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Dorothee S, Sørensen G, Olsen LR, Bastlund JF, Sotty F, Belling D, Olsen MH, Mathiesen TI, Møller K, Larsen F, Birkeland P. Negligible In Vitro Recovery of Macromolecules from Microdialysis Using 100 kDa Probes and Dextran in Perfusion Fluid. Neurochem Res 2024; 49:1322-1330. [PMID: 38478218 PMCID: PMC10991005 DOI: 10.1007/s11064-024-04119-7] [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] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 04/04/2024]
Abstract
Microdialysis is applied in neurointensive care to monitor cerebral glucose metabolism. If recoverable, macromolecules may also serve as biomarkers in brain disease and provide clues to their passage across the blood-brain barrier. Our study aimed to investigate the in vitro recovery of human micro- and macromolecules using microdialysis catheters and perfusion fluids approved for clinical use. In vitro microdialysis of a bulk solution containing physiological or supraphysiological concentrations of glucose, lactate, pyruvate, human IgG, serum albumin, and hemoglobin was performed using two different catheters and perfusion fluids. One had a membrane cut-off of 20 kDa and was used with a standard CNS perfusion fluid, and the other had a membrane cut-off of 100 kDa and was perfused with the same solution supplemented with dextran. The flow rate was 0.3 µl/min. We used both push and push-pull methods. Dialysate samples were collected at 2-h intervals for 6 h and analyzed for relative recovery of each substance. The mean relative recovery of glucose, pyruvate, and lactate was > 90% in all but two sets of experiments. In contrast, the relative recovery of human IgG, serum albumin, and hemoglobin from both bulk solutions was below the lower limit of quantification (LLOQ). Using a push-pull method, recovery of human IgG, serum albumin, and hemoglobin from a bulk solution with supraphysiological concentrations were above LLOQ but with low relative recovery (range 0.9%-1.6%). In summary, exchanging the microdialysis setup from a 20 kDa catheter with a standard perfusion fluid for a 100 kDa catheter with a perfusion solution containing dextran did not affect the relative recovery of glucose and its metabolites. However, it did not result in any useful recovery of the investigated macromolecules at physiological levels, either with or without a push-pull pump system.
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Affiliation(s)
- Spille Dorothee
- Department of Neurosurgery, University Hospital Münster, Münster, Germany
| | - G Sørensen
- H. Lundbeck A/S, Ottiliavej 9, 2500, Copenhagen, Denmark
| | - L R Olsen
- H. Lundbeck A/S, Ottiliavej 9, 2500, Copenhagen, Denmark
| | - J F Bastlund
- H. Lundbeck A/S, Ottiliavej 9, 2500, Copenhagen, Denmark
| | - F Sotty
- H. Lundbeck A/S, Ottiliavej 9, 2500, Copenhagen, Denmark
| | - D Belling
- H. Lundbeck A/S, Ottiliavej 9, 2500, Copenhagen, Denmark
| | - M H Olsen
- Department of Clinical Medicine, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - T I Mathiesen
- Department of Neurosurgery, Rigshospitalet, Inge Lehmannsvej 6, 2100, Copenhagen Ø, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3, Copenhagen, Denmark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - K Møller
- Department of Clinical Medicine, Blegdamsvej 3, 2200, Copenhagen N, Denmark
| | - F Larsen
- H. Lundbeck A/S, Ottiliavej 9, 2500, Copenhagen, Denmark
| | - P Birkeland
- Department of Neurosurgery, Rigshospitalet, Inge Lehmannsvej 6, 2100, Copenhagen Ø, Denmark.
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Olesen TB, Glintborg D, Jøhnk F, Olsen MH, Andersen MS. Blood pressure responses to testosterone therapy are amplified by hematocrit levels in opioid-induced androgen deficiency: a double-blind, randomized, placebo-controlled trial. J Hypertens 2024; 42:893-901. [PMID: 38088425 DOI: 10.1097/hjh.0000000000003638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Our study aimed to examine the effect of testosterone replacement therapy (TRT) on blood pressure in opioid-treated men with relative hypogonadism, and whether the effect of TRT on blood pressure was modified by body composition, red blood cell levels, or carotid intima media thickness. Men (over 18 years old) receiving opioid treatment and total testosterone less than 12 nmol were randomly assigned to receive either TRT or placebo. Baseline and 6-month measurements included anthropometric measurements, office blood pressure (OBPM), 24-h ambulatory blood pressure, blood samples, and carotid ultrasound. The mean systolic OBPM increased by 6.2 mmHg (0.2-12.1) in the TRT group and decreased by 7.0 mmHg (1.0-15.1) in the placebo group, with a mean difference of 13.2 mmHg (3.4-23.1), P = 0.01. In the TRT group, a 10 mmHg increase in systolic OBPM was associated with an increase in hematocrit of 0.3% points (0.1-0.5) ( P = 0.01), whereas no association was observed in the placebo group ( P = 0.266). Daytime SBP showed a nonsignificant increase of 5.2 mmHg (-1.7, 12.1) ( P = 0.134) in the TRT group compared to that in the placebo group. However, the impact of TRT on the increase in daytime ambulatory blood pressure was significantly accentuated by baseline values of BMI, hematocrit, and hemoglobin. In conclusion, TRT was associated with higher OBPM compared to placebo, and the increase in blood pressure was linked to higher hematocrit during TRT. Our data suggest that men with opioid-induced androgen deficiency, particularly those with obesity or red blood cell levels in the upper normal range, are more susceptible to increased daytime SBP during TRT.
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Affiliation(s)
| | - Dorte Glintborg
- Department of Endocrinology, Odense University Hospital, Odense
| | - Frederik Jøhnk
- Department of Internal Medicine, Sygehus Lillebaelt, Kolding
| | - Michael Hecht Olsen
- Department of Internal Medicine, Cardiology Section, Holbaek Hospital, Holbaek, Denmark
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Musimbaggo DJ, Kimera ID, Namugenyi C, Schwartz JI, Ssenyonjo R, Ambangira F, Kizza L, Mbuliro M, Katwesigye R, Ssinabulya I, Muddu M, Neupane D, Olsen MH, Pareek M, Semitala FC. Factors associated with blood pressure control in patients with hypertension and HIV at a large urban HIV clinic in Uganda. J Hum Hypertens 2024; 38:345-351. [PMID: 36476778 PMCID: PMC11001571 DOI: 10.1038/s41371-022-00786-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/20/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
Globally, people living with HIV on antiretroviral therapy have an increased risk of cardiovascular disease. Hypertension is the most important preventable risk factor for cardiovascular disease and is associated with increased morbidity. We conducted an exploratory survey with hypertensive persons living with HIV who received integrated HIV and hypertension care in a large clinic in Uganda between August 2019 and March 2020 to determine factors associated with blood pressure control at six months. Controlled blood pressure was defined as <140/90 mmHg. Multivariable logistic regression was used to determine baseline factors associated with blood pressure control after 6 months of antihypertensive treatment. Of the 1061 participants, 644 (62.6%) were female. The mean age (SD) was 51.1 (9.4) years. Most participants were overweight (n = 411, 38.7%) or obese (n = 276, 25.9%), and 98 (8.9%) had diabetes mellitus. Blood pressure control improved from 14.4% at baseline to 66.1% at 6 months. Comorbid diabetes mellitus (odds ratio (OR) = 0.41, 95% confidence interval (CI) = 0.26-0.64, p < 0.001) and HIV status disclosure (OR = 0.73, 95% CI = 0.55-0.98, p = 0.037) were associated with the absence of controlled blood pressure at 6 months. In conclusion, comorbid diabetes mellitus and the disclosure of an individual's HIV status to a close person were associated with poor blood pressure control among persons living with HIV who had hypertension. Therefore, subpopulations of persons living with HIV with hypertension and comorbid diabetes mellitus may require more thorough assessments and intensive antihypertensive management approaches to achieve blood pressure targets.
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Affiliation(s)
| | | | | | - Jeremy I Schwartz
- Department of Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | | | | | - Lubega Kizza
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Mary Mbuliro
- Makerere University Joint AIDS Program, Kampala, Uganda
| | | | - Isaac Ssinabulya
- Department of Medicine, Makerere University College of Health Science, Kampala, Uganda
- Uganda Heart Institute, Kampala, Uganda
| | - Martin Muddu
- Makerere University Joint AIDS Program, Kampala, Uganda
| | - Dinesh Neupane
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael Hecht Olsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Cardiology Section, Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
| | - Manan Pareek
- Department of Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Fred C Semitala
- Makerere University Joint AIDS Program, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Science, Kampala, Uganda
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Neupane D, Hall B, Mukhtar Q, Delles C, Sharman JE, Cobb LK, Lackland DT, Moran AE, Weber MA, Olsen MH. Emerging Authors Program for Global Cardiovascular Disease Research-A collaboration of the U.S. Centers for Disease Control and Prevention, the Lancet Commission on Hypertension Group, Resolve to Save Lives, and the World Hypertension League. J Hum Hypertens 2024; 38:293-294. [PMID: 35322180 PMCID: PMC8942057 DOI: 10.1038/s41371-022-00678-w] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/23/2022] [Accepted: 03/09/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Dinesh Neupane
- Lancet Commission on Hypertension Group, London, UK.
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Bethany Hall
- Centers for Disease Control and Prevention, Atlanta, GA, USA
- CDC Foundation, Atlanta, GA, USA
| | - Qaiser Mukhtar
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christian Delles
- Lancet Commission on Hypertension Group, London, UK
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | - James E Sharman
- Lancet Commission on Hypertension Group, London, UK
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | | | - Daniel T Lackland
- World Hypertension League, Charleston, SC, USA
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Michael A Weber
- World Hypertension League, Charleston, SC, USA
- State University of New York, New York, NY, USA
| | - Michael Hecht Olsen
- Lancet Commission on Hypertension Group, London, UK
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Frary CE, Blicher MK, Olesen TB, Pareek M, Vishram-Nielsen JKK, Rasmussen S, Olsen MH. N-Terminal Pro-Brain Type Natriuretic Peptide Predicts Cardiovascular Events Independently of Arterial Stiffness, Assessed By Carotid-to-Femoral Pulse Wave Velocity, in Apparently Healthy Subjects. Heart Lung Circ 2024; 33:392-400. [PMID: 38290952 DOI: 10.1016/j.hlc.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 11/07/2023] [Accepted: 11/19/2023] [Indexed: 02/01/2024]
Abstract
AIM This study aimed to evaluate whether N-terminal pro-brain natriuretic peptide (NT-proBNP) and carotid-to-femoral pulse wave velocity (PWV) carried independent prognostic value in predicting cardiovascular events in apparently healthy individuals beyond traditional risk factors. METHODS A total of 1,872 participants aged 41, 51, 61, or 71 years from the MONItoring of trends and determinants in CArdiovascular disease (MONICA) study were included. Traditional risk factors were assessed, including: smoking status; mean systolic and diastolic blood pressure; body mass index; fasting plasma glucose; serum triglycerides; total, high-density, and low-density lipoprotein cholesterol; NT-proBNP; and PWV. The principal endpoint that was assessed during 16 years of follow-up was a composite of major adverse cardiovascular events (MACE). The secondary endpoints were cardiovascular mortality (CVM), hospitalisation for coronary artery disease (CAD), and a composite of hospitalisation for heart failure (HF) or atrial fibrillation (AF). RESULTS At baseline, NT-proBNP was associated with PWV (β=0.14; p<0.001), but not after adjustment for traditional risk factors (β=-0.01; p=0.67). In models including traditional risk factors and PWV, NT-proBNP was associated with all four outcomes (HRMACE=1.33, 95% CI 1.16-1.52; HRCVM=2.02, 95% CI 1.65-2.48; HRCAD=1.29, 95% CI 1.07-1.55; and HRHF or AF=1.79, 95% CI 1.40-2.28). In the same model, PWV was only associated with CVM (HRCVM=1.20, 95% CI 1.01-1.41). No interactions between NT-proBNP and PWV were found. N-terminal pro-brain natriuretic peptide significantly improved net reclassification (NRI) for MACE (NRI=0.12; p=0.03), CVM (NRI=0.33; p<0.001), and HF or AF (NRI=0.33; p<0.001) beyond traditional risk factors, while PWV did not aid in net reclassification improvement for any endpoint. CONCLUSIONS In apparently healthy individuals, NT-proBNP and PWV predicted cardiovascular events independently. N-terminal pro-brain natriuretic peptide improved reclassification for the prediction of MACE, CVM, and hospitalisation for HF or AF beyond traditional risk factors, while PWV did not.
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Affiliation(s)
- Charles Edward Frary
- Cardiology Section, Department of Internal Medicine 1, Holbaek Hospital, Holbaek, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Manan Pareek
- Center for Translational Cardiology and Pragmatic Randomized Trials, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark; Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Julie K K Vishram-Nielsen
- Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark, Copenhagen, Denmark
| | - Susanne Rasmussen
- Department of Clinical Physiology and Nuclear Medicine, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Michael Hecht Olsen
- Cardiology Section, Department of Internal Medicine 1, Holbaek Hospital, Holbaek, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
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Rijal A, Adhikari TB, Dhakal S, Maagaard M, Piri R, Nielsen EE, Neupane D, Jakobsen JC, Olsen MH. Effect of exercise on functional capacity and body weight for people with hypertension, type 2 diabetes, or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis. BMC Sports Sci Med Rehabil 2024; 16:38. [PMID: 38321506 PMCID: PMC10848448 DOI: 10.1186/s13102-024-00829-1] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/28/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Hypertension, type 2 diabetes, and cardiovascular disease affect the activities of daily living at varying degree. While the effects of aerobic exercise on functional capacity are well-documented, the extent of change for different types of exercise in these chronic conditions remains unexplored. Additionally, there is conflicting evidence regarding the role of exercise in reducing body weight. METHODS We conducted systematic review with meta-analysis and trial sequential analysis and searched various databases from inception to July 2020. We included randomised clinical trials adding any form of trialist defined exercise to usual care versus usual care in people with either hypertension, type 2 diabetes, and/or cardiovascular disease irrespective of setting, publication status, year, and language. The outcomes assessed were i) functional capacity assessed through different scales separately i.e., Maximal Oxygen Uptake (VO2max), 6-min walk test (6MWT), 10-m walk test (10MWT), and ii) body weight. RESULTS We included 950 studies out of which 444 trials randomising 20,098 participants reported on various functional outcomes (355 trials) and body weight (169 trials). The median follow-up was 3 months (Interquartile ranges (IQR): 2.25 to 6). Exercise added to the usual care, improved VO2max (Mean Difference (MD):2.72 ml/kg/min; 95% Confidence Interval (CI) 2.38 to 3.06; p < 0.01; I2 = 96%), 6MWT (MD: 42.5 m; 95%CI 34.95 to 50.06; p < 0.01; I2 = 96%), and 10MWT (MD: 0.06 m/s; 95%CI 0.03 to 0.10; p < 0.01; I2 = 93%). Dynamic aerobic and resistance exercise showed a consistent improvement across various functional outcomes, whereas body-mind therapies (MD: 3.23 ml/kg/min; 95%CI 1.97 to 4.49, p < 0.01) seemed especially beneficial for VO2max and inspiratory muscle training (MD: 59.32 m; 95%CI 33.84 to 84.80; p < 0.01) for 6MWT. Exercise yielded significant reduction in body weight for people with hypertension (MD: -1.45 kg; 95%CI -2.47 to -0.43; p < 0.01), and type 2 diabetes (MD: -1.53 kg; 95%CI -2.19 to -0.87; p < 0.01) but not for cardiovascular disease with most pronounced for combined exercise (MD: -1.73 kg; 95%CI -3.08 to -0.39; p < 0.05). The very low certainty of evidence warrants cautious interpretations of the results. CONCLUSION Exercise seemed to improve functional capacity for people with hypertension, type 2 diabetes, and/or cardiovascular disease but the effectiveness seems to vary with different forms of exercise. The potentially superior improvement in VO2max and 6MWT by body-mind therapies and inspiratory muscle training calls for further exploration. Additionally, prescribing exercise for the sole purpose of losing weight may be a potential strategy for people with hypertension and type 2 diabetes. The extent of improvement in functional capacity and body weight reduction differed with different exercise regimens hence personalised exercise prescriptions tailored to individual needs may be of importance. PROSPERO REGISTRATION: PROSPERO registration number: CRD42019142313.
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Affiliation(s)
- Anupa Rijal
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark.
| | - Tara Ballav Adhikari
- Department of Public Health, Research Unit for Environment, Occupation & Health, Aarhus University, Aarhus, Denmark
| | - Sarmila Dhakal
- Center for Research on Environment, Health and Population Activities (CREPHA), Kusunti, Lalitpur, Nepal
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koge, Denmark
| | - Reza Piri
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Emil Eik Nielsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Dinesh Neupane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University Baltimore, Maryland, USA
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Michael Hecht Olsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
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Desson Z, Sharman JE, Searles A, Schutte AE, Delles C, Olsen MH, Ordunez P, Hure A, Morton R, Figtree G, Webster J, Jennings G, Redfern J, Nicholls SJ, McNamara M, Deeming S, Doyle K, Ramanathan S. Improving the accuracy of blood pressure measuring devices in Australia: a modelled return on investment study. J Hum Hypertens 2024; 38:177-186. [PMID: 37938294 PMCID: PMC10844083 DOI: 10.1038/s41371-023-00866-2] [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] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 04/20/2023] [Accepted: 07/10/2023] [Indexed: 11/09/2023]
Abstract
The VALID BP project was initiated to increase the availability of validated blood pressure measuring devices (BPMDs). The goal is to eliminate non validated BPMDs and minimise over- and underdiagnosis of hypertension caused by inaccurate readings. This study was undertaken to assess the potential return on investment in the VALID BP project. The Framework to Assess the Impact of Translational Health Research was applied to the VALID BP project. This paper focuses on the implementation of the cost benefit analysis aspect of this framework to monetise past research investment and model future research costs, implementation costs, and benefits. Analysis was based on reasoned assumptions about potential impacts from availability and use of validated BPMDs (assuming an end goal of 100% validated BPMDs available in Australia by 2028) and improved skills leading to more accurate BP measurement. After 5 years, with 20% attribution of benefits, there is a potential $1.14-$1.30 return for every dollar spent if the proportion of validated BPMDs and staff trained in proper BP measurement technique increased from 20% to 60%. After eight years (2020-2028) and assuming universal validation and training coverage, the returns would be between $2.70 and $3.20 per dollar spent (not including cost of side effects of unnecessary medication or downstream patient impacts from unmanaged hypertension). This modelled economic analysis indicates there will be positive downstream economic benefits if the availability of validated BPMDs is increased. The findings support ongoing efforts toward a universal regulatory framework for BPMDs and can be considered within more detailed future economic analyses.
