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Pareek M, Kristensen AMD, Vaduganathan M, Byrne C, Biering-Sørensen T, Højbjerg Lassen MC, Johansen ND, Skaarup KG, Rosberg V, Pallisgaard JL, Mortensen MB, Maeng M, Polcwiartek CB, Frangeskos J, McCarthy CP, Bonde AN, Lee CJY, Fosbøl EL, Køber L, Olsen NT, Gislason GH, Torp-Pedersen C, Bhatt DL, Kragholm KH. Serial troponin-I and long-term outcomes in subjects with suspected acute coronary syndrome. Eur J Prev Cardiol 2024; 31:615-626. [PMID: 38057157 DOI: 10.1093/eurjpc/zwad373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/28/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023]
Abstract
AIMS It is unclear how serial high-sensitivity troponin-I (hsTnI) concentrations affect long-term prognosis in individuals with suspected acute coronary syndrome (ACS). METHODS AND RESULTS Subjects who underwent two hsTnI measurements (Siemens TnI Flex® Reagent) separated by 1-7 h, during a first-time hospitalization for myocardial infarction, unstable angina, observation for suspected myocardial infarction, or chest pain from 2012 through 2019, were identified through Danish national registries. Individuals were stratified per their hsTnI concentration pattern (normal, rising, persistently elevated, or falling) and the magnitude of hsTnI concentration change (<20%, >20-50%, or >50% in either direction). We calculated absolute and relative mortality risks standardized to the distributions of risk factors for the entire study population. A total of 20 609 individuals were included of whom 2.3% had died at 30 days, and an additional 4.7% had died at 365 days. The standardized risk of death was highest among persons with a persistently elevated hsTnI concentration (0-30 days: 8.0%, 31-365 days: 11.1%) and lowest among those with two normal hsTnI concentrations (0-30 days: 0.5%, 31-365 days: 2.6%). In neither case did relative hsTnI concentration changes between measurements clearly affect mortality risk. Among persons with a rising hsTnI concentration pattern, 30-day mortality was higher in subjects with a >50% rise compared with those with a less pronounced rise (2.2% vs. <0.1%). CONCLUSION Among individuals with suspected ACS, those with a persistently elevated hsTnI concentration consistently had the highest risk of death. In subjects with two normal hsTnI concentrations, mortality was very low and not affected by the magnitude of change between measurements.
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Affiliation(s)
- Manan Pareek
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | | | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Christina Byrne
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Mats Christian Højbjerg Lassen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Niklas Dyrby Johansen
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Kristoffer Grundtvig Skaarup
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Victoria Rosberg
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jannik L Pallisgaard
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Skejby, Aarhus, Denmark
| | | | - Julia Frangeskos
- Department of Cardiology, Peconic Bay Medical Center at Northwell Health, Riverhead, NY, USA
| | - Cian P McCarthy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Christina Ji-Young Lee
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Niels Thue Olsen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital-North Zealand Hospital, Hillerød, Denmark
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, NewYork, NY, USA
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Hansen MK, Mortensen MB, Olesen KKW, Thrane PG, Thomsen RW, Maeng M. Non-HDL cholesterol and residual cardiovascular risk in statin-treated patients with and without diabetes: The Western Denmark Heart Registry. Eur J Prev Cardiol 2024:zwae119. [PMID: 38513361 DOI: 10.1093/eurjpc/zwae119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/28/2024] [Accepted: 03/20/2024] [Indexed: 03/23/2024]
Abstract
AIMS Assessment of residual cardiovascular risk in statin-treated patients with atherosclerotic cardiovascular disease (ASCVD) is pivotal for optimising secondary preventive therapies. This study investigates if non-high-density lipoprotein cholesterol (non-HDL-C) is associated with residual ASCVD risk in statin-treated ischemic heart disease (IHD) patients with and without diabetes. METHODS Using the Western Denmark Heart Registry, we identified statin-treated patients with IHD examined by coronary angiography (CAG) from 2011-2020. Non-HDL-C was assessed within one year after CAG. Outcomes were ASCVD (myocardial infarction, ischemic stroke, and cardiovascular death) and all-cause death. Cox regression analyses obtained hazard ratios adjusted for age, sex, smoking, and hypertension. RESULTS A total of 42,057 patients were included; 8,196 patients with diabetes and 33,861 without diabetes. During median 4.6 years of follow-up event rates per 1000 person-years of ASCVD were 28.8 (27.1-30.5) and 17.2 (16.5-17.8) among patients with and without diabetes. In patients with diabetes the adjusted hazard ratios (HR) of ASCVD as compared with non-HDL-C <25th percentile were 1.0 (0.9-1.2), 1.3 (1.1-1.6), and 1.6 (1.2-2.1) for patients in the 25th-74th, 75th-94th, and ≥95th percentile. In patients without diabetes corresponding adjusted HRs were 1.1 (0.9-1.1), 1.2 (1.1-1.4), and 1.7 (1.4-2.0). Results were consistent across sex, age, clinical presentation, and low-density lipoprotein cholesterol strata. CONCLUSIONS In statin-treated IHD patients with and without diabetes non-HDL-C, especially above the 75th percentile, is associated with residual cardiovascular risk. These results have implications for secondary prevention targeting patients who may benefit most from intensified preventive therapy.
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Affiliation(s)
- Malene Kærslund Hansen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- John Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, John Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | - Reimar Wernich Thomsen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
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Razavi AC, Shaw LJ, Berman DS, Budoff MJ, Wong ND, Vaccarino V, van Assen M, De Cecco CN, Quyyumi AA, Mehta A, Muntner P, Miedema MD, Rozanski A, Rumberger JA, Nasir K, Blumenthal RS, Sperling LS, Mortensen MB, Whelton SP, Blaha MJ, Dzaye O. Left Main Coronary Artery Calcium and Diabetes Confer Very-High-Risk Equivalence in Coronary Artery Calcium >1,000. JACC Cardiovasc Imaging 2024:S1936-878X(24)00026-3. [PMID: 38385932 DOI: 10.1016/j.jcmg.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/04/2023] [Accepted: 12/15/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Although a coronary artery calcium (CAC) of ≥1,000 is a subclinical atherosclerosis threshold to consider combination lipid-lowering therapy, differentiating very high from high atherosclerotic cardiovascular disease (ASCVD) risk in this patient population is not well-defined. OBJECTIVES Among persons with a CAC of ≥1,000, the authors sought to identify risk factors equating with very high-risk ASCVD mortality rates. METHODS The authors studied 2,246 asymptomatic patients with a CAC of ≥1,000 from the CAC Consortium without a prior ASCVD event. Cox proportional hazards regression modelling was performed for ASCVD mortality during a median follow-up of 11.3 years. Crude ASCVD mortality rates were compared with those reported for secondary prevention trial patients classified as very high risk, defined by ≥2 major ASCVD events or 1 major event and ≥2 high-risk conditions (1.4 per 100 person-years). RESULTS The mean age was 66.6 years, 14% were female, and 10% were non-White. The median CAC score was 1,592 and 6% had severe left main (LM) CAC (vessel-specific CAC ≥300). Diabetes (HR: 2.04 [95% CI: 1.47-2.83]) and severe LM CAC (HR: 2.32 [95% CI: 1.51-3.55]) were associated with ASCVD mortality. The ASCVD mortality per 100 person-years for all patients was 0.8 (95% CI: 0.7-0.9), although higher rates were observed for diabetes (1.4 [95% CI: 0.8-1.9]), severe LM CAC (1.3 [95% CI: 0.6-2.0]), and both diabetes and severe LM CAC (7.1 [95% CI: 3.4-10.8]). CONCLUSIONS Among asymptomatic patients with a CAC of ≥1,000 without a prior index event, diabetes, and severe LM CAC define very high risk ASCVD, identifying individuals who may benefit from more intensive prevention therapies across several domains, including low-density lipoprotein-cholesterol lowering.
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Affiliation(s)
- Alexander C Razavi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, Blavatnik Family Women's Health Research Institute, New York, New York, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew J Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Nathan D Wong
- Heart Disease Prevention Program, Division of Cardiology, Department of Medicine, University of California, Irvine, California, USA
| | - Viola Vaccarino
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlo N De Cecco
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arshed A Quyyumi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Anurag Mehta
- VCU Health Pauley Heart Center and Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael D Miedema
- Nolan Family Center for Cardiovascular Health, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St Luke's Hospital, New York, New York, USA
| | | | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laurence S Sperling
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Hansen MK, Mortensen MB, Warnakula Olesen KK, Thrane PG, Maeng M. Non-HDL cholesterol and residual risk of cardiovascular events in patients with ischemic heart disease and well-controlled LDL cholesterol: a cohort study. Lancet Reg Health Eur 2024; 36:100774. [PMID: 38019978 PMCID: PMC10652132 DOI: 10.1016/j.lanepe.2023.100774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/23/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023]
Abstract
Background Identifying patients at high residual risk of atherosclerotic cardiovascular disease (ASCVD) despite statin-treatment is of paramount clinical importance. We aim to investigate if non-high-density lipoprotein cholesterol (non-HDL-C) identifies residual risk of ASCVD and death in statin-treated patients with ischemic heart disease and low-density lipoprotein cholesterol (LDL-C) ≤ 1.8 mmol/L. Methods Leveraging Danish regional and national registries, we identified statin-treated patients with ischemic heart disease who underwent coronary angiography (CAG) and attained LDL-C ≤ 1.8 mmol/L within a year post-CAG. Outcomes were myocardial infarction (MI), ASCVD (MI or ischemic stroke), and all-cause death occurring from one year after CAG to end of follow-up. Cox regression analyses obtained adjusted hazard ratios (HR). Findings Between January 1, 2011, and December 31, 2020, we included 23,641 statin-treated patients with ischemic heart disease and LDL-C ≤ 1.8 mmol/L. During median follow-up of 4.1 years (IQR 2.4-6.1), 893 (3.8%) patients developed MI, 1207 (5.1%) ASCVD, and 3054 (12.9%) patients died. For ASCVD the adjusted HRs (95% confidence interval) for non-HDL-C < 25th percentile (<1.7 mmol/L) versus 25th-74th (1.7-2.1 mmol/L), 75th-94th (2.2-2.6 mmol/L), and ≥95th (≥2.7 mmol/L) percentile were 1.1 (0.9-1.3), 1.4 (1.1-1.7), and 1.8 (1.4-2.4), and for all-cause death 1.0 (0.9-1.1), 1.2 (1.1-1.4), and 1.4 (1.2-1.7), respectively. Interpretation In a contemporary secondary prevention cohort of patients with well-managed LDL-C, non-HDL-C emerges as an easily accessible marker to detect patients facing high residual risk of ASCVD and death. These findings are important for preventive strategies extending beyond LDL-C targets. Funding Research grant from the Novo Nordisk Foundation.
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Affiliation(s)
- Malene Kærslund Hansen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
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Razavi AC, Kim C, van Assen M, De Cecco CN, Berman DS, Budoff MJ, Quyyumi AA, Vaccarino V, Miedema MD, Nasir K, Rozanski A, Fernandez C, Rumberger JA, Shaw LJ, Mortensen MB, Wong ND, Blumenthal RS, Sperling LS, Whelton SP, Blaha MJ, Dzaye O. Thoracic Aortic Calcium Density and Area in Long-Term Atherosclerotic Cardiovascular Disease Risk Among Men Versus Women. Circ Cardiovasc Imaging 2023; 16:e015690. [PMID: 38054290 PMCID: PMC10841590 DOI: 10.1161/circimaging.123.015690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/08/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND The development of thoracic aortic calcium (TAC) temporally precedes coronary artery calcium more often in women versus men. Whether TAC density and area confer sex-specific differences in atherosclerotic cardiovascular disease (ASCVD) risk is unknown. METHODS We studied 5317 primary prevention patients who underwent coronary artery calcium scoring on noncontrast cardiac gated computed tomography with TAC >0. The Agatston TAC score (Agatston units), density (Hounsfield units), and area (mm2) were compared between men and women. Cox proportional hazards regression calculated adjusted hazard ratios for TAC density-area groups with ASCVD mortality, adjusting for traditional risk factors, coronary artery calcium, and TAC. Multinomial logistic regression calculated adjusted odds ratios for the association between traditional risk factors and TAC density-area groups. RESULTS The mean age was 60.7 years, 38% were women, and 163 ASCVD deaths occurred over a median of 11.7-year follow-up. Women had higher median TAC scores (97 versus 84 Agatston units; P=0.004), density (223 versus 210 Hounsfield units; P<0.001), and area (37 versus 32 mm2; P=0.006) compared with men. There was a stepwise higher incidence of ASCVD deaths across increasing TAC density-area groups in men though women with low TAC density relative to TAC area (3.6 per 1000 person-years) had survival probability commensurate with the high-density-high-area group (4.8 per 1000 person-years). Compared with low TAC density-area, low TAC density/high TAC area conferred a 3.75-fold higher risk of ASCVD mortality in women (adjusted hazard ratio, 3.75 [95% CI, 1.13-12.44]) but not in men (adjusted hazard ratio, 1.16 [95% CI, 0.48-2.84]). Risk factors most strongly associated with low TAC density/high TAC area differed in women (diabetes: adjusted odds ratio, 2.61 [95% CI, 1.34-5.07]) versus men (hypertension: adjusted odds ratio, 1.45 [95% CI, 1.11-1.90]). CONCLUSIONS TAC density-area phenotypes do not consistently associate with ASCVD mortality though low TAC density relative to area may be a marker of increased ASCVD risk in women.
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Affiliation(s)
- Alexander C. Razavi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, United States
| | - Cherry Kim
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, United States
- Department of Radiology, Korea University College of Medicine, Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, South Korea
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, United States
| | - Carlo N. De Cecco
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, GA, United States
| | - Daniel S. Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Matthew J. Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Arshed A. Quyyumi
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Viola Vaccarino
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Michael D. Miedema
- Minneapolis Heart Institute and Foundation, Minneapolis, MN, United States
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, United States
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St Luke’s Hospital, New York, NY, United States
| | - Camilo Fernandez
- Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | | | - Leslee J. Shaw
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | | | - Nathan D. Wong
- Heart Disease Prevention Program, University of California Irvine, Irvine, CA, United States
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Laurence S. Sperling
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, United States
| | - Seamus P. Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Nielsen RR, Anker N, Stødkilde-Jørgensen N, Thrane PG, Hansen MK, Pryds K, Mortensen MB, Olesen KKW, Maeng M. Impact of Coronary Artery Disease in Women With Newly Diagnosed Heart Failure and Reduced Ejection Fraction. JACC Heart Fail 2023; 11:1653-1663. [PMID: 37632494 DOI: 10.1016/j.jchf.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND The representation of women in heart failure studies has been inadequate, resulting in a knowledge gap regarding the prognostic impact of coronary artery disease (CAD) on all-cause mortality in women with newly diagnosed heart failure and reduced ejection fraction (HFrEF). OBJECTIVES This study aims to assess the prognostic impact of CAD in women with HFrEF. METHODS Using the Western Denmark Heart Registry, the authors identified 891 women and 2,403 men referred for first-time coronary angiography because of HFrEF. The authors stratified for presence of CAD, estimated 10-year all-cause mortality, and calculated crude and adjusted HRs (aHRs) with 95% CIs. RESULTS The 10-year mortality was 60% in women with CAD and 27% in women without CAD; for men, the corresponding numbers were 54% and 36%. When adjusted for comorbidities, women without CAD had a lower relative 10-year mortality than men without CAD (aHR: 0.73; 95% CI: 0.58-0.91), whereas women with CAD had similar relative mortality as men with CAD (aHR: 1.00; 95% CI: 0.81-1.24) (Pinteraction = 0.037). Assessed by the number of coronary vessels with significant stenosis, CAD extent was associated with mortality for both women (P < 0.01) and men (P < 0.01). However, compared to those without CAD, the aHR was higher for women with any degree of CAD (aHR ranging from 1.61 [95% CI: 1.09-2.38] for diffuse CAD to 2.01 [95% CI: 1.19-3.40] for 3-vessel disease) than for men with 3-vessel disease (aHR: 1.51; 95% CI: 1.19-1.91). CONCLUSIONS In patients with newly diagnosed HFrEF, the presence and extent of CAD has significantly greater prognostic impact among women than among men.
