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Kobo O, Cavender MA, Jensen TJ, Kuhlman AB, Rasmussen S, Verma S. Once-weekly semaglutide reduces the risk of cardiovascular events in people with type 2 diabetes and polyvascular disease: A post hoc analysis. Diabetes Obes Metab 2024; 26:1129-1132. [PMID: 38082468 DOI: 10.1111/dom.15396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/27/2023] [Accepted: 11/17/2023] [Indexed: 02/06/2024]
Affiliation(s)
- Ofer Kobo
- Hillel Yaffe Medical Centre, Hadera, Israel
| | | | | | | | | | - Subodh Verma
- St. Michael's Hospital of Unity Health, Toronto, Canada
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2
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Maffey MW, Cavender MA, Bagur R. Deferring PCI Based on IVUS Assessment: On Par With FFR or FLAVOUR of the Week? Circ Cardiovasc Interv 2023; 16:e013649. [PMID: 38018839 DOI: 10.1161/circinterventions.123.013649] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Affiliation(s)
- Max W Maffey
- Interventional Cardiology, Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, ON, Canada (M.W.M., R.B.)
| | - Matthew A Cavender
- Interventional Cardiology, Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.)
| | - Rodrigo Bagur
- Interventional Cardiology, Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, ON, Canada (M.W.M., R.B.)
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Ofosu-Somuah A, Cavender MA, Stouffer GA. Another Step Forward in Our Ability to Predict Percutaneous Coronary Intervention Outcomes. Am J Cardiol 2023; 206:332-333. [PMID: 37730513 DOI: 10.1016/j.amjcard.2023.08.181] [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] [Received: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Araba Ofosu-Somuah
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina; The McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina
| | - Matthew A Cavender
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina; The McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina
| | - George A Stouffer
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina; The McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina.
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4
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Miller E, Raj D, Cavender MA, Mehanna S, Namvar T, Ochsner R. Cardiorenal care coordination: holistic patient care opportunities in the primary care setting for patients with chronic kidney disease and atherosclerotic cardiovascular disease. Postgrad Med 2023; 135:708-716. [PMID: 37691591 DOI: 10.1080/00325481.2023.2256209] [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] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES Chronic kidney disease (CKD) and atherosclerotic cardiovascular disease (ASCVD) are closely linked conditions, and the presence of each condition promotes incidence and progression of the other. In this study, we sought to better understand the medical journey of patients with CKD and ASCVD and to uncover patients' and healthcare providers' (HCPs) perceptions and attitudes toward CKD and ASCVD diagnosis, treatment, and care coordination. METHODS Cross-sectional, US-population-based online surveys were conducted between May 18, 2021, and June 17, 2021, among 239 HCPs (70 of whom were primary care physicians, or PCPs) and 195 patients with CKD and ASCVD. RESULTS PCPs reported personally diagnosing CKD in 78% and ASVD in 64% of their patients, respectively. PCPs reported they are more likely to serve as the overall coordinator of their patient's care (89%), while slightly more than half of PCPs self-identified as a patient's coordinator of care specifically for CKD (54%) or ASCVD (59%). In contrast, patients viewed their PCP as their coordinator of care for CKD (25%) or ASCVD (9%). PCPs who personally treated patients with CKD and ASCVD most often recalled primarily prescribing or recommending pharmacologic treatments for CKD and ASCVD; however, patients reported that lifestyle modification was the most common treatment modality they had ever used to manage CKD and ASCVD. CONCLUSION CKD and ASCVD are interrelated cardiometabolic conditions with underlying risk factors that can be managed in a primary care setting. However, few patients in our study considered their PCP to be the coordinator of their care for CKD or ASCVD. PCPs can and should take a more active role in educating patients and coordinating care for those with CKD and ASCVD.
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Affiliation(s)
- Eden Miller
- Diabetes and Obesity Care LLC, Bend, OR, USA
| | - Dominic Raj
- Division of Kidney Diseases and Hypertension, The George Washington University, Washington, DC, USA
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5
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Mazzella AJ, Gehi AK, Searcy R, Vavalle JP, Cavender MA, Rosman L. Sex differences in device-measured physical activity after transcatheter aortic valve replacement. J Invasive Cardiol 2023; 35:E375-E384. [PMID: 37769618] [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] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
OBJECTIVE Physical activity (PA) is an important clinical and quality of life outcome after transcatheter aortic valve replacement (TAVR). We examined the effect of TAVR on objectively measured PA in patients with cardiac implanted electronic devices (CIEDs). METHODS Daily accelerometer data was obtained from CIEDs. Patients in the University of North Carolina Health System with continuous PA data at least 6 months before TAVR and 12 months after TAVR were included. Changes in activity pre- and post-TAVR were analyzed with linear mixed-effects models using a random intercept for each patient. An interaction term was included to determine differences in PA between men and women pre- and post-TAVR. RESULTS Of the 306 patients with CIEDs who underwent TAVR, 24,655 patient-days of data from 46 patients, mean age of 82 years old, 44% of whom were female met inclusion criteria. A significant and sustained increase of 14.7% in daily PA was seen after TAVR [10.15 minutes per day, 95% confidence interval (CI) 8.75 to 11.56 P < .001] after adjusting for sex, obesity, race, history of depression, and Charlson Comorbidity Index. Effects were more prominent in women (18.57 [95% CI 16.36 to 20.79, P < .001] minute increase post-TAVR) compared to men (4.51 [95% CI 3.87 to 5.16] minute increase post-TAVR, P < .001). CONCLUSIONS This study demonstrates PA increases after TAVR with effects more pronounced in women than men. Further, this study highlights the potential use of remote monitoring data for monitoring functional outcomes in device patients after a procedure.
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Affiliation(s)
| | | | | | | | | | - Lindsey Rosman
- Division of Cardiology, Department of Medicine, University of North Carolina Hospitals, CB 7075, 160 Dental Circle, 6025 Burnett-Womack Bldg., Chapel Hill, NC 27599-7075.
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6
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Pagidipati NJ, Nelson AJ, Kaltenbach LA, Leyva M, McGuire DK, Pop-Busui R, Cavender MA, Aroda VR, Magwire ML, Richardson CR, Lingvay I, Kirk JK, Al-Khalidi HR, Webb L, Gaynor T, Pak J, Senyucel C, Lopes RD, Green JB, Granger CB. Coordinated Care to Optimize Cardiovascular Preventive Therapies in Type 2 Diabetes: A Randomized Clinical Trial. JAMA 2023; 329:1261-1270. [PMID: 36877177 PMCID: PMC9989955 DOI: 10.1001/jama.2023.2854] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 02/16/2023] [Indexed: 03/07/2023]
Abstract
Importance Evidence-based therapies to reduce atherosclerotic cardiovascular disease risk in adults with type 2 diabetes are underused in clinical practice. Objective To assess the effect of a coordinated, multifaceted intervention of assessment, education, and feedback vs usual care on the proportion of adults with type 2 diabetes and atherosclerotic cardiovascular disease prescribed all 3 groups of recommended, evidence-based therapies (high-intensity statins, angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin receptor blockers [ARBs], and sodium-glucose cotransporter 2 [SGLT2] inhibitors and/or glucagon-like peptide 1 receptor agonists [GLP-1RAs]). Design, Setting, and Participants Cluster randomized clinical trial with 43 US cardiology clinics recruiting participants from July 2019 through May 2022 and follow-up through December 2022. The participants were adults with type 2 diabetes and atherosclerotic cardiovascular disease not already taking all 3 groups of evidence-based therapies. Interventions Assessing local barriers, developing care pathways, coordinating care, educating clinicians, reporting data back to the clinics, and providing tools for participants (n = 459) vs usual care per practice guidelines (n = 590). Main Outcomes and Measures The primary outcome was the proportion of participants prescribed all 3 groups of recommended therapies at 6 to 12 months after enrollment. The secondary outcomes included changes in atherosclerotic cardiovascular disease risk factors and a composite outcome of all-cause death or hospitalization for myocardial infarction, stroke, decompensated heart failure, or urgent revascularization (the trial was not powered to show these differences). Results Of 1049 participants enrolled (459 at 20 intervention clinics and 590 at 23 usual care clinics), the median age was 70 years and there were 338 women (32.2%), 173 Black participants (16.5%), and 90 Hispanic participants (8.6%). At the last follow-up visit (12 months for 97.3% of participants), those in the intervention group were more likely to be prescribed all 3 therapies (173/457 [37.9%]) vs the usual care group (85/588 [14.5%]), which is a difference of 23.4% (adjusted odds ratio [OR], 4.38 [95% CI, 2.49 to 7.71]; P < .001) and were more likely to be prescribed each of the 3 therapies (change from baseline in high-intensity statins from 66.5% to 70.7% for intervention vs from 58.2% to 56.8% for usual care [adjusted OR, 1.73; 95% CI, 1.06-2.83]; ACEIs or ARBs: from 75.1% to 81.4% for intervention vs from 69.6% to 68.4% for usual care [adjusted OR, 1.82; 95% CI, 1.14-2.91]; SGLT2 inhibitors and/or GLP-1RAs: from 12.3% to 60.4% for intervention vs from 14.5% to 35.5% for usual care [adjusted OR, 3.11; 95% CI, 2.08-4.64]). The intervention was not associated with changes in atherosclerotic cardiovascular disease risk factors. The composite secondary outcome occurred in 23 of 457 participants (5%) in the intervention group vs 40 of 588 participants (6.8%) in the usual care group (adjusted hazard ratio, 0.79 [95% CI, 0.46 to 1.33]). Conclusions and Relevance A coordinated, multifaceted intervention increased prescription of 3 groups of evidence-based therapies in adults with type 2 diabetes and atherosclerotic cardiovascular disease. Trial Registration ClinicalTrials.gov Identifier: NCT03936660.
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Affiliation(s)
| | - Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
- Victorian Heart Institute, Monash University, Melbourne, Australia
| | | | - Monica Leyva
- Duke Clinical Research Institute, Durham, North Carolina
| | - Darren K. McGuire
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | | | | | | | | | | | | | - Julienne K. Kirk
- School of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | | | - Laura Webb
- Duke Clinical Research Institute, Durham, North Carolina
| | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut
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Goh SY, Kosiborod MN, Lam CSP, Cavender MA, Kohsaka S, Norhammar A, Birkeland KI, Holl RW, Mauricio D, Tangri N, Shaw JE, Thuresson M, Fenici P, Kim DJ. Lower risk of cardiovascular events and death associated with initiation of SGLT-2 inhibitors versus sulphonylureas - Analysis from the CVD-REAL 2 study. Diabetes Obes Metab 2023. [PMID: 37055714 DOI: 10.1111/dom.15092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/06/2023] [Accepted: 04/09/2023] [Indexed: 04/15/2023]
Affiliation(s)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA
- University Medical Center Groningen, Groningen, The Netherlands
| | - Carolyn S P Lam
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA
- National Heart Center Singapore and SingHealth Duke-NUS, Singapore
- The George Institute for Global Health, Sydney, Australia
| | | | - Shun Kohsaka
- Keio University School of Medicine, Tokyo, Japan
| | | | | | | | - Dídac Mauricio
- Hospital de la Santa Creu i Sant Pau, CIBERDEM, IIB Sant Pau, Barcelona, Spain
| | | | | | | | - Peter Fenici
- School of Medicine and Surgery, Catholic University of the Sacred Heart, Rome, Italy
- Biomagnetism and Clinical Physiology International Center (BACPIC), Rome, Italy
- AstraZeneca SpA, Milan, Italy
| | - Dae Jung Kim
- Ajou University School of Medicine, Suwon, Republic of Korea
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8
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Cannon CP, Kim JM, Lee JJ, Sutherland J, Bachireddy R, Valentine CM, Hearne S, Trebnick A, Jaffer S, Datta S, Semmel E, Thorpe F, Doros G, Cavender MA, Reynolds MR. Patients and Their Physician's Perspectives About Oral Anticoagulation in Patients With Atrial Fibrillation Not Receiving an Anticoagulant. JAMA Netw Open 2023; 6:e239638. [PMID: 37093601 PMCID: PMC10126870 DOI: 10.1001/jamanetworkopen.2023.9638] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 03/09/2023] [Indexed: 04/25/2023] Open
Abstract
Importance The underuse of oral anticoagulation in patients with nonvalvular atrial fibrillation (AF) is a major issue that is not well understood. Objective To understand the lack of anticoagulation by assessing the perceptions of patients with AF who are not receiving anticoagulation and their physician's about the risk of stroke and the benefits and risks of anticoagulation. Design, Setting, and Participants This cohort study included patients with nonvalvular AF and a CHA2DS2-VASc score of 2 or more (calculated as congestive heart failure, hypertension, age 75 years and older, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, and sex category) who were not receiving anticoagulation and were enrolled from 19 sites within the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence Registry (PINNACLE Registry) between January 18, 2017, and May 7, 2018. Data were collected from January 18, 2017, to September 30, 2019, and analyzed from April 2022 to March 2023. Exposure Each patient enrolled in the study completed a survey, and their treating physician then conducted a clinical review of their care. Main Outcomes and Measures Assessment of willingness for anticoagulation treatment and its appropriateness after central review by a panel of 4 cardiologists. Use of anticoagulation at 1 year follow-up was compared vs similar patients at other centers in the PINNACLE Registry. Results Of the 817 patients enrolled, the median (IQR) age was 76.0 (69.0-83.0) years, 369 (45.2%) were women, and the median (IQR) CHA2DS2-VASc score was 4.0 (3.0-6.0). The top 5 reasons physicians cited for no anticoagulation were low AF burden or successful rhythm control (278 [34.0%]), patient refusal (272 [33.3%]), perceived low risk of stroke (206 [25.2%]), fall risk (175 [21.4%]), and high bleeding risk (167 [20.4%]). After rereview, 221 physicians (27.1%) would reconsider prescribing oral anticoagulation as compared with 311 patients (38.1%), including 67 (24.6%) whose physician cited patient refusal. Of 647 patients (79.2%) adjudicated as appropriate or may be appropriate for anticoagulation, physicians would reconsider anticoagulation for only 177 patients (21.2%), while 527 patients (64.5%) would either agree to starting anticoagulation (311 [38.1%]) or were neutral (216 [27.3%]) to starting anticoagulation. Upon follow-up, 119 patients (14.6%) in the BOAT-AF study were prescribed anticoagulation, as compared with 55 879 of 387 975 similar patients (14.4%) at other centers in the PINNACLE Registry. Conclusions and Relevance The findings of this cohort study suggest that patients with AF who are not receiving anticoagulation are more willing to consider anticoagulation than their physicians. These data emphasize the need to revisit any prior decision against anticoagulation in a shared decision-making manner.
