DL, Sacco RL, Mohr JP, Lip GYH, Labovitz AJ, Lee SC, Ponikowski P, Lok DJ, Anker SD, Thompson JLP, Homma S. Aspirin Does Not Increase Heart Failure Events in Heart Failure Patients: From the WARCEF Trial. JACC Heart Fail 2018; 5:603-610. [PMID: 28774396 DOI: 10.1016/j.jchf.2017.04.011] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/24/2017] [Accepted: 04/25/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The aim of this study was to determine whether aspirin increases heart failure (HF) hospitalization or death in patients with HF with reduced ejection fraction receiving an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB). BACKGROUND Because of its cyclooxygenase inhibiting properties, aspirin has been postulated to increase HF events in patients treated with ACE inhibitors or ARBs. However, no large randomized trial has addressed the clinical relevance of this issue. METHODS We compared aspirin and warfarin for HF events (hospitalization, death, or both) in the 2,305 patients enrolled in the WARCEF (Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction) trial (98.6% on ACE inhibitor or ARB treatment), using conventional Cox models for time to first event (489 events). In addition, to examine multiple HF hospitalizations, we used 2 extended Cox models, a conditional model and a total time marginal model, in time to recurrent event analyses (1,078 events). RESULTS After adjustment for baseline covariates, aspirin- and warfarin-treated patients did not differ in time to first HF event (adjusted hazard ratio: 0.87; 95% confidence interval: 0.72 to 1.04; p = 0.117) or first hospitalization alone (adjusted hazard ratio: 0.88; 95% confidence interval: 0.73 to 1.06; p = 0.168). The extended Cox models also found no significant differences in all HF events or in HF hospitalizations alone after adjustment for covariates. CONCLUSIONS Among patients with HF with reduced ejection fraction in the WARCEF trial, there was no significant difference in risk of HF events between the aspirin and warfarin-treated patients. (Warfarin Versus Aspirin in Reduced Cardiac Ejection Fraction trial [WARCEF]; NCT00041938).
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Affiliation(s)
- John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, California
| | - Min Qian
- Columbia University Medical Center, New York, New York
| | | | | | - Bruce Levin
- Columbia University Medical Center, New York, New York
| | | | - Susan Graham
- State University of New York at Buffalo, Buffalo, New York
| | | | | | - J P Mohr
- Columbia University Medical Center, New York, New York
| | - Gregory Y H Lip
- Institute of Birmingham Centre for Cardiovascular Sciences, Birmingham, England, United Kingdom
| | | | - Seitetz C Lee
- Columbia University Medical Center, New York, New York
| | | | - Dirk J Lok
- Deventer Hospital, Deventer, the Netherlands
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology & Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
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7
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Nakanishi K, Di Tullio MR, Qian M, Thompson JLP, Labovitz AJ, Mann DL, Sacco RL, Pullicino PM, Freudenberger RS, Teerlink JR, Graham S, Lip GYH, Levin B, Mohr JP, Buchsbaum R, Estol CJ, Lok DJ, Ponikowski P, Anker SD, Homma S. Resting Heart Rate and Ischemic Stroke in Patients with Heart Failure. Cerebrovasc Dis 2017; 44:43-50. [PMID: 28419982 DOI: 10.1159/000474958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/29/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Although high resting heart rate (RHR) is known to be associated with an increased risk of mortality and hospital admission in patients with heart failure, the relationship between RHR and ischemic stroke remains unclear. This study is aimed at investigating the relationship between RHR and ischemic stroke in patients with heart failure in sinus rhythm. METHODS We examined 2,060 patients with systolic heart failure in sinus rhythm from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial. RHR was determined from baseline electrocardiogram, and was examined as both a continuous variable and a categorical variable using quartiles. Ischemic strokes were identified during follow-up and adjudicated by physician review. RESULTS During 3.5 ± 1.8 years of follow-up, 77 patients (5.3% from Kaplan-Meier [KM] curve) experienced an ischemic stroke. The highest incidence of ischemic stroke (21/503 [KM 6.9%]) was observed in the lowest RHR quartile (RHR <64 beats/min) compared to other groups; 22/573 (KM 5.3%) in 64-70 beats/min, 13/465 (KM 3.5%) in 71-79 beats/min, and 21/519 (KM 5.4%) in RHR >79 beats/min (p = 0.693). Multivariable Cox proportional hazards analysis revealed that RHR was significantly associated with ischemic stroke (hazard ratio per unit decrease: 1.07, 95% CI 1.02-1.13, when RHR <64/beats/min; p = 0.038), along with a history of stroke or transient ischemic attack and left ventricular ejection fraction. CONCLUSIONS In contrast to its beneficial effect on mortality and hospital re-admissions, lower RHR may increase the risk of ischemic stroke in patients with systolic heart failure in sinus rhythm.
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Affiliation(s)
- Koki Nakanishi
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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8
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Ye S, Qian M, Zhao B, Buchsbaum R, Sacco RL, Levin B, Di Tullio MR, Mann DL, Pullicino PM, Freudenberger RS, Teerlink JR, Mohr JP, Graham S, Labovitz AJ, Estol CJ, Lok DJ, Ponikowski P, Anker SD, Lip GYH, Thompson JLP, Homma S. CHA 2 DS 2 -VASc score and adverse outcomes in patients with heart failure with reduced ejection fraction and sinus rhythm. Eur J Heart Fail 2016; 18:1261-1266. [PMID: 27444219 DOI: 10.1002/ejhf.613] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/25/2016] [Accepted: 06/16/2016] [Indexed: 01/06/2023] Open
Abstract
AIMS The aim of this study was to determine whether the CHA2 DS2 -VASc score can predict adverse outcomes such as death, ischaemic stroke, and major haemorrhage, in patients with systolic heart failure in sinus rhythm. METHODS AND RESULTS CHA2 DS2 -VASc scores were calculated for 1101 patients randomized to warfarin and 1123 patients randomized to aspirin. Adverse outcomes were defined as death or ischaemic stroke, death alone, ischaemic stroke alone, and major haemorrhage. Using proportional hazards models, we found that each 1-point increase in the CHA2 DS2 -VASc score was associated with increased hazard of death or ischaemic stroke events [hazard ratio (HR) for the warfarin arm = 1.21, 95% confidence interval (CI) 1.13-1.30, P < 0.001; for aspirin, HR = 1.20, 95% CI 1.11-1.29, P < 0.001]. Similar increased hazards for higher CHA2 DS2 -VASc scores were observed for death alone, ischaemic stroke alone, and major haemorrhage. Overall performance of the CHA2 DS2 -VASc score was assessed using c-statistics for full models containing the risk score, treatment assignment, and score-treatment interaction, with the c-statistics for the full models ranging from 0.57 for death to 0.68 for major haemorrhage. CONCLUSIONS The CHA2 DS2 -VASc score predicted adverse outcomes in patients with systolic heart failure in sinus rhythm, with modest prediction accuracy.