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Affiliation(s)
- Roni Ranghoej Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark.
| | - Nanna Anker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark
| | - Nina Stødkilde-Jørgensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark
| | | | | | - Kasper Pryds
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark; Department of Cardiology, Johns Hopkins, Baltimore, Maryland, USA
| | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Health, Aarhus, Denmark
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Gyldenkerne C, Mortensen MB, Kahlert J, Thrane PG, Warnakula Olesen KK, Sørensen HT, Thomsen RW, Maeng M. 10-Year Cardiovascular Risk in Patients With Newly Diagnosed Type 2 Diabetes Mellitus. J Am Coll Cardiol 2023; 82:1583-1594. [PMID: 37821168 DOI: 10.1016/j.jacc.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/13/2023] [Accepted: 08/14/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Contemporary data on cardiovascular disease (CVD) risk in patients with newly diagnosed type 2 diabetes mellitus (T2DM) is needed to guide appropriate preventive management. OBJECTIVES The authors sought to investigate sex- and age-specific 10-year CVD risk in patients with newly diagnosed T2DM compared with the general population. METHODS A cohort study was conducted of all Danish patients with T2DM diagnosed between 2006 and 2013 (n = 142,587) and sex- and age-matched individuals from the general population (n = 388,410), all without prior atherosclerotic CVD. Ten-year CVD risk (myocardial infarction, stroke, and fatal CVD) was estimated. RESULTS A total of 52,471 CVD events were recorded. Compared with the general population, the 10-year CVD risks were higher in patients with T2DM in both sexes and across all age groups, especially among younger individuals. For example, patients aged 40 to 49 years had the largest 10-year CVD risk difference (T2DM 6.1% vs general population 3.3%; risk difference: 2.8%, subdistribution HR: 1.91; 95% CI: 1.76-2.07). The age when a given CVD risk was reached differed substantially between the cohorts. Thus, a 10-year CVD risk of 5% was reached at age 43 in men with T2DM compared with 12 years later, at age 55, in men without T2DM. A 10-year CVD risk of 5% was reached at age 51 in women with T2DM and 10 years later, at age 61, in women without T2DM. CONCLUSIONS Newly diagnosed T2DM increased 10-year CVD risk across both sexes and all age groups, especially among younger patients, with CVD occurring ≤12 years earlier than in general population individuals.
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Affiliation(s)
- Christine Gyldenkerne
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Ciccarone Center for the Prevention of Cardiovascular Disease, Department of Cardiology, Johns Hopkins, Baltimore, Maryland, USA
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Reimar Wernich Thomsen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
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Søndergaard MM, Freeman P, Kristensen AMD, Chang SM, Nassir K, Mortensen MB, Nørgaard BL, Maeng M, Andersen MP, Søgaard P, Tayal B, Pareek M, Johnsen SP, Køber L, Gislason G, Torp-Pedersen C, Kragholm KH. Education level and the use of coronary computed tomography, functional testing, coronary angiography, revascularization, and outcomes-a 10-year Danish, nationwide, registry-based follow-up study. Eur Heart J Qual Care Clin Outcomes 2023:qcad052. [PMID: 37740574 DOI: 10.1093/ehjqcco/qcad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND AIMS Coronary computed tomography angiography (CCTA) can guide downstream preventive treatment and improve patient prognosis, but its use in relation to education level remains unexplored. METHODS This nationwide register-based cohort study assessed all residents in Denmark between 2008-2018 without coronary artery disease (CAD) and 50-80 years of age (n = 1 469 724). Residents were divided according to four levels of education: low, lower-mid, higher-mid, and high. Outcomes were CCTA, functional testing, invasive coronary angiography (ICA), revascularization, and major adverse cardiovascular and cerebrovascular events (MACCE). RESULTS Individuals with the lowest education level underwent CCTA (absolute risk [AR] 3.95% individuals aged ≥ 50-59, AR 3.62% individuals aged ≥ 60-69, AR 2.19% individuals aged ≥ 70-80) less often than individuals of lower-mid (AR 4.16%, AR 3.90%, AR 2.41%), higher-mid (AR 4.38%, AR 4.30%, AR 2.45%) and highest education level (AR 3.98%, AR 4.37%, AR 2.30%). Similar differences were observed for functional testing. Conversely, use of ICA, and risks of revascularization and MACCE were more common among individuals of lowest education level. Among patients examined with CCTA (n = 50 234), patients of lowest education level less often underwent functional testing and more likely initiated preventive medication, underwent ICA, revascularization, and experienced MACCE. CONCLUSION Despite tax-financed healthcare in Denmark, individuals of lowest education level were less likely to undergo CCTA and functional testing than persons of higher education level. ICA utilization, revascularization and MACCE risks were higher for individuals of lowest education level. Among CCTA-examined patients, patients of lowest education level were more likely to initiate preventive medication and had the highest risks of revascularization and MACCE when compared to higher education level groups. These findings suggest that the preventive potential of CCTA is underutilized in individuals of lower education level, a proxy for socioeconomic status. Socioeconomic differences in CAD assessment, care, and outcomes are likely even larger without tax-financed healthcare.
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Affiliation(s)
| | - Phillip Freeman
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Su Min Chang
- Houston Methodist DeBakey Heart and Vascular Center, Cardiac Imaging Laboratory, Houston, TX, USA
| | - Khurram Nassir
- Houston Methodist DeBakey Heart and Vascular Center, Preventive Cardiology, Houston, TX, USA
| | | | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Bhupendar Tayal
- Department of Cardiology, Houston Methodist Hospital, Houston, TX, USA
| | - Manan Pareek
- Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Hellerup, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Hillerød, Denmark
- Department of Public Health, University of Copenhagen, Denmark
| | - Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Houston Methodist DeBakey Heart and Vascular Center, Cardiac Imaging Laboratory, Houston, TX, USA
- Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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9
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Rafiqi K, Hoeks CB, Løfgren B, Mortensen MB, Bruun JM. Diagnostic Impact of Hs-CRP and IL-6 for Acute Coronary Syndrome in Patients Admitted to the ED with Chest Pain: Added Value to the HEART Score? Open Access Emerg Med 2023; 15:333-342. [PMID: 37753377 PMCID: PMC10519209 DOI: 10.2147/oaem.s425319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023] Open
Abstract
Objective To investigate whether hs-CRP and IL-6 provide additional diagnostic value beyond that achieved by the HEART score in patients with chest pain suggestive of acute coronary syndrome (ACS) admitted to the emergency department (ED). Methods This was a post hoc analysis using data from the RACING-MI study. Baseline data, including hs-CRP and IL-6 levels, were analyzed using the plasma from the biobank. A total of 818 patients with chest pain suggestive of ACS were included in this analysis. Of these, 98 were diagnosed with ACS (12%). Logistic regression was used to identify the independent predictors of ACS development in patients with chest pain. Results hs-CRP levels >2 mg/L were observed in 50% of all ACS cases. IL-6 levels >1.3 pg/mL were observed in 71% of all ACS cases. hs-CRP had a sensitivity of 50% and specificity of 51% for the diagnosis of ACS, whereas IL-6 had a sensitivity of 71% and specificity of 29%. The diagnostic likelihood ratios for ACS was 1.0 for hs-CRP>2 mg/L and IL-6 > 1.3 pg/mL, respectively. Logistic regression analysis revealed that age, male gender, and ongoing smoking were associated with ACS in patients with acute chest pain. No association was found between IL-6 or hs-CRP level and ACS. This was observed for both IL-6 and hs-CRP, whether assessed on a continuous scale or using prespecified cut-off values. Conclusion Among the 818 patients admitted to the ED with chest pain suggestive of ACS, neither hs-CRP nor IL-6 provided an independent added diagnostic value. Our results suggest that inflammatory markers have limited diagnostic value in detecting patients with ACS in the ED.
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Affiliation(s)
- Khalil Rafiqi
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Emergency Department, Aarhus University Hospital, Aarhus, Denmark
| | - Camilla Bang Hoeks
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Bo Løfgren
- Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Ciccarone Center for Prevention of Heart Disease, Johns Hopkins, Baltimore, MD, USA
| | - Jens M Bruun
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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10
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Thrane PG, Olesen KKW, Thim T, Gyldenkerne C, Mortensen MB, Kristensen SD, Maeng M. Mortality Trends After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2023; 82:999-1010. [PMID: 37648359 DOI: 10.1016/j.jacc.2023.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Observational studies have reported that mortality rates after ST-segment elevation myocardial infarction (STEMI) have been stable since 2006 to 2010. OBJECTIVES The aim of this study was to evaluate the temporal trends in 1-year, 30-day, and 31- to 365-day mortality after STEMI in Western Denmark where primary percutaneous coronary intervention (PCI) has been the national reperfusion strategy since 2003. METHODS Using the Western Denmark Heart Registry, the study identified first-time PCI-treated patients undergoing primary PCI (pPCI) for STEMI from 2003 to 2018. Based on the year of pPCI, patients were divided into 4 time-interval groups and followed up for 1 year using the Danish national health registries. RESULTS A total of 19,613 patients were included. Median age was 64 years, and 74% were male. One-year mortality decreased gradually from 10.8% in 2003-2006, 10.4% in 2007-2010, 9.1% in 2011-2014, to 7.7% in 2015-2018 (2015-2018 vs 2003-2006: adjusted HR [aHR]: 0.71; 95% CI: 0.62-0.82). The largest absolute mortality decline occurred in the 0- to 30-day period with a 2.3% reduction (aHR: 0.69; 95% CI: 0.59-0.82), and to a lesser extent in the 31- to 365-day period (risk reduction: 1.0%; aHR: 0.71; 95% CI: 0.56-0.90). CONCLUSIONS In a high-income European country with a fully implemented pPCI strategy, 1-year mortality in pPCI-treated patients with STEMI decreased substantially between 2003 and 2018. Approximately three-quarters of the absolute mortality reduction occurred within the first 30 days after pPCI. These results indicate that optimization of early management of pPCI-treated patients with STEMI offers great opportunities for improving overall survival in contemporary clinical practice.
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Affiliation(s)
| | | | - Troels Thim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | | | | | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark. https://twitter.com/MichaelMaeng1
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11
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Toth PP, Ferrières J, Waters M, Mortensen MB, Lan NSR, Wong ND. Global eligibility and cost effectiveness of icosapent ethyl in primary and secondary cardiovascular prevention. Front Cardiovasc Med 2023; 10:1220017. [PMID: 37719970 PMCID: PMC10501481 DOI: 10.3389/fcvm.2023.1220017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/08/2023] [Indexed: 09/19/2023] Open
Abstract
Icosapent ethyl (IPE) is a purified eicosapentaenoic acid-only omega-3 fatty acid that significantly reduced cardiovascular (CV) events in patients receiving statins with established cardiovascular disease (CVD) and those with diabetes and additional risk factors in the pivotal REDUCE-IT trial. Since the publication of REDUCE-IT, there has been global interest in determining IPE eligibility in different patient populations, the proportion of patients who may benefit from IPE, and cost effectiveness of IPE in primary and secondary prevention settings. The aim of this review is to summarize information from eligibility and cost effectiveness studies of IPE to date. A total of sixteen studies were reviewed, involving 2,068,111 patients in the primary or secondary prevention settings worldwide. Up to forty-five percent of patients were eligible for IPE, depending on the selection criteria used (ie, REDUCE-IT criteria, US Food and Drug Administration label, Health Canada label, practice guidelines) and the population studied. Overall, eight cost-effectiveness studies across the United States, Canada, Germany, Israel, and Australia were included in this review and findings indicated that IPE is particularly cost effective in patients with established CVD.
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Affiliation(s)
- Peter P. Toth
- CGH Medical Center, Sterling, IL, United States
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jean Ferrières
- Department of Cardiology, Toulouse Rangueil University Hospital, Toulouse University School of Medicine, Toulouse, France
| | - Max Waters
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | | | - Nick S. R. Lan
- Department of Cardiology, Fiona Stanley Hospital, Murdoch, WA, Australia
- Medical School, The University of Western Australia, Crawley, WA, Australia
| | - Nathan D. Wong
- Division of Cardiology, University of California, Irvine, CA, United States
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12
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Kristensen FPB, Christensen DH, Mortensen MB, Maeng M, Kahlert J, Sørensen HT, Thomsen RW. Triglycerides and risk of cardiovascular events in statin-treated patients with newly diagnosed type 2 diabetes: a Danish cohort study. Cardiovasc Diabetol 2023; 22:187. [PMID: 37495999 PMCID: PMC10373341 DOI: 10.1186/s12933-023-01921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Elevated triglyceride levels are a clinically useful marker of remnant cholesterol. It is unknown whether triglycerides are associated with residual cardiovascular risk in CVD-naïve patients with newly diagnosed type 2 diabetes mellitus (T2DM), who are already on statin therapy. We aimed to assess the association between triglyceride levels and risk of major cardiovascular events (MACE) in statin-treated patients with newly diagnosed T2DM managed in routine clinical care. METHODS This cohort study included newly diagnosed T2DM patients without a previous diagnosis of cardiovascular disease in Northern Denmark during 2005-2017. Individual triglyceride levels while on statin treatment were assessed within 1 year after T2DM diagnosis. The primary outcome was a composite of myocardial infarction, ischemic stroke, or cardiac death (MACE). Patients were followed from one year after T2DM diagnosis until 30 April 2021, MACE, emigration, or death. We used Cox regression to compute hazard ratios (HRs) controlling for confounding factors. RESULTS Among 27,080 statin-treated patients with T2DM (median age 63 years; 53% males), triglyceride levels were < 1.0 mmol/L in 17%, 1.0-1.9 mmol/L in 52%, 2.0-2.9 mmol/L in 20%, and ≥ 3.0 mmol/L in 11%. During follow-up, 1,957 incident MACE events occurred (11.0 per 1000 person-years). Compared with triglyceride levels < 1.0 mmol/L, confounder-adjusted HRs for incident MACE were 1.14 (95% CI 1.00-1.29) for levels between 1.0 and 1.9 mmol/L, 1.30 (95% CI 1.12-1.51) for levels between 2.0 and 2.9 mmol/L, and 1.44 (95% CI 1.20-1.73) for levels ≥ 3.0 mmol/L. This association was primarily driven by higher rates of myocardial infarction and cardiac death and attenuated only slightly after additional adjustment for LDL cholesterol. Spline analyses confirmed a linearly increasing risk of MACE with higher triglyceride levels. Stratified analyses showed that the associations between triglyceride levels and MACE were stronger among women. CONCLUSIONS In statin-treated patients with newly diagnosed T2DM, triglyceride levels are associated with MACE already from 1.0 mmol/L. This suggests that high triglyceride levels are a predictor of residual cardiovascular risk in early T2DM and could be used to guide allocation of additional lipid-lowering therapies for CVD prevention.