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Affiliation(s)
- Christopher P. Cannon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Joseph M. Kim
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jane J. Lee
- Baim Institute for Clinical Research, Boston, Massachusetts
| | | | | | | | | | - April Trebnick
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Sara Jaffer
- Baim Institute for Clinical Research, Boston, Massachusetts
| | | | | | - Fran Thorpe
- American College of Cardiology, Washington, DC
| | - Gheorghe Doros
- Baim Institute for Clinical Research, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Matthew A. Cavender
- Baim Institute for Clinical Research, Boston, Massachusetts
- University of North Carolina, Chapel Hill
| | - Matthew R. Reynolds
- Baim Institute for Clinical Research, Boston, Massachusetts
- Lahey Hospital and Medical Center, Burlington, Massachusetts
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9
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Sivaraj K, Arora S, Hendrickson M, Slehria T, Chang PP, Weickert T, Vaduganathan M, Qamar A, Pandey A, Caughey MC, Cavender MA, Rosamond W, Vavalle JP. Epidemiology and Outcomes of Aortic Stenosis in Acute Decompensated Heart Failure: The ARIC Study. Circ Heart Fail 2023; 16:e009653. [PMID: 36734224 PMCID: PMC10033327 DOI: 10.1161/circheartfailure.122.009653] [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: 02/28/2022] [Accepted: 10/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few studies characterize the epidemiology and outcomes of aortic stenosis (AS) in acute decompensated heart failure (ADHF). This study investigates the significance of AS in contemporary patients who have experienced an ADHF hospitalization. METHODS The ARIC study (Atherosclerosis Risk in Communities) surveilled ADHF hospitalizations for residents ≥55 years of age in 4 US communities. ADHF cases were stratified by left ventricular ejection fraction (LVEF). Demographic differences in AS burden and the association of varying AS severities with mortality were estimated using multivariable logistic regression. RESULTS From 2005 through 2014, there were 3597 (weighted n=16 692) ADHF hospitalizations of which 48.6% had an LVEF <50% and 51.4% an LVEF ≥50%. AS prevalence was 12.1% and 18.7% in those with an LVEF <50% and ≥50%, respectively. AS was less likely in Black than White patients regardless of LVEF: LVEF <50% (odds ratio [OR], 0.34 [95% CI, 0.28-0.42]); LVEF ≥50% (OR, 0.51 [95% CI, 0.44-0.59]). Higher AS severity was independently associated with 1-year mortality in both LVEF subgroups: LVEF <50% (OR, 1.16 [95% CI, 1.04-1.28]); LVEF ≥50% (OR, 1.40 [95% CI, 1.28-1.54]). Sensitivity analyses excluding severe AS patients detected that mild/moderate AS was independently associated with 1-year mortality in both LVEF subgroups: LVEF <50% (OR, 1.23 [95% CI, 1.02-1.47]); LVEF ≥50% (OR, 1.31 [95% CI, 1.14-1.51]). CONCLUSIONS Among patients who have experienced an ADHF hospitalization, AS is prevalent and portends poor mortality outcomes. Notably, mild/moderate AS is independently associated with 1-year mortality in this high-risk population.
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Affiliation(s)
- Krishan Sivaraj
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Sameer Arora
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Michael Hendrickson
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Trisha Slehria
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Patricia P. Chang
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Thelsa Weickert
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Arman Qamar
- Division of Cardiology, New York University Grossman School of Medicine, New York, New York
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Melissa C. Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, NC
| | - Matthew A. Cavender
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Wayne Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - John P. Vavalle
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC
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10
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Nelson AJ, Pagidipati NJ, Kelsey MD, Ardissino M, Aroda VR, Cavender MA, Lopes RD, Al-Khalidi HR, Braceras R, Gaynor T, Kaltenbach LA, Kirk JK, Lingvay I, Magwire ML, O'Brien EC, Pak J, Pop-Busui R, Richardson CR, Levya M, Senyucel C, Webb L, McGuire DK, Green JB, Granger CB. Coordinating Cardiology clinics randomized trial of interventions to improve outcomes (COORDINATE) - Diabetes: rationale and design. Am Heart J 2023; 256:2-12. [PMID: 36279931 DOI: 10.1016/j.ahj.2022.10.079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 10/13/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
Several medications that are proven to reduce cardiovascular events exist for individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, however they are substantially underused in clinical practice. Clinician, patient, and system-level barriers all contribute to these gaps in care; yet, there is a paucity of high quality, rigorous studies evaluating the role of interventions to increase utilization. The COORDINATE-Diabetes trial randomized 42 cardiology clinics across the United States to either a multifaceted, site-specific intervention focused on evidence-based care for patients with T2DM or standard of care. The multifaceted intervention comprised the development of an interdisciplinary care pathway for each clinic, audit-and-feedback tools and educational outreach, in addition to patient-facing tools. The primary outcome is the proportion of individuals with T2DM prescribed three key classes of evidence-based medications (high-intensity statin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and either a sodium/glucose cotransporter-2 inhibitor (SGLT-2i) inhibitor or glucagon-like peptide 1 receptor agonist (GLP-1RA) and will be assessed at least 6 months after participant enrollment. COORDINATE-Diabetes aims to identify strategies that improve the implementation and adoption of evidence-based therapies.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT
| | | | - Julienne K Kirk
- Wake Forest University School of Medicine, Winston Salem, NC
| | - Ildiko Lingvay
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT
| | | | | | | | | | - Laura Webb
- Duke Clinical Research Institute, Durham, NC
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, Dallas, TX; Parkland Health and Hospital System, Dallas, TX
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11
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Slehria T, Hendrickson MJ, Sivaraj K, Arora S, Caranasos TG, Agala CB, Cavender MA, Vavalle JP. Trends in Percutaneous Balloon Mitral Valvuloplasty Complications for Mitral Stenosis in the United States (the National Inpatient Sample [2008 to 2018]). Am J Cardiol 2022; 182:77-82. [PMID: 36058749 DOI: 10.1016/j.amjcard.2022.07.020] [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: 03/19/2022] [Revised: 06/25/2022] [Accepted: 07/05/2022] [Indexed: 11/01/2022]
Abstract
The epidemiology of mitral stenosis (MS) continues to evolve in the United States. Although the incidence of rheumatic MS has decreased in high-income countries, there is a paucity of data surrounding trends in percutaneous balloon mitral valvuloplasty (PBMV), the current first-line management strategy. This study aimed to identify contemporary trends in PBMV in the United States. Hospitalizations for adults (≥18 years) with MS who underwent PBMV were identified from the National Inpatient Sample from 2008 to 2018. Baseline co-morbidities and outcomes over the study period were determined using Poisson regression. There were 3,980 weighted PBMV cases, 70% of which were women. PBMV hospitalizations decreased from 603 in 2008 to 210 in 2018 (p <0.001). From 2008 to 2018, the age at hospitalization was unchanged in both female and male patients. In contrast, the Charlson Co-morbidity Index increased in both. Baseline heart failure (39% to 64%), hypertension (38% to 43%), and diabetes mellitus (17% to 26%) all substantially increased over the study period. In-hospital mortality occurred in 2% of female and 5% of male patients and was unchanged from 2008 to 2018. Vascular complications (12%) and acute kidney injury (10%) were the most frequent postprocedural complications during the 11-year study period. A composite of mortality or any postprocedural complication did not vary by gender (odds ratio 1.23, 95% confidence interval 0.88 to 1.72). In conclusion, the use of PBMV significantly decreased from 2008 to 2018, and patients with MS who underwent PBMV over this period had an increased burden of co-morbidities, elevated postprocedural complication rate, and no change in in-hospital mortality.
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Affiliation(s)
- Trisha Slehria
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - Krishan Sivaraj
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sameer Arora
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Thomas G Caranasos
- Division of Cardiothoracic Surgery, and University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Chris B Agala
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Matthew A Cavender
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John P Vavalle
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
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Cavender MA, Harrington RA, Bhatt DL. Response by Cavender et al to Letter Regarding Article, "Ischemic Events Occur Early in Patients Undergoing Percutaneous Coronary Intervention and Are Reduced With Cangrelor: Findings From CHAMPION PHOENIX". Circ Cardiovasc Interv 2022; 15:e012222. [PMID: 35861800 DOI: 10.1161/circinterventions.122.012222] [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: 11/16/2022]
Affiliation(s)
- Matthew A Cavender
- Department of Medicine, University of North Carolina, Chapel Hill (M.A.C.)
| | | | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.L.B.)