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Affiliation(s)
- Zachary Desson
- Health Research Economics, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Andrew Searles
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Aletta E Schutte
- School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Pedro Ordunez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Alexis Hure
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Rachael Morton
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Gemma Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Australian Cardiovascular Alliance, Chittaway Bay, NSW, Australia
| | - Jacqui Webster
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Garry Jennings
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Australian Cardiovascular Alliance, Chittaway Bay, NSW, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Julie Redfern
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
| | | | | | - Simon Deeming
- Health Research Economics, Hunter Medical Research Institute, Newcastle, NSW, Australia
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Kerry Doyle
- Australian Cardiovascular Alliance, Chittaway Bay, NSW, Australia
| | - Shanthi Ramanathan
- Health Research Economics, Hunter Medical Research Institute, Newcastle, NSW, Australia.
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia.
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Pontoppidan JRN, Nielsen EE, Olsen MH, Skjødt MK, Christensen JO, Raymond IE, Møller SH, Soja AMB, Gæde PH. A multidisciplinary, shared care clinic using personalized medicine and coordinated care in patients with concomitant type 2 diabetes and cardiovascular disease. Protocol and baseline characteristics. Prev Med Rep 2024; 38:102594. [PMID: 38283962 PMCID: PMC10821603 DOI: 10.1016/j.pmedr.2024.102594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/03/2024] [Accepted: 01/03/2024] [Indexed: 01/30/2024] Open
Abstract
Background Concomitant type 2 diabetes (T2DM) and cardiovascular disease (CVD) is frequent with a poor prognosis with high risk of comorbidities. Strict risk factor control reduces the risk for complications - yet many people do not achieve treatment targets. The complexity and fragmentation of the healthcare system may, together with the vulnerability of these patients, be a reason. Objective The purpose of this paper is to describe the protocol of a non-randomized interventional pilot study testing the feasibility and effect of a multidisciplinary, shared care clinic using personalized medicine and coordinated care in people living with concomitant T2D and CVD. Methods Participants were included from the Holbaek area in Denmark. People suffered from T2DM and CVD and were dysregulated regarding to HbA1c, cholesterol, micro/macroalbuminuaria or blood pressure. Participants went through a thorough evaluation to identify their needs and resources and received consultations every three months for one year. Results A total of 63 participants with T2DM and CVD were enrolled in the clinic. The participants had a mean age of 69 years and a BMI of 30.9 kg/m2. Almost 50 % had heart failure, 95 % dyslipidemia and 91 % hypertension. Around 54 % received GLP-1 agonists and 39 % received SGLT-2-inhibitors. Perspectives To our knowledge, a similar study with a multidisciplinary, shared care, outpatient clinic treating people living with concomitant T2DM and CVD, has not been performed previously. This study will provide information about the feasibility and efficacy of a multidisciplinary clinic based on changes in cardiovascular risk factors and medication.
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Affiliation(s)
- Julie Rye Noer Pontoppidan
- Department of Internal Medicine, Cardiology Section, Holbæk Sygehus, Denmark
- Department of Endocrinology and Cardiology, Slagelse Sygehus, Denmark
| | - Emil Eik Nielsen
- Department of Internal Medicine, Cardiology Section, Holbæk Sygehus, Denmark
| | - Michael Hecht Olsen
- Department of Internal Medicine, Cardiology Section, Holbæk Sygehus, Denmark
| | - Michael Kriegbaum Skjødt
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Denmark
- Department Internal Medicine, Holbæk Sygehus, Denmark
| | | | | | - Sara Hedlund Møller
- Department of Internal Medicine, Cardiology Section, Holbæk Sygehus, Denmark
| | | | - Peter Haulund Gæde
- Department of Endocrinology and Cardiology, Slagelse Sygehus, Denmark
- University of Southern Denmark, Institute for Regional Health, Denmark
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Rijal A, Adhikari TB, Dhakal S, Maagaard M, Piri R, Nielsen EE, Neupane D, Jakobsen JC, Olsen MH. Effects of adding exercise to usual care on blood pressure in patients with hypertension, type 2 diabetes, or cardiovascular disease: a systematic review with meta-analysis and trial sequential analysis. J Hypertens 2024; 42:10-22. [PMID: 37796224 DOI: 10.1097/hjh.0000000000003589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Exercise is the most recommended lifestyle intervention in managing hypertension, type 2 diabetes, and/or cardiovascular disease; however, evidence in lowering blood pressure is still inconsistent and often underpowered. METHOD We conducted a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials adding any form of trialist defined exercise to usual care versus usual care and its effect on systolic blood pressure (SBP) or diastolic blood pressure (DBP) in participants with hypertension, type 2 diabetes, or cardiovascular disease searched in different databases from inception to July 2020. Our methodology was based on PRISMA and Cochrane Risk of Bias-version1. Five independent reviewers extracted data and assessed risk of bias in pairs. RESULTS Two hundred sixty-nine trials randomizing 15 023 participants reported our predefined outcomes. The majority of exercise reported in the review was dynamic aerobic exercise (61%), dynamic resistance (11%), and combined aerobic and resistance exercise (15%). The trials included participants with hypertension (33%), type 2 diabetes (28%), or cardiovascular disease (37%). Meta-analyses and trial sequential analyses reported that adding exercise to usual care reduced SBP [mean difference (MD) MD: -4.1 mmHg; 95% confidence interval (95% CI) -4.99 to -3.14; P < 0.01; I2 = 95.3%] and DBP (MD: -2.6 mmHg; 95% CI -3.22 to -2.07, P < 0.01; I2 = 94%). Test of interaction showed that the reduction of SBP and DBP was almost two times higher among trials from low-and middle-income countries (LMICs) as compared to high-income countries (HICs). The exercise induced SBP reduction was also higher among participants with hypertension and type 2 diabetes compared to participants with cardiovascular disease. The very low certainty of evidence warrants a cautious interpretation of the present results. CONCLUSION Adding any type of exercise to usual care may be a potential complementary strategy for optimal management of blood pressure for patients with hypertension, type 2 diabetes, or cardiovascular disease, especially, in LMICs.PROSPERO registration number CRD42019142313.
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Affiliation(s)
- Anupa Rijal
- Department of Internal Medicine, Holbaek Hospital, Holbaek
- Department of Regional Health Research, University of Southern Denmark
| | - Tara Ballav Adhikari
- Department of Public Health, Research Unit for Environment, Occupation and Health, Aarhus University, Aarhus, Denmark
| | - Sarmila Dhakal
- Center for Research on Environment, Health and Population Activities (CREPHA), Kusunti, Lalitpur, Nepal
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Koge
| | - Reza Piri
- Department of Clinical Research, University of Southern Denmark
- Department of Nuclear Medicine, Odense University Hospital
- Department of Cardiology, Odense University Hospital, Odense Denmark
| | - Emil Eik Nielsen
- Department of Regional Health Research, University of Southern Denmark
- Department of Cardiology, Odense University Hospital, Odense Denmark
| | - Dinesh Neupane
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University Baltimore, Mayland, USA
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital- Rigshospitalet, Copenhagen, Denmark
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital, Holbaek
- Department of Regional Health Research, University of Southern Denmark
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10
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Kristensen AMD, Munkhaugen J, Halvorsen S, Olsen MH, Bakken A, Sehested TSG, Ruddox V, Lange T, Fagerland MW, Torp-Pedersen C, Prescott E, Atar D. The Danish-Norwegian randomized trial on beta-blocker therapy after myocardial infarction: Design, rationale, and baseline characteristics. Eur Heart J Cardiovasc Pharmacother 2023:pvad093. [PMID: 38017624 DOI: 10.1093/ehjcvp/pvad093] [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] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
AIM The evidence for beta-blocker therapy after myocardial infarction (MI) is randomized trials conducted more than 30 years ago, and the continued efficacy has been questioned. DESIGN AND METHODS The ongoing Danish (DANBLOCK) and Norwegian (BETAMI) randomized beta-blocker trials are joined to evaluate the effectiveness and risks of long-term beta-blocker therapy after MI. Patients with normal or mildly reduced left ventricular ejection fraction (LVEF≥40%) will be randomized to open-label treatment with beta-blockers or no such therapy. This event-driven trial will randomize ∼5700 patients and continue until 950 primary endpoints have occurred. As of July 2023, 5228 patients have been randomized. Of the first 4000 patients randomized, median age was 62 years, 79% were men, 48% had a STEMI, and 84% had a normal LVEF. The primary endpoint is a composite of adjudicated recurrent MI, incident heart failure, coronary revascularization, ischemic stroke, all-cause mortality, malignant ventricular arrhythmia, or resuscitated cardiac arrest. The primary safety endpoint includes a composite of recurrent MI, heart failure, all-cause mortality, malignant ventricular arrhythmia, or resuscitated cardiac arrest 30 days after randomization. Secondary endpoints include each of the components of the primary endpoint, patient-reported outcomes, and other clinical outcomes linked to beta-blocker therapy. The primary analysis will be conducted according to the intention-to-treat principle using a Cox proportional hazards regression model. End of follow-up is expected in December 2024. CONCLUSION The combined BETAMI-DANBLOCK trial will have the potential to affect current clinical practice for beta-blocker therapy in patients with normal or mildly reduced LVEF after MI.
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Affiliation(s)
- Anna Meta Dyrvig Kristensen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - John Munkhaugen
- Department of Medicine, Drammen Hospital, Vestre Viken Trust, Drammen, Norway, Institute of Behavioural Medicine, University of Oslo
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, and University of Oslo, Norway
| | - Michael Hecht Olsen
- Department of Regional Health Research, University of Southern Denmark, and Department of Internal Medicine 1, Holbæk Hospital, Holbæk, Denmark
| | - Arnhild Bakken
- Department of Cardiology, Oslo University Hospital Ulleval, and University of Oslo, Norway
| | | | - Vidar Ruddox
- Department of Cardiology, Vestfold Hospital Trust, Tonsberg, Norway
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Morten Wang Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital - North Zealand Hospital, Hillerød, Denmark
| | - Eva Prescott
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, and University of Oslo, Norway
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11
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Kristensen FPB, Christensen DH, Callaghan BC, Stidsen JV, Nielsen JS, Højlund K, Beck-Nielsen H, Jensen TS, Andersen H, Vestergaard P, Jessen N, Olsen MH, Hansen T, Brøns C, Vaag A, Sørensen HT, Thomsen RW. The Prevalence of Polyneuropathy in Type 2 Diabetes Subgroups Based on HOMA2 Indices of β-Cell Function and Insulin Sensitivity. Diabetes Care 2023:dc230079. [PMID: 37335990 DOI: 10.2337/dc23-0079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 05/26/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE Metabolic syndrome components may cumulatively increase the risk of diabetic polyneuropathy (DPN) in type 2 diabetes mellitus (T2DM) patients, driven by insulin resistance and hyperinsulinemia. We investigated the prevalence of DPN in three T2DM subgroups based on indices of β-cell function and insulin sensitivity. RESEARCH DESIGN AND METHODS We estimated β-cell function (HOMA2-B) and insulin sensitivity (HOMA2-S) in 4,388 Danish patients with newly diagnosed T2DM. Patients were categorized into subgroups of hyperinsulinemic (high HOMA2-B, low HOMA2-S), classical (low HOMA2-B, low HOMA2-S), and insulinopenic (low HOMA2-B, high HOMA2-S) T2DM. After a median follow-up of 3 years, patients filled the Michigan Neuropathy Screening Instrument questionnaire (MNSIq) to identify DPN (score ≥ 4). We used Poisson regression to calculate adjusted prevalence ratios (PRs) for DPN, and spline models to examine the association with HOMA2-B and HOMA2-S. RESULTS A total of 3,397 (77%) patients filled in the MNSIq. The prevalence of DPN was 23% among hyperinsulinemic, 16% among classical, and 14% among insulinopenic patients. After adjusting for demographics, diabetes duration and therapy, lifestyle behaviors, and metabolic syndrome components (waist circumference, triglycerides, HDL cholesterol, hypertension, and HbA1c), the PR of DPN was 1.35 (95% CI 1.15-1.57) for the hyperinsulinemic compared with the classical patients. In spline analyses, we observed a linear relation of higher DPN prevalence with increasing HOMA2-B, independent of both metabolic syndrome components and HOMA2-S. CONCLUSIONS Hyperinsulinemia marked by high HOMA2-B is likely an important risk factor for DPN beyond metabolic syndrome components and insulin resistance. This should be considered when developing interventions to prevent DPN.
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Affiliation(s)
| | - Diana Hedevang Christensen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Jens Steen Nielsen
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kurt Højlund
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Vestergaard
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
| | - Niels Jessen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Hecht Olsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Department of Internal Medicine and Steno Diabetes Center Zealand, Holbæk Hospital, Holbæk, Denmark
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Brøns
- Charlotte Brøns, Steno Diabetes Center Copenhagen, Region Hovedstaden, Herlev, Denmark
| | - Allan Vaag
- Charlotte Brøns, Steno Diabetes Center Copenhagen, Region Hovedstaden, Herlev, Denmark
- Allan Vaag, Steno Diabetes Center Copenhagen, Region Hovedstaden, Herlev, Denmark + Lund University Diabetes Center, Lund University, Malmö, Sweden
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Reimar Wernich Thomsen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
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12
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Cold IM, Feinberg JB, Brandes A, Davidsen U, Dixen U, Dominguez H, Gang UJO, Gluud C, Hadad R, Kristensen KE, van Le DT, Nielsen EE, Olsen MH, Pedersen OD, Raymond IE, Sajadieh A, Soja AMB, Jakobsen JC. Lenient rate control versus strict rate control for atrial fibrillation: a statistical analysis plan for the Danish Atrial Fibrillation (DanAF) randomized clinical trial. Trials 2023; 24:250. [PMID: 37005636 PMCID: PMC10068144 DOI: 10.1186/s13063-023-07247-7] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/13/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND A key decision in the treatment of atrial fibrillation is choosing between a rhythm control strategy or a rate control strategy as the main strategy. When choosing rate control, the optimal heart rate target is uncertain. The Danish Atrial Fibrillation trial is a randomized, multicenter, two-group, superiority trial comparing strict rate control versus lenient rate control in patients with either persistent or permanent atrial fibrillation at inclusion. To prevent bias arising from selective reporting and data-driven analyses, we developed a predefined description of the statistical analysis. METHODS The primary outcome of this trial is the physical component score of the SF-36 questionnaire. A total of 350 participants will be enrolled based on a minimal important difference of 3 points on the physical component score of the SF-36 questionnaire, a standard deviation of 10 points, a statistical power of 80% (beta of 20%), and an acceptable risk of type I error of 5%. All secondary, exploratory, and echocardiographic outcomes will be hypothesis-generating. The analyses of all outcomes will be based on the intention-to-treat principle. We will analyze continuous outcomes using linear regression adjusting for "site," type of atrial fibrillation at inclusion (persistent/ permanent), left ventricular ejection fraction (≥ 40% or < 40%), and the baseline value of the outcome (all as fixed effects). We define our threshold for statistical significance as a p-value of 0.05 and assessments of clinical significance will be based on the anticipated intervention effects defined in the sample size and power estimations. Thresholds for both statistical and clinical significance will be assessed according to the 5-step procedure proposed by Jakobsen and colleagues. DISCUSSION This statistical analysis plan will be published prior to enrolment completion and before any data are available and is sought to increase the validity of the DANish Atrial Fibrillation trial. TRIAL REGISTRATION Clinicaltrials.gov NCT04542785. Registered on Sept 09, 2020.
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Affiliation(s)
- Isak Mazanti Cold
- The Faculty of Health and Medical Sciences, The University of Copenhagen, Copenhagen, Denmark.
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark.
| | - Joshua Buron Feinberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense C, Denmark
- Department of Cardiology, Esbjerg Hospital - University Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ulla Davidsen
- Department of Cardiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Capital Region of Denmark, Denmark
| | - Ulrik Dixen
- Department of Cardiology, University Hospital Amager and Hvidovre, Copenhagen, Denmark
| | - Helena Dominguez
- Department of Cardiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Capital Region of Denmark, Denmark
- Department of Biomedicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Uffe Jakob Ortved Gang
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Rakin Hadad
- Department of Cardiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Capital Region of Denmark, Denmark
| | | | - Doan Tuyet van Le
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Emil Eik Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Michael Hecht Olsen
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Ole Dyg Pedersen
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Ilan Esra Raymond
- Department of Cardiology, University Hospital Amager and Hvidovre, Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Capital Region of Denmark, Denmark
| | - Anne Merete Boas Soja
- Department of Internal Medicine - Section of Cardiology, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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13
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Baumann M, Poulsen MM, Mortensen OS, Olsen MH, Korshøj M. How Does Occupational Lifting Affect Ambulatory Blood Pressure, Relative Aerobic Workload and Level of Physical Activity? Ann Work Expo Health 2023:7076304. [PMID: 36905640 DOI: 10.1093/annweh/wxad009] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/16/2023] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION Occupational physical activity (OPA), including occupational lifting (OL), seems to increase the risk of cardiovascular disease (CVD). Knowledge about the association between OL and risk of CVD is sparse, but repeated OL is assumed to result in prolonged raised blood pressure and heart rate (HR) eventually augmenting the risk of CVD. To disentangle parts of the mechanisms behind the raised 24-hour ambulatory blood pressure measurement (24h-ABPM), by exposure to OL, this study aimed to explore the acute differences in 24h-ABPM, relative aerobic workload (RAW) and OPA across workdays with and without OL, and secondary to assess the feasibility and rater agreement of direct field observations of the frequency and load of occupational lifting. METHODS This controlled cross-over study investigates associations between moderate to high OL and 24h-ABPM, RAW in per cent of heart rate reserve (%HRR) and level of OPA. This included 2x24h monitoring of 24h-ABPM (Spacelabs 90217), PA (Axivity) and HR (Actiheart), comprising a workday containing OL and a workday without. The frequency and burden of OL were directly observed in field. The data were time synchronized and processed in the Acti4 software. Differences across workdays with and without OL in 24h-ABPM, RAW and OPA were evaluated using repeated 2 × 2 mixed-models among 60 blue-collar workers in Denmark.. Exposure to OL was estimated by direct manual field observation, registering burden and frequency of OL. Interrater reliability tests were performed across 15 participants representing 7 occupational groups. Interclass correlation coefficient (ICC) estimates of total burden lifted and frequency of lifts were calculated, based on a mean-rating (k = 2), absolute-agreement, 2 way mixed-effects model, indicating the raters as fixed effects. RESULTS OL led to non-significant increases in ABPM during work-time (systolic Δ1.79 mmHg, 95%CI -4.49-8.08, diastolic Δ0.43 mmHg, 95%CI -0.80-1.65), and on 24-hours basis (systolic Δ1.96 mmHg, 95%CI -3.80-7.72, diastolic Δ0.53 mmHg, 95%CI -3.12-4.18), significant increases in RAW during work (Δ7.74 %HRR, 95%CI 3.57-11.91) as well as a raised level of OPA (Δ4156.88 steps, 95%CI 1898.83-6414.93, Δ-0.67 hours of sitting time, 95%CI -1.25-0.10, Δ-0.52 hours of standing time, 95%CI -1.03-0.01, Δ0.48 hours of walking time, 95%CI 0.18-0.78). ICC estimates were 0.998 (95% CI 0.995-0.999) for total burden lifted and 0.992 (95% CI 0.975-0.997) for frequency of lift. DISCUSSION OL increased both intensity and volume of OPA among blue-collar workers, which supposedly to contributes to an augmented risk of CVD. Although this study finds hazardous acute effects, further investigations are needed to evaluate the long-term effects of OL on ABPM, HR and volume of OPA, also effects of cumulative exposure to OL would be relevant to investigate. CONCLUSION OL significantly raised the intensity and volume of OPA. Direct field observation of occupational lifting showed an excellent interrater reliability.