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Affiliation(s)
- Siqin Ye
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY, USA.
| | - Min Qian
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Bo Zhao
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Richard Buchsbaum
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Ralph L Sacco
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Bruce Levin
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Marco R Di Tullio
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Douglas L Mann
- Department of Medicine, Washington University, St. Louis, MO, USA
| | - Patrick M Pullicino
- Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, UK
| | - Ronald S Freudenberger
- Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA, USA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - J P Mohr
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Susan Graham
- Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY, USA
| | - Arthur J Labovitz
- Department of Cardiovascular Medicine, University of South Florida, Tampa, FL, USA
| | - Conrado J Estol
- Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina
| | - Dirk J Lok
- Department of Cardiology, Deventer Hospital, Deventer, The Netherlands
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology & Pneumology, University Medical Centre Göttingen, Göttingen, Germany
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - John L P Thompson
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Shunichi Homma
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
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Di Tullio MR, Qian M, Thompson JLP, Labovitz AJ, Mann DL, Sacco RL, Pullicino PM, Freudenberger RS, Teerlink JR, Graham S, Lip GYH, Levin B, Mohr JP, Buchsbaum R, Estol CJ, Lok DJ, Ponikowski P, Anker SD, Homma S. Left Ventricular Ejection Fraction and Risk of Stroke and Cardiac Events in Heart Failure: Data From the Warfarin Versus Aspirin in Reduced Ejection Fraction Trial. Stroke 2016; 47:2031-7. [PMID: 27354224 DOI: 10.1161/strokeaha.116.013679] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 05/31/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In heart failure (HF), left ventricular ejection fraction (LVEF) is inversely associated with mortality and cardiovascular outcomes. Its relationship with stroke is controversial, as is the effect of antithrombotic treatment. We studied the relationship of LVEF with stroke and cardiovascular events in patients with HF and the effect of different antithrombotic treatments. METHODS In the Warfarin Versus Aspirin in Reduced Ejection Fraction (WARCEF) trial, 2305 patients with systolic HF (LVEF≤35%) and sinus rhythm were randomized to warfarin or aspirin and followed for 3.5±1.8 years. Although no differences between treatments were observed on primary outcome (death, stroke, or intracerebral hemorrhage), warfarin decreased the stroke risk. The present report compares the incidence of stroke and cardiovascular events across different LVEF and treatment subgroups. RESULTS Baseline LVEF was inversely and linearly associated with primary outcome, mortality and its components (sudden and cardiovascular death), and HF hospitalization, but not myocardial infarction. A relationship with stroke was only observed for LVEF of <15% (incidence rates: 2.04 versus 0.95/100 patient-years; P=0.009), which more than doubled the adjusted stroke risk (adjusted hazard ratio, 2.125; 95% CI, 1.182-3.818; P=0.012). In warfarin-treated patients, each 5% LVEF decrement significantly increased the stroke risk (adjusted hazard ratio, 1.346; 95% CI, 1.044-1.737; P=0.022; P value for interaction=0.04). CONCLUSIONS In patients with systolic HF and sinus rhythm, LVEF is inversely associated with death and its components, whereas an association with stroke exists for very low LVEF values. An interaction with warfarin treatment on stroke risk may exist. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00041938.
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Affiliation(s)
- Marco R Di Tullio
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.).
| | - Min Qian
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - John L P Thompson
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Arthur J Labovitz
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Douglas L Mann
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Ralph L Sacco
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Patrick M Pullicino
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Ronald S Freudenberger
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - John R Teerlink
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Susan Graham
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Gregory Y H Lip
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Bruce Levin
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - J P Mohr
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Richard Buchsbaum
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Conrado J Estol
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Dirk J Lok
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Piotr Ponikowski
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Stefan D Anker
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
| | - Shunichi Homma
- From the Division of Cardiology, Department of Medicine (M.R.D.T., S.H.), Department of Biostatistics, Mailman School of Public Health (M.Q., J.L.P.T., B.L., R.B.), and Department of Neurology (J.P.M.), Columbia University Medical Center, New York; Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Cardiovascular Division, Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Departments of Neurology, Epidemiology and Public Health, University of Miami, FL (R.L.S.); Kent Institute of Medicine and Health Science, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Poland (P.P.); and Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Germany (S.D.A.)
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Kato TS, Di Tullio MR, Qian M, Wu M, Thompson JLP, Mann DL, Sacco RL, Pullicino PM, Freudenberger RS, Teerlink JR, Graham S, Lip GYH, Levin B, Mohr JP, Labovitz AJ, Estol CJ, Lok DJ, Ponikowski P, Anker SD, Homma S. Clinical and Echocardiographic Factors Associated With New-Onset Atrial Fibrillation in Heart Failure - Subanalysis of the WARCEF Trial. Circ J 2016; 80:619-26. [PMID: 26804607 DOI: 10.1253/circj.cj-15-1054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND Heart failure (HF) patients have a high incidence of new-onset AF. Given the adverse prognostic influence of AF in HF, identifying patients at high risk of developing AF is important. METHODS AND RESULTS The incidence and factors associated with new-onset AF were investigated in patients in sinus rhythm with reduced LVEF enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial. Analyses involved clinical factors alone (n=2,219), and clinical plus echocardiographic findings (n=1,125). During 3.5±1.8 years of follow-up, 212 patients (9.6% of total cohort) developed AF. In both samples, new-onset AF was associated with age, male sex, White race, and IHD. Among echocardiographic variables, only LAD predicted AF. On multivariate Cox modeling, age (HR, 1.02; 95% CI: 1.00-1.03, P=0.008), IHD (HR, 1.37; 95% CI: 1.02-1.84, P=0.036) and LAD (HR, 1.48; 95% CI: 1.15-1.91, P=0.003) remained associated with AF onset. Patients with IHD, LAD>4.5 cm and age>50 years had a 2.5-fold higher risk of AF than patients without any of these characteristics (HR, 2.52; 95% CI: 1.72-3.69, P<0.0001). CONCLUSIONS Age, IHD and LAD independently predict new-onset AF in HF patients in sinus rhythm, at younger age and smaller LAD than generally believed. This information may be useful to risk-stratify HF patients for AF development, allowing close monitoring and possibly early detection. (Circ J 2016; 80: 619-626).