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Affiliation(s)
- Frederik Pagh Bredahl Kristensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark.
| | - Diana Hedevang Christensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Johnny Kahlert
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark
| | - Reimar Wernich Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Olof Palmes Alle 43-45, 8200, Aarhus N, Denmark
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13
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Graversen M, Rouvelas I, Ainsworth AP, Bjarnesen AP, Detlefsen S, Ellebaek SB, Fristrup CW, Liljefors MG, Lundell L, Nilsson M, Pfeiffer P, Tarpgaard LS, Tsekrekos A, Mortensen MB. ASO Visual Abstract: Feasibility and Safety of Laparoscopic D2 Gastrectomy in Combination with Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in Patients with Gastric Cancer at High Risk of Recurrence: The PIPAC-OPC4 Study. Ann Surg Oncol 2023; 30:4442-4443. [PMID: 37024765 DOI: 10.1245/s10434-023-13404-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Affiliation(s)
- M Graversen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.
- Department of Surgery, Odense University Hospital, Odense, Denmark.
- OPEN-Open Patient data Explorative Network, Odense University Hospital, Odense, Region of Southern Denmark, Denmark.
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - I Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - A P Ainsworth
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - A P Bjarnesen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - S Detlefsen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - S B Ellebaek
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - C W Fristrup
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Surgery, Odense University Hospital, Odense, Denmark
| | - M G Liljefors
- Department of Oncology, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - L Lundell
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - M Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - P Pfeiffer
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - L S Tarpgaard
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - A Tsekrekos
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - M B Mortensen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Surgery, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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14
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Graversen M, Detlefsen S, Ainsworth AP, Fristrup CW, Knudsen AO, Pfeiffer P, Tarpgaard LS, Mortensen MB. ASO Visual Abstract: Treatment of Peritoneal Metastasis with Pressurized IntraPeritoneal Aerosol Chemotherapy-Results from the Prospective PIPAC-OPC2 Study. Ann Surg Oncol 2023; 30:2645. [PMID: 36692612 DOI: 10.1245/s10434-022-13081-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- M Graversen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.
- Department of Surgery, Odense University Hospital, Odense, Denmark.
- OPEN - Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark.
- OPAC - Odense Pancreas Center, Odense University Hospital, Odense, Denmark.
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - S Detlefsen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- OPAC - Odense Pancreas Center, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - A P Ainsworth
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC - Odense Pancreas Center, Odense University Hospital, Odense, Denmark
| | - C W Fristrup
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC - Odense Pancreas Center, Odense University Hospital, Odense, Denmark
| | - A O Knudsen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - P Pfeiffer
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- OPAC - Odense Pancreas Center, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - L S Tarpgaard
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - M B Mortensen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC - Odense Pancreas Center, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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15
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Mortensen MB, Dzaye O, Bøtker HE, Jensen JM, Maeng M, Bentzen JF, Kanstrup H, Sørensen HT, Leipsic J, Blankstein R, Nasir K, Blaha MJ, Nørgaard BL. Low-Density Lipoprotein Cholesterol Is Predominantly Associated With Atherosclerotic Cardiovascular Disease Events in Patients With Evidence of Coronary Atherosclerosis: The Western Denmark Heart Registry. Circulation 2023; 147:1053-1063. [PMID: 36621817 PMCID: PMC10073288 DOI: 10.1161/circulationaha.122.061010] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 12/12/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Low-density lipoprotein cholesterol (LDL-C) is an important causal risk factor for atherosclerotic cardiovascular disease (ASCVD). However, a sizable proportion of middle-aged individuals with elevated LDL-C level have not developed coronary atherosclerosis as assessed by coronary artery calcification (CAC). Whether presence of CAC modifies the association of LDL-C with ASCVD risk is unknown. We evaluated the association of LDL-C with future ASCVD events in patients with and without CAC. METHODS The study included 23 132 consecutive symptomatic patients evaluated for coronary artery disease using coronary computed tomography angiography (CTA) from the Western Denmark Heart Registry, a seminational, multicenter-based registry with longitudinal registration of patient and procedure data. We assessed the association of LDL-C level obtained before CTA with ASCVD (myocardial infarction and ischemic stroke) events occurring during follow-up stratified by CAC>0 versus CAC=0 using Cox regression models adjusted for baseline characteristics. Outcomes were identified through linkage among national registries covering all hospitals in Denmark. We replicated our results in the National Heart, Lung, and Blood Institute-funded Multi-Ethnic Study of Atherosclerosis. RESULTS During a median follow-up of 4.3 years, 552 patients experienced a first ASCVD event. In the overall population, LDL-C (per 38.7 mg/dL increase) was associated with ASCVD events occurring during follow-up (adjusted hazard ratio [aHR], 1.14 [95% CI, 1.04-1.24]). When stratified by the presence or absence of baseline CAC, LDL-C was only associated with ASCVD in the 10 792/23 132 patients (47%) with CAC>0 (aHR, 1.18 [95% CI, 1.06-1.31]); no association was observed among the 12 340/23 132 patients (53%) with CAC=0 (aHR, 1.02 [95% CI, 0.87-1.18]). Similarly, a very high LDL-C level (>193 mg/dL) versus LDL-C <116 mg/dL was associated with ASCVD in patients with CAC>0 (aHR, 2.42 [95% CI, 1.59-3.67]) but not in those without CAC (aHR, 0.92 [0.48-1.79]). In patients with CAC=0, diabetes, current smoking, and low high-density lipoprotein cholesterol levels were associated with future ASCVD events. The principal findings were replicated in the Multi-Ethnic Study of Atherosclerosis. CONCLUSIONS LDL-C appears to be almost exclusively associated with ASCVD events over ≈5 years of follow-up in middle-aged individuals with versus without evidence of coronary atherosclerosis. This information is valuable for individualized risk assessment among middle-aged people with or without coronary atherosclerosis.
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Affiliation(s)
- Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob Fog Bentzen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Helle Kanstrup
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Ron Blankstein
- Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston (TX), USA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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16
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Graversen M, Rouvelas I, Ainsworth AP, Bjarnesen AP, Detlefsen S, Ellebaek SB, Fristrup CW, Liljefors MG, Lundell L, Nilsson M, Pfeiffer P, Tarpgaard LS, Tsekrekos A, Mortensen MB. Feasibility and Safety of Laparoscopic D2 Gastrectomy in Combination with Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in Patients with Gastric Cancer at High Risk of Recurrence-The PIPAC-OPC4 Study. Ann Surg Oncol 2023. [PMID: 36867174 DOI: 10.1245/s10434-023-13278-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Patients with gastric adenocarcinoma (GAC) are at high risk of peritoneal recurrence despite perioperative chemotherapy and radical resection. This study evaluated feasibility and safety of laparoscopic D2 gastrectomy in combination with pressurized intraperitoneal aerosol chemotherapy (PIPAC). METHODS This was a prospective, controlled bi-institutional study in patients with GAC at high risk of recurrence treated with PIPAC with cisplatin and doxorubicin (PIPAC C/D) after laparoscopic D2 gastrectomy. High risk was defined as a poorly cohesive subtype with predominance of signet-ring cells, clinical stage ≥ T3 and/or ≥ N2, or positive peritoneal cytology. Peritoneal lavage fluid was collected before and after resection. Cisplatin (10.5 mg/m2) and doxorubicin (2.1 mg/m2) were aerosolized after anastomosis (flow 0.5-0.8 ml/s, maximum pressure 300 PSI). Treatment was feasible and safe if ≤ 20% had Dindo-Clavien ≥ 3b surgical complications or CTCAE ≥ 4 medical adverse events within 30 days. Secondary outcomes were length of stay (LOS), peritoneal lavage cytology, and completion of postoperative systemic chemotherapy. RESULTS Twenty-one patients were treated with a D2 gastrectomy and PIPAC C/D. The median age was 61 years (range 24-76), there were eleven female patients, and 20 patients had preoperative chemotherapy. There was no mortality. Two patients had grade 3b complications that were potentially related to PIPAC C/D (one anastomotic leakage, and one late duodenal blow-out). One patient had severe neutropenia, and nine patients had moderate pain. The LOS was 6 days (4-26). One patient had positive peritoneal lavage cytology before resection, and none were positive after. Fifteen patients had postoperative chemotherapy. CONCLUSIONS Laparoscopic D2 gastrectomy in combination with PIPAC C/D is feasible and safe.
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Affiliation(s)
- Martin Graversen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark. .,Department of Surgery, Odense University Hospital, Odense, Denmark. .,OPEN - Open Patient data Explorative Network, Odense University Hospital, Region of Southern Denmark, Odense, Denmark. .,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - I Rouvelas
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - A P Ainsworth
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - A P Bjarnesen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - S Detlefsen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - S B Ellebaek
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - C W Fristrup
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - M G Liljefors
- Department of Oncology, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - L Lundell
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - M Nilsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - P Pfeiffer
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - L S Tarpgaard
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - A Tsekrekos
- Department of Upper Abdominal Diseases, Karolinska University Hospital and Division of Surgery and Oncology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - M B Mortensen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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17
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Pareek M, Kragholm KH, Kristensen AMD, Vaduganathan M, Pallisgaard JL, Byrne C, Biering-Sørensen T, Lee CJY, Bonde AN, Mortensen MB, Maeng M, Fosbøl EL, Køber L, Olsen NT, Gislason GH, Bhatt DL, Torp-Pedersen C. Serial troponin-T and long-term outcomes in suspected acute coronary syndrome. Eur Heart J 2023; 44:502-512. [PMID: 36329643 DOI: 10.1093/eurheartj/ehac629] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 05/22/2022] [Revised: 09/11/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Long-term prognostic implications of serial high-sensitivity troponin concentrations in subjects with suspected acute coronary syndrome are unknown. METHODS AND RESULTS Individuals with a first diagnosis of myocardial infarction, unstable angina, observation for suspected myocardial infarction, or chest pain from 2012 through 2019 who underwent two high-sensitivity troponin-T (hsTnT) measurements 1-7 h apart were identified through Danish national registries. Absolute and relative risks for death at days 0-30 and 31-365, stratified for whether subjects had normal or elevated hsTnT concentrations, and whether these concentrations changed by <20%, > 20 to 50%, or >50% in either direction from first to second measurement, were calculated through multivariable logistic regression with average treatment effect modeling. Of the 28 902 individuals included, 2.8% had died at 30 days, whereas 4.9% of those who had survived the first 30 days died between days 31-365. The standardized risk of death was highest among subjects with two elevated hsTnT concentrations (0-30 days: 4.3%, 31-365 days: 7.2%). In this group, mortality was significantly higher in those with a > 20 to 50% or >50% rise from first to second measurement, though only at 30 days. The risk of death was very low in subjects with two normal hsTnT concentrations (0-30 days: 0.1%, 31-365 days: 0.9%) and did not depend on relative or absolute changes between measurements. CONCLUSIONS Individuals with suspected acute coronary syndrome and two consecutively elevated hsTnT concentrations consistently had the highest risk of death. Mortality was very low in subjects with two normal hsTnT concentrations, irrespective of changes between measurements.
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Affiliation(s)
- Manan Pareek
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark.,Department of Cardiology, Copenhagen University Hospital - North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA
| | - Kristian H Kragholm
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Anna Meta Dyrvig Kristensen
- Department of Cardiology, Copenhagen University Hospital - North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA
| | - Jannik L Pallisgaard
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark
| | - Christina Byrne
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark.,Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark.,Institute of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Christina Ji-Young Lee
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Niels Thue Olsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital - North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
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18
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Graversen M, Detlefsen S, Ainsworth AP, Fristrup CW, Knudsen AO, Pfeiffer P, Tarpgaard LS, Mortensen MB. Treatment of Peritoneal Metastasis with Pressurized Intraperitoneal Aerosol Chemotherapy: Results from the Prospective PIPAC-OPC2 Study. Ann Surg Oncol 2023; 30:2634-2644. [PMID: 36602663 DOI: 10.1245/s10434-022-13010-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 12/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pressurized Intraperitoneal Aerosol chemotherapy (PIPAC) is a local treatment for peritoneal metastasis (PM). Prospective data are scarce and evaluation of treatment response remains difficult. This study evaluated the use of the Peritoneal Regression Grading score (PRGS) and its prognostic value. PATIENTS AND METHODS This was a prospective, controlled phase II trial in patients with PM from gastrointestinal, gynaecological, hepatopancreatobiliary, primary peritoneal, or unknown primary cancer. Patients in performance status 0-1, with a non-obstructed gastrointestinal tract, and a maximum of one extraperitoneal metastasis were eligible. Colorectal or appendiceal PM had PIPAC with oxaliplatin, other primaries had PIPAC with cisplatin and doxorubicin. Biopsies were taken at each PIPAC and evaluated using the PRGS. Quality-of-life questionnaires were reported at baseline and after three PIPACs. RESULTS One hundred ten patients were treated with 336 PIPACs (median 3, range 1-12). One hundred patients had prior palliative chemotherapy and 45 patients received bidirectional treatment. Complete or major histological response to treatment (PRGS 1-2) was observed in 38 patients (61%) who had three PIPACs, which was the only independent prognostic factor in a multivariate analysis. The median overall survival (mOS) from PIPAC 1 was 10 months, while patients with PM from gastric, colorectal, and pancreatic cancer had a mOS of 7.4, 16.7, and 8.2 months, respectively. Global health scores were significantly reduced, but patients were less fatigued, nauseated, constipated, and had better appetite after three PIPACs. CONCLUSIONS PIPAC with oxaliplatin or cisplatin and doxorubicin was able to induce a major or complete histological response during three PIPACs, which may provide significant prognostic information, both at baseline and after treatment.