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Affiliation(s)
- Mathilde Baumann
- Department of Occupational and Social Medicine, University Hospital Holbæk, Denmark
| | | | - Ole Steen Mortensen
- Department of Occupational and Social Medicine, University Hospital Holbæk, Denmark.,Department of Public Health, Section of Social Medicine, University of Copenhagen, Denmark
| | - Michael Hecht Olsen
- Department of Internal Medicine 1, Holbæk Hospital, Denmark.,Department of Regional Health Research, University of Southern Denmark, Denmark
| | - Mette Korshøj
- Department of Occupational and Social Medicine, University Hospital Holbæk, Denmark
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14
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Picone DS, Peterson GM, Jackson SL, Campbell NRC, Delles C, Olsen MH, Padwal R, Schutte AE, Sharman JE. Perceptions of pharmacists on the quality of automated blood pressure devices: a national survey. J Hum Hypertens 2023; 37:235-240. [PMID: 35314763 PMCID: PMC9995266 DOI: 10.1038/s41371-022-00670-4] [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: 08/06/2021] [Revised: 02/11/2022] [Accepted: 02/24/2022] [Indexed: 11/09/2022]
Abstract
A recent study found that only 23.8% of blood pressure (BP) devices available for purchase from Australian pharmacies were validated for accuracy. The extent to which pharmacists are aware of this, and other issues related to the accuracy of BP devices, is not known and gathering this information was the aim of this study. An online survey of Australian pharmacists was distributed via the Pharmaceutical Society of Australia between 1 October and 25 November 2020. Questions were focused on the views of pharmacists related to the accuracy of BP devices. Two hundred and ten pharmacists completed the survey. The accuracy of BP devices sold by pharmacists was considered 'quite' or 'extremely important' to most respondents (94%). However, most respondents (90%) were unaware that less than one-quarter of BP devices sold by Australian pharmacies were validated, and this was 'quite' or 'extremely surprising' to many (69%). Many respondents (64%) associated a particular brand of BP device with greater accuracy. There was low awareness on proper ways to identify accurate BP devices, such as checking reputable online databases (43%). BP devices were stocked in respondents' pharmacies based on perceived quality (50%), accuracy (40%), or as determined by the pharmacy chain (36%). In conclusion, providing accurate BP devices to consumers is important to pharmacists, but they were generally unaware that most devices available from pharmacies were not validated for accuracy. Pharmacist education, alongside advocacy for policies including regulations and strategic action, is required to ensure only validated BP devices are sold in Australia.
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Affiliation(s)
- Dean S Picone
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.
| | - Gregory M Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Shane L Jackson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Norm R C Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark.,Centre for Individualized Medicine in Arterial Diseases, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Aletta E Schutte
- School of Population Health, University of New South Wales, Sydney, NSW, Australia.,The George Institute for Global Health, Sydney, NSW, Australia.,Hypertension in Africa Research Team (HART), Potchefstroom, South Africa.,Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
| | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
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15
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Pedersen FN, Stidsen JV, Rasmussen MN, Nielsen HB, Henriksen JE, Olesen TB, Olsen MH, Nielsen JS, Højlund K, Blindbaek SL, Grauslund J. Retinal microvascular markers in type 2 diabetes subphenotypes and latent autoimmune diabetes of adults. Acta Ophthalmol 2023. [PMID: 36750915 DOI: 10.1111/aos.15643] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/17/2023] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE To estimate if newly diagnosed patients with different subphenotypes of type 2 diabetes (T2DM) or latent autoimmune diabetes of adults (LADA) differ with respect to subclinical retinal microvascular structure or diabetic retinopathy (DR). METHODS This population-based, cross-sectional study of 340 patients (675 eyes) classified patients with recently diagnosed T2DM in different subphenotypes according to beta cell function and insulin sensitivity in to; classical (n = 218), hyperinsulinaemic (n = 86), insulinopenic (n = 20), or LADA (n = 16). Retinal 6-field images were graded according to the International Clinical DR Severity Scale by a retinal expert. Retinal microvascular structures were analysed in eyes by a semiautomatic software. RESULTS Median age and duration of diabetes were 58.1 (49.9; 65.5) and 0.9 (0.5; 2.4) years, respectively, and 56.8% were male. In a multivariate linear mixed model regression analysis of eyes without DR (n = 570), there was no statistically significant difference in retinal venular or arteriolar width between subtypes and patients with classical T2DM. In addition, eyes from different subphenotypes did not differ according to vessel density, tortuosity or fractal dimension. In a multivariate logistic regression model adjusted for age, sex, HbA1c, diabetes duration, body mass index, mean arterial blood pressure and history of cardiovascular disease, there was a tendency towards persons with hyperinsulinaemic T2DM to be more likely to have DR (OR 1.97, 95% CI 0.95; 4.09) compared to classical T2DM. CONCLUSION We found no difference in retinal microvascular structure in patients with newly diagnosed subtypes of T2DM. However, DR may be more prevalent in newly diagnosed patients with hyperinsulinaemic T2DM compared to individuals with classical T2DM.
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Affiliation(s)
- Frederik N Pedersen
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jacob V Stidsen
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Martin N Rasmussen
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | | | - Jan Erik Henriksen
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | | | - Michael Hecht Olsen
- Department of Internal Medicine and Steno Diabetes Center Zealand, Holbaek Hospital, Holbaek, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Jens S Nielsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Kurt Højlund
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | | | - Jakob Grauslund
- Department of Ophthalmology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
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16
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Olesen TB, Pareek M, Vishram-Nielsen JKK, Olsen MH. The influence of age and sex on the prognostic importance of traditional cardiovascular risk factors, selected circulating biomarkers and other markers of subclinical cardiovascular damage. Curr Opin Cardiol 2023; 38:21-31. [PMID: 36598446 DOI: 10.1097/hco.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW There is an increasing need for improved risk stratification to better individualize cardiovascular preventive measures. Although age and sex are strong and easily obtained cardiovascular risk factors (CVRFs), their influence on the prognostic importance of other CVRF, circulating biomarkers and other markers of subclinical cardiovascular damage has not previously been systematically and critically appraised. Therefore, we have revisited the European MORGAM and the Danish MONI10 cohorts. RECENT FINDINGS Theoretically, the relative risk of many CVRF is expected to be lower in older healthy individuals due to a combination of selection bias by disease, higher absolute risk primarily due to older age, and the fact that the CVRF and markers may primarily influence or reflect early parts of the cardiovascular disease process. This influence of age may vary between sexes, as the cardiovascular disease process is delayed and possibly different in women compared with men. SUMMARY Adjusted for the remaining Systematic COronary Risk Evaluation (SCORE) CVRF, higher SBP, serum cholesterol, soluble urokinase-type plasminogen activator receptor, left ventricular mass index and atherosclerotic plaques were more closely associated with outcomes in individuals younger than 52 years with some sex-specific differences, whereas higher N-terminal pro-brain natriuretic peptide and urine albumin/creatine ratio were more closely associated with outcomes in subjects aged 61 or 71 years.
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Affiliation(s)
| | - Manan Pareek
- Centre for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen
| | - Julie K K Vishram-Nielsen
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen
- Centre for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, The Capital Region of Denmark
| | - Michael Hecht Olsen
- Department of Internal Medicine 1, Steno Diabetes Centre Zealand, Holbaek Hospital, Holbaek
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Christensen SB, Bomholt T, Olsen MH, Atke AP. [Not Available]. Ugeskr Laeger 2022; 184:V06220395. [PMID: 36345902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
This is a case report of an observation of bradycardia and inverted T-waves anteroseptally on the electrocardiogram along with cardiac symptoms, in a previously healthy 35-year-old woman with post-partum pre-eclampsia. Initially, she had no hypertension or proteinuria, which delayed the time of diagnosis. A possible explanation of bradycardia is a baroreceptor-mediated response to hypertension and hypervolaemia. The changes on the electrocardiogram can be explained by pectus excavatum, an enlarged uterus and endothelial dysfunction. One should always consider peri-partum as well as post-partum pre-eclampsia.
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Dieden A, Holm H, Melander O, Pareek M, Molvin J, Rastam L, Lindblad U, Daka B, Leosdottir M, Nilsson PM, Olsen MH, Gudmundsson P, Jujic A, Magnusson M. Biomarkers associated with prevalent hypertension and higher blood pressure in a population-based cohort: a proteomic approach. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Globally, hypertension represents an enormous health issue as it is a major, yet modifiable risk factor for developing cardiovascular disease. Recently, chitinase-3-like protein 1 (CHI3L1) was shown to be positively associated with the incidence of hypertension among prehypertensive subjects, and variants of CHI3L1 gene were associated with both CHI3L1-levels and hypertension.
Purpose
To explore associations between prevalent hypertension and blood pressure, and 92 proteins with involvement in inflammation and cardiovascular disease.
Methods
Plasma samples from 1713 individuals from a Swedish population-based cohort (mean age 67.3±6.0 years; 28.9% women) were analysed with a proximity extension assay panel, consisting of 92 proteins. Prior to all analyses, subjects with prevalent cardiovascular disease, defined as having a history of prevalent coronary or stroke event, were excluded (n=189). Univariate logistic regression models were carried out exploring associations between each of the 92 proteins and prevalent hypertension, defined as systolic blood pressure ≥140 mmHg and/or a diastolic blood pressure ≥90 mmHg, or use of antihypertensive treatment (n=1168, 76.4%). Bonferroni-corrected significant associations between proteins and hypertension were further analysed using stepwise selection of covariates, namely age, body mass index, diabetes status, and cystatin C, in logistic regression models. Proteins with significant adjusted associations with prevalent hypertension were further analysed for associations with systolic and diastolic blood pressure individually in stepwise linear regression models. Complete data on all variables were available in 1527 subjects.
Results
Sixteen proteins were significantly associated with prevalent hypertension in univariate analyses. After adjustment, three proteins remained significantly associated with prevalent hypertension (i.e., CHI3L1, low-density lipoprotein receptor (LDL receptor) and tissue plasminogen activator (tPA); Table 1). In analyses of associations with systolic blood pressure, CHI3L1 and LDL receptor showed significant associations. In analyses of associations with diastolic blood pressure, CHI3L1, LDL receptor and tPA showed significant associations (Table 1).
Conclusions
Higher CHI3L1, tPA and LDL receptor levels were positively associated with prevalent hypertension after multivariable adjustment, among 1527 elderly subjects without established cardiovascular disease. Furthermore, higher CHI3L and LDL receptor levels were positively associated with mean systolic, as well as mean diastolic blood pressure in multivariable analyses.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The Swedish Medical Research Council and The Swedish Heart and Lung Foundation
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Affiliation(s)
- A Dieden
- Lund University , Malmo , Sweden
| | - H Holm
- Lund University , Malmo , Sweden
| | | | - M Pareek
- Yale New Haven Hospital, Yale School of Medicine , New Haven , United States of America
| | - J Molvin
- Lund University , Malmo , Sweden
| | - L Rastam
- Lund University , Malmo , Sweden
| | - U Lindblad
- Institute of Medicine - Sahlgrenska Academy - University of Gothenburg , Gothenburg , Sweden
| | - B Daka
- Institute of Medicine - Sahlgrenska Academy - University of Gothenburg , Gothenburg , Sweden
| | | | | | - M H Olsen
- University of Southern Denmark , Odense , Denmark
| | | | - A Jujic
- Lund University , Malmo , Sweden
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Hadziselimovic E, Greve AM, Sajadieh A, Olsen MH, Kesaniemi YA, Nienaber CA, Ray SG, Rossebo AB, Willenheimer R, Wachtell K, Nielsen OW. High-sensitive Troponin T is not associated with the progression of asymptomatic mild to moderate aortic stenosis: a post hoc substudy of the SEAS trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Aortic stenosis (AS) and coronary artery disease (CAD) share pathophysiological pathways, as reflected by frequent concomitant revascularization in patients undergoing aortic valve replacement (AVR). High-sensitive Troponin T (hsTnT) is a proven biomarker of cardiomyocyte overload and injury, and predicts postoperative mortality after AVR. However, it is unknown if hsTnT can predict AVR, mortality or ischemic coronary events (ICE) in asymptomatic AS patients.
Purpose
To investigate the hypothesis that increased hsTnT is associated with more severe AS and a higher risk of adverse outcomes in asymptomatic AS patients without overt CAD.
Methods
hsTnT concentrations were examined at baseline and after 1-year follow-up in 1739 asymptomatic AS patients enrolled in the randomized, double-blind Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. The main inclusion criteria were: left ventricular (LV) ejection fraction >55%, transaortic maximal velocity between 2.5–4.0 m/s, and no history of CAD. The primary exposure variable was increased hsTnT (>14 pg/mL according to the assay manufacturer, Roche). This study's primary endpoint was a composite of competing risk outcomes: all-cause mortality as the first event, AVR without revascularization, and ICE (defined as myocardial infarction before AVR, PCI before or combined with AVR, or any CABG). Multivariable regression examined associations between hsTnT and clinical variables. Cox proportional hazards regression models were adjusted for age, sex, creatinine, LV mass index, mean aortic pressure gradient (Pmean) and stratified by center and lipid-lowering treatment. We analyzed outcomes during 5-year follow-up from baseline.
Results
At baseline, 453 (26.0%) patients had increased hsTnT and 302 (17.4%) had moderate-severe AS with a mean (SD) aortic valve area of 0.8 (0.2) cm2 and Pmean of 33.2 (8.8) mmHg. The median annual hsTnT change from baseline to year 1 was 0.8 pg/mL (IQR, −0.4 to 2.3), regardless of AS severity (P=0.08). In adjusted models, log(hsTnT at baseline) was associated with age, sex, creatinine, and LV mass index (all P<0.05), but not with AS severity (P=0.36). The incidence rate ratio for ICE (Figure 1) in patients with increased vs normal baseline hsTnT concentrations was 2.32 (95% CI, 1.72–3.11, P<0.001). In adjusted Cox regression, increased hsTnT was associated with an increased 5-year ICE risk (HR 1.64; 95% CI, 1.18–2.29, P=0.003), but neither with AVR without revascularization nor death (Figure 1).
Conclusion
In these asymptomatic AS patients without overt CAD, hsTnT is often normal and remains stable during 1 year of follow-up regardless of AS severity. Increased hsTnT is associated with CAD-related events, but neither to AS severity nor AVR without concomitant revascularization. This analysis does not support routine hsTnT measurement in asymptomatic AS to predict AVR related to AS progression, although hsTnT could improve the risk assessment for ICE.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Main sponsor (SEAS): Merck & Co Inc, Whitehouse Station, New JerseyBlood analysis sponsor: Roche Diagnostics International Ltd, Switzerland
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Affiliation(s)
- E Hadziselimovic
- Bispebjerg University Hospital, Department of Cardiology , Copenhagen , Denmark
| | - A M Greve
- Rigshospitalet - Copenhagen University Hospital, Department of Clinical Biochemistry 3011 , Copenhagen , Denmark
| | - A Sajadieh
- Bispebjerg University Hospital, Department of Cardiology , Copenhagen , Denmark
| | - M H Olsen
- Holbaek Hospital, Department of Cardiology , Holbaek , Denmark
| | - Y A Kesaniemi
- Oulu University Hospital, Medical Research Center Oulu, Research Unit of Internal Medicine , Oulu , Finland
| | - C A Nienaber
- Imperial College London, Royal Brompton and Harefield NHS Foundation Trust , London , United Kingdom
| | - S G Ray
- Manchester University Hospitals , Manchester , United Kingdom
| | - A B Rossebo
- Oslo University Hospital Ulleval, Department of Cardiology , Oslo , Norway
| | | | - K Wachtell
- Weill Cornell Medicine, Division of Cardiology , New York , United States of America
| | - O W Nielsen
- Bispebjerg University Hospital, Department of Cardiology , Copenhagen , Denmark
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Korshøj M, Baumann M, Olsen MH, Mortensen OS. P05-15 Effects on heart rate, physical activity and ambulatory blood pressure from occupational physical activity with and without lifting among farmers in Denmark. Eur J Public Health 2022. [PMCID: PMC9421794 DOI: 10.1093/eurpub/ckac095.082] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background High levels of occupational physical activity associate to increased risk of cardiovascular disease. However, knowledge regarding the acute effects of different components of the occupational physical activity, such as lifting, on risk factors for cardiovascular disease remains uninvestigated during every day work. Thus, the aim was to investigate the acute effects from exposure to occupational physical activity with and without lifting on heart rate, physical activity and ambulatory blood pressure. Methods A randomized cross-over study among 18 farming workers in Denmark, all working in the stables of pig- producing farms. Workday measurements of heart rate (Actiheart), physical activity (Axivity placed at front thigh and upper back) and ambulatory blood pressure (Spacelabs 90217, measuring every 20th minute) were collected at a workday with and a workday without occupational lifting. The wash out period between the measurements was 48 hours. Data were processed in the Acti4 software. Results During workdays with lifting compared to workdays without lifting we observed higher intensity of occupational physical activity (Δ 6.57% heart rate reserve, 95% CI -1.34 – 14.47), number of steps/workday (Δ 4,965 steps, 95% CI -0.01 – 0.01), standing/walking activities (Δ 83 min/workday, 95% CI 2.49 – 168.97), as well as higher heart rate (Δ 9.10 bpm, 95% CI -4.66 – 22.85) and higher ambulatory blood pressures, both systolic (Δ 3.77 mmHg, 95% CI -2.64 – 10.18) and diastolic (Δ 1.37 mmHg, 95% CI -2.52 – 5.26). The average burden of the occupational lifting were 2,425 kg/workday and amount of lifts/workday were 239 lifts. Conclusions This pilot project indicated that occupational lifting are adding strenuousness on top of the general occupational physical activity, and influence blood pressure and heart rate at clinically relevant magnitudes. Disentangling the potential relations between one component of occupational physical activity, such as lifting, and risk for cardiovascular disease is key in the development of initiatives for specific prevention, exposure recommendations and vocational rehabilitation.