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Affiliation(s)
- Tomoko S Kato
- Department of Medicine, Division of Cardiology, Columbia University Medical Center
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Badings EA, Remkes W, The SH, Dambrink JHE, Van Wijngaarden J, Tjeerdsma G, Rasoul S, Timmer J, Van Der Wielen M, Lok DJ, Hermanides R, van 't Hof A. TCT-2 Early or late intervention in patients with transient ST-segment elevation acute coronary syndromes: subgroup analysis of the ELISA-3 trial. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.08.902] [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: 10/23/2022]
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Ye S, Cheng B, Lip GY, Buchsbaum R, Sacco RL, Levin B, Di Tullio MR, Qian M, Mann DL, Pullicino PM, Freudenberger RS, Teerlink JR, Mohr J, Graham S, Labovitz AJ, Estol CJ, Lok DJ, Ponikowski P, Anker SD, Thompson JL, Homma S. Bleeding Risk and Antithrombotic Strategy in Patients With Sinus Rhythm and Heart Failure With Reduced Ejection Fraction Treated With Warfarin or Aspirin. Am J Cardiol 2015; 116:904-12. [PMID: 26189039 DOI: 10.1016/j.amjcard.2015.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 10/23/2022]
Abstract
We sought to assess the performance of existing bleeding risk scores, such as the Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) score or the Outpatient Bleeding Risk Index (OBRI), in patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm (SR) treated with warfarin or aspirin. We calculated HAS-BLED and OBRI risk scores for 2,305 patients with HFrEF in SR enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial. Proportional hazards models were used to test whether each score predicted major bleeding, and comparison of different risk scores was performed using Harell C-statistic and net reclassification improvement index. For the warfarin arm, both scores predicted bleeding risk, with OBRI having significantly greater C-statistic (0.72 vs 0.61; p = 0.03) compared to HAS-BLED, although the net reclassification improvement for comparing OBRI to HAS-BLED was not significant (0.32, 95% confidence interval [CI] -0.18 to 0.37). Performance of the OBRI and HAS-BLED risk scores was similar for the aspirin arm. For participants with OBRI scores of 0 to 1, warfarin compared with aspirin reduced ischemic stroke (hazard ratio [HR] 0.51, 95% CI 0.26 to 0.98, p = 0.042) without significantly increasing major bleeding (HR 1.24, 95% CI 0.66 to 2.30, p = 0.51). For those with OBRI score of ≥2, there was a trend for reduced ischemic stroke with warfarin compared to aspirin (HR 0.56, 95% CI 0.27 to 1.15, p = 0.12), but major bleeding was increased (HR 4.04, 95% CI 1.99 to 8.22, p <0.001). In conclusion, existing bleeding risk scores can identify bleeding risk in patients with HFrEF in SR and could be tested for potentially identifying patients with a favorable risk/benefit profile for antithrombotic therapy with warfarin.
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Shaffer JA, Thompson JLP, Cheng B, Ye S, Lip GYH, Mann DL, Sacco RL, Pullicino PM, Freudenberger RS, Graham S, Mohr JP, Labovitz AJ, Estol CJ, Lok DJ, Ponikowski P, Anker SD, Di Tullio MR, Homma S. Association of quality of life with anticoagulant control in patients with heart failure: the Warfarin and Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial. Int J Cardiol 2015; 177:715-7. [PMID: 25456692 DOI: 10.1016/j.ijcard.2014.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/03/2014] [Accepted: 10/04/2014] [Indexed: 12/20/2022]
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Homma S, Thompson JLP, Qian M, Ye S, Di Tullio MR, Lip GYH, Mann DL, Sacco RL, Levin B, Pullicino PM, Freudenberger RS, Teerlink JR, Graham S, Mohr JP, Labovitz AJ, Buchsbaum R, Estol CJ, Lok DJ, Ponikowski P, Anker SD. Quality of anticoagulation control in preventing adverse events in patients with heart failure in sinus rhythm: Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial substudy. Circ Heart Fail 2015; 8:504-9. [PMID: 25850425 DOI: 10.1161/circheartfailure.114.001725] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 03/17/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study is to examine the relationship between time in the therapeutic range (TTR) and clinical outcomes in heart failure patients in sinus rhythm treated with warfarin. METHODS AND RESULTS We used data from the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial to assess the relationship of TTR with the WARCEF primary outcome (ischemic stroke, intracerebral hemorrhage, or death), with death alone, ischemic stroke alone, major hemorrhage alone, and net clinical benefit (primary outcome and major hemorrhage combined). Multivariable Cox models were used to examine how the event risk changed with TTR and to compare the high TTR, low TTR, and aspirin-treated patients, with TTR being treated as a time-dependent covariate. A total of 2217 patients were included in the analyses; among whom 1067 were randomized to warfarin and 1150 were randomized to aspirin. The median (interquartile range) follow-up duration was 3.6 (2.0-5.0) years. Mean (±SD) age was 61±11.3 years, with 80% being men. The mean (±SD) TTR was 57% (±28.5%). Increasing TTR was significantly associated with reduction in primary outcome (adjusted P<0.001), death alone (adjusted P=0.001), and improved net clinical benefit (adjusted P<0.001). A similar trend was observed for the other 2 outcomes, but significance was not reached (adjusted P=0.082 for ischemic stroke and adjusted P=0.109 for major hemorrhage). CONCLUSIONS In patients with heart failure in sinus rhythm, increasing TTR is associated with better outcome and improved net clinical benefit. Patients in whom good quality anticoagulation can be achieved may benefit from the use of anticoagulants. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00041938.