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Nelson AJ, O’Brien EC, Kaltenbach LA, Green JB, Lopes RD, Morse CG, Al-Khalidi HR, Aroda VR, Cavender MA, Gaynor T, Kirk JK, Lingvay I, Magwire ML, McGuire DK, Pak J, Pop-Busui R, Richardson CR, Senyucel C, Kelsey MD, Pagidipati NJ, Granger CB. Use of Lipid-, Blood Pressure-, and Glucose-Lowering Pharmacotherapy in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease. JAMA Netw Open 2022; 5:e2148030. [PMID: 35175345 PMCID: PMC8855234 DOI: 10.1001/jamanetworkopen.2021.48030] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Based on contemporary estimates in the US, evidence-based therapies for cardiovascular risk reduction are generally underused among patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE To determine the use of evidence-based cardiovascular preventive therapies in a broad US population with diabetes and ASCVD. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used health system-level aggregated data within the National Patient-Centered Clinical Research Network, including 12 health systems. Participants included patients with diabetes and established ASCVD (ie, coronary artery disease, cerebrovascular disease, and peripheral artery disease) between January 1 and December 31, 2018. Data were analyzed from September 2020 until January 2021. EXPOSURES One or more health care encounters in 2018. MAIN OUTCOMES AND MEASURES Patient characteristics by prescription of any of the following key evidence-based therapies: high-intensity statin, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin-receptor blocker (ARB) and sodium glucose cotransporter-2 inhibitors (SGLT2I) or glucagon-like peptide-1 receptor agonist (GLP-1RA). RESULTS The overall cohort included 324 706 patients, with a mean (SD) age of 68.1 (12.2) years and 144 169 (44.4%) women and 180 537 (55.6%) men. A total of 59 124 patients (18.2% ) were Black, and 41 470 patients (12.8%) were Latinx. Among 205 885 patients with specialized visit data from the prior year, 17 971 patients (8.7%) visited an endocrinologist, 54 330 patients (26.4%) visited a cardiologist, and 154 078 patients (74.8%) visited a primary care physician. Overall, 190 277 patients (58.6%) were prescribed a statin, but only 88 426 patients (26.8%) were prescribed a high-intensity statin; 147 762 patients (45.5%) were prescribed an ACEI or ARB, 12 724 patients (3.9%) were prescribed a GLP-1RA, and 8989 patients (2.8%) were prescribed an SGLT2I. Overall, 14 918 patients (4.6%) were prescribed all 3 classes of therapies, and 138 173 patients (42.6%) were prescribed none. Patients who were prescribed a high-intensity statin were more likely to be men (59.9% [95% CI, 59.6%-60.3%] of patients vs 55.6% [95% CI, 55.4%-55.8%] of patients), have coronary atherosclerotic disease (79.9% [95% CI, 79.7%-80.2%] of patients vs 73.0% [95% CI, 72.8%-73.3%] of patients) and more likely to have seen a cardiologist (40.0% [95% CI, 39.6%-40.4%] of patients vs 26.4% [95% CI, 26.2%-26.6%] of patients). CONCLUSIONS AND RELEVANCE In this large cohort of US patients with diabetes and ASCVD, fewer than 1 in 20 patients were prescribed all 3 evidence-based therapies, defined as a high-intensity statin, either an ACEI or ARB, and either an SGLT2I and/or a GLP-1RA. These findings suggest that multifaceted interventions are needed to overcome barriers to the implementation of evidence-based therapies and facilitate their optimal use.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | | | - Caryn G. Morse
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | | | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
| | | | | | | | - Darren K. McGuire
- University of Texas Southwestern Medical Center, Dallas
- Parkland Health and Hospital System, Dallas, Texas
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
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14
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Cavender MA, O'Donoghue ML, Abbate A, Aylward P, Fox KAA, Glaser RX, Park JG, Lopez-Sendon J, Steg PG, Sabatine MS, Morrow DA. Inhibition of p38 MAP kinase in patients with ST-elevation myocardial infarction - findings from the LATITUDE-TIMI 60 trial. Am Heart J 2022; 243:147-157. [PMID: 34508693 DOI: 10.1016/j.ahj.2021.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 08/24/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND p38 mitogen activated kinase (MAPK) mediates the response to pro-inflammatory cytokines following myocardial infarction (MI) and is inhibited by losmapimod. METHODS LATITUDE-TIMI 60 (ClinicalTrials.gov NCT02145468) randomized patients with MI to losmapimod or placebo for 12 weeks (24 weeks total follow-up). In this pre-specified analysis, we examined outcomes based on MI type [ST-segment elevation MI (STEMI) (865, 25%) and non-STEMI (2624, 75%)]. RESULTS In patients with STEMI, inflammation, measured by hs-CRP, was significantly attenuated with losmapimod at 48 hours (P <0.001) and week 12 (P = 0.01). Losmapimod lowered NT-proBNP in patients with STEMI at 48 hours (P = 0.04) and week 12 (P = 0.02). The effects of losmapimod on CV death (CVD), MI, or severe recurrent ischemia requiring urgent coronary artery revascularization at 24 weeks [MACE] differed in patients with STEMI (7.0% vs 10.8%; HR 0.65, 95%CI 0.41 - 1.03; P= 0.06) and NSTEMI (11.4% vs 8.5%; HR 1.30, 95%CI 1.02 - 1.66; P = 0.04; p[int] = 0.009). CVD or HHF among patients with STEMI were 5.6% (losmapimod) and 8.3% (placebo) (HR 0.66; 95%CI 0.40 - 1.11; P = 0.12) and in NSTEMI were 4.8% (losmapimod) and 4.4% (placebo) (HR 1.09; 95%CI 0.76 - 1.56) in patients with NSTEMI. CONCLUSIONS Patients with STEMI treated with losmapimod had an attenuated inflammatory response. Our collective findings raise the hypothesis that mitigating the inflammatory response may result in different outcomes in patients with STEMI and NSTEMI. While the difference in outcomes is exploratory, these findings do support separate examination of patients with STEMI and NSTEMI and increased emphasis on heart failure in future investigation of modulators of inflammation in MI.
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Kushner PR, Cavender MA, Mende CW. Role of Primary Care Clinicians in the Management of Patients With Type 2 Diabetes and Cardiorenal Diseases. Clin Diabetes 2022; 40:401-412. [PMID: 36381309 PMCID: PMC9606551 DOI: 10.2337/cd21-0119] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Individuals with type 2 diabetes are at increased risk of both renal and cardiovascular events. The convergence of type 2 diabetes, chronic kidney disease, and cardiovascular disease, including heart failure, requires management by a multidisciplinary health care team. Primary care clinicians are likely to be the first and most frequent point of contact for individuals with type 2 diabetes who are at high risk of cardiorenal disease and therefore play a pivotal role in early diagnosis, establishment of effective treatment strategies, and coordination of care. This article presents a clinical perspective with multidisciplinary collaboration on a patient case representative of those seen in routine clinical practice. The authors assess reasons why patients may not receive evidence-based care and identify opportunities to initiate therapies that reduce cardiovascular and renal events in the primary care setting.
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Affiliation(s)
- Pamela R. Kushner
- University of California, Irvine, CA
- Corresponding author: Pamela R. Kushner,
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Cavender MA, Harrington RA, Stone GW, Steg PG, Gibson CM, Hamm CW, Price MJ, Lopes RD, Leonardi S, Deliargyris EN, Prats J, Mahaffey KW, White HD, Bhatt DL. Ischemic Events Occur Early in Patients Undergoing Percutaneous Coronary Intervention and Are Reduced With Cangrelor: Findings From CHAMPION PHOENIX. Circ Cardiovasc Interv 2021; 15:e010390. [PMID: 34915723 PMCID: PMC8765214 DOI: 10.1161/circinterventions.120.010390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Thrombotic events are reduced with cangrelor, an intravenous P2Y12 inhibitor. We sought to characterize the timing, number, and type of early events (within 2 hours of randomization) in CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard of Care Therapy in Subjects Who Require Percutaneous Coronary Intervention). Methods: CHAMPION PHOENIX was a double-blind, placebo-controlled trial that randomized patients undergoing percutaneous coronary intervention to cangrelor or clopidogrel. For this analysis, we evaluated the efficacy of cangrelor in the first 2 hours postrandomization with regards to the primary end point (death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis). Sensitivity analyses were performed evaluating a secondary, post hoc end point (death, Society of Coronary Angiography and Intervention myocardial infarction, ischemia-driven revascularization, or Academic Research Consortium definite stent thrombosis). Results: The majority of events (63%) that occurred in the trial occurred within 2 hours of randomization. The most common early event was myocardial infarction; next were stent thrombosis, ischemia driven revascularization, and death. In the first 2 hours after randomization, cangrelor significantly decreased the primary composite end point compared with clopidogrel (4.1% versus 5.4%; hazard ratio, 0.76 [95% CI, 0.64–0.90], P=0.002). Similar findings were seen for the composite end point of death, Society of Coronary Angiography and Intervention myocardial infarction, ischemia-driven revascularization, or Academic Research Consortium stent thrombosis at 2 hours (0.9% versus 1.6%; hazard ratio, 0.57 [95% CI, 0.40–0.80], P=0.001). Between 2 and 48 hours, there was no difference in the primary composite end point (0.6% versus 0.5%; odds ratio, 1.17 [95% CI, 0.71–1.93]; P=0.53). Early (≤2 hours of randomization) GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) moderate or severe bleeding events were infrequent, and there was no significant difference with cangrelor compared with clopidogrel (0.2% [n=10] versus 0.1% [n=4]; adjusted odds ratio, 1.41 [95% CI, 0.37–5.40]; P=0.62). Conclusions: The reductions in ischemic events and overall efficacy seen with cangrelor in CHAMPION PHOENIX occurred early and during the period of time in which patients were being actively treated with cangrelor. These findings provide evidence that supports the importance of potent platelet inhibition during percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01156571.
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Affiliation(s)
| | | | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY (G.W.S.)
| | - Ph Gabriel Steg
- Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (P.G.S.).,Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London (P.G.S.)
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (C.M.G.)
| | - Christian W Hamm
- Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.)
| | | | | | - Sergio Leonardi
- University of Pavia and Fondazione IRCCS Policlinico San Matteo, Pavia, Italy (S.L.)
| | | | | | | | - Harvey D White
- University of Auckland, Auckland City Hospital, Auckland, New Zealand (H.D.W.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
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Arora S, Cavender MA, Chang PP, Qamar A, Rosamond WD, Hall ME, Rossi JS, Kaul P, Caughey MC. Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study. Eur Heart J Acute Cardiovasc Care 2021; 10:1048-1055. [PMID: 38086075 PMCID: PMC11020253 DOI: 10.1093/ehjacc/zuaa051] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/08/2018] [Indexed: 04/18/2024]
Abstract
BACKGROUND The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern. METHODS We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures. RESULTS A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01). CONCLUSION Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.
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Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Matthew A Cavender
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Patricia P Chang
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Arman Qamar
- Division of Cardiology, Brigham and Women’s Hospital, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, USA
| | - Michael E Hall
- Department of Medicine, University of Mississippi Medical Center, USA
| | - Joseph S Rossi
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Prashant Kaul
- Division of Cardiology, Piedmont Heart Institute, USA
| | - Melissa C Caughey
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
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18
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Arora S, Cavender MA, Chang PP, Qamar A, Rosamond WD, Hall ME, Rossi JS, Kaul P, Caughey MC. Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study. Eur Heart J Acute Cardiovasc Care 2021; 10:1048-1055. [PMID: 30958029 PMCID: PMC6854299 DOI: 10.1177/2048872619842983] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 12/08/2018] [Indexed: 06/03/2023]
Abstract
BACKGROUND The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern. METHODS We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures. RESULTS A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01). CONCLUSION Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.
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Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Matthew A Cavender
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Patricia P Chang
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Arman Qamar
- Division of Cardiology, Brigham and Women’s Hospital, USA
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, USA
| | - Michael E Hall
- Department of Medicine, University of Mississippi Medical Center, USA
| | - Joseph S Rossi
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
| | - Prashant Kaul
- Division of Cardiology, Piedmont Heart Institute, USA
| | - Melissa C Caughey
- Division of Cardiology, University of North Carolina at Chapel Hill, USA
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Cavender MA, Wirka RC. Blood pressure lowering in the prevention of type 2 diabetes. Lancet 2021; 398:1778-1779. [PMID: 34774133 DOI: 10.1016/s0140-6736(21)02340-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/19/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Matthew A Cavender
- Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Robert C Wirka
- Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Department of Cell Biology and Physiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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Haywood HB, Pauley E, Orgel R, Chilcutt B, Gupta A, Cavender MA, Dai X, Vavalle J, Yeung M, Stouffer GA, Rossi JS. Fibrinogen Levels and Bleeding Risk in Patients Undergoing Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism. J Invasive Cardiol 2021; 33:E702-E708. [PMID: 34148867] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES We sought to test the hypothesis that patients undergoing ultrasound-assisted catheter-directed thrombolysis (USAT) with standard alteplase and heparin dosing would not develop significant depletion of systemic fibrinogen, which may account for the lower risk of bleeding seen in contemporary trials. We also sought to compare the relative outcomes of individuals with submassive pulmonary embolism (PE) undergoing USAT and anticoagulation alone. METHODS Utilizing a single-center prospective registry, we identified 102 consecutive adult patients with submassive PE who were considered for USAT based on a standardized treatment algorithm between November 2016 and May 2019. Patients not receiving USAT therapy were treated with anticoagulation alone. RESULTS Baseline characteristics were generally similar between groups (n = 51 in each group). Major bleeding rates were not significantly different between groups (2.0% vs 5.9% in USAT vs control, respectively; P=.62). Notably, no USAT patient experienced clinically significant hypofibrinogenemia (mean trough fibrinogen, 369.8 ± 127.1 mg/dL; minimum, 187 mg/dL). The mean trough fibrinogen of patients experiencing any bleeding event (major or minor) was 306.6 mg/dL (SE, 23.9 mg/dL) vs 380.3 mg/dL (SE, 20.4 mg/dL) in those without a bleeding event (P=.02). CONCLUSIONS In this cohort analysis of patients undergoing USAT, there was no evidence for clinically significant depletion of fibrinogen or intracranial hemorrhage. Although our data suggest an association between lower fibrinogen levels and bleeding events, our results are not clear enough to suggest a clinically useful fibrinogen cut-off value. Further study is needed to determine the utility of routine fibrinogen monitoring in this population.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Joseph S Rossi
- University of North Carolina School of Medicine, Department of Medicine, Division of Cardiology, 160 Dental Circle, Campus Box 7075 Chapel Hill, NC 27599-7075 USA.