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Affiliation(s)
- Mette Korshøj
- Department of Occupational and Social Medicine, Holbæk Hospital, Holbæk, Denmark
- Corresponding author:
| | - Mathilde Baumann
- Department of Occupational and Social Medicine, Holbæk Hospital, Holbæk, Denmark
| | | | - Ole Steen Mortensen
- Department of Occupational and Social Medicine, Holbæk Hospital, Holbæk, Denmark
- Department of Public Health, Section of Social Medicine, University of Copenhagen, Copenhagen, Denmark
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Stidsen JV, Christensen DH, Henriksen JE, Højlund K, Olsen MH, Thomsen RW, Christensen LB, Nielsen JS, Olesen TB, Beck-Nielsen H. Risk of cardiovascular events associated with pathophysiological phenotypes of type 2 diabetes. Eur J Endocrinol 2022; 187:279-291. [PMID: 35670619 DOI: 10.1530/eje-22-0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/06/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Hyperglycaemia in type 2 diabetes is caused by varying degrees of two defects: low insulin sensitivity and beta-cell dysfunction. We assessed if subgrouping of patients into three pathophysiological phenotypes according to these defects could identify individuals with high or low risk of future cardiovascular events. DESIGN This is a prospective cohort study. METHODS We assessed estimates of insulin sensitivity and beta-cell function from the homeostasis model assessment-2 in 4209 individuals with recently diagnosed type 2 diabetes enrolled from general practitioners and outpatient clinics in Denmark. Individuals were followed for a composite cardiovascular endpoint (either atherosclerotic outcomes (myocardial infarction, unstable angina pectoris, stroke, coronary or peripheral revascularization), heart failure, or cardiovascular death) and all-cause mortality. RESULTS Totally 417 individuals with the insulinopenic phenotype (high insulin sensitivity and low beta-cell function) had substantially lower risk of cardiovascular events (5-year cumulative incidence: 4.6% vs 10.1%; age-/sex-adjusted hazard ratio (aHR): 0.49; 95% CI: 0.30-0.82) compared with 2685 individuals with the classical phenotype (low insulin sensitivity and low beta-cell function), driven by atherosclerotic events. Conversely, 1107 individuals with the hyperinsulinaemic phenotype (low insulin sensitivity and high beta-cell function) had more cardiovascular events (5-year cumulative incidence: 12.6%; aHR: 1.33; 95% CI: 1.05-1.69), primarily driven by increased heart failure and cardiovascular death and increased all-cause mortality. CONCLUSIONS Simple phenotyping based on insulin sensitivity and beta-cell function predicts distinct future risks of cardiovascular events and death in patients with type 2 diabetes. These results suggest that precision medicine according to underlying type 2 pathophysiology potentially can reduce diabetes complications.
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Affiliation(s)
| | | | - Jan Erik Henriksen
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Kurt Højlund
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Michael Hecht Olsen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
- Cardiology Section, Department of Internal Medicine and Steno Diabetes Center Zealand, Holbæk Hospital, Holbæk, Denmark
| | | | | | - Jens Steen Nielsen
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
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22
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Hesseldal L, Christensen JR, Olesen TB, Olsen MH, Jakobsen PR, Laursen DH, Lauridsen JT, Nielsen JB, Søndergaard J, Brandt CJ. Long term Weight Loss in a Primary Care-Anchored eHealth Lifestyle Coaching Program in Denmark: Randomized Controlled Trial (Preprint). JMIR Diabetes 2022; 24:e39741. [PMID: 36149735 PMCID: PMC9547330 DOI: 10.2196/39741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/06/2022] [Accepted: 07/31/2022] [Indexed: 12/15/2022] Open
Abstract
Background Long-term weight loss in people living with obesity can reduce the risk and progression of noncommunicable diseases. Observational studies suggest that digital coaching can lead to long-term weight loss. Objective We investigated whether an eHealth lifestyle coaching program for people living with obesity with or without type 2 diabetes led to significant, long-term (12-month) weight loss compared to usual care. Methods In a randomized controlled trial that took place in 50 municipalities in Denmark, 340 people living with obesity with or without type 2 diabetes were enrolled from April 16, 2018, to April 1, 2019, and randomized via an automated computer algorithm to an intervention (n=200) or a control (n=140) group. Patients were recruited via their general practitioners, the Danish diabetes organization, and social media. The digital coaching intervention consisted of an initial 1-hour face-to-face motivational interview followed by digital coaching using behavioral change techniques enabled by individual live monitoring. The primary outcome was change in body weight from baseline to 12 months. Results Data were assessed for 200 participants, including 127 from the intervention group and 73 from the control group, who completed 12 months of follow-up. After 12 months, mean body weight and BMI were significantly reduced in both groups but significantly more so in the intervention group than the control group (–4.5 kg, 95% CI –5.6 to –3.4 vs –1.5 kg, 95% CI –2.7 to –0.2, respectively; P<.001; and –1.5 kg/m2, 95% CI –1.9 to –1.2 vs –0.5 kg/m2, 95% CI –0.9 to –0.1, respectively; P<.001). Hemoglobin A1c was significantly reduced in both the intervention (–6.0 mmol/mol, 95% CI –7.7 to –4.3) and control (–4.9 mmol/mol, 95% CI –7.4 to –2.4) groups, without a significant group difference (all P>.46). Conclusions Compared to usual care, digital lifestyle coaching can induce significant weight loss for people living with obesity, both with and without type 2 diabetes, after 12 months. Trial Registration ClinicalTrials.gov NCT03788915; https://clinicaltrials.gov/ct2/show/NCT03788915
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Affiliation(s)
- Laura Hesseldal
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center Zealand, Holdbaek, Denmark
| | - Jeanette Reffstrup Christensen
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
- User Perspectives and Community-based Interventions, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Research Unit of General Practice, Aarhus University, Aarhus, Denmark
| | | | - Michael Hecht Olsen
- Steno Diabetes Center Zealand, Holdbaek, Denmark
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Pernille Ravn Jakobsen
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | | | | | - Jesper Bo Nielsen
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Jens Søndergaard
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Carl Joakim Brandt
- Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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Kristensen AMD, Pareek M, Kragholm KH, Sehested TSG, Olsen MH, Prescott EB. Unstable Angina as a Component of Primary Composite Endpoints in Clinical Cardiovascular Trials: Pros and Cons. Cardiology 2022; 147:235-247. [PMID: 35537418 PMCID: PMC9393841 DOI: 10.1159/000524948] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/29/2022] [Indexed: 11/19/2022]
Abstract
Background Unstable angina (UA) is a component of acute coronary syndrome that is only occasionally included in primary composite endpoints in clinical cardiovascular trials. The aim of this paper is to elucidate the potential benefits and disadvantages of including UA in such contexts. Summary UA comprises <10% of patients with acute coronary syndromes in contemporary settings. Based on the pathophysiological similarities, it is ideal as a part of a composite endpoint along with myocardial infarction (MI). By adding UA as a component of a primary composite endpoint, the number of events and feasibility of the trial should increase, thus decreasing size and costs of trials. Furthermore, UA has both economic and quality of life implications on a societal and an individual level. However, there are important challenges associated with the use of UA as an endpoint. With the introduction of high-sensitivity troponins, the number of individuals diagnosed with UA has decreased to rather low levels, with a reciprocal increase in the number of MI. In addition, UA is particularly challenging to define given the subjective assessment of the index symptoms, rendering a high risk of bias. To minimize bias, strict criteria are warranted, and events should be adjudicated by a blinded endpoint adjudication committee. Key messages UA should only be chosen as a component of a primary composite endpoint in cardiovascular trials after thoroughly evaluating the pros and cons. If it is chosen to include UA, appropriate precautions should be taken to minimize possible bias.
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Affiliation(s)
- Anna Meta Dyrvig Kristensen
- Department of Cardiology, Copenhagen University Hospital − Bispebjerg and Frederiksberg, Copenhagen, Denmark
- *Anna Meta Dyrvig Kristensen,
| | - Manan Pareek
- Department of Cardiology, Copenhagen University Hospital − Herlev and Gentofte, Copenhagen, Denmark
| | | | - Thomas Steen Gyldenstierne Sehested
- Department of Cardiology, Copenhagen University Hospital − Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Michael Hecht Olsen
- Division of Cardiology, Department of Internal Medicine, Holbæk Hospital, Holbæk, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Eva Bossano Prescott
- Department of Cardiology, Copenhagen University Hospital − Bispebjerg and Frederiksberg, Copenhagen, Denmark
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Pareek M, Vaduganathan M, Byrne C, Mikkelsen AD, Kristensen AMD, Biering-Sørensen T, Kragholm KH, Omar M, Olsen MH, Bhatt DL. Intensive blood pressure control in patients with a history of heart failure: the Systolic Blood Pressure Intervention Trial (SPRINT). Eur Heart J Cardiovasc Pharmacother 2022; 8:E12-E14. [PMID: 34902012 PMCID: PMC9071486 DOI: 10.1093/ehjcvp/pvab085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/20/2021] [Accepted: 12/10/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Manan Pareek
- Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Muthiah Vaduganathan
- Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Christina Byrne
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Astrid Duus Mikkelsen
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Tor Biering-Sørensen
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Institute of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Massar Omar
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Michael Hecht Olsen
- Division of Cardiology, Department of Internal Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Deepak L Bhatt
- Corresponding author. Tel: +1 857 307 4071, Fax: +1 857 307 1955,
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Reinhard M, Schousboe K, Andersen UB, Buus NH, Rantanen JM, Bech JN, Mafi HM, Langfeldt S, Bharadwaz A, Hørlyck A, Jensen MK, Jeppesen J, Olsen MH, Jacobsen IA, Bibby BM, Christensen KL. Renal Artery Stenting in Consecutive High-Risk Patients With Atherosclerotic Renovascular Disease: A Prospective 2-Center Cohort Study. J Am Heart Assoc 2022; 11:e024421. [PMID: 35322677 PMCID: PMC9075498 DOI: 10.1161/jaha.121.024421] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 01/22/2023]
Abstract
Background The aim of this study was to prospectively evaluate the effects of renal artery stenting in consecutive patients with severe atherosclerotic renal artery stenosis and high‐risk clinical presentations as defined in a national protocol developed in 2015. Methods and Results Since the protocol was initiated, 102 patients have been referred for revascularization according to the following high‐risk criteria: severe renal artery stenosis (≥70%) with true resistant hypertension, rapidly declining kidney function, or recurrent heart failure/sudden pulmonary edema. At baseline, the mean 24‐hour ambulatory systolic blood pressure was 166.2 mm Hg (95% CI, 162.0–170.4), the defined daily dose of antihypertensive medication was 6.5 (95% CI, 5.8–7.3), and the estimated glomerular filtration rate was 41.1 mL/min per 1.73m2 (95% CI, 36.6–45.6). In 96 patients with available 3‐month follow‐up data, mean 24‐hour ambulatory systolic blood pressure decreased by 19.6 mm Hg (95% CI, 15.4–23.8; P<0.001), the defined daily dose of antihypertensive medication was reduced by 52% (95% CI, 41%–62%; P<0.001), and estimated glomerular filtration rate increased by 7.8 mL/min per 1.73m2 (95% CI, 4.5–11.1; P<0.001). All changes persisted after 24 month follow‐up. Among 17 patients with a history of hospitalization for acute decompensated heart failure, 14 patients had no new episodes after successful revascularization. Conclusions In this prospective cohort study, we observed a reduction in blood pressure and antihypertensive medication, an increase in estimated glomerular filtration rate, and a decrease in new hospital admissions attributable to heart failure/sudden pulmonary edema after renal artery stenting. Registration URL: https://clinicaltrials.gov. Identifier: NCT02770066.
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Affiliation(s)
- Mark Reinhard
- Department of Renal Medicine and The Clinic of Hypertension Aarhus University Hospital Denmark.,Department of Clinical Medicine Aarhus University Denmark
| | - Karoline Schousboe
- Department of Endocrinology/Steno Diabetes Center Odense and The Clinic of Hypertension Odense University Hospital Denmark
| | - Ulrik B Andersen
- Department of Clinical Physiology and Nuclear Medicine Rigshospitalet, GlostrupUniversity of Copenhagen Glostrup Denmark
| | - Niels Henrik Buus
- Department of Renal Medicine and The Clinic of Hypertension Aarhus University Hospital Denmark.,Department of Clinical Medicine Aarhus University Denmark
| | | | - Jesper Nørgaard Bech
- Department of Medicine University Clinic in Nephrology and HypertensionGodstrup Regional Hospital Denmark
| | | | - Sten Langfeldt
- Department of Radiology Aarhus University Hospital Aarhus N Denmark
| | | | - Arne Hørlyck
- Department of Radiology Aarhus University Hospital Aarhus N Denmark
| | | | - Jørgen Jeppesen
- Department of Medicine Amager Hvidovre Hospital GlostrupUniversity of Copenhagen Glostrup Denmark.,Department of Clinical Medicine Faculty of Health and Medical Sciences University of Copenhagen Denmark
| | - Michael Hecht Olsen
- Department of Internal Medicine Holbaek Hospital Denmark.,Centre for Individualized Medicine in Arterial Diseases (CIMA) Department of Regional Health Research University of Southern Denmark Odense C Denmark
| | - Ib Abildgaard Jacobsen
- Department of Endocrinology/Steno Diabetes Center Odense and The Clinic of Hypertension Odense University Hospital Denmark
| | | | - Kent Lodberg Christensen
- Department of Clinical Medicine Aarhus University Denmark.,Department of Cardiology and The Clinic of Hypertension Aarhus University Hospital Denmark
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Abstract
This study uses data from the publicly available Medaval database to determine the number of upper arm cuff and wrist cuff blood pressure measuring devices sold globally as well as the percentages of those devices that have been clinically validated for accuracy.
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Affiliation(s)
- Dean S. Picone
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | | | - Aletta E. Schutte
- School of Population Health, University of New South Wales, Sydney, Australia
| | | | - Pedro Ordunez
- Department of Non-communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC
| | - Paul K. Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - James E. Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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Pareek M, Byrne C, Mikkelsen AD, Dyrvig Kristensen AM, Vaduganathan M, Biering-Sorensen T, Kragholm KH, Mortensen MB, Singh A, Olsen MH, Bhatt DL. Marital status, cardiovascular events, and intensive blood pressure lowering among men and women in the Systolic Blood Pressure Intervention Trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Married persons may have lower rates of mortality and cardiovascular disease (CV) than unmarried persons although data regarding potential differences between men and women are conflicting. The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced CV morbidity and mortality in high-risk patients. We hypothesized that marital status would influence CV event risk and the impact of intensive BP control, and that these effects would vary according to sex.
Purpose
To assess the risks of CV events and mortality according to marital status in a high-risk population, and to assess if marital status modified the effect of intensive versus standard BP control.
Methods
SPRINT was a randomized, controlled, open-label trial of 9361 individuals at high CV risk, at least 50 years of age, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to either intensive or standard BP control and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. Secondary efficacy endpoints included the individual components of the primary endpoint and all-cause death. Event risk according to marital status, including variation of the effects of intensive BP control, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. The group of subjects who were married or living in a marriage-like relationship served as baseline.
Results
Information on marital status was available for 8762 (93.6%) individuals. A total of 4863 (55.5%) were married or in a marriage-like relationship, 3149 (35.9%) were widowed, divorced, or separated, and 750 (8.6%) were never married. Marital status did not differ between patients randomized to intensive versus standard BP control (P=0.51). The risk of the primary endpoint was not significantly affected by marital status (P>0.05), in neither men nor women (P-interaction>0.05). The same was true for its individual components except the risk of CV death which was higher among never married men (adjusted hazard ratio [aHR], 3.29, 95% confidence interval [CI]: 1.34–8.09; P=0.009; P-sex-interaction=0.99). The risk of all-cause death was higher among widowed, divorced, or separated men (aHR, 1.90, 95% CI: 1.35–2.67; P<0.001) and among never married men (aHR, 2.53, 95% CI: 1.51–4.26; P<0.001), but not women belong to these groups (P>0.05; P-sex-interaction=0.24) (Figure). Associations were not modified by age (P-interaction>0.05). Marital status did not modify the effect of intensive BP control for any of the endpoints (P-interaction>0.05).
Conclusions
In SPRINT, never married men had higher risks of both CV death and all-cause death while widowed, divorced, or separated men had a higher risk of all-cause death. The risks and benefits of intensive BP control were not affected by marital status.