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Affiliation(s)
- Shunichi Homma
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.).
| | - John L P Thompson
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Min Qian
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Siqin Ye
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Marco R Di Tullio
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Gregory Y H Lip
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Douglas L Mann
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Ralph L Sacco
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Bruce Levin
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Patrick M Pullicino
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Ronald S Freudenberger
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - John R Teerlink
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Susan Graham
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - J P Mohr
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Arthur J Labovitz
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Richard Buchsbaum
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Conrado J Estol
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Dirk J Lok
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Piotr Ponikowski
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
| | - Stefan D Anker
- From the Division of Cardiology, Department of Medicine (S.H., S.Y., M.R., D.T.) and Department of Neurology (J.P.M.), Columbia University Medical Center, New York, NY; Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY (J.L.P.T., M.Q., B.L., R.B.); University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom (G.Y.H.L.); Department of Medicine, Washington University, St. Louis, MO (D.L.M.); Department of Neurology, University of Miami Miller School of Medicine, FL (R.L.S.); Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, United Kingdom (P.M.P.); Division of Cardiology, Department of Medicine, Lehigh Valley Hospital, Allentown, PA (R.S.F.); Section of Cardiology, Department of Medicine, San Francisco VA Medical Center and School of Medicine, University of California San Francisco (J.R.T.); Division of Cardiology, Department of Medicine, SUNY Upstate Medical University, Buffalo, NY (S.G.); Department of Cardiovascular Medicine, University of South Florida, Tampa (A.J.L.); Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina (C.J.E.); Department of Cardiology, Deventer Hospital, Deventer, The Netherlands (D.J.L.); Department of Heart Diseases, Wroclaw Medical University, Military Hospital, Wroclaw, Poland (P.P.); and Division of Innovative Clinical Trials, Department of Cardiology, University Medicine Göttingen, Göttingen, Germany (S.D.A.)
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Pullicino PM, Qian M, Sacco RL, Freudenberger R, Graham S, Teerlink JR, Mann D, Di Tullio MR, Ponikowski P, Lok DJ, Anker SD, Lip GYH, Estol CJ, Levin B, Mohr JP, Thompson JLP, Homma S. Recurrent stroke in the warfarin versus aspirin in reduced cardiac ejection fraction (WARCEF) trial. Cerebrovasc Dis 2014; 38:176-81. [PMID: 25300706 DOI: 10.1159/000365502] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 06/25/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE WARCEF randomized 2,305 patients in sinus rhythm with ejection fraction (EF) ≤ 35% to warfarin (INR 2.0-3.5) or aspirin 325 mg. Warfarin reduced the incident ischemic stroke (IIS) hazard rate by 48% over aspirin in a secondary analysis. The IIS rate in heart failure (HF) is too low to warrant routine anticoagulation but epidemiologic studies show that prior stroke increases the stroke risk in HF. In this study, we explore IIS rates in WARCEF patients with and without baseline stroke to look for risk factors for IIS and determine if a subgroup with an IIS rate high enough to give a clinically relevant stroke risk reduction can be identified. METHODS We compared potential stroke risk factors between patients with baseline stroke and those without using the exact conditional score test for Poisson variables. We looked for risk factors for IIS, by comparing IIS rates between different risk factors. For EF we tried cut-off points of 10, 15 and 20%. The cut-off point 15% was used as it was the highest EF that was associated with a significant increase in IIS rate. IIS and EF strata were balanced as to warfarin/aspirin assignment by the stratified randomized design. A multiple Poisson regression examined the simultaneous effects of all risk factors on IIS rate. IIS rates per hundred patient years (/100 PY) were calculated in patient groups with significant risk factors. Missing values were assigned the modal value. RESULTS Twenty of 248 (8.1%) patients with baseline stroke and 64 of 2,048 (3.1%) without had IIS. IIS rate in patients with baseline stroke (2.37/100 PY) was greater than patients without (0.89/100 PY) (rate ratio 2.68, p < 0.001). Fourteen of 219 (6.4%) patients with ejection fraction (EF) <15% and 70 of 2,079 (3.4%) with EF ≥ 15% had IIS. In the multiple regression analysis stroke at baseline (p < 0.001) and EF <15% vs. ≥ 15% (p = 0.005) remained significant predictors of IIS. IIS rate was 2.04/100 PY in patients with EF <15% and 0.95/100 PY in patients with EF ≥ 15% (p = 0.009). IIS rate in patients with baseline stroke and reduced EF was 5.88/100 PY with EF <15% decreasing to 2.62/100 PY with EF <30%. CONCLUSIONS In a WARCEF exploratory analysis, prior stroke and EF <15% were risk factors for IIS. Further research is needed to determine if a clinically relevant stroke risk reduction is obtainable with warfarin in HF patients with prior stroke and reduced EF.
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Lok SI, Lok DJ, van der Weide P, Winkens B, Bruggink-André de la Porte PW, Doevendans PA, de Weger RA, van der Meer P, de Jonge N. Plasma levels of alpha-1-antichymotrypsin are elevated in patients with chronic heart failure, but are of limited prognostic value. Neth Heart J 2014; 22:391-5. [PMID: 25172361 PMCID: PMC4160451 DOI: 10.1007/s12471-014-0584-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background There is increasing interest in utilising novel markers of cardiovascular disease risk in patients with chronic heart failure (HF). Recently, it was shown that alpha-1-antichymotrypsin (ACT), an acute-phase protein and major inhibitor of cathpesin G, plays a role in the pathophysiology of HF and may serve as a marker for myocardial distress. Objective To assess whether ACT is independently associated with long-term mortality in chronic HF patients. Methods ACT plasma levels were categorised into quartiles. Survival times were analysed using Kaplan-Meier curves and Cox proportional hazards regression, without and with correction for clinically relevant risk factors, including sex, age, duration of HF, kidney function (MDRD), ischaemic HF aetiology and NT-proBNP. Results Twenty healthy individuals and 224 patients (mean age 71 years, 72 % male, median HF duration 1.6 years) with chronic HF were included. In total, 159 (71 %) patients died. The median survival time was 5.3 (95 % CI 4.5–6.1) years. ACT was significantly elevated in patients (median 433 μg/ml, IQR 279–680) in comparison with controls (median 214 μg/ml, IQR 166–271; p < 0.001). Cox regression analysis demonstrated that ACT was not independently related to long-term mortality in chronic HF patients (crude HR = 1.03, 95 % CI 0.75–1.41, p = 0.871; adjusted HR = 1.12, 95 % CI 0.78–1.60, p = 0.552), which was confirmed by Kaplan-Meier curves. Conclusion ACT levels are elevated in chronic HF patients, but no independent association with long-term mortality can be established.