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Affiliation(s)
- Martin Graversen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark. .,Department of Surgery, Odense University Hospital, Odense, Denmark. .,OPEN-Open Patient data Explorative Network, Odense University Hospital, Odense, Region of Southern Denmark, Denmark. .,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark. .,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
| | - S Detlefsen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - A P Ainsworth
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark
| | - C W Fristrup
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark
| | - A O Knudsen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - P Pfeiffer
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - L S Tarpgaard
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Oncology, Odense University Hospital, Odense, Denmark
| | - M B Mortensen
- Odense PIPAC Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark.,OPAC-Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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19
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Vela E, Cleries M, Bilal U, Banach M, McEvoy JW, Mortensen MB, Blaha MJ, Nasir K, Comin-Colet J, Mauri J, Cainzos-Achirica M. Implications of the 2021 ESC cardiovascular risk classification among 283,000 European immigrants living in a low-risk region: a population-based analysis in Catalonia. Arch Med Sci 2023; 19:35-45. [PMID: 36817660 PMCID: PMC9897087 DOI: 10.5114/aoms/144631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The ESC recently classified European countries into 4 cardiovascular risk regions. However, whether Europeans from higher-risk countries living in lower-risk regions may benefit from intensive cardiovascular prevention efforts is unknown. We described the burden of risk factors and cardiovascular disease (CVD) among European-born immigrants living in Catalonia, a low-risk region. MATERIAL AND METHODS A retrospective cohort study of 5.6 million adults of European origin living in Catalonia in 2019, including 282,789 European-born immigrants, was performed. We used the regionwide healthcare database and classified participants into 5 groups: low-, moderate-, high-, and very high-risk, and local-born. Age-standardized prevalence was estimated as of December 31st, 2019 and incidence was computed during 2019 among at-risk individuals. RESULTS The very high-risk group was the largest immigrant group (N = 136,910; 48.4%), while the high-risk group was the smallest (N = 15,739; 5.6%). These two had the highest burden of coronary heart disease across all groups evaluated, in both men and women. The very high-risk group also had the highest prevalence of hypertension and obesity at young-to-middle age, and the burden of risk factors newly diagnosed during 2019 was highest in high- and very high-risk participants. The mean age at first diagnosis of risk factors and CVD was lower in these groups. CONCLUSIONS In Catalonia, residents born in high- and very-high-risk European countries are at increased risk of coronary heart disease and newly diagnosed risk factors. Low-risk European countries may consider tailored prevention efforts, early screening of risk factors, and adequate healthcare resource planning to better address the health needs of men and women from higher-risk countries.
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Affiliation(s)
- Emili Vela
- Healthcare Information and Knowledge Unit, Catalan Health Service, Barcelona, Spain
- Digitalization for the Sustainability of the Healthcare System (DS3), Sistema de Salut de Catalunya, Barcelona, Spain
| | - Montse Cleries
- Healthcare Information and Knowledge Unit, Catalan Health Service, Barcelona, Spain
- Digitalization for the Sustainability of the Healthcare System (DS3), Sistema de Salut de Catalunya, Barcelona, Spain
| | - Usama Bilal
- Urban Health Collaborative, Drexel Dornsife School of Public Health, Philadelphia (PA), USA
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz (MUL), Lodz, Poland
| | - John W. McEvoy
- National University of Ireland and National Institute for Preventive Cardiology, Galway, Ireland
- Division of Cardiology, Department of Medicine, Saolta University Healthcare Group, University College Hospital Galway, Galway, Ireland
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore (MD), USA
| | - Michael Joseph Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore (MD), USA
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore (MD), USA
| | - Khurram Nasir
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore (MD), USA
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston (TX), USA
- Center for Outcomes Research, Houston Methodist, Houston (TX), USA
| | - Josep Comin-Colet
- Department of Cardiology, Bellvitge University Hospital, L’Hospitalet de Llobregat, Barcelona, Spain
- Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain
- Pla Director de Malalties Cardiovasculars, Health Department of the Government of Catalonia, Catalonia, Spain
| | - Josepa Mauri
- Pla Director de Malalties Cardiovasculars, Health Department of the Government of Catalonia, Catalonia, Spain
- Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain, Spain
| | - Miguel Cainzos-Achirica
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore (MD), USA
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston (TX), USA
- Pla Director de Malalties Cardiovasculars, Health Department of the Government of Catalonia, Catalonia, Spain
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20
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Razavi AC, Mortensen MB, Blaha MJ, Dzaye O. Coronary artery calcium testing in young adults. Curr Opin Cardiol 2023; 38:32-38. [PMID: 36598447 PMCID: PMC9830553 DOI: 10.1097/hco.0000000000001006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW To provide a summary of recent literature on coronary artery calcium testing (CAC) for risk stratification in young adults <45 years old. RECENT FINDINGS One of every ten young adults in the general population, and one out of every three young adults with traditional atherosclerotic cardiovascular disease (ASCVD) risk factors, have CAC. While the definition of premature CAC has yet to be formally defined in guidelines, it has become increasingly clear that any prevalent CAC among adults <45 years old should be considered premature. Traditional risk factors are strong predictors of CAC in young adults; however, this association has been found to wane over the life course which suggests that the onset and severity of risk factors for calcific atherosclerosis varies as individuals age. Though CAC is a robust predictor of both ASCVD and cancer-related mortality in old age, CAC in young adults confers a stepwise higher risk uniquely for incident ASCVD mortality, and not for non-ASCVD causes. New tools are available to assist in interpretation of CAC in the young, and for estimating the ideal age to initiate CAC scoring. SUMMARY The identification of premature CAC is important because it suggests that calcific plaque can be detected with modern imaging earlier in the natural history than previously thought. Taken together, these findings underline a utility of selective use of CAC scoring on non-contrast computed tomography among at-risk young adults to facilitate timely lifestyle modification and pharmacotherapies for the prevention of later life ASCVD.
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Affiliation(s)
- Alexander C. Razavi
- Center for Heart Disease Prevention, Emory University Hospital, Atlanta, Georgia, United States of America
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | | | - Michael J. Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
| | - Omar Dzaye
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, United States of America
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21
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Dzaye O, Razavi AC, Mortensen MB. Reply: Coronary Artery Calcium Scoring in the Young: A Continuum Risk? JACC Cardiovasc Imaging 2022; 15:2017-2018. [PMID: 36357148 DOI: 10.1016/j.jcmg.2022.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 11/09/2022]
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22
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Razavi AC, van Assen M, De Cecco CN, Dardari ZA, Berman DS, Budoff MJ, Miedema MD, Nasir K, Rozanski A, Rumberger JA, Shaw LJ, Sperling LS, Whelton SP, Mortensen MB, Blaha MJ, Dzaye O. Discordance Between Coronary Artery Calcium Area and Density Predicts Long-Term Atherosclerotic Cardiovascular Disease Risk. JACC Cardiovasc Imaging 2022; 15:1929-1940. [PMID: 35850937 PMCID: PMC9883836 DOI: 10.1016/j.jcmg.2022.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Coronary artery calcium (CAC) is commonly quantified as the product of 2 generally correlated measures: plaque area and calcium density. OBJECTIVES The authors sought to determine whether discordance between calcium area and density has long-term prognostic importance in atherosclerotic cardiovascular disease (ASCVD) risk. METHODS The authors studied 10,373 primary prevention participants from the CAC Consortium with CAC >0. Based on their median values, calcium area and mean calcium density were divided into 4 mutually exclusive concordant/discordant groups. Cox proportional hazards regression assessed the association of calcium area/density groups with ASCVD mortality over a median of 11.7 years, adjusting for traditional risk factors and the Agatston CAC score. RESULTS The mean age was 56.7 years, and 24% were female. The prevalence of plaque discordance was 19% (9% low calcium area/high calcium density, 10% high calcium area/low calcium density). Female sex (odds ratio [OR]: 1.48 [95% CI: 1.27-1.74]) and body mass index (OR: 0.81 [95% CI: 0.76-0.87], per 5 kg/m2 higher) were significantly associated with high calcium density discordance, whereas diabetes (OR: 2.23 [95% CI: 1.85-3.19]) was most strongly associated with discordantly low calcium density. Compared to those with low calcium area/low calcium density, individuals with low calcium area/high calcium density had a 71% lower risk of ASCVD death (HR: 0.29 [95% CI: 0.09-0.95]). CONCLUSIONS For a given CAC score, high calcium density relative to plaque area confers lower long-term ASCVD risk, likely serving as an imaging marker of biological resilience for lesion vulnerability. Additional research is needed to define a robust definition of calcium area/density discordance for routine clinical risk prediction.
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Affiliation(s)
- Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlo N De Cecco
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew J Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Michael D Miedema
- Nolan Family Center for Cardiovascular Health, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St Luke's Hospital, New York, New York, USA
| | - John A Rumberger
- Department of Cardiac Imaging, Princeton Longevity Center, Princeton, New Jersey, USA
| | - Leslee J Shaw
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Laurence S Sperling
- Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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23
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Jensen T, Thrane PG, Olesen KKW, Würtz M, Mortensen MB, Gyldenkerne C, Thim T, Nørgaard BL, Jensen JM, Kristensen SD, Nielsen JC, Eikelboom JW, Maeng M. Antithrombotic treatment beyond one year after percutaneous coronary intervention in patients with atrial fibrillation. European Heart Journal - Cardiovascular Pharmacotherapy 2022; 9:208-219. [PMID: 36269306 DOI: 10.1093/ehjcvp/pvac058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/26/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
Abstract
Aims
Beyond 1 year after percutaneous coronary intervention (PCI), guidelines recommend anticoagulant monotherapy in patients with atrial fibrillation (AF) rather than dual therapy with an anticoagulant and an antiplatelet drug. The risks and benefits of this strategy, however, remain uncertain. We examined hospitalization for bleeding and ischemic risk beyond 1 year after PCI in patients with AF treated with monotherapy versus dual therapy. Furthermore, among patients treated with monotherapy, we compared direct oral anticoagulant (DOAC) therapy and vitamin K antagonist (VKA) therapy.
Methods and results
We included all patients with AF undergoing first-time PCI between 2003 and 2017 from the Western Denmark Heart Registry and followed them for up to 4 years. Follow-up started 15 months after PCI to enable assessment of medical treatment after 12 months. Using a Cox regression model, we computed weighted hazard ratios (HRw) of hospitalization for bleeding and major adverse cardiac events (MACE). Analyses comparing monotherapy versus dual therapy included 3331 patients, and analyses comparing DOAC versus VKA monotherapy included 1275 patients. Risks of hospitalization for bleeding (HRw 0.90, 95% confidence interval [CI] 0.75–1.09) and MACE (HRw 1.04, 95% CI 0.90–1.19) were similar with monotherapy and dual therapy. Similarly, risks of hospitalization for bleeding (HRw 1.27, 95% CI 0.84–1.92) and MACE (HRw 1.15, 95% CI 0.87–1.50) were equal with DOAC and VKA monotherapy.
Conclusion
Our results support long-term OAC monotherapy beyond 1 year after PCI in patients with atrial fibrillation and suggest that DOAC monotherapy is as safe and effective as VKA monotherapy.
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Affiliation(s)
- Thomas Jensen
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
| | | | | | - Morten Würtz
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
| | | | - Christine Gyldenkerne
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital , Aarhus , Denmark
| | - Troels Thim
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
| | | | | | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
- Department of Clinical Medicine, Aarhus University , Aarhus , Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
- Department of Clinical Medicine, Aarhus University , Aarhus , Denmark
| | - John W Eikelboom
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University , Ontario , Canada
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
- Department of Clinical Medicine, Aarhus University , Aarhus , Denmark
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Mortensen MB. Recalibrating 10-Year Risk Models Using Population-Based Data: Not Without Caveats. J Am Coll Cardiol 2022; 80:1343-1345. [PMID: 36175053 DOI: 10.1016/j.jacc.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Ciccarone Center for Cardiovascular Disease Prevention, Johns Hopkins, Baltimore, Maryland, USA.
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25
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Thrane P, Olesen KKW, Wurtz M, Gyldenkerne C, Mortensen MB, Kristensen SD, Maeng MB. Bleeding after percutaneous coronary intervention and selection of candidates for long-term dual antithrombotic treatment. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1174] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/12/2022] Open
Abstract
Abstract
Background
The European Society of Cardiology recommends addition of a second antithrombotic drug (a P2Y12 inhibitor or rivaroxaban 2.5 mg twice daily) on top of aspirin in selected patients with chronic coronary syndrome (CCS) at high residual risk of ischemic events. However, this treatment increases bleeding risk, and identifying subsets of patients with the most favorable trade-off between ischemic and bleeding risk thus is essential. We hypothesized that patients undergoing percutaneous coronary intervention (PCI) who tolerate subsequent dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) without any bleeding complications selected themselves as candidates for prolonged dual antithrombotic therapy.
Methods and results
We included 30,531 patients with CCS treated with dual antiplatelet therapy after first-time PCI with a drug-eluting stent in Western Denmark (3.5 million inhabitants) from 1999 to 2018. Of these, 1,220 (4%) were hospitalized for bleeding within one year after PCI (bleeders) and 29,311 (96%) were not (non-bleeders). Patients were followed for maximum nine years (median follow-up 5.4 years). Bleeders had an increased nine-year risk of death (adjusted hazard ratio [aHR] 1.54, 95% CI 1.37–1.73) and hospitalization for bleeding (aHR 2.53, 95% CI 2.20–2.90). These associations were particularly strong for women. Looking at types of bleeding, the strongest predictors of death were gastrointestinal bleeding, cerebral bleeding, and anemia due to bleeding. Risks of myocardial infarction and ischemic stroke did not differ between bleeders and non-bleeders (Table). We then stratified non-bleeders according to their thromboembolic risk using the CHADS-P2A2RC score – a validated clinical risk prediction model developed to estimate thromboembolic risk in patients without atrial fibrillation. Non-bleeders with a high estimated thromboembolic risk (CHADS-P2A2RC score ≥4) had higher nine-year risks of myocardial infarction (hazard ratio [HR] 1.88, 95% CI 1.78–2.07), ischemic stroke (HR 3.02, 95% CI 2.66–3.43), hospitalization for bleeding (HR 1.98, 95% CI 1.81–2.16) and, in particular, death (HR 4.48, 95% CI 4.21–4.77) than non-bleeders with a low-to-moderate predicted risk (CHADS-P2A2RC score <4).