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Safley DM, Salisbury AC, Tsai TT, Secemsky EA, Kennedy KF, Rogers RK, Latif F, Shammas NW, Garcia L, Cavender MA, Rosenfield K, Prasad A, Spertus JA. Acute Kidney Injury Following In-Patient Lower Extremity Vascular Intervention: From the National Cardiovascular Data Registry. JACC Cardiovasc Interv 2021; 14:333-341. [PMID: 33541543 DOI: 10.1016/j.jcin.2020.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 06/22/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The authors analyzed data from the NCDR (National Cardiovascular Data Registry) PVI Registry and defined acute kidney injury (AKI) as increased creatinine of ≥0.3 mg/dl or 50%, or a new requirement for dialysis after PVI. BACKGROUND AKI is an important and potentially modifiable complication of peripheral vascular intervention (PVI). The incidence, predictors, and outcomes of AKI after PVI are incompletely characterized. METHODS A hierarchical logistic regression risk model using pre-procedural characteristics associated with AKI was developed, followed by bootstrap validation. The model was validated with data submitted after model creation. An integer scoring system was developed to predict AKI after PVI. RESULTS Among 10,006 procedures, the average age of patients was 69 years, 58% were male, and 52% had diabetes. AKI occurred in 737 (7.4%) and was associated with increased in-hospital mortality (7.1% vs. 0.7%). Reduced glomerular filtration rate, hypertension, diabetes, prior heart failure, critical or acute limb ischemia, and pre-procedural hemoglobin were independently associated with AKI. The model to predict AKI showed good discrimination (optimism corrected c-statistic = 0.68) and calibration (corrected slope = 0.97, intercept of -0.07). The integer point system could be incorporated into a useful clinical tool because it discriminates risk for AKI with scores ≤4 and ≥12 corresponding to the lower and upper 20% of risk, respectively. CONCLUSIONS AKI is not rare after PVI and is associated with in-hospital mortality. The NCDR PVI AKI risk model, including the integer scoring system, may prospectively estimate AKI risk and aid in deployment of strategies designed to reduce risk of AKI after PVI.
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Affiliation(s)
- David M Safley
- Cardiology Department, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Division of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri, USA.
| | - Adam C Salisbury
- Cardiology Department, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Division of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Thomas T Tsai
- Interventional Cardiology, Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Eric A Secemsky
- Vascular Intervention, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kevin F Kennedy
- Cardiology Department, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Division of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - R Kevin Rogers
- Vascular Medicine & Intervention, University of Colorado, Aurora, Colorado, USA
| | - Faisal Latif
- Interventional Cardiology, University of Oklahoma & VA Medical Center, Oklahoma City, Oklahoma, USA
| | | | - Lawrence Garcia
- Section of Interventional Cardiology, Tufts University School of Med, Boston, Massachusetts, USA
| | - Matthew A Cavender
- Interventional Cardiology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kenneth Rosenfield
- Interventional Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anand Prasad
- Cardiovascular Disease, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - John A Spertus
- Cardiology Department, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Division of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri, USA
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Khunti K, Kosiborod M, Kim DJ, Kohsaka S, Lam CSP, Goh SY, Chiang CE, Shaw JE, Cavender MA, Tangri N, Franch-Nadal J, Holl RW, Jørgensen ME, Norhammar A, Eriksson JG, Zaccardi F, Karasik A, Magliano DJ, Thuresson M, Chen H, Wittbrodt E, Bodegård J, Surmont F, Fenici P. Cardiovascular outcomes with sodium-glucose cotransporter-2 inhibitors vs other glucose-lowering drugs in 13 countries across three continents: analysis of CVD-REAL data. Cardiovasc Diabetol 2021; 20:159. [PMID: 34332558 PMCID: PMC8325810 DOI: 10.1186/s12933-021-01345-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 04/13/2021] [Accepted: 07/14/2021] [Indexed: 12/28/2022] Open
Abstract
Background Randomized, controlled cardiovascular outcome trials may not be fully representative of the management of patients with type 2 diabetes across different geographic regions. We conducted analyses of data from the multinational CVD-REAL consortium to determine the association between initiation of sodium–glucose cotransporter-2 inhibitors (SGLT-2i) and cardiovascular outcomes, including subgroup analyses based on patient characteristics. Methods De-identified health records from 13 countries across three continents were used to identify patients newly-initiated on SGLT-2i or other glucose-lowering drugs (oGLDs). Propensity scores for SGLT-2i initiation were developed in each country, with 1:1 matching for oGLD initiation. In the matched groups hazard ratios (HRs) for hospitalization for heart failure (HHF), all-cause death (ACD), the composite of HHF or ACD, myocardial infarction (MI) and stroke were estimated by country, and pooled using a weighted meta-analysis. Multiple subgroup analyses were conducted across patient demographic and clinical characteristics to examine any heterogeneity in treatment effects. Results Following matching, 440,599 new users of SGLT-2i and oGLDs were included in each group. Mean follow-up time was 396 days for SGLT-2i initiation and 406 days for oGLDs initiation. SGLT-2i initiation was associated with a lower risk of HHF (HR: 0.66, 95%CI 0.58–0.75; p < 0.001), ACD (HR: 0.52, 95%CI 0.45–0.60; p < 0.001), the composite of HHF or ACD (HR: 0.60, 95%CI 0.53–0.68; p < 0.001), MI (HR: 0.85, 95%CI 0.78–0.92; p < 0.001), and stroke (HR: 0.78, 95%CI 0.72–0.85; p < 0.001); regardless of patient characteristics, including established cardiovascular disease, or geographic region. Conclusions This CVD-REAL study extends the findings from the SGLT-2i clinical trials to the broader setting of an ethnically and geographically diverse population, and across multiple subgroups. Trial registration NCT02993614 Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01345-z.
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Affiliation(s)
- Kamlesh Khunti
- University of Leicester, University Road, Leicester, LE1 7RH, UK.
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, 64111, USA.,University of Missouri-Kansas City, Kansas City, MO, 64110, USA.,The George Institute for Global Health, Sydney, NSW, 2042, Australia
| | - Dae Jung Kim
- Ajou University School of Medicine, Suwon, 16499, Republic of Korea
| | - Shun Kohsaka
- Keio University School of Medicine, Tokyo, 160-8582, Japan
| | - Carolyn S P Lam
- National Heart Center Singapore, Singapore, 169609, Singapore.,SingHealth Duke-NUS, Singapore, 168753, Singapore.,University Medical Center Groningen, Groningen, The Netherlands
| | - Su-Yen Goh
- Singapore General Hospital, Singapore, 169608, Singapore
| | - Chern-En Chiang
- General Clinical Research Center, Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan.,National Yang-Ming University, Taipei, Taiwan
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia
| | | | | | - Josep Franch-Nadal
- Institut Universitari D'investigació en Atenció Primaria (IDIAP Jordi Gol), CIBERDEM, Barcelona, Spain
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, 89081, Ulm, Germany
| | - Marit E Jørgensen
- Steno Diabetes Center Copenhagen, 2820, Gentofte, Denmark.,University of Southern Denmark, Copenhagen, Denmark
| | | | - Johan G Eriksson
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, 00290, Helsinki, Finland.,Folkhälsan Research Center, Helsinki, Finland.,Department of Obstetrics & Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | | | | | - Dianna J Magliano
- School of Public Health and Preventive Medicine, Monash University, Baker Heart and Diabetes Institute, Melbourne, VIC, 3004, Australia
| | | | - Hungta Chen
- BioPharmaceuticals R&D, AstraZeneca, Gaithersburg, MD, 20878, USA
| | - Eric Wittbrodt
- BioPharmaceuticals Medical, AstraZeneca, Gaithersburg, MD, 20878, USA
| | | | - Filip Surmont
- BioPharmaceuticals Medical, AstraZeneca, Cambridge, CB2 8PA, UK
| | - Peter Fenici
- Cardiovascular, Renal and Metabolism, BioPharmaceuticals Medical, AstraZeneca, Cambridge, CB2 8PA, UK
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23
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Nelson AJ, Pagidipati NJ, Aroda VR, Cavender MA, Green JB, Lopes RD, Al-Khalidi H, Gaynor T, Kaltenbach LA, Kirk JK, Lingvay I, Magwire ML, O'Brien EC, Pak J, Pop-Busui R, Richardson CR, Reed M, Senyucel C, Webb L, McGuire DK, Granger CB. Incorporating SGLT2i and GLP-1RA for Cardiovascular and Kidney Disease Risk Reduction: Call for Action to the Cardiology Community. Circulation 2021; 144:74-84. [PMID: 34228476 DOI: 10.1161/circulationaha.121.053766] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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] [Indexed: 01/10/2023]
Abstract
Multiple sodium glucose cotransporter-2 inhibitors (SGLT-2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) have been shown to impart significant cardiovascular and kidney benefits, but are underused in clinical practice. Both SGLT-2i and GLP-1RA were first studied as glucose-lowering drugs, which may have impeded uptake by cardiologists in the wake of proven cardiovascular efficacy. Their significant effect on cardiovascular and kidney outcomes, which are largely independent of glucose-lowering effects, must drive a broader use of these drugs. Cardiologists are 3 times more likely than endocrinologists to see patients with both type 2 diabetes and cardiovascular disease, thus they are ideally positioned to share responsibility for SGLT-2i and GLP-1RA treatment with primary care providers. In order to increase adoption, SGLT-2i and GLP-1RA must be reframed as primarily cardiovascular and kidney disease risk-reducing agents with a side effect of glucose-lowering. Coordinated and multifaceted interventions engaging clinicians, patients, payers, professional societies, and health systems must be implemented to incentivize the adoption of these medications as part of routine cardiovascular and kidney care. Greater use of SGLT-2i and GLP-1RA will improve outcomes for patients with type 2 diabetes at high risk for cardiovascular and kidney disease.
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Affiliation(s)
- Adam J Nelson
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | | | | | - Jennifer B Green
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Hussein Al-Khalidi
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Tanya Gaynor
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (T.G., J.P.)
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | | | - Ildiko Lingvay
- University of Texas Southwestern Medical Center, Dallas (I.L., D.K.)
| | | | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | - Jonathan Pak
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (T.G., J.P.)
| | | | | | - Monica Reed
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | | | - Laura Webb
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
| | | | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC (A.J.N., N.J.P., J.B.G., R.D.L., H.A., L.A.K., E.C.O., M.R., L.W., C.B.G.)
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24
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Lam CSP, Karasik A, Melzer‐Cohen C, Cavender MA, Kohsaka S, Norhammar A, Thuresson M, Chen H, Wittbrodt E, Fenici P, Kosiborod M. Association of sodium-glucose cotransporter-2 inhibitors with outcomes in type 2 diabetes with reduced and preserved left ventricular ejection fraction: Analysis from the CVD-REAL 2 study. Diabetes Obes Metab 2021; 23:1431-1435. [PMID: 33606906 PMCID: PMC8251980 DOI: 10.1111/dom.14356] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 12/15/2022]
Abstract
This study of real-world data from the Maccabi database in Israel compared the risk of heart failure hospitalization (HHF) or death in patients with type 2 diabetes (T2D) initiating sodium-glucose cotransporter-2 (SGLT2) inhibitors versus other glucose-lowering drugs (OGLDs) according to baseline left ventricular (LV) ejection fraction (EF). After propensity-matching patients by baseline EF there were 10 614 episodes of treatment initiation; 57% had diabetes for >10 years, the mean glycated haemoglobin level was 66 mmol/mol (8.2%), ∼43% had cardiovascular disease, ∼7% had heart failure and ∼ 20% had chronic kidney disease. A total of 2876 patients (∼9%) had reduced EF (<50%). Over a mean follow-up of 1.5 years there were 371 HHFs or deaths, 88 (23.7%) in patients with reduced EF. Initiation of SGLT2 inhibitors versus OGLDs was associated with lower risk of HHF or death overall (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.46-0.70]; P < 0.001) and in patients with both reduced EF (HR 0.61, 95% CI 0.40-0.93) and preserved EF (HR 0.55, 95% CI 0.43-0.70), with no significant heterogeneity (Pinteraction = 0.72). Our findings from real-world clinical practice show that the lower risk of HHF and death associated with use of SGLT2 inhibitors versus OGLDs is consistent in T2D patients with both reduced and preserved EF.