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Affiliation(s)
- S I Lok
- Department of Cardiology, University Medical Center, Huispostnummer H04.312, PO Box 85500, 3508 GA, Utrecht, the Netherlands,
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Lok DJ, Klip IJT, Voors AA, Lok SI, Bruggink-André de la Porte PW, Hillege HL, Jaarsma T, van Veldhuisen DJ, van der Meer P. Prognostic value of N-terminal pro C-type natriuretic peptide in heart failure patients with preserved and reduced ejection fraction. Eur J Heart Fail 2014; 16:958-66. [DOI: 10.1002/ejhf.140] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 05/05/2014] [Accepted: 05/06/2014] [Indexed: 11/06/2022] Open
Affiliation(s)
- Dirk J. Lok
- University Medical Center Groningen; Groningen The Netherlands
- Deventer Hospital; Deventer The Netherlands
| | | | | | - Sjoukje I. Lok
- University Medical Center Utrecht; Utrecht The Netherlands
| | | | - Hans L. Hillege
- University Medical Center Groningen; Groningen The Netherlands
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Lok DJ, Klip IT, Lok SI, Bruggink-André de la Porte PW, Badings E, van Wijngaarden J, Voors AA, de Boer RA, van Veldhuisen DJ, van der Meer P. Incremental prognostic power of novel biomarkers (growth-differentiation factor-15, high-sensitivity C-reactive protein, galectin-3, and high-sensitivity troponin-T) in patients with advanced chronic heart failure. Am J Cardiol 2013; 112:831-7. [PMID: 23820571 DOI: 10.1016/j.amjcard.2013.05.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [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: 01/21/2013] [Revised: 05/02/2013] [Accepted: 05/02/2013] [Indexed: 12/11/2022]
Abstract
Elevated natriuretic peptides provide strong prognostic information in patients with heart failure (HF). The role of novel biomarkers in HF needs to be established. Our objective was to evaluate the prognostic power of novel biomarkers, incremental to the N-terminal portion of the natriuretic peptide (NT-proBNP) in chronic HF. Concentrations of circulating NT-proBNP, growth differentiation factor 15 (GDF-15), high-sensitivity C-reactive protein (hs-CRP), galectin-3 (Gal-3), and high-sensitivity troponin T (hs-TnT) were measured and related to all-cause long-term mortality. Of 209 patients (age 71 ± 10 years, 73% male patients, 97% New York Heart Association class III), 151 (72%) died during a median follow-up of 8.7 ± 1 year. The calculated area under the curve for NT-proBNP was 0.63, GDF-15 0.78, hs-CRP 0.66, Gal-3 0.68, and hs-TnT 0.68 (all p <0.01). Each marker was predictive for mortality in univariate analysis. In multivariate analysis, elevated concentrations of GDF-15 (hazard ratio [HR] 1.41, confidence interval [CI] 1.1 to 178, p = 0.005), hs-CRP (HR 1.38, CI 1.15 to 1.67, p = 0.001), and hs-TnT (HR 1.27, CI 1.06 to 1.53, p = 0.008) were independently related to mortality. All novel markers had an incremental value to NT-proBNP, using the integrated discrimination improvement. In conclusion, in chronic HF, GDF-15, hs-CRP, and hs-TnT are independent prognostic markers, incremental to NT-proBNP, in predicting long-term mortality. In this study, GDF-15 is the most predictive marker, even stronger than NT-proBNP.
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Affiliation(s)
- Dirk J Lok
- Deventer Hospital, Deventer, the Netherlands.
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Pullicino PM, Thompson JLP, Sacco RL, Sanford AR, Qian M, Teerlink JR, Haddad H, Diek M, Freudenberger RS, Labovitz AJ, Di Tullio MR, Lok DJ, Ponikowski P, Anker SD, Graham S, Mann DL, Mohr JP, Homma S. Stroke in heart failure in sinus rhythm: the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial. Cerebrovasc Dis 2013; 36:74-8. [PMID: 23921215 DOI: 10.1159/000352058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 05/03/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction trial found no difference between warfarin and aspirin in patients with low ejection fraction in sinus rhythm for the primary outcome: first to occur of 84 incident ischemic strokes (IIS), 7 intracerebral hemorrhages or 531 deaths. Prespecified secondary analysis showed a 48% hazard ratio reduction (p = 0.005) for warfarin in IIS. Cardioembolism is likely the main pathogenesis of stroke in heart failure. We examined the IIS benefit for warfarin in more detail in post hoc secondary analyses. METHODS We subtyped IIS into definite, possible and noncardioembolic using the Stroke Prevention in Atrial Fibrillation method. Statistical tests, stratified by prior ischemic stroke or transient ischemic attack, were the conditional binomial for independent Poisson variables for rates, the Cochran-Mantel-Haenszel test for stroke subtype and the van Elteren test for modified Rankin Score (mRS) and National Institute of Health Stroke Scale (NIHSS) distributions, and an exact test for proportions. RESULTS Twenty-nine of 1,142 warfarin and 55 of 1,163 aspirin patients had IIS. The warfarin IIS rate (0.727/100 patient-years, PY) was lower than for aspirin (1.36/100 PY, p = 0.003). Definite cardioembolic IIS was less frequent on warfarin than aspirin (0.22 vs. 0.55/100 PY, p = 0.012). Possible cardioembolic IIS tended to be less frequent on warfarin than aspirin (0.37 vs. 0.67/100 PY, p = 0.063) but noncardioembolic IIS showed no difference: 5 (0.12/100 PY) versus 6 (0.15/100 PY, p = 0.768). Among patients experiencing IIS, there were no differences by treatment arm in fatal IIS, baseline mRS, mRS 90 days after IIS, and change from baseline to post-IIS mRS. The warfarin arm showed a trend to a lower proportion of severe nonfatal IIS [mRS 3-5; 3/23 (13.0%) vs. 16/48 (33.3%), p = 0.086]. There was no difference in NIHSS at the time of stroke (p = 0.825) or in post-IIS mRS (p = 0.948) between cardioembolic, possible cardioembolic and noncardioembolic stroke including both warfarin and aspirin groups. CONCLUSIONS The observed benefits in the reduction of IIS for warfarin compared to aspirin are most significant for cardioembolic IIS among patients with low ejection fraction in sinus rhythm. This is supported by trends to lower frequencies of severe IIS and possible cardioembolic IIS in patients on warfarin compared to aspirin.