Conclusions
Patients with CCS experiencing a bleeding event during the first year after first-time PCI had a substantially higher long-term risk of death and recurrent bleeding, but not a higher risk of ischemic events. Therefore, bleeding events during the first year after PCI may guide the preclusion of selected patients from long-term dual antithrombotic therapy. Among non-bleeders, the risk of ischemic events rose proportionately more than the risk of bleeding when comparing high-risk with low-risk patients. This is an important finding for clinicians, for whom accurate identification of patients at highest risk of ischemic events is an essential step in treatment allocation.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- P Thrane
- Aarhus University Hospital , Aarhus , Denmark
| | | | - M Wurtz
- Aarhus University Hospital , Aarhus , Denmark
| | | | | | | | - M B Maeng
- Aarhus University Hospital , Aarhus , Denmark
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26
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Pryds K, Nielsen RR, Olesen KKW, Mortensen MB, Nielsen JC, Maeng M. Coronary artery disease is a stronger predictor of mortality than left ventricular ejection fraction among newly diagnosed patients with heart failure. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/15/2022] Open
Abstract
Abstract
Background
Heart failure (HF) prevalence remains high and prognosis is poor despite improvements in both medical treatment and implantation of primary prophylactic implantable cardioverter-defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices. At present, classification of HF and treatment algorithms are determined by the left ventricular ejection fraction (LVEF). However, in patients with LVEF <50% and newly diagnosed HF, evidence remains sparse as to whether LVEF per se or presence of CAD provide independent prognostic information on mortality.
Methods
Using the Western Denmark Heart Registry, we identified newly diagnosed patients with HF and LVEF 10–49% undergoing first-time coronary angiography (CAG) from 2003 to 2016 referred due to HF. Patients were stratified by LVEF (10–35% vs. 36–49%, according as to whether primary prophylactic ICD and CRT treatment should be considered) and presence of coronary artery disease (CAD). Maximum follow-up was 10 years. We estimated 10-year cumulative incidence of death and calculated hazard ratios (HR) adjusted for relevant comorbidities and risk factors.
Results
Of 154,186 Western Danish residents undergoing CAG, 3,620 patients had HF and LVEF 10–49%. Among these, 2,780 (77%) patients had LVEF 10–35% and 840 (23%) patients had LVEF 36–49%. CAD was present in 1,592 (44%) patients.
There was a potential association in 10-year mortality when comparing patients with HF and LVEF 36–49% to those with LVEF 10–35% (37.3% vs. 42.1%, HR 1.15; 95% CI 0.99–1.34) (Figure 1A), with point estimates of mortality ranging from being 1% reduced to 24% increased. This result was not strongly influenced by the presence of CAD (HR 1.11; 95% CI 0.91–1.35) or absence of CAD (HR 1.24; 95% CI 0.97–1.57) (Figure 1B). There was no trend between LVEF categorized by 5-percentiles and mortality (p for trend = 0.24) (Table 1). In contrast, CAD was more strongly associated with increased 10-year mortality (55.0% vs. 31.5%, HR 1.43; 95% CI 1.25–1.64) irrespective of LVEF (Figure 1B).
Conclusion
Among newly diagnosed patients with HF and LVEF 10–49%, presence of CAD impacts mortality substantially more than LVEF per se. These results emphasize that assessment of CAD is pivotal for prognostication of newly diagnosed patients with HF and LVEF 10–49%.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- K Pryds
- Aarhus University Hospital, Department of Cardiology , Aarhus , Denmark
| | - R R Nielsen
- Aarhus University Hospital, Department of Cardiology , Aarhus , Denmark
| | - K K W Olesen
- Aarhus University Hospital, Department of Cardiology , Aarhus , Denmark
| | - M B Mortensen
- Aarhus University Hospital, Department of Cardiology , Aarhus , Denmark
| | - J C Nielsen
- Aarhus University Hospital, Department of Cardiology , Aarhus , Denmark
| | - M Maeng
- Aarhus University Hospital, Department of Cardiology , Aarhus , Denmark
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27
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Razavi AC, Agatston AS, Shaw LJ, De Cecco CN, van Assen M, Sperling LS, Bittencourt MS, Daubert MA, Nasir K, Blumenthal RS, Mortensen MB, Whelton SP, Blaha MJ, Dzaye O. Evolving Role of Calcium Density in Coronary Artery Calcium Scoring and Atherosclerotic Cardiovascular Disease Risk. JACC Cardiovasc Imaging 2022; 15:1648-1662. [PMID: 35861969 PMCID: PMC9908416 DOI: 10.1016/j.jcmg.2022.02.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 10/18/2022]
Abstract
Coronary artery calcium (CAC) is a specific marker of coronary atherosclerosis that can be used to measure calcified subclinical atherosclerotic burden. The Agatston method is the most widely used scoring algorithm for quantifying CAC and is expressed as the product of total calcium area and a quantized peak calcium density weighting factor defined by the calcification attenuation in HU on noncontrast computed tomography. Calcium density has emerged as an important area of inquiry because the Agatston score is upweighted based on the assumption that peak calcium density and atherosclerotic cardiovascular disease (ASCVD) risk are positively correlated. However, recent evidence demonstrates that calcium density is inversely associated with lesion vulnerability and ASCVD risk in population-based cohorts when accounting for age and plaque area. Here, we review calcium density by focusing on 3 main areas: 1) CAC scan acquisition parameters; 2) pathophysiology of calcified plaques; and 3) epidemiologic evidence relating calcium density to ASCVD outcomes. Through this process, we hope to provide further insight into the evolution of CAC scoring on noncontrast computed tomography.
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Affiliation(s)
- Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA; Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Arthur S Agatston
- Department of Medicine, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Leslee J Shaw
- Blavatnik Family Women's Health Research Institute, Mount Sinai School of Medicine, New York, New York, USA
| | - Carlo N De Cecco
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marly van Assen
- Translational Laboratory for Cardiothoracic Imaging and Artificial Intelligence, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laurence S Sperling
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcio S Bittencourt
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Melissa A Daubert
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Khurram Nasir
- Department of Cardiovascular Medicine, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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28
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Mortensen MB, Tybjærg-Hansen A, Nordestgaard BG. Statin Eligibility for Primary Prevention of Cardiovascular Disease According to 2021 European Prevention Guidelines Compared With Other International Guidelines. JAMA Cardiol 2022; 7:836-843. [PMID: 35793078 PMCID: PMC9260641 DOI: 10.1001/jamacardio.2022.1876] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [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: 01/11/2022] [Accepted: 05/05/2022] [Indexed: 12/29/2022]
Abstract
Importance For primary prevention of atherosclerotic cardiovascular disease (ASCVD), the 2021 European Society of Cardiology (ESC) guidelines on statin use (hereafter European-ESC) recommend a new risk model (Systematic Coronary Risk Evaluation 2 [European-SCORE2]) as well as new age-specific treatment thresholds (≥7.5% 10-year ASCVD risk if aged 40-49 years and ≥10% if aged 50-69 years). Objective To compare the clinical performance of the 2021 European-ESC, American College of Cardiology/American Heart Association (hereafter US-ACC/AHA), UK National Institute for Health and Care Excellence (UK-NICE), and 2019 ESC/European Atherosclerosis Society (EAS) guidelines in apparently healthy individuals. Design, Setting, and Participants This population-based contemporary cohort study included 66 909 individuals from the Copenhagen General Population Study. Participants were aged 40 to 69 years and were free of ASCVD, diabetes, chronic kidney disease, and statin use at baseline in 2003 to 2015. Mean follow-up time was 9.2 years. Data were analyzed from November 2021 to April 2022. Exposures Statin treatment according to guideline criteria. Main Outcomes and Measures Calibration of risk calculators, statin eligibility, sensitivity, and specificity for ASCVD events according to guideline criteria. Results During follow-up, a range of 2962 to 4277 nonfatal and fatal ASCVD events was observed, as defined by the 2021 European-SCORE2, US pooled cohort equations (PCE), and UK-QRISK3 models, and 180 fatal ASCVD events were noted as defined by the 2019 European-SCORE1 model. European-SCORE2 was slightly better calibrated with a predicted/observed ASCVD event ratio of 0.8 vs 1.3 for US-PCE, 1.3 for UK-QRISK3, and 5.8 for European-SCORE1. For primary prevention class I recommendations in individuals aged 40 to 69 years, 2862 of 66 909 (4%) qualified for statins according to the 2021 European-ESC guidelines compared with 23 029 (34%) with US-ACC/AHA, 17 659 (26%) with UK-NICE, and 13 496 (20%) with 2019 European-ESC/EAS guidelines, with associated sensitivities for detecting future European-SCORE2-defined ASCVD events of 12%, 60%, 51%, and 36%, respectively. The sensitivity of the European-ESC guidelines was improved considerably by lowering the treatment thresholds, resulting in smaller losses in specificity. To obtain similar clinical performance with the 2021 European-ESC guidelines as in the other guidelines, the threshold with European-SCORE2 should be reduced to 5% overall to match US-ACC/AHA, to 6% to match UK-NICE, and to 7% to match 2019 European-ESC/EAS guidelines. Conclusions and Relevance Despite an improved European-SCORE2 prediction model, the new treatment thresholds in the 2021 European-ESC guidelines dramatically reduce eligibility for primary prevention with statins in low-risk European countries. Using lower treatment thresholds can improve overall guideline performance.
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Affiliation(s)
- Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Internal Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne Tybjærg-Hansen
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Internal Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Biochemistry, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Børge G. Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
- Department of Internal Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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29
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Kragholm K, Rasmussen JG, Søndergaard MM, Zaremba T, Tayal B, Lindgren FL, Sejersen HM, Mortensen MB, Nørgaard BL, Jensen JM, Bøtker HE, Byrne C, Køber L, Torp-Pedersen C, Andersen NH, Søgaard P, Mamas M, Freeman P. Five-Year Outcomes After Coronary Computed Tomography Angiography (From 110,599 Patients in a Danish Nationwide Register-Based Follow-Up Study). Am J Cardiol 2022; 176:1-7. [PMID: 35606174 DOI: 10.1016/j.amjcard.2022.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 01/20/2022] [Revised: 03/27/2022] [Accepted: 04/08/2022] [Indexed: 11/15/2022]
Abstract
The long-term cardiovascular risk for patients examined with coronary computed tomography angiography (CCTA) to rule out coronary heart disease compared with population controls remains unexplored. A nationwide register-based study including first-time CCTA-examined patients between 2007 and 2017 in Denmark alive 180 days post-CCTA was conducted. We evaluated 5-year outcomes of myocardial infarction (MI) or revascularization and all-cause mortality in 3 distinct CCTA-groups: (1) no post-CCTA preventive pharmacotherapy use (cholesterol-lowering drugs, antiplatelets, or anticoagulants); (2) post-CCTA preventive pharmacotherapy use; and (3) revascularization or MI within 180 days post-CCTA. For each patient group, population controls were matched on age, gender, and calendar year. Absolute risks standardized to the age, gender, selected co-morbidity, and anti-anginal pharmacotherapy distributions of the specific CCTA-examined patients and respective controls were obtained from multivariable Cox regression. Of 110,599 CCTA-examined patients, (1) 48,231 patients were not prescribed preventive pharmacotherapy 180 days post-CCTA; (2) 42,798 patients were prescribed preventive pharmacotherapy within 180 days post-CCTA; and (3) 19,570 patients were diagnosed with MI or revascularized within 180 days post-CCTA. For patient groups 1 to 3 versus respective controls, 5-year MI or revascularization risks were <0.1% versus 2.0%, <0.1% versus 3.8%, and 19.0% versus 2.5%, all p<0.001. Five-year all-cause mortality were 2.8% versus 4.2%, 5.5% versus 8.8%, and 6.7% versus 8.5%, all p <0.001. In conclusion, the 5-year MI or revascularization risk can be considered very low for CCTA-examined patients without ischemic events within 180 days post-CCTA. Conversely, CCTA-examined patients with MI or revascularization events within 180 days post-CCTA have significantly elevated 5-year MI or revascularization risk.
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Affiliation(s)
- Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
| | | | | | - Tomas Zaremba
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Bhupendar Tayal
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | | | | | | | | | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christina Byrne
- Department of Cardiology, Rigshospitalet -Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet -Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Peter Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mamas Mamas
- Department of Cardiology, Keele University, Stoke on Trent, England
| | - Phillip Freeman
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Dzaye O, Berning P, Razavi AC, Adhikari R, Jha K, Nasir K, Ayers JW, Mortensen MB, Blaha MJ. Online searches for SGLT-2 inhibitors and GLP-1 receptor agonists correlate with prescription rates in the United States: An infodemiological study. Front Cardiovasc Med 2022; 9:936651. [PMID: 35966558 PMCID: PMC9372305 DOI: 10.3389/fcvm.2022.936651] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/01/2022] [Indexed: 12/02/2022] Open
Abstract
Several clinical trials have demonstrated that many SGLT-2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP-1 RA) can reduce the risk of cardiovascular events in patients with Type 2 diabetes and atherosclerotic cardiovascular disease. Recent reports indicate an underutilization of new cardiometabolic drugs, including SGLT2i and GLP-1 RA. We aimed to evaluate the use of online search volumes to reflect United States prescription rates. A repeated cross-sectional analysis of Google search volumes and corresponding data from the IQVIA National Prescription Audit (NPA) of pharmacy dispensing of newly prescribed drugs was performed. Monthly data for online searches and prescription between January 1, 2016 and December 31, 2021 were collected for selected SGLT2i and GLP-1 RA. Prescription data for drugs classes (SGLT2i and GLP-1 RA) and individual drugs were calculated as the total of queried data for branded drug names. Trends were analyzed for visual and quantitative correlation as well as predictive patterns. Overall, online searches increased by 157.6% (95% CI: 142.2-173.1%) and 295.2% (95% CI: 257.7-332.6%) for SGLT2i and GLP-1RA between 2016 and 2021. Prescription rates raised by 114.6% (95% CI: 110.8-118.4%) and 221.0% (95% CI: 212.1-229.9%) for SGLT2i and GLP-1RA for this period. Correlation coefficients (range 0.86-0.99) were strongest for drugs with growing number of prescriptions, for example dapagliflozin, empagliflozin, ertugliflozin, dulaglutide, and semaglutide. Online searches might represent an additional tool to monitor the utilization trends of cardiometabolic drugs. Associations were strongest for drugs with reported cardioprotective effect. Thus, trends in online searches complement conventionally acquired data to reflect and forecast prescription trends of cardiometabolic drugs.