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Affiliation(s)
- Carolyn S. P. Lam
- National Heart Center Singapore and SingHealth Duke‐NUSSingaporeSingapore
- University Medical Center GroningenGroningenThe Netherlands
| | - Avraham Karasik
- Tel Aviv UniversityTel AvivIsrael
- Maccabi Institute for Research and Innovation, Maccabi Healthcare ServicesTel‐AvivIsrael
| | - Cheli Melzer‐Cohen
- Maccabi Institute for Research and Innovation, Maccabi Healthcare ServicesTel‐AvivIsrael
| | - Matthew A. Cavender
- Department of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Shun Kohsaka
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Anna Norhammar
- Karolinska University Hospital, Karolinska InstitutetSolnaSweden
| | | | - Hungta Chen
- BioPharmaceuticals R&D BioPharmaceuticals MedicalAstraZenecaGaithersburgMarylandUSA
| | - Eric Wittbrodt
- BioPharmaceuticals R&D BioPharmaceuticals MedicalAstraZenecaGaithersburgMarylandUSA
| | - Peter Fenici
- Cardiovascular, Renal and Metabolism, BioPharmaceuticals MedicalAstraZenecaCambridgeUK
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMissouriUSA
- The George Institute for Global Health and University of New South WalesSydneyAustralia
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25
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Tuttle KR, Brosius FC, Cavender MA, Fioretto P, Fowler KJ, Heerspink HJ, Manley T, McGuire DK, Molitch ME, Mottl AK, Perreault L, Rosas SE, Rossing P, Sola L, Vallon V, Wanner C, Perkovic V. SGLT2 Inhibition for CKD and Cardiovascular Disease in Type 2 Diabetes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Am J Kidney Dis 2021; 77:94-109. [DOI: 10.1053/j.ajkd.2020.08.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/04/2020] [Indexed: 12/25/2022]
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26
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Tuttle KR, Brosius FC, Cavender MA, Fioretto P, Fowler KJ, Heerspink HJL, Manley T, McGuire DK, Molitch ME, Mottl AK, Perreault L, Rosas SE, Rossing P, Sola L, Vallon V, Wanner C, Perkovic V. SGLT2 Inhibition for CKD and Cardiovascular Disease in Type 2 Diabetes: Report of a Scientific Workshop Sponsored by the National Kidney Foundation. Diabetes 2021; 70:1-16. [PMID: 33106255 PMCID: PMC8162454 DOI: 10.2337/dbi20-0040] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/04/2020] [Indexed: 12/24/2022]
Abstract
Diabetes is the most frequent cause of chronic kidney disease (CKD), leading to nearly half of all cases of kidney failure requiring replacement therapy. The principal cause of death among patients with diabetes and CKD is cardiovascular disease (CVD). Sodium/glucose cotransporter 2 (SGLT2) inhibitors were developed to lower blood glucose levels by inhibiting glucose reabsorption in the proximal tubule. In clinical trials designed to demonstrate the CVD safety of SGLT2 inhibitors in type 2 diabetes mellitus (T2DM), consistent reductions in risks for secondary kidney disease end points (albuminuria and a composite of serum creatinine doubling or 40% estimated glomerular filtration rate decline, kidney failure, or death), along with reductions in CVD events, were observed. In patients with CKD, the kidney and CVD benefits of canagliflozin were established by the CREDENCE (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation) trial in patients with T2DM, urinary albumin-creatinine ratio >300 mg/g, and estimated glomerular filtration rate of 30 to <90 mL/min/1.73 m2 To clarify and support the role of SGLT2 inhibitors for treatment of T2DM and CKD, the National Kidney Foundation convened a scientific workshop with an international panel of more than 80 experts. They discussed the current state of knowledge and unanswered questions in order to propose therapeutic approaches and delineate future research. SGLT2 inhibitors improve glomerular hemodynamic function and are thought to ameliorate other local and systemic mechanisms involved in the pathogenesis of CKD and CVD. SGLT2 inhibitors should be used when possible by people with T2DM to reduce risks for CKD and CVD in alignment with the clinical trial entry criteria. Important risks of SGLT2 inhibitors include euglycemic ketoacidosis, genital mycotic infections, and volume depletion. Careful consideration should be given to the balance of benefits and harms of SGLT2 inhibitors and risk mitigation strategies. Effective implementation strategies are needed to achieve widespread use of these life-saving medications.
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Affiliation(s)
- Katherine R Tuttle
- Providence Health Care and University of Washington School of Medicine, Spokane, WA
| | | | | | - Paola Fioretto
- Department of Medicine, University of Padua, Padua, Italy
| | | | | | - Tom Manley
- National Kidney Foundation, New York, NY
| | | | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern, University Feinberg School of Medicine, Chicago, IL
| | - Amy K Mottl
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Sylvia E Rosas
- Joslin Diabetes Center and Harvard Medical School, Boston, MA
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Laura Sola
- University of the Republic, Montevideo, Uruguay
| | | | - Christoph Wanner
- Division of Nephrology, University Hospital Würzburg, Würzburg, Germany
| | - Vlado Perkovic
- George Institute for Global Health, UNSW Sydney, Australia
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27
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Arora S, Hendrickson MJ, Strassle PD, Qamar A, Pandey A, Kolte D, Sitammagari K, Cavender MA, Fonarow GC, Bhatt DL, Vavalle JP. Trends in Costs and Risk Factors of 30-Day Readmissions for Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 137:89-96. [PMID: 32991853 DOI: 10.1016/j.amjcard.2020.09.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/29/2022]
Abstract
As transcatheter aortic valve implantation (TAVI) continues its rapid growth as a treatment approach for aortic stenosis, costs associated with TAVI, and its burden to healthcare systems will assume greater importance. Patients undergoing TAVI between January 2012 and November 2017 in the Nationwide Readmission Database were identified. Trends in cause-specific readmissions were assessed using Poisson regression. Thirty-day TAVI cost burden (cost of index TAVI hospitalization plus total 30-day readmissions cost) was adjusted to 2017 U.S. dollars and trended over year from 2012 to 2017. Overall, 47,255 TAVI were included and 30-day readmissions declined from 20% to 12% (p <0.0001). Most common causes of readmission (heart failure, infection/sepsis, gastrointestinal causes, and respiratory) declined as well, except arrhythmia/heart block which increased (1.0% to 1.4%, p <0.0001). Cost of TAVI hospitalization ($52,024 to $44,110, p <0.0001) and 30-day cost burden ($54,122 to $45,252, p <0.0001) declined. Whereas costs of an average readmission did not change ($9,734 to $10,068, p = 0.06), cost burden of readmissions (per every TAVI performed) declined ($4,061 to $1,883, p <0.0001), including reductions in each of the top 5 causes except arrhythmia/heart block ($171 to $263, p = 0.04). Index TAVI hospitalizations complicated by acute kidney injury, length of stay ≥5 days, low hospital procedural volume, and skilled nursing facility discharge were associated with increased odds of 30-day readmissions. In conclusion, the costs of index hospitalizations and 30-day cost burden for TAVI in the U.S. significantly declined from 2012 to 2017. However, readmissions due to arrhythmia/heart block and their associated costs increased. Continued strategies to prevent readmissions, especially those for conduction disturbances, are crucial in the efforts to optimize outcomes and costs with the ongoing expansion of TAVI.
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28
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Arora S, Sivaraj K, Hendrickson M, Chang PP, Weickert T, Qamar A, Vaduganathan M, Caughey MC, Pandey A, Cavender MA, Rosamond W, Vavalle JP. Prevalence and Prognostic Significance of Mitral Regurgitation in Acute Decompensated Heart Failure: The ARIC Study. JACC Heart Fail 2020; 9:179-189. [PMID: 33309575 DOI: 10.1016/j.jchf.2020.09.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES This study investigates the prevalence and prognostic significance of mitral regurgitation (MR) in acute decompensated heart failure (ADHF) patients. BACKGROUND Few studies characterize the burden of MR in heart failure. METHODS The ARIC (Atherosclerosis Risk In Communities) study surveilled ADHF hospitalizations for residents ≥55 years of age in 4 U.S. communities. ADHF cases were stratified by left ventricular ejection fraction (LVEF): <50% and ≥50%. Odds of moderate or severe MR in patients with varying sex and race, and odds of 1-year mortality in those with higher MR severity were estimated using multivariable logistic regression. RESULTS From 2005 to 2014, there were 17,931 weighted ADHF hospitalizations of which 49.2% had an LVEF <50% and 50.8% an LVEF ≥50%. Moderate or severe MR prevalence was 44.5% in those with an LVEF <50% and 27.5% in those with an LVEF ≥50%. Moderate or severe MR was more likely in females than males regardless of LVEF; LVEF <50% (odds ratio [OR]: 1.21 [95% confidence interval (CI): 1.11 to 1.33]), LVEF ≥50% (OR: 1.52 [95% CI: 1.36 to 1.69]). Among hospitalizations with an LVEF ≥50%, moderate or severe MR was less likely in blacks than whites (OR: 0.72 [95% CI: 0.64 to 0.82]). Higher MR severity was independently associated with increased 1-year mortality in those with an LVEF <50% (OR: 1.30 [95% CI: 1.16 to 1.45]). CONCLUSIONS Patients with ADHF have a significant MR burden that varies with sex and race. In ADHF patients with an LVEF <50%, higher MR severity is associated with excess 1-year mortality.
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Affiliation(s)
- Sameer Arora
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Krishan Sivaraj
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Michael Hendrickson
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Patricia P Chang
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Thelsa Weickert
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Arman Qamar
- NorthShore Cardiovascular Institute, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Evanston, Illinois, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa C Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, North Carolina, USA
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew A Cavender
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Wayne Rosamond
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - John P Vavalle
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
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Cavender MA, Forrest JK. Planning for the Next Transcatheter Aortic Valve Replacement Starts Today. Circ Cardiovasc Interv 2020; 13:e010226. [PMID: 33272033 DOI: 10.1161/circinterventions.120.010226] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew A Cavender
- Department of Medicine (Cardiology), University of North Carolina at Chapel Hill (M.A.C.)
| | - John K Forrest
- Department of Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, CT (J.K.F.)
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30
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Affiliation(s)
- Matthew A Cavender
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Benjamin M Scirica
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
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31
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Kohsaka S, Lam CSP, Kim DJ, Cavender MA, Norhammar A, Jørgensen ME, Birkeland KI, Holl RW, Franch-Nadal J, Tangri N, Shaw JE, Ilomäki J, Karasik A, Goh SY, Chiang CE, Thuresson M, Chen H, Wittbrodt E, Bodegård J, Surmont F, Fenici P, Kosiborod M. Risk of cardiovascular events and death associated with initiation of SGLT2 inhibitors compared with DPP-4 inhibitors: an analysis from the CVD-REAL 2 multinational cohort study. Lancet Diabetes Endocrinol 2020; 8:606-615. [PMID: 32559476 DOI: 10.1016/s2213-8587(20)30130-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/26/2020] [Accepted: 04/03/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cardiovascular outcome trials have shown cardiovascular benefit with sodium-glucose co-transporter-2 (SGLT2) inhibitors in patients with type 2 diabetes, whereas dipeptidyl peptidase-4 (DPP-4) inhibitors have not shown an effect. We aimed to address knowledge gaps regarding the comparative effectiveness of SGLT2 inhibitor use in clinical practice (with DPP-4 inhibitor use as an active comparator) across a range of cardiovascular risks and in diverse geographical settings. METHODS In this comparative cohort study, we used data from clinical practice from 13 countries in the Asia-Pacific, Middle East, European, and North American regions to assess the risk of cardiovascular events and death in adult patients with type 2 diabetes newly initiated on SGLT2 inhibitors compared with those newly initiated on DPP-4 inhibitors. De-identified health records were used to select patients who were initiated on these drug classes between Dec 1, 2012, and May 1, 2016, with follow-up until Dec 31, 2014, to Nov 30, 2017 (full range; dates varied by country). Non-parsimonious propensity scores for SGLT2 inhibitor initiation were developed for each country and patients who were initiated on an SGLT2 inhibitor were matched with those who were initiated on a DPP-4 inhibitor in a 1:1 ratio. Outcomes assessed were hospitalisation for heart failure, all-cause death, myocardial infarction, and stroke. Hazard ratios (HRs) were estimated by country and then pooled in a weighted meta-analysis. FINDINGS Following propensity score matching, 193 124 new users of SGLT2 inhibitors and 193 124 new users of DPP-4 inhibitors were included in the study population. Participants had a mean age of 58 years (SD 12·2), 170 335 (44·1%) of 386 248 were women, and 111 933 (30·1%) of 372 262 had established cardiovascular disease. Initiation of an SGLT2 inhibitor versus a DPP-4 inhibitor was associated with substantially lower risks of hospitalisation for heart failure (HR 0·69, 95% CI 0·61-0·77; p<0·0001), all-cause death (0·59, 0·52-0·67; p<0·0001), and the composite of hospitalisation for heart failure or all-cause death (0·64, 0·57-0·72; p<0·0001). Risks of myocardial infarction (HR 0·88, 0·80-0·98; p=0·020) and stroke (0·85 0·77-0·93; p=0·0004) were significantly but modestly lower with SGLT2 inhibitors versus DPP-4 inhibitors. INTERPRETATION In this large, international, observational study, initiation of SGLT2 inhibitors versus DPP-4 inhibitors was associated with lower risks of heart failure, death, myocardial infarction, and stroke, providing further support for the cardiovascular benefits associated with use of SGLT2 inhibitors in patients with type 2 diabetes. FUNDING AstraZeneca.