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Homma S, Thompson JLP, Sanford AR, Mann DL, Sacco RL, Levin B, Pullicino PM, Freudenberger RS, Teerlink JR, Graham S, Mohr JP, Massie BM, Labovitz AJ, Di Tullio MR, Gabriel AP, Lip GYH, Estol CJ, Lok DJ, Ponikowski P, Anker SD. Benefit of warfarin compared with aspirin in patients with heart failure in sinus rhythm: a subgroup analysis of WARCEF, a randomized controlled trial. Circ Heart Fail 2013; 6:988-97. [PMID: 23881846 DOI: 10.1161/circheartfailure.113.000372] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial found no difference in the primary outcome between warfarin and aspirin in 2305 patients with reduced left ventricular ejection fraction in sinus rhythm. However, it is unknown whether any subgroups benefit from warfarin or aspirin. METHODS AND RESULTS We used a Cox model stepwise selection procedure to identify subgroups that may benefit from warfarin or aspirin on the WARCEF primary outcome. A secondary analysis added major hemorrhage to the outcome. The primary efficacy outcome was time to the first to occur of ischemic stroke, intracerebral hemorrhage, or death. Only age group was a significant treatment effect modifier (P for interaction, 0.003). Younger patients benefited from warfarin over aspirin on the primary outcome (4.81 versus 6.76 events per 100 patient-years: hazard ratio, 0.63; 95% confidence interval, 0.48-0.84; P=0.001). In older patients, therapies did not differ (9.91 versus 9.01 events per 100 patient-years: hazard ratio, 1.09; 95% confidence interval, 0.88-1.35; P=0.44). With major hemorrhage added, in younger patients the event rate remained lower for warfarin than aspirin (5.41 versus 7.25 per 100 patient-years: hazard ratio, 0.68; 95% confidence interval, 0.52-0.89; P=0.005), but in older patients it became significantly higher for warfarin (11.80 versus 9.35 per 100 patient-years: hazard ratio, 1.25; 95% confidence interval, 1.02-1.53; P=0.03). CONCLUSIONS In patients <60 years, warfarin improved outcomes over aspirin with or without inclusion of major hemorrhage. In patients ≥60 years, there was no treatment difference, but the aspirin group had significantly better outcomes when major hemorrhage was included.
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Luttik MLA, Brons M, Jaarsma T, Hillege HL, Hoes A, de Jong R, Linssen G, Lok DJ, Berger M, van Veldhuisen DJ. Design and methodology of the COACH-2 (Comparative study on guideline adherence and patient compliance in heart failure patients) study: HF clinics versus primary care in stable patients on optimal therapy. Neth Heart J 2012; 20:307-12. [PMID: 22527916 DOI: 10.1007/s12471-012-0284-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Since the number of heart failure (HF) patients is still growing and long-term treatment of HF patients is necessary, it is important to initiate effective ways for structural involvement of primary care services in HF management programs. However, evidence on whether and when patients can be referred back to be managed in primary care is lacking. AIM To determine whether long-term patient management in primary care, after initial optimisation of pharmacological and non-pharmacological treatment in a specialised HF clinic, is equally effective as long-term management in a specialised HF clinic in terms of guideline adherence and patient compliance. METHOD The study is designed as a randomised, controlled, non-inferiority trial. Two-hundred patients will be randomly assigned to be managed and followed in primary care or in a HFclinic. Patients are eligible to participate if they are (1) clinically stable, (2) optimally up-titrated on medication (according to ESC guidelines) and, (3) have received optimal education and counselling on pre-specified issues regarding HF and its treatment. Furthermore, close cooperation between secondary and primary care in terms of back referral to or consultation of the HF clinic will be provided.The primary outcome will be prescriber adherence and patient compliance with medication after 12 months. Secondary outcomes measures will be readmission rate, mortality, quality of life and patient compliance with other lifestyle changes. EXPECTED RESULTS The results of the study will add to the understanding of the role of primary care and HF clinics in the long-term follow-up of HF patients.
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Affiliation(s)
- M L A Luttik
- Department of Cardiology, University Medical Center Groningen, University of Groningen, PO BOX 30.001, 9700, RB, Groningen, the Netherlands,
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Lok DJ, Lok SI, Bruggink-André de la Porte PW, Badings E, Lipsic E, van Wijngaarden J, de Boer RA, van Veldhuisen DJ, van der Meer P. Galectin-3 is an independent marker for ventricular remodeling and mortality in patients with chronic heart failure. Clin Res Cardiol 2012; 102:103-10. [PMID: 22886030 DOI: 10.1007/s00392-012-0500-y] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [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: 04/27/2012] [Accepted: 07/24/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Galectin-3 (Gal-3) is a recently discovered marker for myocardial fibrosis and elevated levels are associated with an impaired outcome after short-term follow-up in heart failure (HF) patients. However, whether Gal-3 is related to cardiac remodeling and outcome after long-term follow-up is unknown. Therefore, we determined the utility of Gal-3 as a novel biomarker for left ventricular remodeling and long-term outcome in patients with severe chronic HF. METHODS AND RESULTS A total of 240 HF patients with New York Heart Association (NYHA) Class III and IV were included. Patients were followed for 8.7 ± 1 years, had a mean age of 71 ± 0.6 years and 73 % of the study population was male. Circulating levels of NT-proBNP and Gal-3 were measured. Serial echocardiography was performed at baseline and at 3 months. At baseline median left ventricular end-diastolic volume (LVEDV) was 267 mL [interquartile range 232-322]. Patients were divided into three groups according to the change in LVEDV. Patients in whom the LVEDV decreased over time had significant lower levels of Gal-3 at entry compared to patients in whom the LVEDV was stable or increased (14.7 vs. 17.9 vs. 19.0 ng/mL; p = 0.004 for trend), whereas no significant differences were seen in levels of NT-proBNP (p = 0.33). Multivariate linear regression analyses revealed that Gal-3 levels were positively correlated to change in LVEDV (p = 0.007). In addition, Gal-3 was a significant predictor of mortality after long-term follow-up (p = 0.001). CONCLUSION Gal-3 is associated with left ventricular remodeling determined by serial echocardiography and predicts long-term mortality in patients with severe chronic HF.
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Affiliation(s)
- Dirk J Lok
- Deventer Hospital, Nico Bolkesteinlaan 75, 7415 CM, Deventer, The Netherlands.