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Affiliation(s)
- Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Philipp Berning
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Medicine, University Hospital Muenster, Münster, Germany
| | - Alexander C. Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, GA, United States
| | - Rishav Adhikari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kunal Jha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, United States
| | - John W. Ayers
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, United States
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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31
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Razavi AC, Uddin SMI, Dardari ZA, Berman DS, Budoff MJ, Miedema MD, Osei AD, Obisesan OH, Nasir K, Rozanski A, Rumberger JA, Shaw LJ, Sperling LS, Whelton SP, Mortensen MB, Blaha MJ, Dzaye O. Coronary Artery Calcium for Risk Stratification of Sudden Cardiac Death: The Coronary Artery Calcium Consortium. JACC Cardiovasc Imaging 2022; 15:1259-1270. [PMID: 35370113 PMCID: PMC9262828 DOI: 10.1016/j.jcmg.2022.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/07/2022] [Accepted: 02/23/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Coronary artery calcium (CAC) is a marker of plaque burden. Whether CAC improves risk stratification for incident sudden cardiac death (SCD) beyond atherosclerotic cardiovascular disease (ASCVD) risk factors is unknown. OBJECTIVES SCD is a common initial manifestation of coronary heart disease (CHD); however, SCD risk prediction remains elusive. METHODS The authors studied 66,636 primary prevention patients from the CAC Consortium. Multivariable competing risks regression and C-statistics were used to assess the association between CAC and SCD, adjusting for demographics and traditional risk factors. RESULTS The mean age was 54.4 years, 33% were women, 11% were of non-White ethnicity, and 55% had CAC >0. A total of 211 SCD events (0.3%) were observed during a median follow-up of 10.6 years, 91% occurring among those with baseline CAC >0. Compared with CAC = 0, there was a stepwise higher risk (P trend < 0.001) in SCD for CAC 100 to 399 (subdistribution hazard ratio [SHR]: 2.8; 95% CI: 1.6-5.0), CAC 400 to 999 (SHR: 4.0; 95% CI: 2.2-7.3), and CAC >1,000 (SHR: 4.9; 95% CI: 2.6-9.9). CAC provided incremental improvements in the C-statistic for the prediction of SCD among individuals with a 10-year risk <7.5% (ΔC-statistic = +0.046; P = 0.02) and 7.5% to 20% (ΔC-statistic = +0.069; P = 0.003), which were larger when compared with persons with a 10-year risk >20% (ΔC-statistic = +0.01; P = 0.54). CONCLUSIONS Higher CAC burden strongly associates with incident SCD beyond traditional risk factors, particularly among primary prevention patients with low-intermediate risk. SCD risk stratification can be useful in the early stages of CHD through the measurement of CAC, identifying patients most likely to benefit from further downstream testing.
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Affiliation(s)
- Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
| | - S M Iftekhar Uddin
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew J Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Michael D Miedema
- Minneapolis Heart Institute and Foundation, Minneapolis, Minnesota, USA
| | - Albert D Osei
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Olufunmilayo H Obisesan
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St Luke's Hospital, New York, New York, USA
| | - John A Rumberger
- Department of Cardiac Imaging, Princeton Longevity Center, Princeton, New Jersey, USA
| | - Leslee J Shaw
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Laurence S Sperling
- Emory Center for Heart Disease Prevention, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Olesen KKW, Jensen ES, Gyldenkerne C, Würtz M, Mortensen MB, Nørgaard BL, Sørensen HT, Bøtker HE, Maeng M. Thirteen-year trends in cardiovascular risk in men and women with chronic coronary syndrome. Eur Heart J Qual Care Clin Outcomes 2022; 8:437-446. [PMID: 33629103 DOI: 10.1093/ehjqcco/qcab015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/12/2021] [Accepted: 02/22/2021] [Indexed: 06/12/2023]
Abstract
AIMS To examine combined and sex-specific temporal changes in risks of adverse cardiovascular events and coronary revascularization in patients with chronic coronary syndrome undergoing coronary angiography. METHODS AND RESULTS We included all patients with stable angina pectoris and coronary artery disease examined by coronary angiography in Western Denmark from 2004 to 2016. Patients were stratified by examination year interval: 2004-2006, 2007-2009, 2010-2012, and 2013-2016. Outcomes were 2-year risk of myocardial infarction, ischaemic stroke, cardiac death, and all-cause death estimated by adjusted incidence rate ratios using patients examined in 2004-2006 as reference. A total of 29 471 patients were included, of whom 70% were men. The 2-year risk of myocardial infarction [2.8% vs. 1.9%, adjusted incidence rate ratio 0.65, 95% confidence interval (CI) 0.53-0.81], ischaemic stroke (1.8% vs. 1.1%, adjusted incidence rate ratio 0.48, 95% CI 0.37-0.64), cardiac death (2.1% vs. 0.9%, adjusted incidence rate ratio 0.38, 95% CI 0.29-0.51), and all-cause death (5.0% vs. 3.6%, adjusted incidence rate ratio 0.65, 95% CI 0.55-0.76) decreased from the first examination interval (2004-2006) to the last examination interval (2013-2016). Coronary revascularizations also decreased (percutaneous coronary intervention: 51.6% vs. 42.5%; coronary artery bypass grafting: 24.6% vs. 17.5%). Risk reductions were observed in both men and women, however, women had a lower absolute risk. CONCLUSION The risk for adverse cardiovascular events decreased substantially in both men and women with chronic coronary syndrome from 2004 to 2016. These results most likely reflect the cumulative effect of improvements in the management of chronic coronary artery disease.
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Affiliation(s)
- Kevin Kris Warnakula Olesen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Esben Skov Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Christine Gyldenkerne
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Morten Würtz
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
| | - Hans Erik Bøtker
- Faculty of Health, Aarhus University, Vennelyst Boulevard 4, 8000 Aarhus C, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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Mortensen MB, Dzaye O, Razavi AC, Jensen JM, Steffensen FH, Bøtker HE, Cainzos-Achirica M, Sørensen HT, Maeng M, Blaha MJ, Nasir K, Nørgaard BL. Association between REDUCE-IT criteria, coronary artery disease severity and cardiovascular events: The Western Denmark Heart Registry. Eur J Prev Cardiol 2022; 29:1802-1810. [PMID: 35653637 DOI: 10.1093/eurjpc/zwac104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 04/10/2022] [Revised: 05/12/2022] [Accepted: 05/14/2022] [Indexed: 12/11/2022]
Abstract
AIMS The REDUCE-IT trial demonstrated that icosapent ethyl lowered the risk of atherosclerotic cardiovascular disease (ASCVD) among patients with elevated triglycerides. However, how to appropriately implement its use in clinical practice is not well-defined.We aimed to determine whether plaque burden as assessed by coronary artery calcium (CAC) could stratify ASCVD risk among patients eligible for icosapent ethyl. METHODS AND RESULTS Among 23,759 patients who underwent computed tomography angiography (CTA) in the Western Denmark Heart Registry, we identified eligibility for the REDUCE-IT trial. A total of 2146 participants (9%) met enrollment criteria for REDUCE-IT. During a median of 4.3 years of follow-up, 146 ASCVD events occurred. Overall, there was a stepwise increase in ASCVD event rates per 1,000 person-years with increasing CAC (CAC = 0: 10.5, CAC 1-299: 18.7, CAC ≥300: 49.8). REDUCE-IT eligible patients with CAC ≥300 had a multivariable-adjusted hazard ratio of 3.1 compared to CAC = 0 (95%CI: 1.9-4.9). CAC differentiated risk similarly in patients with and without obstructive CAD. Overall, the 5-year estimated number needed to treat to prevent one event with icosapent ethyl was 45 and ranged from 87 in those with CAC = 0 to 17 in those with CAC ≥300. Some patients with non-obstructive CAD had lower estimated NNT than patients with obstructive CAD when their plaque burden was higher. CONCLUSION Atherosclerotic plaque burden as assessed by CAC can identify REDUCE-IT eligible patients who are expected to derive most, and least, absolute benefit from treatment with icosapent ethyl regardless of obstructive versus nonobstructive CAD status.
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Affiliation(s)
- Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | | | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Miguel Cainzos-Achirica
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, United States
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, United States
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Simony SB, Mortensen MB, Langsted A, Afzal S, Kamstrup PR, Nordestgaard BG. Sex differences of lipoprotein(a) levels and associated risk of morbidity and mortality by age: The Copenhagen General Population Study. Atherosclerosis 2022; 355:76-82. [DOI: 10.1016/j.atherosclerosis.2022.06.1023] [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] [Received: 04/26/2022] [Revised: 06/21/2022] [Accepted: 06/22/2022] [Indexed: 11/02/2022]
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Johannesen CDL, Mortensen MB, Langsted A, Nordestgaard BG. ApoB and non-HDL cholesterol versus LDL cholesterol for ischemic stroke risk. Ann Neurol 2022; 92:379-389. [PMID: 35635038 PMCID: PMC9545003 DOI: 10.1002/ana.26425] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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] [Received: 01/20/2022] [Revised: 05/22/2022] [Accepted: 05/27/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Conflicting results have been reported on the association between lipids and risk of ischemic stroke. We tested the hypothesis that the burden of ischemic stroke attributable to either elevated apolipoprotein B (apoB) or non-high-density lipoprotein (non-HDL) cholesterol is higher than that attributable to elevated low-density lipoprotein (LDL) cholesterol. METHODS We included 104 618 individuals from an ongoing cohort study, the Copenhagen General Population Study. The associations of quintiles of apoB, non-HDL cholesterol, and LDL cholesterol with risk of ischemic stroke were estimated by Cox proportional hazards regressions with 95% confidence intervals. With 1st quintile as reference, the proportion of ischemic stroke attributable to the 2nd , 3rd , 4th , and 5th quintiles of apoB, non-HDL cholesterol, and LDL cholesterol were estimated by population attributable fractions. RESULTS Higher quintiles of apoB and non-HDL cholesterol were associated with increased risk of ischemic stroke (both trends: P<0.0001), whereas for LDL cholesterol this association was somewhat attenuated (trend: P=0.0005). A similar pattern was seen for population attributable fraction values. Compared to individuals in the 1st quintile, the combined proportion of ischemic stroke attributable to individuals in the 2nd to 5th quintiles was 16.3% for apoB (levels >82mg/dL), 14.7% for non-HDL cholesterol (>3.0mmol/L; >117mg/dL), and 6.8% for LDL cholesterol (>2.4mmol/L; >94mg/dL). INTERPRETATION The proportion of ischemic stroke attributable to either elevated apoB or non-HDL cholesterol was double that attributable to elevated LDL cholesterol. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Camilla D L Johannesen
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark.,Faculty of Health and Medical Science, University of Copenhagen, Denmark
| | - Martin Bødtker Mortensen
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark.,Faculty of Health and Medical Science, University of Copenhagen, Denmark.,Department of Cardiology, Aarhus University Hospital, Denmark
| | - Anne Langsted
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark.,Faculty of Health and Medical Science, University of Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Denmark.,Faculty of Health and Medical Science, University of Copenhagen, Denmark
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Mortensen MB. The "Power of Zero" in Younger Patients-A Glass Half Empty or a Glass Half Full?-Reply. JAMA Cardiol 2022; 7:774. [PMID: 35583883 DOI: 10.1001/jamacardio.2022.0981] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 11/14/2022]
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Dzaye O, Razavi AC, Michos ED, Mortensen MB, Dardari ZA, Nasir K, Osei AD, Peng AW, Blankstein R, Page JH, Blaha MJ. Coronary artery calcium scores indicating secondary prevention level risk: Findings from the CAC consortium and FOURIER trial. Atherosclerosis 2022; 347:70-76. [PMID: 35197202 PMCID: PMC9030020 DOI: 10.1016/j.atherosclerosis.2022.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/27/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Coronary artery calcium (CAC) burden displays a stepwise association with atherosclerotic cardiovascular disease (ASCVD) risk. Among primary prevention patients, we sought to determine the CAC scores equivalent to ASCVD mortality rates observed in the FOURIER trial, a modern secondary prevention cohort. METHODS AND RESULTS For the main analysis, we included participants from the CAC Consortium ≥50 years old with a 10-year ASCVD risk ≥7.5% (n = 20,207). Poisson regression was used to define the relationship between CAC and annual ASCVD mortality. Equations generated from the regression models were then used to derive CAC scores associated with equivalent annual ASCVD mortality as observed in FOURIER placebo participants from the overall trial and in key trial subgroups. The CAC Consortium participants had a similar age (65.5 versus 62.5 years) and sex (22% versus 24% female) distribution as FOURIER. The annualized ASCVD mortality rate in FOURIER participants (0.766 per 100 person-years) corresponded to a CAC score of 781 (418-1467). A CAC score of 255 (162-394) corresponded to an ASCVD mortality rate equivalent to the lowest risk FOURIER subgroup (presence of myocardial infarction >2 years prior to trial enrollment). No CAC score produced a risk equivalent to high-risk FOURIER subgroups, particularly those with symptomatic peripheral arterial disease and/or multivessel coronary heart disease. CONCLUSIONS Primary prevention individuals with increased CAC burden may have annualized ASCVD mortality rates equivalent to persons with stable secondary prevention-level risk. These findings argue for a risk continuum between higher risk primary prevention and stable secondary prevention patients, as their ASCVD risks may overlap.
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Affiliation(s)
- Omar Dzaye
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander C Razavi
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Erin D Michos
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Albert D Osei
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allison W Peng
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John H Page
- Center for Observational Research, Amgen Inc., Thousand Oaks, CA, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Dzaye O, Razavi AC, Dardari ZA, Berman DS, Budoff MJ, Miedema MD, Obisesan OH, Boakye E, Nasir K, Rozanski A, Rumberger JA, Shaw LJ, Mortensen MB, Whelton SP, Blaha MJ. Mean Versus Peak Coronary Calcium Density on Non-Contrast CT: Calcium Scoring and ASCVD Risk Prediction. JACC Cardiovasc Imaging 2022; 15:489-500. [PMID: 34801452 PMCID: PMC8917973 DOI: 10.1016/j.jcmg.2021.09.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/19/2021] [Accepted: 09/13/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVES This study sought to assess the relationship between mean vs peak calcified plaque density and their impact on calculating coronary artery calcium (CAC) scores and to compare the corresponding differential prediction of atherosclerotic cardiovascular disease (ASCVD) and coronary heart disease (CHD) mortality. BACKGROUND The Agatston CAC score is quantified per lesion as the product of plaque area and a 4-level categorical peak calcium density factor. However, mean calcium density may more accurately measure the heterogenous mixture of lipid-rich, fibrous, and calcified plaque reflective of ASCVD risk. METHODS We included 10,373 individuals from the CAC Consortium who had CAC >0 and per-vessel measurements of peak calcium density factor and mean calcium density. Area under the curve and continuous net reclassification improvement analyses were performed for CHD and ASCVD mortality to compare the predictive abilities of mean calcium density vs peak calcium density factor when calculating the Agatston CAC score. RESULTS Participants were on average 53.4 years of age, 24.4% were women, and the median CAC score was 68 Agatston units. The average values for mean calcium density and peak calcium density factor were 210 ± 50 HU and 3.1 ± 0.5, respectively. Individuals younger than 50 years of age and/or those with a total plaque area <100 mm2 had the largest differences between the peak and mean density measures. Among persons with CAC 1-99, the use of mean calcium density resulted in a larger improvement in ASCVD mortality net reclassification improvement (NRI) (NRI = 0.49; P < 0.001 vs. NRI = 0.18; P = 0.08) and CHD mortality discrimination (Δ area under the curve (AUC) = +0.169 vs +0.036; P < 0.001) compared with peak calcium density factor. Neither peak nor mean calcium density improved mortality prediction at CAC scores >100. CONCLUSION Mean and peak calcium density may differentially describe plaque composition early in the atherosclerotic process. Mean calcium density performs better than peak calcium density factor when combined with plaque area for ASCVD mortality prediction among persons with Agatston CAC 1-99.