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
- M Pareek
- Brigham and Women's Hospital, Boston, United States of America
| | - C Byrne
- Bispebjerg University Hospital, Copenhagen, Denmark
| | | | | | - M Vaduganathan
- Brigham and Women's Hospital, Boston, United States of America
| | | | | | | | - A Singh
- Brigham and Women's Hospital, Boston, United States of America
| | | | - D L Bhatt
- Brigham and Women's Hospital, Boston, United States of America
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Pareek M, Byrne C, Mikkelsen AD, Dyrvig Kristensen AM, Vaduganathan M, Biering-Sorensen T, Kragholm KH, Mortensen MB, Singh A, Olsen MH, Bhatt DL. Greater event rates in high-risk patients with a history of heart disease: from the Systolic Blood Pressure Intervention Trial (SPRINT). Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in patients at high CV risk. Effects were consistent among patients with and without prevalent CV disease. However, it is unknown whether the benefits and risks of intensive BP control are affected by the specific type of heart disease.
Purpose
To assess the risks of incident CV events and safety events in patients with individual types of heart disease, and to assess if the presence of heart disease modified the effect of intensive versus standard BP control.
Methods
SPRINT was a randomized, controlled trial comprising 9,361 individuals ≥50 years of age at high CV risk, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to intensive or standard BP control. The primary efficacy endpoint was the composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events. We assessed event risk in patients with self-reported heart disease versus those without and further assessed the safety and efficacy of intensive BP control, including relevant interactions, in these individuals, using multivariable Cox proportional-hazards regression.
Results
Of 9361 participants, 326 (3.5%) reported a history of congestive heart failure, 760 (8.1%) of myocardial infarction, 1206 (12.9%) of angina, and 1830 (19.6%) of atrial fibrillation, atrial flutter, or irregular heartbeat. The prevalence of these conditions did not significantly differ between patients randomized to intensive versus standard BP control (P>0.05 for all). At median 3.2 years (range 0–4.8 years), congestive heart failure (adjusted hazard ratio [aHR], 1.94, 95% confidence interval [CI], 1.45–2.61; P<0.001), myocardial infarction (aHR, 1.73, 95% CI, 1.33–2.25; P<0.001), angina (aHR, 1.41, 95% CI, 1.09–1.84; P=0.01), and atrial fibrillation, atrial flutter, or irregular heartbeat (aHR, 1.36, 95% CI, 1.12–1.64; P=0.002) were all independently associated with the primary endpoint (Figure). All conditions except prior myocardial infarction were also associated with composite serious adverse events (P=0.24 for myocardial infarction, P<0.05 for all others). A history of angina modified the efficacy of intensive versus standard BP control, i.e., patients without angina appeared to benefit from intensive BP control (aHR, 0.66, 95% CI, 0.54–0.80; P<0.001) while those with angina did not (aHR, 1.04, 95% CI, 0.76–1.44; P=0.80) (P=0.02 for interaction). No significant interactions were detected for the primary safety endpoint.
Conclusions
In SPRINT, a history of any type of heart disease was associated with a greater risk for both efficacy and safety events. Patients with angina did not appear to derive benefit from intensive BP control.
Funding Acknowledgement
Type of funding sources: None. Figure 1
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Affiliation(s)
- M Pareek
- Brigham and Women's Hospital, Boston, United States of America
| | - C Byrne
- Bispebjerg University Hospital, Copenhagen, Denmark
| | | | | | - M Vaduganathan
- Brigham and Women's Hospital, Boston, United States of America
| | | | | | | | - A Singh
- Brigham and Women's Hospital, Boston, United States of America
| | | | - D L Bhatt
- Brigham and Women's Hospital, Boston, United States of America
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Byrne C, Pareek M, Vaduganathan M, Mikkelsen AD, Kristensen AMD, Biering-Sorensen T, Kragholm KH, Mortensen MB, Singh A, Olsen MH, Bhatt DL. Primary health insurance and cardiovascular outcomes in the systolic blood pressure intervention trial. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in high-risk patients. Although antihypertensive therapies were provided at no cost to trial participants, patients were covered by various entities. Insurance coverage provides a unique dimension of risk assessment and may provide additional prognostic information in this setting.
Purpose
To assess the risks of incident CV events and safety events in a high CV risk population according to type of health insurance, and to assess if insurance type interacted with the effect of intensive versus standard BP control.
Methods
SPRINT was a randomized, controlled trial conducted across 102 US sites of 9,361 high-risk adults ≥50 years, without diabetes, and with a systolic BP 130–180 mmHg at screening. Study participants were randomized to intensive (target systolic BP <120mmHg) or standard BP control (target systolic BP <140mmHg) and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. The primary safety endpoint was the composite of serious adverse events. The risk of efficacy and safety events according to type of health insurance, including the effect of intensive BP control in each subgroup, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. Private/other insurance type served as the reference group.
Results
Of 9361 participants, 3980 (42.5%) were covered by private/other insurance, 1483 (15.8%) by a Veterans Affairs (VA) health plan, 2691 (28.8%) by Medicare, 207 (2.2%) by Medicaid, and 1000 (10.7%) were uninsured. Insurance coverage distribution was well-balanced between the two study arms (P>0.05). Compared with patients who had private/other insurance, the risk of the primary endpoint was significantly higher among Medicaid beneficiaries (adj. hazard ratio [HR], 1.81, 95% confidence interval [CI], 1.09–3.00; P=0.02). The risk of death was similarly highest among Medicaid patients (adj. HR, 2.08, 95% CI, 1.08–4.02; P=0.03) and was also significantly higher among VA patients (adj. HR, 1.49, 95% CI, 1.11–2.99; P=0.008) (Figure). Serious adverse events were more common in the VA population (HR, 1.12, 95% CI, 1.01–1.23; P=0.03). Insurance type did not modify the efficacy and safety of intensive BP control (P>0.05 for all interactions).
Conclusions
In SPRINT, Medicaid beneficiaries were at significantly greater risk for experiencing a primary CV event. Medicaid patients and VA patients both had higher mortality than those covered by private/other insurance. The risks and benefits of intensive BP control were not affected by insurance type.
Funding Acknowledgement
Type of funding sources: None. Risk of death and health insurace type
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Affiliation(s)
- C Byrne
- Bispebjerg University Hospital, Copenhagen, Denmark
| | - M Pareek
- Brigham and Women'S Hospital, Harvard Medical School, Heart & Vascular Center, Boston, United States of America
| | - M Vaduganathan
- Brigham and Women'S Hospital, Harvard Medical School, Heart & Vascular Center, Boston, United States of America
| | | | | | - T Biering-Sorensen
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - K H Kragholm
- Aalborg University Hospital, Department of Cardiology, Aalborg, Denmark
| | - M B Mortensen
- Aarhus University Hospital, Department of Cardiology, Aarhus, Denmark
| | - A Singh
- Brigham and Women'S Hospital, Harvard Medical School, Heart & Vascular Center, Boston, United States of America
| | - M H Olsen
- Holbaek Hospital, Department of Internal Medicine, Holbaek, Denmark
| | - D L Bhatt
- Brigham and Women'S Hospital, Harvard Medical School, Heart & Vascular Center, Boston, United States of America
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Byrne C, Pareek M, Vaduganathan M, Biering-Sørensen T, Krogager ML, Kragholm KH, Steensig K, Mortensen MB, Mishra SR, McCullough MJ, Desai NR, Torp-Pedersen C, Olsen MH, Bhatt DL. Serum Potassium and Mortality in High-Risk Patients: SPRINT. Hypertension 2021; 78:1586-1594. [PMID: 34601970 DOI: 10.1161/hypertensionaha.121.17736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Christina Byrne
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark (C.B.)
| | - Manan Pareek
- Brigham and Women's Hospital, Heart & Vascular Center (M.P., M.V., T.B.-S., D.L.B.), Harvard Medical School, Boston, MA.,Department of Cardiology, Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT (M.P., N.R.D.).,Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Hillerød, Denmark (M.P., C.T.-P.)
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital, Heart & Vascular Center (M.P., M.V., T.B.-S., D.L.B.), Harvard Medical School, Boston, MA
| | - Tor Biering-Sørensen
- Brigham and Women's Hospital, Heart & Vascular Center (M.P., M.V., T.B.-S., D.L.B.), Harvard Medical School, Boston, MA.,Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark (T.B.-S.).,Institute of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (T.B.-S.)
| | - Maria Lukács Krogager
- Department of Cardiology, Aalborg University Hospital, Denmark (M.L.K., K.H.K., K.S., C.T.-P.)
| | - Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital, Denmark (M.L.K., K.H.K., K.S., C.T.-P.)
| | - Kamilla Steensig
- Department of Cardiology, Aalborg University Hospital, Denmark (M.L.K., K.H.K., K.S., C.T.-P.)
| | | | - Shiva Raj Mishra
- World Heart Federation, Salim Yusuf Emerging Leaders Program, Geneva, Switzerland (S.R.M.)
| | - Megan J McCullough
- Massachusetts General Hospital Corrigan Minehan Heart Center (M.J.M.S), Harvard Medical School, Boston, MA
| | - Nihar R Desai
- Department of Cardiology, Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT (M.P., N.R.D.)
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Hillerød, Denmark (M.P., C.T.-P.).,Department of Cardiology, Aalborg University Hospital, Denmark (M.L.K., K.H.K., K.S., C.T.-P.)
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital, Denmark (M.H.O.).,Department of Regional Health Research, University of Southern Denmark (M.H.O.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Heart & Vascular Center (M.P., M.V., T.B.-S., D.L.B.), Harvard Medical School, Boston, MA
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31
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Nielsen EE, Feinberg JB, Bu FL, Hecht Olsen M, Raymond I, Steensgaard-Hansen F, Jakobsen JC. Beneficial and harmful effects of sacubitril/valsartan in patients with heart failure: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Open Heart 2021; 7:openhrt-2020-001294. [PMID: 33257469 PMCID: PMC7705560 DOI: 10.1136/openhrt-2020-001294] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 09/10/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022] Open
Abstract
Current guidelines recommend angiotensin receptor blocker neprilysin inhibitors (ARNI) (sacubitril/valsartan) as a replacement for angiotensin-converting-enzymeinhibitor (ACE-I) in heart failure with reduced ejection fraction (HFrEF) who remain symptomatic despite optimal medical therapy. The effects of ARNIs have not previously been assessed in a systematic review. We searched for relevant trials until October 2019 in CENTRAL, MEDLINE, Embase, LILACS, BIOSIS, CNKI, VIP, WanFang and CBM. Our primary outcomes were all-cause mortality and serious adverse events. We systematically assessed the risks of random errors and systematic errors. PROSPERO registration: CRD42019129336. 48 trials randomising 19 086 participants were included. The ARNI assessed in all trials was sacubitril/valsartan. ACE-I or ARB were used as control interventions. Trials randomising HFrEF participants (27 trials) and heart failure with preserved ejection fraction (HFpEF) participants (four trials) were analysed separately. In HFrEF participants, meta-analyses and Trial Sequential Analyses showed evidence of a beneficial effect of sacubitril/valsartan when assessing all-cause mortality (risk ratio (RR), 0.86; 95% CI, 0.79 to 0.94) and serious adverse events (RR, 0.89; 95% CI, 0.86 to 0.93); and the results did not differ between the guideline recommended target population and HFrEF participants in general. We found no evidence of an effect of sacubitril/valsartan in HFpEF participants. Sacubitril/valsartan compared with either ACE-I or ARB seems to have a beneficial effect in patients with HFrEF. Our results indicate that sacubitril/valsartan might be beneficial in a wider population of patients with heart failure than the guideline recommended target population. Sacubitril/valsartan does not seem to show evidence of a difference compared with valsartan in patients with HFpEF.
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Affiliation(s)
- Emil Eik Nielsen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Denmark .,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Joshua Buron Feinberg
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Fan-Long Bu
- Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Michael Hecht Olsen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Denmark.,Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Centre for Individualized Medicine in Arterial Diseases (CIMA), Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Ilan Raymond
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Denmark
| | | | - Janus Christian Jakobsen
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Morales-Salinas A, Olsen MH, Kones R, Kario K, Wang JG, Beilin L, Weber MA, Yano Y, Burrell LM, Orias M, Dzudie A, Lavie C, Ventura H, Sundström J, de Simone G, Coca A, Rumana U, Marrugat J. Erratum to "Second Consensus on Treatment of Patients Recently Diagnosed with Mild Hypertension and Low Cardiovascular Risk". [YMCD 45/10 (October 2020) 100653]. Curr Probl Cardiol 2021; 46:100877. [PMID: 34148707 DOI: 10.1016/j.cpcardiol.2021.100877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- A Morales-Salinas
- Associate Professsor, Universidad de Ciencias Médicas de Villa Clara, Villa Clara, Cuba.
| | - M H Olsen
- Professor, Cardiology Section, Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
| | - R Kones
- Director, Cardiometabolic Research Institute, Houston, TX, USA. Chief Medical Officer, Community Diabetes Prevention Program, Houston, TX, USA. Editor-in-Chief, Research Reports in Clinical Cardiology.
| | - K Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan.
| | - J G Wang
- The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China (Tel: +86-21-64662193 ext 610911).
| | - L Beilin
- Professor of Medicine in the School of Medicine & Pharmacology at the Royal Perth Hospital Campus, University of Western Australia.
| | - M A Weber
- Professor of Medicine, Division of Cardiovascular Medicine, State University of New York, Downstate Medical Center.
| | - Y Yano
- Assistant Professor in Family Medicine and Community Health, Duke University, Durham, NC.
| | - L M Burrell
- Departments of Medicine and Cardiology, The University of Melbourne, Austin Health, Victoria, 3084, Australia.
| | - M Orias
- Department of Nephrology, Sanatorio Allende, Independencia 768, 5000 Córdoba, Argentina.
| | - A Dzudie
- Hôpital Général de Douala Douala, Cameroon.
| | - C Lavie
- Medical Director Cardiac Rehabilitation and Prevention, Director Exercise Laboratories, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, Editor in Chief, Progress in Cardiovascular Diseases, New Orleans, Louisiana.
| | - H Ventura
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana.
| | - J Sundström
- Professor of Epidemiology, Uppsala University, +4670422522.
| | - G de Simone
- Professor of Medicine, Chair, Council on Hypertension, European Society of Cardiology, Hypertension Research Cente & Dprt of Translational Biomedical Sciences, Federico II University Hospital, via S. Pansini 5, bld # 1, 80131 Napoli, Italy.
| | - A Coca
- Honorary Professor of Medicine. Department of Internal Medicine, Hospital Clínic, University of Barcelona, Spain, Phone: +34 618 769 035.
| | - U Rumana
- New York Institute of Technology, Old Westbury, NY.
| | - J Marrugat
- Institut Hospital del Mar d'investigacions Mèdiques (IMIM) - CIBERCV, Barcelona, Catalonia, Spain.
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Jakobsen PR, Christensen JR, Nielsen JB, Søndergaard J, Ejg Jarbøl D, Olsen MH, Nielsen JS, Kristensen JK, Brandt CJ. Identification of Important Factors Affecting Use of Digital Individualised Coaching and Treatment of Type 2 Diabetes in General Practice: A Qualitative Feasibility Study. Int J Environ Res Public Health 2021; 18:ijerph18083924. [PMID: 33917999 PMCID: PMC8068375 DOI: 10.3390/ijerph18083924] [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] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/27/2022]
Abstract
Most type 2 diabetes patients are treated in general practice and there is a need of developing and implementing efficient lifestyle interventions. eHealth interventions have shown to be effective in promoting a healthy lifestyle. The purpose of this study was to test the feasibility, including the identification of factors of importance, when offering digital lifestyle coaching to type 2 diabetes patients in general practice. We conducted a qualitative feasibility study with focus group interviews in four general practices. We identified two overall themes and four subthemes: (1) the distribution of roles and lifestyle interventions in general practice (subthemes: external and internal distribution of roles) and (2) the pros and cons for digital lifestyle interventions in general practice (subthemes: access to real life data and change in daily routines). We conclude that for digital lifestyle coaching to be feasible in a general practice setting, it was of great importance that the general practitioners and practice nurses knew the role and content of the intervention. In general, there was a positive attitude in the general practice setting towards referring type 2 diabetes patients to digital lifestyle intervention if it was easy to refer the patients and if easily understandable and accessible feedback was implemented into the electronic health record. It was important that the digital lifestyle intervention was flexible and offered healthcare providers in general practice an opportunity to follow the type 2 diabetes patient closely.
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Affiliation(s)
- Pernille Ravn Jakobsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, 5000 Odense C, Denmark; (J.R.C.); (J.B.N.); (J.S.); (D.E.J.); (C.J.B.)
- Correspondence: ; Tel.: +45-20775905
| | - Jeanette Reffstrup Christensen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, 5000 Odense C, Denmark; (J.R.C.); (J.B.N.); (J.S.); (D.E.J.); (C.J.B.)
- Research Unit of User Perspectives and Community-Based Interventions, Department of Public Health, University of Southern Denmark, 5000 Odense C, Denmark
| | - Jesper Bo Nielsen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, 5000 Odense C, Denmark; (J.R.C.); (J.B.N.); (J.S.); (D.E.J.); (C.J.B.)
| | - Jens Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, 5000 Odense C, Denmark; (J.R.C.); (J.B.N.); (J.S.); (D.E.J.); (C.J.B.)
- Steno Diabetes Center, Odense University Hospital, 5000 Odense C, Denmark;
| | - Dorte Ejg Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, 5000 Odense C, Denmark; (J.R.C.); (J.B.N.); (J.S.); (D.E.J.); (C.J.B.)
| | - Michael Hecht Olsen
- Department of Internal Medicine and Steno Diabetes Center Zealand, Holbaek Hospital, 4300 Holbaek, Denmark;
- Department for Regional Health Research, University of Southern Denmark, 5000 Odense C, Denmark
| | - Jens Steen Nielsen
- Steno Diabetes Center, Odense University Hospital, 5000 Odense C, Denmark;
- Danish Center for Strategic Research in Type 2 Diabetes, Steno Diabetes Center Odense, Odense University Hospital, 5000 Odense C, Denmark
| | | | - Carl J. Brandt
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, 5000 Odense C, Denmark; (J.R.C.); (J.B.N.); (J.S.); (D.E.J.); (C.J.B.)