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Affiliation(s)
- Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Carolyn S P Lam
- National Heart Center Singapore, Singapore; SingHealth Duke-NUS, Singapore; University Medical Center Groningen, Groningen, Netherlands
| | - Dae Jung Kim
- Department of Endocrinology and Metabolism, Ajou University School of Medicine, Suwon, South Korea
| | | | | | - Marit E Jørgensen
- Steno Diabetes Center Copenhagen, Gentofte, Denmark; University of Southern Denmark, Copenhagen, Denmark
| | | | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | - Josep Franch-Nadal
- Institut Universitari d'investigació en Atenció Primaria (IDIAP Jordi Gol), Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Barcelona, Spain
| | - Navdeep Tangri
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jonathan E Shaw
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
| | | | | | - Chern-En Chiang
- National Yang-Ming University, Taipei, Taiwan; Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | | | | | | - Mikhail Kosiborod
- George Institute for Global Health, Sydney, NSW, Australia; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA; University of New South Wales in Sydney, Sydney, NSW, Australia
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Wittbrodt E, Bhalla N, Andersson Sundell K, Gao Q, Dong L, Cavender MA, Hunt P, Wong ND, Mellström C. Assessment of the high risk and unmet need in patients with CAD and type 2 diabetes (ATHENA): US healthcare resource utilization, cost and burden of illness in the Diabetes Collaborative Registry. Endocrinol Diabetes Metab 2020; 3:e00133. [PMID: 32704557 PMCID: PMC7375123 DOI: 10.1002/edm2.133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 09/04/2019] [Revised: 03/13/2020] [Accepted: 03/14/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND THEMIS (NCT01991795) showed that in patients with type 2 diabetes (T2D) and stable coronary artery disease (CAD) but with no prior myocardial infarction (MI) or stroke, ticagrelor plus acetylsalicylic acid (ASA) decreased the incidence of ischaemic cardiovascular events compared with placebo plus ASA. To complement these findings, we assessed disease burden and healthcare resource utilization (HRU) in US patients with CAD and T2D, but without a prior MI or stroke. METHODS This observational study used 2013-2014 data from the Diabetes Collaborative Registry linked to Medicare administrative claims. Two cohorts of patients with T2D were studied: patients at high cardiovascular risk (THEMIS-like cohort; N = 56 040) and patients at high cardiovascular risk or taking P2Y12 inhibitors (CAD-T2D cohort; N = 69 790). Outcomes included the composite of all-cause death, MI and stroke; the individual events from the composite endpoint; HRU; and costs. RESULTS Median age was 73.0 years, and median follow-up was 1.3 years in both cohorts. Event rates of the composite outcome were 16.34 (95% confidence interval: 16.31-16.37) and 17.64 (17.61-17.67) per 100 person-years for the THEMIS-like and CAD-T2D cohorts, respectively. The incidence rate of bleeding events was 0.13 events per 100 person-years in both cohorts. Healthcare costs per patient-year were USD 8741 and USD 9150 in the THEMIS-like and CAD-T2D cohorts, respectively. CONCLUSIONS Patients in the THEMIS-like cohort and the broader CAD-T2D population had similarly substantial cardiovascular event rates and healthcare costs, indicating that patients with CAD and T2D similar to the THEMIS population are at an increased cardiovascular risk.
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Affiliation(s)
| | | | | | - Qi Gao
- Baim Institute for Clinical ResearchBostonMAUSA
| | - Liyan Dong
- Baim Institute for Clinical ResearchBostonMAUSA
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Abstract
Antiplatelet and anticoagulant medications are the cornerstone of therapy for patients with acute coronary syndrome and have also been shown to reduce recurrent cardiovascular events in patients with stable coronary disease. Whereas antiplatelet medications have been the preferred therapy for long-term secondary prevention, the development of novel oral anticoagulants has renewed interest in the use of anticoagulation to prevent atherosclerotic events. In patients with atrial fibrillation or other indications for anticoagulation, recent clinical trials have shown the benefit of double therapy with full-dose novel oral anticoagulants and P2Y12 inhibitors compared with regimens with vitamin K antagonists. In patients without an indication for anticoagulation, the use of low doses of the factor Xa inhibitor, rivaroxaban, has shown benefit. Clinicians have many pharmacological options when treating patients following percutaneous coronary intervention. This review discusses the evidence for the use of novel oral anticoagulants, with an emphasis on patient selection, choice of therapy, and appropriate dosing of anticoagulant and antiplatelet agents, in secondary prevention strategies for atherosclerosis following coronary revascularization for patients with and without a traditional indication for anticoagulation.
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Affiliation(s)
- Bryan Q. Abadie
- Department of Medicine, University of North Carolina at Chapel Hill (B.Q.A., M.A.C.)
| | - Christopher P. Cannon
- Department of Medicine, Preventive Cardiology Section, Brigham and Women’s Hospital, Boston, MA (C.P.C.)
| | - Matthew A. Cavender
- Department of Medicine, University of North Carolina at Chapel Hill (B.Q.A., M.A.C.)
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Sivaraj K, Arora S, Slehria T, Chang P, Weickert T, Qamar A, Vaduganathan M, Cavender MA, Rosamond WD, Vavalle JP. Abstract 209: Prevalence and Prognostic Significance of Aortic Stenosis in Patients With Acute Decompensated Heart Failure: The Atherosclerosis Risk in Communities Study. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.209] [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: 11/16/2022]
Abstract
Background:
Heart failure (HF) patients with aortic stenosis (AS) constitute a high-risk population posing diagnostic and therapeutic challenges. Few studies have characterized the burden of AS in patients admitted with acute decompensated HF (ADHF), stratified by ejection fraction (EF).
Methods:
The Atherosclerosis Risk in Communities study conducted community-based surveillance of a random sample of ADHF hospitalizations for residents ≥55 years of age in four US communities. ADHF cases were subclassified as having reduced (HFrEF) or preserved (HFpEF) EF using a 50% cutoff. AS severity was determined from echocardiogram reports obtained during abstracted hospitalizations. Odds of moderate or severe AS in patients with varying sex and race, and odds of all-cause 1-year mortality in those with higher AS severity were estimated using multivariable logistic regression.
Results:
From 2005-2014, there were 14,289 weighted ADHF hospitalizations of whom 7,357 had HFrEF (45.0% female, 36.6% black) and 6,932 HFpEF (62.9% female, 26.5% black). The prevalence of moderate or severe AS was 5.67% in HFrEF and 9.43% in HFpEF. Patients with higher AS severity were older than those with none or mild AS in both HFrEF ([mean age] 79.7 vs. 74.4 years, p<0.0001) and HFpEF (81.7 vs. 76.3 years, p<0.0001). No difference in odds of higher AS severity was detected between females and males in both HFrEF (5.49% vs. 5.81%, OR: 1.03, 95% CI: 0.83-1.27) and HFpEF (9.10% vs. 9.99%, OR: 0.89, 95% CI: 0.75-1.06). Moderate or severe AS was more likely in whites than blacks in both HFrEF (8.32% vs. 1.67%, OR: 0.23, 95% CI: 0.17-0.32) and HFpEF (11.1% vs. 6.38%, OR: 0.70, 95% CI: 0.56-0.88). Higher AS severity was independently associated with increased all-cause 1-year mortality after ADHF hospitalization in both HFrEF (44.3% vs. 30.5%, OR: 1.25, 95% CI: 1.16-1.35) and HFpEF (33.4% vs. 26.1%, OR: 1.16, 95% CI: 1.08-1.24).
Conclusion:
In ADHF patients with HFrEF or HFpEF, whites are more affected by AS than blacks, as are older patients when compared to their younger counterparts. Higher AS severity in ADHF patients is independently associated with all-cause mortality at 1 year after hospitalization, regardless of EF.
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O'Leary CP, Cavender MA. Emerging opportunities to harness real world data: An introduction to data sources, concepts, and applications. Diabetes Obes Metab 2020; 22 Suppl 3:3-12. [PMID: 32250526 DOI: 10.1111/dom.13948] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/03/2019] [Revised: 12/16/2019] [Accepted: 12/19/2019] [Indexed: 12/29/2022]
Abstract
While randomized controlled trials (RCTs) are the gold standard for comparative effectiveness research, they are unable to provide the answers to all pertinent clinical and research questions. Real world evidence (RWE), that is, clinical evidence obtained outside RCTs and often through routine clinical practice, offers the potential to conduct observational studies that accelerate advances in care, improve outcomes for patients, and provide important insights that can answer important questions. Once appropriate information technology is available, real world data can be cost-effective to generate. RWE serves a vital role in the evaluation of treatment strategies for which there are no RCTs and for describing patterns of care. RWE also serves as an important adjunct to RCTs and can be used to determine if benefits seen in RCTs extend to clinical practice, provide insight into the findings of RCTs, generate hypotheses for future RCTs, and inform the design of future RCTs. These potential benefits must be balanced against some of the important limitations of RWE, including variable data quality, lack of granularity for important clinical variables, and the potential for bias and confounding. By using appropriate analytic techniques and study design, these limitations can be minimized but not eliminated. Going forward, RWE studies may be enhanced by using rigorous data quality standards, incorporating randomization, developing more prospective registries, and better leveraging data from electronic health records.
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Affiliation(s)
- Colin P O'Leary
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matthew A Cavender
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Hendrickson MJ, Bhyan P, Arora S, Strassle PD, Qamar A, Bahekar AA, Cavender MA, Vavalle JP. Trends in Inpatient Complications and Readmissions After Transcatheter or Surgical Mitral Valve Repair From 2012 to 2016. JACC Cardiovasc Interv 2020; 13:272-274. [PMID: 31564596 DOI: 10.1016/j.jcin.2019.08.002] [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: 05/28/2019] [Revised: 07/22/2019] [Accepted: 08/06/2019] [Indexed: 10/25/2022]
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Guha A, Dey AK, Arora S, Cavender MA, Vavalle JP, Sabik JF, Jimenez E, Jneid H, Addison D. Contemporary Trends and Outcomes of Percutaneous and Surgical Aortic Valve Replacement in Patients With Cancer. J Am Heart Assoc 2020; 9:e014248. [PMID: 31960751 PMCID: PMC7033818 DOI: 10.1161/jaha.119.014248] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Indexed: 11/27/2022]
Abstract
Background Patients with cancer and severe aortic stenosis are often ineligible for surgical aortic valve replacement (SAVR). Patients with cancer may likely benefit from emerging transcatheter aortic valve replacement (TAVR), given its minimally invasive nature. Methods and Results The US‐based National Inpatient Sample was queried between 2012 and 2015 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD‐9‐CM), codes to identify all hospitalized adults (aged ≥50 years), who had a primary diagnosis of aortic stenosis. We examined the effect modification of cancer on the relative use rate, outcomes, and dispositions associated with propensity‐matched cohort TAVR versus SAVR. Overall, 47 295 TAVRs (22.6% comorbid cancer) and 113 405 SAVRs (15.2% comorbid cancer) were performed among admissions with aortic stenosis between 2012 and 2015. In the year 2015, patients with cancer saw relatively higher rates of TAVR use compared with SAVR (relative use rateTAVR versus relative use rateSAVR, 67.8% versus 57.2%; P<0.0001). Among patients with cancer, TAVR was associated with lower odds of acute kidney injury (odds ratio, 0.64; 95% CI, 0.54–0.75) and major bleeding (odds ratio, 0.44; 95% CI, 0.38–0.51]), with no differences in in‐hospital mortality and stroke compared with SAVR. In addition, TAVR was associated with higher odds of home discharge (odds ratio, 1.92; 95% CI, 1.68–2.19) compared with SAVR among patients with cancer. Lower risk of acute kidney injury was noted in cancer versus noncancer (P<0.001) undergoing TAVR versus SAVR in effect modification analysis. Conclusions TAVR use has increased irrespective of cancer status, with a greater increase in cancer versus noncancer. In patients with cancer, there was an association of TAVR with lower periprocedural complications and better disposition when compared with patients undergoing SAVR.