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Homma S, Thompson JLP, Pullicino PM, Levin B, Freudenberger RS, Teerlink JR, Ammon SE, Graham S, Sacco RL, Mann DL, Mohr JP, Massie BM, Labovitz AJ, Anker SD, Lok DJ, Ponikowski P, Estol CJ, Lip GYH, Di Tullio MR, Sanford AR, Mejia V, Gabriel AP, del Valle ML, Buchsbaum R. Warfarin and aspirin in patients with heart failure and sinus rhythm. N Engl J Med 2012; 366:1859-69. [PMID: 22551105 PMCID: PMC3723382 DOI: 10.1056/nejmoa1202299] [Citation(s) in RCA: 459] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND It is unknown whether warfarin or aspirin therapy is superior for patients with heart failure who are in sinus rhythm. METHODS We designed this trial to determine whether warfarin (with a target international normalized ratio of 2.0 to 3.5) or aspirin (at a dose of 325 mg per day) is a better treatment for patients in sinus rhythm who have a reduced left ventricular ejection fraction (LVEF). We followed 2305 patients for up to 6 years (mean [±SD], 3.5±1.8). The primary outcome was the time to the first event in a composite end point of ischemic stroke, intracerebral hemorrhage, or death from any cause. RESULTS The rates of the primary outcome were 7.47 events per 100 patient-years in the warfarin group and 7.93 in the aspirin group (hazard ratio with warfarin, 0.93; 95% confidence interval [CI], 0.79 to 1.10; P=0.40). Thus, there was no significant overall difference between the two treatments. In a time-varying analysis, the hazard ratio changed over time, slightly favoring warfarin over aspirin by the fourth year of follow-up, but this finding was only marginally significant (P=0.046). Warfarin, as compared with aspirin, was associated with a significant reduction in the rate of ischemic stroke throughout the follow-up period (0.72 events per 100 patient-years vs. 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33 to 0.82; P=0.005). The rate of major hemorrhage was 1.78 events per 100 patient-years in the warfarin group as compared with 0.87 in the aspirin group (P<0.001). The rates of intracerebral and intracranial hemorrhage did not differ significantly between the two treatment groups (0.27 events per 100 patient-years with warfarin and 0.22 with aspirin, P=0.82). CONCLUSIONS Among patients with reduced LVEF who were in sinus rhythm, there was no significant overall difference in the primary outcome between treatment with warfarin and treatment with aspirin. A reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage. The choice between warfarin and aspirin should be individualized. (Funded by the National Institute of Neurological Disorders and Stroke; WARCEF ClinicalTrials.gov number, NCT00041938.).
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Affiliation(s)
- Shunichi Homma
- Columbia University Medical Center, New York, NY 10032, USA
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Lok DJ, Bruggink PW, van der Meer P. Prognostic value of galectin-3, a novel marker of fibrosis. Clin Res Cardiol 2010. [PMCID: PMC2911525 DOI: 10.1007/s00392-010-0155-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Neuhaus KL, Molhoek GP, Zeymer U, Tebbe U, Wegscheider K, Schröder R, Camez A, Laarman GJ, Grollier GM, Lok DJ, Kuckuck H, Lazarus P. Recombinant hirudin (lepirudin) for the improvement of thrombolysis with streptokinase in patients with acute myocardial infarction: results of the HIT-4 trial. J Am Coll Cardiol 1999; 34:966-73. [PMID: 10520777 DOI: 10.1016/s0735-1097(99)00319-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.6] [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: 11/21/2022]
Abstract
OBJECTIVES The purpose of this study was to compare recombinant hirudin and heparin as adjuncts to streptokinase thrombolysis in patients with acute myocardial infarction (AMI). BACKGROUND Experimental studies and previous small clinical trials suggest that specific thrombin inhibition improves early patency rates and clinical outcome in patients treated with streptokinase. METHODS In a randomized double-blind, multicenter trial, 1,208 patients with AMI < or =6 h were treated with aspirin and streptokinase and randomized to receive recombinant hirudin (lepirudin, i.v. bolus of 0.2 mg/kg, followed by subcutaneous (s.c.) injections of 0.5 mg/kg b.i.d. for 5 to 7 days) or heparin (i.v. placebo bolus, followed by s.c. injections of 12,500 IU b.i.d. for 5 to 7 days). A total of 447 patients were included in the angiographic substudy in which the primary end point, 90-min Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 of the infarct-related artery, was evaluated, while the other two-thirds served as "safety group" in which only clinical end points were evaluated. As an additional efficacy parameter the ST-segment resolution at 90 and 180 min was measured in all patients. RESULTS TIMI flow grade 3 was observed in 40.7% in the lepirudin and in 33.5% in the heparin group (p = 0.16), respectively. In the entire study population the proportion of patients with complete ST resolution at 90 min (28% vs. 22%, p = 0.05) and at 180 min (52% vs. 48%, p = 0.18) after start of therapy tended to be higher in the lepirudin group. There was no significant difference in the incidence of hemorrhagic stroke (0.2% vs. 0.3%) or total stroke (1.2% vs. 1.5%), reinfarction rate (4.6% vs. 5.1%) and total mortality rate (6.8% vs. 6.4%) at 30 days, as well as the combined end point of death, nonfatal stroke, nonfatal reinfarction, rescue-percutaneous transluminal coronary angioplasty and refractory angina (22.7 vs. 24.3%) were not statistically different between the two groups. CONCLUSIONS Lepirudin as adjunct to thrombolysis with streptokinase did not significantly improve restoration of blood flow in the infarct vessel as assessed by angiography, but was associated with an accelerated ST resolution. There was no increase in the risk of major bleedings with lepirudin compared to heparin.
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Affiliation(s)
- K L Neuhaus
- Städtische Kliniken, Medizinische Klinik II, Kassel, Germany
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de Vries RJ, van den Heuvel AF, Lok DJ, Claessens RJ, Bernink PJ, Pasteuning WH, Kingma JH, Dunselman PH. Nifedipine gastrointestinal therapeutic system versus atenolol in stable angina pectoris. The Netherlands Working Group on Cardiovascular Research (WCN). Int J Cardiol 1996; 57:143-50. [PMID: 9013266 DOI: 10.1016/s0167-5273(96)02806-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [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] [Indexed: 02/03/2023]
Abstract
The gastrointestinal therapeutic system formulation of nifedipine enables a once-daily dosing resulting in predictable, relatively constant plasma concentrations. To evaluate the efficacy and safety of this formulation and to compare this with the beta-blocker atenolol, we conducted a double-blind, randomised, multi-centre study in 129 male patients with documented exercise induced angina pectoris. After 4 weeks' treatment, nifedipine (60 mg), improved time to onset of 0.1 mV ST-segment depression from 536 s by 72 +/- 117s, time to onset of pain from 619 s by 56 +/- 120 s, and total exercise time from 685 s by 40 +/- 88 s. Atenolol 100 mg, had a comparable effect, time to onset of 0.1 mV ST-segment depression improved from 496 s by 53 +/- 129 s, time to onset of pain from 572 s by 57 +/- 118 s, and total exercise time from 653 s by 33 +/- 99 s. Between group analysis revealed no statistically significant differences for these exercise parameters. Atenolol, but not nifedipine, significantly reduced heart rate and systolic blood pressure at rest and during exercise (P < 0.001 between groups), indicating different modes of action of the drugs. With regard to safety, both drugs were generally well tolerated. There were significantly (P = 0.01) more vasodilation related side effects with nifedipine. These data demonstrate that gastrointestinal therapeutic system formulation of nifedipine and atenolol as once-daily monotherapy are equally effective and safe, but with different effects on exercise parameters.