- Steno Diabetes Center, Odense University Hospital, 5000 Odense C, Denmark;
- Liva Healthcare, 1434 Copenhagen, Denmark
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Feinberg JB, Olsen MH, Brandes A, Raymond L, Nielsen WB, Nielsen EE, Stensgaard-Hansen F, Dixen U, Pedersen OD, Gang UJO, Gluud C, Jakobsen JC. Lenient rate control versus strict rate control for atrial fibrillation: a protocol for the Danish Atrial Fibrillation (DanAF) randomised clinical trial. BMJ Open 2021; 11:e044744. [PMID: 33789853 PMCID: PMC8016086 DOI: 10.1136/bmjopen-2020-044744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Atrial fibrillation is the most common heart arrhythmia with a prevalence of approximately 2% in the western world. Atrial fibrillation is associated with an increased risk of death and morbidity. In many patients, a rate control strategy is recommended. The optimal heart rate target is disputed despite the results of the the RAte Control Efficacy in permanent atrial fibrillation: a comparison between lenient vs strict rate control II (RACE II) trial.Our primary objective will be to investigate the effect of lenient rate control strategy (<110 beats per minute (bpm) at rest) compared with strict rate control strategy (<80 bpm at rest) on quality of life in patients with persistent or permanent atrial fibrillation. METHODS AND ANALYSIS We plan a two-group, superiority randomised clinical trial. 350 outpatients with persistent or permanent atrial fibrillation will be recruited from four hospitals, across three regions in Denmark. Participants will be randomised 1:1 to a lenient medical rate control strategy (<110 bpm at rest) or a strict medical rate control strategy (<80 bpm at rest). The recruitment phase is planned to be 2 years with 3 years of follow-up. Recruitment is expected to start in January 2021. The primary outcome will be quality of life using the Short Form-36 (SF-36) questionnaire (physical component score). Secondary outcomes will be days alive outside hospital, symptom control using the Atrial Fibrillation Effect on Quality of Life, quality of life using the SF-36 questionnaire (mental component score) and serious adverse events. The primary assessment time point for all outcomes will be 1 year after randomisation. ETHICS AND DISSEMINATION Ethics approval was obtained through the ethics committee in Region Zealand. The design and findings will be published in peer-reviewed journals as well as be made available on ClinicalTrials.gov. TRIAL REGISTRATION NUMBER NCT04542785.
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Affiliation(s)
- Joshua Buron Feinberg
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Michael Hecht Olsen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense C, Denmark
| | - Llan Raymond
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Walter Bjørn Nielsen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Emil Eik Nielsen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Frank Stensgaard-Hansen
- Department of Internal Medicine - Cardiology Section, Holbaek Hospital, Holbaek, Region Zealand, Denmark
| | - Ulrik Dixen
- Department of Cardiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Ole Dyg Pedersen
- Department of cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Uffe Jakob Ortved Gang
- Department of cardiology, Zealand University Hospital Roskilde, Roskilde, Region Zealand, Denmark
| | - Christian Gluud
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Capital Region of Denmark, Copenhagen, Denmark
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Byrne C, Pareek M, Vaduganathan M, Biering-Sørensen T, Qamar A, Pandey A, Olesen TB, Olsen MH, Bhatt DL. Intensive blood pressure lowering in different age categories: insights from the Systolic Blood Pressure Intervention Trial. Eur Heart J Cardiovasc Pharmacother 2021; 6:356-363. [PMID: 31529024 DOI: 10.1093/ehjcvp/pvz050] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 09/12/2019] [Indexed: 12/12/2022]
Abstract
AIMS The 2018 ESC/ESH guidelines for hypertension recommend differential management of patients who are <65, 65-79, and ≥80 years of age. However, it is unclear whether intensive blood pressure lowering is well-tolerated and modifies risk uniformly across the age spectrum. METHODS AND RESULTS SPRINT randomized 9361 high-risk adults without diabetes and age ≥50 years with systolic blood pressure 130-180 mmHg to either intensive or standard antihypertensive treatment. The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. The primary safety endpoint was composite serious adverse events. We assessed whether age modified the efficacy and safety of intensive vs. standard blood pressure lowering using Cox proportional-hazards regression and restricted cubic splines. In all, 3805 (41%), 4390 (47%), and 1166 (12%) were <65, 65-79, and ≥80 years. Mean age was similar between the two study groups (intensive group 67.9 ± 9.4 years vs. standard group 67.9 ± 9.5 years; P = 0.94). Median follow-up was 3.3 years. In multivariable models, age was linearly associated with the risk of stroke (P < 0.001) and non-linearly associated with the risk of primary efficacy events, death from cardiovascular causes, death from any cause, heart failure, and serious adverse events (P < 0.001). The safety and efficacy of intensive blood pressure lowering were not modified by age, whether tested continuously or categorically (P > 0.05). CONCLUSION In SPRINT, the benefits and risks of intensive blood pressure lowering did not differ according to the age categories proposed by the ESC/ESH guidelines for hypertension. TRIAL REGISTRATION SPRINT (Systolic Blood Pressure Intervention Trial); ClinicalTrials.gov Identifier: NCT01206062, https://clinicaltrials.gov/ct2/show/NCT01206062.
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Affiliation(s)
- Christina Byrne
- Department of Cardiology, The Heart Centre, Rigshospitalet - Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen Ø, Denmark
| | - Manan Pareek
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, 20 York St, New Haven, CT 06510, USA
- Department of Cardiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Tor Biering-Sørensen
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
- Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- Institute of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Arman Qamar
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Ambarish Pandey
- Department of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA
| | - Thomas Bastholm Olesen
- Department of Internal Medicine, Hospital of Little Belt, Sygehusvej 24, 6000 Kolding, Denmark
| | - Michael Hecht Olsen
- Division of Cardiology, Department of Internal Medicine, Holbæk Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
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Neupane D, Cobb LK, Hall B, Lackland DT, Moran AE, Mukhtar Q, Weber MA, Olsen MH. Building research capacity within cardiovascular disease prevention and management in low- and middle-income countries: A collaboration of the US Centers for Disease Control and Prevention, the Lancet Commission on Hypertension Group, Resolve to Save Lives, and the World Hypertension League. J Clin Hypertens (Greenwich) 2021; 23:699-701. [PMID: 33522103 PMCID: PMC8678704 DOI: 10.1111/jch.14181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/16/2020] [Accepted: 12/25/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Dinesh Neupane
- Lancet Commission on Hypertension Group, London, UK.,Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Laura K Cobb
- Resolve to Save Lives, An initiative of Vital Strategies, New York, NY, USA
| | - Bethany Hall
- Centers for Disease Control and Prevention, Atlanta, GA, USA.,CDC Foundation, Atlanta, GA, USA
| | - Daniel T Lackland
- World Hypertension League, Charleston, CA, USA.,Medical University of South Carolina, Charleston, CA, USA
| | - Andrew E Moran
- Resolve to Save Lives, An initiative of Vital Strategies, New York, NY, USA
| | - Qaiser Mukhtar
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michael A Weber
- World Hypertension League, Charleston, CA, USA.,State University of New York, New York, NY, USA
| | - Michael Hecht Olsen
- Lancet Commission on Hypertension Group, London, UK.,Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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Angkurawaranon C, Pinyopornpanish K, Srivanichakorn S, Sanchaisuriya P, Thepthien BO, Tooprakai D, Ngetich E, Damasceno A, Olsen MH, Sharman JE, Garg R. Clinical audit of adherence to hypertension treatment guideline and control rates in hospitals of different sizes in Thailand. J Clin Hypertens (Greenwich) 2021; 23:702-712. [PMID: 33501760 PMCID: PMC8678746 DOI: 10.1111/jch.14193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 11/27/2022]
Abstract
A clinical audit of hospitals in Thailand was conducted to assess compliance with the national hypertension treatment guidelines and determine hypertension control rates across facilities of different sizes. Stratified random sampling was used to select sixteen hospitals of different sizes from four provinces. These included community (<90 beds), large (90–120 beds), and provincial (>120 beds) hospitals. Among new cases, the audit determined whether (i) the recommended baseline laboratory assessment was completed, (ii) the initial choice of medication was appropriate based on the patient's cardiovascular risk, and (iii) patients received medication adjustments when indicated. The hypertension control rates at six months and at the last visit were recorded. Among the 1406 patients, about 75% had their baseline glucose and kidney function assessed. Nearly 30% (n = 425/1406) of patients were indicated for dual therapy but only 43% of them (n = 182/425) received this. During treatment, 28% (198/1406) required adjustments in medication but this was not done. The control of hypertension at six months after treatment initiation was 53% varying between 51% in community and 56% in large hospitals (p < .01). The hypertension control rate at last visit was 64% but varied between 59% in community hospitals and 71% in large hospitals (p < .01). Failure to adjust medication when required was associated with 30% decrease in the odds of hypertension control (OR 0.69, 95% CI 0. 50 to 0.90). Failure to comply with the treatment guidelines regarding adjustment of medication and lost to follow‐up are possible target areas to improve hypertension control in Thailand.
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Affiliation(s)
- Chaisiri Angkurawaranon
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | | | - Pattara Sanchaisuriya
- Department of Public Health Administration, Health Promotion, and Nutrition, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - Bang-On Thepthien
- ASEAN Institute for Health Development, Mahidol University, Salaya, Thailand
| | - Dusida Tooprakai
- Department of Social Medicine, Lampang Hospital, Lampang, Thailand
| | - Elisha Ngetich
- Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Albertino Damasceno
- Lancet Commission on Hypertension Group, London, UK.,Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Michael Hecht Olsen
- Lancet Commission on Hypertension Group, London, UK.,Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - James E Sharman
- Lancet Commission on Hypertension Group, London, UK.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tas, Australia
| | - Renu Garg
- World Health Organization Country Office for Thailand, Nonthaburi, Thailand
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38
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Picone DS, Padwal R, Campbell NRC, Boutouyrie P, Brady TM, Olsen MH, Delles C, Lombardi C, Mahmud A, Meng Y, Mokwatsi GG, Ordunez P, Phan HT, Pucci G, Schutte AE, Sung KC, Zhang XH, Sharman JE. How to check whether a blood pressure monitor has been properly validated for accuracy. J Clin Hypertens (Greenwich) 2020; 22:2167-2174. [PMID: 33017506 DOI: 10.1111/jch.14065] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/27/2020] [Accepted: 09/09/2020] [Indexed: 12/20/2022]
Abstract
Hypertension guidelines recommend that blood pressure (BP) should be measured using a monitor that has passed validation testing for accuracy. BP monitors that have not undergone rigorous validation testing can still be cleared by regulatory authorities for marketing and sale. This is the situation for most BP monitors worldwide. Thus, consumers (patients, health professionals, procurement officers, and general public) may unwittingly purchase BP monitors that are non-validated and more likely to be inaccurate. Without prior knowledge of these issues, it is extremely difficult for consumers to distinguish validated from non-validated BP monitors. For the above reasons, the aim of this paper is to provide consumers guidance on how to check whether a BP monitor has been properly validated for accuracy. The process involves making an online search of listings of BP monitors that have been assessed for validation status. Only those monitors that have been properly validated are recommended for BP measurement. There are numerous different online listings of BP monitors, several are country-specific and two are general (international) listings. Because monitors can be marketed using alternative model names in different countries, if a monitor is not found on one listing, it may be worthwhile cross-checking with a different listing. This information is widely relevant to anyone seeking to purchase a home, clinic, or ambulatory BP monitor, including individual consumers for use personally or policy makers and those procuring monitors for use in healthcare systems, and retailers looking to stock only validated BP monitors.
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Affiliation(s)
- Dean S Picone
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Norm R C Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Pierre Boutouyrie
- Department of Pharmacology, European Georges Pompidou Hospital, Assistance Publique Hôpitaux de Paris, Inserm UMR 970, Université de Paris, Paris, France
| | - Tammy M Brady
- Division of Pediatric Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark.,Centre for Individualized Medicine in Arterial Diseases, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Cintia Lombardi
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Azra Mahmud
- King Abdul Aziz Cardiac Center, King Abdul Aziz Medical City, Riyadh, Saudi Arabia.,National Guard Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center & King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Yaxing Meng
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Gontse G Mokwatsi
- Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa.,Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
| | - Pedro Ordunez
- Department of Non-Communicable Diseases and Mental Health, Pan American Health Organization, Washington, DC, USA
| | - Hoang T Phan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.,Pham Ngoc, Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Giacomo Pucci
- Unit of Internal Medicine at Terni University Hospital, Department of Medicine, University of Perugia, Perugia, Italy
| | - Aletta E Schutte
- Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa.,Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa.,School of Public Health and Community Medicine, University of New South Wales, The George Institute for Global Health, Sydney, Australia
| | - Ki-Chul Sung
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | - James E Sharman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
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Nepali S, Rijal A, Olsen MH, McLachlan CS, Kallestrup P, Neupane D. Factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events. BMC Cardiovasc Disord 2020; 20:425. [PMID: 32972356 PMCID: PMC7517612 DOI: 10.1186/s12872-020-01710-y] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 09/20/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The World Health Organization recommends consumption of a minimum of 400 g of fruits and vegetables per day for prevention of cardiovascular disease. Low fruit and vegetable intake is associated with an increased risk of stroke by 11% and ischemic heart disease by 31%. The present study aims to explore factors affecting the fruit and vegetable intake in Nepal and its association with history of self-reported major cardiovascular events (myocardial infarction and stroke). METHOD Data for this cross-sectional study were collected as part of the study "Community Based Management of Hypertension in Nepal" initiated in the Lekhnath Municipality in 2013. Demographic and nutrition information were collected using the WHO STEPwise approach to a surveillance tool. Descriptive statistics identified the frequency and percentage of fruit and vegetable intake. A Chi-square test examined the association between fruit and vegetable intake and history of self-reported cardiovascular events, socio-demographic and cardiovascular risk factors. Binary logistic regression analysis identified odds ratio with 95% confidence intervals between fruit and vegetable intake and history of self-reported cardiovascular events. RESULTS The mean and median intake of fruits and vegetables were 3.3 ± 0.79 and 3 servings respectively. Of the 2815 respondents, 2% (59) reported having a history of major cardiovascular events. The adjusted odds of having a history of major cardiovascular events was 2.22 (95%CI, 1.06-4.66) for those who consumed < 3 servings compared to those who consumed ≥3 servings of fruits and vegetables a day. CONCLUSION The respondents who consumed < 3 servings of fruits and vegetables a day had higher odds of a history of major cardiovascular events in comparison to those who consumed ≥3 servings. This finding may carry a policy recommendation for those settings where the current recommendation of having ≥5 servings of fruits and vegetables a day is not possible. Our findings also suggest that surviving a major cardiovascular event was not enough in itself to modify nutritional intake. As many Nepali consumes low amount of fruits and vegetables, appropriate measures should be taken to increase this consumption to prevent cardiovascular morbidity and mortality.
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Affiliation(s)
| | - Anupa Rijal
- Department of Internal Medicine, Holbæk Hospital, Holbæk, Denmark
| | | | | | - Per Kallestrup
- Research Unit for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Dinesh Neupane
- Nepal Development Society, Chitwan, Nepal
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
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Mrgan M, Nørgaard BL, Dey D, Gram J, Olsen MH, Gram J, Sand NPR. Coronary flow impairment in asymptomatic patients with early stage type-2 diabetes: Detection by FFR CT. Diab Vasc Dis Res 2020; 17:1479164120958422. [PMID: 32985257 PMCID: PMC7919222 DOI: 10.1177/1479164120958422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
PURPOSE To determine the occurrence of physiological significant coronary artery disease (CAD) by coronary CT angiography (CTA) derived fractional flow reserve (FFRCT) in asymptomatic patients with a new diagnosis (<1 year) of type-2 diabetes mellitus (T2DM). METHODS FFRCT-analysis was performed from standard acquired coronary CTA data sets. The per-patient minimum distal FFRCT-value (d-FFRCT) in coronary vessels (diameter ⩾1.8 mm) was registered. The threshold for categorizing FFRCT-analysis as abnormal was a d-FFRCT ⩽0.75. Total plaque volume and volumes of calcified plaque, non-calcified plaque, and low-density non-calcified plaque (LD-NCP) were assessed by quantitative plaque analysis. RESULTS Overall, 76 patients; age, mean (SD): 56 (11) years; males, n (%): 49(65), were studied. A total of 57% of patients had plaques. The d-FFRCT was ⩽0.75 in 12 (16%) patients. The d-FFRCT, median (IQR), was 0.84 (0.79-0.87). Median (range) d-FFRCT in patients with d-FFRCT ⩽0.75 was 0.70 (0.6-0.74). Patients with d-FFRCT⩽0.75 versus d-FFRCT >0.75 had numerically higher plaque volumes for all plaques components, although only significant for the LD-NCP component. CONCLUSION Every sixth asymptomatic patient with a new diagnosis of T2DM has hemodynamic significant CAD as evaluated by FFRCT. Flow impairment by FFRCT was associated with coronary plaque characteristics.