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Affiliation(s)
- Avirup Guha
- Harrington Heart and Vascular Institute Case Western Reserve University Cleveland OH.,Cardio-Oncology Program Division of Cardiology Ohio State University Columbus OH
| | - Amit K Dey
- National Heart, Lung, and Blood Institute Bethesda MD
| | - Sameer Arora
- Division of Cardiology University of North Carolina Chapel Hill NC.,Division of Epidemiology UNC Gillings School of Global Public Health Chapel Hill NC
| | | | - John P Vavalle
- Division of Cardiology University of North Carolina Chapel Hill NC
| | - Joseph F Sabik
- Division of Cardiac Surgery Department of Surgery University Hospitals Cleveland Medical Center Cleveland OH
| | - Ernesto Jimenez
- Division of Cardiology Michael E. DeBakey VA Hospital Baylor College of Medicine Houston TX
| | - Hani Jneid
- Division of Cardiology Michael E. DeBakey VA Hospital Baylor College of Medicine Houston TX
| | - Daniel Addison
- Cardio-Oncology Program Division of Cardiology Ohio State University Columbus OH.,Cancer Control Program Department of Medicine Ohio State University Comprehensive Cancer Center Columbus OH
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Sheng SP, Strassle PD, Arora S, Kolte D, Ramm CJ, Sitammagari K, Guha A, Paladugu MB, Cavender MA, Vavalle JP. In-Hospital Outcomes After Transcatheter Versus Surgical Aortic Valve Replacement in Octogenarians. J Am Heart Assoc 2020; 8:e011206. [PMID: 30663494 PMCID: PMC6497334 DOI: 10.1161/jaha.118.011206] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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] [Indexed: 01/21/2023]
Abstract
Background Octogenarians have low physiologic reserve and may benefit more from transcatheter aortic valve replacement (TAVR) than surgical aortic valve replacement (SAVR). Methods and Results This retrospective cohort study based on the National Inpatient Sample included octogenarians who underwent TAVR or SAVR from 2012 to 2015. Crude and standardized‐morbidity‐ratio‐weighted regression models were used to compare in‐hospital outcomes. Among 19 145 TAVR and 9815 SAVR hospitalizations, TAVR patients had higher Charlson Comorbidity Index (CCI) scores (2.0 versus 0.8, P<0.0001) than SAVR patients. Before weighting, TAVR was associated with significantly shorter length of stay, more home discharges, and lower incidences of acute kidney injury, bleeding, and cardiogenic shock. Associations were consistent across Charlson Comorbidity Index, except for TAVR being associated with greater length of stay reductions among patients with Charlson Comorbidity Index ≥2, compared with Charlson Comorbidity Index <2 (change in estimate −3.56 versus −2.61 days, P=0.004). After weighting, TAVR patients had significantly shorter length of stay (change in estimate −3.29 days, 95% CI −3.82, −2.75) and lower odds of transfer to skilled nursing facility (odds ratio 0.34, 95% CI 0.29, 0.41), acute kidney injury (odds ratio 0.55, 95% CI 0.45, 0.68), bleeding (odds ratio 0.44, 95% CI 0.37, 0.53), and cardiogenic shock (odds ratio 0.55, 95% CI 0.33, 0.92), compared with SAVR patients. Odds of permanent pacemaker implantation, transient ischemic attack/stroke, vascular complications, and in‐hospital mortality were not significantly different. Conclusions TAVR may be preferred over SAVR in high‐risk octogenarians because of shorter length of stay, better discharge disposition, and less acute kidney injury, and bleeding. All octogenarians may benefit more from TAVR, irrespective of comorbidity burden, but additional research is needed to confirm our findings. See Editorial by Himbert et al
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Affiliation(s)
- Siyuan P Sheng
- 1 University of North Carolina School of Medicine Chapel Hill NC
| | - Paula D Strassle
- 2 Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | - Sameer Arora
- 2 Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC.,3 Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
| | - Dhaval Kolte
- 4 Division of Cardiology Massachusetts General Hospital Boston MA
| | - Cassandra J Ramm
- 3 Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
| | - Kranthi Sitammagari
- 5 Department of Medicine Campbell University School of Osteopathic Medicine Lillington NC
| | - Avirup Guha
- 6 Heart and Vascular Center Ohio State Wexner Medical Center Columbus OH
| | - Madhu B Paladugu
- 5 Department of Medicine Campbell University School of Osteopathic Medicine Lillington NC
| | - Matthew A Cavender
- 3 Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
| | - John P Vavalle
- 3 Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
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Cicci JD, Jagielski SM, Clarke MM, Rayson RA, Cavender MA. Loperamide overdose causing torsades de pointes and requiring Impella temporary mechanical support: a case report. Eur Heart J Case Rep 2019; 3:1-6. [PMID: 31911979 PMCID: PMC6939795 DOI: 10.1093/ehjcr/ytz150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 03/22/2019] [Revised: 04/23/2019] [Accepted: 09/11/2019] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Loperamide is a widely available oral μ-opioid receptor agonist, and loperamide abuse is increasing by those seeking intoxication. Loperamide has potent QTc-prolonging properties, placing patients at risk for ventricular arrhythmias and sudden cardiac death.
Case summary
A 23-year-old woman was found to be in pulseless ventricular fibrillation with a QTc of 554 ms and received multiple defibrillations and IV lidocaine. Her toxicology studies were negative. She subsequently experienced multiple episodes of torsades de pointes and was found to be in cardiogenic shock with a left ventricular ejection fraction of 5%. Following multiple defibrillations, an Impella® mechanical circulatory support device was placed, and she was given IV magnesium and IV lidocaine. After mechanical circulatory support was withdrawn, she experienced major bleeding and was found to have a deep vein thrombosis, bilateral radial artery thrombosis, and multiple pulmonary embolisms in the setting of heparin-induced thrombocytopenia. After stabilizing, she admitted to taking 80 tablets of loperamide 2 mg in pursuit of euphoria.
Discussion
Loperamide is an increasingly popular agent of abuse. Loperamide-associated ventricular arrhythmias are rare with normal doses but more common with high doses, chronic ingestion, or interacting medications. Loperamide cardiotoxicity may be prolonged due to a long half-life and accumulation. Loperamide abuse may be under-recognized, leading to delays in treatment. Intravenous fluids, magnesium supplementation, chronotropes, transcutaneous or transvenous pacing, and defibrillation may be helpful in mitigating loperamide-associated polymorphic ventricular tachycardia. Clinicians should monitor for drug interactions in patients taking loperamide and screen for electrocardiographic abnormalities in those taking chronic or high-dose loperamide.
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Affiliation(s)
- Jonathan D Cicci
- Department of Pharmacy, University of North Carolina Medical Center, 101 Manning Drive, CB 7600, Chapel Hill, NC 27514, USA
| | - Sarah M Jagielski
- UK Healthcare, 1000 S. Limestone, Room H110, Lexington, KY 40536, USA
| | - Megan M Clarke
- Department of Pharmacy, University of North Carolina Medical Center, 101 Manning Drive, CB 7600, Chapel Hill, NC 27514, USA
| | - Robert A Rayson
- Division of Cardiology, Department of Medicine, University of North Carolina, Burnett-Womack Building, 160 Dental Circle, CB# 7075, Chapel Hill, NC 27599, USA
| | - Matthew A Cavender
- Division of Cardiology, Department of Medicine, University of North Carolina, Burnett-Womack Building, 160 Dental Circle, CB# 7075, Chapel Hill, NC 27599, USA
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Jack G, Arora S, Strassle PD, Sitammagari K, Gangani K, Yeung M, Cavender MA, O'Gara PT, Vavalle JP. Differences in Inpatient Outcomes After Surgical Aortic Valve Replacement at Transcatheter Aortic Valve Replacement (TAVR) and Non-TAVR Centers. J Am Heart Assoc 2019; 8:e013794. [PMID: 31718443 PMCID: PMC6915265 DOI: 10.1161/jaha.119.013794] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Indexed: 01/29/2023]
Abstract
Background Transcatheter aortic valve replacement (TAVR) has solidified the importance of a heart team and revolutionized patient selection for surgical aortic valve replacement (SAVR). It is unknown if hospital ability to offer TAVR impacts SAVR outcomes. We investigated outcomes after SAVR between TAVR and non-TAVR centers. Methods and Results Hospitalizations of patients aged ≥50 years, undergoing elective SAVR between January 2012 and September 2015, in the National Readmission Database (NRD) were included. Multivariable logistic, linear, and generalized logistic regression models were used to adjust for patient and hospital characteristics and estimate association between undergoing SAVR at a TAVR center, compared with a non-TAVR center. The association between TAVR volumes and these outcomes were also assessed. SAVR hospitalizations (n = 32 198) were identified; 22 066 (69%) at TAVR and 10 132 (31%) at non-TAVR centers. SAVRs at TAVR centers had lower odds of inpatient mortality (odds ratio 0.67, 95% CI 0.55-0.82) and discharge to skilled nursing facility (odds ratio 0.92, 95% CI 0.85-0.99), compared with non-TAVR centers. There was no difference in LOS (change in estimate -0.09, 95% CI -0.26 to 0.08) or 30-day re-admission (odds ratio 0.95, 95% CI 0.88-1.03). SAVRs performed at the highest TAVR volume centers had the lowest inpatient mortality, compared with non-TAVR centers (odds ratio 0.43 95% CI 0.29-0.63). Conclusions Patients undergoing SAVR at TAVR centers are more likely to survive and have better discharge disposition than patients undergoing SAVR at non-TAVR centers. Whether this represents benefits of a heart-team approach to care or differences in patient selection for SAVR when TAVR is unavailable requires further study.
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Affiliation(s)
- Godly Jack
- Department of Internal Medicine University of North Carolina School of Medicine Chapel Hill NC
| | - Sameer Arora
- Center for Research and Population Health Lillington NC
| | - Paula D Strassle
- Department of Epidemiology Gillings School of Global Public Health University of North Carolina at Chapel Hill NC
| | | | - Kishorbhai Gangani
- Department of Internal Medicine Texas Health Arlington Memorial Hospital Arlington TX
| | - Michael Yeung
- Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
| | - Matthew A Cavender
- Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
| | - Patrick T O'Gara
- Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
| | - John P Vavalle
- Division of Cardiology University of North Carolina School of Medicine Chapel Hill NC
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Cavender MA, Kim SM. Utility of Dual Antiplatelet Therapy for the Prevention of Subclinical Leaflet Thrombosis: Now Is Not the Time to HALT the Use of Dual Antiplatelet Therapy. JACC Cardiovasc Interv 2019; 12:19-21. [PMID: 30621973 DOI: 10.1016/j.jcin.2018.09.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 09/05/2018] [Revised: 09/21/2018] [Accepted: 09/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew A Cavender
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Sun Moon Kim
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Arora S, Strassle PD, Kolte D, Ramm CJ, Falk K, Jack G, Caranasos TG, Cavender MA, Rossi JS, Vavalle JP. Length of Stay and Discharge Disposition After Transcatheter Versus Surgical Aortic Valve Replacement in the United States. Circ Cardiovasc Interv 2019; 11:e006929. [PMID: 30354596 DOI: 10.1161/circinterventions.118.006929] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND As transcatheter aortic valve replacement (TAVR) extends its reach to lower surgical risk patients, the differences between resource utilization for TAVR and surgical AVR (SAVR) will become increasingly important. METHODS AND RESULTS AVR procedures between January 2012 and September 2015 at hospitals performing TAVR were identified using the National Inpatient Sample databases. Adults aged ≥50 years with aortic stenosis who underwent isolated TAVR or SAVR were eligible for inclusion. Standardized morbidity ratio weights were calculated using patient demographics, comorbidities, and hospital characteristics. Weighted linear and generalized logistic regression models were used to estimate the effect of undergoing TAVR, compared with undergoing SAVR, on length of stay (LOS) and discharge disposition. In TAVR-performing hospitals, 7266 (40%) patients underwent TAVR (6107 endovascular approach and 1159 transapical approach), while 10 833 (60%) underwent isolated SAVR. Patients undergoing TAVR were older, more likely to be female, and had more comorbidities. From 2012 to 2015, average LOS declined for both TAVR (6.3 days to 4.6 days; P<0.0001) and SAVR (7.5 days to 6.8 days; P<0.0001), with greater reduction in the TAVR group ( P<0.0001). An increase in home/home health discharge was noted with TAVR (67.7%-77.4%; P<0.0001) but not with SAVR (76.8%-79.5%; P=0.25). After standardizing, patients undergoing TAVR had significantly shorter LOS (change in estimate, -2.93, 95% CI, -3.26 to -2.60) and lower incidence of transfer to skilled nursing facility (odds ratio, 0.45; 95% CI, 0.40-0.51) but no difference in in-hospital mortality (odds ratio, 0.85; 95% CI, 0.61-1.20) compared with if they had undergone SAVR. As compared with SAVR, patients who had TAVR performed via an endovascular approach had shorter LOS and lower rates of skilled nursing facility transfer, whereas in the transapical cohort, LOS, and skilled nursing facility transfer were similar to SAVR. CONCLUSIONS As compared with if they undergo SAVR, patients undergoing TAVR (by a nontransapical approach) had a shorter LOS and higher likelihood of home discharge, as opposed to skilled nursing facility. From 2012 to 2015, there was a greater trend towards a reduction of LOS and more home discharges among TAVR, as opposed to SAVR. These data have important implications in the era of constrained resources with a growing emphasis on reducing health care costs.