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Affiliation(s)
- R J de Vries
- Department of Cardiology/Thoraxcenter, University Hospital Groningen, The Netherlands
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de Vries RJ, Queré M, Lok DJ, Sijbring P, Bucx JJ, van Veldhuisen DJ, Dunselman PH. Comparison of effects on peak oxygen consumption, quality of life, and neurohormones of felodipine and enalapril in patients with congestive heart failure. Am J Cardiol 1995; 76:1253-8. [PMID: 7503006 DOI: 10.1016/s0002-9149(99)80352-x] [Citation(s) in RCA: 17] [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: 01/25/2023]
Abstract
Angiotensin-converting enzyme (ACE) inhibition is currently the cornerstone of congestive heart failure (CHF) therapy, but these drugs are not tolerated in up to 20% of patients. For these patients, therapeutic alternatives with comparable efficacy are needed. Felodipine, a vasoselective dihydropyridine calcium antagonist with a slow onset of action and a long plasma half-life, may be such an agent. Therefore, the efficacy and safety of felodipine were examined and compared with enalapril using a double-blind design. We studied 46 patients with a left ventricular ejection fraction < 0.40, peak oxygen consumption < 20 ml.min-1.kg-1, and symptoms of CHF despite therapy with diuretics and digoxin. After 16 weeks of therapy, there were no statistically significant differences in peak oxygen consumption (felodipine +1.6, enalapril +2.5 ml.min-1.kg-1) and exercise tolerance (felodipine +61 seconds, enalapril +64 seconds). Quality-of-life parameters were affected slightly better by felodipine than by enalapril. Plasma norepinephrine decreased by 143 pg.ml-1 with enalapril and by 12 pg.ml-1 with felodipine (p < 0.20 between groups). Both drugs were generally well tolerated. These data suggest that felodipine and enalapril have comparable effects on exercise parameters in patients with CHF. Neurohumoral activation was not observed with either drug.
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Affiliation(s)
- R J de Vries
- Department of Cardiology, Ignatius Hospital, Breda, The Netherlands
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Molhoek GP, Laarman GJ, Lok DJ, Luz CM, Kingma JH, Van den Bos AA, Zijnen P, Bosma AH, Hertzberger DP, Takens LH. Angiographic dose-finding study with r-hirudin (HBW 023) for the improvement of thrombolytic therapy with streptokinase (HIT-SK). Interim results. Eur Heart J 1995; 16 Suppl D:33-7. [PMID: 8542870 DOI: 10.1093/eurheartj/16.suppl_d.33] [Citation(s) in RCA: 16] [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: 01/31/2023] Open
Abstract
To evaluate the efficacy and safety of hirudin, a direct thrombin inhibitor, in patients with acute myocardial infarction, a dose-finding, angiography study was carried out. After a pilot phase in 10 patients treated with a bolus of 0.1 mg.kg-1 and a continuous infusion of 0.06 mg.kg-1.h-1 (dose group I), two doses of hirudin, bolus 0.2 mg.kg-1.h-1 (DG II), and bolus 0.4 mg.kg-1 with 0.15 mg.kg-1.h-1 (DG III) were tested and compared with heparin as an adjunct to streptokinase and aspirin. This interim analysis was mandatory due to puncture-site related bleedings. Early and complete patency was achieved in 30% of 35 heparin patients, in 40% of 10 DG I, in 47% of 58 DG II and in 62% of 14 DG III patients. A dose-response relationship particularly between DG I and DG II, was also observed in the anti-thrombotic activity monitored by the aPTT. Apart from the catheter-related bleedings, there were low rates of serious adverse events.
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Affiliation(s)
- G P Molhoek
- Department of Cardiology Medisch Spectrum Twente, Enschede, The Netherlands
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van Veldhuisen DJ, Man in 't Veld AJ, Dunselman PH, Lok DJ, Dohmen HJ, Poortermans JC, Withagen AJ, Pasteuning WH, Brouwer J, Lie KI. Double-blind placebo-controlled study of ibopamine and digoxin in patients with mild to moderate heart failure: results of the Dutch Ibopamine Multicenter Trial (DIMT). J Am Coll Cardiol 1993; 22:1564-73. [PMID: 7901256 DOI: 10.1016/0735-1097(93)90579-p] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.0] [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: 01/27/2023]
Abstract
OBJECTIVES This study was conducted to determine the efficacy and safety of long-term treatment with the orally active dopamine agonist ibopamine in patients with mild to moderate chronic congestive heart failure and to compare the results with those of treatment with digoxin and placebo. BACKGROUND Ibopamine and digoxin are drugs that exert hemodynamic and neurohumoral effects. Because there is accumulating evidence that progression of disease in chronic heart failure is related not only to hemodynamic but also to neurohumoral factors, both drugs might be expected to have a favorable long-term effect. METHODS We studied 161 patients with mild to moderate chronic heart failure (80% in New York Heart Association functional class II and 20% in class III), who were treated with ibopamine (n = 53), digoxin (n = 55) or placebo (n = 53) for 6 months. Background therapy consisted of furosemide (0 to 80 mg); all other drugs for heart failure were excluded. Clinical assessments were made at baseline and after 1, 3 and 6 months. RESULTS Of the 161 patients, 128 (80%) completed the study. Compared with placebo, digoxin but not ibopamine significantly increased exercise time after 6 months (p = 0.008 by intention to treat analysis). Ibopamine was only effective in patients with relatively preserved left ventricular function, as it significantly increased exercise time in this subgroup (for patients with a left ventricular ejection fraction > 0.30; p = 0.018 vs. placebo). No patient receiving digoxin withdrew from the study because of progression of heart failure, compared with six patients receiving ibopamine and two receiving placebo. At 6 months, plasma norepinephrine was decreased with digoxin and ibopamine therapy (-106 and -13 pg/ml, respectively) but increased with placebo administration (+62 pg/ml) (both p < 0.05 vs. placebo). Plasma aldosterone was unaffected, but renin was decreased by both agents after 6 months (p < 0.05 vs. placebo). Total mortality and ambulatory arrhythmias were not significantly affected by the two drugs. CONCLUSIONS Ibopamine and digoxin both inhibit neurohumoral activation in patients with mild to moderate chronic heart failure. However, the clinical effects of these drugs are different and appear to be related to the degree of left ventricular dysfunction.
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Affiliation(s)
- D J van Veldhuisen
- Department of Cardiology/Thoraxcenter, University Hospital, Groningen, The Netherlands
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