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Affiliation(s)
- Monija Mrgan
- Department of Cardiology, University
Hospital of Southern Denmark, Esbjerg, Denmark
| | | | - Damini Dey
- Department of Biomedical Sciences
(Biomedical Imaging Research Institute), Cedars-Sinai Medical Center, Los Angeles,
CA, USA
| | - Jørgen Gram
- Unit for Thrombosis Research, University
of Southern Denmark, Odense
- Department of Clinical Biochemistry,
University Hospital of Southern Denmark, Esbjerg, Denmark
| | - Michael Hecht Olsen
- Cardiology Section, Department of
Internal Medicine, Holbæk Hospital, Holbæk, Sjaelland, Denmark
- Centre for Individualized Medicine in
Arterial Diseases (CIMA), University of Southern Denmark, Denmark
| | - Jeppe Gram
- Department of Endocrinology, University
Hospital of Southern Denmark, Esbjerg, Denmark
| | - Niels Peter Rønnow Sand
- Department of Cardiology, University
Hospital of Southern Denmark, Esbjerg, Denmark
- Department of Regional Health Research,
University of Southern Denmark, Denmark
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41
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Frary JMC, Pareek M, Byrne C, Vaduganathan M, Biering-Sørensen T, Rujic D, Kragholm KH, Olesen TB, Olsen MH, Bhatt DL. Intensive blood pressure control appears to be effective and safe in patients with peripheral artery disease: the Systolic Blood Pressure Intervention Trial. Eur Heart J Cardiovasc Pharmacother 2020; 7:e38-e40. [PMID: 32853332 DOI: 10.1093/ehjcvp/pvaa102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/10/2020] [Accepted: 08/20/2020] [Indexed: 01/22/2023]
Affiliation(s)
| | - Manan Pareek
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark.,Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.,Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christina Byrne
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA
| | - Tor Biering-Sørensen
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA.,Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark.,Institute of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dragana Rujic
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | | | | | - Michael Hecht Olsen
- Division of Cardiology, Department of Internal Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA
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42
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Morales-Salinas A, Olsen MH, Kones R, Kario K, Wang J, Beilin L, Weber MA, Yano Y, Burrell L, Orias M, Cameroon DA, Lavie CJ, Ventura H, Sundström J, de Simone G, Coca A, Rumana U, Marrugat J. Second Consensus on Treatment of Patients Recently Diagnosed With Mild Hypertension and Low Cardiovascular Risk. Curr Probl Cardiol 2020; 45:100653. [PMID: 32828558 DOI: 10.1016/j.cpcardiol.2020.100653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/03/2020] [Indexed: 10/23/2022]
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43
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Krogager ML, Pareek M, Kragholm KH, Byrne C, Vaduganathan M, Biering-Sørensen T, Rujic D, Olesen TB, Olsen MH, Bhatt DL. Intensive vs. standard blood pressure control and vascular procedures: insights from the Systolic Blood Pressure Intervention Trial (SPRINT). Eur Heart J Cardiovasc Pharmacother 2020; 7:e35-e37. [PMID: 32722801 DOI: 10.1093/ehjcvp/pvaa093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
| | - Manan Pareek
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA.,Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | | | - Christina Byrne
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Tor Biering-Sørensen
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark.,Institute of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dragana Rujic
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | | | - Michael Hecht Olsen
- Division of Cardiology, Department of Internal Medicine, Holbæk Hospital, Holbæk, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
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Padwal R, Campbell NRC, Schutte AE, Olsen MH, Delles C, Etyang A, Cruickshank JK, Stergiou G, Rakotz MK, Wozniak G, Jaffe MG, Benjamin I, Parati G, Sharman JE. Optimización del desempeño del observador al medir la presión arterial en el consultorio: declaración de posición de la Comisión Lancet de Hipertensión. Rev Panam Salud Publica 2020; 44:e88. [PMID: 32684918 PMCID: PMC7363287 DOI: 10.26633/rpsp.2020.88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 03/11/2019] [Indexed: 01/17/2023] Open
Abstract
La hipertensión arterial es una causa modificable muy prevalente de enfermedades cardiovasculares, accidentes cerebrovasculares y muerte. Medir con exactitud la presión arterial es fundamental, dado que un error de medición de 5 mmHg puede ser motivo para clasificar incorrectamente como hipertensas a 84 millones de personas en todo el mundo. En la presente declaración de posición se resumen los procedimientos para optimizar el desempeño del observador al medir la presión arterial en el consultorio, con atención especial a los entornos de ingresos bajos o medianos, donde esta medición se ve complicada por limitaciones de recursos y tiempo, sobrecarga de trabajo y falta de suministro eléctrico. Es posible reducir al mínimo muchos errores de medición con una preparación adecuada de los pacientes y el uso de técnicas estandarizadas. Para simplificar la medición y prevenir errores del observador, deben usarse tensiómetros semiautomáticos o automáticos de manguito validados, en lugar del método por auscultación. Pueden ayudar también la distribución de tareas, la creación de un área específica de medición y el uso de aparatos semiautomáticos o de carga solar. Es fundamental garantizar la capacitación inicial y periódica de los integrantes del equipo de salud. Debe considerarse la implementación de programas de certificación de bajo costo y fácilmente accesibles con el objetivo de mejorar la medición de la presión arterial.
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Affiliation(s)
- Raj Padwal
- Departamento de Medicina, Universidad de Alberta, Edmonton (Canadá)
| | - Norm R. C. Campbell
- Departamento de Medicina, Fisiología y Farmacología y Salud Comunitaria, Instituto O’Brien de Salud Pública e Instituto Cardiovascular Libin de Alberta, Universidad de Calgary, Calgary, Alberta (Canadá)
| | - Aletta E. Schutte
- Equipo de Investigación de la Hipertensión en África (HART), Unidad de Investigación MRC: Hipertensión y Enfermedades Cardiovasculares, Universidad del Noroeste, Potchefstroom (Sudáfrica)
| | - Michael Hecht Olsen
- Departamento de Medicina Interna, Hospital de Holbæk, Dinamarca; y Centro de Medicina Individualizada en Enfermedades Arteriales
(CIMA), Hospital Universitario de Odense, Universidad del Sur de Dinamarca, Odense (Dinamarca)
| | - Christian Delles
- Instituto de Ciencias Cardiovasculares y Médicas, Universidad de Glasgow (Reino Unido)
| | - Anthony Etyang
- Programa de Investigación KEMRI-Fundación Wellcome, Kilifi (Kenya)
| | - J. Kennedy Cruickshank
- Escuela de Ciencias de la Nutrición y del Curso de la Vida, King’s College, Hospitales St. Thomas & Guy, Londres (Reino Unido)
| | - George Stergiou
- Centro de Hipertensión STRIDE-7, Universidad Nacional y Capodistríaca de Atenas, Facultad de Medicina, Departamento de Medicina III, Hospital Sotiria, Atenas (Grecia)
| | - Michael K. Rakotz
- Asociación Médica Estadounidense (AMA), Chicago (Estados Unidos de América)
| | - Gregory Wozniak
- Asociación Médica Estadounidense (AMA), Chicago (Estados Unidos de América)
| | - Marc G. Jaffe
- Iniciativa de Estrategias Vitales “Resolve to Save Lives”, Nueva York (Estados Unidos de América); y Centro Médico Kaiser Permanente de South San Francisco (Estados Unidos de América)
| | - Ivor Benjamin
- Asociación Estadounidense del Corazón (AHA), Centro Cardiovascular, Facultad de Medicina de Wisconsin, Wauwatosa (Estados Unidos de América)
| | - Gianfranco Parati
- Departamento de Medicina y Cirugía, Universidad de Milán-Bicocca, Milán (Italia); e Instituto Auxológico Italiano, IRCCS, Departamento de Ciencias Cardiovasculares, Neurales y Metabólicas, Hospital S. Luca, Milán (Italia)
| | - James E. Sharman
- Instituto Menzies de Investigación Médica, Universidad de Tasmania, Hobart (Australia)
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Krishnan A, Finkelstein EA, Kallestrup P, Karki A, Olsen MH, Neupane D. Cost-effectiveness and budget impact of the community-based management of hypertension in Nepal study (COBIN): a retrospective analysis. Lancet Glob Health 2020; 7:e1367-e1374. [PMID: 31537367 DOI: 10.1016/s2214-109x(19)30338-9] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 06/10/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The greatest risk factor for cardiovascular disease is hypertension, which can be alleviated via diet, exercise, and adherence to medication. Yet, blood pressure control in Nepal is inadequate, which is partly hindered by a lack of evidence-based, low-cost, scalable, and cost-effective cardiovascular disease prevention programmes. The the community-based management of hypertension in Nepal (COBIN) study was a 12-month community-based hypertension management programme of blood pressure monitoring and lifestyle counselling intervention undertaken by female community health volunteers (FCHVs) in Nepal, against usual care, which showed success in reducing blood pressure. Here we aimed to retrospectively quantify the budget impact and cost-effectiveness of the scale-up of the programme. METHODS In this retrospective analysis, we collected participant-level data from the COBIN study; programme delivery cost data from programme administrators from the COBIN study group; and popualtion and other data from WHO, the World Bank, and the Nepalese Government. We estimated costs per participant and total costs of a national scale-up of the COBIN programme focusing on two scenarios: scenario A, delivery of the intervention to only people aged 25-65 years with hypertension; and scenario B, delivery of the intervention to all adults aged 25-65 years regardless of hypertension status. Effectiveness was based on in-trial blood pressure reductions converted to cardiovascular disease disability-adjusted life-years (DALYs) averted. The primary cost-effectiveness measure was incremental cost per averted cardiovascular disease DALY (calculated using the incremental cost-effectiveness ratio [ICER]) from a health system perspective, including programme delivery and incremental medication costs. We did univariate sensitivity analyses of scenario B to assess the effect of uncertainty in key parameter values in our calculations. FINDINGS From a health system perspective, the first-year budget impact was US$7·1 million in scenario A and $10·8 million in scenario B. With each subsequent year, the costs decreased by approximately 50%. In the base-case cost-effectiveness analysis, from the health system perspective, scenario A resulted in an ICER of $582 per DALY averted and scenario B resulted in an ICER of $411 per DALY averted. The ICER was most sensitive to uncertainty in the number of total avertable cardiovascular disease DALYs in the eligible population. INTERPRETATION The programme is projected to be highly cost-effective in both scenarios compared with the WHO thresholds for cost-effectiveness for Nepal. For policy makers intending to meet the UN Sustainable Development Goal of reducing premature mortality from non-communicible diseases, this intervention should be considered. FUNDING Duke-NUS Medical School, Singapore.
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Affiliation(s)
- Anirudh Krishnan
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | | | - Per Kallestrup
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Arjun Karki
- Patan Academy of Health Sciences, Lagankhel, Lalitpur, Nepal
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital, University of Southern Denmark, Odense, Denmark
| | - Dinesh Neupane
- Nepal Development Society, Bharatpur-10, Chitwan, Nepal; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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46
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Kristensen AMD, Bovin A, Zwisler AD, Cerquira C, Torp-Pedersen C, Bøtker HE, Gustafsson I, Veien KT, Thomsen KK, Olsen MH, Larsen ML, Nielsen OW, Hildebrandt P, Foghmar S, Jensen SE, Lange T, Sehested T, Jernberg T, Atar D, Ibanez B, Prescott E. Design and rationale of the Danish trial of beta-blocker treatment after myocardial infarction without reduced ejection fraction: study protocol for a randomized controlled trial. Trials 2020; 21:415. [PMID: 32446298 PMCID: PMC7245032 DOI: 10.1186/s13063-020-4214-6] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/27/2020] [Indexed: 11/10/2022] Open
Abstract
Background Treatment with beta-blockers is currently recommended after myocardial infarction (MI). The evidence relies on trials conducted decades ago before implementation of revascularization and contemporary medical therapy or in trials enrolling patients with heart failure or reduced left ventricular ejection fraction (LVEF ≤ 40%). Accordingly, the impact of beta-blockers on mortality and morbidity following acute MI in patients without reduced LVEF or heart failure is unclear. Methods/design The Danish trial of beta-blocker treatment after myocardial infarction without reduced ejection fraction (DANBLOCK) is a prospective, randomized, controlled, open-label, non-blinded endpoint clinical trial designed to evaluate the efficacy of beta-blocker treatment in post-MI patients in the absence of reduced LVEF or heart failure. We will randomize 3570 patients will be randomized within 14 days of index MI to beta-blocker or control for a minimum of 2 years. The primary endpoint is a composite of all-cause mortality, recurrent MI, acute decompensated heart failure, unstable angina pectoris, or stroke. The primary composite endpoint will be assessed through locally reported and adjudicated endpoints supplemented by linkage to the Danish national registers. A number of secondary endpoints will be investigated including patient reported outcomes and cardiovascular mortality. Data from similar ongoing trials in Norway and Sweden will be pooled to perform an individual patient data meta-analysis. Discussion DANBLOCK is a randomized clinical trial investigating the effect of long-term beta-blocker therapy after myocardial infarction in patients without heart failure and reduced LVEF. Results from the trial will add important scientific evidence to inform future clinical guidelines. Trial registration Clinicaltrials.gov, NCT03778554. Registered on 19 December 2018. European Clinical Trials Database, 2018-002699-42, registered on 28 September 2018.
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Affiliation(s)
| | - Ann Bovin
- Department of Cardiology, Sygehus Lillebælt, Vejle, Denmark
| | - Ann Dorthe Zwisler
- Danish Centre for Rehabilitation and Palliative Care, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | | | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | | | | | | | | | | | - Per Hildebrandt
- Department of Cardiology, Frederiksberg Heart Clinic, Copenhagen, Denmark
| | - Sussie Foghmar
- Department of Cardiology, Hvidovre-Amager Hospital, Hvidovre, Denmark
| | | | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Sehested
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Tomas Jernberg
- Department of Clinical Sciences, Division of Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) & IIS- Fundación Jiménez Díaz & CIBERCV, Madrid, Spain
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
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47
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Picone DS, Deshpande RA, Schultz MG, Fonseca R, Campbell NRC, Delles C, Hecht Olsen M, Schutte AE, Stergiou G, Padwal R, Zhang XH, Sharman JE. Nonvalidated Home Blood Pressure Devices Dominate the Online Marketplace in Australia: Major Implications for Cardiovascular Risk Management. Hypertension 2020; 75:1593-1599. [PMID: 32275193 DOI: 10.1161/hypertensionaha.120.14719] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Self-home blood pressure (BP) monitoring is recommended to guide clinical decisions on hypertension and is used worldwide for cardiovascular risk management. People usually make their own decisions when purchasing BP devices, which can be made online. If patients purchase nonvalidated devices (those not proven accurate according to internationally accepted standards), hypertension management may be based on inaccurate readings resulting in under- or over-diagnosis or treatment. This study aimed to evaluate the number, type, percentage validated, and cost of home BP devices available online. A search of online businesses selling devices for home BP monitoring was conducted. Multinational companies make worldwide deliveries, so searches were restricted to BP devices available for one nation (Australia) as an example of device availability through the global online marketplace. Validation status of BP devices was determined according to established protocols. Fifty nine online businesses, selling 972 unique BP devices were identified. These included 278 upper-arm cuff devices (18.3% validated), 162 wrist-cuff devices (8.0% validated), and 532 wrist-band wearables (0% validated). Most BP devices (92.4%) were stocked by international e-commerce businesses (eg, eBay, Amazon), but only 5.5% were validated. Validated cuff BP devices were more expensive than nonvalidated devices: median (interquartile range) of 101.1 (75.0-151.5) versus 67.4 (30.4-112.8) Australian Dollars. Nonvalidated BP devices dominate the online marketplace and are sold at lower cost than validated ones, which is a major barrier to accurate home BP monitoring and cardiovascular risk management. Before purchasing a BP device, people should check it has been validated at https://www.stridebp.org.
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Affiliation(s)
- Dean S Picone
- From the Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (D.S.P., R.A.D., M.G.S., R.F., J.E.S.)
| | - Rewati A Deshpande
- From the Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (D.S.P., R.A.D., M.G.S., R.F., J.E.S.)
| | - Martin G Schultz
- From the Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (D.S.P., R.A.D., M.G.S., R.F., J.E.S.)
| | - Ricardo Fonseca
- From the Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (D.S.P., R.A.D., M.G.S., R.F., J.E.S.)
| | - Norm R C Campbell
- Department of Medicine, Physiology and Pharmacology and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (N.R.C.C.)
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (C.D.)
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital, Denmark (M.H.-O.).,Centre for Individualized Medicine in Arterial Diseases, Odense University Hospital, University of Southern Denmark (M.H.-O.)
| | - Aletta E Schutte
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (A.E.S.).,Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa (A.E.S.)
| | - George Stergiou
- Hypertension Center STRIDE-7, National and Kapodistrian University of Athens, School of Medicine, Third Department of Medicine, Sotiria Hospital, Greece (G.S.)
| | - Raj Padwal
- Department of Medicine, University of Alberta, Edmonton, Canada (R.P.)
| | | | - James E Sharman
- From the Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia (D.S.P., R.A.D., M.G.S., R.F., J.E.S.)
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48
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Sharman JE, O’Brien E, Alpert B, Schutte AE, Delles C, Olsen MH, Asmar R, Atkins N, Barbosa E, Calhoun D, Campbell NR, Chalmers J, Benjamin I, Jennings G, Laurent S, Boutouyrie P, Lopez-Jaramillo P, McManus RJ, Mihailidou AS, Ordunez P, Padwal R, Palatini P, Parati G, Poulter N, Rakotz MK, Rosendorff C, Saladini F, Scuteri A, Barroso WS, Cho MC, Sung KC, Townsend RR, Wang JG, Hansen TW, Wozniak G, Stergiou G. [Lancet Commission on Hypertension Group position statement on the global improvement of accuracy standards for devices that measure blood pressurePosicionamento do Grupo da Lancet Commission on Hypertension sobre a melhoria global dos padrões de acurácia para aparelhos que medem a pressão arterial]. Rev Panam Salud Publica 2020; 44:e21. [PMID: 32117468 PMCID: PMC7039279 DOI: 10.26633/rpsp.2020.21] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/14/2019] [Indexed: 11/24/2022] Open
Abstract
The Lancet Commission on Hypertension identified that a key action to address the worldwide burden of high blood pressure (BP) was to improve the quality of BP measurements by using BP devices that have been validated for accuracy. Currently, there are over 3 000 commercially available BP devices, but many do not have published data on accuracy testing according to established scientific standards. This problem is enabled through weak or absent regulations that allow clearance of devices for commercial use without formal validation. In addition, new BP technologies have emerged (e.g. cuffless sensors) for which there is no scientific consensus regarding BP measurement accuracy standards. Altogether, these issues contribute to the widespread availability of clinic and home BP devices with limited or uncertain accuracy, leading to inappropriate hypertension diagnosis, management and drug treatment on a global scale. The most significant problems relating to the accuracy of BP devices can be resolved by the regulatory requirement for mandatory independent validation of BP devices according to the universally-accepted International Organization for Standardization Standard. This is a primary recommendation for which there is an urgent international need. Other key recommendations are development of validation standards specifically for new BP technologies and online lists of accurate devices that are accessible to consumers and health professionals. Recommendations are aligned with WHO policies on medical devices and universal healthcare. Adherence to recommendations would increase the global availability of accurate BP devices and result in better diagnosis and treatment of hypertension, thus decreasing the worldwide burden from high BP.