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Affiliation(s)
- Sameer Arora
- Division of Cardiology (S.A., C.J.R., M.A.C., J.S.R., J.P.V.), University of North Carolina, Chapel Hill.,Division of Epidemiology, Gillings School of Public Health (S.A., P.D.S.), University of North Carolina, Chapel Hill
| | - Paula D Strassle
- Division of Cardiology (S.A., C.J.R., M.A.C., J.S.R., J.P.V.), University of North Carolina, Chapel Hill.,Division of Surgery (P.D.S., T.G.C.), University of North Carolina, Chapel Hill
| | - Dhaval Kolte
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI (D.K.)
| | - Cassandra J Ramm
- Division of Cardiology (S.A., C.J.R., M.A.C., J.S.R., J.P.V.), University of North Carolina, Chapel Hill
| | - Kristine Falk
- Department of Internal Medicine (K.F., G.J.), University of North Carolina, Chapel Hill
| | - Godly Jack
- Department of Internal Medicine (K.F., G.J.), University of North Carolina, Chapel Hill
| | - Thomas G Caranasos
- Division of Surgery (P.D.S., T.G.C.), University of North Carolina, Chapel Hill
| | - Matthew A Cavender
- Division of Cardiology (S.A., C.J.R., M.A.C., J.S.R., J.P.V.), University of North Carolina, Chapel Hill
| | - Joseph S Rossi
- Division of Cardiology (S.A., C.J.R., M.A.C., J.S.R., J.P.V.), University of North Carolina, Chapel Hill
| | - John P Vavalle
- Division of Cardiology (S.A., C.J.R., M.A.C., J.S.R., J.P.V.), University of North Carolina, Chapel Hill
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Abstract
"Periprocedural myocardial infarction (MI) occurs infrequently in the current era of percutaneous coronary interventions (PCI) and is associated with an increased risk of mortality and morbidity. Periprocedural MI can occur due to acute side branch occlusion, distal embolization, slow flow or no reflow phenomenon, abrupt vessel closure, and nonidentifiable mechanical processes. Therapeutic strategies to reduce the risk of periprocedural MI include dual antiplatelet therapy, intravenous cangrelor in the periprocedural setting, intravenous glycoprotein IIb/IIIa inhibitor in high-risk patients, anticoagulation with unfractionated heparin, low-molecular-weight heparin or bivalirudin, and embolic protection devices during saphenous vein graft interventions."
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Affiliation(s)
- David W Lee
- Division of Interventional Cardiology, University of North Carolina, 160 Dental Circle, CB 7075, Chapel Hill, NC 27599, USA.
| | - Matthew A Cavender
- Division of Interventional Cardiology, University of North Carolina, 160 Dental Circle, CB 7075, Chapel Hill, NC 27599, USA
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Arora S, Vemulapalli S, Stebbins A, Ramm CJ, Kosinski AS, Sorajja P, Piccini JP, Cavender MA, Vavalle JP. The Prevalence and Impact of Atrial Fibrillation on 1-Year Outcomes in Patients Undergoing Transcatheter Mitral Valve Repair. JACC Cardiovasc Interv 2019; 12:569-578. [DOI: 10.1016/j.jcin.2018.12.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/27/2018] [Accepted: 12/12/2018] [Indexed: 11/29/2022]
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Affiliation(s)
- David W Lee
- Division of Cardiology, University of North Carolina, Chapel Hill
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46
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Cavender MA, Kolarczyk L. Pulmonary Hypertension and Aortic Stenosis: Further Evidence That TAVR Is Not SAVR. JACC Cardiovasc Imaging 2018; 12:602-604. [PMID: 30553680 DOI: 10.1016/j.jcmg.2018.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 02/28/2018] [Revised: 04/02/2018] [Accepted: 04/04/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew A Cavender
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina
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Bertaina M, Ferraro I, Omedè P, Conrotto F, Saint-Hilary G, Cavender MA, Claessen BE, Henriques JP, Frea S, Usmiani T, Grosso Marra W, Pennone M, Moretti C, D'Amico M, D'Ascenzo F. Meta-Analysis Comparing Complete or Culprit Only Revascularization in Patients With Multivessel Disease Presenting With Cardiogenic Shock. Am J Cardiol 2018; 122:1661-1669. [PMID: 30220420 DOI: 10.1016/j.amjcard.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/30/2018] [Accepted: 08/07/2018] [Indexed: 12/31/2022]
Abstract
The optimal strategy for patients with an acute myocardial infarction (MI) and multivessel (MV) coronary artery disease complicated by cardiogenic shock (CS) remains unknown. We conducted a meta-analysis of all randomized controlled trials and observational studies that reported adjusted effect measures to evaluate the association of MV-PCI (percutaneous coronary intervention), compared with culprit only (C)-PCI, with cardiovascular events in patients admitted for CS and MV disease. We identified 12 studies (n = 1 randomized controlled trials, n = 11 observational) that included 7,417 patients (n = 1,809 treated with MV-PCI and n = 5,608 with C-PCI). When compared with C-PCI, MV-PCI was not associated with an increased risk of short-term death (odds ratio [OR] 1.14, 95% confidence interval [CI] 0.87 to 1.48, p = 0.35 and adjusted OR [ORadj] 1.00, 95% CI 0.70 to 1.43, p = 1.00). In-hospital and/or short-term mortality tended to be higher with MV-PCI, when compared with C-PCI, for CS patients needing dialysis (ß 0.12, 95% CI from 0.049 to 0.198; p= 0.001), whereas MV-PCI was associated with lower in-hospital and/or short-term mortality in patients with an anterior MI (ß -0.022, 95% CI -0.03 to -0.01; p <0.001). MV-PCI strategy was associated with a more frequent need for dialysis or contrast-induced nephropathy after revascularization (OR 1.36, 95% CI 1.06 to 1.75, p = 0.02). In conclusion, MV-PCI seems not to increase risk of death during short- or long-term follow-up when compared with C-PCI in patients admitted for MV coronary artery disease and MI complicated by CS. Furthermore, it appears a more favorable strategy in patients with anterior MI, whereas the increased risk for AKI and its negative prognostic impact should be considered in decision-making process. Further studies are needed to confirm our hypothesis on in these subpopulations of CS patients.
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48
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Cavender MA, White WB, Liu Y, Massaro JM, Bergenstal RM, Mehta CR, Zannad F, Heller S, Cushman WC, Cannon CP. Total cardiovascular events analysis of the EXAMINE trial in patients with type 2 diabetes and recent acute coronary syndrome. Clin Cardiol 2018; 41:1022-1027. [PMID: 29652078 DOI: 10.1002/clc.22960] [Citation(s) in RCA: 3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 04/04/2018] [Indexed: 01/19/2023] Open
Abstract
Alogliptin, a dipeptidyl peptidase-4 inhibitor, is approved for the treatment of patients with type 2 diabetes (T2DM). EXAMINE was a randomized controlled clinical trial designed to demonstrate the cardiovascular (CV) safety of alogliptin. In the trial, 5380 patients with established T2DM who had a recent acute coronary syndrome event (between 15 and 90 days) were randomized to treatment with either alogliptin or placebo. To better understand and describe the CV safety of alogliptin, we analyzed data from the EXAMINE trial to determine whether treatment with alogliptin affected recurrent and total CV events. Poisson regression analysis compared the total number of occurrences of CV death, MI, stroke, unstable angina, and coronary revascularization between all patients randomized to alogliptin vs placebo groups. Patients with recurrent CV events were older and more likely to have renal disease and history of heart failure. There were 1100 first CV events and an additional 666 recurrent events over a median of 18 months of follow-up. There were no significant differences with regard to total number of events in patients treated with alogliptin (n = 873) or placebo (n = 893; P = 0.52). Furthermore, there were no differences in the types of events seen in patients treated with alogliptin or placebo. Alogliptin did not increase the risk of either first or recurrent CV events when compared with placebo in patients with T2DM and recent acute coronary syndrome. These data support the CV safety of alogliptin in patients who are at increased risk of future CV events.
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Affiliation(s)
- Matthew A Cavender
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - William B White
- Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Yuyin Liu
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Joseph M Massaro
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | | | - Cyrus R Mehta
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Faiez Zannad
- Department of Medicine, INSERM 1143, Université de Lorraine, Nancy, France
| | - Simon Heller
- Department of Medicine, University of Sheffield and Sheffield Teaching Hospitals National Health Service Foundation Trust, Sheffield, United Kingdom
| | - William C Cushman
- Department of Medicine, Memphis Veterans Affairs Medical Center and University of Tennessee Health Science Center, Memphis, Tennessee
| | - Christopher P Cannon
- Baim Institute for Clinical Research, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Kosiborod M, Birkeland KI, Cavender MA, Fu AZ, Wilding JP, Khunti K, Holl RW, Norhammar A, Jørgensen ME, Wittbrodt ET, Thuresson M, Bodegård J, Hammar N, Fenici P. Rates of myocardial infarction and stroke in patients initiating treatment with SGLT2-inhibitors versus other glucose-lowering agents in real-world clinical practice: Results from the CVD-REAL study. Diabetes Obes Metab 2018; 20:1983-1987. [PMID: 29569378 PMCID: PMC6055705 DOI: 10.1111/dom.13299] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/09/2018] [Accepted: 03/19/2018] [Indexed: 12/13/2022]
Abstract
The multinational, observational CVD-REAL study recently showed that initiation of sodium-glucose co-transporter-2 inhibitors (SGLT-2i) was associated with significantly lower rates of death and heart failure vs other glucose-lowering drugs (oGLDs). This sub-analysis of the CVD-REAL study sought to determine the association between initiation of SGLT-2i vs oGLDs and rates of myocardial infarction (MI) and stroke. Medical records, claims and national registers from the USA, Sweden, Norway and Denmark were used to identify patients with T2D who newly initiated treatment with SGLT-2i (canagliflozin, dapagliflozin or empagliflozin) or oGLDs. A non-parsimonious propensity score was developed within each country to predict initiation of SGLT-2i, and patients were matched 1:1 in the treatment groups. Pooled hazard ratios (HRs) and 95% CIs were generated using Cox regression models. Overall, 205 160 patients were included. In the intent-to-treat analysis, over 188 551 and 188 678 person-years of follow-up (MI and stroke, respectively), there were 1077 MI and 968 stroke events. Initiation of SGLT-2i vs oGLD was associated with a modestly lower risk of MI and stroke (MI: HR, 0.85; 95%CI, 0.72-1.00; P = .05; Stroke: HR, 0.83; 95% CI, 0.71-0.97; P = .02). These findings complement the results of the cardiovascular outcomes trials, and offer additional reassurance with regard to the cardiovascular effects of SGLT-2i, specifically as it relates to ischaemic events.
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Affiliation(s)
- Mikhail Kosiborod
- Department of Cardiovascular Diseases, Saint Luke's Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMissouri
| | | | - Matthew A. Cavender
- Department of Medicine, University of North CarolinaChapel HillNorth Carolina
| | - Alex Z. Fu
- Georgetown University Medical CenterWashingtonDistrict of Columbia
| | - John P. Wilding
- Obesity and Endocrinology Research Group, University of LiverpoolLiverpoolUK
| | - Kamlesh Khunti
- Leicester Diabetes Centre, University of LeicesterLeicesterUK
| | - Reinhard W. Holl
- Institute of Epidemiology and Medical Biometry, University of UlmUlmGermany
| | - Anna Norhammar
- Karolinska InstitutetStockholmSweden
- Capio S:t Görans HospitalStockholmSweden
| | - Marit E. Jørgensen
- Steno Diabetes CenterCopenhagenDenmark
- National Institute of Public Health, Southern Denmark University, OdenseDenmark
| | - Eric T. Wittbrodt
- Health Economics and Outcomes Research, AstraZenecaWilmingtonDelaware
| | | | | | - Niklas Hammar
- Karolinska InstitutetStockholmSweden
- AstraZeneca R&DGothenburgSweden
| | - Peter Fenici
- Global Medicines Development, AstraZenecaCambridgeUK
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50
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Kosiborod M, Lam CS, Kohsaka S, Kim DJ, Karasik A, Shaw J, Tangri N, Goh SY, Thuresson M, Chen H, Surmont F, Hammar N, Fenici P, Kosiborod M, Cavender MA, Fu AZ, Wilding JP, Khunti K, Norhammar A, Birkeland K, Jørgensen ME, Holl RW, Lam CSP, Gulseth HL, Carstensen B, Bollow E, Franch-Nadal J, García Rodríguez LA, Karasik A, Tangri N, Kohsaka S, Kim DJ, Shaw J, Arnold S, Goh SY, Hammar N, Fenici P, Bodegård J, Chen H, Surmont F, Nahrebne K, Blak BT, Wittbrodt ET, Saathoff M, Noguchi Y, Tan D, Williams M, Lee HW, Greenbloom M, Kaidanovich-Beilin O, Yeo KK, Bee YM, Khoo J, Koong A, Lau YH, Gao F, Tan WB, Kadir HA, Ha KH, Lee J, Chodick G, Melzer Cohen C, Whitlock R, Cea Soriano L, Fernándex Cantero O, Riehle E, Ilomaki J, Magliano D. Cardiovascular Events Associated With SGLT-2 Inhibitors Versus Other Glucose-Lowering Drugs. J Am Coll Cardiol 2018. [DOI: 10.1016/j.jacc.2018.03.009] [Citation(s) in RCA: 238] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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