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Affiliation(s)
- Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew J Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Michael D Miedema
- Minneapolis Heart Institute and Foundation, Minneapolis, Minnesota, USA
| | - Olufunmilayo H Obisesan
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ellen Boakye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St. Luke's Hospital, New York, New York, USA
| | - John A Rumberger
- Department of Cardiac Imaging, Princeton Longevity Center, Princeton, New Jersey, USA
| | - Leslee J Shaw
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Razavi A, Uddin SMI, Dardari Z, Berman DS, Budoff MJ, Miedema MD, Osei A, Obisesan AO, Nasir K, Rozanski A, Rumberger JA, Shaw LJ, Sperling LS, Whelton SP, Mortensen MB, Blaha M, Dzaye O. CORONARY ARTERY CALCIUM FOR RISK STRATIFICATION OF SUDDEN CARDIAC DEATH:THE CORONARY ARTERY CALCIUM CONSORTIUM. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02441-x] [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: 10/18/2022]
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Mortensen MB, Caínzos-Achirica M, Steffensen FH, Bøtker HE, Jensen JM, Sand NPR, Maeng M, Bruun JM, Blaha MJ, Sørensen HT, Pareek M, Nasir K, Nørgaard BL. Association of Coronary Plaque With Low-Density Lipoprotein Cholesterol Levels and Rates of Cardiovascular Disease Events Among Symptomatic Adults. JAMA Netw Open 2022; 5:e2148139. [PMID: 35147685 PMCID: PMC8837910 DOI: 10.1001/jamanetworkopen.2021.48139] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Atherosclerosis burden and coronary artery calcium (CAC) are associated with the risk for atherosclerotic cardiovascular disease (ASCVD) events, with absence of plaque and CAC indicating low risk. Whether this is true in patients with elevated levels of low-density lipoprotein cholesterol (LDL-C) is not known. Specifically, a high prevalence of noncalcified plaque might signal high risk. OBJECTIVE To determine the prevalence of noncalcified and calcified plaque in symptomatic adults and assess its association with cardiovascular events across the LDL-C spectrum. DESIGN, SETTING, AND PARTICIPANTS This cohort study included symptomatic patients undergoing coronary computed tomographic angiography from January 1, 2008, to December 31, 2017, from the seminational Western Denmark Heart Registry. Follow-up was completed on July 6, 2018. Data were analyzed from April 2 to December 2, 2021. EXPOSURES Prevalence of calcified and noncalcified plaque according to LDL-C strata of less than 77, 77 to 112, 113 to 154, 155 to 189, and at least 190 mg/dL. Severity of coronary artery disease was categorized using CAC scores of 0, 1 to 99, and ≥100, where higher numbers indicate greater CAC burden. MAIN OUTCOMES AND MEASURES Atherosclerotic cardiovascular disease events (myocardial infarction and stroke) and death. RESULTS A total of 23 143 patients with a median age of 58 (IQR, 50-65) years (12 857 [55.6%] women) were included in the analysis. During median follow-up of 4.2 (IQR, 2.3-6.1) years, 1029 ASCVD and death events occurred. Across all LDL-C strata, absence of CAC was a prevalent finding (ranging from 438 of 948 [46.2%] in patients with LDL-C levels of at least 190 mg/dL to 4370 of 7964 [54.9%] in patients with LDL-C levels of 77-112 mg/dL) and associated with no detectable plaque in most patients, ranging from 338 of 438 (77.2%) in those with LDL-C levels of at least 190 mg/dL to 1067 of 1204 (88.6%) in those with LDL-C levels of less than 77 mg/dL. In all LDL-C groups, absence of CAC was associated with low rates of ASCVD and death (6.3 [95% CI, 5.6-7.0] per 1000 person-years), with increasing rates in patients with CAC scores of 1 to 99 (11.1 [95% CI, 10.0-12.5] per 1000 person-years) and CAC scores of at least 100 (21.9 [95% CI, 19.9-24.4] per 1000 person-years). Among those with CAC scores of 0, the event rate per 1000 person-years was 6.3 (95% CI, 5.6-7.0) in the overall population compared with 6.9 (95% CI, 4.0-11.9) in those with LDL-C levels of at least 190 mg/dL. Across all LDL-C strata, rates were similar and low in those with CAC scores of 0, regardless of whether they had no plaque or purely noncalcified plaque. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that in symptomatic patients with severely elevated LDL-C levels of at least 190 mg/dL who are universally considered to be at high risk by guidelines, absence of calcified and noncalcified plaque on coronary computed tomographic angiography was associated with low risk for ASCVD events. These results further suggest that atherosclerosis burden, including CAC, can be used to individualize treatment intensity in patients with severely elevated LDL-C levels.
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Affiliation(s)
- Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Miguel Caínzos-Achirica
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
- Center for Outcomes Research, Houston Methodist, Houston, Texas
- Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, Baltimore, Maryland
| | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niels Peter Rønnow Sand
- Department of Cardiology, University Hospital of Southwest Jutland and Institute of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology and Clinical Research, The Johns Hopkins University, Baltimore, Maryland
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Manan Pareek
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
- Center for Outcomes Research, Houston Methodist, Houston, Texas
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Mortensen MB. Coronary Artery Calcium in Acute Chest Pain Patients: Valuable in the High-Sensitivity Troponin Era. JACC Cardiovasc Imaging 2022; 15:281-283. [PMID: 35144765 DOI: 10.1016/j.jcmg.2021.11.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
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Mortensen MB, Nordestgaard BG. Guidelines versus trial-evidence for statin use in primary prevention: The Copenhagen General Population Study. Atherosclerosis 2021; 341:20-26. [PMID: 34959205 DOI: 10.1016/j.atherosclerosis.2021.12.002] [Citation(s) in RCA: 1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/16/2021] [Accepted: 12/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Guideline-recommended use of risk calculators to select for statin therapy in primary prevention has never been tested in a randomized controlled trial (RCT). We determined the extent to which guideline-based statin recommendations from the American College of Cardiology/American Heart Association (ACC/AHA), Canadian Cardiovascular Society(CCS), UK National Institute for Health and Care Excellence (NICE), and European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) is supported by available evidence from RCTs. METHODS 79,171 individuals from the Copenhagen General Population Study who were free of ASCVD and statin use at baseline were included. RCT evidence supporting guideline-recommended statin allocation and the estimated number needed to treat (NNT) to prevent one ASCVD event were assessed. RESULTS During 8.2 years of follow-up, 4031 ASCVD events occurred. Of individuals eligible for statin therapy with the ACC/AHA, CCS, NICE and ESC/EAS guidelines, 86%, 88%, 88% and 84% had direct RCT evidence of statin efficacy, respectively (guideline-positive&RCT-positive). This group represented 26-37% of all 79,171 individuals, while guideline-positive&RCT-negative individuals represented 5-7%, guideline-negative&RCT-positive individuals 28-39%, and guideline-negative&RCT-negative individuals represented 30-31%. The ASCVD events per 1000 person-years were 11.4-12.7 (guideline-positive&RCT-positive), 6.3-8.0 (guideline-positive&RCT-negative), 4.2-5.2 (guideline-negative&RCT-positive), and 2.3-2.5 (guideline-negative&RCT-negative), respectively, while the corresponding NNT to prevent one event in 10 years using high-intensity statin were 19-21, 30-32, 48-60, and 105-125, respectively. CONCLUSIONS The far majority of individuals eligible for guideline-recommended primary prevention with statins have direct RCT evidence supporting statin use. Allocating statins based on guideline-criteria is more efficient with lower NNT for preventing ASCVD events than allocating statin therapy based solely on RCT evidence.
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Affiliation(s)
- Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; The Department of Clinical Biochemistry and The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Børge Grønne Nordestgaard
- The Department of Clinical Biochemistry and The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
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Würtz M, Olesen KKW, Mortensen MB, Eikelboom JW, Mohammad MA, Erlinge D, Kristensen SD, Maeng M. Dual antithrombotic treatment in chronic coronary syndrome: European Society of Cardiology criteria vs. CHADS-P2A2RC score. Eur Heart J 2021; 43:996-1004. [PMID: 34871376 DOI: 10.1093/eurheartj/ehab785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 04/24/2021] [Revised: 07/28/2021] [Accepted: 10/29/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS According to the 2019 European Society of Cardiology (ESC) guidelines on chronic coronary syndromes (CCS), adding a P2Y12 inhibitor or rivaroxaban to aspirin should be considered in high-risk patients. We estimated the proportion of patients eligible for treatment with the ESC criteria and examined if a recently validated risk score (CHADS-P2A2RC) could improve risk prediction. METHODS AND RESULTS We included 61 338 CCS patients undergoing first-time coronary angiography in Western Denmark (2003-16) and classified them according to the ESC criteria and the CHADS-P2A2RC score. The ESC criteria identified 33.9% as high risk, 53.3% as moderate risk, and 12.8% as low risk. The CHADS-P2A2RC score identified 24.9% as high risk (≥4 points), 48.1% as moderate risk (2-3 points), and 27.0% as low risk (≤1 points). Major adverse cardiovascular events per 100 person-years were 4.8 [95% confidence interval (CI) 4.6-5.0] in patients considered high risk with both schemes, 2.1 (95% CI 2.0-2.2) in patients considered high risk with the ESC but low-to-moderate risk with the CHADS-P2A2RC criteria, 3.8 (95% CI 3.6-4.1) in patients considered low-to-moderate risk with the ESC but high risk with the CHADS-P2A2RC criteria, and 1.5 (95% CI 1.5-1.6) in patients considered low-to-moderate risk with both schemes. The CHADS-P2A2RC score enabled correct downward risk reclassification of 5161 patients (8%) without events, yielding an improved specificity of 9.7%, a loss of sensitivity of 4.4%, and an overall net reclassification index of 0.053. CONCLUSION Based on the 2019 ESC guidelines, dual antithrombotic treatment should be considered in one-third of CCS patients. The CHADS-P2A2RC score improved risk classification and may particularly identify low-risk patients with limited benefit from treatment.
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Affiliation(s)
- Morten Würtz
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | | | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences 237 Barton Street East Hamilton, ON L8L 2X2, Canada, and McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada
| | - Moman Aladdin Mohammad
- Department of Cardiology, Clinical Sciences, Skane University Hospital, Entregatan 7, Lund 22185, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Skane University Hospital, Entregatan 7, Lund 22185, Sweden
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark.,Department of Clinical Medicine, Faculty of Health, Institute of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
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Mortensen MB, Dzaye O, Bødtker H, Steffensen FH, Bøtker HE, Jensen JM, Rønnow Sand NP, Maeng M, Warnakula Olesen KK, Sørensen HT, Kanstrup H, Blankstein R, Blaha MJ, Nørgaard BL. Interplay of Risk Factors and Coronary Artery Calcium for CHD Risk in Young Patients. JACC Cardiovasc Imaging 2021; 14:2387-2396. [PMID: 34147446 DOI: 10.1016/j.jcmg.2021.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 03/08/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aim of this study was to examine prevalence, predictors, and impact of coronary artery calcium (CAC) across different risk factor burdens on the prevalence of obstructive coronary artery disease (CAD) and future coronary heart disease (CHD) risk in young patients. BACKGROUND The interplay of risk factors and CAC for predicting CHD in young patients aged ≤45 years is not clear. METHODS The study included 3,691 symptomatic patients (18-45 years of age) from the WDHR (Western Denmark Heart Registry) undergoing coronary computed tomographic angiography. CHD events were myocardial infarction and late revascularization. RESULTS During a median of 4.1 years of follow-up, 57 first-time CHD events occurred. In total, 3,180 patients (86.1%) had CAC = 0 and 511 patients (13.9%) had CAC >0. Presence of CAC increased with number of risk factors (odds ratio: 4.5 [95% CI: 2.7-7.3] in patients with >3 vs 0 risk factors). The prevalence of obstructive CAD at baseline and the rate of future CHD events increased in a stepwise manner with both higher CAC and number of risk factors. The CHD event rate was lowest at 0.5 (95% CI: 0.1-3.6) per 1,000 person-years in patients with 0 risk factors and CAC = 0. Among patients with >3 risk factors, the event rate was 3.1 (95% CI: 1.0-9.7) in patients with CAC = 0 compared with 36.3 (95% CI: 17.3-76.1) in patients with CAC >10. CONCLUSIONS In young patients, there is a strong interplay between CAC and risk factors for predicting the presence of obstructive CAD and for future CHD risk. In the presence of risk factors, even a low CAC score is a high-risk marker. These results demonstrate the importance of assessing risk factors and CAC simultaneously when assessing risk in young patients.
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Affiliation(s)
- Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Henrik Bødtker
- Department of Clinical Medicine, Aarhus University Hospital, Denmark
| | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niels Peter Rønnow Sand
- Department of Cardiology, University Hospital of Southwest Jutland and Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Helle Kanstrup
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Dzaye O, Berning P, Dardari ZA, Berman DS, Budoff MJ, Miedema MD, Nasir K, Rozanski A, Rumberger JA, Shaw LJ, Mortensen MB, Whelton SP, Blaha MJ. Coronary artery calcium is associated with long-term mortality from lung cancer: Results from the Coronary Artery Calcium Consortium. Atherosclerosis 2021; 339:48-54. [PMID: 34756729 PMCID: PMC8678296 DOI: 10.1016/j.atherosclerosis.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/29/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND AIMS Coronary artery calcium (CAC) scores have been shown to be associated with CVD and cancer mortality. The use of CAC scores for overall and lung cancer mortality risk prediction for patients in the Coronary Artery Calcium Consortium was analyzed. METHODS We included 55,943 patients aged 44-84 years without known heart disease from the CAC Consortium. There were 1,088 cancer deaths, among which 231 were lung cancer, identified by death certificates with a mean follow-up of 12.2 ± 3.9 years. Fine-and-Gray competing-risk regression was used for overall and lung cancer-specific mortality, accounting for the competing risk of CVD death and after adjustment for CVD risk factors. Subdistribution hazard ratios (SHR) were reported. RESULTS The mean age of all patients was 57.1 ± 8.6 years, 34.9% were women, and 89.6% were white. Overall, CAC was strongly associated with cancer mortality. Lung cancer mortality increased with increasing CAC scores, with rates per 1000-person years of 0.2 (95% CI: 0.1-0.3) for CAC = 0 and 0.8 (95% CI: 0.6-1.0) for CAC ≥400. Compared with CAC = 0, hazards were increased for those with CAC ≥400 for lung cancer mortality [SHR: 1.7 (95% CI: 1.2-2.6)], which was driven by women [SHR: 2.3 (95% CI: 1.1-4.8)], but not significantly increased for men. Risks were higher in those with positive smoking history [SHR: 2.2 (95% CI: 1.2-4.2)], with associations driven by women [SHR: 4.0 (95% CI: 1.4-11.5)]. CONCLUSIONS CAC scores were associated with increased risks for lung cancer mortality, with strongest associations for current and former smokers, especially in women. Used in conjunction with other clinical variables, our data pinpoint a potential synergistic use of CAC scanning beyond CVD risk assessment for identification of high-risk lung cancer screening candidates.