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Affiliation(s)
- James E. Sharman
- Menzies Institute for Medical ResearchUniversidad de TasmaniaHobartTasmaniaAustraliaMenzies Institute for Medical Research, Universidad de Tasmania, Hobart, Tasmania, Australia.
| | - Eoin O’Brien
- The Conway InstituteUniversity College DublinDublínIrlandaThe Conway Institute, University College Dublin, Dublín, Irlanda.
| | - Bruce Alpert
- Centro de Ciencias de la SaludUniversidad de TennesseeMemphisTennesseeEstados UnidosCentro de Ciencias de la Salud, Universidad de Tennessee, Memphis, Tennessee, Estados Unidos (retirado)
| | - Aletta E. Schutte
- Equipo de investigación en hipertensión en África, Medical Research Council Unit for Hypertension and Cardiovascular DiseaseUniversidad del NoroestePotchefstroomSudáfricaEquipo de investigación en hipertensión en África, Medical Research Council Unit for Hypertension and Cardiovascular Disease, Universidad del Noroeste, Potchefstroom, Sudáfrica.
| | - Christian Delles
- Institute of Cardiovascular and Medical SciencesUniversidad de GlasgowGlasgowReino UnidoInstitute of Cardiovascular and Medical Sciences, Universidad de Glasgow, Glasgow, Reino Unido.
| | - Michael Hecht Olsen
- Departamento de Medicina Interna, Hospital Holbaek, Holbaek, Dinamarca; y Centre for Individualized Medicine in Arterial Diseases (CIMA), Hospital de la Universidad de OdenseUniversidad de Dinamarca MeridionalOdenseDinamarcaDinamarcaDepartamento de Medicina Interna, Hospital Holbaek, Holbaek, Dinamarca; y Centre for Individualized Medicine in Arterial Diseases (CIMA), Hospital de la Universidad de Odense, Universidad de Dinamarca Meridional, Odense, Dinamarca.
| | - Roland Asmar
- Institutos de la Fundación para la Investigación MédicaInstitutos de la Fundación para la Investigación MédicaGinebraSuizaInstitutos de la Fundación para la Investigación Médica, Ginebra, Suiza.
| | - Neil Atkins
- Medaval LtdaMedaval LtdaDublínIrlandaMedaval Ltda., Dublín, Irlanda.
| | - Eduardo Barbosa
- Liga para la hipertensión de Porto AlegreLiga para la hipertensión de Porto AlegrePorto AlegreBrasilLiga para la hipertensión de Porto Alegre, Porto Alegre, Brasil.
| | - David Calhoun
- Grupo de biología vascular e hipertensiónUniversidad de Alabama en BirminghamBirminghamEstados UnidosGrupo de biología vascular e hipertensión, Universidad de Alabama en Birmingham, Birmingham, Estados Unidos.
| | - Norm R.C. Campbell
- Departamento de Medicina, Fisiología y Farmacología y Ciencias de la Salud Comunitaria, O’Brien Institute for Public Health y Libin Cardiovascular Institute of AlbertaUniversidad de CalgaryCalgaryAlbertaCanadáDepartamento de Medicina, Fisiología y Farmacología y Ciencias de la Salud Comunitaria, O’Brien Institute for Public Health y Libin Cardiovascular Institute of Alberta, Universidad de Calgary, Calgary, Alberta, Canadá.
| | - John Chalmers
- George Institute for Global HealthUniversidad de Nueva Gales del SurSídneyNueva Gales del SurAustraliaGeorge Institute for Global Health, Universidad de Nueva Gales del Sur, Sídney, Nueva Gales del Sur, Australia.
| | - Ivor Benjamin
- American Heart AssociationAmerican Heart AssociationDallasTexasEstados UnidosAmerican Heart Association, Dallas, Texas, Estados Unidos.
| | - Garry Jennings
- Facultad de Medicina de SídneyUniversidad de Sídney y Baker Heart & Diabetes InstituteMelbourneVictoriaAustraliaFacultad de Medicina de Sídney, Universidad de Sídney y Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia.
| | - Stéphane Laurent
- Departamentos de Farmacología, Hospital Europeo Georges Pompidou, Assistance Publique Hôpitaux de ParisInserm UMR 970 y Universidad Paris DescartesParísFranciaDepartamentos de Farmacología, Hospital Europeo Georges Pompidou, Assistance Publique Hôpitaux de Paris, Inserm UMR 970 y Universidad Paris Descartes, París, Francia.
| | - Pierre Boutouyrie
- Departamentos de Farmacología, Hospital Europeo Georges Pompidou, Assistance Publique Hôpitaux de ParisInserm UMR 970 y Universidad Paris DescartesParísFranciaDepartamentos de Farmacología, Hospital Europeo Georges Pompidou, Assistance Publique Hôpitaux de Paris, Inserm UMR 970 y Universidad Paris Descartes, París, Francia.
| | - Patricio Lopez-Jaramillo
- FOSCAL, Instituto Masira, Facultad de Ciencias de la SaludUDESBucaramangaColombiaFOSCAL, Instituto Masira, Facultad de Ciencias de la Salud, UDES, Bucaramanga, Colombia.
| | - Richard J. McManus
- Nuffield Department of Primary Care Health SciencesUniversidad de Oxford, Radcliffe Observatory QuarterOxfordReino UnidoNuffield Department of Primary Care Health Sciences, Universidad de Oxford, Radcliffe Observatory Quarter, Oxford, Reino Unido.
| | - Anastasia S. Mihailidou
- Laboratorio de Investigación Cardiovascular y HormonalDepartamento de Cardiología del Kolling Institute, Royal North Shore Hospital y Facultad de Medicina y Ciencias de la Salud, Universidad MacquarieSídneyNueva Gales del SurAustraliaLaboratorio de Investigación Cardiovascular y Hormonal, Departamento de Cardiología del Kolling Institute, Royal North Shore Hospital y Facultad de Medicina y Ciencias de la Salud, Universidad Macquarie, Sídney, Nueva Gales del Sur, Australia.
| | - Pedro Ordunez
- Departamento de Enfermedades no Transmisibles y Salud MentalOrganización Panamericana de la SaludWashington, D.CEstados UnidosDepartamento de Enfermedades no Transmisibles y Salud Mental. Organización Panamericana de la Salud, Washington, D.C., Estados Unidos.
| | - Raj Padwal
- Departamento de Medicina, Universidad de AlbertaDepartamento de Medicina, Universidad de AlbertaEdmontonAlbertaCanadáDepartamento de Medicina, Universidad de Alberta, Edmonton, Alberta, Canadá.
| | - Paolo Palatini
- Studium Patavinum, Universidad de PaduaStudium Patavinum, Universidad de PaduaPaduaItaliaStudium Patavinum, Universidad de Padua, Padua, Italia.
| | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCSDepartamento de Ciencias Cardiovasculares, Neurales y Metabólicas, Hospital San Luca, Milán, Italia; y Departamento de Medicina y Cirugía, Universidad de Milán-BicoccaMilánItaliaIstituto Auxologico Italiano, IRCCS, Departamento de Ciencias Cardiovasculares, Neurales y Metabólicas, Hospital San Luca, Milán, Italia; y Departamento de Medicina y Cirugía, Universidad de Milán-Bicocca, Milán, Italia.
| | - Neil Poulter
- Imperial Clinical Trials UnitImperial College LondonLondresReino UnidoImperial Clinical Trials Unit, Imperial College London, Londres, Reino Unido.
| | - Michael K. Rakotz
- Asociación Médica EstadounidenseMejorar los Resultados en Materia de SaludChicagoIllinoisEstados UnidosAsociación Médica Estadounidense, Mejorar los Resultados en Materia de Salud, Chicago, Illinois, Estados Unidos.
| | - Clive Rosendorff
- Mount Sinai HeartDepartamento de Medicina (cardiología), Icahn School of Medicine en Mount Sinai, Nueva York, Estados Unidos, y The James J. Peters VA Medical CenterBronxNueva YorkEstados UnidosMount Sinai Heart, Departamento de Medicina (cardiología), Icahn School of Medicine en Mount Sinai, Nueva York, Estados Unidos, y The James J. Peters VA Medical Center, Bronx, Nueva York, Estados Unidos.
| | - Francesca Saladini
- Departamento de MedicinaUniversidad de Padua; Unidad de Cardiología, Hospital de CittadellaPaduaItaliaDepartamento de Medicina, Universidad de Padua; Unidad de Cardiología, Hospital de Cittadella, Padua, Italia.
| | - Angelo Scuteri
- Departamento de Ciencias Médicas, Quirúrgicas y ExperimentalesUniversidad de SácerSácerItaliaDepartamento de Ciencias Médicas, Quirúrgicas y Experimentales, Universidad de Sácer, Sácer, Italia.
| | - Weimar Sebba Barroso
- Liga para la hipertensiónDepartamento de Cardiología, Universidad Federal de GoiásGoiâniaBrasilLiga para la hipertensión. Departamento de Cardiología, Universidad Federal de Goiás, Goiânia, Brasil.
| | - Myeong-Chan Cho
- Departamento de Medicina Interna, Facultad de Medicina de la Universidad Nacional ChungbukDepartamento de Medicina Interna, Facultad de Medicina de la Universidad Nacional ChungbukCheongjuRepública de CoreaDepartamento de Medicina Interna, Facultad de Medicina de la Universidad Nacional Chungbuk, Cheongju, República de Corea.
| | - Ki-Chul Sung
- División de CardiologíaDepartamento de Medicina Interna, Hospital Kangbuk Samsung, Facultad de Medicina de la Universidad SungkyunkwanSeúlRepública de CoreaDivisión de Cardiología, Departamento de Medicina Interna, Hospital Kangbuk Samsung, Facultad de Medicina de la Universidad Sungkyunkwan, Seúl, República de Corea.
| | - Raymond R. Townsend
- Facultad de Medicina PerelmanUniversidad de PensilvaniaFiladelfiaEstados UnidosFacultad de Medicina Perelman, Universidad de Pensilvania, Filadelfia, Estados Unidos.
| | - Ji-Guang Wang
- Instituto de hipertensión de Shanghai, Hospital RuijinFacultad de Medicina de la Universidad Shanghai JiaotongShanghaiChinaInstituto de hipertensión de Shanghai, Hospital Ruijin, Facultad de Medicina de la Universidad Shanghai Jiaotong, Shanghai, China.
| | - Tine Willum Hansen
- Steno Diabetes Center CopenhagenSteno Diabetes Center CopenhagenGentofteDinamarcaSteno Diabetes Center Copenhagen, Gentofte, Dinamarca.
| | - Gregory Wozniak
- Asociación Médica EstadounidenseMejorar los Resultados en Materia de SaludChicagoIllinoisEstados UnidosAsociación Médica Estadounidense, Mejorar los Resultados en Materia de Salud, Chicago, Illinois, Estados Unidos.
| | - George Stergiou
- Hypertension Center STRIDE-7Universidad Nacional y Kapodistríaca de Atenas, Facultad de Medicina, Tercer Departamento de Medicina, Hospital SotiriaAtenasGreciaHypertension Center STRIDE-7, Universidad Nacional y Kapodistríaca de Atenas, Facultad de Medicina, Tercer Departamento de Medicina, Hospital Sotiria, Atenas, Grecia.
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Dyrvig Kristensen AM, Pareek M, Olsen MH, Bhatt DL. Baroreflex Activation Therapy for Resistant Hypertension and Heart Failure. US Cardiology Review 2020. [DOI: 10.15420/usc.2019.13.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hypertension and heart failure are important contributors to global morbidity and mortality. Despite therapeutic lifestyle and pharmacological measures, a significant proportion of people with hypertension do not reach treatment targets. Patients with resistant or poorly controlled hypertension are at significantly increased risk of cardiovascular events, including heart failure. Since dysfunction of the sympathetic nervous system appears to play a key role in the development and progression of both hypertension and heart failure, these patients may benefit from treatment modalities aimed at reducing sympathetic function. The purpose of this paper is to provide an overview of baroreflex activation therapy as a potential treatment strategy in patients with resistant hypertension or heart failure.
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Affiliation(s)
| | - Manan Pareek
- Department of Cardiology, North Zealand Hospital, Hilleroed, Denmark; Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA
| | - Michael Hecht Olsen
- Cardiology Section, Department of Internal Medicine, Holbaek Hospital, Holbaek, Denmark
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA
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50
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Bahls M, Lorenz MW, Dörr M, Gao L, Kitagawa K, Tuomainen TP, Agewall S, Berenson G, Catapano AL, Norata GD, Bots ML, van Gilst W, Asselbergs FW, Brouwers FP, Uthoff H, Sander D, Poppert H, Hecht Olsen M, Empana JP, Schminke U, Baldassarre D, Veglia F, Franco OH, Kavousi M, de Groot E, Mathiesen EB, Grigore L, Polak JF, Rundek T, Stehouwer CDA, Skilton MR, Hatzitolios AI, Savopoulos C, Ntaios G, Plichart M, McLachlan S, Lind L, Willeit P, Steinmetz H, Desvarieux M, Ikram MA, Johnsen SH, Schmidt C, Willeit J, Ducimetiere P, Price JF, Bergström G, Kauhanen J, Kiechl S, Sitzer M, Bickel H, Sacco RL, Hofman A, Völzke H, Thompson SG. Progression of conventional cardiovascular risk factors and vascular disease risk in individuals: insights from the PROG-IMT consortium. Eur J Prev Cardiol 2020; 27:234-243. [PMID: 31619084 PMCID: PMC7008553 DOI: 10.1177/2047487319877078] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 03/26/2019] [Accepted: 08/29/2019] [Indexed: 12/23/2022]
Abstract
AIMS Averaged measurements, but not the progression based on multiple assessments of carotid intima-media thickness, (cIMT) are predictive of cardiovascular disease (CVD) events in individuals. Whether this is true for conventional risk factors is unclear. METHODS AND RESULTS An individual participant meta-analysis was used to associate the annualised progression of systolic blood pressure, total cholesterol, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol with future cardiovascular disease risk in 13 prospective cohort studies of the PROG-IMT collaboration (n = 34,072). Follow-up data included information on a combined cardiovascular disease endpoint of myocardial infarction, stroke, or vascular death. In secondary analyses, annualised progression was replaced with average. Log hazard ratios per standard deviation difference were pooled across studies by a random effects meta-analysis. In primary analysis, the annualised progression of total cholesterol was marginally related to a higher cardiovascular disease risk (hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.00 to 1.07). The annualised progression of systolic blood pressure, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol was not associated with future cardiovascular disease risk. In secondary analysis, average systolic blood pressure (HR 1.20 95% CI 1.11 to 1.29) and low-density lipoprotein cholesterol (HR 1.09, 95% CI 1.02 to 1.16) were related to a greater, while high-density lipoprotein cholesterol (HR 0.92, 95% CI 0.88 to 0.97) was related to a lower risk of future cardiovascular disease events. CONCLUSION Averaged measurements of systolic blood pressure, low-density lipoprotein cholesterol and high-density lipoprotein cholesterol displayed significant linear relationships with the risk of future cardiovascular disease events. However, there was no clear association between the annualised progression of these conventional risk factors in individuals with the risk of future clinical endpoints.
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Affiliation(s)
- Martin Bahls
- Department of Internal Medicine B, University Medicine Greifswald, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Greifswald, Germany
| | - Matthias W Lorenz
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
| | - Marcus Dörr
- Department of Internal Medicine B, University Medicine Greifswald, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Greifswald, Germany
| | - Lu Gao
- MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, University of Cambridge, UK
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Tomi-Pekka Tuomainen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio Campus, Kuopio, Finland
| | - Stefan Agewall
- Institute of Clinical Sciences, University of Oslo, Oslo, Norway
- Department of Cardiology, Oslo University Hospital Ullevål, Ullevål, Oslo, Norway
| | - Gerald Berenson
- Department of Medicine, Pediatrics, Biochemistry, Epidemiology, Tulane University School of Medicine and School of Public Health and Tropical Medicine, New Orleans, USA
| | - Alberico L Catapano
- IRCSS Multimedica, Milan, Italy
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Giuseppe D Norata
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
- SISA Center for the Study of Atherosclerosis, Bassini Hospital, Italy
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wiek van Gilst
- Department of Experimental Cardiology, University Medical Center Groningen, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Institute of Cardiovascular Science, University College London, London, UK
- Health Data Research UK and Institute of Health Informatics, University College London, London, UK
| | - Frank P Brouwers
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Heiko Uthoff
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - Dirk Sander
- Department of Neurology, Benedictus Hospital Tutzing, Tutzing, Germany
| | - Holger Poppert
- Department of Neurology, Technical University Munich, Munich, Germany
| | - Michael Hecht Olsen
- Department of Internal Medicine, Holbaek Hospital and Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - Jean Philippe Empana
- Université de Paris, INSERM U970, Paris Cardiovascular Research Centre, Paris, France
| | - Ulf Schminke
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - Damiano Baldassarre
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, Università di Milano, Milan, Italy
| | | | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Eric de Groot
- Imagelabonline and Cardiovascular, Erichem, The Netherlands
| | - Ellisiv B Mathiesen
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - Liliana Grigore
- Centro Sisa per lo Studio della Aterosclerosi, Bassini Hospital, Cinisello Balsamo, Italy
| | - Joseph F Polak
- Tufts University School of Medicine, Tufts Medical Center, Boston, USA
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, USA
| | - Coen DA Stehouwer
- Department of Internal Medicine and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michael R Skilton
- The Boden Collaboration for Obesity, Nutrition, Exercise and Eating Disorders, The University of Sydney, Sydney, Australia
| | - Apostolos I Hatzitolios
- Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki – AHEPA Hospital, Greece
| | - Christos Savopoulos
- Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki – AHEPA Hospital, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Matthieu Plichart
- Centro Sisa per lo Studio della Aterosclerosi, Bassini Hospital, Cinisello Balsamo, Italy
- Assistance Publique, Hôpitaux de Paris, Hôpital Broca, Paris, France
| | | | - Lars Lind
- Department of Medicine, Uppsala University, Uppsala, Sweden
| | - Peter Willeit
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Helmuth Steinmetz
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
| | - Moise Desvarieux
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
- METHODS Core, Centre de Recherche Epidémiologie et Statistique Paris Sorbonne Cité (CRESS), Institut National de la Santé et de la Recherche Médicale (INSERM) UMR 1153, Paris, France
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Radiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Stein Harald Johnsen
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway
| | - Caroline Schmidt
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Johann Willeit
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | | | | | - Göran Bergström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Clinical Physiology, Gothenburg, Sweden
| | - Jussi Kauhanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio Campus, Kuopio, Finland
| | - Stefan Kiechl
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Matthias Sitzer
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
- Department of Neurology, Klinikum Herford, Herford, Germany
| | - Horst Bickel
- Department of Psychiatry and Psychotherapy, Technische Universität München, Munich, Germany
| | - Ralph L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, USA
| | - Albert Hofman
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology | Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Henry Völzke
- German Centre for Cardiovascular Research (DZHK), partner site Greifswald, Germany
- Institute for Community Medicine, SHIP/Clinical-Epidemiological Research, University Medicine Greifswald, Greifswald, Germany
| | - Simon G Thompson
- Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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