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Affiliation(s)
- Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Philipp Berning
- Department of Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Matthew J Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Michael D Miedema
- Minneapolis Heart Institute and Foundation, Minneapolis, MN, United States
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, United States
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St Luke's Hospital, New York, NY, United States
| | - John A Rumberger
- Department of Cardiac Imaging, Princeton Longevity Center, Princeton, NJ, United States
| | - Leslee J Shaw
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Abstract
PURPOSE OF REVIEW To provide a summary of recent literature on the relative impact of luminal stenosis versus atherosclerotic plaque burden in atherosclerotic cardiovascular disease (ASCVD) risk stratification and management. RECENT FINDINGS Recent results from both randomized controlled clinical trials as well as observational cohort studies have demonstrated that ASCVD risk is mediated mainly by the extent of atherosclerotic disease burden rather than by the presence of coronary stenosis or inducible ischemia. Although patients with obstructive CAD are generally at higher risk for ASCVD events than patients with nonobstructive CAD, this is driven by a higher plaque burden in those with obstructive CAD. Accordingly, the ASCVD risk for a given plaque burden is similar in patients with and without obstructive CAD. Accompanying these observations are randomized controlled trial data, which show that optimization of medical therapy instead of early revascularization is most important for improving prognosis in patients with stable obstructive CAD. SUMMARY Emerging evidence shows that atherosclerotic plaque burden, and not stenosis per se, is the main driver of ASCVD risk in patients with CAD. This information challenges the current paradigm of selecting patients for intensive secondary prevention measures based primarily on the presence of obstructive CAD.
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Affiliation(s)
- Omar Dzaye
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Alexander C. Razavi
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Michael J. Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Martin Bødtker Mortensen
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins Hospital, Baltimore, Maryland, USA
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Mortensen MB, Gaur S, Frimmer A, Bøtker HE, Sørensen HT, Kragholm KH, Niels Peter SR, Steffensen FH, Jensen RV, Mæng M, Kanstrup H, Blaha MJ, Shaw LJ, Dzaye O, Leipsic J, Nørgaard BL, Jensen JM. Association of Age With the Diagnostic Value of Coronary Artery Calcium Score for Ruling Out Coronary Stenosis in Symptomatic Patients. JAMA Cardiol 2021; 7:36-44. [PMID: 34705022 DOI: 10.1001/jamacardio.2021.4406] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [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: 01/16/2023]
Abstract
Importance The diagnostic value is unclear of a 0 coronary artery calcium (CAC) score to rule out obstructive coronary artery disease (CAD) and near-term clinical events across different age groups. Objective To assess the diagnostic value of a CAC score of 0 for reducing the likelihood of obstructive CAD and to assess the implications of such a CAC score and obstructive CAD across different age groups. Design, Setting, and Participants This cohort study obtained data from the Western Denmark Heart Registry and had a median follow-up time of 4.3 years. Included patients were aged 18 years or older who underwent computed tomography angiography (CTA) between January 1, 2008, and December 31, 2017, because of symptoms that were suggestive of CAD. Data analysis was performed from April 5 to July 7, 2021. Exposures Obstructive CAD, which was defined as 50% or more luminal stenosis. Main Outcomes and Measures Proportion of individuals with obstructive CAD who had a CAC score of 0. Risk-adjusted diagnostic likelihood ratios were used to assess the diagnostic value of a CAC score of 0 for reducing the likelihood of obstructive CAD beyond clinical variables. Risk factors associated with myocardial infarction and death were estimated. Results A total of 23 759 symptomatic patients, of whom 12 771 (54%) had a CAC score of 0, were included. This cohort had a median (IQR) age of 58 (49-65) years and was primarily composed of women (13 160 [55%]). Overall, the prevalence of obstructive CAD was relatively low across all age groups, ranging from 3% (39 of 1278 patients) in those who were younger than 40 years to 8% (52 of 619) among those who were 70 years or older. In patients with obstructive CAD, 14% (725 of 5043) had a CAC score of 0, and the prevalence varied across age groups from 58% (39 of 68) among those who were younger than 40 years, 34% (192 of 562) among those aged 40 to 49 years, 18% (268 of 1486) among those aged 50 to 59 years, 9% (174 of 1963) among those aged 60 to 69 years, to 5% (52 of 964) among those who were 70 years or older. The added diagnostic value of a CAC score of 0 decreased at a younger age, with a risk factor-adjusted diagnostic likelihood ratio of a CAC score of 0 ranging from 0.68 (approximately 32% lower likelihood of obstructive CAD than expected) in those who were younger than 40 years to 0.18 (approximately 82% lower likelihood than expected) in those who were 70 years or older. The presence of obstructive vs nonobstructive CAD among those with a CAC score of 0 was associated with a multivariable adjusted hazard ratio of 1.51 (95% CI, 0.98-2.33) for myocardial infarction and all-cause death; however, this hazard ratio varied from 1.80 (95% CI, 1.02-3.19) in those who were younger than 60 years to 1.24 (95% CI, 0.64-2.39) in those who were 60 years or older. Conclusions and Relevance This cohort study found that the diagnostic value of a CAC score of 0 to rule out obstructive CAD beyond clinical variables was dependent on age, with the added diagnostic value being smaller for younger patients. In symptomatic patients who were younger than 60 years, a sizable proportion of obstructive CAD occurred among those without CAC and was associated with an increased risk of myocardial infarction and all-cause death.
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Affiliation(s)
- Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Johns Hopkins, Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
| | - Sara Gaur
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Attila Frimmer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Sand Rønnow Niels Peter
- Department of Cardiology, University Hospital of Southwest Jutland and Institute of Regional Health Research, University of Southern Denmark, Denmark
| | | | | | - Michael Mæng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Helle Kanstrup
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael J Blaha
- Johns Hopkins, Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
| | - Leslee J Shaw
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medicine, New York, New York
| | - Omar Dzaye
- Johns Hopkins, Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, Maryland
| | - Jonathon Leipsic
- Department of Radiology, St Paul's Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
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Dzaye O, Razavi AC, Dardari ZA, Shaw LJ, Berman DS, Budoff MJ, Miedema MD, Nasir K, Rozanski A, Rumberger JA, Orringer CE, Smith SC, Blankstein R, Whelton SP, Mortensen MB, Blaha MJ. Modeling the Recommended Age for Initiating Coronary Artery Calcium Testing Among At-Risk Young Adults. J Am Coll Cardiol 2021; 78:1573-1583. [PMID: 34649694 PMCID: PMC9074911 DOI: 10.1016/j.jacc.2021.08.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/21/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are currently no recommendations guiding when best to perform coronary artery calcium (CAC) scanning among young adults to identify those susceptible for developing premature atherosclerosis. OBJECTIVES The purpose of this study was to determine the ideal age at which a first CAC scan has the highest utility according to atherosclerotic cardiovascular disease (ASCVD) risk factor profile. METHODS We included 22,346 CAC Consortium participants aged 30-50 years who underwent noncontrast computed tomography. Sex-specific equations were derived from multivariable logistic modeling to estimate the expected probability of CAC >0 according to age and the presence of ASCVD risk factors. RESULTS Participants were on average 43.5 years of age, 25% were women, and 34% had CAC >0, in whom the median CAC score was 20. Compared with individuals without risk factors, those with diabetes developed CAC 6.4 years earlier on average, whereas smoking, hypertension, dyslipidemia, and a family history of coronary heart disease were individually associated with developing CAC 3.3-4.3 years earlier. Using a testing yield of 25% for detecting CAC >0, the optimal age for a potential first scan would be at 36.8 years (95% CI: 35.5-38.4 years) in men and 50.3 years (95% CI: 48.7-52.1 years) in women with diabetes, and 42.3 years (95% CI: 41.0-43.9 years) in men and 57.6 years (95% CI: 56.0-59.5 years) in women without risk factors. CONCLUSIONS Our derived risk equations among health-seeking young adults enriched in ASCVD risk factors inform the expected prevalence of CAC >0 and can be used to determine an appropriate age to initiate clinical CAC testing to identify individuals most susceptible for early/premature atherosclerosis.
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Affiliation(s)
- Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Alexander C Razavi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zeina A Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leslee J Shaw
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Daniel S Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Matthew J Budoff
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Michael D Miedema
- Minneapolis Heart Institute and Foundation, Minneapolis, Minnesota, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai, St Luke's Hospital, New York, New York, USA
| | - John A Rumberger
- Department of Cardiac Imaging, Princeton Longevity Center, Princeton, New Jersey, USA
| | - Carl E Orringer
- Cardiovascular Division, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Seamus P Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Martin Bødtker Mortensen
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Pareek M, Byrne C, Mikkelsen AD, Dyrvig Kristensen AM, Vaduganathan M, Biering-Sorensen T, Kragholm KH, Mortensen MB, Singh A, Olsen MH, Bhatt DL. Marital status, cardiovascular events, and intensive blood pressure lowering among men and women in the Systolic Blood Pressure Intervention Trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2312] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/13/2022] Open
Abstract
Abstract
Background
Married persons may have lower rates of mortality and cardiovascular disease (CV) than unmarried persons although data regarding potential differences between men and women are conflicting. The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced CV morbidity and mortality in high-risk patients. We hypothesized that marital status would influence CV event risk and the impact of intensive BP control, and that these effects would vary according to sex.
Purpose
To assess the risks of CV events and mortality according to marital status in a high-risk population, and to assess if marital status modified the effect of intensive versus standard BP control.
Methods
SPRINT was a randomized, controlled, open-label trial of 9361 individuals at high CV risk, at least 50 years of age, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to either intensive or standard BP control and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. Secondary efficacy endpoints included the individual components of the primary endpoint and all-cause death. Event risk according to marital status, including variation of the effects of intensive BP control, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. The group of subjects who were married or living in a marriage-like relationship served as baseline.
Results
Information on marital status was available for 8762 (93.6%) individuals. A total of 4863 (55.5%) were married or in a marriage-like relationship, 3149 (35.9%) were widowed, divorced, or separated, and 750 (8.6%) were never married. Marital status did not differ between patients randomized to intensive versus standard BP control (P=0.51). The risk of the primary endpoint was not significantly affected by marital status (P>0.05), in neither men nor women (P-interaction>0.05). The same was true for its individual components except the risk of CV death which was higher among never married men (adjusted hazard ratio [aHR], 3.29, 95% confidence interval [CI]: 1.34–8.09; P=0.009; P-sex-interaction=0.99). The risk of all-cause death was higher among widowed, divorced, or separated men (aHR, 1.90, 95% CI: 1.35–2.67; P<0.001) and among never married men (aHR, 2.53, 95% CI: 1.51–4.26; P<0.001), but not women belong to these groups (P>0.05; P-sex-interaction=0.24) (Figure). Associations were not modified by age (P-interaction>0.05). Marital status did not modify the effect of intensive BP control for any of the endpoints (P-interaction>0.05).
Conclusions
In SPRINT, never married men had higher risks of both CV death and all-cause death while widowed, divorced, or separated men had a higher risk of all-cause death. The risks and benefits of intensive BP control were not affected by marital status.
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
- M Pareek
- Brigham and Women's Hospital, Boston, United States of America
| | - C Byrne
- Bispebjerg University Hospital, Copenhagen, Denmark
| | | | | | - M Vaduganathan
- Brigham and Women's Hospital, Boston, United States of America
| | | | | | | | - A Singh
- Brigham and Women's Hospital, Boston, United States of America
| | | | - D L Bhatt
- Brigham and Women's Hospital, Boston, United States of America
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Pareek M, Byrne C, Mikkelsen AD, Dyrvig Kristensen AM, Vaduganathan M, Biering-Sorensen T, Kragholm KH, Mortensen MB, Singh A, Olsen MH, Bhatt DL. Greater event rates in high-risk patients with a history of heart disease: from the Systolic Blood Pressure Intervention Trial (SPRINT). Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2313] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/13/2022] Open
Abstract
Abstract
Background
The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in patients at high CV risk. Effects were consistent among patients with and without prevalent CV disease. However, it is unknown whether the benefits and risks of intensive BP control are affected by the specific type of heart disease.
Purpose
To assess the risks of incident CV events and safety events in patients with individual types of heart disease, and to assess if the presence of heart disease modified the effect of intensive versus standard BP control.
Methods
SPRINT was a randomized, controlled trial comprising 9,361 individuals ≥50 years of age at high CV risk, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to intensive or standard BP control. The primary efficacy endpoint was the composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events. We assessed event risk in patients with self-reported heart disease versus those without and further assessed the safety and efficacy of intensive BP control, including relevant interactions, in these individuals, using multivariable Cox proportional-hazards regression.
Results
Of 9361 participants, 326 (3.5%) reported a history of congestive heart failure, 760 (8.1%) of myocardial infarction, 1206 (12.9%) of angina, and 1830 (19.6%) of atrial fibrillation, atrial flutter, or irregular heartbeat. The prevalence of these conditions did not significantly differ between patients randomized to intensive versus standard BP control (P>0.05 for all). At median 3.2 years (range 0–4.8 years), congestive heart failure (adjusted hazard ratio [aHR], 1.94, 95% confidence interval [CI], 1.45–2.61; P<0.001), myocardial infarction (aHR, 1.73, 95% CI, 1.33–2.25; P<0.001), angina (aHR, 1.41, 95% CI, 1.09–1.84; P=0.01), and atrial fibrillation, atrial flutter, or irregular heartbeat (aHR, 1.36, 95% CI, 1.12–1.64; P=0.002) were all independently associated with the primary endpoint (Figure). All conditions except prior myocardial infarction were also associated with composite serious adverse events (P=0.24 for myocardial infarction, P<0.05 for all others). A history of angina modified the efficacy of intensive versus standard BP control, i.e., patients without angina appeared to benefit from intensive BP control (aHR, 0.66, 95% CI, 0.54–0.80; P<0.001) while those with angina did not (aHR, 1.04, 95% CI, 0.76–1.44; P=0.80) (P=0.02 for interaction). No significant interactions were detected for the primary safety endpoint.
Conclusions
In SPRINT, a history of any type of heart disease was associated with a greater risk for both efficacy and safety events. Patients with angina did not appear to derive benefit from intensive BP control.
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
- M Pareek
- Brigham and Women's Hospital, Boston, United States of America
| | - C Byrne
- Bispebjerg University Hospital, Copenhagen, Denmark
| | | | | | - M Vaduganathan
- Brigham and Women's Hospital, Boston, United States of America
| | | | | | | | - A Singh
- Brigham and Women's Hospital, Boston, United States of America
| | | | - D L Bhatt
- Brigham and Women's Hospital, Boston, United States of America
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